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8. Foot and Ankle MCQs

Practice Set 234 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 4661

Topic: Midfoot & Hindfoot
A 28-year-old man is involved in a high-speed motor vehicle collision and sustains a Hawkins type III talar neck fracture. Which of the following best describes this injury and its associated risk of avascular necrosis (AVN) of the talar body?
. Nondisplaced talar neck fracture; AVN risk is 0-10%
. Subtalar subluxation or dislocation; AVN risk is 20-50%
. Subtalar and talonavicular dislocation; AVN risk is 50-75%
. Subtalar, tibiotalar, and talonavicular dislocation; AVN risk is nearly 100%
. Subtalar and tibiotalar dislocation; AVN risk is historically approaching 90-100%

Correct Answer & Explanation

. Subtalar, tibiotalar, and talonavicular dislocation; AVN risk is nearly 100%

Explanation

The Hawkins classification is used for talar neck fractures. Type I is a nondisplaced fracture (AVN risk 0-10%). Type II involves subtalar subluxation or dislocation (AVN risk 20-50%). Type III involves both subtalar and tibiotalar dislocation, meaning the talar body is extruded from the ankle mortise. The AVN risk for Type III is historically quoted as nearly 100%, though modern series show it may be slightly lower. Type IV (added by Canale and Kelly) involves subtalar, tibiotalar, and talonavicular dislocation.

Question 4662

Topic: Forefoot

A 42-year-old woman presents with a painful bunion on her right foot. Weight-bearing radiographs reveal a hallux valgus angle (HVA) of 45 degrees and an intermetatarsal angle (IMA) of 18 degrees. There is no hypermobility at the first tarsometatarsal (TMT) joint, and no evidence of osteoarthritis in the first metatarsophalangeal (MTP) joint. Which of the following surgical interventions is most appropriate?

. Proximal first metatarsal osteotomy or Lapidus procedure with distal soft tissue reconstruction
. Distal chevron osteotomy with modified McBride procedure
. First MTP joint arthrodesis
. First TMT joint arthrodesis only
. Keller resection arthroplasty

Correct Answer & Explanation

. Proximal first metatarsal osteotomy or Lapidus procedure with distal soft tissue reconstruction

Explanation

The patient has a severe hallux valgus deformity (HVA >40 degrees, IMA >13-15 degrees). For severe deformities without first MTP joint arthritis, a proximal first metatarsal osteotomy (e.g., proximal crescentic, Ludloff) or a first TMT fusion (Lapidus procedure) combined with a distal soft tissue reconstruction (modified McBride) is indicated to achieve adequate correction of the large IMA. A distal chevron osteotomy is indicated for mild to moderate deformities. First MTP arthrodesis is generally reserved for hallux valgus with severe first MTP osteoarthritis or rheumatoid arthritis.

Question 4663

Topic: 8. Foot and Ankle

A 24-year-old collegiate football player sustains an axial load to a plantarflexed foot. Weight-bearing radiographs of the foot show a 3 mm diastasis between the base of the first and second metatarsals. He undergoes open reduction and internal fixation (ORIF) of the Lisfranc complex. Which of the following ligaments is the primary stabilizer of the Lisfranc joint complex?

. The dorsal ligament from the first cuneiform to the second metatarsal base
. The plantar ligament from the middle cuneiform to the second metatarsal base
. The plantar ligament from the medial cuneiform to the third metatarsal base
. The interosseous ligament from the medial cuneiform to the second metatarsal base
. The intertransverse ligament between the first and second metatarsals

Correct Answer & Explanation

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

Explanation

The Lisfranc ligament is an interosseous ligament that travels from the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. It is the strongest and primary stabilizer of the Lisfranc joint complex. There is no direct transverse intermetatarsal ligament connecting the bases of the first and second metatarsals, which contributes to the vulnerability of this articulation. Dorsal ligaments are the weakest, rendering the joint prone to dorsal dislocation.

Question 4664

Topic: 8. Foot and Ankle
A 58-year-old man with a 15-year history of poorly controlled type 2 diabetes presents with a red, hot, swollen, and painless left foot. He denies any recent trauma, fevers, or chills. Radiographs reveal fragmentation of the tarsal bones, periarticular debris, and subluxation of the midfoot. According to the Eichenholtz classification, what is the current stage of this patient's disease, and what is the gold standard initial treatment?
. Stage 0; Surgical arthrodesis of the midfoot
. Stage I; Immediate open reduction and internal fixation
. Stage I; Total contact casting and non-weight-bearing
. Stage II; Custom orthotics and accommodative shoewear
. Stage III; Exostectomy and ulcer care

Correct Answer & Explanation

. Stage I; Total contact casting and non-weight-bearing

Explanation

The clinical presentation and radiographic findings of fragmentation, periarticular debris, and subluxation are classic for Eichenholtz Stage I (Developmental/Fragmentation stage) of Charcot neuroarthropathy. The gold standard initial treatment for acute Stage I Charcot arthropathy is immobilization and offloading, most effectively achieved with a total contact cast (TCC). Stage 0 (prodromal) presents with erythema and edema but normal radiographs. Stage II (coalescence) shows early healing and sclerosis. Surgery is generally contraindicated in the acute fragmentation phase (Stage I) due to high complication rates, including fixation failure and infection.

Question 4665

Topic: 8. Foot and Ankle
A 40-year-old roofer falls from a height and sustains a closed, displaced intra-articular calcaneus fracture (Sanders Type III). He is scheduled for open reduction and internal fixation (ORIF) via an extensile lateral approach. Which of the following is the most critical technical consideration to minimize the risk of wound complications?
. Using a tourniquet for no more than 60 minutes
. Elevating a full-thickness fasciocutaneous flap directly off the lateral calcaneal wall
. Preserving the sural nerve within the deep tissues rather than the flap
. Ensuring the vertical limb of the incision is placed anterior to the fibula
. Closing the wound under tension to prevent hematoma formation

Correct Answer & Explanation

. Elevating a full-thickness fasciocutaneous flap directly off the lateral calcaneal wall

Explanation

Wound complications are a major concern with the extensile lateral approach to the calcaneus, occurring in up to 10-25% of cases. To minimize this risk, it is critical to create a 'no-touch' full-thickness fasciocutaneous flap by subperiosteal dissection directly off the lateral wall of the calcaneus. This preserves the precarious blood supply to the corner of the flap, which is supplied by the lateral calcaneal artery. The sural nerve should be elevated within the flap to prevent injury and devascularization. The vertical limb should be placed midway between the Achilles tendon and the posterior border of the fibula.

Question 4666

Topic: 8. Foot and Ankle

A 45-year-old woman presents with burning pain in the plantar aspect of her forefoot, which is exacerbated by wearing tight, high-heeled shoes. She describes a sensation of 'walking on a marble.' Examination reveals a positive Mulder's click in the third webspace. Non-operative management has failed. She undergoes surgical excision of the neuroma via a dorsal approach. Which of the following structures must be transected to adequately expose and resect the neuroma?

. Plantar aponeurosis
. Lumbrical tendon
. Interosseous muscle
. Plantar plate
. Deep transverse metatarsal ligament

Correct Answer & Explanation

. Deep transverse metatarsal ligament

Explanation

Morton's neuroma is a compressive neuropathy of the common digital nerve, most commonly occurring in the third webspace. When approaching a Morton's neuroma surgically through a dorsal incision, the deep transverse metatarsal ligament must be identified and transected. The neuroma is typically located just plantar to this ligament. Dividing the ligament allows for adequate exposure, mobilization, and proximal resection of the neuroma to prevent a symptomatic stump neuroma.

Question 4667

Topic: 8. Foot and Ankle

A 26-year-old man sustains a pronation-external rotation (PER) ankle fracture. Intraoperative stress testing after fibular fixation demonstrates widening of the distal tibiofibular clear space. The surgeon decides to use suture-button fixation instead of traditional screw fixation for the syndesmosis. According to current literature, which of the following is a recognized advantage of flexible suture-button fixation over rigid screw fixation?

. Lower risk of hardware irritation requiring removal
. Maintenance of physiologic motion at the syndesmosis
. Increased incidence of syndesmotic malreduction
. Cost-effectiveness due to cheaper implant costs
. Significantly faster time to bone healing

Correct Answer & Explanation

. Maintenance of physiologic motion at the syndesmosis

Explanation

Suture-button fixation for syndesmotic injuries is a form of dynamic or flexible fixation. One of its primary recognized advantages is that it allows for the maintenance of physiologic motion at the distal tibiofibular joint during weight-bearing and ankle range of motion. Studies have shown it leads to similar or better clinical outcomes compared to screw fixation and avoids the need for routine hardware removal (which is often debated with screw fixation). Suture buttons are generally more expensive, and hardware irritation can still occur from the knot/button.

Question 4668

Topic: 8. Foot and Ankle

A 24-year-old football player presents with midfoot pain after a twisting injury with the foot plantar flexed. Weight-bearing radiographs show 2 mm of widening between the base of the 1st and 2nd metatarsals. Non-weight-bearing radiographs show no widening. MRI confirms a complete rupture of the Lisfranc ligament. What is the most appropriate management?

. Short leg cast and non-weight-bearing for 6 weeks
. Rigid orthotic with a carbon fiber plate and immediate weight-bearing
. Closed reduction and percutaneous pinning
. Open reduction and internal fixation (ORIF) or primary arthrodesis
. Corticosteroid injection and return to play in 2 weeks

Correct Answer & Explanation

. Open reduction and internal fixation (ORIF) or primary arthrodesis

Explanation

A complete rupture of the Lisfranc ligament with diastasis on weight-bearing radiographs indicates instability. Nonoperative management is reserved for stable injuries (sprains without diastasis). Unstable Lisfranc injuries require anatomic reduction and stabilization. For purely ligamentous injuries with instability, primary arthrodesis or ORIF are both acceptable surgical options.

Question 4669

Topic: 8. Foot and Ankle
A 55-year-old female presents with medial ankle pain and a progressive flatfoot deformity over the last 18 months. On examination, she has a flexible hindfoot valgus, a medial prominence, and is unable to perform a single-limb heel rise on the affected side. Radiographs show a talonavicular uncoverage of 30% and a talocalcaneal angle of 25 degrees. Conservative management has failed. What is the most appropriate surgical intervention?
. Subtalar arthrodesis alone
. Flexor digitorum longus (FDL) transfer to the navicular and a medializing calcaneal osteotomy
. Triple arthrodesis
. Spring ligament repair and Achilles tendon lengthening
. Gastrocnemius recession and orthotics

Correct Answer & Explanation

. Flexor digitorum longus (FDL) transfer to the navicular and a medializing calcaneal osteotomy

Explanation

The patient has a Stage II adult acquired flatfoot deformity (posterior tibial tendon dysfunction), characterized by a flexible deformity and inability to perform a single-limb heel rise. Surgical management typically involves an FDL transfer to replace the diseased posterior tibial tendon and a medializing calcaneal osteotomy to correct the hindfoot valgus. Triple arthrodesis is reserved for Stage III (rigid deformity).

Question 4670

Topic: Forefoot

A 45-year-old female presents with a painful bunion. Weight-bearing radiographs reveal a hallux valgus angle (HVA) of 35 degrees and an intermetatarsal angle (IMA) of 14 degrees. The first tarsometatarsal (TMT) joint shows no hypermobility or arthritic changes. The distal metatarsal articular angle (DMAA) is normal. What is the most appropriate surgical procedure?

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

Correct Answer & Explanation

. Proximal metatarsal osteotomy and distal soft-tissue reconstruction

Explanation

The patient has a moderate to severe hallux valgus deformity (IMA between 13 and 20 degrees, HVA between 30 and 40 degrees). Distal chevron osteotomy is generally indicated for mild deformities (IMA < 13 degrees). For an IMA of 14 degrees, a proximal metatarsal osteotomy combined with distal soft-tissue reconstruction (or a diaphyseal osteotomy) is indicated to provide adequate translation and angular correction.

Question 4671

Topic: 8. Foot and Ankle

A 60-year-old male with poorly controlled diabetes mellitus presents with a swollen, erythematous, and warm right foot for 3 weeks. He reports no trauma and denies systemic symptoms such as fever or chills. White blood cell count and inflammatory markers are mildly elevated. Radiographs show fragmentation and periarticular debris at the tarsometatarsal joints. What is the most appropriate next step in management?

. Intravenous antibiotics and incision and drainage
. Urgent open reduction and internal fixation
. Midfoot arthrodesis
. Total contact casting and non-weight-bearing
. Transtibial amputation

Correct Answer & Explanation

. Total contact casting and non-weight-bearing

Explanation

The clinical presentation is classic for acute (Eichenholtz Stage I) Charcot neuroarthropathy, which is often mistaken for infection. The radiographic findings of fragmentation and debris confirm the diagnosis. The cornerstone of treatment in the acute phase is offloading, typically with a total contact cast (TCC), to prevent further progression of the deformity.

Question 4672

Topic: 8. Foot and Ankle

A 35-year-old recreational basketball player presents with a 'pop' in his left posterior ankle followed by pain and weakness in plantarflexion. Clinical examination reveals a positive Thompson test and a palpable gap 4 cm proximal to the calcaneal insertion. He opts for nonoperative management. Which of the following functional outcomes is most likely compared to surgical repair?

. Significantly lower risk of rerupture
. Higher rate of deep vein thrombosis
. Increased risk of wound complications
. Decreased plantar flexion strength by 50%
. Similar functional outcomes with functional rehabilitation

Correct Answer & Explanation

. Similar functional outcomes with functional rehabilitation

Explanation

Recent high-quality studies have shown that nonoperative management of acute Achilles tendon ruptures using early functional rehabilitation and weight-bearing in a functional brace yields functional outcomes and rerupture rates similar to those of surgical repair. Surgery has historically been associated with a slightly lower rerupture rate but higher risks of wound complications.

Question 4673

Topic: 8. Foot and Ankle

A 14-year-old male presents with recurrent ankle sprains and deep hindfoot pain exacerbated by sports. Examination reveals a rigid, flat foot with decreased subtalar motion and peroneal muscle spasm. Radiographs show a 'C-sign' on the lateral view. CT scan confirms a bony coalition. Which of the following joints is most likely involved?

. Talonavicular
. Talocalcaneal
. Calcaneocuboid
. Naviculocuneiform
. Metatarsocuneiform

Correct Answer & Explanation

. Talocalcaneal

Explanation

The presentation is typical for a tarsal coalition. The 'C-sign' on a lateral radiograph is a classic finding for a talocalcaneal (subtalar) coalition, representing the continuous outline of the medial outline of the talar dome and the posterior outline of the sustentaculum tali. Calcaneonavicular coalitions often show an 'anteater nose' sign.

Question 4674

Topic: 8. Foot and Ankle

A 28-year-old hockey player sustains an external rotation injury to his ankle. He is tender over the anterior inferior tibiofibular ligament (AITFL). Radiographs show no fractures, but the medial clear space is widened to 6 mm on a gravity stress view. Which of the following is true regarding the management of this injury?

. Nonoperative management with a boot for 4 weeks is the standard of care
. Fixation should involve placing syndesmotic screws rigidly across all 4 cortices and leaving them permanently
. Suture button constructs have been shown to have lower rates of malreduction compared to screw fixation
. The patient can return to play within 2 weeks if pain allows
. Ankle arthroscopy is contraindicated in this setting

Correct Answer & Explanation

. Suture button constructs have been shown to have lower rates of malreduction compared to screw fixation

Explanation

Widening of the medial clear space indicates an unstable syndesmosis injury requiring operative reduction and stabilization. Flexible fixation with suture button constructs yields similar or better clinical outcomes than rigid screws, allows earlier weight-bearing, avoids hardware removal, and is associated with a lower rate of syndesmotic malreduction.

Question 4675

Topic: 8. Foot and Ankle

A 41-year-old man sustains a twisting injury to his midfoot. Weight-bearing radiographs demonstrate a 3 mm widening between the base of the first and second metatarsals. MRI confirms a purely ligamentous Lisfranc injury. He is treated with primary arthrodesis of the first, second, and third tarsometatarsal joints. Compared to open reduction and internal fixation (ORIF), which of the following is a recognized advantage of this approach for his specific injury pattern?

. Decreased rate of subsequent surgeries for hardware removal
. Improved restoration of the medial longitudinal arch
. Shorter required period of postoperative non-weight bearing
. Decreased rate of complex regional pain syndrome
. Preservation of hindfoot motion

Correct Answer & Explanation

. Decreased rate of subsequent surgeries for hardware removal

Explanation

In purely ligamentous Lisfranc injuries, primary arthrodesis has been shown to yield better functional outcomes and lower rates of subsequent surgeries compared to ORIF. ORIF of ligamentous injuries often requires a second surgery for hardware removal and has a higher rate of secondary post-traumatic arthritis requiring salvage arthrodesis. Both procedures require similar postoperative immobilization protocols. Arthrodesis does not uniquely improve arch restoration over a well-reduced ORIF, nor does it necessarily decrease CRPS rates.

Question 4676

Topic: 8. Foot and Ankle

A 34-year-old recreational athlete presents with a palpable gap in his posterior ankle following a sudden acceleration during a tennis match. The Thompson test is positive. He is discussing treatment options. According to recent high-quality evidence regarding acute Achilles tendon ruptures treated with an early functional rehabilitation protocol, how do the outcomes of nonoperative management compare to surgical repair?

. Nonoperative management has a significantly higher rerupture rate
. Surgical repair offers superior long-term plantar flexion strength
. Nonoperative management results in an equivalent rerupture rate and similar functional outcomes
. Surgical repair significantly reduces the time to return to sport
. Nonoperative management is associated with a higher rate of deep vein thrombosis

Correct Answer & Explanation

. Nonoperative management results in an equivalent rerupture rate and similar functional outcomes

Explanation

Recent randomized controlled trials and meta-analyses (such as those by Willits et al.) have demonstrated that when an early functional rehabilitation protocol (incorporating early weight-bearing and range of motion in a functional brace) is utilized, the rerupture rates between nonoperative and operative management of acute Achilles tendon ruptures are statistically similar. Functional outcomes and strength are also equivalent, while operative management carries a higher risk of soft tissue complications and infection.

Question 4677

Topic: 8. Foot and Ankle

A 60-year-old woman with a 15-year history of poorly controlled type 2 diabetes mellitus presents with a red, hot, swollen right foot that has been present for 3 weeks. She denies any trauma or systemic symptoms. She has palpable pedal pulses and severe peripheral neuropathy. Radiographs demonstrate fragmentation, periarticular debris, and subluxation at the tarsometatarsal joints. Her ESR is 18 mm/hr and CRP is 4 mg/L. Which of the following is the most appropriate next step in management?

. MRI with intravenous contrast to evaluate for osteomyelitis
. Prompt surgical debridement and application of an external fixator
. Total contact casting and strict non-weight bearing
. Intravenous antibiotics and close observation
. Primary arthrodesis of the midfoot with rigid plate fixation

Correct Answer & Explanation

. Total contact casting and strict non-weight bearing

Explanation

The patient presents with acute Eichenholtz stage I Charcot neuroarthropathy. The classic presentation includes a red, hot, swollen foot in a patient with profound neuropathy, often mimicking infection. Normal inflammatory markers and absence of a skin breach or ulcer make osteomyelitis highly unlikely. The gold standard for initial management of acute Charcot arthropathy is offloading via total contact casting to prevent progressive deformity while the acute inflammatory stage resolves. Surgical intervention in the acute stage is generally contraindicated due to profound hyperemia, poor bone quality, and a high risk of failure.

Question 4678

Topic: Forefoot

A 55-year-old woman presents with progressive, painful deformity of her great toe. Clinical examination reveals severe hallux valgus with an overarching second toe and significant first ray hypermobility in the sagittal plane. Weight-bearing radiographs show a hallux valgus angle of 45 degrees, an intermetatarsal angle of 20 degrees, and no signs of degenerative joint disease at the first metatarsophalangeal joint. Which of the following procedures is most appropriate?

. Distal chevron osteotomy
. Akin osteotomy
. First metatarsophalangeal joint arthrodesis
. First tarsometatarsal joint arthrodesis (Lapidus procedure)
. Proximal opening wedge osteotomy

Correct Answer & Explanation

. First tarsometatarsal joint arthrodesis (Lapidus procedure)

Explanation

The patient has a severe hallux valgus deformity (Intermetatarsal Angle > 15°, Hallux Valgus Angle > 40°) accompanied by first ray hypermobility. The Lapidus procedure (first tarsometatarsal joint arthrodesis) is the procedure of choice in this scenario. It provides powerful correction of large intermetatarsal angles and addresses the underlying hypermobility by stabilizing the medial column. Distal chevron is indicated for mild-to-moderate deformity. First MTP arthrodesis is typically reserved for hallux valgus with concurrent severe degenerative changes (hallux rigidus) or in recurrent/salvage situations.

Question 4679

Topic: 8. Foot and Ankle
A 48-year-old woman complains of progressive medial ankle pain and flattening of her right foot arch over the past year. She is unable to perform a single-leg heel raise on the right side. Examination reveals a flexible pes planovalgus deformity with 'too many toes' visible from behind. Radiographs of the foot show increased talonavicular uncoverage but no arthritic changes in the subtalar, talonavicular, or calcaneocuboid joints. Nonoperative management with a custom orthosis has failed. What is the most appropriate surgical intervention?
. Subtalar joint arthrodesis
. Triple arthrodesis
. Flexor digitorum longus transfer and medial displacement calcaneal osteotomy
. Tibialis anterior tendon transfer
. First metatarsophalangeal joint arthrodesis

Correct Answer & Explanation

. Flexor digitorum longus transfer and medial displacement calcaneal osteotomy

Explanation

This patient presents with Stage II adult-acquired flatfoot deformity (posterior tibial tendon dysfunction). Stage II is characterized by a flexible flatfoot deformity, inability to perform a single-leg heel rise, and the absence of significant degenerative arthritis in the hindfoot. The standard surgical treatment for Stage II disease that has failed conservative management includes a soft tissue procedure (such as FDL transfer to the navicular to replace the dysfunctional posterior tibial tendon) combined with a bony procedure to correct the deformity and protect the transfer (most commonly a medial displacement calcaneal osteotomy). Triple arthrodesis is indicated for Stage III disease, which presents with a rigid deformity and arthritic changes.

Question 4680

Topic: 8. Foot and Ankle

The 'windlass mechanism' of the foot provides dynamic stability to the longitudinal arch and facilitates propulsion. This mechanism is primarily driven by the dynamic tensioning of the plantar fascia during which specific phase of the gait cycle?

. Initial contact (heel strike)
. Loading response (foot flat)
. Midstance
. Terminal stance to preswing (heel-off to toe-off)
. Initial swing

Correct Answer & Explanation

. Terminal stance to preswing (heel-off to toe-off)

Explanation

The windlass mechanism is described by J.H. Hicks as the dynamic tensioning of the plantar fascia as it wraps around the metatarsal heads during passive extension (dorsiflexion) of the metatarsophalangeal (MTP) joints. This tensioning occurs primarily during terminal stance and preswing (heel-off to toe-off), drawing the calcaneus and metatarsals closer together, thereby elevating the longitudinal arch and locking the midtarsal joints to create a rigid lever for forward propulsion.

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