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8. Foot and Ankle MCQs

Practice Set 271 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 5401

Topic: 8. Foot and Ankle

A direct posterior approach is chosen to access the posterior malleolus. The patient is prone. Which of the following nerves is at greatest risk during the superficial surgical dissection of the posterolateral approach to the distal tibia?

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

Correct Answer & Explanation

. Sural nerve

Explanation

The sural nerve runs parallel and lateral to the Achilles tendon in the posterolateral aspect of the ankle. It is superficial and highly vulnerable during the superficial dissection of the posterolateral approach to the distal tibia/ankle.

Question 5402

Topic: 8. Foot and Ankle

When performing an extensile lateral approach to the calcaneus for a displaced intra-articular fracture, a full-thickness subperiosteal flap is created. Which of the following structures is explicitly preserved and elevated within this full-thickness flap?

. Sural nerve, peroneal tendons, and calcaneofibular ligament
. Superficial peroneal nerve and extensor digitorum brevis
. Sural nerve, tibialis posterior tendon, and spring ligament
. Saphenous nerve and great saphenous vein
. Tibial nerve and posterior tibial artery

Correct Answer & Explanation

. Sural nerve, peroneal tendons, and calcaneofibular ligament

Explanation

The extensile lateral approach to the calcaneus requires a 'no-touch' full-thickness flap to avoid skin necrosis. The flap includes the skin, subcutaneous tissue, sural nerve, peroneal tendons, and the calcaneofibular ligament (CFL), all of which are elevated anteriorly and superiorly together as a single tissue block off the lateral wall of the calcaneus.

Question 5403

Topic: 8. Foot and Ankle

A 55-year-old male with poorly controlled diabetes presents with a unilaterally swollen, erythematous, and warm foot without an open ulcer. Pedal pulses are strong. Radiographs reveal early fragmentation and subluxation of the tarsometatarsal joints. What is the most appropriate initial management?

. Intravenous antibiotics and emergent midfoot debridement
. Immediate open reduction and midfoot arthrodesis
. Immobilization in a total contact cast and strict non-weight bearing
. Intra-articular corticosteroid injection
. Vascular surgery consultation for urgent revascularization

Correct Answer & Explanation

. Immobilization in a total contact cast and strict non-weight bearing

Explanation

The patient is presenting with acute Charcot neuropathic arthropathy (Eichenholtz stage I). The standard initial treatment to halt progression and prevent severe deformity is immediate immobilization, ideally with a total contact cast (TCC), and offloading.

Question 5404

Topic: Midfoot & Hindfoot

A 55-year-old male with poorly controlled diabetes mellitus presents with a massively swollen, warm, and erythematous right foot. He denies pain and lacks protective sensation. Radiographs reveal midfoot bony fragmentation, joint subluxation, and extensive debris. There are no skin ulcerations. What is the most appropriate initial management?

. Immediate surgical arthrodesis
. Intravenous antibiotics
. Total contact casting
. Below knee amputation
. Open reduction and internal fixation

Correct Answer & Explanation

. Total contact casting

Explanation

The patient is in the acute (Eichenholtz stage I) phase of Charcot neuroarthropathy. The gold standard for initial management of acute, non-ulcerated Charcot arthropathy is offloading and immobilization using a total contact cast (TCC).

Question 5405

Topic: Midfoot & Hindfoot

A 55-year-old male with long-standing, poorly controlled type 2 diabetes presents with a swollen, erythematous, and painless right foot. The erythema resolves significantly when the leg is elevated. Radiographs reveal soft tissue swelling, periarticular osteopenia, and early fragmentation at the tarsometatarsal joint. What is the most appropriate initial management?

. Immediate arthrodesis of the midfoot
. Intravenous antibiotics and surgical debridement
. Total contact casting (TCC) and non-weight-bearing
. Customized accommodative shoe wear
. Administration of intravenous bisphosphonates

Correct Answer & Explanation

. Total contact casting (TCC) and non-weight-bearing

Explanation

The clinical picture describes acute Charcot arthropathy (Eichenholtz stage 0 or 1). The gold standard for initial management is immobilization and offloading, typically achieved with a Total Contact Cast (TCC) to prevent further joint destruction.

Question 5406

Topic: Midfoot & Hindfoot

A 60-year-old diabetic patient presents with a red, hot, swollen foot. Radiographs demonstrate acute bony fragmentation, joint subluxation, and periarticular debris. Inflammatory markers are mildly elevated, but there is no ulceration. This presentation corresponds to Eichenholtz Stage 1. What is the most appropriate initial management?

. Total contact casting and strict non-weight bearing
. Immediate midfoot arthrodesis with robust hardware
. Intravenous antibiotics for presumed osteomyelitis
. Custom orthotic shoes with a rocker bottom sole
. Below-knee amputation

Correct Answer & Explanation

. Total contact casting and strict non-weight bearing

Explanation

The patient has Eichenholtz Stage 1 (Developmental/Fragmentation) Charcot arthropathy. The standard of care is immediate immobilization and offloading, typically using a total contact cast, until the active inflammatory phase subsides.

Question 5407

Topic: 8. Foot and Ankle

A 55-year-old male with poorly controlled type 2 diabetes presents with a swollen, warm, and erythematous foot without ulceration. Radiographs reveal fragmentation and destruction of the tarsometatarsal joints. According to the neurovascular theory of Charcot arthropathy, which of the following directly drives the increased osteoclastic bone resorption?

. Direct bacterial destruction of subchondral bone
. Loss of protective sensation leading to repetitive microtrauma
. Ischemic necrosis due to advanced microvascular disease
. Sympathetic denervation causing autonomic neuropathy and increased local blood flow
. Autoimmune targeting of peripheral myelin sheaths

Correct Answer & Explanation

. Sympathetic denervation causing autonomic neuropathy and increased local blood flow

Explanation

The neurovascular theory of Charcot arthropathy postulates that autonomic neuropathy leads to a loss of sympathetic tone. This causes vasodilation, bounding pulses, and increased local bone blood flow, which washes out bone mineral and enhances osteoclastic activity.

Question 5408

Topic: 8. Foot and Ankle

A 28-year-old man with a history of recurrent uveitis and Achilles tendinopathy presents with worsening low back pain that improves with exercise and worsens with rest. Which of the following human leukocyte antigens (HLA) is most strongly associated with his underlying condition?

. HLA-DR4
. HLA-B27
. HLA-B8
. HLA-DR2
. HLA-DQ2

Correct Answer & Explanation

. HLA-B27

Explanation

The patient's clinical presentation (inflammatory back pain, uveitis, enthesitis at the Achilles) is highly characteristic of Ankylosing Spondylitis (AS), a seronegative spondyloarthropathy. AS is strongly associated with the HLA-B27 allele. HLA-DR4 is associated with rheumatoid arthritis.

Question 5409

Topic: 8. Foot and Ankle

A 22-year-old football player sustains an axial load injury to a plantarflexed foot. He has severe midfoot pain and bruising on the plantar aspect of the foot. The Lisfranc ligament is crucial for midfoot stability and is anatomically defined as connecting which two structures?

. Medial cuneiform to the base of the 1st metatarsal
. Medial cuneiform to the base of the 2nd metatarsal
. Middle cuneiform to the base of the 2nd metatarsal
. Lateral cuneiform to the base of the 3rd metatarsal
. Cuboid to the base of the 4th metatarsal

Correct Answer & Explanation

. Medial cuneiform to the base of the 2nd metatarsal

Explanation

The Lisfranc ligament is the strongest interosseous ligament in the midfoot, originating from the lateral aspect of the medial cuneiform and inserting onto the medial aspect of the base of the second metatarsal. There is no direct ligamentous connection between the first and second metatarsal bases, making this articulation vulnerable.

Question 5410

Topic: 8. Foot and Ankle

Based on current high-level evidence, when comparing non-operative management featuring early functional rehabilitation to operative repair for acute Achilles tendon ruptures, non-operative management demonstrates:

. Significantly higher re-rupture rates across all demographics
. Equivalent re-rupture rates but higher deep vein thrombosis (DVT) rates
. Equivalent re-rupture rates and lower overall complication rates
. Significantly lower functional outcome scores at 1 year
. Higher rates of subsequent sural nerve entrapment

Correct Answer & Explanation

. Equivalent re-rupture rates and lower overall complication rates

Explanation

Recent meta-analyses and Level I randomized controlled trials have demonstrated that when acute Achilles tendon ruptures are treated non-operatively with an early weight-bearing and functional rehabilitation protocol, the re-rupture rates are statistically equivalent to operative repair. However, non-operative treatment avoids surgical complications such as wound breakdown, infection, and sural nerve injury.

Question 5411

Topic: 8. Foot and Ankle

A 40-year-old recreational tennis player suffers an acute complete tear of the Achilles tendon. During shared decision-making regarding operative versus non-operative management, the patient asks about the primary advantage of surgical repair. According to classical meta-analyses, which of the following is the most significant statistical advantage of operative treatment?

. Lower incidence of deep venous thrombosis
. Lower rate of tendon re-rupture
. Decreased risk of sural nerve injury
. Elimination of the need for post-injury immobilization
. Lower rate of soft tissue infection

Correct Answer & Explanation

. Lower rate of tendon re-rupture

Explanation

Historically, the main advantage of operative repair of an acute Achilles tendon rupture has been a significantly lower re-rupture rate compared to traditional non-operative casting. However, modern functional rehabilitation protocols have narrowed this gap.

Question 5412

Topic: Midfoot & Hindfoot

A 30-year-old construction worker drops a heavy beam on his midfoot. Radiographs and CT imaging

demonstrate a purely ligamentous Lisfranc injury with significant lateral and dorsal displacement of the 2nd through 5th metatarsals. Based on recent literature comparing operative techniques, what is the favored surgical management for purely ligamentous Lisfranc injuries?

. Closed reduction and percutaneous pinning (CRPP)
. Primary arthrodesis of the medial column tarsometatarsal joints
. Open reduction and internal fixation (ORIF) with transarticular screws
. Excision of the torn Lisfranc ligament and isolated capsule repair
. Conservative management in a non-weight bearing cast for 8 weeks

Correct Answer & Explanation

. Primary arthrodesis of the medial column tarsometatarsal joints

Explanation

Recent level 1 orthopedic trauma literature (such as the study by Coetzee et al. and subsequent meta-analyses) has shown that primary arthrodesis for purely ligamentous Lisfranc injuries provides superior short- and mid-term functional outcomes and lower rates of hardware removal and secondary surgery compared to Open Reduction and Internal Fixation (ORIF).

Question 5413

Topic: 8. Foot and Ankle

Fractures of the talar neck carry a famously high risk of avascular necrosis due to the tenuous, retrograde blood supply to the talar body.

Which of the following arteries provides the major contribution to the vascularity of the talar body?

. Artery of the tarsal sinus
. Artery of the tarsal canal
. Anterior tibial artery
. Deltoid branch
. Dorsalis pedis artery

Correct Answer & Explanation

. Artery of the tarsal canal

Explanation

The artery of the tarsal canal (a major branch of the posterior tibial artery) provides the predominant blood supply to the body of the talus, entering via the talar neck and running in a retrograde fashion. This makes it highly vulnerable to injury in displaced talar neck fractures.

Question 5414

Topic: 8. Foot and Ankle

A 55-year-old diabetic male presents with a swollen, erythematous, and warm right foot without open ulceration. Radiographs show early fragmentation at the tarsometatarsal joints. What is the most appropriate initial management?

. Immediate open reduction and internal fixation
. Total contact casting and non-weight bearing
. Intravenous antibiotics for 6 weeks
. Amputation at the transmalleolar level
. Application of a hinged ankle-foot orthosis

Correct Answer & Explanation

. Total contact casting and non-weight bearing

Explanation

The initial treatment for acute, active (Eichenholtz stage 0 or 1) Charcot arthropathy is strict immobilization and offloading. A total contact cast (TCC) combined with non-weight bearing is the gold standard to prevent further deformity.

Question 5415

Topic: 8. Foot and Ankle

A 40-year-old weekend warrior sustains an acute Achilles tendon rupture. Which clinical test is most sensitive and specific for diagnosing a complete Achilles tendon rupture?

. Matles test
. Thompson test
. O'Brien test
. Copeland test
. Simmonds triad

Correct Answer & Explanation

. Thompson test

Explanation

The Thompson test (calf squeeze test) is the most reliable clinical sign. A lack of passive plantarflexion when squeezing the calf muscles strongly indicates a complete rupture of the Achilles tendon.

Question 5416

Topic: Midfoot & Hindfoot
A 55-year-old diabetic patient presents with a warm, swollen, erythematous left foot. Radiographs show fragmentation, joint subluxation, and debris at the tarsometatarsal joints. According to the Eichenholtz classification, what stage of Charcot arthropathy is this?
. Stage 0
. Stage I
. Stage II
. Stage III
. Stage IV

Correct Answer & Explanation

. Stage II

Explanation

Eichenholtz Stage I is the developmental (fragmentation) stage, characterized by clinical inflammation and radiographic evidence of osteopenia, periarticular fragmentation, subluxation, and debris.

Question 5417

Topic: 8. Foot and Ankle

In the setting of a complete Achilles tendon rupture, what is the most sensitive physical examination test?

. Thompson test
. Matles test
. O'Brien's test
. Crossover test
. Gait analysis

Correct Answer & Explanation

. Thompson test

Explanation

The Thompson test (calf squeeze test) is the most sensitive and widely used physical examination test for a complete Achilles tendon rupture. A positive test is the absence of plantarflexion of the foot when the calf muscle is squeezed, indicating a complete tear. The Matles test is another useful test (prone, knee flexed to 90 degrees, no plantarflexion when foot allowed to relax). O'Brien's and Crossover tests are for shoulder pathology. Gait analysis would show weakness but is not as specific as the Thompson test for a complete rupture.

Question 5418

Topic: 8. Foot and Ankle

What is the primary function of the deltoid ligament complex in the ankle?

. Preventing anterior drawer of the talus
. Resisting inversion stress
. Resisting eversion stress
. Stabilizing the distal tibiofibular syndesmosis
. Limiting plantarflexion

Correct Answer & Explanation

. Resisting eversion stress

Explanation

The deltoid ligament complex (medial collateral ligament of the ankle) is a strong ligamentous structure composed of several bands that primarily resists eversion stress and limits external rotation of the talus. The lateral collateral ligaments (anterior talofibular, calcaneofibular, posterior talofibular) resist inversion stress. The anterior talofibular ligament is the primary restraint to anterior drawer of the talus. The distal tibiofibular syndesmosis is stabilized by the anterior and posterior inferior tibiofibular ligaments and the interosseous membrane.

Question 5419

Topic: 8. Foot and Ankle

A 25-year-old male sustains a high-energy knee dislocation. After reduction, pulses are palpable, and sensation is intact. What is the most critical next step in management?

. Immediate operative repair of all torn ligaments
. Application of a knee immobilizer and discharge home
. Angiography or Ankle-Brachial Index (ABI) assessment
. MRI of the knee
. Physical therapy referral

Correct Answer & Explanation

. Angiography or Ankle-Brachial Index (ABI) assessment

Explanation

Knee dislocations, even if reduced and with initially palpable pulses, carry a high risk of popliteal artery injury due to the tethering of the artery by the adductor hiatus proximally and the soleus arch distally. Therefore, a vascular assessment, typically involving an Ankle-Brachial Index (ABI) or urgent angiography, is mandatory to rule out occult vascular injury, even if pulses are initially present. Delayed presentation of vascular compromise can lead to limb loss. MRI is for assessing ligamentous injuries, which would be addressed later. Immediate ligament repair is not always indicated and should follow vascular assessment. Discharge is contraindicated.

Question 5420

Topic: 8. Foot and Ankle

What is the most common ligament injured in an ankle inversion sprain?

. Posterior talofibular ligament
. Anterior inferior tibiofibular ligament
. Calcaneofibular ligament
. Anterior talofibular ligament
. Deltoid ligament

Correct Answer & Explanation

. Anterior talofibular ligament

Explanation

The anterior talofibular ligament (ATFL) is the most commonly injured ligament in an ankle inversion sprain. It is the weakest of the lateral ankle ligaments and the first to be stretched or torn with excessive inversion and plantarflexion. The calcaneofibular ligament (CFL) is injured secondarily with more severe inversion. The posterior talofibular ligament (PTFL) is rarely injured in isolation. The anterior inferior tibiofibular ligament is part of the syndesmosis. The deltoid ligament is on the medial side.

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