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8. Foot and Ankle MCQs

Practice Set 300 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 5981

Topic: 8. Foot and Ankle
A 2.5-year-old girl is diagnosed with infantile Blount disease (tibia vara) with bilateral Langenskiöld stage II changes. What is the most appropriate initial management?
. Reassurance and observation
. High-dose Vitamin D supplementation
. Knee-ankle-foot orthoses (KAFOs) during weight-bearing
. Proximal tibial valgus osteotomy
. Lateral hemiepiphysiodesis

Correct Answer & Explanation

. Knee-ankle-foot orthoses (KAFOs) during weight-bearing

Explanation

For children under age 3 with infantile Blount disease exhibiting Langenskiöld stages I or II, bracing with KAFOs worn during weight-bearing is the standard initial treatment to correct the varus deformity. Surgery is indicated for children over 3-4 years old with progressive deformity or those with Langenskiöld stage III or higher.

Question 5982

Topic: 8. Foot and Ankle

In a patient with spastic diplegic cerebral palsy, a 'crouch gait' can be severely exacerbated by isolated, iatrogenic surgical lengthening of which of the following structures?

. Hamstrings
. Achilles tendon
. Iliopsoas
. Rectus femoris
. Adductor longus

Correct Answer & Explanation

. Hamstrings

Explanation

Crouch gait is characterized by excessive hip and knee flexion with increased ankle dorsiflexion during the stance phase. Isolated lengthening of the Achilles tendon (heel cords) in a child with spastic diplegia severely weakens the plantarflexion-knee extension couple, causing the tibia to advance too rapidly over the foot and forcing the knee into iatrogenic crouch.

Question 5983

Topic: 8. Foot and Ankle

A 12-year-old boy presents with a rigid, painful flatfoot and peroneal muscle spasm. A lateral radiograph of the foot demonstrates the 'C-sign'. Which of the following is the most likely anatomical location of his pathology?

. Calcaneonavicular joint
. Talocalcaneal middle facet
. Talocalcaneal posterior facet
. Talonavicular joint
. Naviculocuneiform joint

Correct Answer & Explanation

. Calcaneonavicular joint

Explanation

The 'C-sign' on a lateral radiograph is indicative of a talocalcaneal coalition, which most commonly occurs at the middle facet. A calcaneonavicular coalition would instead show the 'anteater nose' sign on a 45-degree oblique view.

Question 5984

Topic: 8. Foot and Ankle

A 13-year-old girl sustains an isolated fracture of the anterolateral distal tibial epiphysis. What is the pathomechanics of this specific injury pattern?

. Avulsion by the anterior inferior tibiofibular ligament (AITFL) due to external rotation
. Axial loading with forced dorsiflexion
. Avulsion by the calcaneofibular ligament
. Impaction from the talus during extreme plantar flexion
. Avulsion by the posterior inferior tibiofibular ligament (PITFL)

Correct Answer & Explanation

. Avulsion by the anterior inferior tibiofibular ligament (AITFL) due to external rotation

Explanation

A juvenile Tillaux fracture occurs due to external rotation forces avulsing the anterolateral distal tibial epiphysis via the AITFL. This happens because the distal tibial physis closes asymmetrically from central to anteromedial, leaving the anterolateral portion open and vulnerable.

Question 5985

Topic: 8. Foot and Ankle

A 14-year-old boy presents with rigid, painful flatfeet and a history of recurrent ankle sprains. Radiographs reveal an "anteater nose" sign on the lateral view. Which of the following is the most appropriate initial management for this condition?

. Subtalar arthrodesis
. Calcaneonavicular coalition resection with fat graft
. Short leg cast immobilization or orthotics
. Triple arthrodesis
. Talocalcaneal coalition resection

Correct Answer & Explanation

. Subtalar arthrodesis

Explanation

The "anteater nose" sign is pathognomonic for a calcaneonavicular tarsal coalition. Initial management of symptomatic tarsal coalition is conservative, typically involving cast immobilization or orthotics before considering surgical resection.

Question 5986

Topic: 8. Foot and Ankle

The majority of the blood supply to the body of the talus is provided by the artery of the tarsal canal. This vessel is a direct branch of which artery?

. Anterior tibial artery
. Posterior tibial artery
. Peroneal artery
. Dorsalis pedis artery
. Medial plantar artery

Correct Answer & Explanation

. Posterior tibial artery

Explanation

The artery of the tarsal canal provides the dominant blood supply to the talar body. It typically arises from the posterior tibial artery, about 1-2 cm proximal to its bifurcation. The artery of the tarsal sinus arises from the anterior tibial/dorsalis pedis and peroneal arteries.

Question 5987

Topic: 8. Foot and Ankle

A 25-year-old football player undergoes evaluation for midfoot pain after an axial load injury to a plantarflexed foot. Weight-bearing radiographs demonstrate widening of the space between the first and second metatarsals. The Lisfranc ligament, which is presumed disrupted in this patient, anatomically connects which two osseous structures?

. Medial cuneiform and first metatarsal base
. Intermediate cuneiform and second metatarsal base
. Medial cuneiform and second metatarsal base
. Lateral cuneiform and cuboid
. Navicular and medial cuneiform

Correct Answer & Explanation

. Medial cuneiform and second metatarsal base

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. It is critical for the stability of the midfoot. Disruption leads to diastasis between the first and second metatarsal bases.

Question 5988

Topic: Midfoot & Hindfoot

A 55-year-old male with long-standing, poorly controlled type 2 diabetes presents with a unilaterally swollen, red, warm, and painless foot. Radiographs demonstrate periarticular debris, fragmentation of the tarsometatarsal joints, and subluxation, without evidence of osteomyelitis. According to the Eichenholtz classification of Charcot arthropathy, what stage does this represent?

. Stage 0 (Prodromal/Inflammatory)
. Stage 1 (Developmental/Fragmentation)
. Stage 2 (Coalescence)
. Stage 3 (Consolidation/Reconstruction)
. Stage 4 (Ulceration)

Correct Answer & Explanation

. Stage 1 (Developmental/Fragmentation)

Explanation

The Eichenholtz classification stages Charcot neuroarthropathy. Stage 0 features erythema, edema, and heat with normal radiographs. Stage 1 (Fragmentation) is characterized clinically by a hot, swollen foot and radiographically by periarticular debris, bone fragmentation, and subluxation/dislocation. Stage 2 (Coalescence) shows absorption of fine debris and early fusion. Stage 3 (Consolidation) shows remodeling and stable ankylosis.

Question 5989

Topic: 8. Foot and Ankle
A 30-year-old male falls from a height and sustains a Hawkins Type III talar neck fracture. This fracture pattern involves dislocation of the talar body from both the subtalar and tibiotalar joints. Which of the following blood supplies to the talar body is consistently disrupted in this specific injury?
. Artery of the tarsal canal, artery of the tarsal sinus, and deltoid branches
. Artery of the tarsal canal only
. Deltoid branches only
. Dorsalis pedis branches only
. Peroneal artery branches only

Correct Answer & Explanation

. Artery of the tarsal canal, artery of the tarsal sinus, and deltoid branches

Explanation

A Hawkins Type III talar neck fracture is characterized by a fracture of the talar neck with posterior dislocation of the talar body, disrupting the subtalar and tibiotalar joints. This extreme displacement disrupts all three major sources of blood supply to the talar body: the artery of the tarsal canal, the artery of the tarsal sinus, and the deltoid branches. The rate of avascular necrosis (AVN) in Type III fractures approaches 100%.

Question 5990

Topic: 8. Foot and Ankle

A 50-year-old female presents with a progressively painful flatfoot deformity. Examination reveals a positive 'too many toes' sign and an inability to perform a single-leg heel rise. The hindfoot remains flexible and passively corrects to neutral. Which of the following is the most standard surgical intervention if conservative measures fail?

. Subtalar arthrodesis
. Triple arthrodesis
. Flexor digitorum longus (FDL) transfer, medial displacement calcaneal osteotomy (MDCO), and Achilles lengthening
. Anterior tibial tendon transfer to the navicular
. Pantalar arthrodesis

Correct Answer & Explanation

. Flexor digitorum longus (FDL) transfer, medial displacement calcaneal osteotomy (MDCO), and Achilles lengthening

Explanation

The patient has Stage II posterior tibial tendon dysfunction (PTTD), characterized by an acquired flatfoot deformity with a flexible hindfoot. The standard joint-sparing surgical treatment involves an FDL transfer (to substitute for the diseased posterior tibial tendon), a Medial Displacement Calcaneal Osteotomy (MDCO) to correct the mechanical axis and hindfoot valgus, and gastrocnemius or Achilles lengthening for any equinus contracture.

Question 5991

Topic: 8. Foot and Ankle

A 28-year-old male sustains a traumatic dislocation of the knee. After reduction, his ankle-brachial index (ABI) is measured at 0.8. What is the most appropriate next step in management?

. Routine neurovascular checks every 4 hours
. Immediate surgical exploration of the popliteal artery
. CT angiography of the lower extremity
. Application of a hinged knee brace and discharge
. Intra-articular injection of a local anesthetic

Correct Answer & Explanation

. CT angiography of the lower extremity

Explanation

In the setting of a knee dislocation, an ABI less than 0.9 is highly suspicious for a popliteal artery injury. It warrants advanced imaging, such as a CT angiogram, to definitively map the vascular injury before surgical intervention.

Question 5992

Topic: 8. Foot and Ankle
A 35-year-old construction worker falls from a height and sustains a calcaneus fracture. Computed tomography (CT) reveals a joint-depressed Sanders Type III fracture. The primary objective of open reduction and internal fixation (ORIF) for this fracture is the restoration of which of the following?
. The calcaneocuboid joint articulation
. The Bohler angle and posterior facet of the subtalar joint
. The anterior process of the calcaneus
. The medial longitudinal arch of the foot
. The sustentaculum tali

Correct Answer & Explanation

. The Bohler angle and posterior facet of the subtalar joint

Explanation

The main goal of operative treatment for intra-articular calcaneus fractures is to anatomically reduce the posterior facet of the subtalar joint and restore overall calcaneal morphology, height, and width to minimize post-traumatic arthritis.

Question 5993

Topic: 8. Foot and Ankle

A 55-year-old poorly controlled diabetic patient presents with a unilaterally swollen, erythematous, and warm left foot. Dorsalis pedis and posterior tibial pulses are bounding. Radiographs demonstrate periarticular debris, fragmentation, and joint subluxation at the tarsometatarsal joints.

According to the Eichenholtz classification, which stage does this clinical and radiographic picture represent, and what is the primary pathophysiological driver?

. Stage 0; microtrauma leading to acute inflammation without radiographic changes
. Stage 1; autonomic neuropathy causing hyperemia and active bone resorption
. Stage 2; peripheral neuropathy causing osteosclerosis and fusion
. Stage 3; somatosensory neuropathy leading to joint remodeling and rounding of bone ends
. Stage 4; motor neuropathy leading to intrinsic minus foot and ulceration

Correct Answer & Explanation

. Stage 1; autonomic neuropathy causing hyperemia and active bone resorption

Explanation

This patient presents with Stage 1 (Developmental/Fragmentation) Charcot arthropathy, characterized clinically by a red, hot, swollen foot and radiographically by periarticular debris, fragmentation of bone, and subluxation/dislocation. The bounding pulses indicate autonomic neuropathy leading to a loss of sympathetic tone, causing arteriovenous shunting, hyperemia, and active bone resorption (neurovascular theory).

Question 5994

Topic: Forefoot

A 42-year-old female presents with severe bunion pain. Weight-bearing radiographs reveal a Hallux Valgus Angle (HVA) of 48 degrees and an Intermetatarsal Angle (IMA) of 22 degrees. On physical exam, there is demonstrable hypermobility at the first tarsometatarsal (TMT) joint. Which of the following surgical procedures is most appropriate to correct this deformity?

. Distal chevron osteotomy
. Proximal crescentic osteotomy with distal soft tissue release
. First tarsometatarsal arthrodesis (Lapidus procedure)
. First metatarsophalangeal arthrodesis
. Akin osteotomy

Correct Answer & Explanation

. First tarsometatarsal arthrodesis (Lapidus procedure)

Explanation

A first TMT arthrodesis (Lapidus procedure) is indicated for severe hallux valgus (IMA > 20 degrees, HVA > 40 degrees), particularly in the presence of first TMT hypermobility or arthritis. A distal chevron osteotomy is for mild deformity. A proximal osteotomy could address a high IMA but does not address TMT hypermobility, leading to a high recurrence rate.

Question 5995

Topic: 8. Foot and Ankle

In patients with Charcot-Marie-Tooth (CMT) disease, a cavovarus foot deformity progressively develops. The initial driver of this deformity is a specific muscle imbalance. Which of the following correctly describes the predominant muscle imbalances in the classic CMT foot?

. Weak peroneus longus overpowered by a strong tibialis anterior
. Weak tibialis anterior overpowered by a strong peroneus longus, and weak peroneus brevis overpowered by a strong tibialis posterior
. Weak tibialis posterior overpowered by a strong peroneus brevis
. Weak flexor hallucis longus overpowered by a strong extensor hallucis longus
. Global weakness of all extrinsic leg musculature with intrinsic contracture

Correct Answer & Explanation

. Weak tibialis anterior overpowered by a strong peroneus longus, and weak peroneus brevis overpowered by a strong tibialis posterior

Explanation

In CMT, the cavovarus deformity is classically driven by the peroneus longus (which remains strong) overpowering the weak tibialis anterior, leading to plantarflexion of the 1st ray (forefoot valgus). Additionally, the tibialis posterior (strong) overpowers the weak peroneus brevis, driving the hindfoot into varus.

Question 5996

Topic: Midfoot & Hindfoot
A 28-year-old male sustains a high-energy motor vehicle collision resulting in a Hawkins Type III talar neck fracture. What is the defining anatomical feature of a Hawkins Type III fracture, and what is the approximate risk of avascular necrosis (AVN)?
. Talar neck fracture with subtalar dislocation; 20-50% risk of AVN
. Talar neck fracture with subtalar and tibiotalar dislocation; nearly 100% risk of AVN
. Talar neck fracture with subtalar, tibiotalar, and talonavicular dislocation; 100% risk of AVN
. Non-displaced talar neck fracture; <10% risk of AVN
. Talar body fracture with extrusion; 50% risk of AVN

Correct Answer & Explanation

. Talar neck fracture with subtalar and tibiotalar dislocation; nearly 100% risk of AVN

Explanation

A Hawkins Type III fracture is a displaced talar neck fracture with dislocation of both the subtalar and tibiotalar joints. The risk of AVN is historically reported as nearly 100% due to the disruption of all three major blood supplies to the talar body (artery of the tarsal canal, deltoid branches, and anterior tibial/dorsalis pedis branches). Type IV involves the talonavicular joint as well.

Question 5997

Topic: 8. Foot and Ankle

A 35-year-old recreational basketball player felt a 'pop' in his heel and presents with a positive Thompson test. He elects for non-operative management of his acute Achilles tendon rupture. Based on recent high-quality randomized controlled trials comparing operative to non-operative treatment with functional rehabilitation, which of the following statements is true?

. Operative treatment has a significantly lower re-rupture rate when functional rehabilitation protocols are used for both groups
. Non-operative treatment with functional rehabilitation results in equivalent re-rupture rates but higher rates of sural nerve injury
. Non-operative treatment with functional rehabilitation yields similar functional outcomes and re-rupture rates compared to operative management
. Operative treatment results in superior plantarflexion strength and is universally recommended for all non-elite athletes
. Non-operative treatment requires a minimum of 12 weeks of strict non-weight-bearing cast immobilization

Correct Answer & Explanation

. Non-operative treatment with functional rehabilitation yields similar functional outcomes and re-rupture rates compared to operative management

Explanation

Recent high-level evidence (such as the Willits trial) demonstrates that when dynamic functional rehabilitation protocols are employed, non-operative management of acute Achilles tendon ruptures yields similar functional outcomes and similar re-rupture rates compared to operative management, while entirely avoiding surgical complications such as infection and wound breakdown.

Question 5998

Topic: 8. Foot and Ankle

Which of the following structures constitutes the primary attachment points for the Lisfranc ligament?

. Plantar aspect of the medial cuneiform to the plantar base of the second metatarsal
. Dorsal aspect of the middle cuneiform to the dorsal base of the second metatarsal
. Plantar aspect of the medial cuneiform to the plantar base of the first metatarsal
. Plantar aspect of the lateral cuneiform to the plantar base of the third metatarsal
. Navicular to the medial aspect of the medial cuneiform

Correct Answer & Explanation

. Plantar aspect of the medial cuneiform to the plantar base of the second 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 strongest on the plantar surface. There is no direct ligamentous connection between the bases of the first and second metatarsals.

Question 5999

Topic: Midfoot & Hindfoot
A 50-year-old female presents with progressive medial ankle pain, swelling, and a 'flattening' of her arch. On examination, she is unable to perform a single-leg heel raise on the affected side. Weight-bearing radiographs reveal >40% uncovering of the talar head on the AP view (forefoot abduction). What is the appropriate classification and most comprehensive surgical reconstruction for this patient?
. Stage IIa Posterior Tibial Tendon Dysfunction; FDL transfer and Medial Displacement Calcaneal Osteotomy (MDCO)
. Stage IIb Posterior Tibial Tendon Dysfunction; FDL transfer, MDCO, and Lateral Column Lengthening (Evans osteotomy)
. Stage III Posterior Tibial Tendon Dysfunction; Triple arthrodesis
. Stage IV Posterior Tibial Tendon Dysfunction; Tibiotalocalcaneal (TTC) arthrodesis
. Stage I Posterior Tibial Tendon Dysfunction; Tenosynovectomy and orthotics

Correct Answer & Explanation

. Stage IIb Posterior Tibial Tendon Dysfunction; FDL transfer, MDCO, and Lateral Column Lengthening (Evans osteotomy)

Explanation

This patient has a flexible flatfoot deformity with significant forefoot abduction (>30-40% talonavicular uncoverage), consistent with Stage IIb PTTD. To correct the multiplanar deformity, the standard surgical reconstruction includes a tendon transfer (usually FDL to navicular), a medial displacement calcaneal osteotomy (MDCO) to correct hindfoot valgus, and a lateral column lengthening (e.g., Evans osteotomy) to correct the forefoot abduction.

Question 6000

Topic: 8. Foot and Ankle

In the setting of a displaced intra-articular calcaneus fracture, one bony fragment typically remains anatomically reduced relative to the talus despite significant comminution elsewhere. Which fragment is this, and what ligamentous structures maintain its alignment?

. The tuberosity fragment; maintained by the Achilles tendon
. The anterolateral fragment; maintained by the bifurcate ligament
. The sustentacular fragment; maintained by the deltoid and talocalcaneal interosseous ligaments
. The posterior facet fragment; maintained by the calcaneofibular ligament
. The medial wall fragment; maintained by the plantar fascia

Correct Answer & Explanation

. The sustentacular fragment; maintained by the deltoid and talocalcaneal interosseous ligaments

Explanation

The sustentaculum tali (anteromedial fragment) is known as the 'constant' fragment in calcaneus fractures. It remains tightly bound to the talus by the strong deltoid ligament complex and the interosseous talocalcaneal ligaments, and typically remains in its anatomic position beneath the talus.

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