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8. Foot and Ankle MCQs

Practice Set 281 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 5601

Topic: 8. Foot and Ankle

A 14-year-old male presents with recurrent ankle sprains and a rigid, painful flatfoot. A lateral weight-bearing radiograph demonstrates a continuous, C-shaped bony contour extending from the talar dome to the sustentaculum tali. What is the most likely diagnosis and appropriate initial management?

. Calcaneonavicular coalition; observation
. Talocalcaneal coalition; short leg cast immobilization
. Calcaneonavicular coalition; short leg cast immobilization
. Talocalcaneal coalition; immediate subtalar arthrodesis
. Accessory navicular; physical therapy

Correct Answer & Explanation

. Calcaneonavicular coalition; observation

Explanation

A rigid flatfoot with a "C-sign" on a lateral radiograph is classic for a talocalcaneal (middle facet) coalition. Initial nonoperative management focuses on reducing inflammation and pain through a trial of short leg cast immobilization.

Question 5602

Topic: Midfoot & Hindfoot

A 55-year-old female presents with Stage IIB adult-acquired flatfoot deformity. Clinical exam demonstrates a flexible hindfoot valgus and significant forefoot abduction (too many toes sign). Radiographs show greater than 30% uncovering of the talonavicular joint. Which of the following procedures is essential to correct her deformity in addition to a flexor digitorum longus transfer and medial displacement calcaneal osteotomy?

. Spring ligament reconstruction
. Lateral column lengthening
. First tarsometatarsal arthrodesis
. Subtalar arthrodesis
. Triple arthrodesis

Correct Answer & Explanation

. Spring ligament reconstruction

Explanation

Stage IIB flatfoot is characterized by substantial forefoot abduction due to talonavicular uncoverage (>30%). A lateral column lengthening (e.g., Evans osteotomy) is necessary to restore the lateral column length and correct the abduction deformity.

Question 5603

Topic: Midfoot & Hindfoot

A 60-year-old male with poorly controlled diabetes presents with a red, hot, swollen right foot. There are no open ulcers or portals of entry. Radiographs show fragmentation and debris at the tarsometatarsal joints. What is the most appropriate initial management?

. Intravenous antibiotics and MRI
. Surgical debridement and acute midfoot fusion
. Total contact casting (TCC) and strict non-weight bearing
. Exostectomy of the prominent midfoot bone
. Charcot restraint orthotic walker (CROW)

Correct Answer & Explanation

. Intravenous antibiotics and MRI

Explanation

The patient has acute (Eichenholtz Stage I) Charcot arthropathy, which presents similarly to an infection but lacks an ulcer. The gold standard initial treatment is offloading with total contact casting (TCC) to halt progression during the acute inflammatory phase.

Question 5604

Topic: 8. Foot and Ankle

A surgeon is performing a minimally invasive percutaneous repair of an acute Achilles tendon rupture. Which nerve is at the highest risk of iatrogenic injury during this procedure, and in what anatomical zone?

. Tibial nerve; medial to the tendon at the calcaneal insertion
. Sural nerve; lateral to the tendon at the proximal aspect of the repair
. Deep peroneal nerve; anterior to the ankle joint
. Superficial peroneal nerve; lateral to the fibula
. Saphenous nerve; medial to the Achilles tendon

Correct Answer & Explanation

. Tibial nerve; medial to the tendon at the calcaneal insertion

Explanation

The sural nerve crosses from lateral to medial across the Achilles tendon approximately 9-12 cm proximal to the calcaneal insertion. Percutaneous or minimally invasive repairs place the nerve at significant risk in the proximal-lateral zone of the repair.

Question 5605

Topic: 8. Foot and Ankle
A 35-year-old construction worker sustains a Sanders type III calcaneus fracture after a fall from a ladder. The surgeon elects to use an extensile lateral approach for open reduction and internal fixation. Which structure is elevated within the full-thickness subperiosteal flap and must be protected?
. Medial plantar nerve
. Sural nerve
. Deep peroneal nerve
. Superficial peroneal nerve
. Saphenous nerve

Correct Answer & Explanation

. Sural nerve

Explanation

The extensile lateral approach to the calcaneus requires developing a full-thickness subperiosteal flap "down to bone" to minimize skin necrosis. The sural nerve is housed within this flap and is protected by retracting the entire flap "no-touch" using K-wires in the talus.

Question 5606

Topic: Ankle Trauma & Sports

During open reduction and internal fixation of a pronation-external rotation ankle fracture, the surgeon is evaluating the syndesmosis. What intraoperative step provides the most reliable assessment to ensure anatomic reduction of the syndesmosis?

. Direct open visualization of the incisura and anterior inferior tibiofibular ligament
. Restoration of the tibiofibular overlap to >10mm on the AP view
. Restoration of fibular length using the talocrural angle
. Measurement of the medial clear space on a stress mortise view
. Cotton test under fluoroscopy

Correct Answer & Explanation

. Direct open visualization of the incisura and anterior inferior tibiofibular ligament

Explanation

Malreduction of the syndesmosis is common when relying solely on fluoroscopy. Direct open visualization of the anterior syndesmosis (AITFL and incisura fibularis) provides the most reliable confirmation of anatomic reduction.

Question 5607

Topic: 8. Foot and Ankle

A 40-year-old female complains of burning pain in her third webspace, exacerbated by wearing narrow shoes. Examination reveals a painful click when compressing the metatarsal heads (Mulder's sign). The pathogenesis of this condition involves perineural fibrosis caused by compression against which structure?

. Plantar fascia
. Deep transverse metatarsal ligament
. Superficial transverse metatarsal ligament
. Flexor digitorum brevis tendon
. Plantar plate

Correct Answer & Explanation

. Plantar fascia

Explanation

Morton's neuroma is a perineural fibrosis of the common digital nerve. It is caused by mechanical entrapment and compression of the nerve against the deep transverse metatarsal ligament during the toe-off phase of gait.

Question 5608

Topic: 8. Foot and Ankle

A 65-year-old female with end-stage post-traumatic ankle arthritis desires a total ankle arthroplasty (TAA). Which of the following conditions is considered an absolute contraindication for TAA?

. Age greater than 60 years
. Charcot neuroarthropathy
. Advanced subtalar joint arthritis
. Previous medial malleolus fracture
. Body mass index of 28

Correct Answer & Explanation

. Age greater than 60 years

Explanation

Absolute contraindications for total ankle arthroplasty include active infection, inadequate soft-tissue envelope, severe peripheral vascular disease, and Charcot neuroarthropathy. Neuropathy with loss of protective sensation results in premature implant failure and profound complications.

Question 5609

Topic: 8. Foot and Ankle

When performing a Scarf osteotomy for correction of moderate to severe hallux valgus, which of the following is a unique and recognized complication specific to the geometry of this osteotomy?

. Nonunion of the medial cuneiform
. Troughing of the metatarsal shaft
. Avascular necrosis of the metatarsal head
. Dorsal malunion of the first ray
. First metatarsophalangeal joint stiffness

Correct Answer & Explanation

. Nonunion of the medial cuneiform

Explanation

The Scarf osteotomy is a versatile Z-step diaphyseal osteotomy. "Troughing" is a unique complication where the hard cortical edge of one fragment collapses into the cancellous medullary canal of the other, leading to loss of fixation and elevation of the metatarsal head.

Question 5610

Topic: 8. Foot and Ankle
A 30-year-old male sustains a Hawkins Type III talar neck fracture following a high-energy motor vehicle collision. What is the approximate risk of avascular necrosis (AVN) for this injury, and what is the primary arterial supply to the talar body?
. 10%; Artery of the tarsal canal
. 50%; Dorsalis pedis artery
. 100%; Artery of the tarsal sinus
. 80-100%; Artery of the tarsal canal
. 20%; Peroneal artery

Correct Answer & Explanation

. 80-100%; Artery of the tarsal canal

Explanation

Hawkins Type III fractures (talar neck fracture with subtalar and tibiotalar dislocation) disrupt multiple blood supplies, resulting in an 80-100% rate of AVN. The primary blood supply to the talar body is the artery of the tarsal canal, a branch of the posterior tibial artery.

Question 5611

Topic: 8. Foot and Ankle

A 45-year-old male with chronic, recalcitrant plantar fasciitis undergoes an open complete release of the plantar fascia after failing 12 months of conservative care. What is a recognized biomechanical complication of releasing the entire plantar fascia?

. Hallux rigidus
. Lateral column overload and arch collapse
. Tarsal tunnel syndrome
. Posterior tibial tendon rupture
. Flexor hallucis longus tendinitis

Correct Answer & Explanation

. Hallux rigidus

Explanation

Releasing more than 50% of the plantar fascia can result in loss of the windlass mechanism, leading to longitudinal arch collapse. This shift in biomechanics commonly results in lateral column overload and subsequent lateral midfoot pain.

Question 5612

Topic: 8. Foot and Ankle

A 22-year-old football player sustains an external rotation injury to his ankle and has a positive squeeze test. He is diagnosed with an acute syndesmotic sprain. Which ligament is considered the strongest component of the inferior tibiofibular syndesmotic complex?

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

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament (AITFL)

Explanation

The posterior inferior tibiofibular ligament (PITFL) is anatomically the strongest component of the syndesmosis. It contributes the most significant resistance to posterior translation and diastasis of the distal fibula.

Question 5613

Topic: 8. Foot and Ankle

A 28-year-old male with Charcot-Marie-Tooth disease presents with a progressive cavovarus foot deformity. A Coleman block test is performed, and the hindfoot corrects from a varus to a neutral position. What does this test signify about the primary driver of his deformity?

. The deformity is rigid and driven by the subtalar joint.
. The deformity is flexible and driven by a plantarflexed first ray.
. The deformity is driven by Achilles tendon contracture.
. The deformity is driven by isolated weakness of the peroneus longus.
. The deformity requires a triple arthrodesis.

Correct Answer & Explanation

. The deformity is rigid and driven by the subtalar joint.

Explanation

The Coleman block test evaluates hindfoot flexibility in cavovarus deformities. Correction to neutral indicates that the hindfoot varus is flexible and compensatory, driven primarily by a plantarflexed first ray acting as a "kickstand."

Question 5614

Topic: 8. Foot and Ankle

A 28-year-old male presents with bilateral cavovarus feet. A Coleman block test is performed, and the hindfoot corrects to a neutral alignment. Which of the following is the most appropriate primary osseous surgical procedure?

. Triple arthrodesis
. Lateralizing calcaneal osteotomy
. Dorsiflexion closing wedge osteotomy of the first metatarsal
. Plantarflexion osteotomy of the first metatarsal
. Subtalar arthrodesis

Correct Answer & Explanation

. Triple arthrodesis

Explanation

A flexible hindfoot varus that corrects with a Coleman block test is primarily driven by a rigidly plantarflexed first ray. A dorsiflexion closing wedge osteotomy of the first metatarsal addresses the primary apex of deformity. A lateralizing calcaneal osteotomy would be indicated if the hindfoot deformity was rigid.

Question 5615

Topic: 8. Foot and Ankle

During normal human gait, maximum ankle dorsiflexion occurs during which specific phase of the gait cycle?

. Initial contact
. Loading response
. Mid-stance
. Terminal stance
. Initial swing

Correct Answer & Explanation

. Initial contact

Explanation

Maximum ankle dorsiflexion (approximately 10 degrees) occurs at the end of terminal stance, just before heel-off. This allows the body's center of mass to advance over the supporting foot.

Question 5616

Topic: 8. Foot and Ankle

During the normal human gait cycle, the ankle joint moves through varying degrees of flexion and extension. At what specific phase of the gait cycle does the ankle reach its maximum normal degree of dorsiflexion?

. Initial contact (Heel strike)
. Mid-stance
. Terminal stance (Heel off)
. Pre-swing (Toe off)
. Mid-swing

Correct Answer & Explanation

. Initial contact (Heel strike)

Explanation

Maximum ankle dorsiflexion (approximately 10 degrees) occurs during terminal stance, just prior to heel off. During this phase, the tibia actively rolls forward over the planted foot. Immediately after heel off, the ankle rapidly transitions into plantarflexion during pre-swing to achieve a forceful push-off.

Question 5617

Topic: 8. Foot and Ankle

An axial MRI of the ankle reveals pathology in the posteromedial compartment.

Immediately posterior/lateral to the flexor digitorum longus (FDL) tendon at the level of the medial malleolus, which anatomic structure is located?

. Tibialis posterior tendon
. Flexor hallucis longus tendon
. Posterior tibial artery
. Tibial nerve
. Sural nerve

Correct Answer & Explanation

. Tibialis posterior tendon

Explanation

The structures in the posteromedial ankle behind the medial malleolus follow the mnemonic 'Tom, Dick, And Very Nervous Harry': Tibialis posterior tendon, flexor Digitorum longus tendon, posterior tibial Artery, posterior tibial Vein, tibial Nerve, and flexor Hallucis longus tendon. Therefore, the posterior tibial artery lies immediately posterior to the FDL tendon.

Question 5618

Topic: Ankle Trauma & Sports

The stability of the distal tibiofibular syndesmosis is dependent on several ligamentous structures. Which of the following ligaments provides the greatest contribution to the strength of the syndesmotic complex?

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

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament (AITFL)

Explanation

Biomechanical studies (e.g., Ogilvie-Harris) demonstrate that the posterior inferior tibiofibular ligament (PITFL) provides the greatest strength to the distal tibiofibular syndesmosis, contributing approximately 42% of the overall stability. The AITFL contributes ~35%, and the interosseous ligament provides ~22%.

Question 5619

Topic: 8. Foot and Ankle

An axial MRI of the ankle at the level of the medial malleolus demonstrates the contents of the tarsal tunnel. From anterior to posterior, the posterior tibial artery and tibial nerve are located between which two tendons?

. Tibialis posterior and flexor digitorum longus
. Flexor digitorum longus and flexor hallucis longus
. Tibialis anterior and extensor hallucis longus
. Peroneus brevis and peroneus longus
. Flexor hallucis longus and Achilles tendon

Correct Answer & Explanation

. Tibialis posterior and flexor digitorum longus

Explanation

The structures passing posterior to the medial malleolus, from anterior to posterior, are Tibialis posterior, Flexor digitorum longus, Posterior tibial Artery, Tibial Nerve, and Flexor hallucis longus (Tom, Dick, AND Very Nervous Harry). The neurovascular bundle lies between the FDL and FHL.

Question 5620

Topic: 8. Foot and Ankle

An axial T2 MRI of the L4-L5 level shows a far lateral (extraforaminal) disc herniation.

Which nerve root is most likely compressed, and what is the primary expected clinical motor deficit?

. L4 root, weak ankle dorsiflexion
. L4 root, weak knee extension
. L5 root, weak great toe extension
. L5 root, decreased sensation over the lateral foot
. S1 root, absent Achilles reflex

Correct Answer & Explanation

. L4 root, weak ankle dorsiflexion

Explanation

A far lateral disc herniation at L4-L5 compresses the exiting L4 nerve root, unlike a paracentral herniation which affects the traversing L5 root. L4 compression leads to quadriceps weakness (weak knee extension) and a diminished patellar reflex.

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