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8. Foot and Ankle MCQs

Practice Set 244 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 4861

Topic: 8. Foot and Ankle

A 24-year-old football player sustains a hyperplantarflexion injury to his midfoot. Weight-bearing radiographs reveal a 3 mm diastasis between the base of the 1st and 2nd metatarsals. Injury to which of the following anatomic structures is the primary cause of this finding?

. The ligament connecting the 1st and 2nd metatarsal bases
. The ligament connecting the medial cuneiform to the base of the 2nd metatarsal
. The central cord of the plantar fascia
. The spring ligament complex
. The bifurcate ligament

Correct Answer & Explanation

. The ligament connecting the medial cuneiform to the base of the 2nd metatarsal

Explanation

The Lisfranc ligament originates on the lateral aspect of the medial cuneiform and inserts on the medial base of the second metatarsal. Rupture of this critical stabilizing structure leads to diastasis between the first and second rays.

Question 4862

Topic: 8. Foot and Ankle

A 22-year-old football player presents with midfoot pain after his foot was axially loaded in plantar flexion. Radiographs show a "fleck sign" at the base of the second metatarsal. Which ligament is avulsed in this injury?

. Dorsal tarso-metatarsal ligament
. Plantar ligament between the medial cuneiform and second metatarsal base
. Interosseous ligament between the medial cuneiform and second metatarsal base
. Plantar calcaneocuboid ligament
. Spring ligament

Correct Answer & Explanation

. Interosseous ligament between the medial cuneiform and second metatarsal base

Explanation

The "fleck sign" is pathognomonic for a Lisfranc injury and represents an avulsion fracture of the Lisfranc ligament. This strong interosseous ligament connects the lateral aspect of the medial cuneiform to the medial base of the second metatarsal.

Question 4863

Topic: 8. Foot and Ankle
A 35-year-old man sustains a Hawkins type III talar neck fracture following a fall from height. What is the approximate risk of developing avascular necrosis (AVN) of the talar body?
. 0-10%
. 15-30%
. 40-50%
. 75-100%
. 100% only if not reduced within 2 hours

Correct Answer & Explanation

. 75-100%

Explanation

Hawkins Type III fractures involve dislocation of the talar body from both the subtalar and ankle joints, disrupting all three major blood supplies to the talus. Consequently, the risk of developing AVN is exceedingly high, approaching 75-100%.

Question 4864

Topic: Midfoot & Hindfoot
A 28-year-old male sustains a high-energy motor vehicle collision resulting in a closed, displaced talar neck fracture. Radiographs and CT scan demonstrate displacement of both the subtalar and tibiotalar joints, while the talonavicular joint remains congruent. Based on the Hawkins classification, what is the approximate rate of avascular necrosis (AVN) of the talar body associated with this specific injury pattern?
. 0 to 10 percent
. 15 to 30 percent
. 40 to 50 percent
. 70 to 100 percent
. Uniformly 100 percent regardless of treatment

Correct Answer & Explanation

. 70 to 100 percent

Explanation

This describes a Hawkins Type III talar neck fracture, which involves subluxation or dislocation of both the subtalar and tibiotalar joints. The risk of AVN for Hawkins Type III fractures is historically reported between 70% and 100% due to the disruption of multiple major blood supplies to the talar body.

Question 4865

Topic: 8. Foot and Ankle

A 45-year-old recreational athlete sustains an acute Achilles tendon rupture and opts for non-operative management. According to high-level evidence and current consensus guidelines, which specific rehabilitation strategy most effectively mitigates the higher re-rupture rate traditionally associated with non-operative treatment?

. Strict immobilization in a long-leg cast for 8 weeks
. Strict non-weight-bearing in a short-leg equinus cast for 6 weeks
. Application of therapeutic ultrasound starting on day 3 post-injury
. Early functional rehabilitation with protected weight-bearing and controlled ankle mobilization
. Corticosteroid injections into the paratenon to decrease acute inflammation

Correct Answer & Explanation

. Early functional rehabilitation with protected weight-bearing and controlled ankle mobilization

Explanation

Recent high-quality studies show that when early functional rehabilitation (protected weight-bearing and early range of motion) is employed, the re-rupture rates of non-operatively managed Achilles ruptures are equivalent to those managed operatively, while avoiding surgical wound complications.

Question 4866

Topic: 8. Foot and Ankle
A 25-year-old male sustains a Hawkins Type III talar neck fracture. Which of the following sources of blood supply to the talus is most likely to remain intact?
. Artery of the tarsal canal
. Artery of the tarsal sinus
. Deltoid branch of the posterior tibial artery
. Dorsalis pedis branches
. Peroneal artery branches

Correct Answer & Explanation

. Deltoid branch of the posterior tibial artery

Explanation

A Hawkins Type III fracture involves subluxation or dislocation of the subtalar and tibiotalar joints, disrupting the artery of the tarsal canal and tarsal sinus. The deltoid branch is often the only remaining blood supply, making preservation of the medial soft tissues critical.

Question 4867

Topic: 8. Foot and Ankle

An extensile lateral approach is planned for a severely displaced intra-articular calcaneus fracture. Which of the following structures is at highest risk of iatrogenic injury during the full-thickness flap elevation?

. Sural nerve
. Deep peroneal nerve
. Tibial nerve
. Medial plantar nerve
. Saphenous nerve

Correct Answer & Explanation

. Sural nerve

Explanation

The sural nerve crosses the lateral aspect of the hindfoot and is at significant risk during the initial incision and elevation of the L-shaped full-thickness flap utilized in the extensile lateral approach to the calcaneus.

Question 4868

Topic: 8. Foot and Ankle

During fixation of a pronation-external rotation ankle fracture, the syndesmosis is found to be unstable after medial and lateral malleolar fixation, and a syndesmotic screw is placed. According to current literature, what dictates the most appropriate time for routine removal of the syndesmotic screw?

. Before initiating any weight-bearing
. At 6 weeks postoperatively
. At 3 months postoperatively
. At 1 year postoperatively
. Routine removal is not necessary unless symptomatic

Correct Answer & Explanation

. Routine removal is not necessary unless symptomatic

Explanation

Current orthopedic literature demonstrates no significant functional difference between retained versus removed syndesmotic screws. Routine removal is generally not required and is reserved for cases where the implant breaks, backs out, or causes local irritation.

Question 4869

Topic: Midfoot & Hindfoot

A 55-year-old woman sustains a highly comminuted, purely ligamentous Lisfranc injury. Current evidence suggests that which of the following treatments provides the best long-term functional outcome for this specific injury pattern?

. Closed reduction and percutaneous pinning
. Open reduction and internal fixation with transarticular screws
. Primary partial midfoot arthrodesis
. Open reduction and internal fixation with dorsal bridge plating
. Nonoperative management in a short leg cast for 12 weeks

Correct Answer & Explanation

. Primary partial midfoot arthrodesis

Explanation

For purely ligamentous Lisfranc injuries, primary arthrodesis of the first, second, and third tarsometatarsal joints yields superior functional outcomes. It also demonstrates lower reoperation rates compared to traditional ORIF.

Question 4870

Topic: 8. Foot and Ankle

A 36-year-old male undergoes open reduction and internal fixation of a displaced intra-articular calcaneus fracture via an extensile lateral approach. Which of the following patient factors is most strongly associated with postoperative wound complications in this scenario?

. Body mass index > 30
. Use of nonsteroidal anti-inflammatory drugs
. Tobacco smoking
. Age > 35 years
. Delay of surgery beyond 7 days

Correct Answer & Explanation

. Tobacco smoking

Explanation

Tobacco smoking drastically increases the risk of wound complications, infection, and flap necrosis after an extensile lateral approach to the calcaneus. The risk of wound healing problems in smokers can be up to three times higher than in non-smokers.

Question 4871

Topic: 8. Foot and Ankle

A 19-year-old football player sustains a high-energy knee dislocation. The knee is reduced in the emergency department. The pedal pulses are palpable and symmetric to the contralateral side. What is the most appropriate next step in management to evaluate the vascular status?

. Immediate surgical exploration of the popliteal artery
. Measurement of Ankle-Brachial Indices (ABI)
. Discharge with close outpatient follow-up
. Routine formal CT angiography regardless of examination
. Magnetic resonance angiography (MRA)

Correct Answer & Explanation

. Measurement of Ankle-Brachial Indices (ABI)

Explanation

After a knee dislocation, even with normal palpable pulses, an Ankle-Brachial Index (ABI) should be measured. If the ABI is >0.9, serial examinations are appropriate; if it is <0.9, a CT angiogram or formal vascular surgery consultation is required.

Question 4872

Topic: Midfoot & Hindfoot
A 35-year-old female falls from a height and sustains a Hawkins Type III fracture of the talar neck. Which of the following best describes the articulations disrupted in this injury pattern?
. Subtalar joint only
. Tibiotalar joint only
. Subtalar and tibiotalar joints
. Subtalar, tibiotalar, and talonavicular joints
. Talonavicular joint only

Correct Answer & Explanation

. Subtalar and tibiotalar joints

Explanation

A Hawkins Type III talar neck fracture involves displacement of the talar body with subluxation or dislocation of both the subtalar and tibiotalar joints. The risk of avascular necrosis (AVN) in Type III injuries is extremely high, approaching 80-100%.

Question 4873

Topic: 8. Foot and Ankle

Review the clinical image provided.

A patient presents with midfoot pain and swelling after a fall. Radiographs show a "fleck sign" in the first intermetatarsal space. The primary ligament ruptured in this injury originates from the lateral aspect of the medial cuneiform and inserts onto which structure?

. Base of the first metatarsal
. Base of the second metatarsal
. Medial aspect of the intermediate cuneiform
. Base of the third metatarsal
. Navicular bone

Correct Answer & Explanation

. Base of the second metatarsal

Explanation

The fleck sign is pathognomonic for a Lisfranc injury and represents an avulsion of the Lisfranc ligament. This critical stabilizing ligament courses from the lateral aspect of the medial cuneiform to the medial base of the second metatarsal.

Question 4874

Topic: 8. Foot and Ankle

A 30-year-old male sustains a Hawkins type II talar neck fracture following a motor vehicle collision. Which of the following best describes the anatomical disruption of blood supply and the associated risk of avascular necrosis (AVN)?

. Disruption of blood supply from the artery of the tarsal canal alone with a 0-10% risk of AVN
. Disruption of blood supply from the artery of the tarsal canal and branches of the dorsalis pedis with a 20-50% risk of AVN
. Complete disruption of all extraosseous blood supply with a 90-100% risk of AVN
. Disruption of the deltoid branch only with a 10% risk of AVN
. Disruption of the fibular artery branches with a 50% risk of AVN

Correct Answer & Explanation

. Disruption of blood supply from the artery of the tarsal canal and branches of the dorsalis pedis with a 20-50% risk of AVN

Explanation

A Hawkins II fracture involves a talar neck fracture with subluxation or dislocation of the subtalar joint, compromising the artery of the tarsal canal and superior neck branches. This typically results in a 20-50% risk of AVN.

Question 4875

Topic: Midfoot & Hindfoot
A 25-year-old female sustains a Hawkins Type III talar neck fracture. What is the estimated risk of developing avascular necrosis (AVN) of the talar body?
. 0-10%
. 15-20%
. 20-50%
. 70-100%
. 100% inevitable

Correct Answer & Explanation

. 70-100%

Explanation

A Hawkins Type III fracture involves displacement of the talar neck with subluxation or dislocation of both the subtalar and tibiotalar joints. This severely disrupts the delicate retrograde blood supply, carrying a 70-100% risk of AVN.

Question 4876

Topic: 8. Foot and Ankle

A 29-year-old male sustains a high-energy traumatic knee dislocation that is reduced in the emergency department. His pedal pulses are palpable. What is the recommended Ankle-Brachial Index (ABI) threshold below which an immediate CT angiogram or surgical exploration is indicated?

. 1.0
. 0.9
. 0.8
. 0.7
. 0.6

Correct Answer & Explanation

. 0.9

Explanation

Following a knee dislocation, an ABI of less than 0.9 strongly suggests an underlying arterial injury, even if pedal pulses are palpable. Such patients require immediate further vascular evaluation, typically via CT angiography.

Question 4877

Topic: 8. Foot and Ankle
A 45-year-old woman falls from a height and sustains a talar neck fracture with displacement of the talar body from both the subtalar and tibiotalar joints. According to the Hawkins classification, what is the approximate risk of developing avascular necrosis (AVN) of the talar body?
. 0-10%
. 15-30%
. 40-50%
. 80-100%
. AVN does not occur with this injury pattern

Correct Answer & Explanation

. 80-100%

Explanation

This is a Hawkins type III talar neck fracture (displaced from both the subtalar and tibiotalar joints). The disruption of the major blood supplies to the talus in this pattern results in an AVN rate of approximately 80-100%.

Question 4878

Topic: 8. Foot and Ankle

A 24-year-old gymnast presents with midfoot pain after landing awkwardly. Non-weight-bearing AP and lateral radiographs of the foot appear normal. Clinical suspicion for a Lisfranc injury remains high. What is the most appropriate next step in diagnosis?

. Reassurance and discharge with NSAIDs
. Weight-bearing AP, lateral, and oblique radiographs of both feet
. Ultrasound of the dorsal foot
. Injection of local anesthetic into the tarsometatarsal joint
. Immediate operative exploration

Correct Answer & Explanation

. Weight-bearing AP, lateral, and oblique radiographs of both feet

Explanation

Subtle Lisfranc injuries can be missed on non-weight-bearing films. Weight-bearing radiographs of both feet are essential to assess for diastasis (>2 mm) between the first and second metatarsal bases or cuneiforms.

Question 4879

Topic: Ankle Trauma & Sports

During the open reduction and internal fixation of a pronation-external rotation (Weber C) ankle fracture, the surgeon decides to place a syndesmotic position screw. Which of the following is the strongest predictor of long-term functional outcome in this patient?

. The use of three versus four cortices of screw purchase
. The use of a 3.5 mm versus a 4.5 mm syndesmotic screw
. Anatomic reduction of the tibiofibular syndesmosis
. Routine removal of the syndesmotic screw at 8 weeks
. The specific material (titanium vs. stainless steel) of the plate

Correct Answer & Explanation

. Anatomic reduction of the tibiofibular syndesmosis

Explanation

Multiple studies have shown that the anatomic reduction of the syndesmosis is the single most important factor determining functional outcomes in syndesmotic injuries. Screw size, number of cortices, and removal protocols do not significantly alter outcomes if reduction is perfect.

Question 4880

Topic: 8. Foot and Ankle
A 28-year-old male snowboarder sustains a high-energy hyperdorsiflexion injury to his right foot, resulting in a Hawkins Type III talar neck fracture. Which of the following vessels provides the dominant blood supply to the talar body and is at greatest risk of disruption in this injury pattern?
. Artery of the tarsal canal
. Artery of the sinus tarsi
. Anterior tibial artery
. Dorsalis pedis artery
. Peroneal artery

Correct Answer & Explanation

. Artery of the tarsal canal

Explanation

The artery of the tarsal canal, a branch of the posterior tibial artery, provides the dominant blood supply to the talar body. It is highly susceptible to disruption in displaced talar neck fractures, contributing to the high rate of avascular necrosis in Hawkins Type III and IV injuries.

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