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8. Foot and Ankle MCQs

Practice Set 29 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 561

Topic: 8. Foot and Ankle

A 23-year-old woman with a bilateral leg and foot deformity presents for evaluation. She has weakness in the foot and ankle, giving way of the ankle, and difficulty with exercise activities. She mentions that both her brother and uncle have similar problems and deformities with their limbs. On examination, she has a cavovarus foot deformity and muscle weakness. The most likely combination of muscle loss is:

. Anterior tibial and intrinsic muscles
. Peroneus longus, peroneus brevis, and intrinsic muscles
. Peroneus brevis, anterior tibial, and intrinsic muscles
. Posterior tibial, anterior tibial, and peroneus longus muscles
. Peroneus longus, extensor hallucis longus, and intrinsic muscles

Correct Answer & Explanation

. Peroneus brevis, anterior tibial, and intrinsic muscles

Explanation

By history, this patient has hereditary sensorimotor neuropathy (C harcot- Marie-Tooth disorder). Historically referred to as peroneal muscular atrophy, this condition initially affects the peroneus brevis, followed by the intrinsic and anterior tibial muscles. Other patterns of deformity and muscle loss are occasionally present.

Question 562

Topic: 8. Foot and Ankle
A 63-year-old woman presents for evaluation and treatment of a painful bunion deformity. She has a moderate hallux valgus deformity. Pain and crepitus are present with range of motion of the hallux metatarsophalangeal joint. The hallux valgus deformity measures 25° and the intermetatarsal angle is 14°. The recommended surgical procedure is:
. Distal metatarsal osteotomy
. Proximal metatarsal osteotomy
. Distal soft tissue release and proximal metatarsal osteotomy
. Metatarsophalangeal joint arthrodesis
. Distal soft tissue release and first metatarsal cuneiform arthrodesis

Correct Answer & Explanation

. Metatarsophalangeal joint arthrodesis

Explanation

Although resection arthroplasty (Keller procedure) may be a reasonable alternative, arthrodesis of the hallux metatarsophalangeal joint is required in the presence of arthritis. Other alternatives, such as osteotomies, are impractical.

Question 563

Topic: Midfoot & Hindfoot

The nerve commonly associated with painful heel syndrome is the:

. Medial plantar nerve
. Lateral plantar nerve
. First branch of the lateral plantar nerve
. C alcaneal nerve
. Deep peroneal nerve

Correct Answer & Explanation

. First branch of the lateral plantar nerve

Explanation

The first branch of the lateral plantar nerve (occasionally referred to as the nerve to the abductor digiti quinti) is occasionally involved in pathologic painful heel syndrome and plantar fasciitis.

Question 564

Topic: 8. Foot and Ankle
A 63-year-old woman with diabetes has had an ulcer under the plantar aspect of the foot for 3 months. The ulcer extends from the inferior aspect of the heel pad toward the midfoot. Nonoperative measures have failed to heal the ulcer. The amputation that is most likely to be successful is a:
. Midfoot amputation with a skin graft
. Syme's amputation
. Below the knee amputation
. Transmetatarsal amputation
. Transverse tarsal amputation

Correct Answer & Explanation

. Below the knee amputation

Explanation

A foot salvage amputation, including the transarticular ankle amputation (Syme's amputation), will not work in the presence of a disrupted heel pad (with or without ulceration) and infection of the heel.

Question 565

Topic: 8. Foot and Ankle
A 56-year-old man has a painful flatfoot deformity. Attempts at orthotic support and bracing of the foot have not been successful. On examination, the forefoot is abducted, the heel is fixed in valgus, and the subtalar joint is rigid. The operation that is most likely to correct the foot deformity is:
. Flexor digitorum longus transfer into the navicular
. Calcaneus osteotomy
. Transverse tarsal arthrodesis
. Triple arthrodesis
. Lateral column lengthening calcaneus osteotomy

Correct Answer & Explanation

. Triple arthrodesis

Explanation

By history and physical examination, this patient has a Stage III flatfoot deformity. Due to the rigidity, only an arthrodesis will correct this abnormality. Although a transverse tarsal arthrodesis (Chopart's arthrodesis) may adequately correct the deformity, a triple arthrodesis will correct all of the components including heel valgus, forefoot abduction, and midfoot pronation.

Question 566

Topic: 8. Foot and Ankle

A 54-year-old woman with a 10-year history of diabetes presents for treatment of a non-healing ulcer that has been present under the plantar aspect of her second metatarsal for 9 months. The ulcer is 1.5 cm in diameter, is associated with mild serous drainage, and has shown no radiographic changes. She has normal circulation to the forefoot. The recommended treatment is:

. Osteotomy second metatarsal
. Resection of the second metatarsal head
. Shoe wear modification
. Total contact cast
. Orthotic shoe support and shoe modification

Correct Answer & Explanation

. Total contact cast

Explanation

Management of the non-infected plantar neuropathic ulcer is nonoperative, with the exception of refractory recurrent ulceration. In this case, surgery may be indicated. The most reliable means of healing the ulcer is with the use of a total contact cast that permits immediate ambulation and protection for the rest of the foot. Shoe modifications are required following healing of the ulcer but are insufficient as part of the initial treatment program.

Question 567

Topic: 8. Foot and Ankle

A 63-year-old woman presents for treatment of pain and a burning/tingling sensation along the medial aspect of the foot and hallux. She underwent a tarsal tunnel release 12 months ago, but she has not experienced much symptomatic relief. Upon clinical examination, she has a positive percussion test (Tinel sign) along the course of the distal tibial nerve and pain upon pressure of the tarsal canal. There are no other pertinent clinical findings and a magnetic resonance image does not reveal any pathologic lesion. The next course of treatment is:

. Multiple cortisone injections
. Implantation of a peripheral nerve stimulator
. Repeat release of the tarsal tunnel, specifically of the medial plantar nerve
. Multiple sessions of physical therapy
. Nerve desensitization with peripheral nerve stimulation

Correct Answer & Explanation

. Repeat release of the tarsal tunnel, specifically of the medial plantar nerve

Explanation

This patient presents with symptoms of a tarsal tunnel syndrome, specifically involving the medial plantar nerve. Because she did not experience any initial pain relief from her surgery, one may suspect that an inadequate release was initially performed. Cortisone injection and physical therapy have no role in the management of a recurrent tarsal tunnel syndrome, although desensitization treatments with neuroleptic medication and manual massage are beneficial following surgery. It is important to rule out a sympathetically mediated pain syndrome prior to embarking on repeat surgery.

Question 568

Topic: 8. Foot and Ankle

For 3 years, a 23-year-old female gymnast has experienced recurrent ankle sprains associated with a sense of instability of the hindfoot. Upon examination, a positive anterior drawer test is present and stress radiographs are taken. She has attempted rehabilitation numerous times. She is unable to compete with her current symptoms. The recommended treatment is:

. Reconstruction of subtalar instability with the peroneus brevis tendon
. Reconstruction of ankle instability with an anatomic repair (Brostrom procedure)
. Reconstruction of ankle instability with the split peroneus brevis (Evans procedure)
. Reconstruction of ankle instability with the split peroneus brevis (C hrisman-Snook procedure)
. Arthroscopic evaluation of ankle joint followed by reconstruction with split peroneus brevis tendon

Correct Answer & Explanation

. Reconstruction of ankle instability with an anatomic repair (Brostrom procedure)

Explanation

For athletes, particularly those involved in activities that require repetitive proprioceptive and balance activities of the foot and ankle, an anatomic repair (Brostrom procedure) with addition of the extensor retinaculum (Gould modification) is the only procedure that will allow this individual to return to athletic activity. Surgeons must not sacrifice the peroneal tendon, or part thereof, since this may unnecessarily weaken the foot.

Question 569

Topic: 8. Foot and Ankle

A 31-year-old recreational soccer player presents for evaluation of chronic ankle pain during physical activity. He reports a severe inversion ankle sprain that occurred 1 year ago and notes that he was treated with cast immobilization. Upon examination, he does not demonstrate laxity of the ankle ligaments and pain is present along the anterior medial ankle. A radiograph is presented. The recommended treatment is:

. Ankle arthrotomy and excision of loose body
. Ankle arthrotomy and ankle synovectomy
. Retrograde drilling and bone graft
. Osteochondral autograft procedure
. Arthroscopic debridement and drilling

Correct Answer & Explanation

. Arthroscopic debridement and drilling

Explanation

This patient has an osteochondral defect of the talus. According to most classification systems, the grade of the defect is not severe. Retrograde drilling of the defect through the sinus tarsi is possible for a posteromedial lesion of the talus for which the cartilage surface is intact. An autogenous osteochondral bone graft is indicated for a severe lesion with bone loss or following failure of previous attempts at arthroscopic drilling. The ideal procedure is arthroscopic debridement and drilling of the subchondral bone.

Question 570

Topic: 8. Foot and Ankle

A 25-year-old football player sustained an injury to his ankle 2 months ago. He has ankle pain upon dorsiflexion and external rotation. A radiograph demonstrates widening of the tibiofibular syndesmosis and a 3-mm space between the medial talus and the medial malleolus. The recommended treatment is:

. Open reduction and internal fixation of a high fibula fracture
. Reconstruction with peroneus brevis followed by aggressive rehabilitation of the ankle
. Repair of the high ankle sprain with syndesmosis screw
. Arthrodesis of the tibiofibular syndesmosis
. Ankle arthroscopy, synovectomy, and repair of the deltoid ligament

Correct Answer & Explanation

. Repair of the high ankle sprain with syndesmosis screw

Explanation

It is imperative that any diastasis of the tibiofibular joint is repaired to prevent the late sequelae (e.g., arthritis), particularly in the athlete. Arthroscopy is not sufficient, other than evaluation for additional joint pathology, and syndesmosis arthrodesis would rarely be indicated for this condition. There is no evidence of a high fibula fracture, although this must be a concern and should always be considered.

Question 571

Topic: 8. Foot and Ankle

Which of the following ligaments is primarily responsible for stabilizing the base of the second metatarsal to the medial cuneiform, and is critically evaluated in midfoot trauma?

. Spring ligament
. Plantar fascia
. Lisfranc ligament
. Bifurcate ligament
. Long plantar ligament

Correct Answer & Explanation

. Lisfranc ligament

Explanation

The Lisfranc ligament is a stout intra-articular, interosseous ligament connecting the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. Disruption of this ligament leads to critical midfoot instability.

Question 572

Topic: 8. Foot and Ankle

A 35-year-old construction worker falls from a height and sustains a comminuted, displaced intra-articular calcaneus fracture.

If utilizing an extensile lateral approach for ORIF, the sural nerve is most at risk in which part of the incision?

. Proximal horizontal limb
. Distal horizontal limb
. Apex of the curve
. Proximal vertical limb
. Distal vertical limb

Correct Answer & Explanation

. Distal horizontal limb

Explanation

During the extensile lateral approach to the calcaneus, the sural nerve is most commonly at risk near the distal extent of the horizontal limb of the incision. The nerve must be carefully protected to prevent painful neuromas.

Question 573

Topic: 8. Foot and Ankle



A 28-year-old male presents with midfoot swelling after a fall from a horse. The AP foot radiograph demonstrates a small bony avulsion fragment in the first intermetatarsal space (the "fleck sign"). This fragment represents an avulsion of a ligament that classically originates from the:

. Medial aspect of the intermediate cuneiform
. Plantar base of the first metatarsal
. Lateral aspect of the medial cuneiform
. Medial base of the second metatarsal
. Navicular tuberosity

Correct Answer & Explanation

. Medial base of the second metatarsal

Explanation

The "fleck sign" is pathognomonic for a Lisfranc injury, representing an avulsion fracture. The Lisfranc ligament originates from the lateral aspect of the medial cuneiform and inserts onto the medial base of the second metatarsal.

Question 574

Topic: 8. Foot and Ankle

A 30-year-old equestrian rider gets her foot caught in the stirrup, causing a severe hyperplantarflexion midfoot injury. Radiographs reveal pathological widening of the space between the medial and middle cuneiforms. The injured Lisfranc ligament primarily connects which two bony structures?

. 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 cuboid
. Navicular to the medial cuneiform

Correct Answer & Explanation

. Medial cuneiform to the base of the second metatarsal

Explanation

The Lisfranc ligament 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. It provides critical stability to the tarsometatarsal articulation.

Question 575

Topic: 8. Foot and Ankle

During the initial orthopedic evaluation, the patient exhibited specific neurological deficits. Given the rapid decline in motor strength and altered sensation, which of the following nerve-compartment associations was most significantly affected in this patient, based on the clinical findings?

. A. Tibial nerve - Superficial posterior compartment
. B. Superficial peroneal nerve - Deep posterior compartment
. C. Deep peroneal nerve - Anterior compartment
. D. Common peroneal nerve - Lateral compartment
. E. Saphenous nerve - Medial compartment

Correct Answer & Explanation

. C. Deep peroneal nerve - Anterior compartment

Explanation

Correct Answer: COption C is correct. The case describes 'profound weakness' in active dorsiflexion of the ankle (tibialis anterior) and toe extension (EHL, EDL), with a rapid decline from 3/5 to 1/5. These muscles are located in the anterior compartment and are innervated by the deep peroneal nerve. Furthermore, 'diminished two-point discrimination in the first dorsal webspace' is a classic sensory deficit associated with deep peroneal nerve compromise, as this nerve provides sensation to this area. This combination of motor and sensory deficits points directly to significant involvement of the deep peroneal nerve within the anterior compartment.Option A is incorrect. The tibial nerve innervates the superficial and deep posterior compartments. While the posterior compartments showed some edema, the case states the superficial posterior compartment (gastrocnemius/soleus) maintained 4/5 strength for plantarflexion, indicating less severe involvement compared to the anterior compartment.Option B is incorrect. The superficial peroneal nerve innervates the lateral compartment (peroneus longus and brevis) and provides sensation to the lateral dorsum of the foot. While the lateral compartment showed a decline in eversion strength (3/5 to 2/5) and altered sensation, the deficits in the anterior compartment (deep peroneal nerve) were described as 'profound' and more rapidly deteriorating.Option D is incorrect. The common peroneal nerve divides into the deep and superficial peroneal nerves. While it is at risk around the fibular neck, the specific deficits described are distal to this division, affecting the deep and superficial peroneal nerves individually within their respective compartments, rather than a global common peroneal nerve palsy.Option E is incorrect. The saphenous nerve is a purely sensory nerve providing sensation to the medial aspect of the leg. The case does not describe specific deficits related to this nerve, and there is no distinct 'medial compartment' in the context of ACS, as the medial aspect of the tibia is subcutaneous.

Question 576

Topic: 8. Foot and Ankle

A patient is evaluated for an acute anterior compartment syndrome of the lower leg. If left untreated, what primary sensory deficit will eventually manifest as a consequence of this specific compartment's ischemia?

. Decreased sensation over the dorsal aspect of the first web space
. Decreased sensation over the plantar aspect of the heel
. Decreased sensation over the lateral aspect of the foot
. Decreased sensation over the medial malleolus
. Decreased sensation over the entire dorsum of the foot

Correct Answer & Explanation

. Decreased sensation over the dorsal aspect of the first web space

Explanation

The deep peroneal nerve traverses the anterior compartment of the leg. Ischemia in this compartment leads to deep peroneal nerve dysfunction, causing sensory loss over the dorsal aspect of the first web space of the foot, along with weakness in ankle dorsiflexion.

Question 577

Topic: 8. Foot and Ankle

A 35-year-old man develops unrecognized compartment syndrome of the foot following a severe crush injury. Which of the following late deformities is the hallmark sequela of isolated, untreated ischemic contracture of the deep intrinsic muscles of the foot?

. Equinovarus deformity
. Pes planus
. Clawing of the lesser toes
. Hallux valgus
. Drop foot

Correct Answer & Explanation

. Clawing of the lesser toes

Explanation

Untreated compartment syndrome of the foot typically involves the central compartments housing the intrinsic muscles. Ischemic contracture of these muscles leads to a classic rigid clawing deformity of the lesser toes.

Question 578

Topic: 8. Foot and Ankle

During surgical release for an acute anterior compartment syndrome of the leg, it is critical to understand the anatomy at risk. Ischemia or iatrogenic injury to the major nerve running within this compartment will result in which of the following primary clinical deficits?

. Inability to plantarflex the ankle and numbness on the plantar surface of the foot
. Weakness of great toe extension and numbness in the first dorsal web space
. Weakness of ankle eversion and numbness over the lateral aspect of the foot
. Inability to flex the knee and numbness over the posterior calf
. Weakness of toe flexion and numbness over the medial malleolus

Correct Answer & Explanation

. Weakness of great toe extension and numbness in the first dorsal web space

Explanation

The anterior compartment of the leg contains the deep peroneal nerve. Injury or ischemia to this nerve results in weakness of ankle and toe dorsiflexion (extensor hallucis longus) and decreased sensation in the first dorsal web space.

Question 579

Topic: Forefoot

A 50-year-old male requires open reduction and internal fixation of a complex, intra-articular distal humerus fracture (AO/OTA 13C3). The surgeon decides to perform an olecranon osteotomy for adequate joint visualization. Which of the following describes the most mechanically stable orientation for the osteotomy?

. Transverse osteotomy perpendicular to the ulnar shaft
. Chevron osteotomy with the apex pointing distally
. Chevron osteotomy with the apex pointing proximally
. Oblique osteotomy from proximal-medial to distal-lateral
. Step-cut osteotomy exiting through the coronoid

Correct Answer & Explanation

. Chevron osteotomy with the apex pointing distally

Explanation

A chevron osteotomy with the apex pointing distally provides superior inherent mechanical stability against torsional and translational forces compared to transverse or apex-proximal osteotomies.

Question 580

Topic: 8. Foot and Ankle

According to the Lauge-Hansen classification, which of the following is the first structure injured in a Supination-External Rotation (SER) ankle fracture?

. Anterior inferior tibiofibular ligament
. Short oblique fracture of the fibula
. Posterior inferior tibiofibular ligament
. Deltoid ligament
. Medial malleolus

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament

Explanation

The SER pattern progresses in four predictable stages. Stage 1 is injury to the anterior inferior tibiofibular ligament (AITFL), followed by a short oblique fibula fracture (Stage 2), PITFL tear or posterior malleolus fracture (Stage 3), and finally medial injury (Stage 4).

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