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8. Foot and Ankle MCQs

Practice Set 25 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 481

Topic: 8. Foot and Ankle

A 65-year-old woman presents with pain along the posteromedial aspect of her right ankle. She has a clinical deformity of her foot with loss of normal arch height. Her hindfoot is in valgus but is passively correctable to neutral. She has weakness with inversion and cannot perform a single stance heel raise. She has not had any form of treatment. Recommended treatment includes:

. Debridement of posterior tibial tendon
. Transfer of the flexor digitorum longus tendon and medial displacement calcaneal osteotomy
. A molded ankle orthosis
. Corticosteroid injection of posterior tibial tendon sheath
. Lateral column lengthening with flexor digitorum longus tendon transfer

Correct Answer & Explanation

. A molded ankle orthosis

Explanation

Although there is the likelihood that this patient may ultimately require surgery, the nonoperative management of posterior tibial tendon rupture is important. The success rate of bracing is variable, but bracing must be used as the first line of treatment for a patient as described above.

Question 482

Topic: 8. Foot and Ankle

After counseling a 22-year-old patient who is scheduled to undergo a triple arthrodesis, he wants to know the risk that he will develop ankle arthritis. You tell him:

. The risk of developing ankle arthritis after a triple arthrodesis is unknown.
. Ankle arthritis does not occur following triple arthrodesis.
. 100% at 5 years
. 25% at 5 years
. 50% at 5 years

Correct Answer & Explanation

. 50% at 5 years

Explanation

Ankle arthritis commonly occurs following a triple arthrodesis. In a recent study by Pell and colleagues, the incidence of ankle arthritis in 134 patients who underwent a triple arthrodesis with a 5.6-year mean follow-up was 53%. Although not all of these patients are symptomatic, this is a problem.

Question 483

Topic: 8. Foot and Ankle

A 57-year-old woman presents for treatment of a painful flatfoot deformity. She says that her foot has been painful for 4 years, but she does not recall any injury to the foot. The opposite foot is not bothersome. Upon examination, she has pain in the midfoot and hindfoot. Resisted inversion is strong and painful. She is able to perform a single and repetitive heel rise test. The most likely diagnosis is:

. An unrecognized Lisfranc injury
. Posterior tibial tendon rupture
. Rupture of the spring ligament
. Idiopathic tarsometatarsal arthritis
. C alcaneonavicular tarsal coalition

Correct Answer & Explanation

. Idiopathic tarsometatarsal arthritis

Explanation

Osteoarthritis of the tarsometatarsal joints in the adult is common. Patients are usually 50 to 60 years old, and the condition typically presents with pain in the midfoot and becomes progressively worse over time. The posterior tibial tendon is not torn, but as the foot becomes flatter and the forefoot more abducted there may be secondary stretching or tearing of the posterior tibial tendon.

Question 484

Topic: 8. Foot and Ankle

Which clinical examination is likely to confirm a suspected rupture of the posterior tibial tendon:

. Active plantarflexion of the foot against resistance
. C ombined active plantarflexion and inversion of the foot against resistance
. Resisted active inversion of the foot when the foot is positioned in abduction
. Ability to perform a single heel rise test
. The presence of forefoot abduction upon standing and inability to adduct the foot

Correct Answer & Explanation

. Resisted active inversion of the foot when the foot is positioned in abduction

Explanation

The anterior tibial tendon can compensate for a weak posterior tibial tendon. The primary function of the anterior tibial tendon is dorsiflexion, although the tendon may also invert the foot, particularly against resistance in the presence of a ruptured posterior tibial tendon. To prevent the anterior tibial tendon from inverting the foot, position the foot in plantarflexion and abduction to begin with when testing resistance to inversion.

Question 485

Topic: 8. Foot and Ankle
A 68-year-old patient presents for evaluation of ankle pain. He is unable to walk more than 10 minutes without pain and stiffness. He has been treated with anti-inflammatory medication, intra-articular injection of steroid, and an ankle foot orthosis. He has 35° of clinical motion associated with crepitus and pain and there is no motion in the subtalar joint. Radiographs demonstrate large osteophytes in the anterior ankle, no joint space, and mild osteophytes of the talonavicular joint. The recommended surgical treatment is:
. Anterior ankle cheilectomy
. Ankle arthroscopy
. Ankle arthrodesis
. Tibiotalocalcaneal arthrodesis
. Total ankle replacement

Correct Answer & Explanation

. Total ankle replacement

Explanation

A patient with good range of motion of the ankle associated with poor subtalar motion and ankle arthritis is a candidate for a total ankle replacement. Although ankle arthrodesis may be considered, in the presence of a stiff subtalar joint, osteophytes of the talonavicular joint, and good ankle motion, this procedure is likely to lead to a high incidence of peritalar arthritis and pain.

Question 486

Topic: 8. Foot and Ankle

A 21-year-old recreational athlete presents for treatment of ankle weakness. She notes that she trips frequently, that the ankle feels unstable, particularly on uneven ground surfaces, and that she has experienced frequent sprains. On examination, the ankle appears to be unstable and radiographs demonstrate no instability on stress testing. The most likely diagnosis is:

. Generalized ligamentous laxity
. Tear of the anterior talofibular ligament
. Tear of the calcaneofibular ligament
. Tear of the talocalcaneal interosseous ligament
. Tear of the anterior talofibular and calcaneofibular

Correct Answer & Explanation

. Tear of the talocalcaneal interosseous ligament

Explanation

This patient has subtalar instability. When there is no instability demonstrated on radiographic stress testing despite a history of recurrent ankle sprains, the subtalar joint must be assessed.

Question 487

Topic: 8. Foot and Ankle

The symptoms of a tarsal tunnel syndrome may become aggravated by:

. Pronation of the foot
. Plantarflexion of the foot
. Dorsiflexion of the ankle
. Inversion of the foot
. Rotation of the ankle

Correct Answer & Explanation

. Pronation of the foot

Explanation

Pronation of the foot places increased stretch on the tibial nerve. This motion has important implications for treatment because the pronated flatfoot should be supported with an orthotic arch support in patients with symptoms of a tarsal tunnel syndrome.

Question 488

Topic: 8. Foot and Ankle

A 38-year-old woman presents for evaluation of painful hallux rigidus. Her clinical and radiographic images are shown (Slide 1 and Slide 2). Based upon her presentation, what is the likelihood that first metatarsus elevatus is responsible for her clinical condition:

. Rare
. 25%
. 50%
. 75%
. 100%

Correct Answer & Explanation

. Rare

Explanation

Surgeons cannot assume that an elevated first metatarsal is responsible for causing hallux rigidus. On a lateral radiograph, there may be notable elevation of the first metatarsal (as present in this patient), but the elevation may be a secondary result of the limited motion of the hallux metatarsophalangeal joint. Studies have demonstrated that there is no difference in the elevation of the first metatatarsal in patients with hallux rigidus.

Question 489

Topic: Forefoot

The patient shown in Slide 1 and Slide 2 underwent surgical correction of painful hallux rigidus. The purpose of the procedure on the hallux was:

. To increase the range of motion of the hallux metatarsophalangeal (MP) joint
. To elevate the hallux off the ground
. To depress the hallux and improve push off strength
. To decrease the jamming of the hallux MP joint on push off
. To change the kinematics of the hallux MP joint, thereby decreasing the likelihood of recurrent deformity

Correct Answer & Explanation

. To elevate the hallux off the ground

Explanation

The osteotomy of the proximal phalanx of the hallux (the Moberg osteotomy) is designed to elevate the hallux off the ground. The procedure does not improve the range of motion of the MP joint, but it increases the available motion of the hallux in toe off.

Question 490

Topic: 8. Foot and Ankle

Of the proximal first metatarsal osteotomies listed below, which has the least stability for dorsiflexion load:

. Ludloff osteotomy
. C rescentic osteotomy
. Scarf osteotomy
. C hevron osteotomy
. C losing wedge osteotomy

Correct Answer & Explanation

. C rescentic osteotomy

Explanation

The crescentic osteotomy is inferior on mechanical testing to the other proximal first metatarsal osteotomies. This must be considered when planning correction of deformity associated with hallux valgus, particularly in a patient with osteopenia.

Question 491

Topic: 8. Foot and Ankle

A 54-year-old patient presents for correction of painful hallux valgus. She has a prominent medial eminence, pain on pressure over the metatarsophalangeal (MP) joint, increased elevation of the first metatarsal, and painful callosity under the second metatarsal. The recommended procedure is:

. Arthrodesis of the hallux MP joint
. Proximal first metatarsal osteotomy and distal soft tissue release
. Distal metatarsal osteotomy and distal soft tissue release
. Arthrodesis of the metatarsocuneiform joint
. Proximal first metatarsal osteotomy, distal soft tissue release, and condylectomy of the second metatarsal head

Correct Answer & Explanation

. Arthrodesis of the metatarsocuneiform joint

Explanation

This patient has typical findings of hypermobility of the first metatarsal. The increased pressure under the second metatarsal head may be the result of elevation of the first metatarsal or dysfunction of the windlass mechanism that depresses the first metatarsal upon toe off. Hypermobility of the first ray associated with hallux valgus is successfully treated with arthrodesis of the metatarsocuneiform joint or the modified Lapidus procedure.

Question 492

Topic: 8. Foot and Ankle

This patient was treated for metatarsalgia with an oblique osteotomy of the metatarsal head and neck (Weil osteotomy). Although the symptoms of metatarsalgia dissipated, she has continued complaints about the position of the toe (Slide 1 and Slide

. Subluxation of the metatarsophalangeal (MP) joint
. Tearing of the volar plate
. Dorsal shift of the interosseous tendon
. Scarring in the skin and subcutaneous tissue
. Persistent contracture of the lumbrical tendons

Correct Answer & Explanation

. Dorsal shift of the interosseous tendon

Explanation

Following an oblique osteotomy of the metatarsal head and neck (Weil osteotomy), the interosseous tendons shift dorsal to the axis of the metatarsal head. Instead of functioning as strong plantarflexors of the MP joint, they may now function as dorsiflexors, leading to the elevation of the toe off the ground and dorsal contracture.

Question 493

Topic: 8. Foot and Ankle

A 35-year-old male sustains an axial load injury to a plantarflexed foot. Radiographs reveal widening of the space between the first and second metatarsals. A "fleck sign" is also noted. The primary ligament injured in this condition originates from and inserts into which of the following structures?

. Medial cuneiform to the base of the second metatarsal
. Lateral cuneiform to the base of the third metatarsal
. Navicular to the medial cuneiform
. Cuboid to the base of the fourth metatarsal
. Calcaneus to the cuboid

Correct Answer & Explanation

. Medial cuneiform to the base of the second metatarsal

Explanation

The Lisfranc ligament is a critical stabilizing structure of the midfoot. It traverses from the medial cuneiform to the base of the second metatarsal. A "fleck sign" represents a bony avulsion of this exact ligament.

Question 494

Topic: 8. Foot and Ankle

A 40-year-old construction worker undergoes ORIF of a displaced intra-articular calcaneus fracture via an extensile lateral approach. The most common wound complication associated with this approach is necrosis of the flap apex. Which artery primarily supplies this flap?

. Lateral calcaneal artery
. Medial calcaneal artery
. Sural artery
. Dorsalis pedis artery
. Posterior tibial artery

Correct Answer & Explanation

. Lateral calcaneal artery

Explanation

The extensile lateral approach to the calcaneus relies on the blood supply from the lateral calcaneal artery. Proper full-thickness flap creation (no-touch technique) is essential to prevent apical wound necrosis.

Question 495

Topic: 8. Foot and Ankle

A 55-year-old man with poorly controlled diabetes presents with a swollen, warm, and erythematous right foot. Radiographs reveal prominent bone fragmentation, subluxation at the tarsometatarsal joints, and joint debris.

According to the Eichenholtz classification, what is the current stage and most appropriate management?

. Stage 0; immediate arthrodesis
. Stage 1; total contact casting and non-weight bearing
. Stage 2; custom orthotic shoe wear
. Stage 3; midfoot osteotomy
. Stage 4; below-knee amputation

Correct Answer & Explanation

. Stage 1; total contact casting and non-weight bearing

Explanation

The clinical and radiographic presentation describes Eichenholtz Stage 1 (Developmental/Fragmentation), characterized by debris, fragmentation, and subluxation. The mainstay of treatment during this active phase is offloading and immobilization, typically with a total contact cast.

Question 496

Topic: 8. Foot and Ankle

A 55-year-old man with a 15-year history of poorly controlled type 2 diabetes presents with a swollen, warm, and erythematous right foot. He denies fever, chills, or any open wounds. Plain radiographs show midfoot osteopenia and early subluxation of the tarsometatarsal joints. Inflammatory markers are only mildly elevated. What is the most appropriate initial management?

. Intravenous broad-spectrum antibiotics
. Total contact casting and non-weight bearing
. Open reduction and internal fixation of the midfoot
. Below-knee amputation
. Incision and drainage of the midfoot joints

Correct Answer & Explanation

. Total contact casting and non-weight bearing

Explanation

The clinical presentation describes the acute (Eichenholtz stage I) phase of Charcot neuroarthropathy. The gold standard for initial management is immediate offloading and immobilization using a total contact cast to arrest the progression of bone destruction and deformity.

Question 497

Topic: 8. Foot and Ankle

While he is working, an industrial worker sustains a puncture wound to the plantar aspect of his foot. He suspects the wound was caused by a sharp protruding nail that penetrated his sneaker. The most likely organism to be responsible for a subsequent infection is:

. Staphylococcus aureus
. Pseudomonas aeruginosa
. Staphylococcus epidermidis
. Streptococcus viridans
. Enterobacter

Correct Answer & Explanation

. Staphylococcus aureus

Explanation

Although one must be concerned about the possibility of a Pseudomonas infection, the most common organism following puncture injury is staphylococcus aureus. Unless in the setting of diabetes or immune compromise, anaerobic infection rarely occurs.

Question 498

Topic: 8. Foot and Ankle

A 54-year-old woman sustained an injury to her knee 16 months ago. She describes the injury as a dislocation, and she was treated with ligament reconstruction. She has plantarflexion and inversion strength, absent ankle dorsiflexion, and weak eversion. She desires an improvement in the function of the ankle and the ability to comfortably ambulate. The ideal treatment for her is:

. Ankle arthrodesis in a neutral position
. Intramembranous transfer of the posterior tibial tendon
. Neurolysis of the common peroneal nerve
. Nerve graft of the common peroneal nerve
. Dorsal transfer of the peroneus brevis and longus tendons

Correct Answer & Explanation

. Intramembranous transfer of the posterior tibial tendon

Explanation

Following peroneal nerve injury, varying degrees of plantarflexion weakness may be present. In the patient with an intact and strong posterior tibial muscle, an intramembranous transfer to the dorsum of the foot may yield positive results with possible active dorsiflexion. Although neurolysis or nerve graft may be considered for selected patients, it is unlikely to yield a satisfactory result at this time following injury.

Question 499

Topic: Forefoot

A 61-year-old man has been treated for type I diabetes for 6 years and presents for evaluation and treatment of an ulcer on the plantar aspect of the forefoot. The ulcer has been present for 4 weeks. The ulcer does not appear infected, claw toe deformities are present, and a posterior tibial pulse is palpable. An important screening test for this patient is:

. Doppler ultrasound
. 128-MHz tuning fork examination
. C ombined technetium-indium scan
. Semmes-Weinstein monofilament testing
. Transcutaneous oxygen measurements

Correct Answer & Explanation

. Semmes-Weinstein monofilament testing

Explanation

Although vascular evaluation of all patients with diabetes is important, this patient has a neuropathic plantar ulcer and it is important to assess the extent of neuropathy. The Semmes-Weinstein monofilament is a first-rate screening tool.

Question 500

Topic: 8. Foot and Ankle

The most common complication following medial subtalar dislocation with incarceration of the talus in the extensor brevis muscle is:

. Avascular necrosis talus
. Ankle arthritis
. Tarsal tunnel syndrome
. Subtalar joint arthritis
. Peroneal tendonitis

Correct Answer & Explanation

. Subtalar joint arthritis

Explanation

A medial peritalar dislocation is easy to reduce even when the head of the talus is incarcerated in the extensor brevis muscle. Following reduction, stiffness and arthritis of the subtalar joint occurs. Ankle arthritis and tarsal tunnel syndrome may occur following lateral subtalar dislocation.

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