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8. Foot and Ankle MCQs

Practice Set 298 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 5941

Topic: 8. Foot and Ankle

A 22-year-old football player sustains a hyperplantarflexion injury to his midfoot. Weight-bearing radiographs show 3 mm of widening between the medial cuneiform and the base of the second metatarsal. Which ligament is primarily disrupted in this classic injury?

. Plantar calcaneonavicular (spring) ligament
. Dorsal tarsometatarsal ligament
. Interosseous ligament connecting the medial cuneiform and second metatarsal base
. Bifurcate ligament
. Plantar fascia

Correct Answer & Explanation

. Plantar calcaneonavicular (spring) ligament

Explanation

The Lisfranc ligament is an interosseous ligament that runs from the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. It is the primary stabilizer of the second tarsometatarsal joint.

Question 5942

Topic: 8. Foot and Ankle

A 55-year-old male develops a spontaneous Achilles tendon rupture two weeks after completing a course of antibiotics for a respiratory infection. Which class of antibiotics is associated with an increased risk of tendinopathy and rupture by upregulating matrix metalloproteinases (MMPs) and decreasing type I collagen synthesis?

. Macrolides
. Aminoglycosides
. Fluoroquinolones
. Tetracyclines
. Beta-lactams

Correct Answer & Explanation

. Macrolides

Explanation

Fluoroquinolones (e.g., ciprofloxacin, levofloxacin) are known to cause tendinopathy and tendon rupture. The mechanism involves toxicity to tenocytes, upregulation of MMPs, and inhibition of type I collagen synthesis.

Question 5943

Topic: 8. Foot and Ankle

The Lisfranc ligament is crucial for the stability of the midfoot and prevention of tarsometatarsal dissociation. What are the correct anatomical origin and insertion points of the Lisfranc ligament?

. Plantar-lateral aspect of the medial cuneiform to the plantar-medial base of the 2nd metatarsal
. Dorsal aspect of the medial cuneiform to the dorsal base of the 2nd metatarsal
. Plantar aspect of the intermediate cuneiform to the base of the 2nd metatarsal
. Plantar-medial aspect of the lateral cuneiform to the base of the 3rd metatarsal
. Navicular tuberosity to the base of the 1st metatarsal

Correct Answer & Explanation

. Plantar-lateral aspect of the medial cuneiform to the plantar-medial base of the 2nd metatarsal

Explanation

The Lisfranc ligament is a strong interosseous ligament that runs from the plantar-lateral aspect of the medial cuneiform to the plantar-medial aspect of the base of the second metatarsal. There is no direct ligamentous connection between the 1st and 2nd metatarsal bases.

Question 5944

Topic: 8. Foot and Ankle

Averaging 60% articular cartilage coverage, the talus has limited areas for vascular penetration, rendering it susceptible to avascular necrosis following a talar neck fracture. Which of the following arteries is the major contributor to the blood supply of the talar body?

. Artery of the sinus tarsi
. Artery of the tarsal canal
. Dorsalis pedis artery
. Deltoid branch of the posterior tibial artery
. Perforating peroneal artery

Correct Answer & Explanation

. Artery of the sinus tarsi

Explanation

The artery of the tarsal canal, a branch of the posterior tibial artery, is the most significant source of blood to the talar body. It anastomoses with the artery of the sinus tarsi, but disruption of the tarsal canal vessel during talar neck fractures critically endangers the body's perfusion.

Question 5945

Topic: 8. Foot and Ankle

During the healing process of a surgically repaired Achilles tendon, when is the repair mechanically at its weakest, making it most susceptible to re-rupture?

. Immediately post-operatively
. Days 7 to 14
. Weeks 4 to 6
. Months 3 to 4
. 1 year post-operatively

Correct Answer & Explanation

. Immediately post-operatively

Explanation

A repaired tendon is mechanically weakest between days 7 and 14. During the inflammatory and early proliferative phases, collagenase activity degrades necrotic tissue, temporarily reducing the tensile strength before new collagen significantly cross-links.

Question 5946

Topic: 8. Foot and Ankle

A 22-year-old football player sustains a syndesmotic 'high ankle' sprain. To evaluate the stability, an external rotation stress test is performed. Which ligament of the syndesmotic complex provides the greatest resistance to distal tibiofibular diastasis?

. 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

While the AITFL is the most commonly injured and the first to tear in a high ankle sprain, the posterior inferior tibiofibular ligament (PITFL) is the strongest component of the syndesmosis and provides the greatest resistance (approximately 42%) to distal tibiofibular diastasis. The AITFL provides about 35%, and the interosseous ligament provides about 22%.

Question 5947

Topic: 8. Foot and Ankle

A 30-year-old male sustains a traumatic knee dislocation during a rugby match. It is reduced in the emergency department. MRI shows complete tears of the ACL, PCL, and MCL, while the LCL remains intact. Pulses are 2+ and symmetric to the contralateral side, and the foot is well perfused. What is the most appropriate next step in acute management regarding his neurovascular status?

. Immediate operative arterial exploration
. Perform an Ankle-Brachial Index (ABI)
. Apply a spanning external fixator
. CT Angiography of the lower extremity
. Four-compartment fasciotomies

Correct Answer & Explanation

. Immediate operative arterial exploration

Explanation

Vascular injury is a devastating complication of knee dislocations, occurring in up to 18% of cases. Even in the presence of normal, symmetric palpable pulses, an intimal flap tear may be present. Current guidelines dictate that an Ankle-Brachial Index (ABI) should be measured in all dislocated knees. If the ABI is <0.9, an urgent CT angiogram is indicated. If >0.9, serial examinations are appropriate.

Question 5948

Topic: 8. Foot and Ankle

A 24-year-old professional football player suffers a 'high ankle sprain' with a syndesmotic injury after an external rotation force to a dorsiflexed foot. Which ligament of the syndesmotic complex is the primary restraint to anterior translation of the distal fibula relative to the tibia?

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

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament (AITFL)

Explanation

The syndesmotic complex stabilizes the distal tibiofibular joint. The AITFL is the first structure injured in an external rotation mechanism and is the primary restraint against anterior translation of the fibula relative to the tibia (providing approximately 35% of the total syndesmotic resistance to this specific displacement).

Question 5949

Topic: Ankle Trauma & Sports

A 21-year-old soccer player sustains a high ankle sprain. Which of the following ligaments provides the greatest percentage of biomechanical restraint against diastasis of the distal tibiofibular syndesmosis?

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

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament (AITFL)

Explanation

The posterior inferior tibiofibular ligament (PITFL) is the strongest ligament of the syndesmotic complex. Biomechanical studies have shown that the PITFL contributes approximately 42% of the resistance to syndesmotic diastasis, whereas the AITFL contributes ~35%, and the interosseous ligament provides ~22%.

Question 5950

Topic: 8. Foot and Ankle

A 35-year-old male sustains an acute, complete Achilles tendon rupture. He discusses treatment options with his orthopedic surgeon. Based on current high-level randomized controlled trials, which of the following statements most accurately compares non-operative management with an early functional rehabilitation protocol to operative repair?

. Non-operative management has a significantly higher rate of major soft-tissue complications.
. Non-operative management utilizing an early functional rehabilitation protocol has a re-rupture rate statistically similar to operative management.
. Operative management results in a significantly earlier return to heavy labor.
. Non-operative management results in profound, debilitating plantarflexion weakness compared to operative management at 2 years.
. Operative management is associated with a lower rate of sural nerve injury.

Correct Answer & Explanation

. Non-operative management has a significantly higher rate of major soft-tissue complications.

Explanation

Modern literature, notably the Willits et al. trial, demonstrates that non-operative management combined with an early dynamic functional rehabilitation protocol yields re-rupture rates that are statistically similar to those of operative repair. Operative repair carries higher risks of wound complications and iatrogenic sural nerve injury.

Question 5951

Topic: 8. Foot and Ankle
A professional American football player sustains a forced hyperextension injury to his first metatarsophalangeal (MTP) joint, resulting in a 'turf toe' injury. Which of the following clinical or radiographic findings is an absolute indication for acute surgical intervention?
. Grade I sprain with a negative Lachman test
. Proximal retraction of the sesamoids indicating complete plantar plate disruption
. An asymptomatic dorsal osteophyte of the metatarsal head
. Pre-existing hallux rigidus
. An isolated rupture of the medial collateral ligament of the MTP joint

Correct Answer & Explanation

. Proximal retraction of the sesamoids indicating complete plantar plate disruption

Explanation

Indications for surgical management of turf toe (MTP joint sprain) include a Grade III injury characterized by complete disruption of the plantar plate with gross instability, proximal retraction of the sesamoids on radiographs, intra-articular loose bodies, or an intra-articular fracture. Proximal migration of the sesamoids confirms complete disruption of the functional flexor apparatus.

Question 5952

Topic: 8. Foot and Ankle

A 35-year-old male undergoes percutaneous repair of an acute Achilles tendon rupture. Post-operatively, he complains of numbness and tingling along the lateral aspect of his foot. Which of the following best describes the anatomic course of the nerve most likely injured during the procedure, relative to the Achilles tendon?

. It crosses from medial to lateral at the level of the musculotendinous junction.
. It crosses from lateral to medial at the level of the musculotendinous junction.
. It runs parallel to the medial border of the Achilles tendon throughout its course.
. It courses strictly deep to the flexor hallucis longus muscle.
. It enters the foot through the tarsal tunnel.

Correct Answer & Explanation

. It crosses from medial to lateral at the level of the musculotendinous junction.

Explanation

The sural nerve provides sensation to the lateral aspect of the foot and is at risk during percutaneous or minimally invasive Achilles tendon repairs. The sural nerve typically crosses from medial to lateral near the level of the gastrocnemius musculotendinous junction (approximately 10 cm proximal to the calcaneal insertion) and runs intimately close to the lateral border of the Achilles tendon distally.

Question 5953

Topic: 8. Foot and Ankle

During a percutaneous repair of an acute Achilles tendon rupture, the surgeon places lateral sutures. To avoid iatrogenic injury to the sural nerve, the surgeon must be aware of its anatomic course. At approximately what distance proximal to the calcaneal insertion does the sural nerve cross the lateral border of the Achilles tendon?

. 2 cm
. 5 cm
. 10 cm
. 18 cm
. It crosses medial to the tendon at the musculotendinous junction

Correct Answer & Explanation

. 2 cm

Explanation

The sural nerve courses distally in the posterior calf and crosses from midline to the lateral border of the Achilles tendon approximately 9.8 to 10 cm proximal to the calcaneal insertion. Sutures placed blindly in this lateral region risk nerve entrapment.

Question 5954

Topic: 8. Foot and Ankle

A 40-year-old male sustains an acute, complete mid-substance Achilles tendon rupture playing basketball. He elects for functional nonoperative management with early mobilization. According to recent literature, what is the primary risk associated with this approach compared to operative repair?

. Increased rate of sural nerve injury
. Increased rate of deep vein thrombosis
. Significant decrease in final plantarflexion strength
. Slightly higher rate of tendon re-rupture
. Higher incidence of post-traumatic ankle osteoarthritis

Correct Answer & Explanation

. Increased rate of sural nerve injury

Explanation

Nonoperative management of Achilles tendon ruptures, even with modern functional rehabilitation protocols, historically and currently carries a slightly higher rate of re-rupture compared to operative repair. Conversely, operative repair is associated with higher rates of superficial and deep wound infections, as well as sural nerve injury.

Question 5955

Topic: 8. Foot and Ankle

The Lisfranc ligament is a critical stabilizing structure of the midfoot. Which two osseous structures does it directly connect?

. Medial (first) cuneiform and base of the second metatarsal
. Intermediate (second) cuneiform and base of the second metatarsal
. Medial (first) cuneiform and base of the first metatarsal
. Navicular and medial (first) cuneiform
. Cuboid and base of the fourth metatarsal

Correct Answer & Explanation

. Medial (first) cuneiform and base of the second metatarsal

Explanation

The Lisfranc ligament is an interosseous ligament that runs obliquely from the lateral aspect of the medial (first) cuneiform to the medial aspect of the base of the second metatarsal. There is no direct ligamentous connection between the first and second metatarsal bases, making the Lisfranc ligament crucial for stabilizing the tarsometatarsal joint.

Question 5956

Topic: 8. Foot and Ankle

When comparing operative versus nonoperative management of acute Achilles tendon ruptures using modern functional rehabilitation protocols, which of the following statements is most accurate?

. Operative management has a significantly higher re-rupture rate
. Nonoperative management has a significantly higher re-rupture rate
. Operative management is associated with a higher risk of wound complications and sural nerve injury
. Nonoperative management results in significantly decreased plantarflexion strength
. There is no difference in the risk of wound complications between the two groups

Correct Answer & Explanation

. Operative management has a significantly higher re-rupture rate

Explanation

Recent high-quality studies demonstrate that when functional rehabilitation (early weight-bearing and range of motion) is employed, the re-rupture rates between operative and nonoperative management of acute Achilles tendon ruptures are comparable. However, operative management carries a higher risk of complications such as infection, wound breakdown, and sural nerve injury.

Question 5957

Topic: 8. Foot and Ankle

A 24-year-old football player sustains an axial load to a plantarflexed foot. Weight-bearing radiographs demonstrate a 3 mm diastasis between the base of the first and second metatarsals. The primary stabilizing structure that is injured connects which two bones?

. First metatarsal and second metatarsal
. Medial cuneiform and second metatarsal base
. Intermediate cuneiform and second metatarsal base
. Medial cuneiform and first metatarsal base
. Navicular and medial cuneiform

Correct Answer & Explanation

. First metatarsal and second metatarsal

Explanation

The Lisfranc ligament is an intra-articular ligament that connects the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. There is no transverse intermetatarsal ligament between the bases of the first and second metatarsals, making the Lisfranc ligament the critical stabilizer of this complex.

Question 5958

Topic: 8. Foot and Ankle

A 27-year-old male sustains a foot injury while playing football. Weight-bearing radiographs reveal widening of the space between the medial cuneiform and the base of the second metatarsal, with a small avulsion fracture noted in this interval. What is the primary stabilizing structure that has been disrupted?

. Spring ligament
. Plantar fascia
. Lisfranc ligament
. Anterior talofibular ligament
. Bifurcate ligament

Correct Answer & Explanation

. Spring ligament

Explanation

The Lisfranc ligament connects the medial cuneiform to the base of the second metatarsal and is essential for midfoot stability. An avulsion fracture in this space (the "fleck sign") is pathognomonic for a Lisfranc injury.

Question 5959

Topic: 8. Foot and Ankle

An extensile lateral approach is utilized for the open reduction and internal fixation of a displaced intra-articular calcaneus fracture. In creating the full-thickness subperiosteal flap, which neurovascular structure is at highest risk of injury in the proximal vertical limb of the incision?

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

Correct Answer & Explanation

. Sural nerve

Explanation

The sural nerve and the lesser saphenous vein run posterior to the lateral malleolus and are at high risk of iatrogenic injury during the vertical portion of the extensile lateral approach to the calcaneus. The incision must be carried straight down to the bone to create a thick "no-touch" subperiosteal flap, containing the sural nerve and peroneal tendons, to minimize wound necrosis and nerve injury.

Question 5960

Topic: 8. Foot and Ankle
A 25-year-old male sustains a displaced talar neck fracture (Hawkins Type III). He is at significant risk for avascular necrosis of the talar body. Which of the following arteries provides the dominant blood supply to the talar body in a normal anatomical state?
. Artery of the tarsal canal (branch of the posterior tibial artery)
. Artery of the tarsal sinus (branch of the dorsalis pedis/perforating peroneal)
. Deltoid branch (branch of the posterior tibial artery)
. Dorsalis pedis artery (direct branches to the dorsal neck)
. Medial plantar artery

Correct Answer & Explanation

. Artery of the tarsal canal (branch of the posterior tibial artery)

Explanation

The artery of the tarsal canal, which typically arises from the posterior tibial artery about 1-2 cm proximal to its bifurcation, is the dominant blood supply to the body of the talus. It forms an anastomotic sling with the artery of the tarsal sinus beneath the talar neck. While the deltoid branch supplies the medial third of the body, the artery of the tarsal canal supplies the majority (middle and lateral thirds).

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