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8. Foot and Ankle MCQs

Practice Set 278 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 5541

Topic: 8. Foot and Ankle

A 24-year-old football player sustains a hyperplantarflexion injury to his midfoot. Radiographs show widening of the space between the base of the first and second metatarsals, indicative of a Lisfranc injury.

The critical Lisfranc ligament, disrupted in this injury, connects which two osseous structures?

. Base of the 1st metatarsal to the medial cuneiform
. Base of the 2nd metatarsal to the medial cuneiform
. Base of the 2nd metatarsal to the middle cuneiform
. Base of the 1st metatarsal to the base of the 2nd metatarsal
. Navicular to the medial cuneiform

Correct Answer & Explanation

. Base of the 1st metatarsal to the medial cuneiform

Explanation

The Lisfranc ligament is an essential stabilizing structure of the tarsometatarsal joint complex. It is a robust 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 direct intermetatarsal ligament connecting the bases of the first and second metatarsals, which creates an inherent area of biomechanical vulnerability.

Question 5542

Topic: 8. Foot and Ankle

A 40-year-old roofer falls from a height and sustains a closed, displaced intra-articular calcaneus fracture. Surgery is planned using an extensile lateral approach. Which of the following nerves is at greatest risk of iatrogenic injury during this specific surgical approach?

. Sural nerve
. Superficial peroneal nerve
. Deep peroneal nerve
. Posterior tibial nerve
. Saphenous nerve

Correct Answer & Explanation

. Sural nerve

Explanation

The extensile lateral approach to the calcaneus involves creating a full-thickness "no-touch" subperiosteal flap. The sural nerve crosses the lateral border of the foot and is incorporated into the flap. It is at significant risk of injury either from the initial incision or from traction/retraction during the procedure.

Question 5543

Topic: 8. Foot and Ankle

A 25-year-old football player sustains a forced plantar flexion injury to his midfoot. He has plantar ecchymosis and pain over the tarsometatarsal joints. Weight-bearing radiographs show 3 mm of widening between the bases of the 1st and 2nd metatarsals. Which ligament is primarily injured, and what structures does it connect?

. Spring ligament; connects navicular to calcaneus
. Lisfranc ligament; connects medial cuneiform to the base of the 2nd metatarsal
. Lisfranc ligament; connects lateral cuneiform to the base of the 2nd metatarsal
. Bifurcate ligament; connects calcaneus to cuboid and navicular
. Plantar fascia; connects calcaneus to proximal phalanges

Correct Answer & Explanation

. Spring ligament; connects navicular to calcaneus

Explanation

The Lisfranc ligament is a strong interosseous ligament that connects the medial cuneiform to the base of the 2nd metatarsal. It is critical for the stability of the midfoot because there is no direct intermetatarsal ligament between the 1st and 2nd metatarsal bases. Disruption of this ligament leads to widening of the interval, a hallmark of a Lisfranc injury. Plantar ecchymosis is a highly specific clinical sign.

Question 5544

Topic: 8. Foot and Ankle
A 30-year-old male falls from a height and sustains a Hawkins Type III talar neck fracture. Which of the following best describes the disruption of blood supply leading to the near 100% rate of avascular necrosis in this specific fracture pattern?
. Disruption of the artery of the tarsal canal, deltoid branches, and dorsalis pedis branches
. Disruption of the sural artery, anterior tibial artery, and medial plantar artery
. Disruption of the lateral tarsal artery, peroneal artery, and posterior tibial artery
. Disruption of the calcaneal branches, lateral plantar artery, and dorsalis pedis
. Disruption of the medial circumflex artery, lateral circumflex artery, and artery of the ligamentum teres

Correct Answer & Explanation

. Disruption of the artery of the tarsal canal, deltoid branches, and dorsalis pedis branches

Explanation

A Hawkins Type III fracture is a talar neck fracture with both subtalar and tibiotalar dislocation. This severe displacement tears all three major blood supplies to the talar body, leading to a profound risk of avascular necrosis.

Question 5545

Topic: 8. Foot and Ankle

Nonoperative management of an acute Achilles tendon rupture using a functional rehabilitation protocol has been shown to result in which of the following compared to traditional immobilization?

. Higher rerupture rates
. Similar rerupture rates and improved functional outcomes
. Higher rates of deep vein thrombosis
. Decreased plantarflexion strength
. Increased risk of sural nerve injury

Correct Answer & Explanation

. Higher rerupture rates

Explanation

Modern nonoperative management of acute Achilles tendon ruptures with early functional rehabilitation (early weight-bearing in a boot with wedges and active range of motion) has been shown to have rerupture rates comparable to surgical repair, with improved functional outcomes compared to traditional prolonged cast immobilization.

Question 5546

Topic: Ankle Trauma & Sports

A 28-year-old soccer player is diagnosed with a syndesmotic injury (high ankle sprain). If plain radiographs are equivocal, what is the most sensitive imaging modality to assess the integrity and dynamic reduction of the distal tibiofibular syndesmosis?

. Weight-bearing plain radiographs
. Ultrasound
. Axial Computed Tomography (CT)
. Non-contrast Magnetic Resonance Imaging (MRI)
. Radionuclide bone scan

Correct Answer & Explanation

. Weight-bearing plain radiographs

Explanation

Axial CT imaging is the gold standard for evaluating syndesmotic reduction. It clearly delineates the anatomic relationship and distances between the distal tibia and fibula compared to the contralateral normal side.

Question 5547

Topic: 8. Foot and Ankle
A patient undergoes surgical repair of an acute Achilles tendon rupture. During the early proliferative phase of tendon healing, the newly synthesized extracellular matrix is predominantly composed of which type of collagen?
. Type I
. Type II
. Type III
. Type IX
. Type X

Correct Answer & Explanation

. Type III

Explanation

Normal tendon is mostly Type I collagen. However, during the early proliferative (reparative) phase of healing, fibroblasts predominantly synthesize Type III collagen, which is later replaced by Type I during the remodeling phase.

Question 5548

Topic: Midfoot & Hindfoot
Which of the following patients who sustained a calcaneal fracture will most likely undergo an eventual subtalar fusion?
. Male worker's compensation patient who participates in heavy labor work with an initial Böhler angle less than 0 degrees
. Female worker's compensation patient who participates in heavy labor work with an initial Böhler angle >15 degrees
. Male non-worker's compensation patient who participates in heavy labor work with an initial Böhler angle less than 0 degrees
. Male worker's compensation patient who participates in heavy labor work with an initial Böhler angle >15 degrees
. Female non-worker's compensation patient who participates in heavy labor work with an initial Böhler less than 0 degrees

Correct Answer & Explanation

. Male worker's compensation patient who participates in heavy labor work with an initial Böhler angle less than 0 degrees

Explanation

The Level 2 study by Czisy et al is a review of a randomized trial database that analyzed the prospective clinical outcome of 45 patients who failed closed or open treatment of displaced intra-articular calcaneal fractures. The cohort underwent a subtalar fusion by distraction bone-block arthrodesis for subtalar arthritis. They found that male worker's compensation patients who participate in heavy labor work with a fracture pattern with a Böhler angle less than 0 degrees were the most likely to undergo a subtalar fusion. The meta-analysis by Randle et al reviewed 6 clinical studies comparing the results of operative vs. conservative management of calcaneal fracture studies. They found a trend for nonoperatively treated patients to have a higher risk of experiencing severe foot pain than did operatively treated patients, however they could not draw any definitive conclusions guiding treatment.

Question 5549

Topic: 8. Foot and Ankle

When comparing the fibular plating techniques shown in Figures A and B, the plate position shown in Figure B is associated with which of the following?


. Increased stiffness
. Increased strength
. Decreased rate of hardware prominence
. Increased risk of intra-articular screw penetration
. Increased peroneal tendinitis

Correct Answer & Explanation

. Increased stiffness

Explanation

Lateral plating of the distal fibula has an increased risk of intra-articular screw penetration with the trajectory of the screws distally; bicortical screws will be intra-articular in nature, whereas posterior plating screws will exit anteriorly.Figure A shows an antiglide (posterior) plating of the distal fibula, while Figure B shows a lateral neutralization plating of the distal fibula. Both methods are acceptable, but posterior antiglide plating is associated with increased construct stiffness and strength, decreased hardware prominence, decreased rates of ankle joint screw penetration, and improved biomechanical findings in osteoporotic bone. However, posterior plating is associated with an increased rate of peroneal tendonitis and irritation. Illustration A shows a lateral radiograph of a posterior fibular plate.The referenced article by Ostrum et al is a case series of 32 patients who had antiglide plating; he reported a 100% union rate, 95% patient satisfaction rate, and only 4/32 reported peroneal tendinitis, with all resolving by 2months.The other referenced article by Schaffer et al reported that the posterolateral antiglide plate demonstrated improved biomechanical stability as compared to the lateral plating, with increased construct stiffness and load to failure.

Question 5550

Topic: 8. Foot and Ankle

A 40-year-old female presents with a distal third spiral fracture of the tibial shaft. Which of the following associated injuries MUST be ruled out with advanced imaging or careful radiographic scrutiny?

. Proximal fibula fracture (Maisonneuve)
. Posterior malleolus fracture
. Achilles tendon rupture
. Calcaneus fracture
. Medial meniscus tear

Correct Answer & Explanation

. Proximal fibula fracture (Maisonneuve)

Explanation

Distal third spiral tibial shaft fractures have a high association (up to 90%) with occult posterior malleolus fractures. A dedicated ankle CT scan is routinely recommended to evaluate for intra-articular extension.

Question 5551

Topic: 8. Foot and Ankle

A 24-year-old athlete sustains a midfoot injury. Weight-bearing radiographs show a 3 mm diastasis between the base of the first and second metatarsals. What is the most appropriate definitive management?

. Rigid orthotic shoe wear
. Six weeks in a non-weight-bearing cast
. Closed reduction and percutaneous pinning
. Open reduction and internal fixation or primary arthrodesis
. Immediate physical therapy and taping

Correct Answer & Explanation

. Rigid orthotic shoe wear

Explanation

A diastasis greater than 2 mm indicates an unstable Lisfranc injury. Surgical stabilization through either open reduction and internal fixation or primary arthrodesis is required to prevent debilitating midfoot arthritis and deformity.

Question 5552

Topic: 8. Foot and Ankle

A 14-year-old male presents with recurrent ankle sprains and rigid flatfeet. On examination, he has restricted subtalar motion and pain reproduced with forced inversion. Radiographs show a "C sign" on the lateral view. Which of the following is the most appropriate initial management for this condition?

. Custom foot orthotics with medial arch support
. Serial casting or a controlled ankle motion (CAM) boot for 4 to 6 weeks
. Subtalar arthrodesis
. Excision of the coalition with fat pad interposition
. Calcaneal lengthening osteotomy

Correct Answer & Explanation

. Custom foot orthotics with medial arch support

Explanation

The clinical presentation and "C sign" on a lateral radiograph are pathognomonic for a talocalcaneal coalition. Initial management of a symptomatic tarsal coalition is conservative and aims to break the pain-spasm cycle. This is best achieved with a period of immobilization using a short leg cast or CAM boot for 4 to 6 weeks. Operative intervention (resection or arthrodesis) is reserved for cases that fail conservative management.

Question 5553

Topic: 8. Foot and Ankle

A 13-year-old boy presents with recurrent ankle sprains and a rigid, painful flat foot. Passive inversion and eversion of the subtalar joint are significantly restricted and painful. You suspect a tarsal coalition.

Which radiographic sign is classically associated with a calcaneonavicular coalition on an oblique radiograph of the foot?

. The 'C' sign
. The anteater nose sign
. The fleck sign
. The double density sign
. The crescent sign

Correct Answer & Explanation

. The 'C' sign

Explanation

The 'anteater nose sign' is classically seen on a 45-degree internal oblique radiograph of the foot in patients with a calcaneonavicular coalition. It represents a tubular elongation of the anterior process of the calcaneus projecting toward the navicular. The 'C' sign, seen on a lateral radiograph, is associated with a talocalcaneal (middle facet) coalition.

Question 5554

Topic: 8. Foot and Ankle
A 14-year-old boy presents with ankle pain after twisting his leg while playing soccer. Radiographs demonstrate an isolated Salter-Harris Type III fracture of the anterolateral aspect of the distal tibial epiphysis. What is the mechanism of injury, and which ligament provides the deforming force causing this specific fracture pattern?
. Supination-inversion mechanism; pulled by the anterior talofibular ligament (ATFL)
. External rotation mechanism; pulled by the anterior inferior tibiofibular ligament (AITFL)
. Plantarflexion mechanism; pulled by the Achilles tendon
. Pronation-abduction mechanism; pulled by the deltoid ligament
. Axial loading mechanism; pulled by the posterior inferior tibiofibular ligament (PITFL)

Correct Answer & Explanation

. External rotation mechanism; pulled by the anterior inferior tibiofibular ligament (AITFL)

Explanation

The fracture described is a juvenile Tillaux fracture. It occurs in adolescents (typically ages 12-15) because the distal tibial physis closes in a specific pattern: central, then medial, and finally lateral. An external rotation force on the foot creates tension in the anterior inferior tibiofibular ligament (AITFL), which avulses the still-open anterolateral portion of the distal tibial epiphysis (a Salter-Harris III fracture).

Question 5555

Topic: 8. Foot and Ankle

An 8-year-old boy with a known diagnosis of Duchenne Muscular Dystrophy (DMD) presents with progressively rigid equinovarus foot deformities that are severely impacting his ambulation. Surgical lengthening of the Achilles tendon and tendon transfers are planned.

During the anesthetic planning for this procedure, which of the following agents must be strictly avoided due to a severe, potentially fatal complication?

. Propofol
. Ketamine
. Succinylcholine
. Nitrous oxide
. Fentanyl

Correct Answer & Explanation

. Propofol

Explanation

Patients with Duchenne Muscular Dystrophy (DMD) lack dystrophin, which compromises the integrity of the muscle cell membrane. The use of depolarizing neuromuscular blocking agents, such as succinylcholine, can cause a massive release of intracellular potassium and catastrophic rhabdomyolysis. This leads to severe hyperkalemia, triggering malignant hyperthermia-like reactions and intractable cardiac arrest. Therefore, succinylcholine is absolutely contraindicated in DMD.

Question 5556

Topic: 8. Foot and Ankle

A 12-year-old boy presents with frequent ankle sprains and a painful, rigid flatfoot. Physical examination reveals limited subtalar motion and peroneal muscle spasm. A lateral radiograph demonstrates a continuous C-shaped arc connecting the talar dome and the sustentaculum tali. What is the most appropriate initial management for this condition?

. Surgical resection of the coalition with interposition arthroplasty
. Subtalar arthrodesis
. Short leg walking cast for 4 to 6 weeks
. Triple arthrodesis
. Physical therapy focusing on peroneal strengthening

Correct Answer & Explanation

. Surgical resection of the coalition with interposition arthroplasty

Explanation

The clinical and radiographic presentation ('C-sign') is diagnostic of a talocalcaneal (subtalar) coalition. Initial treatment for a symptomatic tarsal coalition is almost always nonoperative, typically involving immobilization in a short leg walking cast for 4 to 6 weeks. This helps to rest the joint and relieve the painful peroneal muscle spasms. Surgical resection is indicated only if conservative measures fail.

Question 5557

Topic: 8. Foot and Ankle

A 10-year-old boy presents with frequent ankle sprains and foot pain. Examination reveals a rigid flatfoot and peroneal spasticity. Radiographs demonstrate an 'anteater nose' sign. Which of the following is the most appropriate initial management for this specific condition?

. Talonavicular arthrodesis
. Resection of the coalition with interposition of the extensor digitorum brevis
. Subtalar arthrodesis
. Short leg cast immobilization for 4-6 weeks
. Medial displacement calcaneal osteotomy

Correct Answer & Explanation

. Talonavicular arthrodesis

Explanation

The 'anteater nose' sign is seen on the oblique foot radiograph and is pathognomonic for a calcaneonavicular tarsal coalition. Regardless of the coalition type (calcaneonavicular or talocalcaneal), the initial management for symptomatic tarsal coalition is nonoperative to allow for inflammation to subside. This typically involves immobilization with a short leg walking cast or a rigid orthosis for 4 to 6 weeks. Surgical resection (e.g., with EDB or fat interposition) is indicated only if conservative measures fail.

Question 5558

Topic: 8. Foot and Ankle

A 14-year-old boy presents with recurrent right ankle sprains, pain, and a rigid, flat arch. A classic 'C-sign' is noted on the lateral ankle radiograph.

This finding indicates a tarsal coalition most commonly involving which specific joint?

. Calcaneonavicular joint
. Anterior facet of the talocalcaneal joint
. Middle facet of the talocalcaneal joint
. Posterior facet of the talocalcaneal joint
. Talonavicular joint

Correct Answer & Explanation

. Calcaneonavicular joint

Explanation

The 'C-sign' on a lateral radiograph is a continuous C-shaped arc formed by the medial border of the talar dome and the posterior outline of the sustentaculum tali. It is highly specific for a talocalcaneal coalition, which overwhelmingly involves the middle facet. Calcaneonavicular coalitions are visualized on oblique radiographs (the 'anteater nose' sign).

Question 5559

Topic: 8. Foot and Ankle
A 10-year-old boy with spastic hemiplegic cerebral palsy presents with a dynamic equinovarus foot deformity evident strictly during the swing phase of gait. He fails bracing, and a Split Anterior Tibial Tendon Transfer (SPLATT) is considered. To which structural location is the lateral half of the transferred tendon typically attached?
. Navicular tuberosity
. Medial cuneiform
. Cuboid or peroneus brevis tendon
. Achilles tendon
. Flexor hallucis longus tendon

Correct Answer & Explanation

. Cuboid or peroneus brevis tendon

Explanation

The dynamic equinovarus deformity in CP is often caused by an overactive anterior tibial tendon (ATT) during swing phase. The SPLATT procedure involves splitting the ATT, leaving the medial half attached to its native insertion (medial cuneiform/1st metatarsal) and transferring the lateral half to the lateral aspect of the midfoot, typically the cuboid or into the peroneus brevis tendon. This balances the dorsiflexion forces, neutralizing the varus moment.

Question 5560

Topic: 8. Foot and Ankle

An infant with idiopathic clubfoot is being treated with the Ponseti method of serial casting.

The forefoot has been successfully abducted to 60 degrees, and the heel is in valgus. However, the foot remains in 20 degrees of equinus. What is the most appropriate next step in management?

. Application of another cast focused on forcing dorsiflexion
. Percutaneous Achilles tenotomy
. Posterior release of the tibiotalar joint capsule
. Anterior tibial tendon transfer
. Tibialis posterior tendon transfer

Correct Answer & Explanation

. Application of another cast focused on forcing dorsiflexion

Explanation

In the Ponseti method (CAVE: Cavus, Adductus, Varus, Equinus), equinus is the final deformity to be corrected. Once the forefoot reaches roughly 60 degrees of abduction and the heel varus is corrected to valgus, a percutaneous Achilles tenotomy is indicated if ankle dorsiflexion is less than 15 degrees. Forcing dorsiflexion in a cast against a tight Achilles can cause a midfoot rocker-bottom deformity.

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