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8. Foot and Ankle MCQs

Practice Set 24 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 461

Topic: 8. Foot and Ankle

Which statement regarding the peroneal tendon(s) is incorrect:

. The peroneus longus tendon attaches to the first metatarsal.
. The peroneus brevis tendon is a plantarflexor of the ankle.
. The peroneus brevis tendon has muscle attached to the tendon at a level lower than the peroneus longus tendon.
. The peroneus longus tendon lies anterior to the peroneus brevis tendon at the level of the distal fibula.
. There are two separate retinacular sheaths for the peroneal tendons distal to the tip of the fibula.

Correct Answer & Explanation

. The peroneus longus tendon lies anterior to the peroneus brevis tendon at the level of the distal fibula.

Explanation

The peroneus brevis tendon plantarflexes and everts the foot and ankle. The peroneus longus tendon plantarflexes the foot, is a mild evertor of the foot, and plantarflexes the first metatarsal. The peroneus brevis tendon is prone to tears or splits at the level of the distal fibula and lies anterior to the peroneus longus tendon at this level.

Question 462

Topic: 8. Foot and Ankle

A 41-year-old patient presents for treatment of a joint depression calcaneus fracture. A Sanders type IIA fracture is visible on a computerized tomography scan. After appropriate counseling, the patient elects nonoperative treatment. What is the most common complication of this injury that may subsequently occur in this patient:

. Peroneal tendon dislocation
. Achilles tendonitis
. C alcaneofibular impingement pain
. Subtalar arthritis
. Tarsal tunnel syndrome

Correct Answer & Explanation

. C alcaneofibular impingement pain

Explanation

Subtalar arthritis occurs when a calcaneus fracture is treated nonoperatively; however, impingement of the fibula against the widened calcaneus will more frequently cause symptoms. Soft tissue problems, including tarsal tunnel syndrome, peroneal tendonitis, and sural neuritis, occur less frequently.

Question 463

Topic: 8. Foot and Ankle
A patient presents for treatment of a painful ankle 2 years after a hindfoot injury. He was treated nonsurgically for a calcaneus fracture that occurred when he fell. His symptoms include anterior ankle pain, weakness during pushing off, and pain along the lateral aspect of the hindfoot. On examination, he has pain to palpation at the tip of the fibula, absent inversion and eversion, 20° of plantarflexion, and no dorsiflexion. Plantarflexion strength appears adequate, and there is no compromise of the forefoot flexor function. The recommended surgical procedure is:
. Anterior ankle cheilectomy and lateral calcaneus ostectomy
. Anterior ankle cheilectomy and subtalar arthrodesis
. In situ subtalar arthrodesis and lateral calcaneus ostectomy
. Subtalar bone block distraction arthrodesis and lateral calcaneus ostectomy
. Triple arthrodesis and Achilles tendon lengthening

Correct Answer & Explanation

. Subtalar bone block distraction arthrodesis and lateral calcaneus ostectomy

Explanation

This patient sustained a joint depression calcaneus fracture with a loss of the talar declination angle. He has limited dorsiflexion that is characteristic of a negative talar declination angle. This decreases the fulcrum of the Achilles tendon and weakens pushoff strength. An in situ subtalar arthrodesis may correct the subtalar joint pain but will not address the decreased height of the hindfoot and the negative talar declination angle. The negative talar declination angle can only be corrected by inserting a tricortical bone graft into the subtalar joint.

Question 464

Topic: 8. Foot and Ankle
A 56-year-old patient sustained an ankle fracture 3 years ago that was treated with closed reduction and cast immobilization. Since the injury, she has experienced pain upon ambulation and ankle stiffness. On examination, the range of motion of the ankle is 5° of dorsiflexion and 30° of plantarflexion. Crepitus with motion is not present, but the patient does experience severe pain. A radiograph is presented (Slide). The recommended procedure to alleviate the patient's pain and improve function is:
. Total ankle replacement
. Ankle arthrodesis
. Ankle arthroscopy and joint debridement
. Osteotomy of the fibula
. Anterior ankle cheilectomy, Achilles lengthening, and joint debridement

Correct Answer & Explanation

. Osteotomy of the fibula

Explanation

The arthritis in this joint is not severe, but there is joint malalignment associated with a short and externally rotated fibula. Joint malalignment is correctable with a lengthening and rotational (internal) osteotomy of the fibula with bone graft. Joint debridement, either open or arthroscopic, is not effective in the management of posttraumatic ankle arthritis. Arthrodesis and arthroplasty are not necessary at this stage.

Question 465

Topic: 8. Foot and Ankle
A 43-year-old construction worker presents for treatment of ankle pain. The patient recounts a fall from a height that caused an ankle fracture 2 years ago. The fracture was treated with closed reduction and cast immobilization for 5 months. He experiences pain upon ambulation and is unable to work. On examination, the range of ankle motion is 5° dorsiflexion and 20° plantarflexion. There is no crepitus with motion, but severe pain is present. A radiograph is presented (Slide 1). The recommended procedure to alleviate pain and improve function is:
. Total ankle replacement
. Ankle arthrodesis
. Arthroscopy ankle and joint debridement
. Osteotomy of the tibia and fibula
. Anterior ankle cheilectomy, Achilles lengthening, and joint debridement

Correct Answer & Explanation

. Osteotomy of the tibia and fibula

Explanation

The arthritis in this joint is not severe, but there is joint malalignment associated with a short and externally rotated fibula and a marked valgus tibiotalar deformity. Although arthrodesis or total ankle replacement may be considered as treatment for some patients, this patient is not a good candidate for these procedures because he does not have severe arthritis. The deformity must be corrected with an osteotomy of the tibia and fibula. Although an opening wedge osteotomy may be considered, a closing wedge procedure is easier to perform and has a higher rate of healing.

Question 466

Topic: 8. Foot and Ankle

A 29-year-old patient has had pain in her foot for 1 year. She twisted her ankle and was treated for a sprain with a brace and therapy. She has persistent pain in her foot and pain on ambulation. On examination, slight pes planus is present, pain is noted on manipulation of the foot, and there is tenderness in the midfoot and hindfoot. A radiograph is presented (Slide). The most likely cause of the pain is:

. A tear of the posterior tibial tendon
. A tear of the spring ligament
. A tear of the short plantar ligament
. A tear of the deltoid ligament
. A tear of the metatarsocuneiform ligament

Correct Answer & Explanation

. A tear of the metatarsocuneiform ligament

Explanation

Slight abduction of the tarsometatarsal joints is noted, along with arthritis of the medial and middle columns of the midfoot. This likely resulted from a tear of the ligament between the base of the second metatarsal and the medial cuneiform (Lisfranc ligament).

Question 467

Topic: 8. Foot and Ankle

A 53-year-old man presents with a swollen foot. He does not recall any injury to the foot, and he has minimal pain. He does not have any pertinent medical history. The clinical and radiographic appearance of the foot is presented (Slide 1 and Slide 2). Based upon the information, the recommended treatment of this injury is:

. Open reduction and internal fixation (ORIF)
. No weight bearing and immobilization in a removable boot
. Open reduction and primary arthrodesis
. Hospitalization, bedrest, and intravenous antibiotics
. Debridement of the foot, deep tissue cultures, and organism-specific intravenous antibiotics

Correct Answer & Explanation

. Open reduction and primary arthrodesis

Explanation

Patients with neuropathy may present for the first time with a neuropathic dislocation (C harcot neuroarthropathy) even before the cause of the neuropathy is diagnosed. The recommended treatment of an acute neuropathic midfoot dislocation is open reduction and primary arthrodesis. Although ORIF without arthrodesis may be considered, recurrent deformity frequently occurs.

Question 468

Topic: 8. Foot and Ankle

A 49-year-old woman has had swelling in the posterior aspect of the ankle for 5 years (Slide). The pain is focal and does not radiate. She notes that pain is worse with activity, exercise, and shoe wear. Which of the following is not an acceptable treatment for this patient:

. Short leg cast immobilization
. High heel shoe with no heel counter
. Debridement of the insertion of the Achilles tendon
. Osteotomy of the calcaneus
. Achilles stretching exercises and physical therapy modalities including corticosteroid application

Correct Answer & Explanation

. Achilles stretching exercises and physical therapy modalities including corticosteroid application

Explanation

Insertional Achilles tendinopathy is aggravated by a hard heel counter on the shoe, a flat shoe, or exercise without stretching. Therapy modalities are effective for treatment of this condition. If patients do not respond to nonoperative measures, then surgery with debridement of the Achilles tendon and posterior calcaneus may be required. Osteotomy of the calcaneus (as opposed to ostectomy) is not an effective treatment.

Question 469

Topic: 8. Foot and Ankle

This slide (the arrow is pointing in the direction of the pathology) illustrates which of the following conditions of the Achilles tendon:

. Chronic degenerative tendinosis
. Acute paratendinitis
. Acute inflammatory tendinopathy
. Acute tendon rupture
. C hronic myxoid degeneration

Correct Answer & Explanation

. Acute tendon rupture

Explanation

This ultrasound is a longitudinal section of the Achilles tendon demonstrating acute rupture. Note the defect in continuity of the tendon below the skin surface. No tendon defects are noted in paratendinitis and tendinosis.

Question 470

Topic: 8. Foot and Ankle

Which of the statements regarding paratendinitis of the Achilles tendon is true:

. Paratendinitis of the Achilles tendon is commonly associated with racket sports.
. Paratendinitis of the Achilles tendon is common in patients who have a cavus foot.
. Paratendinitis of the Achilles tendon is effectively treated with Achilles stretching and orthoses.
. Paratendinitis of the Achilles tendon is associated with tendon degeneration.
. Paratendinitis of the Achilles tendon leads to chronic rupture of the tendon.

Correct Answer & Explanation

. Paratendinitis of the Achilles tendon is effectively treated with Achilles stretching and orthoses.

Explanation

Paratendinitis of the Achilles tendon is commonly associated with runners who hyperpronate. Paratendinitis of the Achilles tendon is amenable to stretching, physical therapy treatments, and an orthotic support that controls rapid pronation during the flat foot phase of gait. Although the condition can become chronic and require surgery, it does not lead to or predispose to a degenerative rupture.

Question 471

Topic: 8. Foot and Ankle

A 65-year-old woman presents for treatment of a painful flatfoot condition. On examination, the hindfoot is in marked valgus and a rupture of the posterior tibial tendon is noted. The recommended treatment is a transfer of the flexor digitorum longus tendon and a medial translational osteotomy of the calcaneus. The rationale for the osteotomy includes all of the following except:

. To increase the ground reaction forces medially
. To make the Achilles tendon vector lateral to the axis of the subtalar joint
. To improve the weight bearing tripod effect of the foot
. To augment the flexor transfer medially
. To decrease the valgus force of the gastrocnemius on the hindfoot

Correct Answer & Explanation

. To make the Achilles tendon vector lateral to the axis of the subtalar joint

Explanation

A medial translational osteotomy of the calcaneus shifts the axis of the Achilles tendon insertion medial to the axis of the subtalar joint. In doing so, the lateralizing force of the gastrocnemius on the heel is lessened and the medial tendon shift augments the strength of the flexor digitorum longus transfer and improves the mechanical efficiency of the foot by altering the ground reaction forces.

Question 472

Topic: 8. Foot and Ankle

Which of the following muscles has the largest cross-sectional diameter:

. Flexor hallucis longus
. Flexor digitorum longus
. Peroneus longus
. Peroneus brevis
. Extensor digitorum longus

Correct Answer & Explanation

. Flexor hallucis longus

Explanation

Following the muscles of the gastrocnemius soleus muscle group, the flexor hallucis longus is the most powerful flexor of the ankle. The flexor hallucis longus is almost twice as strong as the flexor digitorum longus. These are important factors when planning tendon transfers in the foot and ankle.

Question 473

Topic: 8. Foot and Ankle

After surgery to the hallux, a patient complains of burning and numbness along the medial aspect of the first metatarsal. The numbness extends from the medial cuneiform distally to the midportion of the first metatarsal and junction of the plantar and dorsal skin. The nerve involved with the pain is the:

. Intermediate dorsal cutaneous branch superficial peroneal
. Medial cutaneous branch deep peroneal
. Medial cutaneous branch superficial peroneal
. Dorsal cutaneous branch medial plantar
. Intermediate cutaneous branch deep peroneal

Correct Answer & Explanation

. Medial cutaneous branch superficial peroneal

Explanation

The branches of the various sensory nerves of the foot are important to understand. The normal and aberrant topographic anatomy is important in any foot surgery, and management of posttraumatic neuritis is contingent upon an understanding of the anatomy.

Question 474

Topic: 8. Foot and Ankle

The most common complication after resection arthroplasty (Keller) of the base of the hallucal proximal phalanx for correction of hallux valgus is:

. Recurrent hallux valgus
. Hallux varus
. Stiffness of the hallux metatarsophalangeal joint
. C ock-up deformity of the hallux
. Stress fracture of the second metatarsal

Correct Answer & Explanation

. C ock-up deformity of the hallux

Explanation

Resection of the base of the hallucal proximal phalanx detaches the volar plate and the medial and lateral head of the flexor brevis tendon. This leads to weakening of plantarflexion strength and dorsal contracture. The weakness may also lead to lateral overload, metatarsalgia, and stress fracture.

Question 475

Topic: 8. Foot and Ankle

A patient sustains a fracture of the anterior process of the calcaneus. What ligament is responsible for avulsion of this bone:

. Short plantar
. Long plantar
. Anterior talofibular
. C alcaneofibular
. Bifurcate

Correct Answer & Explanation

. Bifurcate

Explanation

The bifurcate ligament extends from the anterior process of the calcaneus to the cuboid and navicular. In certain plantarflexion and inversion injuries of the hindfoot, the ligament, which is strong, will avulse the anterior process of the calcaneus.

Question 476

Topic: 8. Foot and Ankle

The ball and socket ankle deformity shown (Slide) is associated with all of the following except:

. A short femur
. A short fibula
. A talocalcaneal fusion
. C avovarus
. Missing lateral rays of the foot

Correct Answer & Explanation

. A talocalcaneal fusion

Explanation

A ball and socket ankle deformity is caused by limited motion of the peritalar joints, particularly the subtalar and talonavicular joints, during childhood. For example, a talonavicular coalition limits inversion and eversion, and the tibiotalar joint compensates for this loss by increasing motion in the horizontal plane. As motion is increased in the horizontal plane, the medial and lateral edges of the tibiotalar articulation round off and the ball and socket joint develops.

Question 477

Topic: 8. Foot and Ankle

A foot is maximally dorsiflexed during this point of the gait cycle:

. Midswing
. Midstance
. Toe off
. Heelstrike
. First one-third of stance

Correct Answer & Explanation

. Midstance

Explanation

During gait, a foot is dorsiflexed during midswing and foot flat. During midswing, the anterior tibial muscle maintains the foot in a dorsiflexed position to facilitate a smooth heelstrike. This is an active dorsiflexion of the foot and ankle. The maximum dorsiflexion of the foot, however, is passive and occurs as the leg moves forward over the foot during foot flat at midstance.

Question 478

Topic: 8. Foot and Ankle

Which of the following structures is disrupted in patients with an acute medial subtalar dislocation:

. Lisfranc ligament
. Long plantar ligament
. Talocalcaneal ligament
. Calcaneonavicular ligament
. Anterior talofibular ligament

Correct Answer & Explanation

. Talocalcaneal ligament

Explanation

As the foot and the subtalar joint move medially, the subtalar ligaments and the ligaments on the lateral aspect of the ankle are disrupted. The talocalcaneal, or interosseous, ligament is the only ligament that is vulnerable in an acute medial subtalar dislocation.

Question 479

Topic: 8. Foot and Ankle

An 8-year-old soccer player has had bilateral heel pain for 3 months. He has no constitutional complaints. Isolated tenderness to the posterior aspect of his calcaneal tuberosity is present. Recommended treatment is:

. Bone scan to rule out infectious and/or malignant conditions
. Magnetic resonance image to assess for signs of calcaneal avascular necrosis
. A short leg cast
. Computerized tomography scan to rule out osseous abnormality and/or coalition
. Achilles tendon stretching

Correct Answer & Explanation

. Achilles tendon stretching

Explanation

Posterior heel pain in a child is common. This scenario describes an apophysitis of the insertion of the Achilles tendon, referred to as Sever disease. The condition is self-limited and responds well to stretching of the Achilles tendon, temporary limitation of activities, and ice applied to the heel after exercise.

Question 480

Topic: 8. Foot and Ankle

A 26-year-old recreational volleyball player presents with complaints of recurrent right ankle instability. She has undergone 3 months of peroneal strengthening and proprioceptive training without success. She has tried and failed ankle bracing. She has a positive anterior drawer finding on examination, and her hindfoot is in neutral alignment. The recommended surgical plan is:

. Transfer half of the peroneus brevis tendon obliquely through the fibula to recreate the vector of the anterior talofibular and calcaneofibular ligaments
. Reconstruction of the anterior talofibular and calcaneofibular ligaments with imbrication and advancement of the extensor retinaculum
. C alcaneal osteotomy with reconstruction of the anterior talofibular and calcaneofibular ligaments
. Allograft ligament reconstruction
. Ankle ligament reconstruction with additional attention to the osteochondral talar dome injury

Correct Answer & Explanation

. Reconstruction of the anterior talofibular and calcaneofibular ligaments with imbrication and advancement of the extensor retinaculum

Explanation

In an athlete, unless there are unusual anatomic and physical findings, the appropriate ankle reconstruction is an anatomic repair of the ligaments as originally described by Brostrum. Procedures that use the peroneal tendon or tendon grafts should be used in circumstances when a high demand is put on the ankle (e.g., if the patient is heavy or if generalized ligamentous laxity is present).

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