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8. Foot and Ankle MCQs

Practice Set 241 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 4801

Topic: 8. Foot and Ankle

While performing a tarsal tunnel release, the surgeon identifies the structures passing posterior to the medial malleolus. What anatomical structure is located immediately posterior to the flexor digitorum longus (FDL) tendon?

. Flexor hallucis longus tendon
. Saphenous nerve
. Tibialis posterior tendon
. Posterior tibial artery
. Tibial nerve

Correct Answer & Explanation

. Posterior tibial artery

Explanation

The anatomical order of structures behind the medial malleolus from anterior to posterior is: Tibialis posterior, Flexor digitorum longus, posterior tibial Artery, tibial Nerve, and Flexor hallucis longus (Tom, Dick, AND Harry). Therefore, the artery is immediately posterior to the FDL.

Question 4802

Topic: 8. Foot and Ankle

During ankle arthroscopy, establishment of the posterolateral portal places a specific neurovascular bundle at highest risk of iatrogenic injury. Which of the following structures is most vulnerable?

. Deep peroneal nerve and anterior tibial artery
. Sural nerve and small saphenous vein
. Saphenous nerve and great saphenous vein
. Superficial peroneal nerve
. Tibial nerve and posterior tibial artery

Correct Answer & Explanation

. Sural nerve and small saphenous vein

Explanation

The posterolateral portal in ankle arthroscopy is made just lateral to the Achilles tendon. This location places the sural nerve and the small saphenous vein at significant risk if the incision is strayed too far laterally or made too deeply.

Question 4803

Topic: 8. Foot and Ankle

A 28-year-old sustains a displaced talar neck fracture. Which of the following blood vessels provides the primary blood supply to the talar body, placing it at high risk for avascular necrosis?

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

Correct Answer & Explanation

. Artery of the tarsal canal

Explanation

The artery of the tarsal canal, a branch of the posterior tibial artery, is the dominant blood supply to the talar body. Disruption of this vessel in talar neck fractures significantly increases the risk of avascular necrosis.

Question 4804

Topic: Ankle Trauma & Sports

A 24-year-old rugby player sustains an external rotation injury to the ankle. Examination reveals tenderness over the anterior syndesmosis, and radiographs demonstrate widening of the tibiofibular clear space.

Which ligament provides the greatest absolute resistance to diastasis of the distal tibiofibular syndesmosis?

. Anterior inferior tibiofibular ligament (AITFL)
. Posterior inferior tibiofibular ligament (PITFL)
. Interosseous ligament
. Transverse tibiofibular ligament
. Deep deltoid ligament

Correct Answer & Explanation

. Posterior inferior tibiofibular ligament (PITFL)

Explanation

Biomechanical studies show that the posterior inferior tibiofibular ligament (PITFL) contributes approximately 42% of the resistance to syndesmotic diastasis, making it the strongest and most important individual stabilizer of the syndesmosis.

Question 4805

Topic: 8. Foot and Ankle

A 28-year-old male is brought to the emergency department after a high-velocity knee dislocation. His knee is reduced, but the ankle-brachial index (ABI) is 0.8. Which of the following is the most appropriate next step in management?

. Discharge with close outpatient follow-up
. Serial ABI measurements every 4 hours for 24 hours
. CT angiography of the lower extremity
. Emergent surgical exploration without further imaging
. MR angiography of the lower extremity

Correct Answer & Explanation

. CT angiography of the lower extremity

Explanation

An ABI less than 0.9 in the setting of a knee dislocation is highly suggestive of an arterial injury. CT angiography is the gold standard diagnostic tool to confirm a popliteal artery injury and should be performed urgently to guide surgical intervention.

Question 4806

Topic: 8. Foot and Ankle

A 40-year-old male sustains an acute Achilles tendon rupture. When discussing surgical versus nonoperative management with a functional rehabilitation protocol, the patient should be informed that surgical repair provides which of the following advantages?

. Lower risk of sural nerve injury
. Lower rate of tendon re-rupture
. Lower risk of deep vein thrombosis
. Decreased risk of soft tissue infection
. Earlier ability to bear weight

Correct Answer & Explanation

. Lower rate of tendon re-rupture

Explanation

Historically, operative repair of Achilles tendon ruptures is associated with a lower rate of re-rupture compared to nonoperative management. However, operative management carries higher risks of wound complications and iatrogenic sural nerve injury.

Question 4807

Topic: 8. Foot and Ankle

A professional American football player sustains a 'turf toe' injury. Which of the following mechanisms is the primary cause of this condition?

. Forced plantarflexion of the ankle with toe clawing
. Inversion injury of the midfoot
. Axial load with forced hyperdorsiflexion (hyperextension) of the first metatarsophalangeal (MTP) joint
. Direct crush injury to the first metatarsal head
. Valgus stress applied to the first MTP joint

Correct Answer & Explanation

. Axial load with forced hyperdorsiflexion (hyperextension) of the first metatarsophalangeal (MTP) joint

Explanation

Turf toe is a sprain of the first MTP joint plantar capsuloligamentous complex. It is typically caused by an axial load applied to a foot fixed in equinus, resulting in hyperdorsiflexion (hyperextension) of the first MTP joint.

Question 4808

Topic: 8. Foot and Ankle

A 19-year-old soccer player presents with anterior ankle pain after a twisting injury. Physical examination raises suspicion for a syndesmotic sprain (high ankle sprain). Which of the following physical examination tests has the highest inter-observer reliability and sensitivity for diagnosing a syndesmotic injury?

. Anterior drawer test
. Talar tilt test
. External rotation stress test
. Squeeze test
. Cotton test

Correct Answer & Explanation

. External rotation stress test

Explanation

The external rotation stress test is considered one of the most reliable and sensitive clinical tests for diagnosing syndesmotic ankle sprains. The squeeze test is highly specific but lacks sensitivity.

Question 4809

Topic: 8. Foot and Ankle
A 22-year-old college football player suffers a multiligament knee injury (KD-III). During the initial emergency department evaluation, his 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
. CT angiography of the lower extremity
. Serial ABI measurements every 4 hours
. Application of a knee-spanning external fixator
. Duplex ultrasonography within 24 hours

Correct Answer & Explanation

. CT angiography of the lower extremity

Explanation

An ABI of less than 0.9 in the setting of a knee dislocation or multiligament knee injury is highly suspicious for a vascular injury. CT angiography is the gold standard next step to confirm, localize, and characterize the arterial injury before surgical intervention.

Question 4810

Topic: 8. Foot and Ankle

A 34-year-old male suffers an acute mid-substance Achilles tendon rupture. He is treated non-operatively with a functional rehabilitation protocol. Compared to historical rigid cast immobilization, early functional rehabilitation demonstrates:

. A significantly higher re-rupture rate
. Decreased range of motion at 1 year
. Similar re-rupture rates with improved early functional outcomes
. Increased rates of deep vein thrombosis
. Higher incidence of chronic regional pain syndrome

Correct Answer & Explanation

. Similar re-rupture rates with improved early functional outcomes

Explanation

Modern non-operative management using early weight-bearing and functional rehabilitation protocols has shown re-rupture rates comparable to operative treatment. This avoids surgical complications while improving early functional outcomes compared to prolonged cast immobilization.

Question 4811

Topic: 8. Foot and Ankle

A 22-year-old collegiate football player sustains a multiligamentous knee injury resulting in a knee dislocation. Upon reduction, he has an asymmetric, diminished dorsalis pedis pulse compared to the contralateral side. An ankle-brachial index (ABI) is measured at 0.85. What is the most appropriate next step in management?

. Observation and serial vascular checks
. CT angiography
. Immediate surgical exploration
. Magnetic resonance angiography (MRA)
. Duplex ultrasonography

Correct Answer & Explanation

. CT angiography

Explanation

An ABI less than 0.9 after a knee dislocation raises high suspicion for a popliteal artery injury. CT angiography is the gold standard next step to rapidly define the vascular injury before surgical intervention.

Question 4812

Topic: 8. Foot and Ankle

A 45-year-old weekend warrior sustains an acute Achilles tendon rupture. He discusses operative versus non-operative management with you. Based on recent high-level evidence utilizing modern functional rehabilitation protocols, non-operative management compared to operative management is associated with:

. Similar re-rupture rates but a higher risk of deep vein thrombosis
. A significantly higher re-rupture rate
. Similar re-rupture rates but a lower rate of soft tissue complications
. Better peak plantar flexion strength at 1 year
. A longer time to return to work

Correct Answer & Explanation

. Similar re-rupture rates but a lower rate of soft tissue complications

Explanation

Recent evidence shows that when early functional rehabilitation is employed, non-operative management of Achilles ruptures yields similar re-rupture rates compared to surgical repair, while successfully avoiding surgical risks such as infection.

Question 4813

Topic: Ankle Trauma & Sports

A 21-year-old collegiate soccer player presents with a high ankle sprain (syndesmotic injury) confirmed by an increased tibiofibular clear space. He undergoes dynamic fixation using a suture-button construct. Compared to traditional syndesmotic screw fixation, the suture-button construct has been shown to:

. Require a second routine surgery for hardware removal
. Result in a significantly higher rate of late diastasis
. Provide identical rigid fixation preventing any physiologic motion
. Show a faster return to sport and lower rate of hardware-related complications
. Have a higher incidence of deep surgical site infection

Correct Answer & Explanation

. Show a faster return to sport and lower rate of hardware-related complications

Explanation

Suture-button constructs for syndesmosis injuries offer dynamic stabilization mimicking physiologic motion. They demonstrate a faster return to sport and a lower need for routine hardware removal compared to rigid screw fixation.

Question 4814

Topic: 8. Foot and Ankle
A 28-year-old male is brought to the trauma bay after a motorcycle accident. He has a grossly unstable knee with a suspected multi-ligamentous injury (KD-III). His dorsalis pedis pulse is palpable, but the ankle-brachial index (ABI) is 0.85. What is the most appropriate next step in management?
. Immediate surgical exploration of the popliteal artery
. Observation and repeat ABI in 4 hours
. CT angiography of the lower extremity
. Application of a spanning external fixator and discharge
. Magnetic resonance angiography (MRA)

Correct Answer & Explanation

. CT angiography of the lower extremity

Explanation

An ABI < 0.9 in the setting of a knee dislocation indicates a high risk for popliteal artery injury, even if distal pulses are palpable. CT angiography is the gold standard next step to rapidly and non-invasively evaluate for a vascular injury requiring surgical intervention.

Question 4815

Topic: 8. Foot and Ankle

A 24-year-old wide receiver sustains an external rotation injury to his ankle. He exhibits tenderness over the anterior inferior tibiofibular ligament (AITFL) and has a positive external rotation stress test. Which imaging modality is most sensitive for detecting subtle syndesmotic diastasis?

. AP ankle radiograph
. Mortise radiograph
. External rotation stress radiograph
. Bilateral weight-bearing CT scan
. Bone scan

Correct Answer & Explanation

. Bilateral weight-bearing CT scan

Explanation

Bilateral weight-bearing CT is highly sensitive and specific for evaluating the distal tibiofibular syndesmosis. It detects subtle rotational or translational malalignment that static or stress radiographs may miss.

Question 4816

Topic: 8. Foot and Ankle

A 35-year-old recreational basketball player opts for a percutaneous Achilles tendon repair following an acute rupture. Injury to which nerve is the most frequently cited complication of this specific minimally invasive technique?

. Sural nerve
. Tibial nerve
. Deep peroneal nerve
. Superficial peroneal nerve
. Saphenous nerve

Correct Answer & Explanation

. Sural nerve

Explanation

The sural nerve courses distally along the lateral border of the Achilles tendon. Its close proximity makes it particularly vulnerable to entrapment or transection during percutaneous suture passage.

Question 4817

Topic: 8. Foot and Ankle

A 30-year-old male sustains a spontaneously reduced knee dislocation during a football game. His pedal pulses are palpable, but his ankle-brachial index (ABI) is 0.8. What is the most appropriate next step in management?

. Immediate discharge with a hinged knee brace
. CT angiography
. MRI of the knee
. Application of an external fixator
. Reassure and re-examine in 1 week

Correct Answer & Explanation

. CT angiography

Explanation

An Ankle-Brachial Index (ABI) less than 0.9 in the setting of a knee dislocation is highly suspicious for a popliteal artery injury. Immediate vascular imaging with CT angiography or formal arteriography is mandatory.

Question 4818

Topic: 8. Foot and Ankle

A 35-year-old male recreational basketball player sustains an acute Achilles tendon rupture and elects to undergo a percutaneous repair. During the procedure, which nerve is at the highest risk of iatrogenic injury at the level of the distal repair, and where is it located anatomically?

. Sural nerve; anterior to the lateral malleolus.
. Tibial nerve; posteromedial to the Achilles tendon.
. Sural nerve; between the lateral malleolus and the Achilles tendon.
. Superficial peroneal nerve; deep to the peroneus brevis tendon.
. Saphenous nerve; medial to the flexor hallucis longus tendon.

Correct Answer & Explanation

. Sural nerve; between the lateral malleolus and the Achilles tendon.

Explanation

The sural nerve is at significant risk during percutaneous Achilles tendon repair. It courses distally in the posterolateral leg, crossing from medial to lateral, and runs between the lateral malleolus and the Achilles tendon at the level of the ankle.

Question 4819

Topic: 8. Foot and Ankle

A 35-year-old recreational basketball player sustains an acute, closed midsubstance Achilles tendon rupture. Compared to surgical repair, which of the following is a known outcome of modern functional bracing and early weight-bearing (nonoperative management)?

. Higher rate of sural nerve injury
. Higher rate of deep infection
. Significantly decreased plantar flexion strength
. Equivalent rerupture rates
. Increased risk of chronic regional pain syndrome

Correct Answer & Explanation

. Equivalent rerupture rates

Explanation

Modern nonoperative management with functional bracing and early, protected weight-bearing has been shown to have rerupture rates equivalent to operative repair. However, surgical repair is associated with higher risks of wound complications and infection.

Question 4820

Topic: 8. Foot and Ankle

A 28-year-old patient presents with a knee dislocation following a motorcycle accident. The knee has been reduced, and pedal pulses are palpable. What is the most appropriate next step in evaluating the vascular status of the limb?

. Immediate vascular surgery consultation for bypass
. Measure ankle-brachial indices (ABI)
. Observation with serial clinical exams every 4 hours
. Obtain a venous duplex ultrasound
. Discharge with a knee immobilizer

Correct Answer & Explanation

. Measure ankle-brachial indices (ABI)

Explanation

An ankle-brachial index (ABI) is the most appropriate initial screening tool for vascular injury following a knee dislocation, even when pulses are palpable. An ABI < 0.9 necessitates further advanced imaging, such as a CT angiogram, to rule out a popliteal artery injury.

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