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8. Foot and Ankle MCQs

Practice Set 233 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 4641

Topic: 8. Foot and Ankle

A 30-year-old male is involved in a motor vehicle collision and sustains a displaced talar neck fracture with subluxation of the subtalar joint. The ankle joint remains reduced (Hawkins Type II). Which of the following vascular supplies to the talar body is most likely preserved?

. Artery of the tarsal canal
. Artery of the tarsal sinus
. Deltoid branches of the posterior tibial artery
. Anterior tibial artery branches
. Dorsalis pedis branches

Correct Answer & Explanation

. Deltoid branches of the posterior tibial artery

Explanation

The talus has a tenuous, retrograde blood supply. The artery of the tarsal canal (from the posterior tibial artery) is the dominant supply to the body. In a Hawkins II fracture (subtalar subluxation/dislocation), the artery of the tarsal canal and the artery of the tarsal sinus are typically disrupted. The deltoid branches (supplying the medial body) are the most consistently preserved vascular supply, provided the medial malleolus and deltoid ligament are intact.

Question 4642

Topic: Midfoot & Hindfoot

A 60-year-old male with poorly controlled type 2 diabetes presents with a red, hot, swollen right foot of 3 weeks' duration. He denies ulceration, fevers, or chills. Laboratory studies show normal WBC and CRP. Radiographs demonstrate early fragmentation and periarticular debris at the tarsometatarsal joints. What is the initial treatment of choice?

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

Correct Answer & Explanation

. Total contact casting and strict non-weight-bearing

Explanation

The presentation is classic for acute (Eichenholtz Stage I) Charcot neuroarthropathy. The absence of an ulcer and normal inflammatory markers make osteomyelitis unlikely. The initial treatment of choice for acute Charcot arthropathy is strict immobilization and offloading, best achieved with a total contact cast (TCC). This prevents further architectural collapse while allowing the acute inflammatory process to consolidate. Surgery is generally contraindicated in the acute inflammatory phase.

Question 4643

Topic: 8. Foot and Ankle

During operative fixation of a pronation-external rotation ankle fracture, the syndesmosis is found to be unstable after rigid fixation of the medial and lateral malleoli. Which of the following is true regarding syndesmotic screw fixation?

. The screw must engage 4 cortices to be clinically effective
. The ankle must be held in maximal plantarflexion during screw insertion
. The screw should be placed parallel to the ankle joint and angled roughly 30 degrees anteriorly
. The screw should be removed routinely at 6 weeks to prevent ankle stiffness
. Suture-button constructs have a significantly higher rate of hardware removal compared to screws

Correct Answer & Explanation

. The screw should be placed parallel to the ankle joint and angled roughly 30 degrees anteriorly

Explanation

Syndesmotic screws are typically placed 2-3 cm proximal to the tibial plafond, parallel to the joint line, and angled 20-30 degrees anteriorly from posterolateral to anteromedial to align with the anatomic position of the fibula relative to the tibia. Engaging 3 or 4 cortices shows no significant difference in outcomes. Current evidence does not support routine screw removal, and position of the ankle (neutral vs. plantarflexion) during insertion does not significantly alter final dorsiflexion. Suture-button constructs actually have a lower rate of hardware removal.

Question 4644

Topic: Midfoot & Hindfoot

A 30-year-old male sustains a purely ligamentous Lisfranc injury after a fall from a horse. The first and second tarsometatarsal joints are widely displaced. What is the most appropriate definitive management for this specific injury pattern?

. Closed reduction and casting for 6 weeks
. Open reduction and internal fixation (ORIF) with transarticular screws
. Primary arthrodesis of the first, second, and third tarsometatarsal joints
. Dorsal bridge plating of the midfoot
. Primary arthrodesis of the fourth and fifth tarsometatarsal joints

Correct Answer & Explanation

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

Explanation

In purely ligamentous Lisfranc injuries, the interosseous and plantar ligaments are disrupted without substantial bony avulsions, rendering the healing potential poor with simple stabilization. High-level evidence has demonstrated that primary arthrodesis of the medial and middle columns (1st, 2nd, and 3rd tarsometatarsal joints) yields superior functional outcomes, a higher rate of return to pre-injury activity levels, and significantly lower rates of reoperation or hardware failure compared to ORIF. The 4th and 5th TMT joints should be left mobile.

Question 4645

Topic: Midfoot & Hindfoot

A 55-year-old female presents with progressive flattening of her left foot, pain along the medial ankle, and inability to perform a single-leg heel raise. Examination reveals a flexible hindfoot valgus and forefoot abduction. Radiographs show uncovering of the talonavicular joint but no arthritic changes. What is the best surgical management if prolonged conservative care fails?

. Posterior tibial tendon debridement and tenosynovectomy
. Flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy (MDCO)
. Lateral column lengthening (Evans osteotomy) in isolation
. Triple arthrodesis
. Isolated subtalar arthrodesis

Correct Answer & Explanation

. Flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy (MDCO)

Explanation

The patient presents with Stage IIA adult-acquired flatfoot deformity (posterior tibial tendon dysfunction), characterized by a flexible deformity without significant arthritic changes in the hindfoot. The standard of care for a symptomatic flexible deformity that fails conservative management is a joint-sparing flatfoot reconstruction. This typically consists of transferring the FDL to substitute for the deficient posterior tibial tendon, combined with an MDCO to correct the mechanical axis of the hindfoot.

Question 4646

Topic: 8. Foot and Ankle
A 28-year-old male is involved in a high-speed motor vehicle collision. Radiographs and CT reveal a Hawkins Type III talar neck fracture. Which of the following best describes the disruption of blood supply in this injury?
. Disruption of the artery of the tarsal canal, artery of the tarsal sinus, and deltoid branches
. Disruption of the artery of the tarsal canal and artery of the tarsal sinus only
. Disruption of the dorsalis pedis branches only
. Disruption of the peroneal artery branches only
. Intact blood supply with high risk of nonunion

Correct Answer & Explanation

. Disruption of the artery of the tarsal canal, artery of the tarsal sinus, and deltoid branches

Explanation

A Hawkins Type III talar neck fracture involves a fracture of the talar neck with dislocation of both the subtalar and tibiotalar joints. The talus relies on a tenuous retrograde blood supply, primarily from the artery of the tarsal canal, the artery of the tarsal sinus, and the deltoid branches. In a Type III injury, the severe displacement and dislocation disrupt all three of these primary vascular sources, resulting in a risk of avascular necrosis (AVN) of the talar body approaching 90-100%.

Question 4647

Topic: Forefoot

A 62-year-old female presents with a painful bunion. Weight-bearing radiographs demonstrate a hallux valgus angle of 45 degrees, an intermetatarsal angle (IMA) of 18 degrees, and obvious clinical hypermobility of the first tarsometatarsal (TMT) joint. No degenerative changes are noted at the metatarsophalangeal (MTP) joint. What is the most appropriate surgical intervention?

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

Correct Answer & Explanation

. First tarsometatarsal arthrodesis (Lapidus procedure)

Explanation

The patient presents with a severe hallux valgus deformity accompanied by hypermobility of the first TMT joint. An isolated distal or proximal osteotomy is prone to failure and high recurrence rates in the setting of first ray hypermobility. A first TMT arthrodesis (Lapidus procedure) allows for powerful correction of the severe intermetatarsal angle and stabilizes the medial column, preventing recurrence.

Question 4648

Topic: Midfoot & Hindfoot

A 58-year-old male with poorly controlled type 2 diabetes presents with a swollen, erythematous, and warm left foot. He denies trauma. X-rays show extensive fragmentation, debris, and subluxation of the midfoot joints. There are no skin ulcers. What is the most appropriate initial management?

. Intravenous antibiotics and emergent surgical debridement
. Total contact casting and strict non-weight-bearing
. Open reduction and internal fixation of the midfoot
. Primary midfoot arthrodesis
. Custom orthotics and supportive shoe wear

Correct Answer & Explanation

. Total contact casting and strict non-weight-bearing

Explanation

The patient's clinical and radiographic presentation is classic for Eichenholtz Stage I (acute fragmentation stage) Charcot arthropathy. The gold standard of treatment at this stage is immediate offloading and immobilization to prevent further mechanical destruction of the midfoot while the severe inflammatory process resolves. This is most effectively achieved with a total contact cast (TCC) and strict non-weight-bearing. Surgery during the acute inflammatory phase is highly discouraged due to the extreme risk of hardware failure.

Question 4649

Topic: Ankle Trauma & Sports

A 25-year-old male sustains a severe twisting injury to his ankle. Radiographs reveal a medial clear space of 6 mm and a tibiofibular clear space of 7 mm on the AP view. A fracture of the proximal third of the fibula is also noted. What is the diagnosis and most appropriate management?

. Maisonneuve fracture; closed reduction and short leg cast
. Maisonneuve fracture; syndesmotic screw or suture button fixation
. Danis-Weber A fracture; open reduction and internal fixation of the fibula
. Pilon fracture; external fixation
. Bosworth fracture-dislocation; emergent open reduction

Correct Answer & Explanation

. Maisonneuve fracture; syndesmotic screw or suture button fixation

Explanation

A pronation-external rotation injury resulting in a proximal fibular fracture and disruption of the tibiofibular syndesmosis is known as a Maisonneuve fracture. The widening of the medial clear space indicates associated rupture of the deltoid ligament. This highly unstable injury pattern necessitates surgical reduction and stabilization of the syndesmosis, typically achieved with either syndesmotic screws or a dynamic suture-button construct.

Question 4650

Topic: Forefoot

A 45-year-old woman presents with a severe, painful bunion deformity. She reports a long history of wearing narrow-toed shoes. Weight-bearing radiographs demonstrate a hallux valgus angle (HVA) of 45 degrees, an intermetatarsal angle (IMA) of 18 degrees, and clinical hypermobility of the first tarsometatarsal (TMT) joint. What is the most appropriate surgical management?

. Distal chevron osteotomy
. Proximal crescentic osteotomy with distal soft tissue realignment
. First metatarsophalangeal (MTP) joint arthrodesis
. First tarsometatarsal (TMT) joint arthrodesis (Lapidus procedure) with distal soft tissue realignment
. Keller resection arthroplasty

Correct Answer & Explanation

. First tarsometatarsal (TMT) joint arthrodesis (Lapidus procedure) with distal soft tissue realignment

Explanation

The patient has severe hallux valgus (HVA > 40 degrees, IMA > 13 degrees) combined with first TMT joint hypermobility. A Lapidus procedure (first TMT arthrodesis) is the most appropriate choice to provide powerful correction of the high intermetatarsal angle and address the apex of the deformity (the hypermobile TMT joint). Distal chevron osteotomies are indicated for mild to moderate deformities. First MTP fusion is typically reserved for severe deformities with concurrent first MTP osteoarthritis or in cases of rheumatoid arthritis. The Keller procedure is historically used in low-demand, elderly patients.

Question 4651

Topic: Midfoot & Hindfoot
A 50-year-old woman presents with progressive medial ankle pain and a severe flatfoot deformity. She is unable to perform a single-limb heel rise on the affected side. Examination reveals a flexible hindfoot with significant forefoot abduction. Weight-bearing radiographs show greater than 40% uncoverage of the talonavicular joint on the AP view. What is the most appropriate operative treatment?
. Flexor digitorum longus (FDL) transfer to the navicular alone
. Medial displacement calcaneal osteotomy (MDCO) + FDL transfer
. FDL transfer + MDCO + lateral column lengthening
. Triple arthrodesis
. Isolated subtalar arthrodesis

Correct Answer & Explanation

. FDL transfer + MDCO + lateral column lengthening

Explanation

This patient has Stage IIB adult-acquired flatfoot deformity (posterior tibial tendon dysfunction). Stage II is characterized by a flexible deformity, whereas Stage III is rigid. Stage IIB is distinguished from IIA by the presence of significant forefoot abduction (clinically seen as 'too many toes' and radiographically as >30-40% talonavicular uncoverage). To adequately address the forefoot abduction in Stage IIB, a lateral column lengthening (such as an Evans calcaneal osteotomy) is required in addition to a medial displacement calcaneal osteotomy and FDL transfer.

Question 4652

Topic: 8. Foot and Ankle

A 34-year-old man sustains an acute Achilles tendon rupture while playing basketball. He is discussing treatment options with his surgeon. If he chooses non-operative management utilizing an accelerated functional rehabilitation protocol (early weight-bearing in a functional brace) compared to operative repair, which of the following outcomes is supported by current literature?

. Significantly higher re-rupture rate with non-operative management
. Significantly higher risk of sural nerve injury with non-operative management
. Lower rate of return to sport with non-operative management
. Similar re-rupture rate with a significantly lower rate of soft-tissue complications
. Significant decrease in long-term plantar flexion strength with non-operative management

Correct Answer & Explanation

. Similar re-rupture rate with a significantly lower rate of soft-tissue complications

Explanation

Recent high-quality level I evidence (such as the meta-analysis by Soroceanu et al. and the Willits et al. RCT) demonstrates that when functional rehabilitation protocols (early weight-bearing and mobilization in an orthosis) are utilized, non-operative management of acute Achilles tendon ruptures yields functional outcomes and re-rupture rates that are not significantly different from operative management, but with a substantially lower risk of complications such as infection, wound breakdown, and iatrogenic sural nerve injury.

Question 4653

Topic: Midfoot & Hindfoot

A 58-year-old man with poorly controlled type 2 diabetes and profound peripheral neuropathy presents with a red, hot, swollen unilateral foot. He denies any prior trauma or fevers. Pulses are palpable and laboratory markers (WBC, CRP) are within normal limits. Radiographs demonstrate periarticular debris, fragmentation of the tarsometatarsal joints, and early subluxation.

What is the most appropriate initial management?

. Urgent irrigation and debridement of the midfoot
. Total contact casting and strict non-weight-bearing
. Open reduction and internal fixation of the midfoot
. Prescription of a Charcot Restraint Orthotic Walker (CROW) and full weight-bearing
. Intravenous antibiotics and observation

Correct Answer & Explanation

. Total contact casting and strict non-weight-bearing

Explanation

The clinical and radiographic picture is pathognomonic for acute Charcot arthropathy (Eichenholtz Stage I - Developmental/Fragmentation phase). There is no clinical or laboratory evidence of acute infection to warrant antibiotics or debridement. The gold standard for initial management of acute active Charcot arthropathy is strict immobilization and offloading, typically achieved with a total contact cast (TCC) to halt the progression of deformity and allow progression to the coalescent and reconstructive phases. CROW boots are utilized in the later, quiescent phases.

Question 4654

Topic: 8. Foot and Ankle
A 28-year-old man involved in a high-speed motorcycle collision sustains a displaced talar neck fracture with associated dislocations of the subtalar, tibiotalar, and talonavicular joints. According to the classic Hawkins classification and long-term studies, what is the approximate risk of developing avascular necrosis (AVN) of the talar body following this specific injury pattern?
. 0-10%
. 15-25%
. 40-50%
. 75-100%
. 100% isolated to the talar head only

Correct Answer & Explanation

. 75-100%

Explanation

The patient has a Hawkins Type IV fracture (displaced talar neck fracture with dislocation of the subtalar, ankle, and talonavicular joints). The blood supply to the talar body (primarily from the artery of the tarsal canal, deltoid branches, and artery of the sinus tarsi) is completely disrupted. AVN rates follow the classification: Type I (nondisplaced) 0-10%; Type II (subtalar subluxation/dislocation) 20-50%; Type III (subtalar and tibiotalar dislocation) and Type IV have an AVN risk of nearly 75-100%.

Question 4655

Topic: 8. Foot and Ankle

A 22-year-old collegiate offensive lineman sustains an axial load injury to a plantarflexed foot. He presents with midfoot swelling and plantar ecchymosis. Weight-bearing radiographs reveal a 3 mm diastasis between the bases of the first and second metatarsals without any associated fractures (purely ligamentous injury). Which of the following treatments has been shown to provide the most reliable long-term functional outcome and lowest reoperation rate for this specific injury pattern?

. Primary arthrodesis of the medial three tarsometatarsal joints
. Closed reduction and short leg cast immobilization
. Open reduction and internal fixation with trans-articular screws
. Suture-button suspensionplasty alone
. Midfoot offloading in a CAM boot for 6 weeks

Correct Answer & Explanation

. Primary arthrodesis of the medial three tarsometatarsal joints

Explanation

This is a purely ligamentous Lisfranc injury. Multiple studies, including the landmark prospective randomized trial by Coetzee and Ly, have demonstrated that primary arthrodesis of the affected tarsometatarsal joints (typically the medial three) provides superior functional outcomes, a higher rate of return to pre-injury activity levels, and a significantly lower hardware removal/reoperation rate compared to ORIF in purely ligamentous Lisfranc injuries. ORIF remains a valid option for injuries with significant bony avulsions or fractures.

Question 4656

Topic: 8. Foot and Ankle

A 20-year-old elite collegiate basketball player presents with lateral foot pain after a sudden pivoting maneuver. Radiographs demonstrate a transverse fracture of the fifth metatarsal located at the metaphyseal-diaphyseal junction, without evidence of intramedullary sclerosis. He wishes to return to play as safely and quickly as possible. What is the most appropriate management?

. Hard-soled shoe and weight-bearing as tolerated
. Intramedullary screw fixation
. Short leg cast, non-weight-bearing for 6 weeks
. Open reduction and plating of the fifth metatarsal
. Excision of the proximal fragment and peroneus brevis advancement

Correct Answer & Explanation

. Intramedullary screw fixation

Explanation

This is an acute Jones fracture (Zone 2 of the proximal fifth metatarsal). Due to the watershed blood supply in this region, these fractures have a higher risk of delayed union or nonunion. In elite athletes, early intramedullary screw fixation is recommended as it significantly decreases the time to clinical and radiographic union and allows for a faster, more predictable return to sport compared to non-operative cast immobilization.

Question 4657

Topic: 8. Foot and Ankle

Careful patient selection is paramount for the success of Total Ankle Arthroplasty (TAA). Which of the following patients represents the most appropriate candidate for a primary TAA rather than an ankle arthrodesis?

. A 35-year-old manual laborer with severe post-traumatic ankle arthritis
. A 60-year-old with end-stage ankle arthritis and severe, active Charcot neuropathy
. A 50-year-old with ankle arthritis and greater than 50% avascular necrosis of the talar body
. A 45-year-old with ankle arthritis and an insensate foot due to diabetes
. A 68-year-old sedentary female with primary ankle osteoarthritis and a well-aligned hindfoot

Correct Answer & Explanation

. A 68-year-old sedentary female with primary ankle osteoarthritis and a well-aligned hindfoot

Explanation

The ideal candidate for a total ankle arthroplasty is an older, lower-demand patient with a well-aligned hindfoot, preserved motion, and good bone stock. Contraindications to TAA include active infection, severe peripheral neuropathy/insensate foot (Charcot), substantial avascular necrosis of the talus (poor bone stock for implant seating), severe uncorrectable malalignment, and young age with high physical demands (due to early implant wear and failure).

Question 4658

Topic: 8. Foot and Ankle

A 40-year-old construction worker falls from a height and sustains a closed, displaced intra-articular calcaneus fracture. Surgery via an extensile lateral approach is planned. To minimize wound healing complications, the surgeon waits until the 'wrinkle test' is positive. During the extensile lateral approach, which nerve is at greatest risk of iatrogenic injury if the vertical limb of the incision is placed too far posteriorly?

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

Correct Answer & Explanation

. Sural nerve

Explanation

The extensile lateral approach to the calcaneus involves an L-shaped incision. The vertical limb is placed midway between the posterior border of the fibula and the lateral border of the Achilles tendon. If this vertical limb is placed too far posteriorly or if dissection is not carefully maintained in a full-thickness subperiosteal plane, the sural nerve is at high risk of transection or entrapment. The sural nerve provides sensation to the lateral aspect of the foot.

Question 4659

Topic: 8. Foot and Ankle

A 45-year-old woman presents with severe burning pain in the plantar aspect of her forefoot, radiating into her third and fourth toes. The pain is exacerbated by wearing narrow-toed, high-heeled shoes. Examination reveals a palpable click when compressing the metatarsal heads while applying plantar pressure to the third webspace (Mulder's sign). If non-operative management fails, surgical excision of the offending structure is planned. Anatomically, where is this structure located relative to the deep transverse metatarsal ligament?

. Plantar to the deep transverse metatarsal ligament
. Dorsal to the deep transverse metatarsal ligament
. Within the substance of the deep transverse metatarsal ligament
. Proximal to the bifurcation of the proper plantar digital nerves and dorsal to the ligament
. Medial to the extensor digitorum longus tendon

Correct Answer & Explanation

. Plantar to the deep transverse metatarsal ligament

Explanation

The patient is presenting with an interdigital neuroma (Morton's neuroma), most commonly found in the third webspace. Pathophysiologically, it is a perineural fibrosis of the common digital nerve. Anatomically, the common digital nerve runs plantar to the deep transverse metatarsal ligament. Irritation occurs as the nerve is compressed against the unyielding ligament, particularly when the transverse arch is compressed by tight shoes.

Question 4660

Topic: Midfoot & Hindfoot
A 55-year-old woman presents with medial ankle pain and progressive flattening of her left foot over the past year. On examination, she has a flexible flatfoot deformity, is unable to perform a single-leg heel raise on the left, and has >40% of the talar head uncovered on the AP weight-bearing radiograph. There is notable forefoot abduction. What is the most appropriate surgical management for this Stage IIb flatfoot deformity after failure of non-operative treatment?
. Gastrocnemius recession, FDL transfer to the navicular, and medial displacement calcaneal osteotomy
. Subtalar arthrodesis
. Gastrocnemius recession, FDL transfer to the navicular, medial displacement calcaneal osteotomy, and lateral column lengthening
. Triple arthrodesis
. Spring ligament repair only

Correct Answer & Explanation

. Gastrocnemius recession, FDL transfer to the navicular, medial displacement calcaneal osteotomy, and lateral column lengthening

Explanation

Stage IIb posterior tibial tendon dysfunction (PTTD) is characterized by a flexible deformity with significant forefoot abduction (typically >40% talonavicular uncoverage). Surgical management for Stage IIb typically involves a combination of soft tissue and bony procedures: gastrocnemius recession (if equinus is present), flexor digitorum longus (FDL) transfer to the navicular, medial displacement calcaneal osteotomy (MDCO) to correct hindfoot valgus, and a lateral column lengthening (e.g., Evans osteotomy) to correct the forefoot abduction. A procedure without lateral column lengthening is generally indicated for Stage IIa (minimal to no forefoot abduction). Subtalar and triple arthrodesis are reserved for rigid deformities (Stage III) or when degenerative joint disease is present.

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