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8. Foot and Ankle MCQs

Practice Set 237 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 4721

Topic: 8. Foot and Ankle

A 35-year-old male sustains an acute Achilles tendon rupture playing basketball. He elects for non-operative management. According to recent randomized controlled trials and AAOS clinical practice guidelines, which of the following protocols provides rerupture rates most comparable to operative repair?

. Strict cast immobilization in equinus for 8 weeks
. Early functional rehabilitation with early weight-bearing in a functional orthosis
. Application of a short leg cast in neutral dorsiflexion
. Six weeks of non-weight-bearing in a rigid boot
. Serial casting over 12 weeks

Correct Answer & Explanation

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

Explanation

Historically, non-operative management of Achilles tendon ruptures (involving prolonged cast immobilization) had higher rerupture rates than surgical repair. However, modern level I evidence demonstrates that early functional rehabilitation protocols (involving early weight-bearing and functional bracing with range of motion) yield rerupture rates that are equivalent to operative management, while entirely avoiding surgical complications such as wound breakdown or infection.

Question 4722

Topic: 8. Foot and Ankle

A 21-year-old hockey player sustains a forceful external rotation injury to his right ankle. Examination reveals point tenderness over the anterior inferior tibiofibular ligament (AITFL). Radiographs reveal no fractures. The external rotation stress test elicits pain, but fluoroscopic stress views demonstrate no widening of the medial clear space or tibiofibular overlap. MRI confirms an isolated full-thickness tear of the AITFL; the deltoid and posterior inferior tibiofibular ligaments are intact. What is the most appropriate management?

. Open reduction and syndesmotic screw fixation
. Arthroscopic syndesmotic debridement
. Suture button fixation of the syndesmosis
. Rigid cast immobilization for 8 weeks without weight-bearing
. Boot immobilization with progressive weight-bearing as tolerated

Correct Answer & Explanation

. Boot immobilization with progressive weight-bearing as tolerated

Explanation

This patient has a stable grade I/II syndesmotic injury (isolated AITFL tear with intact deltoid and PITFL, and no dynamic widening on stress imaging). High ankle sprains without dynamic instability are appropriately managed non-operatively with brief immobilization (e.g., walking boot) and early progressive weight-bearing and physical therapy. Operative fixation (screws or suture buttons) is indicated for unstable syndesmotic injuries demonstrating dynamic or static widening.

Question 4723

Topic: 8. Foot and Ankle

A 45-year-old recreational tennis player feels a sudden 'pop' in the posterior aspect of his right ankle during a match. Examination reveals a positive Thompson test and a palpable gap 4 cm proximal to the calcaneal insertion. He chooses to undergo non-operative management utilizing a functional rehabilitation protocol. Based on recent high-level evidence, how do the outcomes of functional non-operative management compare to surgical repair for acute Achilles tendon ruptures?

. Significantly higher rate of re-rupture in the non-operative group
. Significantly lower plantar flexion strength at 2 years in the non-operative group
. Equivalent re-rupture rates but a lower risk of soft-tissue complications in the non-operative group
. Increased incidence of deep vein thrombosis in the non-operative group
. Equivalent rates of sural nerve injury between both groups

Correct Answer & Explanation

. Equivalent re-rupture rates but a lower risk of soft-tissue complications in the non-operative group

Explanation

Recent multi-center randomized controlled trials (e.g., Willits et al.) have demonstrated that non-operative management of acute Achilles tendon ruptures utilizing a functional rehabilitation protocol (early weight-bearing and range of motion in an orthosis) results in re-rupture rates that are equivalent to surgical repair. However, non-operative management significantly decreases the risk of soft-tissue and wound complications (including infections and nerve injuries) associated with surgery.

Question 4724

Topic: 8. Foot and Ankle

A 27-year-old male is brought to the emergency department following a high-speed motorcycle accident. Clinical and radiographic evaluation confirms a Schenck KD-IV knee dislocation. After closed reduction, the dorsalis pedis and posterior tibial pulses are palpable but slightly weaker compared to the contralateral limb. The ankle-brachial index (ABI) is measured at 0.85. What is the most appropriate next step in management?

. Immediate surgical exploration of the popliteal artery
. Application of a hinged knee brace and discharge with outpatient MRI
. CT angiography of the lower extremities
. Application of a spanning external fixator and serial physical exams
. Immediate single-stage multi-ligament knee reconstruction

Correct Answer & Explanation

. CT angiography of the lower extremities

Explanation

In the setting of a knee dislocation, vascular status must be carefully assessed. An ABI < 0.90 or asymmetric pulses indicate a high suspicion for a vascular injury (specifically the popliteal artery). The most appropriate next step is advanced imaging with a CT angiogram to definitively diagnose the injury. Immediate surgical exploration is indicated only if 'hard' signs of ischemia are present (e.g., absent pulses, active hemorrhage, expanding hematoma, pulseless cold limb).

Question 4725

Topic: 8. Foot and Ankle

A 28-year-old female sustains an ultra-low velocity knee dislocation during a gymnastics routine. Her knee spontaneously reduces before arrival at the emergency department. The pedal pulses are palpable and symmetric, but her Ankle-Brachial Index (ABI) is 0.85. What is the most appropriate next step in management?

. Serial physical examinations every 4 hours for 24 hours
. Immediate exploration of the popliteal artery
. CT angiography of the lower extremity
. MRI of the knee to evaluate ligamentous injury
. Discharge with a hinged knee brace and early outpatient follow-up

Correct Answer & Explanation

. CT angiography of the lower extremity

Explanation

An Ankle-Brachial Index (ABI) < 0.9 in the setting of a knee dislocation is highly sensitive for an occult vascular injury, even if palpable pulses are present. CT angiography is the gold standard next step to definitively evaluate for popliteal artery intimal tears or occlusion. Normal pulses do not rule out intimal injury, which can thrombose later, leading to limb ischemia.

Question 4726

Topic: 8. Foot and Ankle
A 28-year-old man sustains a knee dislocation (KD-III) following a motorcycle collision. The joint is reduced in the emergency department. He has weakness in ankle dorsiflexion and decreased sensation over the dorsal aspect of his foot. Which of the following structures was most likely injured, and what is its expected recovery rate without surgical repair?
. Tibial nerve; <20% recovery
. Common peroneal nerve; <50% recovery
. Saphenous nerve; >90% recovery
. Common peroneal nerve; >90% recovery
. Femoral nerve; <50% recovery

Correct Answer & Explanation

. Common peroneal nerve; <50% recovery

Explanation

The common peroneal nerve is injured in 10-40% of multiligament knee injuries, often due to a stretch injury during a varus/hyperextension mechanism. The prognosis for functional recovery of a complete common peroneal nerve palsy associated with a knee dislocation is generally poor (<50%).

Question 4727

Topic: 8. Foot and Ankle
A 24-year-old male is brought to the emergency department after a high-velocity knee dislocation (KD-III). The knee is urgently reduced. His foot is warm, but palpable pulses are asymmetric. An ankle-brachial index (ABI) is measured at 0.85. What is the most appropriate next step in management?
. Immediate surgical exploration of the popliteal artery in the operating room
. Duplex ultrasonography of the lower extremity at the bedside
. Computed tomography angiography (CTA) of the lower extremity
. Observation and repeat ABI in 4 hours
. Application of a knee-spanning external fixator before any imaging

Correct Answer & Explanation

. Computed tomography angiography (CTA) of the lower extremity

Explanation

An Ankle-Brachial Index (ABI) of less than 0.9 in the setting of a multiligamentous knee injury is a "hard-soft" sign of potential popliteal artery compromise. The standard of care mandates immediate advanced vascular imaging, most commonly CTA, to evaluate for an intimal tear or occlusion prior to definitive orthopedic intervention.

Question 4728

Topic: 8. Foot and Ankle

A 24-year-old soccer player sustains an external rotation injury to his ankle. He has a positive squeeze test and radiographs show increased medial clear space on external rotation stress views. What is the primary ligamentous stabilizer of the distal tibiofibular syndesmosis that has been compromised?

. Anterior inferior tibiofibular ligament (AITFL)
. Posterior inferior tibiofibular ligament (PITFL)
. Interosseous ligament
. Deltoid ligament
. Calcaneofibular ligament

Correct Answer & Explanation

. Posterior inferior tibiofibular ligament (PITFL)

Explanation

While the AITFL is the most commonly injured ligament in syndesmotic sprains, the posterior inferior tibiofibular ligament (PITFL) is the strongest. The PITFL contributes over 40% of the resistance to diastasis and is the primary stabilizer of the syndesmosis.

Question 4729

Topic: 8. Foot and Ankle

A 21-year-old collegiate basketball player complains of acute lateral foot pain after a pivot maneuver. Radiographs reveal a transverse fracture at the metaphyseal-diaphyseal junction of the fifth metatarsal. What is the optimal initial management for this elite athlete?

. Non-weight bearing cast for 6 to 8 weeks
. Walking boot for 4 weeks
. Percutaneous intramedullary screw fixation
. Open reduction and locking plate fixation
. Primary bone grafting without fixation

Correct Answer & Explanation

. Percutaneous intramedullary screw fixation

Explanation

Acute Jones fractures (metaphyseal-diaphyseal junction of the 5th metatarsal) in elite athletes are optimally treated with early intramedullary screw fixation. This provides the highest union rates and fastest return to sport, minimizing the high nonunion risk seen with conservative care.

Question 4730

Topic: 8. Foot and Ankle

A wide receiver sustains an ankle injury during a tackle. He is tender over the anterior inferior tibiofibular ligament and has pain with the external rotation stress test. Routine radiographs are negative for fracture. Which specific imaging finding would best dictate the need for surgical stabilization?

. Anterior talar translation of 5 mm on a lateral stress view
. Medial clear space widening of 6 mm on external rotation stress radiograph
. Fluid around the peroneal tendons on MRI
. Bone bruise of the medial talar dome on MRI
. Calcification of the interosseous membrane on CT

Correct Answer & Explanation

. Medial clear space widening of 6 mm on external rotation stress radiograph

Explanation

Widening of the medial clear space (>4-5 mm) under external rotation stress indicates incompetence of the deep deltoid ligament and dynamic syndesmotic instability. This unstable 'high ankle sprain' warrants surgical fixation.

Question 4731

Topic: 8. Foot and Ankle

A 25-year-old is brought to the emergency department after a severe hyperextension injury to his right knee during a motor vehicle collision. The knee is grossly unstable. The foot is pale and pulseless, and the Ankle-Brachial Index (ABI) is 0.6. Following a successful closed reduction of the knee, the pedal pulses remain absent. What is the critical next step?

. Obtain a CT angiogram of the lower extremity
. Observe the limb and recheck pulses in 2 hours
. Immediate surgical exploration by vascular surgery
. Place a spanning external fixator
. Perform a duplex ultrasound

Correct Answer & Explanation

. Immediate surgical exploration by vascular surgery

Explanation

The patient exhibits 'hard signs' of vascular injury (pulselessness, pallor) and an ABI < 0.9 that persist after knee reduction. Immediate surgical exploration by vascular surgery is mandated to prevent limb ischemia; delaying for advanced imaging is contraindicated.

Question 4732

Topic: 8. Foot and Ankle

A 32-year-old recreational athlete undergoes minimally invasive repair of an acute mid-substance Achilles tendon rupture. Which postoperative rehabilitation protocol provides the best balance of minimizing re-rupture risk while optimizing functional outcomes?

. Non-weight-bearing in a short leg cast for 8 weeks
. Immediate unprotected full weight-bearing without a brace
. Early functional rehabilitation with protected weight-bearing and active range of motion
. Continuous passive motion machine use while strictly non-weight-bearing
. Immobilization in a rigid boot fixed in maximal dorsiflexion

Correct Answer & Explanation

. Early functional rehabilitation with protected weight-bearing and active range of motion

Explanation

Modern evidence supports early functional rehabilitation protocols following Achilles tendon repair. Protected weight-bearing and controlled early range of motion improve tendon healing and functional scores without increasing the re-rupture rate compared to prolonged immobilization.

Question 4733

Topic: 8. Foot and Ankle

A 25-year-old rugby player sustains an acute, ultra-low velocity knee dislocation. After emergent closed reduction, the patient has palpable but diminished pedal pulses. An ankle-brachial index (ABI) is measured at 0.85. What is the most appropriate next step in management?

. Immediate operative exploration of the popliteal artery
. CT angiography of the lower extremity
. Routine observation with serial neurovascular checks every 4 hours
. Application of a hinged knee brace and discharge to home
. Application of a spanning external fixator and delayed MRI

Correct Answer & Explanation

. CT angiography of the lower extremity

Explanation

An ABI less than 0.90 in the setting of a knee dislocation is highly suggestive of a vascular injury, even if pulses are palpable. CT angiography is immediately indicated to definitively evaluate the popliteal artery and plan potential surgical or endovascular intervention.

Question 4734

Topic: 8. Foot and Ankle

A 23-year-old wide receiver sustains an external rotation injury to his right ankle. Examination reveals tenderness extending 5 cm proximally over the anterior inferior tibiofibular ligament (AITFL). A gravity stress radiograph demonstrates 6 mm of medial clear space widening. What is the most appropriate treatment?

. Short leg cast immobilization for 6 weeks
. Controlled ankle motion (CAM) boot and immediate physical therapy
. Operative syndesmotic stabilization
. Ankle arthroscopy with isolated debridement
. Primary repair of the deltoid ligament only

Correct Answer & Explanation

. Operative syndesmotic stabilization

Explanation

Medial clear space widening greater than 4-5 mm on stress radiographs indicates dynamic syndesmotic instability combined with deltoid ligament incompetence. Operative stabilization of the syndesmosis (via screws or suture button) is required to restore joint congruity and prevent post-traumatic arthritis.

Question 4735

Topic: 8. Foot and Ankle

A 32-year-old recreational basketball player sustains an acute mid-substance Achilles tendon rupture. He elects to pursue nonoperative management. Which of the following rehabilitation protocols is associated with a re-rupture rate that most closely approaches that of surgical repair?

. Prolonged non-weight bearing cast immobilization in equinus for 8 weeks
. Early functional rehabilitation with dynamic bracing and early weight-bearing
. Strict non-weight bearing in a neutral CAM boot for 6 weeks
. Immediate unbraced weight-bearing as tolerated
. Corticosteroid injections combined with aggressive eccentric stretching

Correct Answer & Explanation

. Early functional rehabilitation with dynamic bracing and early weight-bearing

Explanation

Modern evidence demonstrates that early functional rehabilitation—incorporating early protected weight-bearing in a functional brace—significantly reduces the re-rupture rate in nonoperatively managed Achilles tendon ruptures, making the outcomes comparable to operative repair.

Question 4736

Topic: 8. Foot and Ankle

A 35-year-old male presents with acute posterior ankle pain and a palpable gap in the Achilles tendon. If non-operative management is chosen, which rehabilitation protocol yields re-rupture rates most comparable to operative repair?

. Strict cast immobilization in equinus for 8 weeks
. Strict cast immobilization in neutral for 8 weeks
. Early functional rehabilitation with protected weight-bearing in a functional brace
. Non-weight-bearing in a CAM boot for 12 weeks
. Immediate barefoot weight-bearing as tolerated

Correct Answer & Explanation

. Early functional rehabilitation with protected weight-bearing in a functional brace

Explanation

Recent high-quality evidence shows that early functional rehabilitation protocols (early weight-bearing and ROM in a functional brace) for non-operatively managed Achilles ruptures yield re-rupture rates statistically similar to surgical repair.

Question 4737

Topic: 8. Foot and Ankle

A 14-year-old boy complains of vague midfoot pain and recurrent ankle sprains for the past 6 months. Physical examination reveals bilateral flatfeet with significantly decreased subtalar motion and peroneal spasticity. A lateral radiograph of the right foot demonstrates the 'anteater nose' sign. Which of the following statements regarding his condition is correct?

. The pathology is most commonly a fibrous or bony bridge between the talus and calcaneus.
. The 'C-sign' on a lateral radiograph is the primary diagnostic indicator for this specific pathology.
. A 45-degree internal oblique radiograph of the foot is the best initial imaging to visualize the defect.
. Initial management consists of surgical resection and interposition of the extensor digitorum brevis muscle.
. This condition typically ossifies and becomes symptomatic between the ages of 12 and 16 years.

Correct Answer & Explanation

. A 45-degree internal oblique radiograph of the foot is the best initial imaging to visualize the defect.

Explanation

The 'anteater nose' sign on a lateral radiograph is pathognomonic for a calcaneonavicular coalition, which represents an elongated anterior process of the calcaneus approaching the navicular. The best initial radiograph to visualize this specific coalition is the 45-degree internal oblique view. Talocalcaneal coalitions are typically visualized on Harris axial views and are associated with the 'C-sign' on lateral films. Calcaneonavicular coalitions ossify and become symptomatic earlier (ages 8-12) than talocalcaneal coalitions (ages 12-16). Initial management is non-operative (e.g., immobilization, orthotics).

Question 4738

Topic: 8. Foot and Ankle
A 3-year-old girl is evaluated for bilateral bowing of the lower extremities. Her BMI is above the 95th percentile. Standing radiographs demonstrate a metaphyseal-diaphyseal angle (Drennan's angle) of 18 degrees bilaterally, with prominent medial beaking of the proximal tibia. What is the most appropriate initial management?
. Reassurance and observation
. High-dose Vitamin D supplementation
. Knee-ankle-foot orthosis (KAFO) during weight-bearing
. Proximal tibial valgus osteotomy
. Epiphysiodesis of the lateral proximal tibia

Correct Answer & Explanation

. Knee-ankle-foot orthosis (KAFO) during weight-bearing

Explanation

This patient has infantile Blount disease. A metaphyseal-diaphyseal angle > 16 degrees strongly suggests true Blount disease rather than physiologic bowing. In a child under 3 to 4 years of age with Langenskiöld stage I or II, nonoperative management with a daytime Knee-Ankle-Foot Orthosis (KAFO) is the initial treatment of choice. Surgical intervention is typically reserved for those who fail bracing or present at an older age with advanced stages.

Question 4739

Topic: 8. Foot and Ankle

A 3-month-old infant is undergoing serial casting for idiopathic congenital talipes equinovarus using the Ponseti method. During the casting process, the physician attempts to correct the equinus deformity by dorsiflexing the foot before the heel varus and forefoot adductus are fully corrected. This technical error is most likely to result in which of the following iatrogenic deformities?

. Dynamic supination
. Rocker-bottom foot
. Metatarsus adductus
. Iatrogenic tibial torsion
. Pes cavus

Correct Answer & Explanation

. Rocker-bottom foot

Explanation

In the Ponseti method, attempting to dorsiflex the foot before the calcaneocuboid joint is unlocked (which requires full correction of cavus, adductus, and varus) will cause a breach at the midtarsal joint rather than true ankle dorsiflexion. This midfoot break results in an iatrogenic rocker-bottom foot. The equinus deformity must be addressed last, usually requiring a percutaneous Achilles tenotomy.

Question 4740

Topic: Midfoot & Hindfoot

A 14-year-old male presents with rigid, painful flatfeet and a history of recurrent ankle sprains. Examination shows significantly restricted subtalar motion and peroneal spasticity. A CT scan confirms a middle facet talocalcaneal coalition involving 60% of the posterior facet area, accompanied by early degenerative changes in the talonavicular joint. What is the most appropriate definitive surgical intervention?

. Resection of the coalition with interposition of the extensor digitorum brevis
. Resection of the coalition with fat graft interposition
. Isolated subtalar arthrodesis
. Triple arthrodesis
. Calcaneal lengthening osteotomy (Evans procedure)

Correct Answer & Explanation

. Triple arthrodesis

Explanation

Resection of a talocalcaneal coalition is generally contraindicated if the coalition involves > 50% of the posterior facet or if there is evidence of advanced degenerative arthritis in adjacent joints. Because this patient has extensive facet involvement (>50%) and concomitant talonavicular arthritis, resection alone is destined to fail. A triple arthrodesis (fusion of the talocalcaneal, talonavicular, and calcaneocuboid joints) is the treatment of choice to address both the rigid deformity and the arthritic changes.

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