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8. Foot and Ankle MCQs

Practice Set 273 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 5441

Topic: 8. Foot and Ankle

Which of the following surgical procedures is considered the gold standard for treating severe, symptomatic hallux valgus (bunion deformity) in a young, active patient with a high intermetatarsal angle and hallux valgus angle?

. Bunionectomy (exostectomy) alone.
. Keller arthroplasty.
. Distal metatarsal osteotomy (e.g., Chevron, Weil).
. Proximal metatarsal osteotomy (e.g., Ludloff, Scarf) or Lapidus procedure.
. Arthrodesis of the first metatarsophalangeal (MTP) joint.

Correct Answer & Explanation

. Proximal metatarsal osteotomy (e.g., Ludloff, Scarf) or Lapidus procedure.

Explanation

For severe, symptomatic hallux valgus in a young, active patient with a high intermetatarsal (IM) angle (>15 degrees) and hallux valgus angle, a proximal metatarsal osteotomy (such as Ludloff or Scarf) or a Lapidus procedure (fusion of the first metatarsal-cuneiform joint) is often considered the gold standard. These procedures address the proximal metatarsal malalignment, which is the primary driver of the deformity in these cases, providing powerful correction and stability. Bunionectomy alone is insufficient. Keller arthroplasty is a resection arthroplasty reserved for elderly, low-demand patients. Distal metatarsal osteotomies (Chevron, Weil) are typically for mild-to-moderate deformities. Arthrodesis of the first MTP joint is a salvage procedure for severe arthritis or failed previous surgeries, not usually primary for bunion correction in a young patient without arthritis.

Question 5442

Topic: 8. Foot and Ankle

A 40-year-old active male presents with chronic plantar heel pain, worse with the first steps in the morning and after periods of rest. Physical examination reveals tenderness at the origin of the plantar fascia on the medial calcaneal tuberosity. What is the most important long-term conservative management strategy?

. Corticosteroid injections.
. Extracorporeal shockwave therapy (ESWT).
. Custom orthotics with arch support and heel cushioning.
. Night splints to maintain ankle dorsiflexion.
. Surgical release of the plantar fascia.

Correct Answer & Explanation

. Custom orthotics with arch support and heel cushioning.

Explanation

The patient presents with classic symptoms of plantar fasciitis. While all options except surgery are conservative treatments, custom or over-the-counter orthotics with adequate arch support and heel cushioning, along with appropriate footwear, are crucial long-term management strategies. They help to offload the plantar fascia, correct biomechanical imbalances, and reduce repetitive stress. Corticosteroid injections provide temporary relief but are associated with complications. ESWT and night splints are also conservative treatments, often used in conjunction with orthotics, but orthotics address the underlying biomechanics more fundamentally long-term. Surgical release is reserved for recalcitrant cases after extensive failed conservative management.

Question 5443

Topic: 8. Foot and Ankle

A 28-year-old male sustains a spiral fracture of the mid-shaft of the tibia and a fracture of the fibula neck after a twisting injury. On examination, he has numbness in the dorsum of his foot and weakness in ankle dorsiflexion and great toe extension. Which nerve is most likely injured?

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

Correct Answer & Explanation

. Deep peroneal nerve

Explanation

The deep peroneal nerve (DPN) is a branch of the common peroneal nerve. It provides motor innervation to the anterior compartment muscles of the leg (dorsiflexors of the ankle and extensors of the toes) and sensory innervation to the first web space of the foot. Injury to the common peroneal nerve, which often occurs with fibular neck fractures, can lead to foot drop (weakness in dorsiflexion and toe extension). The specific sensory loss to the dorsum of the foot (excluding the first web space, which is deep peroneal) points to the superficial peroneal nerve, also a branch of the common peroneal nerve. Therefore, both common peroneal and deep peroneal nerve injuries are plausible, but the pattern of weakness and sensory loss points strongly to the deep peroneal nerve for motor function of dorsiflexion and toe extension, and superficial peroneal for the dorsum of the foot sensory. Given the options, the deep peroneal nerve injury explains the motor deficits, and the superficial peroneal nerve explains sensory loss. However, a fibular neck fracture is classic for common peroneal nerve injury which contains both, and the motor deficit described is deep peroneal. Let's re-evaluate. The question states numbness in the dorsum of the foot and weakness in ankle dorsiflexion and great toe extension. The dorsum of the foot sensation is primarily superficial peroneal nerve, while ankle dorsiflexion and great toe extension are deep peroneal nerve functions. Since the common peroneal nerve divides into superficial and deep peroneal nerves near the fibular neck, an injury at the fibular neck typically affects the common peroneal nerve, manifesting in both superficial and deep peroneal nerve deficits. Among the choices, the deep peroneal nerve specifically accounts for the motor weakness in dorsiflexion and toe extension. If 'Common Peroneal Nerve' was an option, it would be the most comprehensive answer. Since it's not, and the motor deficit is specific, deep peroneal is the best fit for the motor component. Let's consider the sensory part more carefully. Numbness in the dorsum of the foot implies superficial peroneal. However, the first web space (deep peroneal) might also be involved. Without more precision on sensory, focusing on motor, deep peroneal is correct for motor. If the superficial peroneal was selected, it wouldn't account for motor weakness. Therefore, deep peroneal nerve is the best answer given the motor symptoms listed.

Question 5444

Topic: 8. Foot and Ankle

What is the most common site for a stress fracture in a distance runner?

. Femoral shaft
. Tibia
. Fibula
. Calcaneus
. Metatarsals

Correct Answer & Explanation

. Tibia

Explanation

The tibia is the most common site for stress fractures in distance runners, particularly the proximal or distal thirds. Other common sites include the metatarsals (especially second and third), fibula, femur, and navicular bone. The femoral shaft is less common than the tibia or metatarsals for stress fractures in runners.

Question 5445

Topic: 8. Foot and Ankle

A 40-year-old male develops a painful lump in his plantar fascia near the medial calcaneal tuberosity. He reports worsening pain with first steps in the morning and after prolonged sitting. What is the most likely diagnosis?

. Achilles tendinitis
. Tarsal tunnel syndrome
. Morton's neuroma
. Plantar fasciitis
. Stress fracture of the calcaneus

Correct Answer & Explanation

. Plantar fasciitis

Explanation

The symptoms (pain in the plantar aspect of the foot, worse with first steps in the morning and after rest, tenderness near the medial calcaneal tuberosity) are classic for plantar fasciitis. Achilles tendinitis is posterior heel pain. Tarsal tunnel syndrome involves nerve compression with numbness/tingling. Morton's neuroma is pain between metatarsal heads. A stress fracture would have a different pain pattern and potentially different imaging findings.

Question 5446

Topic: 8. Foot and Ankle

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

. Deltoid ligament
. Anterior talofibular ligament (ATFL)
. Posterior talofibular ligament (PTFL)
. Calcaneofibular ligament (CFL)
. Syndesmotic ligaments

Correct Answer & Explanation

. Anterior talofibular ligament (ATFL)

Explanation

The anterior talofibular ligament (ATFL) is the weakest of the lateral ankle ligaments and is the most commonly injured ligament in an ankle inversion injury (sprain). In more severe inversion injuries, the calcaneofibular ligament (CFL) and then the posterior talofibular ligament (PTFL) may also be injured. The deltoid ligament is on the medial side and resists eversion. Syndesmotic ligaments are injured in high ankle sprains.

Question 5447

Topic: 8. Foot and Ankle

A patient is diagnosed with a 'drop foot' due to L5 radiculopathy. Which muscle is primarily responsible for ankle dorsiflexion and is therefore most affected?

. Gastrocnemius
. Soleus
. Tibialis posterior
. Peroneus longus
. Tibialis anterior

Correct Answer & Explanation

. Tibialis anterior

Explanation

The tibialis anterior is the primary dorsiflexor of the ankle. L5 radiculopathy commonly affects the muscles innervated by the deep peroneal nerve, which includes the tibialis anterior, leading to foot drop (inability to dorsiflex the ankle). Gastrocnemius and soleus are plantarflexors. Tibialis posterior is an invertor and plantarflexor. Peroneus longus is an evertor and plantarflexor.

Question 5448

Topic: 8. Foot and Ankle

A 68-year-old diabetic patient with a chronic non-healing foot ulcer develops signs of sepsis. Source control is a critical aspect of management. What does 'source control' primarily involve in this orthopedic context?

. Administering broad-spectrum antibiotics empirically
. Optimizing glycemic control to enhance wound healing
. Surgical debridement of infected tissue and drainage of pus
. Aggressive fluid resuscitation to improve tissue perfusion
. Applying topical antimicrobial agents to the ulcer

Correct Answer & Explanation

. Surgical debridement of infected tissue and drainage of pus

Explanation

Source control in sepsis involves physical measures to eliminate the focus of infection. In the context of a chronic foot ulcer with sepsis, this primarily means surgical debridement of necrotic or infected tissue, drainage of any abscesses, and potentially removal of infected hardware or amputation if severe. While antibiotics, glycemic control, fluid resuscitation, and topical agents are all important aspects of care, they do not constitute source control itself.

Question 5449

Topic: 8. Foot and Ankle

Which of the following is a primary clinical manifestation of critical illness polyneuropathy/myopathy (CIP/CIM), a common complication in prolonged severe sepsis in orthopedic patients?

. Acute onset hemiplegia
. Proximal muscle weakness and difficulty weaning from mechanical ventilation
. Severe peripheral neuropathic pain
. Spasticity and hyperreflexia
. Unilateral foot drop

Correct Answer & Explanation

. Proximal muscle weakness and difficulty weaning from mechanical ventilation

Explanation

Critical illness polyneuropathy (CIP) and critical illness myopathy (CIM) are common causes of prolonged weakness in patients surviving severe sepsis and MODS. They are characterized by diffuse, symmetrical, often profound weakness, particularly affecting proximal muscles and respiratory muscles. This can manifest as difficulty in weaning from mechanical ventilation and general muscle wasting. The other options describe focal neurological deficits, pain syndromes, or upper motor neuron signs not typical of CIP/CIM.

Question 5450

Topic: 8. Foot and Ankle

A 28-year-old male sustains a comminuted intra-articular calcaneal fracture after a fall from height. Which of the following factors is most predictive of a poor functional outcome and may influence the decision for operative versus non-operative management?

. Patient's body mass index (BMI).
. Amount of initial fracture displacement.
. Involvement of the posterior facet and degree of talar-calcaneal articulation disruption.
. Presence of associated spinal fractures.
. Patient's smoking status.

Correct Answer & Explanation

. Involvement of the posterior facet and degree of talar-calcaneal articulation disruption.

Explanation

For intra-articular calcaneal fractures, involvement of the posterior facet (which articulates with the talus) and the degree of disruption of the talar-calcaneal articulation (subtalar joint) are the most critical factors influencing functional outcome. Significant displacement and comminution of the posterior facet lead to subtalar arthritis, pain, and stiffness, which are major determinants of poor outcomes regardless of management. While BMI, smoking, and displacement are relevant, the integrity of the subtalar joint is paramount. Associated spinal fractures are important for overall patient management but not directly predictive of calcaneal fracture outcome specifically.

Question 5451

Topic: 8. Foot and Ankle

A 45-year-old male presents with acute onset of severe left foot pain, swelling, and inability to bear weight after jumping from a ladder. On examination, he has tenderness over the midfoot, a 'gap' is palpable along the medial aspect, and radiographs show disruption of the tarso-metatarsal joint complex with lateral displacement of the second cuneiform. Which of the following is the most appropriate management for this injury?

. Rest, ice, compression, elevation (RICE) and non-weight bearing.
. Closed reduction and short leg cast for 6 weeks.
. Open reduction and internal fixation (ORIF) of the Lisfranc joint.
. Steroid injection into the tarso-metatarsal joint.
. Physical therapy focusing on strengthening the intrinsic foot muscles.

Correct Answer & Explanation

. Open reduction and internal fixation (ORIF) of the Lisfranc joint.

Explanation

The described injury is a Lisfranc injury (tarso-metatarsal joint complex disruption) with clear displacement. These are often high-energy injuries that are inherently unstable and have a high risk of long-term pain and arthritis if not anatomically reduced and stably fixed. Therefore, Open Reduction and Internal Fixation (ORIF) is the standard of care for displaced and unstable Lisfranc injuries to restore anatomical alignment and prevent long-term complications. Conservative management (RICE, casting) is only appropriate for purely ligamentous, non-displaced injuries (often diagnosed by stress radiographs or MRI). Steroid injections and physical therapy are not primary treatments for acute displaced Lisfranc injuries.

Question 5452

Topic: 8. Foot and Ankle

A 65-year-old male presents with severe right ankle pain and deformity after a twisting injury. Radiographs reveal a trimalleolar fracture. Which of the following is the most important component of the trimalleolar fracture to reduce anatomically to restore ankle stability and prevent post-traumatic arthritis?

. Lateral malleolus (fibula).
. Medial malleolus.
. Posterior malleolus.
. Anterior inferior tibiofibular ligament.
. Deltoid ligament.

Correct Answer & Explanation

. Posterior malleolus.

Explanation

A trimalleolar fracture involves the lateral, medial, and posterior malleoli. While all three are important, theposterior malleolusis crucial for ankle stability. If the posterior fragment is large (typically >25-30% of the articular surface) or significantly displaced, it must be anatomically reduced and fixed to restore the ankle mortise's stability and concentric reduction of the talus, preventing posterior subluxation of the talus and subsequent post-traumatic arthritis. The lateral and medial malleoli also require fixation, but the posterior malleolus is often the overlooked critical component for stability and articular congruence. Ligament integrity is also crucial but refers to soft tissue rather than bony reduction.

Question 5453

Topic: 8. Foot and Ankle

A 45-year-old male presents with left foot drop and numbness over the dorsal aspect of his foot and lateral calf. He denies any recent trauma. On examination, he has weakness of ankle dorsiflexion and eversion. Which of the following conditions is the most likely cause of his symptoms?

. Sciatic nerve compression at the piriformis.
. Sural nerve entrapment.
. L5 radiculopathy from lumbar disc herniation.
. Common peroneal nerve entrapment at the fibular head.
. Tibial nerve entrapment at the tarsal tunnel.

Correct Answer & Explanation

. Common peroneal nerve entrapment at the fibular head.

Explanation

Foot drop (weakness of ankle dorsiflexion and eversion) with sensory loss over the dorsal foot and lateral calf is the classic presentation of common peroneal nerve dysfunction. The most common site of compression or entrapment of the common peroneal nerve is around the fibular head, where it is superficial and vulnerable. Sciatic nerve compression would cause more widespread deficits. Sural nerve is purely sensory. L5 radiculopathy could cause similar motor deficits but often involves more proximal pain and potentially weakness of gluteus medius/minimus. Tibial nerve entrapment (tarsal tunnel syndrome) affects sensation on the sole of the foot and intrinsic foot muscles.

Question 5454

Topic: 8. Foot and Ankle

A 50-year-old male presents with chronic foot pain, progressive flatfoot deformity, and difficulty with heel rise. On examination, he has tenderness and swelling along the medial ankle, and a 'too many toes' sign. Which of the following tendons is most likely dysfunctional?

. Achilles tendon.
. Peroneus longus tendon.
. Posterior tibial tendon.
. Extensor hallucis longus tendon.
. Flexor digitorum longus tendon.

Correct Answer & Explanation

. Posterior tibial tendon.

Explanation

The symptoms (chronic foot pain, progressive flatfoot deformity, difficulty with heel rise, medial ankle tenderness, and 'too many toes' sign) are classic for Posterior Tibial Tendon Dysfunction (PTTD), often progressing to adult acquired flatfoot deformity. The posterior tibial tendon is a primary stabilizer of the medial longitudinal arch. Achilles tendon pathology causes different symptoms. Peroneus longus is involved in lateral foot stability. The other tendons have different primary functions.

Question 5455

Topic: 8. Foot and Ankle

A 40-year-old male sustains an Achilles tendon rupture. Physical examination reveals a palpable gap in the tendon and a positive Thompson test. He opts for non-operative management. Which of the following is the most important component of non-operative management to optimize healing and minimize re-rupture risk?

. Immediate full weight-bearing in a walking boot.
. Prolonged immobilization in a plantarflexion cast.
. Early functional rehabilitation with progressive weight-bearing and controlled range of motion.
. Local steroid injections to reduce inflammation.
. Oral NSAIDs for 6 weeks.

Correct Answer & Explanation

. Early functional rehabilitation with progressive weight-bearing and controlled range of motion.

Explanation

For Achilles tendon rupture, both operative and non-operative management aim for functional recovery. Non-operative treatment involvesearly functional rehabilitationwith progressive weight-bearing and controlled range of motion in a functional brace or boot, typically starting with the ankle in plantarflexion and gradually progressing to neutral. This approach has been shown to optimize tendon healing, reduce atrophy, and minimize re-rupture rates compared to prolonged rigid immobilization. Immediate full weight-bearing is too aggressive. Prolonged rigid immobilization leads to stiffness and atrophy. Steroid injections are contraindicated due to rupture risk. NSAIDs are for pain control, not primary healing.

Question 5456

Topic: Forefoot
A 60-year-old female presents with severe pain and functional limitations due to advanced hallux rigidus (osteoarthritis of the first metatarsophalangeal joint). She desires a definitive surgical solution. Which of the following is the most appropriate surgical option for her condition?
. Bunionectomy (chevron osteotomy).
. Arthrodesis (fusion) of the first MTP joint.
. Keller arthroplasty (resection of proximal phalanx base).
. Distal metatarsal osteotomy.
. Cheilectomy (dorsal osteophyte resection).

Correct Answer & Explanation

. Arthrodesis (fusion) of the first MTP joint.

Explanation

For advanced hallux rigidus (Grade III/IV), especially in an older patient with severe pain and functional limitation, arthrodesis (fusion) of the first metatarsophalangeal (MTP) joint is considered the gold standard. It provides excellent pain relief, stable weight-bearing, and predictable long-term results by eliminating motion at the painful joint. Cheilectomy is for earlier stages (Grade I/II). Bunionectomy and distal metatarsal osteotomy are for hallux valgus (bunion deformity). Keller arthroplasty is a salvage procedure with higher rates of metatarsalgia and instability.

Question 5457

Topic: 8. Foot and Ankle

A 30-year-old female presents with a several-month history of right posterior ankle pain, exacerbated by push-off during walking and running. On examination, she has tenderness over the posterior aspect of the Achilles tendon, approximately 2-6 cm proximal to its insertion. What is the most likely diagnosis?

. Insertional Achilles tendinopathy.
. Retrocalcaneal bursitis.
. Non-insertional Achilles tendinopathy (mid-portion).
. Haglund's deformity.
. Achilles tendon rupture.

Correct Answer & Explanation

. Non-insertional Achilles tendinopathy (mid-portion).

Explanation

The location of pain (2-6 cm proximal to insertion) is characteristic of non-insertional (mid-portion) Achilles tendinopathy, which is the most common form of Achilles tendon pain. Insertional tendinopathy occurs at the tendon's attachment to the calcaneus. Retrocalcaneal bursitis is pain anterior to the Achilles tendon at the superior calcaneal tuberosity. Haglund's deformity is a bony prominence causing pain, often at the insertion. Achilles rupture presents with acute pain, a palpable gap, and a positive Thompson test.

Question 5458

Topic: 8. Foot and Ankle

Which of the following is a classic clinical triad for a ruptured Achilles tendon?

. Anterior ankle pain, swelling, difficulty walking.
. Posterior heel pain, palpable gap, positive Thompson test.
. Lateral ankle swelling, ecchymosis, inability to bear weight.
. Midfoot pain, pes planus, inability to perform single heel rise.
. Calf pain, numbness, weakness in plantarflexion.

Correct Answer & Explanation

. Posterior heel pain, palpable gap, positive Thompson test.

Explanation

The classic clinical triad for a ruptured Achilles tendon includes posterior heel/calf pain, a palpable gap in the tendon (often 2-6 cm proximal to the calcaneal insertion), and a positive Thompson test (absence of plantarflexion when squeezing the calf muscle). The other options describe symptoms related to different conditions: anterior ankle pain (e.g., impingement), lateral ankle swelling (e.g., ankle sprain), midfoot pain (e.g., posterior tibial tendon dysfunction), or calf pain/numbness/weakness (e.g., nerve impingement or compartment syndrome).

Question 5459

Topic: 8. Foot and Ankle

The anterior drawer test of the ankle assesses the integrity of which ligament?

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

Correct Answer & Explanation

. Anterior talofibular ligament.

Explanation

The anterior drawer test of the ankle specifically assesses the integrity of the anterior talofibular ligament (ATFL), which is the most commonly injured ligament in ankle sprains. The test involves stabilizing the tibia and fibula with one hand and drawing the foot anteriorly with the other. Excessive anterior translation or a 'clunk' indicates ATFL laxity/tear. The calcaneofibular ligament and posterior talofibular ligament are assessed by other maneuvers.

Question 5460

Topic: 8. Foot and Ankle

A patient presents with persistent foot drop and weakness in ankle dorsiflexion after a knee injury. There is also numbness in the dorsum of the foot. Which nerve is most likely injured?

. Tibial nerve.
. Sural nerve.
. Saphenous nerve.
. Common fibular (peroneal) nerve.
. Femoral nerve.

Correct Answer & Explanation

. Common fibular (peroneal) nerve.

Explanation

Foot drop (inability to dorsiflex the ankle and extend the toes) and sensory loss on the dorsum of the foot are classic signs of common fibular (peroneal) nerve injury. This nerve is particularly vulnerable at the fibular head due to its superficial course. The tibial nerve controls plantarflexion. The sural and saphenous nerves are purely sensory. The femoral nerve controls knee extension and hip flexion.

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