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8. Foot and Ankle MCQs

Practice Set 28 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 541

Topic: 8. Foot and Ankle

A 25-year-old athlete presents with midfoot pain after an axial load to a plantarflexed foot. On an anteroposterior radiograph of the foot, which alignment abnormality is most indicative of a Lisfranc injury?

. Lateral displacement of the second metatarsal base relative to the middle cuneiform
. Medial displacement of the first metatarsal base relative to the medial cuneiform
. Plantar displacement of the navicular relative to the talus
. Widening of the calcaneocuboid joint
. Dorsal subluxation of the first metatarsophalangeal joint

Correct Answer & Explanation

. Lateral displacement of the second metatarsal base relative to the middle cuneiform

Explanation

A Lisfranc injury involves the tarsometatarsal joint complex. The classic radiographic hallmark is a disruption of normal alignment where the medial border of the second metatarsal base fails to align with the medial border of the middle cuneiform.

Question 542

Topic: 8. Foot and Ankle

A 58-year-old man with a 15-year history of poorly controlled diabetes presents with a red, hot, swollen right foot. There are no open ulcers, and radiographs show fragmentation, periarticular debris, and subluxation of the tarsometatarsal joints. His WBC count is normal. What is the most appropriate initial management?

. Intravenous antibiotics and MRI
. Immediate surgical arthrodesis of the midfoot
. Total contact casting and non-weight-bearing
. Incision and drainage of the midfoot
. Prescription of custom orthotic shoes

Correct Answer & Explanation

. Total contact casting and non-weight-bearing

Explanation

The patient is presenting with acute Eichenholtz Stage I (fragmentation) Charcot arthropathy, characterized by a red, hot, swollen foot without infection. The standard of care for acute Charcot is rigid immobilization and offloading, most effectively achieved with a total contact cast.

Question 543

Topic: 8. Foot and Ankle

A 28-year-old construction worker drops a heavy beam on his midfoot. Radiographs reveal widening of the space between the bases of the first and second metatarsals. What is the anatomical path 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 connects the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. It is a critical stabilizer of the midfoot arch, given the absence of an intermetatarsal ligament between the first and second metatarsals.

Question 544

Topic: 8. Foot and Ankle

Three years ago, a patient underwent successful resection of a third web space neuroma. She now presents with identical symptoms in the same location. She requests surgery because all attempts at conservative care have failed. Recommended treatment includes:

. Phenol injection
. Electrical ablation of the nerve
. Deep transverse metatarsal ligament resection
. Resection of a stump neuroma
. Tarsal tunnel release

Correct Answer & Explanation

. Resection of a stump neuroma

Explanation

The recurrence rate of a previously resected neuroma is approximately 15%. The deep transverse metatarsal ligament is involved in the pathogenesis of a primary, but not a recurrent, neuroma. None of the present symptoms suggests tarsal tunnel syndrome, although this may exist concurrently with a neuroma. Phenol has ablative neural properties, but it cannot be injected due to the local effect on tissue necrosis.

Question 545

Topic: 8. Foot and Ankle
A 72-year-old woman presents for treatment of a painful hallux valgus deformity. On examination of the foot, crepitus is present to range of motion of the hallux. Pain upon compression of the joint is also present. The hallux valgus angle is 45° and the intermetatarsal angle is 20°. The recommended surgical procedure is:
. Arthrodesis of the hallux metatarsalphalangeal (MP) joint
. Proximal first metatarsal osteotomy and distal soft tissue release
. Distal metatarsal osteotomy and distal soft tissue release
. Resection arthroplasty MP joint (Keller procedure)
. Arthrodesis first MP joint and distal soft tissue release (Lapidus procedure)

Correct Answer & Explanation

. Arthrodesis of the hallux metatarsalphalangeal (MP) joint

Explanation

In the presence of metatarsalphalangeal joint arthritis, either resection arthroplasty or arthrodesis is recommended. However, with this degree of intermetatarsal deformity, a resection arthroplasty may lead to a high recurrence rate of hallux valgus deformity.

Question 546

Topic: Forefoot

Resection of the tibial sesamoid may result in which deformity of the hallux:

. Hallux extensus
. Hallux valgus
. Hallux varus
. C ock-up deformity
. Supination deformity

Correct Answer & Explanation

. Hallux varus

Explanation

The abductor hallucis muscle attaches to the tibial sesamoid and resection without repair of the abductor and medial capsule may lead to hallux valgus. Hallux varus may occur after resection of the fibular sesamoid, and a cock- up extension hallux deformity occurs after resection of both sesamoids or with a rupture of the volar plate.

Question 547

Topic: 8. Foot and Ankle

Arthrodesis of the ankle in a 34-year-old woman should be performed with the ankle positioned in:

. 10° plantarflexion, neutral rotation
. 10° dorsiflexion, 5° external rotation
. Neutral dorsiflexion, 5° valgus
. 10° plantarflexion, 15° external rotation
. 10° plantarflexion, 5° internal rotation

Correct Answer & Explanation

. Neutral dorsiflexion, 5° valgus

Explanation

Although the woman may wish to wear shoes of varying height, there is sufficient plantarflexion occurring through the transverse tarsal joint to permit the wearing of high-heel shoes. Any plantarflexion of the fusion will cause arthritis of the transverse tarsal joint, particularly the talonavicular joint. Dorsiflexion of an ankle arthrodesis is associated with a calcaneus position and heel pain. The ankle should be fused in a similar position for both male and female patients.

Question 548

Topic: 8. Foot and Ankle
A 23-year-old collegiate athlete presents for evaluation of recurrent ankle pain associated with ankle sprains. Upon examination, pain is present along the lateral ankle, an anterior drawer test is negative, and marked instability is apparent with inversion stress of the ankle. Stress radiographs are normal. The most likely cause of the patient's symptoms is:
. Stress fracture of the navicular bone
. Peroneus brevis tear
. Recurrent dislocation of peroneal tendons
. Osteochondral lesion of the talus
. Subtalar instability

Correct Answer & Explanation

. Subtalar instability

Explanation

Subtalar instability is not common, although a component of instability may be present in conjunction with ankle instability. If symptoms are suggestive of ankle instability but cannot be verified upon clinical or radiographic examination, then subtalar instability is likely to be present. The clinical diagnosis of subtalar instability is difficult.

Question 549

Topic: 8. Foot and Ankle

A 46-year-old nurse presents for treatment of pain in the heel. The pain has been present for 6 months and increases upon rising from bed and after sedentary periods. The pain is focal and reproduced with pressure over the proximal medial heel. The initial treatment most likely to be associated with relief of symptoms is:

. Semi-rigid orthotic support
. Stiff sole shoe with heel wedge
. Achilles tendon stretching exercises
. C ortisone injection
. Physical therapy modalities

Correct Answer & Explanation

. Achilles tendon stretching exercises

Explanation

With the exception of physical therapy and a rigid orthotic support, most of the treatment alternatives would be helpful in the initial treatment of plantar fasciitis. Achilles stretching combined with a soft, gel-type heel cushion is consistently the most successful modality.

Question 550

Topic: 8. Foot and Ankle

A 72-year-old man presents for evaluation and treatment of pain and limited motion in his arthritic ankle and subtalar joint. The foot is plantigrade with respect to the leg. Radiographs demonstrate ankle arthritis, an absent joint space, no malalignment of the tibiotalar joint, and a normal subtalar joint. The most reliable surgical procedure consistent with maintaining increased activity and patient function is:

. Total ankle replacement
. Supramalleolar tibial opening wedge osteotomy
. Supramalleolar tibial closing wedge osteotomy
. Ankle arthrodesis
. Ankle arthroscopy

Correct Answer & Explanation

. Ankle arthrodesis

Explanation

Ankle replacement is a treatment alternative that is widely recommended today, although it is still not as reliable as an ankle arthrodesis in terms of predictability and absence of complications. One must consider the option of arthrodesis and replacement carefully with each patient.

Question 551

Topic: 8. Foot and Ankle

A 37-year-old construction worker presents for evaluation and treatment of a painful stiff foot. He has noticed the stiffness for approximately 12 years, and particularly feels the stiffness when he is working on uneven ground surfaces. Upon clinical and radiographic examination, he is noted to have a calcaneonavicular coalition without any peritalar arthritis. Your recommended treatment is:

. Triple arthrodesis
. Subtalar arthrodesis
. Resection of the coalition
. C alcaneal osteotomy
. C alcaneocuboid and talonavicular arthrodesis

Correct Answer & Explanation

. Resection of the coalition

Explanation

Although arthrodesis has proved reliable with respect to managing tarsal coalition in the adult, resection of a calcaneonavicular coalition should be performed whenever possible. This procedure is preferable to a triple arthrodesis. A subtalar arthrodesis would be applicable as treatment for a middle facet coalition in the adult.

Question 552

Topic: 8. Foot and Ankle

A 28-year-old male runner presents for treatment of a painful lesion under the first metatarsal head (located more toward the medial aspect of the metatarsophalangeal joint). The lesion is associated with painful callosity to palpation, normal hallux function, and a normal position of the first metatarsal. Attempts to relieve the pressure with orthoses and shoe modifications have not been successful. The ideal treatment is:

. Arthrodesis of the first metatarsophalangeal joint
. Dorsal wedge osteotomy of the distal first metatarsal
. Resection of the tibial sesamoid
. Plantar shaving of the tibial sesamoid
. Proximal first metatarsal osteotomy

Correct Answer & Explanation

. Plantar shaving of the tibial sesamoid

Explanation

Planing or shaving of the sesamoid is a reliable procedure for treatment of a specific focal keratosis beneath the tibial sesamoid. Resection of the tibial sesamoid is a reasonable alternative, although it should be used only for pathology of the sesamoid itself. In this individual, the position of the first metatarsal is normal. Since no plantarflexion is present, an osteotomy is not indicated.

Question 553

Topic: 8. Foot and Ankle
A 29-year-old football player twisted his foot 1 year ago, and he recalls pain and swelling of the midfoot at the time of the injury. No definitive treatment was provided at that time. Although he returned to athletic activity, he has experienced constant pain and occasional swelling. The pain is present upon passive pronation and abduction of the midfoot, and radiographs demonstrate that there is a 2.5-mm gap between the base of the first and second metatarsal and medial and middle cuneiform. Initial management should include:
. Medial to middle column tarsometatarsal arthrodesis
. Cortisone injection to the midfoot
. Delayed open reduction and internal fixation
. Physical therapy modalities aimed at mobilization of the midfoot
. A rigid orthotic support and a stiff-soled shoe

Correct Answer & Explanation

. A rigid orthotic support and a stiff-soled shoe

Explanation

The patient's history and clinical findings indicate an injury to the tarsometatarsal joint complex, specifically between the middle and the medial columns. Although surgery may become necessary, initial treatment should consist of support. Physical therapy will worsen foot pain and injection is not indicated.

Question 554

Topic: 8. Foot and Ankle
A 32-year-old woman with a history of diabetes presents with a 1-month history of painless swelling in the foot. The foot is swollen, warm, and erythema is present in the midfoot. She has no fever and her blood sugars are normal. Radiographs demonstrate the presence of fracture and dislocation of the tarsometatarsal joint. There are no new periosteal bone formations, and complete dorsal dislocation of the metatarsals on the cuneiforms is noted. The ideal treatment is:
. Open reduction and internal fixation
. Bedrest, limb elevation, and cast immobilization
. Tarsometatarsal arthrodesis
. Midfoot biopsy followed by organism-specific antibiotics
. Weight-bearing total contact cast

Correct Answer & Explanation

. Tarsometatarsal arthrodesis

Explanation

If there is a contraindication to performing surgery, nonoperative methods of treatment for an acute Charcot neuroarthropathy may be acceptable. This patient's midfoot is dislocated and is likely to result in a worsening deformity over time, with ulceration and infection possible. Open reduction with internal fixation has not proven sufficient in patients presenting with the symptoms indicated in the scenario. Arthrodesis is most likely to yield a satisfactory outcome.

Question 555

Topic: 8. Foot and Ankle

A 54-year-old woman presents with a 1-year history of medial foot and ankle pain. She does not recall an episode of trauma, and she has had no change in her daily living activities. Her foot is changing shape; it is flatter than the opposite foot. On clinical examination she has a unilateral flatfoot deformity, an inability to perform a single heel rise, and weak inversion strength. The subtalar joint is flexible. Following an initial period of support of the foot, surgery is recommended. The ideal procedure is:

. Subtalar arthrodesis
. Triple arthrodesis
. Repair torn spring ligament
. Posterior tibial tendon repair
. Flexor digitorum longus transfer with calcaneal osteotomy

Correct Answer & Explanation

. Flexor digitorum longus transfer with calcaneal osteotomy

Explanation

This patient has a rupture of the posterior tibial tendon. Repair of the tendon will not work because there is a degenerative elongation of the tendon that will not heal. Because the foot is flexible, arthrodesis is not necessary. Flexor digitorum longus transfer with calcaneal osteotomy is a reliable procedure for treatment of Stage II posterior tibial tendon insufficiency.

Question 556

Topic: 8. Foot and Ankle

The anatomic structure responsible for the development of an interdigital neuroma is:

. The intermetatarsal bursa
. The interosseous tendon
. The deep transverse metatarsal ligament
. The third metatarsal head
. The bifurcation of the lateral plantar nerve

Correct Answer & Explanation

. The deep transverse metatarsal ligament

Explanation

The deep transverse metatarsal ligament passes between the undersurface of the metatarsal heads and connects the volar plate to the adjacent soft tissue structures. The common digital nerve becomes irritated under the sharp edge of the distal portion of the ligament, resulting in nerve swelling and formation of the neuroma.

Question 557

Topic: 8. Foot and Ankle

A 14-year-old boy with a painful flatfoot deformity presents for evaluation and treatment. He has had pain of the midfoot associated with thickening, callosity, and shoe wear. Shoe wear modifications, orthoses, and restriction of activity have not been successful. On examination, he has a very flexible flatfoot deformity. The hindfoot and midfoot are passively correctable, the subtalar and transverse tarsal joints are mobile, and callosity is present over the talar head. The recommended treatment is:

. Arthrodesis of the subtalar joint
. Triple arthrodesis
. Lateral column lengthening osteotomy through the neck of the calcaneus
. Medial displacement calcaneal osteotomy with flexor digitorum longus tendon transfer
. Resection of the symptomatic accessory navicular bone and advancement of the posterior tibial tendon

Correct Answer & Explanation

. Lateral column lengthening osteotomy through the neck of the calcaneus

Explanation

It is unusual for an adolescent to require surgical correction of a flatfoot deformity, however, when the deformity is markedly symptomatic, surgery is a reasonable treatment option. Arthrodesis should not be considered as treatment of the flexible flatfoot in the adolescent. There is no indication of an accessory navicular bone being present. Lateral column lengthening (Evans Procedure) is a reliable procedure in this age group. The most common correction in kids with severe flexible pes planus is a lateral column lengthening. This is because most children, such as in this case, have severe forefoot abduction with significant talo-navicular uncoverage. (The description stated that the patient had a callus under the talar head, which means the talus is protruding beyond the navicular medially.) Medial slide calcaneal osteotomy would only correct the heel valgus, whereas a lateral column lengthening has the potential to correct both heel valgus and forefoot abduction.

Question 558

Topic: 8. Foot and Ankle

A 23-year-old woman with juvenile rheumatoid arthritis presents for treatment of painful forefoot deformity. Painful hallux valgus is present and is associated with dislocation of the lesser metatarsophalangeal joints. The recommended surgical treatment is:

. Bunionectomy, first metatarsal osteotomy, and arthroplasty of the lesser metatarsophalangeal joints
. Resection arthroplasty (Keller procedure) of the first metatarsophalangeal joint and arthroplasty of the lesser metatarsophalangeal joints
. Arthrodesis hallux metatarsophalangeal joint and resection of the lesser metatarsal heads
. Bunionectomy, first metatarsal osteotomy, and resection of the lesser metatarsal heads
. Resection of all of the metatarsal heads

Correct Answer & Explanation

. Arthrodesis hallux metatarsophalangeal joint and resection of the lesser metatarsal heads

Explanation

The gold standard surgical treatment for rheumatoid patients with severe forefoot deformities is first metatarsophalangeal fusion with second through fifth metatarsal head resections.

Question 559

Topic: 8. Foot and Ankle

The most common complication following triple arthrodesis in the adult patient is:

. Malunion of the arthrodesis
. Nonunion of the arthrodesis
. Ankle instability
. Ankle arthritis
. Transverse tarsal arthritis

Correct Answer & Explanation

. Ankle arthritis

Explanation

Each of the possible answers may occur following triple arthrodesis. In numerous studies, ankle arthritis is the complication most likely to occur regardless of the underlying disease process.

Question 560

Topic: 8. Foot and Ankle

A pantalar arthrodesis is described as a:

. Subtalar and tibiotalar arthrodesis
. Tibiotalocalcaneal arthrodesis
. Ankle and triple arthrodesis
. Triple arthrodesis and transverse tarsal arthrodesis
. Ankle arthrodesis and transverse tarsal arthrodesis

Correct Answer & Explanation

. Ankle and triple arthrodesis

Explanation

A pantalar arthrodesis is the combination of an ankle and triple arthrodesis. It should not be confused with an ankle and subtalar arthrodesis (tibiotalocalcaneal).

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