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8. Foot and Ankle MCQs

Practice Set 249 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 4961

Topic: Midfoot & Hindfoot

A 58-year-old man with poorly controlled diabetes mellitus presents with a red, hot, swollen right foot. He has no open wounds or systemic signs of infection. Radiographs reveal fragmentation and subluxation of the midfoot. What is the most appropriate initial management?

. Intravenous antibiotics
. Urgent irrigation and debridement
. Total contact casting and strict non-weight-bearing
. Open reduction and internal fixation of the midfoot
. Midfoot arthrodesis

Correct Answer & Explanation

. Total contact casting and strict non-weight-bearing

Explanation

This presentation is classic for acute Eichenholtz stage 1 (fragmentation) Charcot arthropathy. Initial treatment demands strict immobilization and offloading with a total contact cast until the acute inflammatory phase resolves.

Question 4962

Topic: 8. Foot and Ankle

A 25-year-old skier sustains a forced dorsiflexion injury to his ankle while actively everting his foot. He complains of a snapping sensation over the posterolateral ankle during walking. What anatomical structure is most likely injured?

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

Correct Answer & Explanation

. Superior peroneal retinaculum

Explanation

The superior peroneal retinaculum prevents bowstringing of the peroneal tendons. Injury to this retinaculum leads to recurrent peroneal tendon subluxation over the lateral malleolus.

Question 4963

Topic: 8. Foot and Ankle

A 14-year-old boy presents with a history of recurrent ankle sprains and rigid flatfeet. A CT scan of the foot confirms an osseous calcaneonavicular coalition. If nonoperative treatments fail, what is the surgical treatment of choice for a symptomatic coalition without arthritic changes?

. Triple arthrodesis
. Subtalar arthrodesis
. Resection of the coalition and interposition of the extensor digitorum brevis muscle
. Calcaneal lengthening osteotomy
. Flexor digitorum longus transfer

Correct Answer & Explanation

. Resection of the coalition and interposition of the extensor digitorum brevis muscle

Explanation

In young patients lacking degenerative joint changes, resection of the calcaneonavicular bar with interposition of tissue (e.g., extensor digitorum brevis or fat) restores motion and prevents recurrence.

Question 4964

Topic: 8. Foot and Ankle

A 65-year-old man with end-stage post-traumatic ankle osteoarthritis desires surgical intervention. He has a history of a talar neck fracture that led to avascular necrosis (AVN) of the talar body involving 60% of the bone. Which of the following is an absolute contraindication to total ankle arthroplasty (TAA) in this patient?

. Age greater than 60 years
. Extensive avascular necrosis of the talus
. Previous ankle fracture
. Hindfoot valgus of 5 degrees
. Body Mass Index of 28

Correct Answer & Explanation

. Extensive avascular necrosis of the talus

Explanation

Extensive avascular necrosis of the talus (>50%) is an absolute contraindication for total ankle arthroplasty due to inadequate viable bone stock to support the talar component. Arthrodesis is the preferred alternative.

Question 4965

Topic: 8. Foot and Ankle

A 65-year-old active man presents with a 2-week history of a "slapping gait" and inability to clear his foot during the swing phase. Examination reveals an inability to actively dorsiflex the ankle with the foot in inversion, and a palpable defect over the anterior ankle. For a healthy, active patient, what is the most appropriate treatment?

. Ankle-foot orthosis (AFO) indefinitely
. Primary end-to-end surgical repair
. Transfer of the peroneus longus tendon
. Tibiotalar arthrodesis
. Achilles tendon lengthening alone

Correct Answer & Explanation

. Primary end-to-end surgical repair

Explanation

An acute tibialis anterior tendon rupture in an active patient is best treated with primary surgical repair. This restores physiological dorsiflexion power and avoids the need for lifelong bracing.

Question 4966

Topic: 8. Foot and Ankle
A 55-year-old female presents with medial ankle pain and a progressively flattening arch. Examination shows a "too-many-toes" sign, flexible hindfoot valgus, and forefoot abduction of 35 degrees. Radiographs demonstrate >40% uncoverage of the talonavicular joint. What is the most appropriate surgical management?
. Flexor digitorum longus (FDL) transfer alone
. FDL transfer combined with a medial displacement calcaneal osteotomy
. FDL transfer combined with a lateral column lengthening osteotomy
. Isolated subtalar arthrodesis
. Triple arthrodesis

Correct Answer & Explanation

. FDL transfer combined with a lateral column lengthening osteotomy

Explanation

This clinical scenario describes a Stage IIb adult-acquired flatfoot deformity characterized by significant forefoot abduction. Management typically requires a lateral column lengthening (e.g., Evans osteotomy) to correct the abduction, combined with a medial soft tissue procedure like an FDL transfer.

Question 4967

Topic: 8. Foot and Ankle

A 24-year-old equestrian presents with severe midfoot pain after falling from a horse. Examination reveals plantar ecchymosis. Weight-bearing radiographs show a 3 mm diastasis between the base of the first and second metatarsals without associated fractures. What is the most appropriate definitive management?

. Closed reduction and short leg cast for 6 weeks
. Open reduction and internal fixation with screws
. Primary arthrodesis of the first, second, and third tarsometatarsal joints
. Primary arthrodesis of the fourth and fifth tarsometatarsal joints
. Suture button suspensionplasty alone

Correct Answer & Explanation

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

Explanation

Purely ligamentous Lisfranc injuries have higher rates of hardware failure and post-traumatic arthritis with ORIF compared to primary arthrodesis. Arthrodesis of the medial columns (1st-3rd TMT joints) is the preferred definitive treatment for purely ligamentous injuries.

Question 4968

Topic: Midfoot & Hindfoot
A 55-year-old woman presents with medial ankle pain and a progressive flatfoot deformity. Examination shows a flexible hindfoot valgus and inability to perform a single-leg heel raise. Radiographs demonstrate >40% talonavicular uncoverage. Which surgical intervention is most appropriate if conservative management fails?
. Isolated flexor digitorum longus (FDL) transfer to the navicular
. FDL transfer and medial displacement calcaneal osteotomy (MDCO)
. FDL transfer, MDCO, and lateral column lengthening
. Subtalar arthrodesis alone
. Triple arthrodesis

Correct Answer & Explanation

. FDL transfer, MDCO, and lateral column lengthening

Explanation

This patient has Stage IIb adult-acquired flatfoot deformity, characterized by a flexible deformity with forefoot abduction (>30-40% talonavicular uncoverage). Treatment requires an FDL transfer, medial displacement calcaneal osteotomy, and a lateral column lengthening (Evans osteotomy) to correct the forefoot abduction.

Question 4969

Topic: 8. Foot and Ankle

During a percutaneous repair of an acute Achilles tendon rupture, the surgeon places sutures in the proximal stump. Which of the following describes the most at-risk anatomic structure and its location relative to the calcaneal insertion?

. Tibial nerve, 5 cm proximal to the insertion
. Tibial nerve, 10 cm proximal to the insertion
. Sural nerve, 5 cm proximal to the insertion
. Sural nerve, 10 cm proximal to the insertion
. Saphenous nerve, 10 cm proximal to the insertion

Correct Answer & Explanation

. Sural nerve, 10 cm proximal to the insertion

Explanation

The sural nerve is at highest risk during percutaneous Achilles tendon repair. It typically crosses the lateral border of the Achilles tendon approximately 9.8 to 10 cm proximal to its insertion on the calcaneus.

Question 4970

Topic: 8. Foot and Ankle

A 30-year-old man sustains a Hawkins type II fracture of the talar neck. Which blood supply to the talar body is most likely preserved in this specific injury pattern?

. Artery of the tarsal canal
. Deltoid branch of the posterior tibial artery
. Artery of the tarsal sinus
. Dorsalis pedis branches
. Peroneal artery branches

Correct Answer & Explanation

. Deltoid branch of the posterior tibial artery

Explanation

A Hawkins type II fracture involves a talar neck fracture with subluxation or dislocation of the subtalar joint, disrupting the artery of the tarsal canal and tarsal sinus. The deltoid branch of the posterior tibial artery is typically preserved as the tibiotalar joint remains reduced.

Question 4971

Topic: Midfoot & Hindfoot

A 60-year-old patient with poorly controlled diabetes presents with a unilaterally swollen, red, and warm foot for 3 weeks. Radiographs show periarticular debris, fragmentation, and subluxation at the tarsometatarsal joints. What is the most appropriate immediate management?

. Intravenous antibiotics and emergent surgical debridement
. Total contact casting and strict non-weight-bearing
. Primary arthrodesis of the tarsometatarsal joints
. Open reduction and internal fixation of the midfoot
. Custom orthotic shoe wear and weight-bearing as tolerated

Correct Answer & Explanation

. Total contact casting and strict non-weight-bearing

Explanation

This patient presents with Eichenholtz Stage I (developmental/fragmentation) Charcot arthropathy. The mainstay of initial treatment for acute Charcot is immobilization and offloading, most effectively achieved with a total contact cast to prevent further deformity.

Question 4972

Topic: Forefoot

A 45-year-old woman complains of painful bunions. Examination reveals first tarsometatarsal (TMT) joint hypermobility. Radiographs demonstrate a hallux valgus angle (HVA) of 45 degrees and an intermetatarsal angle (IMA) of 18 degrees. Which of the following procedures is most appropriate?

. Distal chevron osteotomy
. Proximal crescentic osteotomy
. Lapidus procedure (1st TMT arthrodesis)
. Akin osteotomy alone
. Keller resection arthroplasty

Correct Answer & Explanation

. Lapidus procedure (1st TMT arthrodesis)

Explanation

A Lapidus procedure (first TMT arthrodesis) is indicated for moderate-to-severe hallux valgus (IMA >15 degrees) accompanied by first TMT joint hypermobility. It provides powerful correction of the intermetatarsal angle and stabilizes the medial column.

Question 4973

Topic: 8. Foot and Ankle

A 14-year-old boy presents with frequent ankle sprains and rigid pes planus. Radiographs reveal an 'anteater nose' sign on the lateral view. Which of the following anatomical structures is most likely involved in this patient's pathology?

. Calcaneus and navicular
. Talus and calcaneus
. Talus and navicular
. Calcaneus and cuboid
. Navicular and medial cuneiform

Correct Answer & Explanation

. Calcaneus and navicular

Explanation

The 'anteater nose' sign on a lateral foot radiograph is highly indicative of a calcaneonavicular coalition. This results from a tubular prolongation of the anterior process of the calcaneus approaching or overlapping the navicular.

Question 4974

Topic: 8. Foot and Ankle

In a displaced intra-articular calcaneus fracture, the 'constant fragment' remains anatomically aligned with the talus. Which ligamentous attachment is primarily responsible for maintaining the position of this fragment?

. Calcaneofibular ligament
. Spring ligament
. Interosseous talocalcaneal ligament
. Deltoid ligament
. Bifurcate ligament

Correct Answer & Explanation

. Deltoid ligament

Explanation

The sustentaculum tali is referred to as the 'constant fragment' in calcaneus fractures because it remains securely attached to the talus. This stability is maintained primarily by the strong deltoid and talocalcaneal ligaments.

Question 4975

Topic: Forefoot

A 62-year-old man presents with painful, restricted dorsiflexion of the great toe. Radiographs show severe joint space narrowing, large dorsal osteophytes, and subchondral sclerosis at the first metatarsophalangeal (MTP) joint. He has pain throughout the entire arc of motion. What is the most reliable surgical option for long-term pain relief?

. Cheilectomy
. First MTP joint arthrodesis
. Moberg osteotomy
. First TMT joint arthrodesis
. Silicone implant arthroplasty

Correct Answer & Explanation

. First MTP joint arthrodesis

Explanation

This patient has Grade 3/4 hallux rigidus with pain throughout the arc of motion and severe radiographic changes. First MTP joint arthrodesis is the gold standard for end-stage hallux rigidus, providing the most reliable long-term pain relief.

Question 4976

Topic: Ankle Trauma & Sports

A 28-year-old athlete sustains an external rotation injury to the ankle. Intraoperatively, the syndesmosis is evaluated. Which of the following ligaments contributes the greatest percentage of mechanical stability to the distal tibiofibular syndesmosis?

. Anterior inferior tibiofibular ligament (AITFL)
. Posterior inferior tibiofibular ligament (PITFL)
. Interosseous ligament
. Deltoid ligament
. Calcaneofibular ligament

Correct Answer & Explanation

. Posterior inferior tibiofibular ligament (PITFL)

Explanation

The posterior inferior tibiofibular ligament (PITFL) is the strongest and provides the greatest mechanical stability to the syndesmosis, contributing approximately 42% of its resistance to diastasis.

Question 4977

Topic: Midfoot & Hindfoot

A 25-year-old professional football player sustains a purely ligamentous Lisfranc injury involving the first, second, and third tarsometatarsal joints. Nonoperative management is deemed inappropriate due to the severity of the instability. According to recent high-level prospective studies, which of the following surgical interventions is associated with the best functional outcome and lowest rate of hardware removal in purely ligamentous injuries?

. Open reduction and internal fixation with transarticular screws
. Open reduction and internal fixation with dorsal spanning plates
. Primary arthrodesis of the first, second, and third tarsometatarsal joints
. Closed reduction and percutaneous pinning
. Suture button suspensionplasty of the medial column

Correct Answer & Explanation

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

Explanation

For purely ligamentous Lisfranc injuries, primary arthrodesis of the involved medial rays (1st-3rd TMT joints) has been shown to yield superior functional outcomes and lower reoperation rates compared to ORIF. ORIF is generally preferred when there is significant bony involvement rather than purely ligamentous disruption.

Question 4978

Topic: 8. Foot and Ankle

A 56-year-old man with poorly controlled type 2 diabetes and peripheral neuropathy presents with a red, hot, and swollen left foot that began 2 weeks ago without distinct trauma.

Pedal pulses are bounding. Weight-bearing radiographs reveal diffuse osteopenia but no fractures, joint subluxation, or fragmentation. What is the most appropriate initial management?

. Immediate operative debridement and culture
. Intravenous antibiotics and MRI of the foot
. Total contact casting and non-weight-bearing restrictions
. Surgical arthrodesis of the midfoot
. Corticosteroid injection into the midtarsal joints

Correct Answer & Explanation

. Total contact casting and non-weight-bearing restrictions

Explanation

This clinical presentation is characteristic of an Eichenholtz stage 0 Charcot neuroarthropathy. The most appropriate initial treatment is total contact casting to immobilize the foot and prevent progression to fragmentation and deformity.

Question 4979

Topic: 8. Foot and Ankle

A 40-year-old recreational athlete sustains an acute, closed midsubstance Achilles tendon rupture. He opts for nonoperative management. To optimize his outcomes and reduce the rerupture rate to a level comparable with surgical repair, which of the following rehabilitation protocols should be employed?

. Long-leg casting in equinus for 6 weeks followed by progressive stretching
. Early functional rehabilitation with protected weight-bearing in a functional brace
. Strict non-weight-bearing in a short-leg cast for 8 weeks
. Immediate unrestricted weight-bearing in regular shoewear
. Immobilization in a rigid splint at neutral ankle position for 4 weeks

Correct Answer & Explanation

. Early functional rehabilitation with protected weight-bearing in a functional brace

Explanation

Modern evidence demonstrates that functional rehabilitation protocols with early, protected weight-bearing in a brace significantly lower rerupture rates in nonoperatively managed Achilles tendon ruptures, making them comparable to operative outcomes. Prolonged static immobilization is associated with higher rerupture rates and worse functional recovery.

Question 4980

Topic: Forefoot

A 62-year-old woman presents with end-stage hallux rigidus (Coughlin and Shurnas Grade 3) and severe pain with ambulation. Conservative measures have failed, and she elects to undergo first metatarsophalangeal (MTP) joint arthrodesis. To ensure an optimal functional outcome, in what position should the first MTP joint be fused?

. 10 degrees of plantarflexion and 5 degrees of varus
. Neutral dorsiflexion and neutral rotation
. 30 degrees of dorsiflexion and 20 degrees of valgus
. 10 to 15 degrees of valgus and 15 degrees of dorsiflexion relative to the floor
. 5 degrees of valgus and 40 degrees of dorsiflexion relative to the floor

Correct Answer & Explanation

. 10 to 15 degrees of valgus and 15 degrees of dorsiflexion relative to the floor

Explanation

The ideal position for a first MTP joint arthrodesis is approximately 10-15 degrees of valgus and 15 degrees of dorsiflexion relative to the floor. This position allows for normal toe-off during the gait cycle and accommodates standard shoe wear.

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