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8. Foot and Ankle MCQs

Practice Set 280 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 5581

Topic: 8. Foot and Ankle

A 50-year-old overweight male presents with posterior heel pain. Examination reveals a tender, bulbous enlargement at the Achilles insertion. Radiographs show a large dorsal calcaneal exostosis (Haglund's deformity) and intratendinous calcification. Non-operative management for 6 months has failed. MRI shows tendinosis involving 60% of the tendon width at the insertion. What is the most appropriate surgical management?

. Endoscopic calcaneal exostectomy
. Gastrocnemius recession
. Open debridement, exostectomy, and reattachment of the Achilles tendon with FHL transfer
. Extracorporeal shockwave therapy
. Achilles tendon lengthening

Correct Answer & Explanation

. Endoscopic calcaneal exostectomy

Explanation

In insertional Achilles tendinopathy with extensive degeneration (>50% of the tendon width) and a large Haglund's deformity, open debridement and exostectomy are required. Because more than 50% of the tendon must be detached and debrided, augmentation with a Flexor Hallucis Longus (FHL) tendon transfer is indicated to restore plantarflexion strength and provide vascularized tissue to enhance healing.

Question 5582

Topic: Ankle Trauma & Sports

A 28-year-old soccer player sustains a twisting injury to his ankle. Radiographs show a spiral fracture of the proximal third of the fibula. An external rotation stress view shows widening of the medial clear space to 6 mm. Which of the following structures is most likely to be completely disrupted?

. Anterior talofibular ligament
. Calcaneofibular ligament
. Spring ligament
. Deltoid ligament and syndesmosis
. Superficial peroneal nerve

Correct Answer & Explanation

. Anterior talofibular ligament

Explanation

The scenario describes a Maisonneuve fracture, which involves a proximal fibula fracture associated with a syndesmotic disruption and a medial injury (either a medial malleolus fracture or deltoid ligament rupture). The widened medial clear space on stress views confirms instability due to deltoid ligament rupture, and the force transmission through the interosseous membrane implies disruption of the tibiofibular syndesmosis.

Question 5583

Topic: Midfoot & Hindfoot
A 30-year-old involved in a motor vehicle collision sustains a Hawkins Type III talar neck fracture. What does this classification imply regarding the displacement and the blood supply to the talar body?
. Non-displaced fracture; minimal risk of avascular necrosis (AVN)
. Subtalar subluxation; ~50% risk of AVN
. Subtalar and tibiotalar dislocation; close to 100% risk of AVN
. Subtalar, tibiotalar, and talonavicular dislocation; ~20% risk of AVN
. Talar head fracture; high risk of nonunion

Correct Answer & Explanation

. Subtalar and tibiotalar dislocation; close to 100% risk of AVN

Explanation

The Hawkins classification evaluates talar neck fractures and predicts the risk of avascular necrosis (AVN). Type I: non-displaced (0-10% AVN risk). Type II: subtalar dislocation or subluxation (20-50% AVN risk). Type III: subtalar and tibiotalar dislocation (nearly 100% AVN risk). Type IV (added by Canale): subtalar, tibiotalar, and talonavicular dislocation (also near 100% AVN risk).

Question 5584

Topic: 8. Foot and Ankle

A 22-year-old offensive lineman sustains an axial load to a plantarflexed foot. Weight-bearing radiographs demonstrate a 3 mm diastasis between the bases of the first and second metatarsals without any visible fractures. What is the recommended definitive treatment for this pure ligamentous injury in a high-level athlete?

. Rigid short-leg walking boot for 6 weeks
. Closed reduction and percutaneous pinning
. Open reduction and internal fixation with screws
. Primary arthrodesis of the first, second, and third tarsometatarsal joints
. Corticosteroid injection and immediate return to play

Correct Answer & Explanation

. Rigid short-leg walking boot for 6 weeks

Explanation

Purely ligamentous Lisfranc injuries have a high rate of poor outcomes and post-traumatic arthritis when treated with ORIF. Recent literature supports primary arthrodesis of the medial column (first, second, and often third TMT joints) for pure ligamentous injuries, especially in athletes, to facilitate a reliable return to sport and avoid the need for hardware removal and treatment of late arthritis.

Question 5585

Topic: Forefoot
A 24-year-old professional football player hyperextends his great toe on artificial turf. He has severe pain, ecchymosis, and inability to bear weight. MRI shows a complete tear of the plantar plate with proximal retraction of the sesamoids. What is the most appropriate management?
. Taping and rigid carbon fiber orthosis
. First MTP arthrodesis
. Surgical repair of the plantar plate
. Excision of both sesamoids
. Corticosteroid injection

Correct Answer & Explanation

. Surgical repair of the plantar plate

Explanation

The patient has a Grade III turf toe injury (complete tear of the plantar plate/capsule complex) with proximal retraction of the sesamoids. Surgical repair is indicated for Grade III injuries with significant instability, sesamoid retraction, or intra-articular loose bodies. This is particularly true in professional athletes to restore push-off strength and prevent hallux rigidus or clawing.

Question 5586

Topic: Midfoot & Hindfoot

A 60-year-old diabetic patient presents with a warm, swollen, erythematous left foot. Radiographs reveal fragmentation and periarticular debris around the midfoot, with subluxation of the tarsometatarsal joints. Skin is intact. Inflammatory markers are mildly elevated. What is the appropriate initial management?

. Total contact casting and non-weight bearing
. Immediate surgical arthrodesis of the midfoot
. Intravenous antibiotics for 6 weeks
. Below-knee amputation
. Incision and drainage

Correct Answer & Explanation

. Total contact casting and non-weight bearing

Explanation

The patient is in the acute fragmentation phase (Eichenholtz stage I) of Charcot arthropathy. The hallmark of initial treatment for acute Charcot is offloading and immobilization, most effectively achieved with a total contact cast. Surgery in the acute inflammatory phase is generally contraindicated due to poor bone quality and high failure rates, unless there is severe impending ulceration or instability that cannot be managed conservatively.

Question 5587

Topic: 8. Foot and Ankle

A 26-year-old skier presents with a snapping sensation at the posterolateral ankle. Examination reveals the peroneal tendons dislocating anteriorly over the lateral malleolus with resisted dorsiflexion and eversion. Conservative treatment has failed. Surgical exploration reveals a shallow fibular groove and an incompetent superior peroneal retinaculum (SPR). What is the standard surgical procedure?

. Tenodesis of the peroneus brevis to the peroneus longus
. Resection of the peroneus brevis
. Transfer of the FDL to the peroneus brevis
. Lateral column lengthening
. Deepening of the fibular groove and repair/reefing of the SPR

Correct Answer & Explanation

. Tenodesis of the peroneus brevis to the peroneus longus

Explanation

Recurrent peroneal tendon subluxation is caused by incompetence of the superior peroneal retinaculum (SPR), often associated with a shallow fibular retromalleolar groove. The gold standard surgical treatment involves deepening the fibular groove and repairing or tightening (reefing) the SPR over the tendons.

Question 5588

Topic: 8. Foot and Ankle

A 45-year-old woman complains of sharp, burning pain in the plantar aspect of her forefoot, radiating to the third and fourth toes. Symptoms worsen with tight shoes. A Mulder's click is positive. The most likely diagnosis involves entrapment of a nerve beneath which of the following structures?

. Superficial transverse metatarsal ligament
. Plantar fascia
. Deep transverse metatarsal ligament
. Flexor digitorum brevis
. Adductor hallucis

Correct Answer & Explanation

. Superficial transverse metatarsal ligament

Explanation

Morton's neuroma most commonly occurs in the third web space. It is a compressive neuropathy of the common digital nerve as it passes under the deep transverse metatarsal ligament. Treatment options include wide shoe wear, metatarsal pads, steroid injections, and, if conservative measures fail, surgical excision of the neuroma and release of the deep transverse metatarsal ligament.

Question 5589

Topic: 8. Foot and Ankle

A 14-year-old boy presents with frequent ankle sprains and a rigid flatfoot. Radiographs show a "C-sign" on the lateral view and an irregular subtalar joint. Which type of tarsal coalition does this patient most likely have, and which imaging modality is best to confirm it?

. Calcaneonavicular coalition; MRI
. Calcaneonavicular coalition; CT scan
. Talocalcaneal coalition; Ultrasound
. Talocalcaneal coalition; CT scan
. Talonavicular coalition; Bone scan

Correct Answer & Explanation

. Calcaneonavicular coalition; MRI

Explanation

A talocalcaneal (subtalar) coalition often presents with a rigid flatfoot and peroneal spasticity. The "C-sign" on a lateral radiograph is formed by the medial outline of the talar dome and the posteroinferior outline of the sustentaculum tali, strongly suggesting a talocalcaneal coalition (most often involving the middle facet). A CT scan is the gold standard for defining the location, extent, and joint involvement of the coalition.

Question 5590

Topic: 8. Foot and Ankle

A 45-year-old active man presents with asymmetric anterior ankle pain. Radiographs demonstrate asymmetric narrowing of the medial ankle joint space with a varus tibial plafond angle. The lateral joint space is preserved. Hindfoot motion is normal. What is the primary rationale for performing a supramalleolar osteotomy in this patient?

. To completely eliminate pain by fusing the ankle
. To increase dorsiflexion by removing anterior osteophytes
. To shift the mechanical axis laterally to the preserved cartilage
. To treat concomitant subtalar arthritis
. To reconstruct the deltoid ligament

Correct Answer & Explanation

. To completely eliminate pain by fusing the ankle

Explanation

A supramalleolar osteotomy (SMO) is a joint-preserving procedure indicated for asymmetric ankle arthritis with coronal plane deformity (e.g., varus ankle arthritis). By correcting the tibial deformity, the mechanical axis is shifted away from the worn, arthritic side (medial) toward the side with preserved cartilage (lateral), thereby reducing pain and potentially delaying the need for ankle arthroplasty or arthrodesis.

Question 5591

Topic: 8. Foot and Ankle

A 55-year-old diabetic male presents with an ulcer under his first metatarsal head and a swollen foot. It is critical to differentiate osteomyelitis from acute Charcot arthropathy. On MRI, which finding is most specific for osteomyelitis over acute Charcot neuroarthropathy?

. Subchondral bone marrow edema
. Joint subluxation
. Presence of a sinus tract extending to the bone
. Tarsometatarsal joint effusion
. Diffuse soft tissue edema

Correct Answer & Explanation

. Subchondral bone marrow edema

Explanation

Both acute Charcot arthropathy and osteomyelitis can present with bone marrow edema, soft tissue swelling, and joint effusions on MRI. However, the presence of a sinus tract extending from a skin ulcer down to the bone, or replacement of marrow fat with fluid signal on T1 images near an ulcer (often called the 'ghost sign'), is highly specific for osteomyelitis. Charcot changes are typically periarticular and centered around the midfoot (TMT joints), while osteomyelitis occurs contiguous to an ulcer, often at pressure points like the metatarsal heads.

Question 5592

Topic: Midfoot & Hindfoot

A 55-year-old female presents with medial ankle pain and a progressively flattening arch. She has pain with single-limb heel rise but is able to perform it weakly. Passively, her hindfoot corrects to neutral. What is the most appropriate surgical intervention if conservative management fails?

. Gastrocnemius recession, flexor digitorum longus (FDL) transfer to the navicular, and medial displacement calcaneal osteotomy
. Triple arthrodesis
. Talonavicular arthrodesis
. Isolated flexor digitorum longus (FDL) transfer to the navicular
. Subtalar arthrodesis

Correct Answer & Explanation

. Gastrocnemius recession, flexor digitorum longus (FDL) transfer to the navicular, and medial displacement calcaneal osteotomy

Explanation

This presentation is consistent with Stage II posterior tibial tendon dysfunction (flexible deformity). Standard surgical treatment includes a soft tissue reconstruction (FDL transfer) combined with an extra-articular bony procedure (medial displacement calcaneal osteotomy) and often a gastroc recession.

Question 5593

Topic: 8. Foot and Ankle
A 28-year-old male sustains a Hawkins Type III talar neck fracture following a motor vehicle collision. Which of the following best describes the disruption of blood supply and the associated risk of avascular necrosis (AVN)?
. Disruption of the artery of the tarsal canal alone; less than 20% AVN risk
. Disruption of the artery of the tarsal canal and deltoid branches; 50% AVN risk
. Disruption of the artery of the tarsal sinus, tarsal canal, and deltoid branches; near 100% AVN risk
. Disruption of the anterior tibial artery branches; 25% AVN risk
. Disruption of the peroneal artery branches; 75% AVN risk

Correct Answer & Explanation

. Disruption of the artery of the tarsal sinus, tarsal canal, and deltoid branches; near 100% AVN risk

Explanation

A Hawkins Type III fracture involves subluxation or dislocation of both the subtalar and tibiotalar joints. This disrupts all three major blood supplies to the talus, leading to a nearly 100% risk of AVN.

Question 5594

Topic: 8. Foot and Ankle

A 22-year-old football player sustains an axial load to a plantarflexed foot. Weight-bearing radiographs reveal a 3 mm diastasis between the base of the first and second metatarsals. What is the most appropriate definitive management?

. Non-weight bearing cast for 6 weeks
. Primary arthrodesis of the 1st, 2nd, and 3rd TMT joints
. Open reduction and internal fixation of the Lisfranc complex
. Closed reduction and percutaneous pinning
. Carbon fiber shoe insert and progressive weight-bearing

Correct Answer & Explanation

. Non-weight bearing cast for 6 weeks

Explanation

In a young athlete with an acute, primarily ligamentous or bony Lisfranc injury, open reduction and internal fixation (ORIF) is generally preferred to restore exact anatomy. Primary arthrodesis is often reserved for non-athletes, delayed presentations, or severe intra-articular comminution.

Question 5595

Topic: 8. Foot and Ankle

A 62-year-old male undergoes surgical debridement for severe insertional Achilles tendinopathy. During the procedure, 60% of the tendon insertion is resected to remove calcifications and degenerative tissue. What is the most appropriate next step in management?

. Direct repair using a Krackow stitch with heavy nonabsorbable suture
. V-Y tendon advancement alone
. Flexor hallucis longus (FHL) tendon transfer
. Peroneus brevis tendon transfer
. Gastrocnemius recession and cast immobilization

Correct Answer & Explanation

. Direct repair using a Krackow stitch with heavy nonabsorbable suture

Explanation

When more than 50% of the Achilles tendon insertion requires debridement, augmentation is indicated to prevent catastrophic failure. FHL transfer is the gold standard due to its strength, line of pull, and matched phase of firing.

Question 5596

Topic: 8. Foot and Ankle



A 24-year-old marathon runner presents with vague dorsal midfoot pain. A CT scan confirms an incomplete, non-displaced stress fracture of the tarsal navicular in the sagittal plane. What is the most appropriate initial management?

. Strict non-weight bearing in a short leg cast for 6 weeks
. Weight-bearing in a controlled ankle motion (CAM) boot
. Immediate percutaneous screw fixation
. Open reduction and internal fixation with bone grafting
. Extracorporeal shock wave therapy

Correct Answer & Explanation

. Strict non-weight bearing in a short leg cast for 6 weeks

Explanation

Non-displaced, incomplete navicular stress fractures are initially treated with strict non-weight-bearing in a cast for 6 to 8 weeks. Operative fixation is indicated for displaced fractures or failure of conservative management.

Question 5597

Topic: 8. Foot and Ankle

A 72-year-old thin female with rheumatoid arthritis and low functional demands presents with severe, bone-on-bone ankle osteoarthritis. She has preserved subtalar and midfoot motion. What is the primary advantage of total ankle arthroplasty (TAA) over ankle arthrodesis in this patient?

. Higher rate of union
. Better preservation of adjacent joint kinematics
. Lower risk of wound complications
. Decreased risk of deep infection
. No requirement for postoperative immobilization

Correct Answer & Explanation

. Higher rate of union

Explanation

TAA is an excellent option for older, lower-demand patients, particularly those with inflammatory arthritis. The primary advantage of TAA over arthrodesis is the preservation of tibiotalar motion, which protects the adjacent hindfoot and midfoot joints from accelerated degeneration.

Question 5598

Topic: 8. Foot and Ankle

A 16-year-old male presents with bilateral progressive cavovarus feet. Examination shows weak tibialis anterior and peroneus brevis muscles, with a strong peroneus longus and tibialis posterior. A Coleman block test normalizes the hindfoot varus. What is the primary driver of this patient's deformity?

. Spasticity of the Achilles tendon
. Plantarflexed first ray driven by an overactive peroneus longus
. Fixed subtalar joint arthritis
. Weakness of the flexor hallucis longus
. Contracture of the plantar fascia alone

Correct Answer & Explanation

. Spasticity of the Achilles tendon

Explanation

Charcot-Marie-Tooth disease causes a classic pattern of muscle imbalance. An overactive peroneus longus plantarflexes the first ray, driving the forefoot into pronation and forcing the hindfoot into a compensatory flexible varus alignment (corrects on Coleman block test).

Question 5599

Topic: 8. Foot and Ankle
A 35-year-old roofer falls 15 feet, sustaining a closed, displaced intra-articular calcaneus fracture (Sanders Type III). He is scheduled for ORIF via an extensile lateral approach. Which of the following patient factors is the strongest contraindication to this surgical approach?
. Active smoking
. Age greater than 30
. Worker's compensation claim
. Male sex
. Presence of fracture blisters on the medial foot

Correct Answer & Explanation

. Active smoking

Explanation

Active smoking dramatically increases the risk of catastrophic wound complications (necrosis, infection) following an extensile lateral approach to the calcaneus. Many surgeons consider heavy active smoking a strict contraindication to this specific approach.

Question 5600

Topic: 8. Foot and Ankle

A 25-year-old male presents with severe midfoot pain after a football injury. He states another player fell on his heel while his foot was plantarflexed. Radiographs reveal a widening of the space between the 1st and 2nd metatarsal bases with a small osseous fragment visible in the interspace.

What is the most likely mechanism of this injury?

. Direct crush injury to the midfoot
. Axial load applied to a plantarflexed foot
. Pronation external rotation force
. Supination adduction force
. Dorsiflexion with axial loading

Correct Answer & Explanation

. Direct crush injury to the midfoot

Explanation

Lisfranc injuries classically occur due to an axial load applied to a plantarflexed foot. The "fleck sign" seen on radiographs is pathognomonic, representing an avulsion of the Lisfranc ligament from the base of the second metatarsal.

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