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8. Foot and Ankle MCQs

Practice Set 301 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 6001

Topic: 8. Foot and Ankle

A professional football player sustains a 'turf toe' injury characterized by a complete tear of the plantar plate with proximal retraction of the sesamoids. What is the primary mechanism of injury leading to this specific pathology?

. Axial load on a plantarflexed ankle and hyperflexed first MTP joint
. Direct crush injury to the dorsal aspect of the first MTP joint
. Hyperextension of the first MTP joint with an axial load
. Forced hyperabduction of the hallux
. Sudden acceleration leading to a forced varus stress at the first MTP joint

Correct Answer & Explanation

. Hyperextension of the first MTP joint with an axial load

Explanation

Turf toe represents a sprain or tear of the first MTP joint capsuloligamentous complex (plantar plate). The classic mechanism of injury is forced hyperextension of the first MTP joint with an axial load applied to a foot fixed on the playing surface.

Question 6002

Topic: 8. Foot and Ankle

Following open reduction and internal fixation of an ankle fracture with a concomitant syndesmotic injury, what imaging modality and specific parameter are considered the gold standard for verifying accurate anatomic reduction of the distal tibiofibular syndesmosis?

. AP radiograph evaluating the tibiofibular clear space
. Mortise radiograph evaluating the medial clear space
. Intraoperative fluoroscopy comparing the injured side to standard radiographic norms
. Axial CT scan evaluating the anterior-to-posterior translation and rotation of the fibula in the incisura
. MRI to evaluate the integrity of the Anterior Inferior Tibiofibular Ligament (AITFL)

Correct Answer & Explanation

. Axial CT scan evaluating the anterior-to-posterior translation and rotation of the fibula in the incisura

Explanation

Postoperative axial CT scanning is the most accurate imaging modality for assessing syndesmotic reduction. Plain radiographs have been shown to be notoriously unreliable for detecting syndesmotic malreduction. CT best visualizes anterior-to-posterior translation and rotational alignment of the fibula within the tibial incisura.

Question 6003

Topic: 8. Foot and Ankle

Osteochondral lesions of the talus (OLT) exhibit distinct characteristics based on their anatomic location on the talar dome. Based on the widely taught mnemonic 'DIAL a PIMP', which of the following descriptions accurately characterizes a posteromedial talar dome lesion?

. Shallow, wafer-shaped, and usually associated with an acute traumatic inversion injury
. Deep, cup-shaped, and often insidious or non-traumatic in origin
. Usually located strictly anteriorly and driven by repetitive microtrauma
. Superficial and strictly associated with high ankle sprains
. Typically benign and resolves spontaneously without deep subchondral extension

Correct Answer & Explanation

. Deep, cup-shaped, and often insidious or non-traumatic in origin

Explanation

The mnemonic 'DIAL a PIMP' helps distinguish OLTs. 'DIAL' = Dorsiflexion, Inversion, Anterior, Lateral lesions (these are typically shallow, wafer-shaped, and traumatic). 'PIMP' = Plantarflexion, Inversion, Medial, Posterior lesions (these are typically deep, cup-shaped, and often insidious/non-traumatic in origin).

Question 6004

Topic: 8. Foot and Ankle

A 14-year-old male presents with recurrent ankle sprains and rigid 'spastic' flatfeet. Lateral radiographs demonstrate a 'C-sign'

representing continuity between the talar dome and the sustentaculum tali. Which tarsal coalition does this patient have, and what joint is most directly involved?

. Calcaneonavicular coalition; Chopart joint
. Talocalcaneal coalition; middle facet of the subtalar joint
. Talocalcaneal coalition; posterior facet of the subtalar joint
. Talonavicular coalition; transverse tarsal joint
. Naviculocuneiform coalition; medial column joints

Correct Answer & Explanation

. Talocalcaneal coalition; middle facet of the subtalar joint

Explanation

The 'C-sign' on a lateral radiograph of the foot is highly suggestive of a talocalcaneal coalition. This coalition almost exclusively involves the middle facet of the subtalar joint. It typically presents slightly later (ages 12-16) than calcaneonavicular coalitions (ages 8-12).

Question 6005

Topic: 8. Foot and Ankle

During surgical decompression for Tarsal Tunnel Syndrome, the surgeon releases the flexor retinaculum. The structures passing through the tarsal tunnel from anterior to posterior (or medial to lateral) follow a specific order. Which of the following correctly identifies the relative anatomical position of the posterior tibial artery?

. It lies immediately posterior to the Tibialis Posterior tendon.
. It lies between the Flexor Digitorum Longus tendon and the Tibial Nerve.
. It lies posterior to the Flexor Hallucis Longus tendon.
. It lies anterior to the Flexor Digitorum Longus tendon.
. It lies between the Tibial Nerve and the Flexor Hallucis Longus tendon.

Correct Answer & Explanation

. It lies between the Flexor Digitorum Longus tendon and the Tibial Nerve.

Explanation

The structures passing through the tarsal tunnel from anterior to posterior (medial malleolus to calcaneus) are: Tibialis posterior tendon, Flexor Digitorum Longus tendon, Posterior tibial Artery, posterior tibial Vein, Tibial Nerve, Flexor Hallucis Longus tendon (Mnemonic: Tom, Dick, And Very Nervous Harry). Therefore, the artery lies between the FDL tendon and the tibial nerve.

Question 6006

Topic: 8. Foot and Ankle
A 15-year-old female cross-country runner presents with isolated, localized pain over the dorsal aspect of her forefoot. Radiographs reveal flattening and sclerosis of the second metatarsal head. What is the diagnosis and its underlying pathophysiology?
. Kรถhler's disease; avascular necrosis of the navicular
. Sever's disease; calcaneal apophysitis
. Freiberg's infraction; avascular necrosis of the metatarsal head
. Morton's neuroma; perineural fibrosis of the interdigital nerve
. Iselin's disease; traction apophysitis of the fifth metatarsal base

Correct Answer & Explanation

. Freiberg's infraction; avascular necrosis of the metatarsal head

Explanation

Freiberg's infraction is avascular necrosis of the metatarsal head, most commonly affecting the second metatarsal head. It frequently presents in adolescent females who participate in sports or activities that repetitively load the forefoot.

Question 6007

Topic: Ankle Trauma & Sports

A 25-year-old skier presents after an acute injury feeling a 'snap' behind his lateral malleolus. On examination, the peroneal tendons dislocate anteriorly over the lateral malleolus with resisted dorsiflexion and eversion. Radiographs show a small bony avulsion flake lateral to the distal fibula.

What structure has been compromised?

. Anterior Talofibular Ligament (ATFL)
. Calcaneofibular Ligament (CFL)
. Inferior Extensor Retinaculum
. Superior Peroneal Retinaculum (SPR)
. Peroneus Longus tendon itself

Correct Answer & Explanation

. Superior Peroneal Retinaculum (SPR)

Explanation

The 'fleck sign' lateral to the distal fibula represents an avulsion of the Superior Peroneal Retinaculum (SPR) from its fibular attachment. Disruption of the SPR allows the peroneal tendons to subluxate or dislocate anteriorly over the lateral malleolus. Treatment often requires deepening of the fibular groove and repair of the SPR.

Question 6008

Topic: 8. Foot and Ankle

A 60-year-old male with end-stage post-traumatic ankle arthritis undergoes an open ankle arthrodesis.

To optimize postoperative gait and limit compensatory stress on adjacent hindfoot joints, what is the ideal position for fusing the tibiotalar joint?

. Neutral dorsiflexion/plantarflexion, 0 to 5 degrees of valgus, and 5 to 10 degrees of external rotation
. 5 degrees of plantarflexion, 5 degrees of varus, and neutral rotation
. 10 degrees of dorsiflexion, neutral coronal alignment, and 15 degrees of external rotation
. Neutral dorsiflexion/plantarflexion, 5 degrees of varus, and 5 degrees of internal rotation
. 10 degrees of plantarflexion, 5 degrees of valgus, and neutral rotation

Correct Answer & Explanation

. Neutral dorsiflexion/plantarflexion, 0 to 5 degrees of valgus, and 5 to 10 degrees of external rotation

Explanation

The ideal position for ankle arthrodesis is neutral sagittal alignment (0 degrees dorsiflexion/plantarflexion), 0 to 5 degrees of hindfoot valgus, and 5 to 10 degrees of external rotation (or symmetric to the contralateral limb). Plantarflexion leads to genu recurvatum (back-knee), and varus locks the transverse tarsal joints, accelerating adjacent joint arthritis.

Question 6009

Topic: 8. Foot and Ankle

A collegiate track athlete presents with insidious onset dorsal midfoot pain. CT scan confirms a non-displaced stress fracture of the navicular. Due to the vascular anatomy of the navicular, which region is most susceptible to delayed union or non-union, thus dictating strict non-weight-bearing management?

. The medial tuberosity
. The central third of the navicular body
. The dorsal avulsion site of the talonavicular capsule
. The lateral articular facet for the lateral cuneiform
. The plantar aspect near the tibialis posterior insertion

Correct Answer & Explanation

. The central third of the navicular body

Explanation

The central third of the tarsal navicular body is relatively avascular (a watershed zone) because the primary blood supply enters dorsally and plantarly, branching toward the medial and lateral poles but leaving the central zone hypovascular. Stress fractures in this region have a high risk of non-union and require strict non-weight-bearing cast immobilization or surgical fixation.

Question 6010

Topic: Forefoot

A 65-year-old male presents with severe pain in his first metatarsophalangeal (MTP) joint, constant pain throughout the entire arc of motion, and large dorsal osteophytes. Radiographs confirm end-stage Hallux Rigidus (Coughlin and Shurnas Grade 4). He elects to undergo a first MTP arthrodesis. What is the optimal position for this fusion?

. Neutral dorsiflexion and neutral valgus
. 10 to 15 degrees of valgus, and 10 to 15 degrees of dorsiflexion relative to the floor
. 30 degrees of dorsiflexion relative to the floor and 5 degrees of varus
. 5 degrees of plantarflexion and 15 degrees of valgus
. 15 degrees of dorsiflexion relative to the floor and neutral coronal alignment

Correct Answer & Explanation

. 10 to 15 degrees of valgus, and 10 to 15 degrees of dorsiflexion relative to the floor

Explanation

The optimal position for a first MTP joint arthrodesis is approximately 10-15 degrees of valgus (to mimic the normal hallux valgus angle and clear the second toe) and 10-15 degrees of dorsiflexion relative to the floor (which translates to about 20-25 degrees of dorsiflexion relative to the first metatarsal shaft). This allows for proper roll-off during the terminal stance phase of the gait cycle.

Question 6011

Topic: 8. Foot and Ankle

A 25-year-old football player presents with midfoot pain after a hyperplantarflexion injury during a tackle. Weight-bearing radiographs show 2.5 mm widening between the 1st and 2nd metatarsal bases.

What are the exact anatomical attachments of the primary ligamentous structure injured in this condition?

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

Correct Answer & Explanation

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

Explanation

The patient has a Lisfranc injury. The Lisfranc ligament is the strongest of the tarsometatarsal ligaments and acts as the primary stabilizer of the 2nd tarsometatarsal joint. It runs obliquely from the plantar-lateral aspect of the medial cuneiform to the plantar-medial base of the 2nd metatarsal. The dorsal ligaments are much weaker, which explains why dorsal dislocation is more common in Lisfranc fracture-dislocations.

Question 6012

Topic: 8. Foot and Ankle

A 40-year-old marathon runner is diagnosed with non-insertional Achilles tendinopathy. The underlying pathophysiology involves degeneration in a hypovascular zone. What is the typical location of this hypovascular watershed zone?

. At the direct insertion onto the calcaneal tuberosity
. 2 to 6 cm proximal to the calcaneal insertion
. 8 to 10 cm proximal to the calcaneal insertion
. At the musculotendinous junction of the gastrocnemius
. At the musculotendinous junction of the soleus

Correct Answer & Explanation

. 2 to 6 cm proximal to the calcaneal insertion

Explanation

Non-insertional Achilles tendinopathy and acute ruptures most commonly occur in the functional 'watershed' or hypovascular zone, which is located approximately 2 to 6 cm proximal to the insertion on the calcaneus. Blood supply in this region is relatively sparse, predisposing the tendon to microtrauma and impaired healing.

Question 6013

Topic: 8. Foot and Ankle

A 14-year-old boy with Charcot-Marie-Tooth (CMT) disease presents with bilateral progressive 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. Which of the following describes the primary pathologic muscle imbalance driving the initial deformity?

. Weakness of the tibialis anterior and peroneus brevis, with relative overactivity of the peroneus longus and tibialis posterior
. Weakness of the peroneus longus and tibialis posterior, with relative overactivity of the tibialis anterior and peroneus brevis
. Weakness of the gastrocnemius and soleus, with overactivity of the extensor digitorum longus
. Weakness of the tibialis posterior and flexor digitorum longus, with overactivity of the peroneus brevis
. Global lower extremity weakness with isolated spasticity of the flexor hallucis longus

Correct Answer & Explanation

. Weakness of the tibialis anterior and peroneus brevis, with relative overactivity of the peroneus longus and tibialis posterior

Explanation

The classic cavovarus foot deformity in CMT disease is driven by a characteristic pattern of muscle denervation and imbalance. The tibialis anterior and peroneus brevis weaken early. The relative preservation and overpowering force of the peroneus longus (plantarflexing the 1st ray) and tibialis posterior (inverting the hindfoot) drive the plantarflexed first ray and secondary hindfoot varus. A flexible hindfoot (positive Coleman block test) indicates that addressing the forefoot pathology (e.g., via peroneus longus to brevis transfer and 1st metatarsal dorsiflexion osteotomy) may correct the hindfoot without needing an arthrodesis.

Question 6014

Topic: Midfoot & Hindfoot
A 55-year-old woman presents with progressive flattening of her left medial longitudinal arch, medial ankle pain, and an inability to perform a single-leg heel raise. The deformity remains flexible on examination. Which of the following surgical combinations is the most appropriate initial joint-sparing approach?
. Flexor digitorum longus (FDL) transfer to the navicular alone
. Flexor digitorum longus (FDL) transfer combined with a medial displacement calcaneal osteotomy (MDCO)
. Triple arthrodesis
. Subtalar arthrodesis alone
. Tibialis anterior tendon transfer to the navicular

Correct Answer & Explanation

. Flexor digitorum longus (FDL) transfer combined with a medial displacement calcaneal osteotomy (MDCO)

Explanation

The patient has Stage II Adult Acquired Flatfoot Deformity (Posterior Tibial Tendon Insufficiency). Stage II is characterized by a flexible deformity. Joint-sparing procedures are indicated. The standard of care includes addressing both the soft tissue deficit and the bony malalignment. This is typically achieved with an FDL tendon transfer (to replace the deficient posterior tibial tendon) and a medial displacement calcaneal osteotomy (to correct the valgus hindfoot vector and protect the tendon transfer). Arthrodesis is reserved for rigid deformities (Stage III) or advanced arthritis.

Question 6015

Topic: 8. Foot and Ankle

A 60-year-old male presents with dorsal midfoot and 1st MTP pain. Radiographs demonstrate moderate dorsal osteophytes of the 1st MTP joint with joint space narrowing affecting less than 50% of the joint. Nonsurgical management has failed. What is the most appropriate surgical intervention?

. 1st MTP joint arthrodesis
. Keller resection arthroplasty
. Cheilectomy
. Proximal phalanx extension osteotomy (Moberg)
. Total 1st MTP joint arthroplasty

Correct Answer & Explanation

. Cheilectomy

Explanation

The patient has Grade 2 hallux rigidus (Coughlin and Shurnas classification). Grade 1 and 2 (mild to moderate joint space narrowing, dorsal osteophytes, and pain primarily at the extremes of dorsiflexion) are ideally treated with a cheilectomy (excision of dorsal osteophytes and dorsal third of the metatarsal head) to improve motion and relieve impingement pain. Arthrodesis is the gold standard for Grade 3 (severe narrowing) and Grade 4 (pain in the mid-range of motion).

Question 6016

Topic: Midfoot & Hindfoot
A 30-year-old driver is involved in a high-speed motor vehicle collision. Radiographs demonstrate a displaced talar neck fracture with subluxation of the subtalar joint, but the tibiotalar and talonavicular joints remain congruent. According to the Hawkins classification, what is the type of fracture and its associated risk of avascular necrosis (AVN)?
. Type I; AVN risk is 0-10%
. Type II; AVN risk is 20-50%
. Type III; AVN risk is 80-100%
. Type IV; AVN risk is 100%
. Type II; AVN risk is greater than 80%

Correct Answer & Explanation

. Type II; AVN risk is 20-50%

Explanation

Hawkins Type II talar neck fractures involve displacement with subtalar subluxation or dislocation while the tibiotalar and talonavicular joints remain intact. The risk of AVN for Type II fractures is historically quoted as 20% to 50%. Type I is nondisplaced (0-15% AVN risk). Type III involves both subtalar and tibiotalar dislocation (~80-100% AVN risk). Type IV includes subtalar, tibiotalar, and talonavicular dislocation (near 100% AVN risk).

Question 6017

Topic: 8. Foot and Ankle

When utilizing the extensile lateral approach for open reduction and internal fixation of a displaced intra-articular calcaneus fracture, a full-thickness subperiosteal flap must be developed.

Which nerve is at greatest risk of iatrogenic injury during the creation and retraction of this specific flap?

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

Correct Answer & Explanation

. Sural nerve

Explanation

The sural nerve courses along the lateral aspect of the hindfoot, passing posterior and inferior to the lateral malleolus. During the extensile lateral approach to the calcaneus, the sural nerve is at high risk of injury, either from direct laceration or excessive traction. It is typically managed by incorporating it into the full-thickness subperiosteal 'no-touch' flap to protect it during retraction.

Question 6018

Topic: 8. Foot and Ankle
A 55-year-old patient with long-standing peripheral neuropathy secondary to diabetes presents with a unilaterally swollen, warm, and erythematous foot and ankle. Radiographs demonstrate dramatic midfoot fragmentation, periarticular debris, and joint subluxation without evidence of ulceration or skin breakdown. According to the Eichenholtz classification of Charcot neuroarthropathy, what stage does this represent?
. Stage 0 (Prodromal)
. Stage I (Developmental/Fragmentation)
. Stage II (Coalescence)
. Stage III (Reconstruction/Consolidation)
. Stage IV (Late Deformity)

Correct Answer & Explanation

. Stage I (Developmental/Fragmentation)

Explanation

The clinical picture of a warm, swollen foot coupled with radiographic evidence of bone fragmentation, joint subluxation, and debris characterizes Stage I (Developmental or Fragmentation) of the Eichenholtz classification for Charcot neuroarthropathy. Stage 0 features clinical erythema and swelling but normal radiographs. Stage II (Coalescence) shows absorption of fine debris and early fusion. Stage III (Reconstruction) shows rounding of bone ends, sclerosis, and stabilization of deformity.

Question 6019

Topic: 8. Foot and Ankle

During the standard dorsal surgical approach for the excision of a primary Morton's neuroma located in the 3rd web space, which specific anatomical structure is routinely transected to allow adequate visualization and resection of the neuroma?

. Deep transverse metatarsal ligament
. Superficial transverse metatarsal ligament
. Plantar plate
. Lisfranc ligament
. Lumbrical tendon

Correct Answer & Explanation

. Deep transverse metatarsal ligament

Explanation

A Morton's neuroma most commonly occurs in the 3rd intermetatarsal space. It is an entrapment neuropathy of the common digital nerve. The nerve runs plantar to the deep transverse metatarsal ligament. During a dorsal approach, the deep transverse metatarsal ligament must be identified and transected to release the compression, allowing the surgeon to elevate the nerve into the dorsal wound for proximal resection.

Question 6020

Topic: 8. Foot and Ankle

A 45-year-old female presents with chronic burning pain radiating along the medial heel and plantar aspect of the foot. Tinel's sign is markedly positive when percussing posterior to the medial malleolus. The structures passing through the tarsal tunnel are maintained by the flexor retinaculum. In evaluating this space from anterior to posterior, which structure is the most anterior?

. Tibialis posterior tendon
. Flexor digitorum longus tendon
. Posterior tibial artery
. Tibial nerve
. Flexor hallucis longus tendon

Correct Answer & Explanation

. Tibialis posterior tendon

Explanation

Tarsal tunnel syndrome involves entrapment of the tibial nerve under the flexor retinaculum. The structures passing behind the medial malleolus, ordered from anterior to posterior, are remembered by the mnemonic 'Tom, Dick, And Very Nervous Harry': Tibialis posterior tendon, flexor Digitorum longus tendon, posterior tibial Artery, posterior tibial Vein, tibial Nerve, and flexor Hallucis longus tendon. Therefore, the tibialis posterior tendon is the most anterior structure.

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