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8. Foot and Ankle MCQs

Practice Set 274 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 5461

Topic: 8. Foot and Ankle

What is the most common presenting symptom of a patient with a stress fracture of the metatarsals?

. Acute, sharp pain after a single traumatic event.
. Gradual onset of forefoot pain, worse with activity, relieved by rest.
. Sudden numbness and tingling in the toes.
. Visible deformity of the foot.
. Systemic fever and chills.

Correct Answer & Explanation

. Gradual onset of forefoot pain, worse with activity, relieved by rest.

Explanation

Stress fractures, including those of the metatarsals, are characterized by a gradual onset of localized pain that worsens with activity (e.g., running, prolonged walking) and is relieved by rest. There is typically no acute traumatic event, and visible deformity or systemic symptoms are usually absent. Acute, sharp pain after trauma suggests an acute fracture. Numbness/tingling suggests nerve involvement. Fever/chills suggest infection.

Question 5462

Topic: Forefoot

What is the primary goal of surgical treatment for hallux valgus (bunion deformity)?

. Cosmetic improvement of foot appearance.
. Complete elimination of pain and restoration of normal foot mechanics.
. Correction of the intermetatarsal angle and hallux valgus angle.
. Fusion of the first metatarsophalangeal (MTP) joint.
. Amputation of the hallux.

Correct Answer & Explanation

. Correction of the intermetatarsal angle and hallux valgus angle.

Explanation

The primary goal of surgical treatment for hallux valgus is to correct the underlying bony deformity, specifically the increased intermetatarsal angle (IMA) between the first and second metatarsals, and the increased hallux valgus angle (HVA). This bony realignment aims to relieve pain, improve foot mechanics, and prevent recurrence. While pain relief is a significant outcome, restoring 'normal' mechanics can be challenging. Fusion is reserved for severe arthritis or failed previous surgeries. Cosmetic improvement is a secondary benefit, not the primary goal. Amputation is not a standard treatment.

Question 5463

Topic: 8. Foot and Ankle

A 40-year-old construction worker presents with chronic low back pain radiating to his left buttock and posterolateral thigh, worsening with standing and walking, and relieved by sitting. Neurological examination reveals diminished left ankle dorsiflexion and sensation over the dorsum of the foot. What is the most likely level of nerve root compression?

. L3-L4
. L4-L5
. L5-S1
. S1-S2
. L2-L3

Correct Answer & Explanation

. L4-L5

Explanation

Diminished ankle dorsiflexion (weakness of tibialis anterior, extensor hallucis longus) and sensory loss over the dorsum of the foot are classic signs of L4-L5 disc herniation compressing the L5 nerve root. L3-L4 compression affects the L4 nerve root, typically causing weakness in knee extension (quadriceps) and sensory loss over the medial calf. L5-S1 compression affects the S1 nerve root, leading to weakness in plantarflexion and sensory loss over the lateral foot and sole. S1-S2 is less commonly compressed in typical lumbar disc herniations. L2-L3 involves the L3 nerve root, affecting hip flexion and thigh sensation.

Question 5464

Topic: Ankle Trauma & Sports

Which ligament is most commonly injured in an inversion ankle sprain?

. Deltoid ligament
. Anterior inferior tibiofibular ligament (AITFL)
. Posterior talofibular ligament (PTFL)
. Calcaneofibular ligament (CFL)
. Anterior talofibular ligament (ATFL)

Correct Answer & Explanation

. Anterior talofibular ligament (ATFL)

Explanation

The anterior talofibular ligament (ATFL) is the most commonly injured ligament in an inversion ankle sprain, often being the first to tear. It is the weakest of the lateral ankle ligaments. If the inversion force continues, the calcaneofibular ligament (CFL) may also be injured. The posterior talofibular ligament (PTFL) is less commonly injured in isolated inversion sprains. The deltoid ligament is on the medial side and is injured in eversion sprains. The AITFL is part of the syndesmosis and is injured in high ankle sprains.

Question 5465

Topic: 8. Foot and Ankle

A patient presents with a chronically painful, stiff ankle following a severe pilon fracture treated with ORIF. Radiographs show significant post-traumatic arthritis. What is the most appropriate surgical management for end-stage ankle arthritis in an active patient?

. Ankle arthrodesis (fusion)
. Total ankle arthroplasty (TAA)
. Distraction arthroplasty
. Debridement and osteophyte resection
. Supramalleolar osteotomy

Correct Answer & Explanation

. Total ankle arthroplasty (TAA)

Explanation

For end-stage ankle arthritis in an active patient, total ankle arthroplasty (TAA) is increasingly considered a viable option. It aims to relieve pain while preserving motion, which is desirable for active individuals. Ankle arthrodesis (fusion) is a reliable pain-relieving procedure but sacrifices motion, which can lead to increased stress on adjacent joints. Distraction arthroplasty is for early to mid-stage arthritis. Debridement is for early stages. Supramalleolar osteotomy is for correction of malalignment with early arthritis.

Question 5466

Topic: 8. Foot and Ankle

Which clinical finding is most indicative of a complete tear of the Achilles tendon?

. Pain and swelling over the posterior ankle
. Limited passive dorsiflexion
. Positive Thompson test
. Difficulty with heel raises
. Palpable gap in the tendon

Correct Answer & Explanation

. Positive Thompson test

Explanation

A positive Thompson test (absence of plantarflexion of the foot when the calf muscle is squeezed) is the most reliable clinical sign for a complete rupture of the Achilles tendon. While a palpable gap and difficulty with heel raises are often present, the Thompson test specifically demonstrates the functional loss of the gastrocnemius-soleus complex's connection to the calcaneus. Pain and swelling are non-specific, and limited passive dorsiflexion is not typically associated with an Achilles rupture unless there's concomitant injury.

Question 5467

Topic: Midfoot & Hindfoot

A 40-year-old male develops a significant malunion of a calcaneal fracture, resulting in hindfoot varus, subtalar stiffness, and impingement on the lateral malleolus. He experiences chronic pain and difficulty with ambulation. Which of the following surgical procedures is most appropriate to address his symptoms?

. Subtalar arthrodesis
. Triple arthrodesis
. Lateralizing calcaneal osteotomy with subtalar arthrodesis
. Exostectomy of the lateral malleolus
. Arthrodesis of the calcaneocuboid joint

Correct Answer & Explanation

. Lateralizing calcaneal osteotomy with subtalar arthrodesis

Explanation

A malunited calcaneal fracture with hindfoot varus and lateral impingement requires a complex correction. A lateralizing calcaneal osteotomy addresses the varus deformity and widens the calcaneal body to decompress the lateral structures. Combining this with a subtalar arthrodesis stabilizes the hindfoot, corrects the deformity, and addresses the painful subtalar stiffness. Isolated subtalar arthrodesis may not correct the varus and impingement adequately. Triple arthrodesis includes the talonavicular and calcaneocuboid joints, which may be excessive if pathology is confined to the subtalar joint and calcaneal body. Exostectomy alone is insufficient for the underlying deformity. Calcaneocuboid arthrodesis alone does not address the hindfoot varus or subtalar pathology.

Question 5468

Topic: 8. Foot and Ankle

A 50-year-old male, a recreational runner, develops insidious onset pain on the plantar aspect of his heel, worse with the first steps in the morning and after periods of rest. Physical examination reveals tenderness at the medial plantar calcaneal tuberosity. Dorsiflexion of the ankle and toes exacerbates the pain. Which of the following is the most appropriate initial treatment?

. Corticosteroid injection into the plantar fascia origin.
. Night splinting and stretching exercises for the Achilles tendon and plantar fascia.
. Extracorporeal shockwave therapy.
. Platelet-rich plasma (PRP) injection.
. Surgical release of the plantar fascia.

Correct Answer & Explanation

. Night splinting and stretching exercises for the Achilles tendon and plantar fascia.

Explanation

This is a classic presentation of plantar fasciitis. The initial treatment is overwhelmingly conservative. Night splinting to keep the ankle in dorsiflexion, stretching exercises for the Achilles tendon and plantar fascia, ice, activity modification, and supportive footwear are the mainstays. Corticosteroid injections can provide short-term relief but are associated with risks of fat pad atrophy or plantar fascia rupture. ESWT and PRP are typically considered for refractory cases after several months of failed conservative management. Surgical release is a last resort for chronic, recalcitrant cases.

Question 5469

Topic: 8. Foot and Ankle

A 45-year-old female presents with chronic Achilles tendon pain and swelling, approximately 4 cm proximal to its insertion. She is a recreational runner and has failed extensive conservative management. MRI shows tendon thickening and degeneration without a full-thickness tear. What is the most appropriate surgical intervention?

. Debridement of the degenerated tendon and plantaris tendon transfer.
. Achilles tendon repair with augmentation.
. Percutaneous Achilles tenotomy.
. Open debridement of the degenerated tendon with repair if partial tear present.
. Gastroc recession.

Correct Answer & Explanation

. Open debridement of the degenerated tendon with repair if partial tear present.

Explanation

This scenario describes non-insertional Achilles tendinopathy that has failed conservative management. The most appropriate surgical intervention is open debridement of the degenerated tendon (often involving excision of the pathologic nodule) and repair of any partial tears. If a significant defect remains after debridement, augmentation with a local tendon (e.g., FHL or plantaris) may be considered, but debridement and primary repair/closure of the defect are usually sufficient. Achilles tendon repair with augmentation is for full-thickness tears. Percutaneous tenotomy is for severe spasticity or contractures. Gastroc recession addresses equinus contracture. The key is to remove the diseased tissue and promote healing.

Question 5470

Topic: 8. Foot and Ankle

Which of the following is most commonly associated with a 'Maisonneuve fracture'?

. A fracture of the base of the 5th metatarsal.
. A fibula shaft fracture with an associated syndesmotic injury and deltoid ligament rupture.
. A fracture of the posterior malleolus of the tibia.
. A calcaneal fracture with subtalar dislocation.
. An avulsion fracture of the anterior inferior iliac spine.

Correct Answer & Explanation

. A fibula shaft fracture with an associated syndesmotic injury and deltoid ligament rupture.

Explanation

A Maisonneuve fracture is a specific type of ankle injury characterized by a fracture of the proximal fibula shaft, often proximally near the fibular head, in conjunction with an ankle injury involving rupture of the deltoid ligament (medially) and/or syndesmotic disruption (between tibia and fibula). This occurs due to an external rotation injury to the ankle, transmitting forces up the interosseous membrane to fracture the fibula. It is crucial to recognize because isolated proximal fibula fractures can be missed, leading to chronic ankle instability if the syndesmotic injury is not addressed.

Question 5471

Topic: Midfoot & Hindfoot

What is the most common cause of painful pes planus in an adult, often leading to progressive flatfoot deformity?

. Spring ligament insufficiency
. Accessory navicular syndrome
. Tibialis anterior tendon rupture
. Posterior tibial tendon dysfunction (PTTD)
. Charcot arthropathy

Correct Answer & Explanation

. Posterior tibial tendon dysfunction (PTTD)

Explanation

Posterior tibial tendon dysfunction (PTTD) is the most common cause of adult-acquired flatfoot deformity, leading to progressive painful pes planus. The posterior tibial tendon is a primary supporter of the medial longitudinal arch. Its dysfunction leads to failure of the arch. While spring ligament insufficiency can contribute, it's often secondary to PTTD. Accessory navicular syndrome is a congenital anomaly that can cause pain, but not typically progressive flatfoot. Tibialis anterior tendon rupture results in a cavus-like deformity, and Charcot arthropathy is a neuropathic joint condition seen in diabetes, not the most common cause of painful acquired flatfoot.

Question 5472

Topic: 8. Foot and Ankle

A 30-year-old male is brought to the trauma bay after a high-speed motorcycle collision. He has a grossly deformed left knee. Radiographs reveal an anterior knee dislocation. The dislocation is urgently reduced. Post-reduction, he has a palpable dorsalis pedis pulse, but his Ankle-Brachial Index (ABI) is measured at 0.85. What is the most appropriate next step in management?

. Discharge with a hinged knee brace and instructions for non-weight bearing
. Serial physical examinations and ABI measurements every 4 hours
. CT angiography of the lower extremity
. Immediate surgical exploration of the popliteal artery
. Duplex ultrasonography at 24 hours post-reduction

Correct Answer & Explanation

. CT angiography of the lower extremity

Explanation

Knee dislocations carry a high risk of popliteal artery injury. Current guidelines recommend measuring the Ankle-Brachial Index (ABI) after reduction of all knee dislocations. If the ABI is >0.9, serial examinations are generally safe. However, an ABI <0.9 or asymmetric pulses indicates a high likelihood of vascular compromise and necessitates advanced imaging, most commonly CT angiography (CTA), to locate the level and extent of the vascular injury before surgical intervention.

Question 5473

Topic: 8. Foot and Ankle

A 22-year-old collegiate football player experiences a severe axial load on a plantarflexed foot. He complains of intense midfoot pain and inability to bear weight. An anteroposterior (AP) radiograph demonstrates the 'fleck sign' in the first intermetatarsal space. This bony avulsion historically represents the attachment site of the Lisfranc ligament to which of the following structures?

. Medial aspect of the medial cuneiform
. Medial aspect of the base of the second metatarsal
. Lateral aspect of the base of the first metatarsal
. Distal aspect of the navicular
. Plantar aspect of the cuboid

Correct Answer & Explanation

. Medial aspect of the base of the second metatarsal

Explanation

The Lisfranc ligament is a stout, interosseous ligament that connects the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. There is no ligamentous connection between the first and second metatarsals. The 'fleck sign' is pathognomonic for a Lisfranc injury and represents a bony avulsion fracture typically from the base of the second metatarsal, though it can occasionally avulse from the medial cuneiform.

Question 5474

Topic: 8. Foot and Ankle

A 28-year-old male sustains a lateral subtalar dislocation after a severe inversion and plantarflexion injury. Attempted closed reduction in the emergency department is unsuccessful, requiring operative intervention. What is the most common anatomical structure that blocks the reduction of a lateral subtalar dislocation?

. Extensor digitorum brevis
. Posterior tibial tendon
. Flexor hallucis longus
. Peroneus brevis
. Extensor retinaculum

Correct Answer & Explanation

. Posterior tibial tendon

Explanation

Subtalar dislocations are classified by the direction the foot moves relative to the talus. Medial subtalar dislocations are the most common (up to 80%) and when irreducible, are typically blocked by the extensor retinaculum, extensor digitorum brevis, or talonavicular capsule. Lateral subtalar dislocations (where the foot moves laterally) are less common but are frequently irreducible because the posterior tibial tendon (PTT) becomes interposed in the talonavicular joint, blocking reduction.

Question 5475

Topic: 8. Foot and Ankle

A 24-year-old gymnast sustains a rare pure tibiotalar (ankle) dislocation without any associated fractures of the malleoli or talus. What is the most common direction of a pure ankle dislocation, and what specific foot positioning during the traumatic axial load strongly predisposes to this injury pattern?

. Posteromedial dislocation; maximum plantarflexion and inversion
. Anterolateral dislocation; maximum dorsiflexion and eversion
. Posterior dislocation; maximum dorsiflexion with internal rotation
. Anterior dislocation; maximum plantarflexion with an anterior tibial blow
. Lateral dislocation; maximum eversion and external rotation

Correct Answer & Explanation

. Posteromedial dislocation; maximum plantarflexion and inversion

Explanation

Pure tibiotalar dislocations (without fracture) are exceedingly rare due to the inherent bony stability of the ankle mortise. The most common direction for a pure ankle dislocation is posteromedial. This injury classically occurs from a high-energy axial load applied to a foot that is maximally plantarflexed and inverted. In this position, the narrow posterior portion of the talar dome is positioned in the mortise, rendering the joint anatomically at its least stable state.

Question 5476

Topic: 8. Foot and Ankle

A 32-year-old male is brought to the trauma bay after a high-speed motor vehicle collision. He sustained an obvious left knee dislocation that was immediately reduced in the emergency department. Post-reduction, he has palpable and symmetric dorsalis pedis and posterior tibial pulses. The Ankle-Brachial Index (ABI) on the affected limb is 0.85. What is the most appropriate next step in management?

. Discharge with a knee immobilizer and close outpatient follow-up
. Serial neurovascular examinations every 4 hours for 24 hours
. CT angiography of the lower extremity
. Immediate surgical exploration by vascular surgery
. Magnetic Resonance Angiography (MRA) of the lower extremity

Correct Answer & Explanation

. CT angiography of the lower extremity

Explanation

In the setting of a knee dislocation, vascular injury (specifically to the popliteal artery) is a major concern. Even in the presence of palpable pulses, an ABI of less than 0.90 is highly sensitive for arterial injury and mandates further advanced vascular imaging, most commonly a CT angiogram. Immediate surgical exploration is reserved for hard signs of vascular injury (e.g., absent pulses, expanding hematoma, pulsatile bleeding).

Question 5477

Topic: 8. Foot and Ankle

A 30-year-old female sustains a lateral subtalar dislocation after a fall from a height. Closed reduction under conscious sedation in the emergency department is unsuccessful. Which of the following anatomical structures is most likely interposing and preventing closed reduction?

. Tibialis anterior tendon
. Posterior tibial tendon
. Extensor digitorum brevis muscle
. Flexor hallucis longus tendon
. Peroneus brevis tendon

Correct Answer & Explanation

. Posterior tibial tendon

Explanation

Subtalar dislocations are classified by the direction of the foot relative to the talus. Medial dislocations are more common and, when irreducible, are typically blocked by the extensor retinaculum, extensor digitorum brevis, or the talonavicular joint capsule. Lateral dislocations, though less common, are more likely to be irreducible and are classically blocked by the interposition of the posterior tibial tendon.

Question 5478

Topic: 8. Foot and Ankle

A 45-year-old male sustains a twisting injury to his midfoot. Anteroposterior radiographs demonstrate a 'fleck sign' in the first intermetatarsal space. This pathognomonic finding represents an avulsion of the Lisfranc ligament. What are the correct anatomical attachment sites of the intact Lisfranc ligament?

. Medial cuneiform to the base of the first metatarsal
. Medial cuneiform to the base of the second metatarsal
. Middle cuneiform to the base of the second metatarsal
. Lateral cuneiform to the base of the third metatarsal
. Cuboid to the base of the fourth metatarsal

Correct Answer & Explanation

. Medial cuneiform to the base of the second metatarsal

Explanation

The Lisfranc ligament is a large, strong interosseous ligament that connects the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. It is the primary stabilizer of the midfoot arch, as there is no intermetatarsal ligament connecting the first and second metatarsal bases. The 'fleck sign' represents an avulsion fracture of this ligament's attachment, most commonly off the base of the second metatarsal.

Question 5479

Topic: 8. Foot and Ankle

During intraoperative evaluation of ankle syndesmotic instability (the 'Cotton test'), a lateral force is applied to the fibula using a bone hook. Which of the following ligaments provides the primary resistance to lateral displacement of the fibula, functioning as the strongest component of the syndesmotic complex?

. Anterior inferior tibiofibular ligament (AITFL)
. Posterior inferior tibiofibular ligament (PITFL)
. Interosseous membrane
. Transverse tibiofibular ligament
. Deltoid ligament

Correct Answer & Explanation

. Posterior inferior tibiofibular ligament (PITFL)

Explanation

The syndesmotic complex consists of the AITFL, PITFL, interosseous ligament/membrane, and the transverse ligament. Biomechanical studies have demonstrated that the posterior inferior tibiofibular ligament (PITFL) is the strongest component of the syndesmosis, contributing approximately 42% of the total resistance to lateral fibular displacement.

Question 5480

Topic: 8. Foot and Ankle

A 25-year-old male sustains a multiligamentous knee injury following a high-speed motorcycle collision. His knee was visibly dislocated at the scene but reduced by paramedics. In the emergency department, his Ankle-Brachial Index (ABI) is measured at 0.85. His foot is warm and well-perfused, and he has palpable but slightly diminished distal pulses compared to the contralateral side. What is the most appropriate next step in management?

. Immediate surgical exploration of the popliteal artery
. Close clinical observation with serial ABIs every 2 hours
. CT angiography (CTA) of the lower extremity
. Application of a spanning external fixator and discharge
. Fasciotomy of the four compartments of the leg

Correct Answer & Explanation

. CT angiography (CTA) of the lower extremity

Explanation

An Ankle-Brachial Index (ABI) < 0.90 or asymmetry in pulses after a knee dislocation is highly suspicious for a vascular injury. The current standard of care dictates that patients with an ABI < 0.90 should undergo advanced imaging, typically CT angiography (CTA), to delineate the vascular anatomy and rule out intimal tears or occlusions. Immediate surgical exploration is reserved for 'hard signs' of arterial injury (e.g., active pulsatile bleeding, expanding hematoma, absent pulse with ischemia). If the ABI is > 0.90, serial observation is appropriate.

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