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8. Foot and Ankle MCQs

Practice Set 247 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 4921

Topic: 8. Foot and Ankle

A 24-year-old male sustains a midfoot injury during a rugby tackle. Weight-bearing radiographs demonstrate a 3-mm diastasis between the base of the first and second metatarsals. MRI confirms a purely ligamentous tear of the Lisfranc complex without associated fractures. Which of the following treatments has been shown to provide the best long-term functional outcome for this specific injury pattern?

. Non-weight-bearing cast immobilization for 8 weeks
. Open reduction and internal fixation with transarticular screws
. Primary arthrodesis of the first, second, and third tarsometatarsal joints
. Closed reduction and percutaneous pinning
. Suture button suspensionplasty

Correct Answer & Explanation

. Primary arthrodesis of the first, second, and third tarsometatarsal joints

Explanation

Recent evidence demonstrates that primary arthrodesis yields superior functional outcomes and lower reoperation rates compared to ORIF for purely ligamentous Lisfranc injuries. ORIF is generally preferred for bony Lisfranc fracture-dislocations.

Question 4922

Topic: Midfoot & Hindfoot
A 55-year-old woman presents with severe flexible flatfoot deformity. Examination shows inability to perform a single-leg heel rise. Radiographs demonstrate >40% uncoverage of the talonavicular joint and severe forefoot abduction. What surgical reconstruction is most appropriate for this Stage IIb posterior tibial tendon dysfunction?
. Isolated flexor digitorum longus (FDL) transfer to the navicular
. Medial displacement calcaneal osteotomy and FDL transfer
. Medial displacement calcaneal osteotomy, lateral column lengthening, and FDL transfer
. Talonavicular arthrodesis alone
. Triple arthrodesis

Correct Answer & Explanation

. Medial displacement calcaneal osteotomy, lateral column lengthening, and FDL transfer

Explanation

Stage IIb adult-acquired flatfoot involves significant forefoot abduction (>30% talonavicular uncoverage). A lateral column lengthening (Evans osteotomy) is necessary to correct the abduction, combined with an FDL transfer and medializing calcaneal osteotomy.

Question 4923

Topic: 8. Foot and Ankle

During surgical excision of a symptomatic Haglund's deformity and debridement of insertional Achilles tendinosis, the surgeon notes that 60% of the Achilles tendon insertion has been debrided to remove all tendinopathic tissue. What is the most appropriate next step?

. Primary repair using heavy nonabsorbable sutures only
. Tendon transfer using the flexor hallucis longus (FHL)
. Tendon transfer using the peroneus brevis
. Gastrocnemius recession and application of a tension-band wire
. V-Y fractional lengthening of the Achilles tendon

Correct Answer & Explanation

. Tendon transfer using the flexor hallucis longus (FHL)

Explanation

If more than 50% of the Achilles tendon insertion is compromised during debridement for insertional tendinopathy, augmentation with a Flexor Hallucis Longus (FHL) tendon transfer is indicated to restore plantarflexion strength and prevent rupture.

Question 4924

Topic: 8. Foot and Ankle

A 14-year-old boy presents with a history of recurrent lateral ankle sprains and a rigid, painful flatfoot. Oblique radiographs demonstrate an "anteater nose" sign. Nonoperative management has failed. What is the most appropriate surgical intervention?

. Triple arthrodesis
. Subtalar arthrodesis
. Resection of the coalition with extensor digitorum brevis interposition
. Medial displacement calcaneal osteotomy
. Talonavicular arthrodesis

Correct Answer & Explanation

. Resection of the coalition with extensor digitorum brevis interposition

Explanation

The "anteater nose" sign indicates a calcaneonavicular coalition. In a young patient without advanced arthritis, the treatment of choice after failed conservative care is resection of the coalition and interposition of the extensor digitorum brevis muscle or fat pad.

Question 4925

Topic: 8. Foot and Ankle

A 62-year-old male with severe ankle osteoarthritis is evaluated for a total ankle arthroplasty (TAA). Which of the following is considered an absolute contraindication to this procedure?

. Age greater than 60 years
. Body mass index (BMI) of 28
. Charcot neuroarthropathy of the ankle
. Mild to moderate adjacent joint arthritis
. A correctable varus deformity of 5 degrees

Correct Answer & Explanation

. Charcot neuroarthropathy of the ankle

Explanation

Absolute contraindications to total ankle arthroplasty include Charcot neuroarthropathy, active or recent infection, absent leg sensation, severe inadequate soft tissue envelope, and avascular necrosis of the entire talus.

Question 4926

Topic: Forefoot
A 55-year-old man presents with chronic pain and stiffness in his first metatarsophalangeal (MTP) joint. Examination reveals a palpable dorsal prominence and dorsiflexion limited to 10 degrees. Radiographs reveal advanced joint space narrowing (<50% remaining) and large dorsal osteophytes. What is the most reliable definitive treatment for this patient?
. Aggressive physical therapy and stretching
. First MTP joint cheilectomy
. First MTP joint arthrodesis
. Proximal phalanx osteotomy (Moberg)
. Silicone implant arthroplasty

Correct Answer & Explanation

. First MTP joint arthrodesis

Explanation

This patient has Grade 3 hallux rigidus. While cheilectomy is highly effective for Grade 1 and 2, arthrodesis of the first MTP joint is the most reliable, definitive treatment for advanced (Grade 3 and 4) hallux rigidus, providing predictable pain relief.

Question 4927

Topic: 8. Foot and Ankle

A 58-year-old diabetic male presents with an acutely swollen, red, and warm right foot. He denies trauma. Pulses are bounding and skin is intact. Radiographs show early fragmentation and debris at the tarsometatarsal joints. Which of the following is the most appropriate initial management?

. Intravenous antibiotics and emergent surgical debridement
. Open reduction and internal fixation of the midfoot
. Total contact casting and strict non-weight-bearing
. Primary midfoot arthrodesis
. Prescription of rigid accommodative footwear

Correct Answer & Explanation

. Total contact casting and strict non-weight-bearing

Explanation

The patient is presenting with acute Eichenholtz Stage I Charcot neuroarthropathy. The gold standard for initial management is total contact casting to immobilize the foot and prevent further deformity until the acute inflammatory stage resolves.

Question 4928

Topic: 8. Foot and Ankle

A 28-year-old skier reports a "popping" sensation behind his lateral malleolus followed by swelling. Examination reveals tenderness posterior to the fibula, and the tendons can be felt subluxating anteriorly with active ankle dorsiflexion and eversion. Injury to which of the following structures is the primary cause of this condition?

. Anterior talofibular ligament
. Calcaneofibular ligament
. Superior peroneal retinaculum
. Inferior extensor retinaculum
. Peroneus brevis tendon

Correct Answer & Explanation

. Superior peroneal retinaculum

Explanation

Peroneal tendon subluxation is caused by an injury to or incompetence of the superior peroneal retinaculum (SPR), which is the primary restraint to anterior displacement of the peroneal tendons out of the retromalleolar groove.

Question 4929

Topic: 8. Foot and Ankle
A 35-year-old woman presents with chronic medial ankle pain. On physical examination, her ankle dorsiflexion improves significantly when her knee is flexed compared to when her knee is extended. Which of the following procedures would specifically target the pathology indicated by this examination finding?
. Achilles tendon lengthening (Z-plasty)
. Proximal medial gastrocnemius recession
. Flexor hallucis longus transfer
. Endoscopic plantar fasciotomy
. Tarsal tunnel release

Correct Answer & Explanation

. Proximal medial gastrocnemius recession

Explanation

The physical exam describes a positive Silfverskiöld test, which differentiates isolated gastrocnemius tightness from combined gastrocnemius-soleus contracture. If dorsiflexion improves with knee flexion, an isolated gastrocnemius recession is indicated.

Question 4930

Topic: Forefoot

A 45-year-old woman with a painful bunion has an intermetatarsal angle of 18 degrees, a hallux valgus angle of 45 degrees, and clinical hypermobility of the first tarsometatarsal (TMT) joint. Which of the following procedures is most appropriate to comprehensively address her pathology?

. Distal chevron osteotomy
. Akin osteotomy alone
. Keller resection arthroplasty
. First TMT joint arthrodesis (Lapidus procedure)
. First MTP joint arthrodesis

Correct Answer & Explanation

. First TMT joint arthrodesis (Lapidus procedure)

Explanation

Severe hallux valgus (IMA >15 degrees, HVA >40 degrees) accompanied by hypermobility of the first TMT joint is best treated with a Lapidus procedure (first TMT arthrodesis) to provide medial column stability and robust correction of the deformity.

Question 4931

Topic: 8. Foot and Ankle

A 16-year-old female presents with localized pain and swelling over the dorsal aspect of the second metatarsophalangeal joint. Radiographs reveal flattening, sclerosis, and fragmentation of the second metatarsal head. What is the most likely diagnosis?

. Sever's disease
. Kohler's disease
. Freiberg's infarction
. Morton's neuroma
. Stress fracture of the metatarsal shaft

Correct Answer & Explanation

. Freiberg's infarction

Explanation

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

Question 4932

Topic: Forefoot

A 45-year-old female presents with severe bunion pain. Weight-bearing radiographs reveal a Hallux Valgus Angle (HVA) of 45 degrees, an Intermetatarsal Angle (IMA) of 18 degrees, and hypermobility at the first tarsometatarsal (TMT) joint. What is the most appropriate surgical management?

. Distal chevron osteotomy
. Proximal opening wedge osteotomy
. Lapidus procedure (first TMT arthrodesis)
. Akin osteotomy alone
. Keller resection arthroplasty

Correct Answer & Explanation

. Lapidus procedure (first TMT arthrodesis)

Explanation

The Lapidus procedure is indicated for moderate to severe hallux valgus (IMA > 15 degrees) especially in the presence of first TMT joint hypermobility. Distal osteotomies cannot adequately correct an IMA of this magnitude.

Question 4933

Topic: 8. Foot and Ankle

A 35-year-old recreational basketball player sustains an acute Achilles tendon rupture. Compared to surgical repair, modern nonoperative management utilizing early functional rehabilitation is associated with a higher rate of which of the following?

. Deep vein thrombosis
. Infection
. Sural nerve injury
. Re-rupture
. None of the above; re-rupture rates are equivalent

Correct Answer & Explanation

. None of the above; re-rupture rates are equivalent

Explanation

Recent high-quality studies demonstrate that when functional rehabilitation protocols with early weight-bearing are used, nonoperative management has re-rupture rates equivalent to operative management. Operative management carries higher risks of infection and nerve injury.

Question 4934

Topic: Midfoot & Hindfoot

A 55-year-old female presents with medial ankle pain and a progressively flattening arch. Examination reveals a flexible hindfoot valgus and inability to perform a single-leg heel raise. Nonoperative management has failed. Which of the following is the most appropriate surgical intervention?

. Subtalar arthrodesis
. Triple arthrodesis
. Flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy
. Talonavicular arthrodesis
. Kidner procedure

Correct Answer & Explanation

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

Explanation

This patient has Stage II adult-acquired flatfoot deformity (posterior tibial tendon dysfunction) characterized by a flexible deformity. Joint-sparing procedures such as an FDL transfer combined with a medial displacement calcaneal osteotomy are indicated.

Question 4935

Topic: 8. Foot and Ankle

A 14-year-old male presents with a progressive bilateral cavovarus foot deformity. Neurological evaluation confirms Charcot-Marie-Tooth disease. The plantarflexed first ray in this deformity is primarily driven by the overpull of which muscle?

. Tibialis anterior
. Tibialis posterior
. Peroneus longus
. Peroneus brevis
. Extensor hallucis longus

Correct Answer & Explanation

. Peroneus longus

Explanation

In Charcot-Marie-Tooth disease, the peroneus brevis and tibialis anterior become weak. The preserved strength of the peroneus longus overpowers the weak tibialis anterior, causing a plantarflexed first ray and forefoot pronation.

Question 4936

Topic: Midfoot & Hindfoot

A 24-year-old football player sustains a high-energy midfoot injury. Radiographs reveal a "fleck sign" in the first intermetatarsal space. Ligamentous Lisfranc injuries are most reliably treated with which of the following methods to minimize the risk of hardware failure and long-term midfoot arthritis?

. Closed reduction and cast immobilization
. Percutaneous Kirschner wire fixation
. Primary arthrodesis of the first, second, and third tarsometatarsal joints
. Open reduction and internal fixation with rigid transarticular screws
. Suture button suspensionplasty alone

Correct Answer & Explanation

. Primary arthrodesis of the first, second, and third tarsometatarsal joints

Explanation

For purely ligamentous Lisfranc injuries, primary arthrodesis of the medial columns (1st-3rd TMT joints) has been shown to have superior long-term outcomes and fewer reoperations compared to ORIF.

Question 4937

Topic: 8. Foot and Ankle

A 42-year-old marathon runner complains of burning pain and tingling in the plantar aspect of her foot, which worsens at night and after long runs. Examination reveals a positive Tinel's sign posterior to the medial malleolus. Which structure forms the roof of the anatomic space where this nerve is compressed?

. Plantar fascia
. Flexor retinaculum
. Superior extensor retinaculum
. Inferior extensor retinaculum
. Spring ligament

Correct Answer & Explanation

. Flexor retinaculum

Explanation

Tarsal tunnel syndrome involves compression of the tibial nerve posterior to the medial malleolus. The flexor retinaculum forms the roof of the tarsal tunnel, while the medial malleolus and talus/calcaneus form the floor.

Question 4938

Topic: 8. Foot and Ankle

A 62-year-old male with post-traumatic end-stage ankle arthritis is being evaluated for surgical intervention. Which of the following is considered an absolute contraindication to a total ankle arthroplasty?

. Age over 60 years
. Concomitant subtalar arthritis
. Body Mass Index (BMI) of 32
. Severe peripheral neuropathy with lack of protective sensation
. A prior history of a bimalleolar ankle fracture

Correct Answer & Explanation

. Severe peripheral neuropathy with lack of protective sensation

Explanation

Severe peripheral neuropathy with lack of protective sensation (e.g., Charcot arthropathy) is an absolute contraindication for total ankle arthroplasty due to the high risk of catastrophic failure and implant subsidence.

Question 4939

Topic: 8. Foot and Ankle

A 28-year-old male presents with chronic ankle pain following a severe inversion sprain 6 months ago. MRI demonstrates an osteochondral lesion of the talus. Based on typical anatomic patterns, an anterolateral talar dome lesion is most likely to have which of the following characteristics?

. Insidious onset and deep, cup-shaped morphology
. Traumatic etiology and shallow, wafer-shaped morphology
. Insidious onset and shallow, wafer-shaped morphology
. Traumatic etiology and deep, cup-shaped morphology
. Location primarily on the posterior margin of the talus

Correct Answer & Explanation

. Traumatic etiology and shallow, wafer-shaped morphology

Explanation

Anterolateral osteochondral lesions of the talus are typically traumatic in etiology and present as shallow, wafer-shaped defects. Posteromedial lesions are typically non-traumatic (insidious), deep, and cup-shaped.

Question 4940

Topic: 8. Foot and Ankle

A 40-year-old female complains of burning pain in her forefoot that radiates into her third and fourth toes, exacerbated by wearing high-heeled shoes. Squeezing the metatarsal heads together while applying plantar pressure produces a painful click. What is the most appropriate initial management?

. Surgical excision of the neuroma
. Release of the deep transverse metatarsal ligament
. Custom orthotics with a metatarsal pad and wide-toe box shoes
. Radiofrequency ablation of the interdigital nerve
. Primary first TMT joint arthrodesis

Correct Answer & Explanation

. Custom orthotics with a metatarsal pad and wide-toe box shoes

Explanation

This patient presents with a classic Morton's neuroma in the third web space, accompanied by a positive Mulder's click. Initial management is nonoperative, including wide-toe box shoes and metatarsal pads to offload the neuroma.

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