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8. Foot and Ankle MCQs

Practice Set 238 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 4741

Topic: 8. Foot and Ankle

A 14-year-old boy presents with chronic, vague hindfoot pain and a history of recurrent ankle sprains. Physical examination reveals bilateral rigid, flat feet with markedly decreased subtalar motion and peroneal spasticity. A 45-degree internal oblique radiograph of the foot demonstrates an elongated anterior process of the calcaneus bridging to the navicular, often referred to as the 'anteater nose' sign. What is the most likely diagnosis?

. Talocalcaneal coalition
. Calcaneonavicular coalition
. Cuboid-navicular coalition
. Congenital vertical talus
. Symptomatic accessory navicular

Correct Answer & Explanation

. Calcaneonavicular coalition

Explanation

The clinical presentation of a rigid flatfoot with peroneal spasticity in an adolescent is characteristic of a tarsal coalition. The 'anteater nose' sign on a 45-degree internal oblique radiograph is pathognomonic for a calcaneonavicular coalition. A talocalcaneal coalition typically presents with the 'C-sign' on a lateral radiograph and is best visualized on a coronal CT scan. Vertical talus presents at birth with a rigid rocker-bottom foot.

Question 4742

Topic: 8. Foot and Ankle

A 13-year-old girl complains of frequent right ankle sprains and midfoot pain that worsens with activity. On examination, she has a rigid pes planovalgus foot and significantly limited subtalar motion. Radiographs reveal an elongated anterior process of the calcaneus (the 'anteater nose' sign).

Initial nonoperative management with a short leg cast fails to alleviate her symptoms. What is the most appropriate surgical intervention?

. Resection of the calcaneonavicular coalition with interposition of the extensor digitorum brevis
. Subtalar arthrodesis
. Triple arthrodesis
. Resection of a talocalcaneal coalition with fat graft interposition
. Calcaneal lengthening osteotomy (Evans procedure)

Correct Answer & Explanation

. Resection of the calcaneonavicular coalition with interposition of the extensor digitorum brevis

Explanation

The 'anteater nose' sign on the lateral radiograph is pathognomonic for a calcaneonavicular coalition. If nonoperative management (casting, orthotics) fails, the treatment of choice for a calcaneonavicular coalition in an adolescent without severe degenerative joint disease is surgical resection of the coalition with the interposition of tissue (most commonly the extensor digitorum brevis muscle or fat) to prevent recurrence.

Question 4743

Topic: 8. Foot and Ankle
A 2.5-year-old girl is evaluated for severe bilateral bowing of her legs. She is at the 95th percentile for weight. Standing radiographs show a metaphyseal-diaphyseal angle of 18 degrees bilaterally, with prominent medial metaphyseal beaking of the proximal tibias. What is the most appropriate initial management?
. Reassurance and annual follow-up for physiologic bowing
. Knee-ankle-foot orthoses (KAFOs)
. Proximal tibial valgus-producing osteotomies
. Guided growth via hemiepiphysiodesis of the lateral proximal tibia
. Administration of high-dose Vitamin D and Calcium

Correct Answer & Explanation

. Knee-ankle-foot orthoses (KAFOs)

Explanation

The patient has infantile Blount disease, indicated by her age, obesity, metaphyseal beaking, and a metaphyseal-diaphyseal angle > 16 degrees (which distinguishes it from physiologic bowing). For infantile Blount disease in children under the age of 3, the initial treatment of choice is bracing with Knee-Ankle-Foot Orthoses (KAFOs). Surgical osteotomy is reserved for children who fail bracing, present after age 4, or have advanced Langenskiöld stage (III or greater).

Question 4744

Topic: 8. Foot and Ankle

A 14-year-old boy presents with recurrent right ankle sprains and deep, aching midfoot pain that worsens with sporting activities. On physical examination, he has pes planus, a rigid subtalar joint, and valgus heel alignment. When asked to stand on his tiptoes, his right heel fails to invert. Lateral radiographs reveal an elongated anterior process of the calcaneus (the 'anteater nose' sign). Which of the following plain radiographic views is most specifically diagnostic for confirming the suspected condition?

. Standard weight-bearing AP radiograph of the foot
. 45-degree internal oblique radiograph of the foot
. Harris axial radiograph of the heel
. Lateral radiograph in maximum plantarflexion
. Weight-bearing AP radiograph of the ankle

Correct Answer & Explanation

. 45-degree internal oblique radiograph of the foot

Explanation

The clinical presentation of a rigid flatfoot with absent subtalar motion and an 'anteater nose sign' on a lateral radiograph is classic for a calcaneonavicular coalition. The best initial radiographic view to definitively visualize and confirm a calcaneonavicular coalition is the 45-degree internal oblique radiograph of the foot. Talocalcaneal coalitions, on the other hand, are better evaluated initially with Harris axial views or a CT scan (often indicated by the C-sign on a lateral X-ray).

Question 4745

Topic: 8. Foot and Ankle
A 3-year-old girl is evaluated for severe bilateral bowlegs. She has a BMI in the 98th percentile. Standing radiographs show an abrupt varus angulation at the proximal tibial metaphysis with a metaphyseal-diaphyseal angle (MDA) of 18 degrees, consistent with Langenskiöld stage II. What is the most appropriate initial management for this patient?
. Reassurance and annual observation
. Knee-ankle-foot orthoses (KAFOs) during weight-bearing
. Proximal tibial valgus osteotomy
. Guided growth with lateral tension band plates
. Epiphysiodesis of the lateral proximal tibia

Correct Answer & Explanation

. Knee-ankle-foot orthoses (KAFOs) during weight-bearing

Explanation

The patient presents with infantile Blount disease, as evidenced by her age, obesity, severe varus, and a metaphyseal-diaphyseal angle (MDA) greater than 16 degrees. For children younger than 4 years with early-stage infantile Blount disease (Langenskiöld stage I or II), initial management is conservative with knee-ankle-foot orthoses (KAFOs). Surgery (proximal tibial osteotomy) is reserved for children older than 4 years, advanced Langenskiöld stages, or failure of bracing.

Question 4746

Topic: 8. Foot and Ankle

A 12-year-old boy presents with frequent ankle sprains and chronic vague foot pain. Examination reveals rigid, flat feet bilaterally with severely restricted subtalar motion. The peroneal tendons are noted to be spastic. Lateral radiographs reveal an elongated anterior process of the calcaneus (the 'anteater nose' sign).

Which of the following represents the most appropriate initial management for this condition?

. Rigid ankle-foot orthoses (AFO)
. Short-leg walking cast for 4 to 6 weeks
. Corticosteroid injection into the subtalar joint
. Custom medial heel wedges
. Botulinum toxin injection into the peroneal muscles

Correct Answer & Explanation

. Short-leg walking cast for 4 to 6 weeks

Explanation

The patient has a calcaneonavicular tarsal coalition, strongly indicated by the rigid flatfoot, peroneal spasticity, and the radiographic 'anteater nose' sign. Initial conservative management for symptomatic tarsal coalition usually involves rigid immobilization to reduce joint inflammation and relieve muscle spasm. A short-leg walking cast for 4-6 weeks is the most effective initial non-operative treatment.

Question 4747

Topic: 8. Foot and Ankle

A 14-year-old boy presents with a rigid flatfoot and a history of recurrent ankle sprains. Radiographs show a "C sign" on the lateral view. Which of the following is the best imaging modality to confirm the suspected diagnosis and assist in preoperative planning?

. AP and lateral radiographs of the ankle
. Harris axial view radiograph
. CT scan of the foot and ankle
. MRI of the ankle without contrast
. Bone scintigraphy

Correct Answer & Explanation

. CT scan of the foot and ankle

Explanation

The "C sign" on a lateral radiograph is indicative of a talocalcaneal coalition. A CT scan is the gold standard for defining the location, extent, and joint involvement of tarsal coalitions, which is critical for preoperative planning.

Question 4748

Topic: 8. Foot and Ankle

A 3-year-old obese male presents with progressive bowing of the left leg. Standing radiographs reveal a sharp varus deformity at the proximal tibial metaphysis. The metaphyseal-diaphyseal angle (MDA) is measured at 18 degrees. What is the most appropriate management?

. Observation and reassurance
. Vitamin D and calcium supplementation
. Knee-ankle-foot orthosis (KAFO)
. Proximal tibial valgus-producing osteotomy
. Hemiepiphysiodesis of the medial proximal tibia

Correct Answer & Explanation

. Knee-ankle-foot orthosis (KAFO)

Explanation

An MDA greater than 16 degrees in a child under 4 years old indicates infantile Blount disease with a high risk of progression. The initial treatment for stage I/II infantile Blount disease in a 3-year-old is bracing with a KAFO.

Question 4749

Topic: 8. Foot and Ankle

A 12-year-old boy complains of recurrent ankle sprains and lateral foot pain. On examination, he has restricted subtalar motion and peroneal spasticity. An oblique radiograph of the foot demonstrates the 'anteater nose' sign. What is the most likely diagnosis?

. Talocalcaneal coalition
. Calcaneonavicular coalition
. Accessory navicular
. Osteochondritis dissecans of the talus
. Talonavicular coalition

Correct Answer & Explanation

. Calcaneonavicular coalition

Explanation

The 'anteater nose' sign on an oblique radiograph of the foot is pathognomonic for a calcaneonavicular coalition. Talocalcaneal coalitions are best seen on Harris axial views and may show the 'C-sign' on a lateral radiograph.

Question 4750

Topic: 8. Foot and Ankle

A 2-year-old boy is evaluated for bilateral genu varum. Clinical examination shows a lateral thrust during gait. Radiographs show prominent beaking of the medial metaphysis, and the metaphyseal-diaphyseal angle (Drennan angle) is 18 degrees. What is the most appropriate initial management?

. Observation and reassurance
. Vitamin D supplementation
. Knee-ankle-foot orthoses (KAFO)
. Proximal tibial valgus osteotomy
. Medial hemiepiphysiodesis

Correct Answer & Explanation

. Knee-ankle-foot orthoses (KAFO)

Explanation

A metaphyseal-diaphyseal angle >16 degrees with metaphyseal beaking is highly predictive of infantile Blount disease. In children <3 years old, bracing with KAFOs is the appropriate initial management.

Question 4751

Topic: 8. Foot and Ankle

A 14-year-old boy presents with rigid flatfeet and recurrent ankle sprains. Lateral radiographs demonstrate an elongated lateral process of the talus (the "anteater nose" sign). Which of the following is the best initial diagnostic modality to confirm the suspected diagnosis?

. Ultrasound of the ankle
. MRI of the hindfoot
. CT scan of the foot
. Weight-bearing AP and lateral radiographs of the foot
. 45-degree internal rotation oblique radiograph of the foot

Correct Answer & Explanation

. 45-degree internal rotation oblique radiograph of the foot

Explanation

The "anteater nose" sign is pathognomonic for a calcaneonavicular coalition. The best initial study to clearly visualize this specific coalition is a 45-degree internal rotation oblique radiograph of the foot.

Question 4752

Topic: 8. Foot and Ankle

A 13-year-old boy complains of recurrent right foot sprains and vague midfoot pain. Physical examination demonstrates rigid pes planovalgus and decreased subtalar motion. Oblique radiographs demonstrate an elongation of the anterior process of the calcaneus. What is the most appropriate initial management?

. Excision of the coalition with fat graft interposition
. Subtalar arthrodesis
. Short leg cast or walking boot immobilization for 4 to 6 weeks
. Medial calcaneal sliding osteotomy
. Custom orthotics with medial arch support

Correct Answer & Explanation

. Short leg cast or walking boot immobilization for 4 to 6 weeks

Explanation

The clinical and radiographic findings (anteater sign) indicate a calcaneonavicular coalition. Initial management of symptomatic tarsal coalition is conservative, utilizing immobilization in a cast or walking boot to reduce inflammation before considering surgical resection.

Question 4753

Topic: 8. Foot and Ankle

A 13-year-old boy presents with frequent ankle sprains and rigid flatfeet. Radiographs demonstrate an elongated anterior process of the calcaneus (anteater sign). Which of the following is the most likely diagnosis?

. Talocalcaneal coalition
. Calcaneonavicular coalition
. Congenital vertical talus
. Accessory navicular
. Naviculocuneiform coalition

Correct Answer & Explanation

. Calcaneonavicular coalition

Explanation

The "anteater sign" refers to an elongated anterior process of the calcaneus, which is pathognomonic for a calcaneonavicular tarsal coalition on an oblique foot radiograph.

Question 4754

Topic: 8. Foot and Ankle

A 14-year-old boy presents with rigid, painful flatfeet and a history of recurrent ankle sprains. Computed tomography confirms a talocalcaneal coalition. If non-operative management is chosen first, what is the most appropriate initial intervention?

. Corticosteroid injection into the subtalar joint
. Short leg cast immobilization
. Aggressive physical therapy for peroneal tendon strengthening
. Medial arch supports with heel cord stretching
. Surgical resection of the coalition

Correct Answer & Explanation

. Short leg cast immobilization

Explanation

Initial non-operative management for symptomatic tarsal coalition is aimed at reducing inflammation and pain by restricting subtalar motion. A short leg cast or rigid CAM boot immobilization for 3 to 6 weeks is the most effective first-line conservative treatment.

Question 4755

Topic: Ankle Trauma & Sports
A 13-year-old boy sustains an ankle injury while playing soccer. Radiographs reveal a Salter-Harris type III fracture of the anterolateral aspect of the distal tibial epiphysis. What structure avulses this bone fragment during the injury mechanism?
. Anterior inferior tibiofibular ligament (AITFL)
. Posterior inferior tibiofibular ligament (PITFL)
. Anterior talofibular ligament (ATFL)
. Calcaneofibular ligament (CFL)
. Deltoid ligament

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament (AITFL)

Explanation

This describes a juvenile Tillaux fracture, which occurs due to an external rotation force. The fragment is avulsed by the tension of the anterior inferior tibiofibular ligament (AITFL) on the unfused anterolateral distal tibial epiphysis.

Question 4756

Topic: 8. Foot and Ankle

A 14-year-old boy presents with a painful, rigid flatfoot and recurrent ankle sprains. Examination shows peroneal spasm. A lateral radiograph of the foot reveals a continuous "C-sign." This radiographic finding represents abnormal continuity between which of the following structures?

. Talar dome and the sustentaculum tali
. Anterior process of the calcaneus and the navicular
. Cuboid and the navicular
. Lateral process of the talus and the calcaneus
. Medial cuneiform and the first metatarsal

Correct Answer & Explanation

. Talar dome and the sustentaculum tali

Explanation

The "C-sign" on a lateral radiograph is indicative of a talocalcaneal coalition. It represents the bony continuity between the medial outline of the talar dome and the posterior outline of the sustentaculum tali.

Question 4757

Topic: 8. Foot and Ankle

A 9-year-old male soccer player presents with bilateral posterior heel pain. The pain worsens with activity and is relieved by rest. Examination reveals a positive "squeeze test" with pain on mediolateral compression of the posterior calcaneus. What is the primary pathophysiologic mechanism of this condition?

. Microtrauma and traction apophysitis at the Achilles insertion
. Avascular necrosis of the calcaneal apophysis
. An osteochondral defect of the subtalar joint
. Inflammation of the plantar fascia origin
. Congenital failure of segmentation between the talus and calcaneus

Correct Answer & Explanation

. Microtrauma and traction apophysitis at the Achilles insertion

Explanation

The patient has Sever disease (calcaneal apophysitis). This is an overuse injury caused by repetitive microtrauma and traction from the Achilles tendon on the relatively weak calcaneal apophysis before it fuses.

Question 4758

Topic: 8. Foot and Ankle

A 13-year-old boy presents with recurrent ankle sprains and rigid, painful flatfeet. A lateral radiograph of the foot demonstrates a prominent "C sign." Which of the following is the most likely diagnosis?

. Calcaneonavicular coalition
. Talocalcaneal coalition
. Cubonavicular coalition
. Talonavicular coalition
. Symptomatic accessory navicular

Correct Answer & Explanation

. Talocalcaneal coalition

Explanation

The radiographic "C sign" is formed by the continuous bony outline of the medial talar dome and the sustentaculum tali, which is highly indicative of a talocalcaneal coalition. In contrast, a calcaneonavicular coalition typically presents with the "anteater nose" sign on an oblique radiograph.

Question 4759

Topic: 8. Foot and Ankle

A 12-year-old boy presents with recurrent ankle sprains and a painful, rigid flatfoot. Physical examination reveals restricted subtalar motion. To identify the most common etiology of this condition, which imaging view is most helpful?

. Anteroposterior view of the ankle
. Harris axial view of the calcaneus
. Oblique radiograph of the foot
. Weight-bearing lateral view of the ankle
. Mortise view of the ankle

Correct Answer & Explanation

. Oblique radiograph of the foot

Explanation

The presentation is classic for a tarsal coalition, with calcaneonavicular being the most common type. An oblique radiograph of the foot is the best initial view to visualize the 'anteater sign' indicative of a calcaneonavicular coalition.

Question 4760

Topic: 8. Foot and Ankle

A 3-week-old boy is undergoing Ponseti casting for bilateral idiopathic clubfoot. After 5 weekly casts, the cavus, adductus, and varus deformities have been corrected, but 15 degrees of rigid hindfoot equinus remains. What is the next recommended step in management?

. Additional serial casting for 3 more weeks
. Open posterior release of the ankle and subtalar joints
. Tibialis anterior tendon transfer
. Percutaneous Achilles tendon lengthening
. Application of a Denis Browne splint immediately

Correct Answer & Explanation

. Percutaneous Achilles tendon lengthening

Explanation

In the Ponseti method, once the forefoot and midfoot deformities (cavus, adductus, varus) are fully corrected, persistent hindfoot equinus (seen in >80% of cases) is treated with a percutaneous Achilles tendon tenotomy. A final cast is then applied for 3 weeks before transitioning to a foot abduction orthosis.

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