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8. Foot and Ankle MCQs

Practice Set 294 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 5861

Topic: 8. Foot and Ankle

A 30-year-old male undergoes a multi-ligament knee reconstruction following a traumatic knee dislocation. Six weeks postoperatively, he presents with a persistent, profound foot drop. Electromyography (EMG) reveals a severe, complete common peroneal nerve injury with no motor unit potentials and no signs of early reinnervation. The patient has zero active ankle dorsiflexion. If there is absolutely no clinical or electrodiagnostic recovery by 1 year post-injury, what is the most appropriate definitive surgical management to restore active ambulation without an orthosis?

. Common peroneal nerve neurolysis
. Sural nerve autograft interposition
. Tibialis posterior tendon transfer through the interosseous membrane
. Achilles tendon fractional lengthening and dynamic bracing
. First metatarsophalangeal joint arthrodesis

Correct Answer & Explanation

. Common peroneal nerve neurolysis

Explanation

At 1 year post-injury with no clinical or EMG signs of recovery, a peroneal nerve injury is generally considered irreversible. Nerve repairs or grafts performed this late have dismal outcomes due to motor endplate atrophy. The gold standard definitive management for permanent common peroneal nerve palsy (foot drop) to restore active dorsiflexion is a tendon transfer, specifically the transfer of the functional tibialis posterior tendon to the dorsal midfoot (often through the interosseous membrane).

Question 5862

Topic: 8. Foot and Ankle

A 28-year-old male sustains a severe hyperplantarflexion injury to his foot. Radiographs demonstrate widening between the base of the first and second metatarsals. An MRI confirms a complete rupture of the Lisfranc ligament. Anatomically, the Lisfranc ligament originates from which structure and inserts onto which structure?

. 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 first metatarsal

Explanation

The Lisfranc ligament is a strong 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 is the primary stabilizer of the tarsometatarsal joint complex, as there is no transverse ligament connecting the bases of the first and second metatarsals.

Question 5863

Topic: 8. Foot and Ankle

A 30-year-old male sustains a high-energy midfoot injury. Radiographs reveal a fleck sign at the base of the second metatarsal. The Lisfranc ligament originates from the medial cuneiform and inserts onto which of the following structures?

. Base of the first metatarsal
. Base of the second metatarsal
. Base of the third metatarsal
. Intermediate cuneiform
. Cuboid

Correct Answer & Explanation

. Base of the first metatarsal

Explanation

The Lisfranc ligament is a strong interosseous ligament running from the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. It is critical for the stabilization of the tarsometatarsal joint complex.

Question 5864

Topic: 8. Foot and Ankle

A 45-year-old male presents with acute posterior ankle pain after hearing a "pop" while playing tennis. The Thompson test is positive. The decision is made to manage the patient non-operatively. Which of the following rehabilitation protocols provides the lowest rerupture rate?

. Prolonged cast immobilization in equinus for 12 weeks
. Early functional rehabilitation with weight-bearing in a functional brace
. Immobilization in a short leg cast in neutral for 6 weeks
. Immediate unprotected weight-bearing
. Non-weight bearing in a controlled ankle motion (CAM) boot for 8 weeks

Correct Answer & Explanation

. Prolonged cast immobilization in equinus for 12 weeks

Explanation

Modern early functional rehabilitation protocols, which include early weight-bearing in an equinus brace and early range of motion, yield rerupture rates for non-operative management comparable to operative treatment.

Question 5865

Topic: 8. Foot and Ankle

A 24-year-old football player presents with midfoot pain after an axial load to a plantarflexed foot. Radiographs demonstrate a 3 mm widening between the medial and middle cuneiforms, and a "fleck sign". The primary injured ligament connects which two structures?

. Medial cuneiform to the base of the 1st metatarsal
. Medial cuneiform to the base of the 2nd metatarsal
. Middle cuneiform to the base of the 2nd metatarsal
. Lateral cuneiform to the cuboid
. Navicular to the medial cuneiform

Correct Answer & Explanation

. Medial cuneiform to the base of the 1st metatarsal

Explanation

The Lisfranc ligament traverses from the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. A "fleck sign" represents a bony avulsion of this ligament, indicating severe midfoot instability.

Question 5866

Topic: 8. Foot and Ankle

The Lisfranc ligament is the primary stabilizer of the tarsometatarsal joint complex. Between which two osseous structures does the main intraosseous component of the Lisfranc ligament course?

. Medial cuneiform and base of the 1st metatarsal
. Medial cuneiform and base of the 2nd metatarsal
. Intermediate cuneiform and base of the 2nd metatarsal
. Lateral cuneiform and base of the 3rd metatarsal
. Cuboid and base of the 4th metatarsal

Correct Answer & Explanation

. Medial cuneiform and base of the 1st metatarsal

Explanation

The Lisfranc ligament complex is a strong intraosseous ligament that originates on the lateral aspect of the medial cuneiform and inserts on the medial aspect of the base of the second metatarsal. There is notably no direct ligamentous connection between the bases of the first and second metatarsals.

Question 5867

Topic: 8. Foot and Ankle
A 28-year-old snowboarder sustains a Hawkins Type III talar neck fracture. What is the approximate risk of developing avascular necrosis (AVN) of the talar body in this patient?
. 0-10%
. 20-30%
. 40-50%
. 80-100%
. 0% if reduced emergently

Correct Answer & Explanation

. 80-100%

Explanation

Hawkins Type III fractures involve a talar neck fracture with dislocation of the talar body from both the subtalar and tibiotalar joints. This typically disrupts all three major blood supplies to the talar body (artery of the tarsal canal, deltoid branches, and dorsalis pedis branches), resulting in an AVN risk approaching 80-100%.

Question 5868

Topic: Ankle Trauma & Sports

According to the Lauge-Hansen classification, what is the sequence of structural failure in a pronation-abduction (PA) ankle injury?

. Anterior inferior tibiofibular ligament -> Fibula fracture -> Posterior inferior tibiofibular ligament -> Deltoid ligament
. Deltoid ligament -> Anterior inferior tibiofibular ligament -> Fibula fracture above syndesmosis -> Posterior inferior tibiofibular ligament
. Deltoid ligament -> Anterior and posterior inferior tibiofibular ligaments -> Transverse or comminuted fibula fracture at or just above the joint line
. Lateral collateral ligaments -> Medial malleolus transverse fracture
. Anterior inferior tibiofibular ligament -> Short oblique fibula fracture -> Posterior inferior tibiofibular ligament -> Medial malleolus

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament -> Fibula fracture -> Posterior inferior tibiofibular ligament -> Deltoid ligament

Explanation

The Pronation-Abduction (PA) sequence begins with 1) Medial structure failure (Deltoid ligament rupture or medial malleolus transverse fracture), 2) Syndesmotic ligament failure (AITFL, PITFL), and 3) Fibula fracture (short oblique or transverse fracture at or just above the joint line, frequently featuring lateral comminution/butterfly fragment).

Question 5869

Topic: 8. Foot and Ankle

A 22-year-old athlete sustains a hyperplantarflexion injury to the midfoot. Radiographs demonstrate a 3 mm diastasis between the bases of the first and second metatarsals. Anatomically, what is the structure and orientation of the primary ligament ruptured in this specific injury?

. A dorsal ligament connecting the bases of the 1st and 2nd metatarsals
. An interosseous plantar ligament connecting the lateral aspect of the medial cuneiform to the medial base of the 2nd metatarsal
. A dorsal ligament connecting the medial and middle cuneiforms
. A plantar ligament connecting the navicular to the medial cuneiform
. The calcaneonavicular (spring) ligament

Correct Answer & Explanation

. A dorsal ligament connecting the bases of the 1st and 2nd metatarsals

Explanation

The Lisfranc ligament is an oblique interosseous ligament that runs from the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. It is the largest and strongest ligament stabilizing the first/second ray articulation; its disruption leads to characteristic diastasis.

Question 5870

Topic: Midfoot & Hindfoot
A 28-year-old patient sustains a Hawkins type III talar neck fracture. Which of the following best describes the displacement pattern and the approximate associated risk of avascular necrosis (AVN)?
. Subtalar subluxation with a 20% AVN risk
. Subtalar and tibiotalar dislocation with an AVN risk approaching 90-100%
. Nondisplaced fracture with a 10% AVN risk
. Talonavicular dislocation only with a 50% AVN risk
. Subtalar and talonavicular dislocation with an 80% AVN risk

Correct Answer & Explanation

. Subtalar and tibiotalar dislocation with an AVN risk approaching 90-100%

Explanation

A Hawkins type III fracture involves dislocation of both the subtalar and tibiotalar joints. Because of the severe disruption to the retrograde blood supply, the risk of AVN is extremely high.

Question 5871

Topic: 8. Foot and Ankle

In a displaced intra-articular calcaneus fracture, which fracture fragment classically remains securely attached to the talus via the strong interosseous and deltoid ligaments, serving as the 'constant' fragment for reduction?

. Tuberosity fragment
. Sustentacular fragment
. Anterior process fragment
. Lateral wall fragment
. Posterior facet fragment

Correct Answer & Explanation

. Tuberosity fragment

Explanation

The sustentacular (anteromedial) fragment remains strongly tethered to the talus by the medial collateral (deltoid) and talocalcaneal interosseous ligaments, making it the constant fragment to which the rest of the calcaneus is reduced.

Question 5872

Topic: 8. Foot and Ankle

A 22-year-old athlete sustains a midfoot injury. Radiographs reveal a "fleck sign" in the first intermetatarsal space. This indicates a bony avulsion of the Lisfranc ligament from which specific structure?

. Medial aspect of the medial cuneiform
. Plantar aspect of the middle cuneiform
. Base of the second metatarsal
. Base of the first metatarsal
. Dorsal aspect of the navicular

Correct Answer & Explanation

. Medial aspect of the medial cuneiform

Explanation

The "fleck sign" represents a bony avulsion of the Lisfranc ligament, which runs from the lateral aspect of the medial cuneiform to the medial base of the second metatarsal, most commonly avulsing from the second metatarsal base.

Question 5873

Topic: Ankle Trauma & Sports

A 40-year-old male falls from a ladder and sustains a pilon fracture. Preoperative CT imaging shows a displaced anterolateral distal tibia fragment. This specific fragment remains attached to which of the following ligaments?

. Posterior inferior tibiofibular ligament (PITFL)
. Anterior talofibular ligament (ATFL)
. Anterior inferior tibiofibular ligament (AITFL)
. Deltoid ligament
. Calcaneofibular ligament (CFL)

Correct Answer & Explanation

. Posterior inferior tibiofibular ligament (PITFL)

Explanation

The anterolateral fragment of the distal tibia (the Tillaux-Chaput fragment) serves as the tibial attachment for the anterior inferior tibiofibular ligament (AITFL). Understanding these ligamento-osseous relationships dictates the reduction sequence.

Question 5874

Topic: Ankle Trauma & Sports
A 27-year-old male sustains an isolated Lauge-Hansen Supination-External Rotation (SER) stage IV ankle fracture. According to this classification, what is the precise sequential order of structural failure?
. Medial malleolus -> ATFL -> Lateral malleolus -> PITFL
. AITFL -> Lateral malleolus -> PITFL -> Deltoid ligament/Medial malleolus
. Deltoid ligament -> AITFL -> Fibula fracture above syndesmosis -> PITFL
. Lateral malleolus -> AITFL -> Medial malleolus -> PITFL
. ATFL -> CFL -> PTFL -> Medial malleolus

Correct Answer & Explanation

. AITFL -> Lateral malleolus -> PITFL -> Deltoid ligament/Medial malleolus

Explanation

In the Lauge-Hansen SER sequence, failure begins anterolaterally with the AITFL (Stage I), followed by a spiral lateral malleolus fracture (Stage II), PITFL rupture or posterior malleolus fracture (Stage III), and finally deltoid rupture or medial malleolus fracture (Stage IV).

Question 5875

Topic: 8. Foot and Ankle

During open reduction and internal fixation of a pronation-external rotation (Weber C) ankle fracture, the surgeon needs to assess the syndesmosis. Which intraoperative test is considered the most reliable method to evaluate latent syndesmotic instability after fibular fixation?

. Cotton test (lateral pull test) with a bone hook under fluoroscopy
. Squeeze test of the mid-calf
. Measuring the tibiofibular clear space on a standard non-stressed AP radiograph
. Dorsiflexion stress test alone
. Anterior drawer test of the ankle

Correct Answer & Explanation

. Cotton test (lateral pull test) with a bone hook under fluoroscopy

Explanation

The Cotton test, which involves applying lateral traction on the fibula using a bone hook or reduction clamp under direct fluoroscopic visualization, is the gold standard for intraoperatively detecting syndesmotic instability. It directly stresses the interosseous and inferior tibiofibular ligaments.

Question 5876

Topic: 8. Foot and Ankle

Which of the following arteries provides the dominant blood supply to the body of the talus, rendering it susceptible to avascular necrosis following a talar neck fracture?

. Anterior tibial artery
. Perforating peroneal artery
. Artery of the tarsal canal
. Artery of the tarsal sinus
. Medial plantar artery

Correct Answer & Explanation

. Anterior tibial artery

Explanation

The artery of the tarsal canal is a branch of the posterior tibial artery and provides the dominant blood supply to the talar body. It forms an anastomotic sling with the artery of the tarsal sinus (branch of the dorsalis pedis/anterior tibial artery). Disruption of the artery of the tarsal canal in talar neck fractures is the primary reason for the high incidence of avascular necrosis.

Question 5877

Topic: 8. Foot and Ankle

A 25-year-old professional football player sustains a hyperplantarflexion injury to his foot. Radiographs demonstrate diastasis between the medial cuneiform and the base of the second metatarsal. The primary stabilizing ligament disrupted in this injury connects which two structures?

. Dorsal medial cuneiform to the base of the first metatarsal
. Plantar medial cuneiform to the base of the first metatarsal
. Interosseous medial cuneiform to the base of the second metatarsal
. Interosseous intermediate cuneiform to the base of the second metatarsal
. Plantar lateral cuneiform to the cuboid

Correct Answer & Explanation

. Dorsal medial cuneiform to the base of the first metatarsal

Explanation

The Lisfranc ligament is an interosseous ligament that connects the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. It is the largest and most critical primary stabilizer of the tarsometatarsal joint complex, as there is no direct ligamentous connection between the bases of the first and second metatarsals.

Question 5878

Topic: 8. Foot and Ankle
A 55-year-old female presents with medial foot pain and a progressive flatfoot deformity. Examination reveals a flexible flatfoot, an inability to perform a single-leg heel raise, and correctable hindfoot valgus. According to the Johnson and Strom classification for posterior tibial tendon dysfunction, what stage represents her condition?
. Stage I
. Stage II
. Stage III
. Stage IV
. Stage V

Correct Answer & Explanation

. Stage II

Explanation

The Johnson and Strom classification (modified by Myerson) categorizes Adult Acquired Flatfoot Deformity. Stage I features tenosynovitis with mild pain but no deformity. Stage II features a flexible flatfoot deformity, unable to perform a single-leg heel raise. Stage III is a rigid, non-correctable flatfoot deformity. Stage IV includes rigid ankle valgus with deltoid ligament compromise.

Question 5879

Topic: Forefoot

A 45-year-old female with severe hallux valgus has a Hallux Valgus Angle (HVA) of 48 degrees, an Intermetatarsal Angle (IMA) of 20 degrees, and significant hypermobility of the first tarsometatarsal (TMT) joint. Which surgical procedure is most indicated to correct her deformity?

. Distal chevron osteotomy
. Akin osteotomy
. Scarf osteotomy
. Lapidus procedure
. Keller resection arthroplasty

Correct Answer & Explanation

. Distal chevron osteotomy

Explanation

The Lapidus procedure consists of a fusion of the first tarsometatarsal (TMT) joint. It is highly indicated for severe hallux valgus (IMA > 15-20 degrees) combined with clinical hypermobility of the first ray. Distal osteotomies (like the Chevron) cannot adequately correct an IMA of 20 degrees. The Scarf is a diaphyseal osteotomy but does not specifically address TMT hypermobility as reliably as a Lapidus fusion.

Question 5880

Topic: Midfoot & Hindfoot
A 60-year-old male with long-standing diabetes presents with a swollen, erythematous, and warm foot but no systemic signs of infection. Radiographs reveal joint fragmentation, periarticular debris, and subluxation of the midfoot joints. According to the Eichenholtz classification of Charcot arthropathy, what is the current stage of this disease process?
. Stage 0 (Prodromal)
. Stage I (Developmental/Fragmentation)
. Stage II (Coalescence)
. Stage III (Reconstruction/Consolidation)
. Stage IV (Degenerative)

Correct Answer & Explanation

. Stage I (Developmental/Fragmentation)

Explanation

Eichenholtz Stage I is the developmental or fragmentation stage, characterized clinically by an acute, swollen, erythematous foot. Radiographically, it shows joint effusion, subchondral osteopenia, fragmentation, joint subluxation/dislocation, and bony debris. Stage II (Coalescence) shows absorption of debris and early fusion. Stage III (Consolidation) shows remodeling and stable deformity.

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