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8. Foot and Ankle MCQs

Practice Set 246 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 4901

Topic: 8. Foot and Ankle

A 30-year-old male sustains a purely ligamentous Lisfranc injury. Weight-bearing radiographs show 3 mm of widening between the base of the first and second metatarsals. What is the most appropriate definitive management?

. Non-weight-bearing in a short leg cast for 6 weeks
. Open reduction and internal fixation using screws
. Primary arthrodesis of the medial midfoot joints
. Percutaneous Kirschner wire fixation
. Carbon fiber stiff-soled shoe insertion and early weight-bearing

Correct Answer & Explanation

. Primary arthrodesis of the medial midfoot joints

Explanation

Purely ligamentous Lisfranc injuries have a high rate of hardware failure and post-traumatic arthritis with ORIF. Primary arthrodesis of the first, second, and third tarsometatarsal joints yields superior functional outcomes.

Question 4902

Topic: 8. Foot and Ankle

When comparing operative versus nonoperative management of acute Achilles tendon ruptures using early functional rehabilitation protocols, operative management is traditionally associated with which of the following?

. Decreased risk of deep vein thrombosis
. Decreased risk of rerupture
. Decreased risk of sural nerve injury
. Improved long-term ankle range of motion
. Significantly improved return to elite level sports

Correct Answer & Explanation

. Decreased risk of rerupture

Explanation

Operative management of acute Achilles tendon ruptures has historically been associated with a lower rerupture rate, though it carries a higher risk of soft tissue complications and sural nerve injury.

Question 4903

Topic: 8. Foot and Ankle

A 60-year-old male with end-stage post-traumatic ankle osteoarthritis is considering surgical intervention. He has a history of avascular necrosis of the talus with significant collapse. Which procedure is most appropriate?

. Total ankle arthroplasty
. Isolated ankle arthrodesis
. Tibiotalocalcaneal (TTC) arthrodesis
. Supramalleolar osteotomy
. Subtalar arthrodesis

Correct Answer & Explanation

. Tibiotalocalcaneal (TTC) arthrodesis

Explanation

In the presence of significant talar body collapse due to avascular necrosis, total ankle arthroplasty and isolated ankle arthrodesis are contraindicated due to inadequate talar bone stock. A TTC arthrodesis is the appropriate salvage procedure.

Question 4904

Topic: 8. Foot and Ankle

A 14-year-old boy presents with frequent ankle sprains and a rigid flatfoot. Radiographs show an elongated lateral process of the talus and a prominent "C-sign". What is the most likely diagnosis?

. Calcaneonavicular coalition
. Talocalcaneal coalition
. Accessory navicular syndrome
. Posterior tibial tendon insufficiency
. Congenital vertical talus

Correct Answer & Explanation

. Talocalcaneal coalition

Explanation

A rigid flatfoot and a "C-sign" on the lateral radiograph are pathognomonic for a talocalcaneal coalition. This most commonly affects the middle facet of the subtalar joint.

Question 4905

Topic: Midfoot & Hindfoot

A 55-year-old woman presents with medial ankle pain and a progressively flattening arch. She has a flexible flatfoot, cannot perform a single-leg heel rise, and has tenderness over the posterior tibial tendon. Nonoperative management has failed. What is the most appropriate surgical procedure?

. Triple arthrodesis
. Flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy
. Gastrocnemius recession and isolated FDL transfer
. Subtalar arthrodesis
. Talonavicular arthrodesis

Correct Answer & Explanation

. Flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy

Explanation

This patient has Stage II (flexible) adult-acquired flatfoot deformity. The standard joint-sparing surgical treatment utilizes an FDL transfer and a medial displacement calcaneal osteotomy (MDCO) to restore the arch.

Question 4906

Topic: Forefoot

A 60-year-old man presents with pain and stiffness in his right great toe, especially with push-off. Radiographs show dorsal osteophytes and joint space narrowing of the first metatarsophalangeal joint, but the plantar joint space is well preserved. He desires to maintain motion. What is the most appropriate surgical option?

. First MTP arthrodesis
. Cheilectomy
. Keller resection arthroplasty
. Total joint arthroplasty
. Lapidus procedure

Correct Answer & Explanation

. Cheilectomy

Explanation

For mild to moderate hallux rigidus with preserved plantar joint space, a cheilectomy is highly effective. Removing the dorsal osteophytes and the dorsal one-third of the metatarsal head relieves impingement while preserving motion.

Question 4907

Topic: 8. Foot and Ankle

A 26-year-old professional athlete sustains an external rotation injury to his ankle. Intraoperative stress testing confirms syndesmotic instability after fixing the associated fibula fracture. Which syndesmotic fixation strategy has been shown to allow the most physiologic motion?

. Two 3.5-mm tricortical screws
. One 4.5-mm quadricortical screw
. Suture button construct
. Rigid plate fixation across the syndesmosis
. Primary repair of the AITFL without implants

Correct Answer & Explanation

. Suture button construct

Explanation

Flexible fixation with a suture button construct allows for more physiologic motion of the syndesmosis. It reduces the risk of hardware breakage and often eliminates the need for routine hardware removal.

Question 4908

Topic: 8. Foot and Ankle

A 15-year-old female dancer presents with insidious onset of pain in her forefoot. Examination reveals localized swelling and tenderness over the second metatarsophalangeal joint. Radiographs show flattening and sclerosis of the second metatarsal head. What is the most likely diagnosis?

. Morton's neuroma
. Stress fracture of the second metatarsal
. Freiberg's infraction
. Sesamoiditis
. Rheumatoid arthritis

Correct Answer & Explanation

. Freiberg's infraction

Explanation

Freiberg's infraction is avascular necrosis of the metatarsal head, most commonly affecting the second metatarsal in adolescent females. Radiographs typically demonstrate flattening, sclerosis, and fragmentation.

Question 4909

Topic: 8. Foot and Ankle

A 55-year-old female presents with progressive flattening of her left foot, pain along the medial ankle, and an inability to perform a single-leg heel raise. Examination reveals abduction of the forefoot with 'too many toes' visible from behind. Weight-bearing radiographs show significant uncovering of the talonavicular joint. What is the most appropriate surgical management?

. Flexor digitorum longus transfer alone
. Medial calcaneal slide osteotomy alone
. Flexor digitorum longus transfer and medial calcaneal slide osteotomy
. Flexor digitorum longus transfer, medial calcaneal slide osteotomy, and lateral column lengthening
. Subtalar and talonavicular arthrodesis

Correct Answer & Explanation

. Flexor digitorum longus transfer, medial calcaneal slide osteotomy, and lateral column lengthening

Explanation

This patient has Stage IIb adult-acquired flatfoot deformity characterized by flexible hindfoot valgus and significant forefoot abduction. Surgical reconstruction requires addressing the medial tendon dysfunction and correcting both hindfoot valgus and forefoot abduction using an FDL transfer, medial calcaneal osteotomy, and a lateral column lengthening procedure.

Question 4910

Topic: Midfoot & Hindfoot

A 45-year-old runner presents with chronic, aching heel pain that is worse at the end of the day. Examination reveals maximal tenderness over the medial calcaneal tuberosity and an inability to abduct the fifth toe. Compression of which of the following nerves is the most likely cause?

. First branch of the lateral plantar nerve
. Medial plantar nerve
. Medial calcaneal nerve
. Deep peroneal nerve
. Sural nerve

Correct Answer & Explanation

. First branch of the lateral plantar nerve

Explanation

Baxter's nerve is the first branch of the lateral plantar nerve and provides motor innervation to the abductor digiti minimi. Entrapment commonly causes chronic heel pain and weakness in abducting the fifth toe, mimicking plantar fasciitis.

Question 4911

Topic: 8. Foot and Ankle

A 24-year-old elite rugby player presents with midfoot pain after a hyperplantarflexion injury. Weight-bearing radiographs show 3 mm of diastasis between the first and second metatarsal bases without fracture. What is the most appropriate management?

. Short leg cast for 6 weeks
. Primary arthrodesis of the first, second, and third tarsometatarsal joints
. Open reduction and internal fixation or suture button fixation
. Cam boot immobilization and immediate weight-bearing
. Corticosteroid injection into the Lisfranc joint

Correct Answer & Explanation

. Open reduction and internal fixation or suture button fixation

Explanation

Subtle, purely ligamentous Lisfranc injuries with diastasis greater than 2 mm on weight-bearing films in young athletes require surgical stabilization. ORIF or flexible suture-button fixation restores anatomy and stability, whereas nonoperative treatment leads to chronic pain and midfoot collapse.

Question 4912

Topic: 8. Foot and Ankle

A 65-year-old woman with end-stage ankle osteoarthritis complains of severe pain. She has a history of severe peripheral neuropathy and prior deep infection in the ipsilateral leg. Which of the following is an absolute contraindication to total ankle arthroplasty (TAR) in this patient?

. Age greater than 60 years
. Severe peripheral neuropathy
. End-stage osteoarthritis
. Female sex
. History of distal fibula fracture

Correct Answer & Explanation

. Severe peripheral neuropathy

Explanation

Absolute contraindications to total ankle arthroplasty include active infection, severe peripheral neuropathy (e.g., Charcot arthropathy), and absent lower extremity sensation. These conditions significantly increase the risk of implant failure, collapse, and perioperative wound complications.

Question 4913

Topic: 8. Foot and Ankle

A 28-year-old man with Charcot-Marie-Tooth disease presents with a bilateral cavovarus foot deformity. A Coleman block test is performed and the hindfoot varus corrects to a neutral alignment. What does this finding indicate regarding surgical planning?

. The hindfoot deformity is rigid and requires a triple arthrodesis
. The hindfoot deformity is driven by a plantarflexed first ray
. The Achilles tendon is overlengthened
. The tibialis anterior is spastic
. A calcaneal osteotomy is strictly contraindicated

Correct Answer & Explanation

. The hindfoot deformity is driven by a plantarflexed first ray

Explanation

A flexible hindfoot that corrects to neutral on a Coleman block test indicates that the varus deformity is primarily driven by a rigid, plantarflexed first ray. Surgical reconstruction should focus on a first metatarsal dorsiflexion osteotomy and soft-tissue balancing rather than a rigid hindfoot fusion.

Question 4914

Topic: 8. Foot and Ankle

A 42-year-old woman presents with symptomatic hallux valgus. Radiographs demonstrate a hallux valgus angle (HVA) of 30 degrees, an intermetatarsal angle (IMA) of 13 degrees, and a distal metatarsal articular angle (DMAA) of 25 degrees. To avoid postoperative hallux valgus recurrence or joint incongruity, which surgical step is essential?

. Akin osteotomy
. Lapidus procedure
. Distal soft tissue release only
. Biplanar distal metatarsal osteotomy to correct the DMAA
. First metatarsophalangeal joint arthrodesis

Correct Answer & Explanation

. Biplanar distal metatarsal osteotomy to correct the DMAA

Explanation

An abnormally high DMAA (greater than 15 degrees) indicates an incongruent joint surface orientation. A standard metatarsal osteotomy without addressing the DMAA leaves the articular cartilage laterally deviated, so a biplanar osteotomy is required to rotate the articular surface medially.

Question 4915

Topic: 8. Foot and Ankle

A 26-year-old skier presents with lateral ankle pain and a snapping sensation behind the lateral malleolus when dorsiflexing and everting the foot. MRI confirms an intact superior peroneal retinaculum (SPR) that has avulsed from its fibular insertion, creating a false pouch. What is the most appropriate surgical intervention?

. Repair of the SPR directly to the fibular ridge and groove deepening
. Peroneus brevis to peroneus longus tenodesis
. Lateral column lengthening
. Sural nerve decompression
. Primary repair of the anterior talofibular ligament only

Correct Answer & Explanation

. Repair of the SPR directly to the fibular ridge and groove deepening

Explanation

The patient has a Grade I peroneal tendon subluxation with an SPR avulsion. The standard of care is deepening of the fibular groove and anatomical repair or reefing of the superior peroneal retinaculum to the periosteum of the posterolateral fibular ridge.

Question 4916

Topic: 8. Foot and Ankle

When counseling a 35-year-old recreational athlete regarding non-operative versus operative management of an acute Achilles tendon rupture, which of the following statements is most supported by recent level I evidence utilizing early functional rehabilitation?

. Operative management significantly reduces the re-rupture rate compared to functional non-operative management.
. Non-operative management with early functional rehab has similar re-rupture rates to operative management.
. Operative management yields significantly greater long-term plantarflexion strength.
. Non-operative management increases the risk of sural nerve injury.
. Casting in equinus for 8 weeks is superior to early functional rehabilitation.

Correct Answer & Explanation

. Non-operative management with early functional rehab has similar re-rupture rates to operative management.

Explanation

Recent level I trials demonstrate that when early functional rehabilitation (weight-bearing and ROM) is utilized, the re-rupture rates between non-operative and operative management of Achilles ruptures are equivalent. Operative management does, however, carry a higher risk of wound complications and nerve injury.

Question 4917

Topic: 8. Foot and Ankle
A 56-year-old man with poorly controlled diabetes mellitus presents with a swollen, red, and warm right foot. Radiographs show periarticular fragmentation, bone debris, and subluxation of the midfoot without signs of consolidation. He is afebrile with normal inflammatory markers. What Eichenholtz stage does this represent and what is the best initial treatment?
. Stage 0; immediate midfoot arthrodesis
. Stage I; total contact casting
. Stage II; total contact casting
. Stage III; custom orthoses
. Stage I; immediate open reduction and internal fixation

Correct Answer & Explanation

. Stage I; total contact casting

Explanation

Eichenholtz Stage I (Development/Fragmentation) is characterized by acute inflammation, osteopenia, bone fragmentation, and joint subluxation. The standard initial treatment is strict offloading with a total contact cast to prevent further deformity until the active inflammatory phase resolves.

Question 4918

Topic: 8. Foot and Ankle

A 40-year-old roofer falls and sustains a closed, displaced, intra-articular joint-depression calcaneus fracture. The surgeon elects to perform an open reduction and internal fixation via an extensile lateral approach. Which of the following vascular structures must be protected within the full-thickness flap?

. Dorsalis pedis artery
. Posterior tibial artery
. Lateral calcaneal artery
. Medial plantar artery
. First dorsal metatarsal artery

Correct Answer & Explanation

. Lateral calcaneal artery

Explanation

The lateral calcaneal artery provides the primary blood supply to the corner of the skin flap used in the extensile lateral approach to the calcaneus. The flap must be full-thickness, subperiosteal, and handled atraumatically to minimize the high risk of tip necrosis and wound breakdown.

Question 4919

Topic: 8. Foot and Ankle

A 29-year-old professional football player sustains an ankle fracture-dislocation with a confirmed complete syndesmotic disruption. He is treated with open reduction and flexible suture-button fixation. Compared to traditional rigid screw fixation, what is a recognized advantage of flexible syndesmotic fixation?

. Lower risk of hardware removal and improved physiological joint kinematics
. Higher absolute construct stiffness limiting late diastasis
. Decreased risk of superficial peroneal nerve injury
. Requires less surgical time due to avoiding fibular reduction
. Promotes earlier syndesmotic fusion

Correct Answer & Explanation

. Lower risk of hardware removal and improved physiological joint kinematics

Explanation

Flexible suture-button constructs provide sufficient stability while allowing physiologic micro-motion at the syndesmosis during gait. They significantly reduce the need for routine hardware removal and decrease the risk of hardware breakage compared to rigid syndesmotic screws.

Question 4920

Topic: 8. Foot and Ankle

A 45-year-old woman complains of sharp, burning pain in the ball of her foot radiating into the third and fourth toes. Examination reveals a positive Mulder's click. After failing non-operative management, she is scheduled for surgical excision via a dorsal approach. Which structure must be transected to adequately resect the neuroma?

. Deep transverse metatarsal ligament
. Plantar fascia
. Flexor digitorum brevis tendon
. Lumbrical tendon
. Plantar plate

Correct Answer & Explanation

. Deep transverse metatarsal ligament

Explanation

When excising a Morton's neuroma (commonly found in the 3rd intermetatarsal space) through a dorsal approach, the deep transverse metatarsal ligament must be released. This allows adequate visualization and proximal retraction of the nerve to resect it in healthy tissue.

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