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8. Foot and Ankle MCQs

Practice Set 295 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 5881

Topic: Forefoot
Operative intervention for an acute turf toe injury is most clearly indicated in which of the following scenarios?
. Grade I sprain with localized pain
. Grade II sprain with partial tearing of the plantar plate
. Grade III complete plantar plate tear with proximal migration of the sesamoids
. Medial capsular sprain without clinical instability
. Failure of 2 weeks of conservative management in a Grade I sprain

Correct Answer & Explanation

. Grade III complete plantar plate tear with proximal migration of the sesamoids

Explanation

Turf toe is a sprain of the first metatarsophalangeal (MTP) joint plantar plate. Grade III injuries involve a complete tear of the plantar plate. Indications for surgery include a Grade III tear with proximal migration of the sesamoids, large intra-articular bony avulsion, traumatic bunion deformity, or progressive instability. Grades I and II are treated nonoperatively.

Question 5882

Topic: 8. Foot and Ankle

A 14-year-old male with Charcot-Marie-Tooth disease presents with a significant bilateral cavovarus foot deformity. The Coleman block test is performed during the physical examination. This test is primarily used to evaluate which of the following?

. First ray mobility and forefoot adduction
. Flexibility of the hindfoot varus deformity
. Rigidity of the Achilles tendon contracture
. Degree of peroneal nerve motor weakness
. Presence of an underlying tarsal coalition

Correct Answer & Explanation

. First ray mobility and forefoot adduction

Explanation

The Coleman block test evaluates whether the hindfoot varus in a cavovarus foot is flexible (driven by a plantarflexed first ray) or fixed. A block is placed under the lateral foot, allowing the first ray to drop off. If the hindfoot varus corrects to neutral or valgus, the deformity is flexible and primarily forefoot-driven, dictating surgical interventions that address the first ray (e.g., dorsiflexion osteotomy) rather than needing a corrective hindfoot osteotomy.

Question 5883

Topic: 8. Foot and Ankle

During open reduction and internal fixation of a displaced intra-articular calcaneus fracture utilizing an extensile lateral approach, which nerve is at the highest risk for iatrogenic injury or inclusion in the surgical incision?

. Deep peroneal nerve
. Superficial peroneal nerve
. Sural nerve
. Saphenous nerve
. Medial calcaneal nerve

Correct Answer & Explanation

. Deep peroneal nerve

Explanation

The sural nerve courses posterior to the lateral malleolus and along the lateral aspect of the hindfoot and midfoot. During the standard extensile lateral approach to the calcaneus, the sural nerve is highly vulnerable to injury, traction, or entrapment in the surgical scar. Care must be taken to create full-thickness flaps to protect it.

Question 5884

Topic: Forefoot

A 62-year-old male presents with severe hallux rigidus (Coughlin and Shurnas Grade 3) and pain with daily activities. He does not engage in running or high-impact sports. Radiographs demonstrate severe joint space narrowing and large dorsal osteophytes. What is the gold standard surgical intervention for this patient?

. Cheilectomy with dorsal capsulectomy
. Silicone total joint arthroplasty
. First metatarsophalangeal (MTP) joint arthrodesis
. Keller resection arthroplasty
. Moberg osteotomy

Correct Answer & Explanation

. Cheilectomy with dorsal capsulectomy

Explanation

For advanced (Grade 3 or 4) hallux rigidus with diffuse joint degeneration, the gold standard treatment is first MTP joint arthrodesis. It provides reliable pain relief and durability. Cheilectomy is indicated for Grade 1 or 2 hallux rigidus where arthritis is confined to the dorsal aspect of the joint. Keller arthroplasty and silicone implants carry higher risks of failure and transfer metatarsalgia.

Question 5885

Topic: 8. Foot and Ankle

Which of the following conditions is considered an absolute contraindication for a primary Total Ankle Arthroplasty (TAA)?

. Patient age > 65 years
. Bilateral post-traumatic ankle osteoarthritis
. Severe lower extremity neuropathy (e.g., Charcot arthropathy)
. Rheumatoid arthritis
. Previous syndesmotic screw fixation

Correct Answer & Explanation

. Patient age > 65 years

Explanation

Absolute contraindications for Total Ankle Arthroplasty (TAA) include active infection, severe peripheral neuropathy/Charcot neuroarthropathy, avascular necrosis of a significant portion of the talar body, and poor soft tissue envelope or vascular compromise. Rheumatoid arthritis and older age are often considered excellent indications for TAA over arthrodesis.

Question 5886

Topic: 8. Foot and Ankle

A 35-year-old female presents with burning pain in the third webspace of her foot, consistent with a Morton's neuroma. This common digital nerve in the third webspace is classically formed by communicating branches from which two nerves?

. Medial and lateral plantar nerves
. Deep and superficial peroneal nerves
. Sural and lateral plantar nerves
. Saphenous and medial plantar nerves
. Medial calcaneal and lateral plantar nerves

Correct Answer & Explanation

. Medial and lateral plantar nerves

Explanation

Morton's neuroma most commonly occurs in the third intermetatarsal space. The common digital nerve in this space is uniquely formed by communicating branches from both the medial and lateral plantar nerves, making it relatively thicker and more prone to mechanical tethering and compression under the transverse intermetatarsal ligament.

Question 5887

Topic: Midfoot & Hindfoot

A 45-year-old distance runner presents with chronic heel pain. It is maximal on the plantar-medial aspect of the heel and radiates distally along the lateral border of the foot. The pain is not worse with the first step in the morning but worsens after prolonged activity. Entrapment of Baxter's nerve is suspected. Baxter's nerve is the first branch of which nerve?

. Medial plantar nerve
. Lateral plantar nerve
. Sural nerve
. Medial calcaneal nerve
. Deep peroneal nerve

Correct Answer & Explanation

. Medial plantar nerve

Explanation

Baxter's nerve is the first branch of the lateral plantar nerve. It courses deep to the abductor hallucis muscle and supplies motor innervation to the abductor digiti minimi. Entrapment of Baxter's nerve can cause chronic heel pain that mimics, or coexists with, plantar fasciitis but often includes radiating pain and possible hypotrophy of the abductor digiti minimi on MRI.

Question 5888

Topic: 8. Foot and Ankle

A 28-year-old soccer player experiences a snapping sensation behind the lateral malleolus when abruptly changing directions. On physical examination, resisted eversion of the foot with the ankle in dorsiflexion reproduces the snapping and pain. Injury to which of the following structures is most likely responsible for this clinical presentation?

. Anterior talofibular ligament
. Calcaneofibular ligament
. Superior peroneal retinaculum
. Inferior peroneal retinaculum
. Peroneus tertius tendon

Correct Answer & Explanation

. Anterior talofibular ligament

Explanation

The clinical presentation describes peroneal tendon subluxation or dislocation. The primary restraint to peroneal tendon subluxation is the superior peroneal retinaculum (SPR). Injury to the SPR, often occurring with forced dorsiflexion and eversion, leads to the tendons snapping out of the retromalleolar groove.

Question 5889

Topic: 8. Foot and Ankle

A 12-year-old boy presents with a history of recurrent ankle sprains. Examination reveals a rigid, flat arch and severe pain when attempting to invert the heel. CT scan confirms a calcaneonavicular coalition. During the physical exam, which of the following findings is most characteristically associated with this condition?

. Decreased ankle dorsiflexion range of motion
. Significantly decreased subtalar range of motion
. A positive anterior drawer test
. A flexible hindfoot varus during the block test
. Hypermobility of the first tarsometatarsal joint

Correct Answer & Explanation

. Decreased ankle dorsiflexion range of motion

Explanation

Tarsal coalitions (most commonly calcaneonavicular or talocalcaneal) restrict the normal motion of the hindfoot joints. The hallmark physical exam finding is a rigid flatfoot with significantly decreased or completely absent subtalar range of motion. The hindfoot fails to invert during the single-leg heel raise, and forced inversion elicits pain.

Question 5890

Topic: 8. Foot and Ankle

A patient presents with a painful, flexible hallux varus deformity 1 year after bunion surgery. Review of the previous operative note reveals an aggressive medial eminence resection and a complete fibular sesamoidectomy. Which of the following tendon transfers is most appropriate for dynamic correction of this flexible deformity?

. Flexor hallucis longus (FHL) to the proximal phalanx
. Abductor hallucis to the lateral proximal phalanx
. Extensor hallucis brevis (EHB) transfer under the deep transverse metatarsal ligament
. Extensor hallucis longus (EHL) to the first metatarsal neck
. Peroneus longus to the first metatarsal base

Correct Answer & Explanation

. Flexor hallucis longus (FHL) to the proximal phalanx

Explanation

Iatrogenic hallux varus is often caused by over-resection of the medial eminence, excessive lateral release, or fibular sesamoidectomy. For a flexible deformity, a dynamic tendon transfer is indicated. The extensor hallucis brevis (EHB) tendon is detached proximally, passed deep to the deep transverse metatarsal ligament, and attached to the lateral aspect of the proximal phalanx to recreate the lateral stabilizing force.

Question 5891

Topic: 8. Foot and Ankle

A 13-year-old boy presents with frequent ankle sprains and rigid flatfeet. Radiographs reveal a continuous osseous bridge between the calcaneus and the navicular on the oblique view. Which of the following radiographic signs is most commonly associated with this specific type of tarsal coalition?

. C-sign on the lateral radiograph
. Anteater nose sign on the lateral radiograph
. Talar beaking on the AP radiograph
. Double density sign on the Harris axial view
. Too many toes sign on the weight-bearing AP view

Correct Answer & Explanation

. C-sign on the lateral radiograph

Explanation

The patient has a calcaneonavicular coalition, which is best seen on a 45-degree internal rotation oblique radiograph. On a lateral radiograph, the anterior process of the calcaneus appears elongated, resembling an anteater's nose ('anteater sign'). The 'C-sign' is classically associated with talocalcaneal coalitions.

Question 5892

Topic: 8. Foot and Ankle
A 28-year-old male sustains a Hawkins Type III talar neck fracture following a high-speed motor vehicle collision. Which of the following best describes the expected rate of avascular necrosis (AVN) of the talar body associated with this injury pattern?
. 0-10%
. 15-30%
. 40-50%
. 70-100%
. Invariably 100% regardless of surgical timing

Correct Answer & Explanation

. 70-100%

Explanation

Hawkins Type III talar neck fractures involve displacement of the talar body with subluxation or dislocation from both the subtalar and tibiotalar joints. This disrupts all three major sources of blood supply (artery of the tarsal canal, deltoid branches, and dorsalis pedis branches), resulting in a high AVN rate historically reported between 70% and 100%.

Question 5893

Topic: 8. Foot and Ankle

During a percutaneous repair of an acute Achilles tendon rupture using a standard passing jig, the patient develops neuropathic pain and numbness along the lateral border of the foot postoperatively. Which of the following structures was most likely injured during the proximal lateral suture passage?

. Superficial peroneal nerve
. Deep peroneal nerve
. Sural nerve
. Lateral plantar nerve
. Saphenous nerve

Correct Answer & Explanation

. Superficial peroneal nerve

Explanation

The sural nerve crosses from the midline to the lateral side of the Achilles tendon approximately 10 cm proximal to its insertion on the calcaneus. It is at significant risk during percutaneous Achilles tendon repairs, especially when placing proximal lateral locking sutures.

Question 5894

Topic: Midfoot & Hindfoot
A 65-year-old woman presents with a painful, severe flatfoot deformity. Examination reveals a rigid deformity that is not passively correctable to neutral, and she cannot perform a single-limb heel rise. Radiographs demonstrate advanced degenerative changes in the subtalar and talonavicular joints. What is the most appropriate definitive surgical management?
. FDL transfer and medial displacement calcaneal osteotomy
. Lateral column lengthening and medial cuneiform osteotomy
. Subtalar arthrodesis alone
. Triple arthrodesis
. Tibiotalocalcaneal arthrodesis

Correct Answer & Explanation

. Triple arthrodesis

Explanation

The patient has Stage III Adult Acquired Flatfoot Ddeformity (Posterior Tibial Tendon Dysfunction), characterized by a rigid deformity and hindfoot arthrosis. Joint-sparing osteotomies and tendon transfers (Stages I and II) are no longer appropriate. A triple arthrodesis (subtalar, talonavicular, and calcaneocuboid) is the gold standard for restoring a plantigrade foot and eliminating arthritic pain.

Question 5895

Topic: Midfoot & Hindfoot

A 45-year-old marathon runner presents with chronic, recalcitrant heel pain. Clinical examination reveals maximal tenderness at the medial aspect of the calcaneal tuberosity. MRI demonstrates fatty atrophy of the abductor digiti minimi muscle. Entrapment of which of the following nerves is the most likely cause of these findings?

. Medial plantar nerve
. Lateral plantar nerve
. First branch of the lateral plantar nerve
. First branch of the medial plantar nerve
. Medial calcaneal nerve

Correct Answer & Explanation

. Medial plantar nerve

Explanation

Baxter's nerve is the first branch of the lateral plantar nerve. It supplies motor innervation to the abductor digiti minimi. Entrapment typically occurs between the deep fascia of the abductor hallucis and the medial margin of the quadratus plantae, leading to chronic heel pain and isolated fatty atrophy of the abductor digiti minimi on MRI.

Question 5896

Topic: Midfoot & Hindfoot

A 55-year-old poorly controlled diabetic male presents with a markedly swollen, erythematous, and warm foot. Radiographs demonstrate periarticular bone fragmentation, subluxation, and soft tissue swelling at the tarsometatarsal joints. Based on the Eichenholtz classification, what is the appropriate stage and recommended initial management?

. Stage 0; Total contact casting
. Stage 1; Total contact casting
. Stage 2; Surgical arthrodesis
. Stage 3; Surgical arthrodesis
. Stage 1; Immediate surgical debridement and external fixation

Correct Answer & Explanation

. Stage 0; Total contact casting

Explanation

The patient is in Eichenholtz Stage 1 (Development/Fragmentation) of Charcot arthropathy, characterized by clinical inflammation and radiographic evidence of osteopenia, fragmentation, and joint subluxation/dislocation. The standard of care during the acute phase (Stage 1) is offloading and immobilization, most commonly via total contact casting. Surgery is generally contraindicated during the acute inflammatory phase.

Question 5897

Topic: 8. Foot and Ankle

A 50-year-old male presents with dorsal first metatarsophalangeal (MTP) joint pain. Examination shows restricted MTP dorsiflexion with pain only at the extremes of motion. Radiographs reveal dorsal osteophytes with preserved joint space and no central cartilage loss. What is the most appropriate surgical treatment if nonoperative measures fail?

. First MTP arthrodesis
. Dorsal cheilectomy
. Metatarsal head resurfacing
. Proximal phalanx osteotomy (Moberg) alone
. Keller resection arthroplasty

Correct Answer & Explanation

. First MTP arthrodesis

Explanation

This patient has early-stage hallux rigidus (Coughlin and Shurnas Grade 1 or 2) with preserved joint space and pain primarily on terminal dorsiflexion due to impingement. Dorsal cheilectomy (excision of dorsal osteophytes and the dorsal third of the metatarsal head) is highly effective for these grades. First MTP arthrodesis is reserved for advanced disease (Grade 3 or 4) with significant cartilage loss.

Question 5898

Topic: 8. Foot and Ankle

A 40-year-old female complains of burning pain in her forefoot, specifically radiating to her third and fourth toes. She reports the pain worsens when wearing narrow-toed shoes. Excision of a suspected Morton's neuroma is planned. Between which metatarsal heads is this lesion most commonly located, and which nerve is predominantly affected?

. First web space; deep peroneal nerve
. Second web space; medial plantar nerve branch
. Third web space; common digital branch of the medial and lateral plantar nerves
. Fourth web space; lateral plantar nerve branch
. Third web space; sural nerve branch

Correct Answer & Explanation

. First web space; deep peroneal nerve

Explanation

Morton's neuroma is a perineural fibrosis most frequently found in the third web space. The nerve involved is the third common digital nerve, which is uniquely formed by communicating branches from both the medial and lateral plantar nerves, making it thicker and more prone to tethering and compression under the deep transverse metatarsal ligament.

Question 5899

Topic: 8. Foot and Ankle

A 24-year-old football lineman sustains an axial load to a plantarflexed foot. Non-weight-bearing radiographs appear normal, but a weight-bearing AP radiograph reveals a 3 mm diastasis between the medial cuneiform and the base of the second metatarsal. Which of the following is the most appropriate management?

. Short leg walking boot for 6 weeks
. Closed reduction and percutaneous pinning
. Open reduction and internal fixation or primary arthrodesis
. Non-weight bearing in a cast for 12 weeks
. Rigid orthotic insert and return to play in 2 weeks

Correct Answer & Explanation

. Short leg walking boot for 6 weeks

Explanation

This represents a subtle but unstable Lisfranc injury. Diastasis greater than 2 mm on weight-bearing views indicates frank instability. Nonoperative management leads to midfoot collapse and arthritis. The standard of care is anatomic restoration via Open Reduction Internal Fixation (ORIF) or primary arthrodesis (often preferred for purely ligamentous injuries).

Question 5900

Topic: 8. Foot and Ankle

A 15-year-old female dancer presents with pain and swelling over the dorsal aspect of her forefoot. Radiographs show flattening, sclerosis, and fragmentation of the second metatarsal head. What is the most likely diagnosis?

. Sever's disease
. Kohler's disease
. Iselin's disease
. Freiberg's infraction
. Treves' disease

Correct Answer & Explanation

. Sever's disease

Explanation

Freiberg's infraction is avascular necrosis of a metatarsal head, most commonly affecting the second metatarsal in adolescent females. Repetitive microtrauma, especially in activities like dance, disrupts the tenuous blood supply to the epiphysis, leading to collapse and fragmentation.

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