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8. Foot and Ankle MCQs

Practice Set 276 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 5501

Topic: Midfoot & Hindfoot
A 60-year-old diabetic patient presents with a swollen, warm foot. Radiographs show marked periarticular fragmentation, subluxation of the tarsometatarsal joints, and considerable bony debris, without signs of consolidation. According to the Eichenholtz classification of Charcot arthropathy, which stage does this represent?
. Stage 0 (High Risk)
. Stage I (Development/Fragmentation)
. Stage II (Coalescence)
. Stage III (Reconstruction/Consolidation)
. Stage IV (Ulceration)

Correct Answer & Explanation

. Stage I (Development/Fragmentation)

Explanation

The Eichenholtz classification describes Charcot arthropathy stages. Stage I (Development/Fragmentation) is characterized by acute inflammation, osteopenia, periarticular fragmentation, subluxation, and bony debris. Stage II (Coalescence) involves absorption of debris and early fusion. Stage III (Consolidation) shows remodeling and stable deformity.

Question 5502

Topic: Midfoot & Hindfoot
According to the Eichenholtz classification of Charcot arthropathy, which of the following radiographic findings characterizes the coalescence stage (Stage II)?
. Osseous fragmentation, joint dislocation, and extensive subchondral debris.
. Absorption of fine debris, fusion of larger fragments, and early sclerosis.
. Subchondral bone marrow edema on MRI with entirely normal plain radiographs.
. Remodeling of bone ends, decreased sclerosis, and reformation of the joint architecture.
. Acute osteopenia, periarticular fracture, and gas in the soft tissues.

Correct Answer & Explanation

. Absorption of fine debris, fusion of larger fragments, and early sclerosis.

Explanation

The Eichenholtz classification divides Charcot arthropathy into three stages. Stage I (Development/Fragmentation) involves debris, fragmentation, and dislocation. Stage II (Coalescence) involves absorption of fine debris, early fusion of fragments, and sclerosis. Stage III (Reconstruction) involves rounding of bone ends and decreased sclerosis.

Question 5503

Topic: 8. Foot and Ankle

In evaluating a suspected Lisfranc injury, the presence of a 'fleck sign' on an anteroposterior (AP) radiograph of the foot is highly suggestive of a major ligamentous avulsion. The primary Lisfranc ligament connects which two osseous structures?

. Medial cuneiform and the base of the first metatarsal
. Middle cuneiform and the base of the second metatarsal
. Medial cuneiform and the base of the second metatarsal
. Navicular and the medial cuneiform
. Lateral cuneiform and the cuboid

Correct Answer & Explanation

. Medial cuneiform and the base of the second metatarsal

Explanation

The Lisfranc ligament is an intraosseous ligament that runs obliquely from the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. A 'fleck sign' in this space represents an avulsion fracture of this ligament's attachment and implies Lisfranc joint instability.

Question 5504

Topic: 8. Foot and Ankle

In a suspected Lisfranc injury, which radiographic finding is considered pathognomonic (the "Fleck sign") for avulsion of the Lisfranc ligament?

. A bone fragment in the first intermetatarsal space
. Widening of the talonavicular joint
. Dorsal displacement of the cuboid
. Fracture of the fifth metatarsal base
. Avulsion fracture of the navicular tuberosity

Correct Answer & Explanation

. A bone fragment in the first intermetatarsal space

Explanation

The Fleck sign is a bony avulsion in the space between the base of the first and second metatarsals. It represents an avulsion of the Lisfranc ligament, which connects the medial cuneiform to the base of the second metatarsal.

Question 5505

Topic: 8. Foot and Ankle

A 55-year-old poorly controlled diabetic male presents with a swollen, warm, and erythematous right foot. He denies any systemic symptoms. Radiographs show fragmentation of the navicular and cuneiforms with early subluxation at the midtarsal joints. Which of the following is the most appropriate initial management?

. Intravenous antibiotics and MRI
. Incision and drainage of the midfoot
. Total contact casting and non-weight bearing
. Arthrodesis of the midfoot
. Custom orthotic shoe wear

Correct Answer & Explanation

. Total contact casting and non-weight bearing

Explanation

The patient is presenting with acute Eichenholtz stage I Charcot neuroarthropathy. The mainstay of initial treatment is immobilization and offloading, typically with a total contact cast (TCC), to prevent further deformity until the acute inflammatory phase resolves and coalescence occurs.

Question 5506

Topic: 8. Foot and Ankle

Which of the following vessels provides the predominant blood supply to the body of the talus?

. Dorsalis pedis artery
. Artery of the tarsal sinus
. Artery of the tarsal canal
. Deltoid branch of the posterior tibial artery
. Perforating peroneal artery

Correct Answer & Explanation

. Artery of the tarsal canal

Explanation

The artery of the tarsal canal, which is a branch of the posterior tibial artery, provides the majority of the blood supply to the talar body. It forms an anastomotic sling with the artery of the tarsal sinus (derived from the anterior tibial and peroneal arteries) beneath the talar neck.

Question 5507

Topic: 8. Foot and Ankle

A 55-year-old diabetic patient presents with a red, hot, swollen right foot and ankle. Radiographs show periarticular debris, fragmentation of the navicular, and subluxation of the midtarsal joints. According to the Eichenholtz classification, what is the most appropriate management at this stage?

. Emergent irrigation and debridement for septic arthritis
. Midfoot arthrodesis with rigid internal fixation
. Application of a total contact cast and strict non-weight-bearing
. Prescription of custom orthoses and shoe modifications
. Below-knee amputation

Correct Answer & Explanation

. Application of a total contact cast and strict non-weight-bearing

Explanation

The patient is in Eichenholtz Stage I (Development/Fragmentation) of Charcot arthropathy. The mainstay of treatment in the acute, active phase is rigid immobilization and offloading, which is most effectively achieved with a total contact cast. Surgical reconstruction is generally contraindicated in the acute phase.

Question 5508

Topic: 8. Foot and Ankle

A 24-year-old football player sustains a hyperplantarflexion injury to his foot. Radiographs show a "fleck sign" at the base of the second metatarsal. The primary stabilizing ligament of this joint connects which two structural bones?

. First metatarsal and second metatarsal
. Medial cuneiform and second metatarsal
. Middle cuneiform and second metatarsal
. Medial cuneiform and first metatarsal
. Lateral cuneiform and third metatarsal

Correct Answer & Explanation

. Medial cuneiform and second metatarsal

Explanation

The Lisfranc ligament is an interosseous ligament that connects the medial cuneiform to the base of the second metatarsal. It provides critical stability to the midfoot articulation, and avulsion results in the pathognomonic "fleck sign."

Question 5509

Topic: Midfoot & Hindfoot
A 28-year-old female falls from a height and sustains a Hawkins Type III fracture of the talar neck. Which of the following best describes the articulations dislocated in this injury pattern?
. Subtalar joint only
. Subtalar and tibiotalar joints
. Subtalar, tibiotalar, and talonavicular joints
. Talonavicular joint only
. Tibiotalar joint only

Correct Answer & Explanation

. Subtalar, tibiotalar, and talonavicular joints

Explanation

In the Hawkins classification of talar neck fractures, a Type III injury involves displacement of the fracture with dislocation of the subtalar, tibiotalar, and talonavicular joints. It carries a nearly 100% risk of avascular necrosis.

Question 5510

Topic: Midfoot & Hindfoot

A 58-year-old patient with long-standing, poorly controlled diabetes mellitus presents with a swollen, erythematous, and warm foot but no open ulcers. Radiographs demonstrate periarticular fragmentation, subchondral cyst formation, and joint subluxation at the tarsometatarsal joints. According to the Eichenholtz classification, what is the most appropriate initial management?

. Immediate open reduction and internal fixation
. Intravenous antibiotics and urgent surgical debridement
. Total contact casting and non-weight-bearing
. Custom orthotic shoe wear and weight-bearing as tolerated
. Midfoot arthrodesis using a rigid plating system

Correct Answer & Explanation

. Total contact casting and non-weight-bearing

Explanation

This patient is in Eichenholtz Stage I (Development/Fragmentation) of Charcot arthropathy, characterized by acute inflammation, hyperemia, and bony fragmentation. The gold standard for initial management in this active phase is rigid immobilization and offloading, typically achieved with a total contact cast (TCC), to prevent progressive deformity until the process reaches the consolidation phase.

Question 5511

Topic: 8. Foot and Ankle

A 40-year-old male undergoes percutaneous repair of an acute Achilles tendon rupture. Postoperatively, he notes numbness and paresthesias along the lateral aspect of his heel and foot. Which nerve was most likely injured during the procedure, and at what anatomical location is it at greatest risk?

. Superficial peroneal nerve; as it crosses anterior to the lateral malleolus
. Deep peroneal nerve; in the first web space
. Tibial nerve; posterior to the medial malleolus
. Sural nerve; as it crosses the lateral border of the Achilles tendon approximately 10 cm proximal to the calcaneal insertion
. Saphenous nerve; along the medial border of the Achilles tendon

Correct Answer & Explanation

. Sural nerve; as it crosses the lateral border of the Achilles tendon approximately 10 cm proximal to the calcaneal insertion

Explanation

The sural nerve is at the highest risk of injury during percutaneous or minimally invasive Achilles tendon repair. It courses down the posterior leg and reliably crosses the lateral border of the Achilles tendon approximately 9.8 to 10 cm proximal to its insertion on the calcaneus.

Question 5512

Topic: 8. Foot and Ankle

The Lisfranc ligament is an essential stabilizing structure of the midfoot. Which of the following describes the true anatomic attachments of the Lisfranc ligament?

. Medial cuneiform to the base of the first metatarsal
. Lateral cuneiform to the base of the second metatarsal
. Lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal
. Intermediate cuneiform to the base of the second metatarsal
. Navicular to the base of the first metatarsal

Correct Answer & Explanation

. Lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal

Explanation

The Lisfranc ligament is a strong interosseous ligament that runs obliquely from the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. There is no transverse intermetatarsal ligament connecting the bases of the first and second metatarsals, making this region highly susceptible to traumatic disruption.

Question 5513

Topic: 8. Foot and Ankle
A 55-year-old woman presents with medial ankle pain, a progressively flattening arch, and a positive 'too many toes' sign. She is diagnosed with Stage II adult acquired flatfoot deformity (posterior tibial tendon dysfunction). Which of the following radiographic findings distinguishes Stage IIb from Stage IIa and frequently requires a lateral column lengthening procedure?
. Talonavicular uncoverage of greater than 40%
. Subtalar joint arthritis
. Ankle joint valgus tilt
. Rigid, irreducible hindfoot valgus
. Complete rupture of the spring ligament

Correct Answer & Explanation

. Talonavicular uncoverage of greater than 40%

Explanation

Stage II posterior tibial tendon dysfunction involves a flexible hindfoot valgus deformity. It is subclassified into IIa (hindfoot valgus with minimal forefoot abduction) and IIb (hindfoot valgus with significant forefoot abduction). Forefoot abduction is radiographically quantified by talonavicular uncoverage on an AP foot X-ray. Uncoverage greater than 30-40% typically defines Stage IIb and often necessitates a lateral column lengthening. Rigid hindfoot/arthritis is Stage III, and ankle involvement is Stage IV.

Question 5514

Topic: 8. Foot and Ankle

A 22-year-old rugby player sustains an axial load injury to an extreme plantarflexed foot. Weight-bearing radiographs reveal a 3 mm diastasis between the medial cuneiform and the base of the second metatarsal. The primary deforming force pulling the 1st metatarsal medially is the insertion of which structure?

. Tibialis anterior tendon
. Peroneus longus tendon
. Lisfranc ligament
. Plantar fascia
. Posterior tibial tendon

Correct Answer & Explanation

. Tibialis anterior tendon

Explanation

The tibialis anterior inserts onto the medial cuneiform and the base of the first metatarsal, acting as a strong deforming force that pulls the first ray medially during a Lisfranc injury. The Lisfranc ligament itself connects the medial cuneiform to the base of the second metatarsal.

Question 5515

Topic: 8. Foot and Ankle

A 55-year-old diabetic patient presents with a swollen, erythematous, and warm unilateral foot without any skin ulceration. Radiographs show fragmentation and subluxation of the tarsometatarsal joints. Which of the following is the most appropriate initial management?

. Intravenous antibiotics and urgent surgical debridement
. Total contact casting and strict non-weight bearing
. Arthrodesis of the midfoot
. MRI of the foot to rule out osteomyelitis
. Administration of intravenous bisphosphonates

Correct Answer & Explanation

. Total contact casting and strict non-weight bearing

Explanation

The clinical presentation is classic for acute Eichenholtz stage I Charcot arthropathy. The gold standard initial treatment to prevent further deformity and progression is strict non-weight bearing and immobilization, typically with a total contact cast.

Question 5516

Topic: 8. Foot and Ankle

The 'watershed area' of the Achilles tendon is the most frequent anatomical site for tendinopathy and acute rupture due to its relative hypovascularity. This susceptible zone is typically located at what distance proximal to the tendon's insertion on the calcaneal tuberosity?

. 0-2 cm
. 2-6 cm
. 6-10 cm
. 10-12 cm
. At the musculotendinous junction

Correct Answer & Explanation

. 2-6 cm

Explanation

The watershed zone of the Achilles tendon is a relatively hypovascular region located approximately 2 to 6 cm proximal to its insertion on the calcaneus. This poor intrinsic blood supply contributes to its susceptibility to degeneration and rupture.

Question 5517

Topic: 8. Foot and Ankle

Based on current Level 1 evidence comparing operative versus non-operative management of acute Achilles tendon ruptures utilizing an early functional rehabilitation protocol, non-operative management is associated with which of the following outcomes compared to operative treatment?

. Significantly higher re-rupture rates
. Equivalent re-rupture rates but higher complication rates
. Equivalent re-rupture rates with lower soft-tissue complication rates
. Decreased plantarflexion strength by 50%
. Higher rates of deep vein thrombosis

Correct Answer & Explanation

. Significantly higher re-rupture rates

Explanation

Recent randomized controlled trials utilizing early functional weight-bearing rehabilitation show equivalent re-rupture rates between operative and non-operative groups. However, non-operative management avoids surgical soft-tissue complications and infections.

Question 5518

Topic: 8. Foot and Ankle

A 30-year-old football player presents with midfoot pain after his foot was axially loaded while plantarflexed. Weight-bearing radiographs demonstrate a widening between the first and second metatarsals. The primary Lisfranc ligament connects which two structures?

. Medial cuneiform to the base of the second metatarsal
. Intermediate cuneiform to the base of the second metatarsal
. Medial cuneiform to the base of the first metatarsal
. Lateral cuneiform to the cuboid
. Navicular to the medial cuneiform

Correct Answer & Explanation

. Medial cuneiform to the base of the second metatarsal

Explanation

The Lisfranc ligament is a strong interosseous ligament that connects the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. It is critical for the stability of the tarsometatarsal articulation.

Question 5519

Topic: Midfoot & Hindfoot

Which of the following lower extremity amputation levels is generally associated with the highest increase in metabolic energy expenditure during ambulation compared to a healthy, non-amputee baseline?

. Syme amputation
. Transtibial amputation
. Knee disarticulation
. Transfemoral amputation
. Chopart amputation

Correct Answer & Explanation

. Syme amputation

Explanation

The metabolic energy required for ambulation increases exponentially as the level of lower extremity amputation becomes more proximal. A transfemoral amputation requires a significantly higher metabolic energy increase (approximately 60-65%) than a transtibial amputation.

Question 5520

Topic: 8. Foot and Ankle

Which of the following radiographic findings is the most reliable indicator of a subtle Lisfranc ligament disruption on a weight-bearing anteroposterior view of the foot?

. Fleck sign at the base of the first metatarsal
. More than 2 mm of widening between the first and second metatarsal bases
. Plantar gaping of the first tarsometatarsal joint
. Medial subluxation of the cuboid
. Calcaneal pitch less than 15 degrees

Correct Answer & Explanation

. Fleck sign at the base of the first metatarsal

Explanation

Widening of more than 2 mm between the bases of the first and second metatarsals on a weight-bearing AP radiograph is highly indicative of a Lisfranc injury. The classic fleck sign represents an avulsion from the base of the second metatarsal, not the first.

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