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8. Foot and Ankle MCQs

Practice Set 296 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 5901

Topic: 8. Foot and Ankle

A 42-year-old woman presents with lateral foot pain after an inversion injury. Radiographs show an extra-articular fracture through the tuberosity of the fifth metatarsal. Which structures are primarily responsible for the deforming force associated with this specific avulsion fracture?

. Peroneus longus tendon only
. Peroneus brevis tendon and the lateral band of the plantar fascia
. Extensor digitorum longus tendon and peroneus tertius
. Abductor digiti minimi muscle
. Plantar calcaneocuboid ligament

Correct Answer & Explanation

. Peroneus longus tendon only

Explanation

Zone 1 fractures of the fifth metatarsal are avulsion fractures of the tuberosity. The mechanism involves an inversion injury where the peroneus brevis tendon and the lateral cord of the plantar fascia exert a strong pulling force, avulsing the proximal tip of the bone. The peroneus longus passes under the cuboid to insert on the first metatarsal and medial cuneiform.

Question 5902

Topic: 8. Foot and Ankle

A 62-year-old male with symptomatic end-stage osteoarthritis of the right ankle is being evaluated for surgical intervention. Which of the following is considered an absolute contraindication to Total Ankle Arthroplasty (TAA) in this patient?

. Obesity with a BMI of 32
. Severe peripheral neuropathy and lack of protective sensation
. Mild hindfoot varus deformity of 5 degrees
. Concomitant ipsilateral subtalar arthritis
. Age over 60 years

Correct Answer & Explanation

. Obesity with a BMI of 32

Explanation

Severe peripheral neuropathy, lack of protective sensation, and Charcot arthropathy are absolute contraindications to Total Ankle Arthroplasty due to the extremely high risk of implant loosening, progressive deformity, and failure. Concomitant subtalar arthritis is actually an indication for TAA over arthrodesis to preserve remaining hindfoot motion. Mild varus can be corrected concurrently.

Question 5903

Topic: 8. Foot and Ankle

A 28-year-old female presents with a progressive cavovarus foot deformity. A Coleman block test is performed by placing a block under the lateral aspect of her foot, allowing the first metatarsal to drop off. Upon doing so, her hindfoot varus corrects to a neutral alignment. This finding indicates:

. A rigid, structural hindfoot varus deformity requiring a calcaneal osteotomy.
. A forefoot-driven hindfoot varus primarily caused by a plantarflexed first ray.
. Paresis of the peroneus longus muscle.
. Spasticity of the tibialis anterior muscle.
. The absolute need for a triple arthrodesis.

Correct Answer & Explanation

. A rigid, structural hindfoot varus deformity requiring a calcaneal osteotomy.

Explanation

The Coleman block test differentiates between a flexible (forefoot-driven) and a fixed hindfoot varus. When the hindfoot corrects to neutral after allowing the plantarflexed first ray to drop off the block, it confirms that the hindfoot varus is flexible and driven by the forefoot pathology (typically a plantarflexed first ray driven by an overpowering peroneus longus relative to a weak tibialis anterior).

Question 5904

Topic: 8. Foot and Ankle
A 55-year-old male with poorly controlled diabetes mellitus presents with a swollen, erythematous, and warm right foot. He denies trauma. Pulses are palpable. Radiographs reveal prominent periarticular debris, fragmentation of the tarsal bones, and joint subluxation without consolidation. According to the Eichenholtz classification, what stage of Charcot arthropathy is this, and what is the optimal initial management?
. Stage 0; open reduction internal fixation
. Stage I; total contact casting and non-weight bearing
. Stage II; custom accommodative shoe wear
. Stage III; midfoot arthrodesis
. Stage I; immediate primary amputation

Correct Answer & Explanation

. Stage I; total contact casting and non-weight bearing

Explanation

The patient is in Eichenholtz Stage I (Developmental/Fragmentation), characterized clinically by a red, hot, swollen foot and radiographically by osteopenia, fragmentation, joint subluxation, and debris. The cornerstone of treatment in Stage I is offloading and immobilization, most effectively achieved with a total contact cast (TCC) to prevent further deformity while the acute inflammatory process resolves.

Question 5905

Topic: 8. Foot and Ankle

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

. End-stage post-traumatic ankle osteoarthritis
. Concomitant subtalar joint arthritis
. Severe sensory neuropathy and history of Charcot arthropathy
. Age greater than 70 years
. Bilateral ankle osteoarthritis

Correct Answer & Explanation

. End-stage post-traumatic ankle osteoarthritis

Explanation

Absolute contraindications for Total Ankle Arthroplasty (TAA) include active infection, severe neuroarthropathy (Charcot disease), absent plantar sensation, avascular necrosis involving >50% of the talar body, and severe uncorrectable malalignment. Concomitant subtalar arthritis is actually often an indication for TAA rather than arthrodesis to preserve remaining hindfoot motion.

Question 5906

Topic: 8. Foot and Ankle

A 42-year-old weekend warrior sustains an acute Achilles tendon rupture during a tennis match. Non-operative management is chosen utilizing functional rehabilitation. Compared to traditional open surgical repair, which of the following outcomes is most closely associated with non-operative management utilizing an accelerated functional rehabilitation protocol?

. Significantly higher rates of sural nerve injury
. Comparable rerupture rates but fewer wound complications
. Significantly lower rates of deep vein thrombosis
. A three-fold increase in the overall rerupture rate
. Delayed return to work by an average of 4 weeks

Correct Answer & Explanation

. Significantly higher rates of sural nerve injury

Explanation

Modern high-quality randomized controlled trials (e.g., Willits et al.) have consistently demonstrated that non-operative management using an accelerated, functional rehabilitation protocol with early weight-bearing and motion yields rerupture rates comparable to surgical repair, while effectively avoiding the surgical risks of wound complications, infection, and iatrogenic nerve injury.

Question 5907

Topic: 8. Foot and Ankle
A 25-year-old skier presents with posterolateral ankle pain after catching an edge. Examination reveals snapping of the peroneal tendons over the lateral malleolus with resisted dorsiflexion and eversion. Surgical exploration demonstrates that the superior peroneal retinaculum is avulsed along with a small fleck of bone from the lateral malleolus. According to the Eckert and Davis classification, what grade is this injury?
. Grade I
. Grade II
. Grade III
. Grade IV
. Grade V

Correct Answer & Explanation

. Grade III

Explanation

The Eckert and Davis classification describes superior peroneal retinaculum (SPR) injuries: Grade I is elevation of the SPR with the periosteum; Grade II is a tear of the fibrocartilaginous ridge; Grade III is an avulsion of the SPR with a bony fragment from the lateral malleolus. Grade IV (added by Oden) is a complete tear of the SPR from its posterior attachment.

Question 5908

Topic: 8. Foot and Ankle

A 16-year-old female gymnast complains of insidious onset pain in her forefoot. Examination reveals tenderness over the dorsal aspect of the second metatarsophalangeal joint. Radiographs display sclerosis, flattening, and early fragmentation of the second metatarsal head. What is the most likely underlying pathophysiology of her condition?

. Repetitive microtrauma leading to avascular necrosis
. Entrapment of the common plantar digital nerve
. Autoimmune destruction of the articular cartilage
. Congenital tarsal coalition altering forefoot mechanics
. Chronic attenuation and eventual rupture of the plantar plate

Correct Answer & Explanation

. Repetitive microtrauma leading to avascular necrosis

Explanation

Freiberg's infraction is an avascular necrosis of a metatarsal head, most commonly the second metatarsal. It is generally thought to be caused by repetitive microtrauma and subsequent vascular compromise. It frequently affects adolescent females, especially those involved in high-stress forefoot activities like gymnastics or dance.

Question 5909

Topic: Midfoot & Hindfoot

A 22-year-old collegiate athlete sustains a purely ligamentous Lisfranc injury with 3 mm of diastasis between the medial and middle cuneiforms. Based on comparative literature regarding purely ligamentous Lisfranc injuries in adults, which procedure provides the most predictable long-term functional outcome and lowest rate of revision surgery?

. Closed reduction and percutaneous pinning
. Open reduction and internal fixation (ORIF) with rigid transarticular screws
. Primary arthrodesis of the first, second, and third tarsometatarsal joints
. Non-weight bearing cast immobilization for 8 weeks
. Excision of the Lisfranc ligament and extensor digitorum brevis transfer

Correct Answer & Explanation

. Closed reduction and percutaneous pinning

Explanation

Several pivotal studies, notably by Coetzee and Ly, have demonstrated that for purely ligamentous Lisfranc injuries, primary arthrodesis of the medial columns (1st, 2nd, and 3rd TMT joints) yields significantly better functional outcomes and lower revision rates compared to ORIF, which often leads to hardware failure, loss of reduction, or progressive post-traumatic arthritis requiring salvage arthrodesis.

Question 5910

Topic: 8. Foot and Ankle

An extensile lateral approach is utilized for the open reduction and internal fixation of a highly comminuted, displaced intra-articular calcaneus fracture. During the surgical exposure, a full-thickness subperiosteal flap is created. Which nerve is most at risk of iatrogenic injury if the vertical or horizontal limbs of the incision are improperly placed too anteriorly or dorsally over the lateral hindfoot?

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

Correct Answer & Explanation

. Sural nerve

Explanation

The sural nerve courses posterior to the lateral malleolus and travels along the lateral aspect of the foot. It is highly vulnerable to transection or traction injury during the extensile lateral approach for calcaneus fractures, particularly when creating the vertical and horizontal limbs of the L-shaped incision. The horizontal limb must be carefully placed in line with the glabrous junction to minimize this specific risk.

Question 5911

Topic: Forefoot

A 58-year-old male presents with severe pain and stiffness in his right great toe, notably worsening at both extremes of dorsiflexion and plantarflexion. Radiographs reveal advanced dorsal osteophyte formation, near complete obliteration of the MTP joint space, and multiple subchondral cysts (Coughlin and Shurnas Grade 3). He has failed extensive conservative management. What is the gold standard surgical treatment?

. Extensive dorsal cheilectomy
. First MTP joint arthrodesis
. First MTP joint hemiarthroplasty
. Keller resection arthroplasty
. Proximal phalanx closing wedge osteotomy (Moberg)

Correct Answer & Explanation

. Extensive dorsal cheilectomy

Explanation

For advanced hallux rigidus (Coughlin and Shurnas Grade 3 or 4), where the joint space is obliterated and pain occurs throughout the entire range of motion, the gold standard surgical treatment providing the most reliable pain relief and predictable functional improvement is first MTP joint arthrodesis. Cheilectomy is indicated for early-stage disease (Grades 1 and 2) with preserved joint space and pain primarily at terminal dorsiflexion.

Question 5912

Topic: Midfoot & Hindfoot

A 52-year-old obese female presents with a progressive, painful flatfoot. She is unable to perform a single-leg heel raise. Upon examination, her hindfoot valgus deformity is fully flexible. Weight-bearing radiographs demonstrate an AP talonavicular coverage angle of 45 degrees, consistent with greater than 30% uncovering of the talar head. Which of the following surgical interventions is most appropriate for this specific stage of Posterior Tibial Tendon Dysfunction (PTTD)?

. Isolated primary end-to-end repair of the posterior tibial tendon
. Flexor digitorum longus (FDL) transfer to the navicular and medial displacement calcaneal osteotomy alone
. FDL transfer, medial displacement calcaneal osteotomy, and a lateral column lengthening
. Triple arthrodesis
. Isolated talonavicular arthrodesis

Correct Answer & Explanation

. Isolated primary end-to-end repair of the posterior tibial tendon

Explanation

This is a Stage IIb PTTD (Johnson and Strom/Myerson classification), characterized by a flexible deformity with severe forefoot abduction (>30% talonavicular uncovering). Management requires FDL transfer and a medial displacement calcaneal osteotomy (MDCO) to address the tendon insufficiency and hindfoot valgus, PLUS a lateral column lengthening (e.g., Evans osteotomy) to adequately correct the severe forefoot abduction component.

Question 5913

Topic: Midfoot & Hindfoot

A 40-year-old long-distance runner experiences refractory heel pain despite 6 months of conservative treatment, including stretching, custom orthotics, and night splints. He describes a radiating, burning pain over the medial heel that worsens considerably following a long run. Examination reveals maximal tenderness at the medial aspect of the heel, just distal to the medial malleolus, without pinpoint tenderness at the medial calcaneal tubercle. Entrapment of which specific nerve is the most likely cause?

. Medial calcaneal nerve
. First branch of the lateral plantar nerve
. Superficial peroneal nerve
. Sural nerve
. Deep peroneal nerve

Correct Answer & Explanation

. Medial calcaneal nerve

Explanation

The first branch of the lateral plantar nerve (Baxter's nerve) can become entrapped between the deep fascia of the abductor hallucis and the medial margin of the quadratus plantae. It often mimics severe plantar fasciitis but typically presents with radiating, burning neurological pain. Tenderness is slightly more proximal and medial along the nerve's course, rather than directly at the plantar medial calcaneal tubercle.

Question 5914

Topic: 8. Foot and Ankle

During the operative fixation of a Weber C ankle fracture, an intraoperative 'Cotton test' is performed to critically assess the stability of the syndesmosis. Which of the following describes the correct maneuver for executing this test?

. Applying external rotation stress to the foot while viewing the mortise radiographically
. Applying direct downward axial traction on the talus to assess lateral tilting
. Placing a bone hook or clamp around the distal fibula and applying a lateral and posterior pull
. Palpating the distal tibiofibular joint manually during forced dorsiflexion
. Squeezing the proximal calf aggressively to elicit widening at the ankle mortise

Correct Answer & Explanation

. Applying external rotation stress to the foot while viewing the mortise radiographically

Explanation

The intraoperative Cotton test involves securely placing a bone hook or clamp around the distal fibula and applying a direct lateral and posterior pull (away from the tibia) while visualizing the syndesmosis dynamically under fluoroscopy. Asymmetric widening of the syndesmotic space (tibiofibular clear space) during this maneuver strongly indicates syndesmotic instability requiring operative fixation.

Question 5915

Topic: 8. Foot and Ankle

A 24-year-old professional ballerina complains of chronic posterior ankle pain selectively triggered by rising onto her toes (en pointe). MRI reveals a prominent os trigonum with intense surrounding marrow edema and fluid within the flexor hallucis longus (FHL) tendon sheath. She opts for open surgical excision via a posteromedial approach. Which critical neurovascular structure is at highest risk during this specific surgical approach?

. Anterior tibial artery and deep peroneal nerve
. Posterior tibial artery and tibial nerve
. Peroneal artery and sural nerve
. Dorsalis pedis artery and superficial peroneal nerve
. Medial plantar artery and saphenous nerve

Correct Answer & Explanation

. Anterior tibial artery and deep peroneal nerve

Explanation

The posteromedial surgical approach to the posterior ankle and os trigonum carries a significantly high risk to the structures contained within the tarsal tunnel, specifically the posterior tibial artery and the tibial nerve (along with its calcaneal branches). Because of this risk, an os trigonum excision is most often performed via a posterolateral open approach or via posterior endoscopy to safely avoid these critical medial neurovascular structures.

Question 5916

Topic: Forefoot

A 50-year-old female presents with symptomatic hallux valgus. Radiographs show a hallux valgus angle (HVA) of 35 degrees, an intermetatarsal angle (IMA) of 16 degrees, and clinical examination reveals a hypermobile first tarsometatarsal joint. Which surgical procedure is most appropriate?

. Distal chevron osteotomy
. Proximal crescentic osteotomy
. Lapidus procedure
. Akin osteotomy
. Keller resection arthroplasty

Correct Answer & Explanation

. Distal chevron osteotomy

Explanation

The Lapidus procedure (first tarsometatarsal arthrodesis) is indicated for moderate to severe hallux valgus associated with first ray hypermobility. Distal osteotomies are insufficient for an IMA greater than 13 degrees combined with significant instability.

Question 5917

Topic: Midfoot & Hindfoot

A 45-year-old woman presents with a painful, flexible flatfoot. Clinical exam reveals weakness in single-leg heel rise but a passively correctable hindfoot valgus deformity. Which of the following is the most appropriate surgical intervention if conservative measures fail?

. Triple arthrodesis
. Isolated subtalar arthrodesis
. Flexor digitorum longus (FDL) transfer to the navicular and medial displacement calcaneal osteotomy
. Spring ligament repair alone
. Gastrocnemius recession alone

Correct Answer & Explanation

. Triple arthrodesis

Explanation

Stage II adult-acquired flatfoot deformity involves a flexible deformity with posterior tibial tendon insufficiency. Joint-sparing procedures like an FDL transfer combined with a medializing calcaneal osteotomy are the standard surgical treatment.

Question 5918

Topic: 8. Foot and Ankle

A 22-year-old male with Charcot-Marie-Tooth disease presents with bilateral cavovarus foot deformities. A Coleman block test demonstrates that the hindfoot varus corrects to neutral when the first ray is allowed to drop off the block. What does this indicate?

. The hindfoot deformity is rigid and requires a triple arthrodesis
. The deformity is driven by a plantarflexed first ray, and hindfoot joints are flexible
. There is a primary contracture of the Achilles tendon
. The anterior tibial tendon is overactive
. The subtalar joint requires an isolated fusion

Correct Answer & Explanation

. The hindfoot deformity is rigid and requires a triple arthrodesis

Explanation

The Coleman block test evaluates hindfoot flexibility in cavovarus feet. If the hindfoot corrects when the plantarflexed first ray is accommodated, the hindfoot is flexible, meaning treatment should focus on restoring forefoot alignment (e.g., dorsiflexing first metatarsal osteotomy).

Question 5919

Topic: 8. Foot and Ankle

Three years following nonoperative treatment of a displaced intra-articular calcaneus fracture, a patient complains of severe lateral heel pain and difficulty walking on uneven ground. Radiographs show loss of Bohler's angle and subtalar arthritis. What is the most likely cause of the lateral heel pain?

. Sural nerve neuroma
. Subfibular impingement and peroneal tendon pathology
. Medial calcaneal nerve entrapment
. Plantar fasciitis
. Tarsal tunnel syndrome

Correct Answer & Explanation

. Sural nerve neuroma

Explanation

Lateral wall blow-out in calcaneus fractures often leads to subfibular impingement and secondary peroneal tendon irritation. In the setting of subtalar arthritis, this late complication typically requires subtalar fusion and lateral wall exostectomy.

Question 5920

Topic: Midfoot & Hindfoot

A 55-year-old diabetic male presents with an acutely swollen, erythematous, and warm foot with a bounding dorsalis pedis pulse. Radiographs show fragmentation and periarticular debris around the midfoot. What is the most appropriate initial management?

. Urgent irrigation and debridement
. Intravenous antibiotics for 6 weeks
. Total contact casting and non-weight-bearing
. Midfoot arthrodesis with rigid fixation
. Amputation at the Chopart level

Correct Answer & Explanation

. Urgent irrigation and debridement

Explanation

The patient is presenting in the acute, fragmentation phase (Eichenholtz stage I) of Charcot arthropathy. The gold standard of initial treatment is offloading with a total contact cast to prevent further deformity until the active phase resolves.

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