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8. Foot and Ankle MCQs

Practice Set 26 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 501

Topic: 8. Foot and Ankle

A patient sustained a fracture of the calcaneus 9 months ago. The fracture was treated with non-weight bearing and cast immobilization. The patient experiences constant pain and is unable to work. On examination, he has limited inversion, eversion motion of the foot, and lateral foot pain. Radiographs are presented. The recommended treatment is:

. Physical therapy aimed at increasing subtalar joint motion
. Nonsteroidal anti-inflammatory medication and orthotic treatment
. Triple arthrodesis
. Osteotomy of calcaneus and debridement of peroneal tendonitis
. Subtalar arthrodesis

Correct Answer & Explanation

. Subtalar arthrodesis

Explanation

In the presence of stiffness of the subtalar joint, physical therapy modalities are unlikely to improve the foot function. For the young active worker, an early subtalar arthrodesis is the most reliable procedure to return him to work and an active lifestyle. A triple arthrodesis is contraindicated in the absence of painful transverse tarsal arthritis.

Question 502

Topic: 8. Foot and Ankle

A 44-year-old woman presents with chronic pain in the region of the forefoot. She is unable to wear a shoe with a heel and she has pain in the region of the second toe. On examination, she has swelling of the second toe and painful inflammation of the metatarsophalangeal joint. A clinical picture of her foot is presented. Your initial treatment consists of:

. Rigid shoe and a toe splint
. C ortisone injection
. Semirigid orthotic support
. Night splinting of the second toe
. Nonsteroidal anti-inflammatory medication and physical therapy treatments

Correct Answer & Explanation

. Rigid shoe and a toe splint

Explanation

This patient has idiopathic synovitis of the second metatarsophalangeal (MP) joint. This may be associated with hallux valgus or a long second metatarsal, leading to attritional changes in the volar plate and secondary instability of the MP joint. Immobilization of the toe with limitation of dorsiflexion is required. Although cortisone injection may be effective, toe support must be the initial form of treatment.

Question 503

Topic: 8. Foot and Ankle

A 9-year-old girl presents for treatment of a calcaneus deformity of the foot that has progressively worsened over the past 3 years. She has a history of poliomyelitis. Upon examination, she has poor plantarflexion, neutral varus and valgus of the hindfoot, and strong dorsiflexion. The preferred treatment for this deformity is:

. Posterior transfer of the posterior tibial tendon to the fibula
. Posterior transfer of the anterior tibial tendon to the calcaneus
. Posterior transfer of the posterior tibial and peroneal tendons to the calcaneus
. Pantalar arthrodesis
. Ankle arthrodesis in slight plantarflexion

Correct Answer & Explanation

. Posterior transfer of the anterior tibial tendon to the calcaneus

Explanation

A calcaneus deformity is ideally treated with posterior transfer of the anterior tibial tendon to the calcaneus. In the presence of calcaneovalgus deformity (which is not present in this child), posterior transfer to the fibula is a better procedure to prevent continued valgus deformity of the ankle.

Question 504

Topic: 8. Foot and Ankle

A 54-year-old woman presents for treatment of leg weakness. She is unable to walk up stairs. She recalls an injury to her ankle while playing tennis 1 year ago. Upon examination, she has poor plantarflexion strength, but excellent dorsiflexion and inversion strength. A magnetic resonance image of her leg is presented. The recommended treatment is:

. Transfer of the flexor hallucis longus muscle to the calcaneus
. Repair of the Achilles tendon
. Transfer of the anterior tibial tendon to the distal Achilles tendon
. Transfer of the anterior tibial tendon to the calcaneus
. Transfer of the posterior tibial and peroneus brevis tendons to the calcaneus

Correct Answer & Explanation

. Transfer of the flexor hallucis longus muscle to the calcaneus

Explanation

This patient sustained a rupture of the Achilles tendon that went untreated for 1 year. She has symptomatic weak plantarflexion that may be improved by tendon transfer. Achilles repair is not possible due to the size of the defect. Although transfer of the peroneus brevis muscle or the flexor digitorum longus muscle has been described for correction of plantarflexion weakness, the flexor hallucis longus muscle is stronger and a better transfer.

Question 505

Topic: 8. Foot and Ankle

A 19-year-old woman presents for treatment of a painful hallux valgus deformity. In addition to the foot deformity, she has spastic hemiplegic cerebral palsy. A clinical picture of her foot is presented. The recommended treatment is:

. Distal metatarsal osteotomy
. Proximal metatarsal osteotomy
. Distal metatarsal and proximal hallux phalangeal osteotomy
. Tendon transfer of the adductor hallucis to the abductor hallucis
. Arthrodesis hallux metatarsophalangeal (MP) joint

Correct Answer & Explanation

. Arthrodesis hallux metatarsophalangeal (MP) joint

Explanation

In patients with spasticity, arthrodesis of the hallux metatarsophalangeal joint is the only reliable means of controlling the hallux and preventing recurrent deformity.

Question 506

Topic: Forefoot

The most common complication of arthrodesis of the proximal interphalangeal (PIP) joint is:

. Claw toe deformity
. Mallet toe deformity
. Hammer toe deformity
. Curly toe deformity
. Instability of metatarsophalangeal (MP) joint

Correct Answer & Explanation

. Mallet toe deformity

Explanation

With arthrodesis of the proximal interphalangeal joint (PIP), the long flexor tendon that remains intact flexes the toe at the metatarsophalangeal (MP) joint and also at the distal interphalangeal (DIP) joint, thus the development of a mallet toe deformity.

Question 507

Topic: 8. Foot and Ankle

A 59-year-old woman presents for treatment of a painful hallux valgus deformity. She has a prominent bunion, normal motion of the hallux metatarsophalangeal (MP) joint, and painful callosity under the second MP joint. Radiographs of the foot are presented. The recommended treatment is:

. Arthrodesis of the hallux MP joint
. Soft tissue release and distal metatarsal osteotomy
. Soft tissue release and proximal metatarsal osteotomy
. Soft tissue release and arthrodesis metatarsocuneiform joint
. Resection arthroplasty of the hallux MP joint

Correct Answer & Explanation

. Soft tissue release and arthrodesis metatarsocuneiform joint

Explanation

This patient has probable instability of the metatarsocuneiform joint manifested by the overload phenomenon of the second metatarsal. Although this is not a sufficient indication for performing an arthrodesis of the metatarsocuneiform joint (modified Lapidus procedure), other findings of second metatarsal overload, including thickening of the cortex of the second metatarsal and instability of the first metatatarsocuneiform joint, should be looked for in addition to hypermobility of the first ray.

Question 508

Topic: 8. Foot and Ankle

In surgical correction of the adult acquired flatfoot deformity, a medial translational calcaneal osteotomy is often performed in conjunction with additional soft tissue correction medially. One of the proposed biomechanical effects of the osteotomy associated with improvement in the arch of the foot is:

. Weakening the peroneus brevis tendon
. Tightening the plantar fascia
. Tightening the lateral plantar ligament
. Depression of the first metatarsal axis
. Medial shift of the Achilles tendon

Correct Answer & Explanation

. Medial shift of the Achilles tendon

Explanation

The medial shift of the calcaneus effectively moves the Achilles tendon, thereby increasing the medial torque on the subtalar joint. The valgus deforming force of the Achilles on the heel is neutralized. The plantar fascia is lengthened, not tightened, by the medial shift of the calcaneus.

Question 509

Topic: 8. Foot and Ankle

One year ago, a patient underwent a triple arthrodesis for management of a severe foot deformity. Although the deformity of her foot is notably improved since the surgery, she has not walked comfortably and the pain is worse than it had been prior to surgery. Upon clinical examination, she is noted to have a fixed supination deformity of the forefoot and callosity under the base of the fifth metatarsal. The recommended management of this problem is:

. Semirigid orthotic shoe support
. Bracing with a dynamic ankle foot orthoses
. C alcaneal osteotomy
. Excision of the base of the fifth metatarsal
. Revision triple arthrodesis

Correct Answer & Explanation

. Revision triple arthrodesis

Explanation

This patient underwent a triple arthrodesis that resulted in malunion as demonstrated by the location of the callosity and the fixed forefoot deformity. A calcaneus osteotomy will not correct the midfoot deformity. Nonoperative treatment will not be sufficient in long-term management.

Question 510

Topic: 8. Foot and Ankle

A 28-year-old woman presents for treatment of pain and swelling in the foot. She had twisted her ankle 2 months ago and her initial treatment consisted of limited activity, crutches, and immobilization. Because she has not been able to wean off the crutches, she has pain in the foot radiating to the ankle and distal lateral leg. She has constant pain in the foot and the swelling appears worse than at the time of her injury. C linically, there are multiple areas of tenderness in the foot and ankle that appear swollen and sensitive to examination. The study that would be most helpful to clarify this diagnosis is:

. Magnetic resonance imaging examination of the ankle
. Weight-bearing radiographs of the ankle and foot
. Ultrasound examination of the ankle ligaments
. Technetium bone scan
. C omputerized axial tomography scan of the ankle and subtalar joint

Correct Answer & Explanation

. Technetium bone scan

Explanation

This patient appears to have an acute sympathetically mediated pain syndrome. Previously referred to as reflex sympathetic dystrophy, it is essential to make an early diagnosis and initiate treatment. While a lumbar sympathetic block has both diagnostic and therapeutic value, a bone scan is an excellent imaging study for screening and diagnostic purposes in this patient.

Question 511

Topic: 8. Foot and Ankle

A 52-year-old man presents for evaluation and treatment of a painful flatfoot deformity. While playing tennis 2 years ago, he felt a tearing sensation in his foot and ankle. Since that time, he notes that the arch of his foot has become progressively flatter. Upon examination, he has a flatfoot inability to perform a single heel rise and weak inversion strength. He desires to have this deformity corrected. At surgery, the posterior tibial tendon is grossly normal in appearance. The most likely source of his deformity is:

. Rupture of the Achilles tendon
. Rupture of the peroneus longus tendon
. Rupture of the plantar fascia
. Rupture of the spring ligament
. Rupture of the inferolateral long plantar ligament

Correct Answer & Explanation

. Rupture of the spring ligament

Explanation

A rupture of the spring ligament, the talonavicular capsule, or the deltoid ligament should be looked for in the patient with an acquired flatfoot following trauma. Intratendinous tear of the posterior tibial tendon is also possible.

Question 512

Topic: 8. Foot and Ankle
A 27-year-old man sustained an injury to his foot 2.5 years ago when a forklift crushed his foot. He sustained a fracture dislocation of the midfoot and was treated with open reduction and internal fixation. His current complaints are burning in the foot associated with numbness over the dorsal foot surface. On examination, he has severe focal sensitivity over the dorsal foot, particularly in the first web space radiating proximally to the ankle. Radiographs demonstrate mild arthritis and anatomic reduction of the tarsometatarsal and midfoot joints. The prognosis for relief of his foot pain at this stage is:
. Excellent with neuroleptic medication and physical therapy
. Fair regardless of the treatment provided
. Good with treatment for a sympathetically mediated pain syndrome
. Excellent following tarsal tunnel release
. Good with biofeedback and job modification

Correct Answer & Explanation

. Fair regardless of the treatment provided

Explanation

This patient sustained a crush injury to the foot, and although the dislocation was apparently treated with anatomic reduction, he experiences focal neuritis. It is unlikely that he has a sympathetically mediated pain syndrome, although this should always be considered. The outcome, regardless of treatment, must be guarded for this post-traumatic crush syndrome.

Question 513

Topic: 8. Foot and Ankle

A 34-year-old woman presents for treatment of pain in the hallux. She notes pain upon weight bearing and wearing high-heel shoes. Upon examination, the range of motion of the hallux metatarsophalangeal (MP) joint is 10° dorsiflexion and 30° plantarflexion, with pain upon passive dorsiflexion. Radiographs demonstrate osteophytes over the dorsal surface of the metatarsal head, maintenance of the joint space, and a metatarsal declination angle of 10°. The first metatarsal is elevated above the second metatarsal at the level of the metatarsal neck by 4 mm. The ideal procedure to correct this problem and alleviate pain is:

. Plantarflexion osteotomy first metatarsal neck
. Plantarflexion osteotomy first metatarsal base
. Dorsiflexion osteotomy first metatarsal neck
. Cheilectomy first metatarsal and dorsiflexion osteotomy hallux proximal phalanx
. Arthrodesis hallux MP joint

Correct Answer & Explanation

. Cheilectomy first metatarsal and dorsiflexion osteotomy hallux proximal phalanx

Explanation

This patient has mild hallux rigidus with a normal alignment of the first metatarsal. The average elevation of the first metatarsal above the second metatarsal at the level of the metatarsal neck is 7.5 mm, thus, 4 mm is within normal limits. Arthrodesis is not indicated for mild rigidus and osteotomy is indicated only for severe elevation of the first metatarsal. C heilectomy combined with osteotomy of the proximal phalanx (the Moberg osteotomy) is the preferred procedure.

Question 514

Topic: 8. Foot and Ankle

A patient experienced a nondisplaced fracture of the medial and middle cuneiforms. His nonoperative treatment consisted of cast immobilization for 2 weeks with no weight bearing permitted, followed by ambulation as tolerated. He presents for treatment 1 week later with severe swelling in the foot, stiffness of the toes, and limited motion of the hindfoot. The fracture of the cuneiforms appears healed. The ideal management of the stiffness and swelling of the foot is:

. Application of an intermittent foot pump compression device
. C ontinued cast immobilization and weight bearing as tolerated
. Removable stirrup brace and anti-inflammatory medication
. Deep friction massage combined with acupuncture treatments
. C ast immobilization with frequent changes to monitor swelling

Correct Answer & Explanation

. Application of an intermittent foot pump compression device

Explanation

Patients who develop swelling of the foot and ankle following trauma and surgery can be effectively treated with application of an intermittent foot pump device. The bladder of the foot pump can be inserted into either a removable boot or cast, or applied to the foot in combination with other methods of rehabilitation. The foot pump is an effective device for decreasing swelling of the foot in association with acute trauma.

Question 515

Topic: 8. Foot and Ankle

A 31-year-old woman presents for treatment of pain in the hallux. She has been experiencing the pain for 2 years. She notes limited motion of the hallux with pain in the joint, particularly when wearing high-heel shoes. She is unable to toe off with running activities. Upon examination, the motion in the hallux metatarsophalangeal (MP) joint is limited in dorsiflexion and radiographs demonstrate mild arthritis of the joint. She requests surgery to correct this disorder. The recommended treatment is:

. Arthrodesis hallux MP joint
. Plantarflexion osteotomy of the first metatarsal neck
. Plantarflexion osteotomy of the first metatarsal base
. Dorsiflexion osteotomy of the metatarsal neck
. Dorsal cheilectomy metatarsal head

Correct Answer & Explanation

. Dorsal cheilectomy metatarsal head

Explanation

Cheilectomy is the ideal treatment for correction of mild hallux rigidus. Although elevation of the first metatarsal rarely occurs (metatarsus primus elevatus) as the cause for hallux rigidus, osteotomy of the metatarsal should not be used as the treatment for correction of hallux rigidus with normal alignment of the first metatarsal.

Question 516

Topic: 8. Foot and Ankle

A 17-year-old woman presents for evaluation of a painful hallux valgus deformity. She is unable to wear shoes comfortably, has pain with athletic and daily activities, and notices that the deformity is gradually worsening. Upon clinical examination, she has generalized ligamentous laxity, with motion of the hallux metatarsophalangeal (MP) joint 75° dorsiflexion and 25° plantarflexion. Motion of the first metatarsal is approximately 8° to 10° of combined dorsiflexion and plantarflexion. There is no pain to range of motion of these joints. The hallux valgus angle is 28° and the 1-2 intermetatarsal angle is 12°. The recommended treatment is:

. Arthrodesis of the first metatarsocuneiform joint (Lapidus)
. Proximal metatarsal osteotomy
. Distal metatarsal osteotomy
. Resection arthroplasty of the MP joint
. Arthrodesis of the hallux MP joint

Correct Answer & Explanation

. Distal metatarsal osteotomy

Explanation

This adolescent has symptomatic hallux valgus, and surgery is warranted. The motion at the metatarsophalangeal and talometatarsal joints is normal, and there is no evidence of hypermobility despite her generalized ligamentous laxity. Therefore, the modified Lapidus procedure is not indicated. With this deformity, a distal metatarsal osteotomy is ideal.

Question 517

Topic: 8. Foot and Ankle

An 82-year-old woman presents for treatment of a painful second toe deformity. The toe is subluxated at the metatarsophalangeal (MP) joint, and a fixed claw toe deformity is present. Despite severe hallux valgus, and the hallux under riding the second toe, the hallux and bunion are not symptomatic. The procedure that will ideally correct this deformity is:

. Resection arthroplasty hallux, MP, and proximal interphalangeal joint (PIP) arthroplasty second toe
. Arthrodesis hallux MP joint, MP, and PIP arthroplasty second toe
. Proximal metatarsal osteotomy first metatarsal, MP, and PIP arthroplasty second toe
. Amputation second toe at the MP joint level
. MP and PIP arthroplasty second toe with flexor to extensor tendon transfer

Correct Answer & Explanation

. Amputation second toe at the MP joint level

Explanation

This elderly patient has a symptomatic second toe deformity only, and surgery to the hallux should be avoided if possible. This is a common clinical problem, and although patients do not readily accept amputation of the toe, it is the preferred procedure because it does not involve reconstruction of the hallux. C orrection of the second toe without amputation will not work unless the hallux deformity is addressed.

Question 518

Topic: 8. Foot and Ankle

A 19-year-old woman had previously been treated for hallux valgus deformity with resection of the medial eminence only. She now presents with severe recurrent deformity of the hallux, with pain. There is neither pain nor crepitus upon range of motion of the hallux metatarsophalangeal (MP) joint. The procedure that will successfully correct the deformity of the hallux and the first metatarsal and maintain motion at the MP joint is:

. Distal metatarsal osteotomy
. Biplanar distal metatarsal osteotomy
. Arthrodesis of the first talometatarsal joint (modified Lapidus)
. Proximal metatarsal osteotomy
. Double first metatarsal osteotomy

Correct Answer & Explanation

. Double first metatarsal osteotomy

Explanation

This patient has recurrent hallux valgus with a marked increase in the distal metatarsal articular angle (DMAA). C orrection of this increased DMAA is essential to obtain motion at the metatarsophalangeal joint, and can only be accomplished with a closing wedge type of osteotomy distally. Although a distal biplanar osteotomy may be sufficient, in view of the magnitude of the deformity, a double first metatarsal osteotomy is preferred.

Question 519

Topic: Midfoot & Hindfoot

A 66-year-old woman has experienced the gradual onset of a flatfoot deformity over the past 10 years. She notes that the condition is bilateral, although worse on one side. Presented are clinical and radiographic images of her condition. This is associated with pain upon ambulation and difficulty with shoe wear. The most likely cause of this flatfoot deformity is:

. Posterior tibial tendon tear
. Spring ligament tear
. Neuropathy
. Subtalar arthritis
. Tarsometatarsal arthritis

Correct Answer & Explanation

. Tarsometatarsal arthritis

Explanation

Although posterior tibial tendon insufficiency is a more common cause of adult acquired flatfoot, in this patient the associated clinical and radiographic deformity makes the diagnosis of tarsometatarsal arthritis more likely.

Question 520

Topic: 8. Foot and Ankle

A 66-year-old woman has experienced the gradual onset of a flatfoot deformity over the past 10 years. She notes that the condition is bilateral, although worse on one side. Presented are clinical and radiographic images of her condition. This is associated with pain upon ambulation and difficulty with shoe wear. The most likely cause of this flatfoot deformity is tarsometatarsal arthritis. The initial recommended treatment is:

. Tarsometatarsal arthrodesis
. Flexor tendon transfer and osteotomy calcaneus
. Triple arthrodesis
. Orthotic arch supports
. C orset type ankle-foot orthosis

Correct Answer & Explanation

. Orthotic arch supports

Explanation

The initial treatment of idiopathic tarsometatarsal arthritis in the adult is through foot support, shoe modifications, and orthoses. Tarsometatarsal arthrodesis may be required if these treatments fail.

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