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8. Foot and Ankle MCQs

Practice Set 251 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 5001

Topic: 8. Foot and Ankle

A 25-year-old athlete sustains a forced plantar flexion injury to his midfoot. Weight-bearing radiographs show 3 mm of widening between the base of the first and second metatarsals. What is the primary stabilizing structure injured in this scenario?

. Interosseous ligament between the medial cuneiform and second metatarsal base
. Dorsal ligament between the first and second metatarsals
. Plantar ligament between the first and second cuneiforms
. Spring ligament
. Short plantar ligament

Correct Answer & Explanation

. Interosseous ligament between the medial cuneiform and second metatarsal base

Explanation

The Lisfranc ligament is an interosseous ligament connecting the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. It is the primary stabilizer of the second tarsometatarsal joint and its disruption leads to midfoot instability.

Question 5002

Topic: 8. Foot and Ankle
A 32-year-old man falls from a height and sustains a Hawkins type III talar neck fracture. Which of the following best describes the disruption of blood supply leading to the high rate of avascular necrosis in this injury?
. Artery of the tarsal canal, deltoid branch, and dorsalis pedis branch
. Anterior tibial artery and peroneal artery only
. Medial plantar artery and lateral plantar artery
. Artery of the tarsal sinus and medial calcaneal artery
. Perforating peroneal artery and sural artery

Correct Answer & Explanation

. Artery of the tarsal canal, deltoid branch, and dorsalis pedis branch

Explanation

A Hawkins type III fracture involves subluxation or dislocation of both the subtalar and tibiotalar joints. This disrupts the three major blood supplies to the talar body: the artery of the tarsal canal, the deltoid branch, and the capsular branches from the dorsalis pedis.

Question 5003

Topic: 8. Foot and Ankle

A 16-year-old girl presents with progressive bilateral foot deformities and frequent ankle sprains. Examination reveals a rigid hindfoot varus that corrects with a Coleman block test. Which of the following muscle imbalances is the primary driver of the forefoot-driven cavovarus deformity?

. Strong peroneus brevis and weak peroneus longus
. Strong peroneus longus and weak tibialis anterior
. Strong tibialis anterior and weak peroneus longus
. Strong gastrocnemius and weak soleus
. Strong extensor hallucis longus and weak flexor hallucis longus

Correct Answer & Explanation

. Strong peroneus longus and weak tibialis anterior

Explanation

In Charcot-Marie-Tooth disease, a plantarflexed first ray is driven by a strong peroneus longus overpulling a weak tibialis anterior. This causes a forefoot-driven hindfoot varus which is initially flexible (corrects on Coleman block test) but can become rigid over time.

Question 5004

Topic: 8. Foot and Ankle

A 65-year-old man with end-stage post-traumatic ankle osteoarthritis is considering surgical intervention. Which of the following is an absolute contraindication to a total ankle arthroplasty (TAA)?

. Age greater than 60 years
. Body mass index (BMI) of 28
. Charcot neuroarthropathy of the ankle
. Prior open reduction and internal fixation of a bimalleolar fracture
. Moderate limitation of subtalar motion

Correct Answer & Explanation

. Charcot neuroarthropathy of the ankle

Explanation

Absolute contraindications to total ankle arthroplasty include active infection, Charcot neuroarthropathy, absent lower extremity sensation, and avascular necrosis of the talus (>50%). Age, moderate obesity, and prior trauma without active infection are not absolute contraindications.

Question 5005

Topic: Midfoot & Hindfoot
A 55-year-old woman presents with medial foot 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. What is the most appropriate surgical management?
. Isolated posterior tibial tendon debridement
. Posterior tibial tendon debridement with tenosynovectomy
. Flexor digitorum longus (FDL) transfer to the navicular and medial displacement calcaneal osteotomy (MDCO)
. FDL transfer, MDCO, and lateral column lengthening
. Triple arthrodesis

Correct Answer & Explanation

. FDL transfer, MDCO, and lateral column lengthening

Explanation

This patient has Stage IIb adult acquired flatfoot deformity (flexible, >40% talonavicular uncoverage indicating severe forefoot abduction). Treatment requires FDL transfer, MDCO, and a lateral column lengthening (e.g., Evans osteotomy) to correct the forefoot abduction.

Question 5006

Topic: 8. Foot and Ankle

During the extensile lateral approach for open reduction and internal fixation of a displaced intra-articular calcaneus fracture, what structure is at highest risk of iatrogenic injury when elevating the full-thickness flap?

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

Correct Answer & Explanation

. Sural nerve

Explanation

The sural nerve is at high risk of injury during the extensile lateral approach to the calcaneus. A meticulous "no-touch" subperiosteal full-thickness flap dissection is essential to protect the nerve and the fragile skin flap's blood supply.

Question 5007

Topic: Forefoot

A 45-year-old woman complains of a painful bunion. Weight-bearing radiographs show a hallux valgus angle of 45 degrees and an intermetatarsal angle (IMA) of 16 degrees. The first tarsometatarsal joint is hypermobile. What is the most appropriate surgical procedure?

. Distal chevron osteotomy
. Akin osteotomy
. Proximal phalangeal exostectomy
. Lapidus procedure (first TMT arthrodesis)
. First metatarsophalangeal joint arthrodesis

Correct Answer & Explanation

. Lapidus procedure (first TMT arthrodesis)

Explanation

A Lapidus procedure (first tarsometatarsal arthrodesis) is indicated for severe hallux valgus (IMA >15 degrees, HVA >40 degrees), particularly in the presence of first TMT joint hypermobility. Distal osteotomies are insufficient for large intermetatarsal angles.

Question 5008

Topic: 8. Foot and Ankle

A 58-year-old man with poorly controlled type 2 diabetes presents with an ulcer under the first metatarsal head. The ulcer extends to the bone, and a sterile probe easily touches the metatarsal head, which feels gritty. There is surrounding erythema and purulent drainage. According to the Wagner classification, what grade is this lesion?

. Grade 1
. Grade 2
. Grade 3
. Grade 4
. Grade 5

Correct Answer & Explanation

. Grade 3

Explanation

The Wagner classification grades diabetic foot ulcers. Grade 3 denotes a deep ulcer with osteomyelitis, deep abscess, or joint sepsis. Probing to bone strongly correlates with clinical osteomyelitis.

Question 5009

Topic: 8. Foot and Ankle

A 21-year-old skier presents with lateral ankle pain and a snapping sensation behind the lateral malleolus after a twisting fall. Examination reveals subluxation of the peroneal tendons over the fibula during active eversion. Which structure is compromised in this condition?

. Inferior extensor retinaculum
. Superior peroneal retinaculum
. Anterior talofibular ligament
. Calcaneofibular ligament
. Cervical ligament

Correct Answer & Explanation

. Superior peroneal retinaculum

Explanation

Peroneal tendon subluxation is caused by injury to or incompetence of the superior peroneal retinaculum (SPR). Surgical treatment typically involves SPR repair and may require deepening of the retromalleolar fibular groove.

Question 5010

Topic: 8. Foot and Ankle

A 52-year-old man with peripheral neuropathy presents with a swollen, erythematous, and warm right foot. Radiographs reveal prominent soft tissue swelling, fragmentation of the navicular and cuboid, and periarticular debris without frank dislocation. Inflammatory markers are normal. According to the Eichenholtz classification, what stage is this?

. Stage 0
. Stage 1 (Developmental/Fragmentation)
. Stage 2 (Coalescence)
. Stage 3 (Reconstruction)
. Stage 4 (Consolidation)

Correct Answer & Explanation

. Stage 1 (Developmental/Fragmentation)

Explanation

Eichenholtz Stage 1 (Developmental/Fragmentation) is characterized by joint edema, radiolucency, bony fragmentation, and debris. Treatment requires strict immobilization in a total contact cast to prevent further collapse.

Question 5011

Topic: Forefoot

A 45-year-old female presents with a painful bunion. Clinical exam reveals a hypermobile first tarsometatarsal (TMT) joint. Radiographs show a hallux valgus angle of 35 degrees and an intermetatarsal angle of 16 degrees. What is the most appropriate surgical treatment?

. Proximal crescentic osteotomy
. Distal chevron osteotomy
. First TMT arthrodesis (Lapidus)
. MTP arthrodesis
. Keller resection arthroplasty

Correct Answer & Explanation

. First TMT arthrodesis (Lapidus)

Explanation

First TMT arthrodesis (Lapidus procedure) is indicated for moderate to severe hallux valgus with 1st ray hypermobility to correct the intermetatarsal angle and stabilize the medial column.

Question 5012

Topic: Midfoot & Hindfoot

A 55-year-old diabetic male presents with a swollen, erythematous, warm, and painless left foot. Radiographs reveal fragmentation of the navicular and cuneiforms with joint subluxation. What is the most appropriate initial management?

. Urgent surgical debridement and internal fixation
. Non-weight bearing in a total contact cast
. Intravenous antibiotics and MRI
. Midfoot arthrodesis
. Calcaneal osteotomy

Correct Answer & Explanation

. Non-weight bearing in a total contact cast

Explanation

This patient is in the acute fragmentation phase (Eichenholtz stage I) of Charcot arthropathy. The gold standard initial management is immobilization and offloading, typically with a total contact cast, until the inflammatory phase resolves.

Question 5013

Topic: 8. Foot and Ankle

A 60-year-old male presents with chronic Achilles tendinopathy and a 5 cm defect following a spontaneous rupture 3 months ago. An FHL transfer is planned. To minimize morbidity, which function is most important to evaluate postoperatively regarding the donor tendon?

. Lesser toe extension
. Lesser toe flexion
. Great toe extension
. Great toe flexion at the IP joint
. Ankle dorsiflexion

Correct Answer & Explanation

. Great toe flexion at the IP joint

Explanation

The flexor hallucis longus (FHL) provides flexion at the interphalangeal (IP) joint of the great toe. Harvesting the FHL for Achilles reconstruction can lead to a loss of active IP joint flexion, though functional deficit is usually minimal.

Question 5014

Topic: 8. Foot and Ankle

A 22-year-old male presents with bilateral cavovarus feet. A Coleman block test is performed by placing the heel and lateral foot on a block while the first metatarsal hangs off. The hindfoot varus corrects to neutral. What does this finding indicate?

. The hindfoot deformity is rigid and requires a triple arthrodesis
. The deformity is driven by a plantarflexed first ray
. There is isolated weakness of the peroneus brevis
. A lateralizing calcaneal osteotomy is contraindicated
. The subtalar joint is arthritic

Correct Answer & Explanation

. The deformity is driven by a plantarflexed first ray

Explanation

A flexible hindfoot varus that corrects during the Coleman block test indicates that the deformity is forefoot-driven, typically due to a plantarflexed first ray. Management should primarily target the first ray, such as a dorsiflexing osteotomy.

Question 5015

Topic: Midfoot & Hindfoot

A 50-year-old female presents with a painful, progressive flatfoot. She can perform a single leg heel rise but it is painful and incomplete. Examination shows a flexible hindfoot valgus. What is the most appropriate surgical intervention if conservative measures fail?

. Flexor digitorum longus (FDL) transfer and medializing calcaneal osteotomy
. Triple arthrodesis
. Isolated subtalar arthrodesis
. Tibialis anterior transfer
. First TMT arthrodesis

Correct Answer & Explanation

. Flexor digitorum longus (FDL) transfer and medializing calcaneal osteotomy

Explanation

The patient has Stage II adult-acquired flatfoot deformity (flexible hindfoot, PTT insufficiency). Joint-sparing surgery with FDL transfer and a medializing calcaneal osteotomy corrects the deformity and restores tendon function.

Question 5016

Topic: 8. Foot and Ankle

A 35-year-old female falls from a horse, injuring her midfoot. Radiographs show a 3 mm diastasis between the base of the first and second metatarsals, with dorsal subluxation on the lateral view. Which of the following ligaments is primarily injured?

. Dorsal ligament between the 1st and 2nd metatarsals
. Plantar ligament from the medial cuneiform to the 2nd metatarsal base
. Interosseous ligament from the lateral cuneiform to the 3rd metatarsal
. Spring ligament
. Plantar fascia

Correct Answer & Explanation

. Plantar ligament from the medial cuneiform to the 2nd metatarsal base

Explanation

The Lisfranc ligament is an interosseous ligament that runs from the plantar-lateral aspect of the medial cuneiform to the plantar-medial base of the second metatarsal. It is the primary stabilizer of the second TMT joint.

Question 5017

Topic: 8. Foot and Ankle
A 40-year-old roofer falls 15 feet, sustaining a closed, displaced, intra-articular calcaneal fracture with loss of Bรถhler's angle and widening of the heel. If open reduction and internal fixation via an extensile lateral approach is planned, what is the most significant risk associated with this surgical approach?
. Sural nerve injury
. Tibial nerve injury
. Wound necrosis and infection
. Subtalar arthritis
. Flexor hallucis longus entrapment

Correct Answer & Explanation

. Wound necrosis and infection

Explanation

The extensile lateral approach to the calcaneus carries a high risk of wound healing complications (up to 25%). This includes edge necrosis and deep infection, due to the tenuous vascular supply of the lateral heel flap.

Question 5018

Topic: 8. Foot and Ankle

A 42-year-old female presents with burning pain and tingling in the plantar aspect of her foot, which worsens at night and after prolonged standing. Tinel's sign is positive posterior to the medial malleolus. Which nerve is compressed?

. Deep peroneal nerve
. Sural nerve
. Posterior tibial nerve
. Saphenous nerve
. Superficial peroneal nerve

Correct Answer & Explanation

. Posterior tibial nerve

Explanation

Tarsal tunnel syndrome results from the compression of the posterior tibial nerve or its branches. This occurs as it passes through the fibro-osseous tunnel beneath the flexor retinaculum, posterior to the medial malleolus.

Question 5019

Topic: 8. Foot and Ankle

A 22-year-old football player sustains a rotational injury to his midfoot. Radiographs demonstrate widening between the 1st and 2nd metatarsal bases with a "fleck sign". The primary ligament injured in this condition connects which of the following structures?

. Base of the 1st metatarsal to the 2nd cuneiform
. Base of the 2nd metatarsal to the medial cuneiform
. Base of the 2nd metatarsal to the middle cuneiform
. Base of the 1st metatarsal to the medial cuneiform
. Navicular to the medial cuneiform

Correct Answer & Explanation

. Base of the 2nd metatarsal to the medial cuneiform

Explanation

The Lisfranc ligament is an intra-articular ligament that connects the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. Disruption leads to midfoot instability and requires anatomic reduction.

Question 5020

Topic: 8. Foot and Ankle

During an extensile lateral approach for the open reduction and internal fixation of a displaced intra-articular calcaneus fracture, the surgeon must carefully identify and protect which of the following nerves in the superior and posterior aspect of the flap?

. Tibial nerve
. Sural nerve
. Deep peroneal nerve
. Superficial peroneal nerve
. Saphenous nerve

Correct Answer & Explanation

. Sural nerve

Explanation

The sural nerve courses along the lateral aspect of the hindfoot and is at high risk of iatrogenic injury during the extensile lateral approach to the calcaneus. Retracting it within the full-thickness soft tissue flap protects it.

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