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8. Foot and Ankle MCQs

Practice Set 315 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 6281

Topic: Ankle Trauma & Sports

A patient undergoes a modified Brostrom-Gould repair. What is the typical initial rehabilitation phase (0-2 weeks post-op) focused on?

. Full weight-bearing and active range of motion.
. Immobilization in a boot or cast, non-weight-bearing, and pain/swelling control.
. Aggressive strengthening of peroneal muscles.
. Initiation of plyometric exercises.
. Return to sport-specific drills.

Correct Answer & Explanation

. Immobilization in a boot or cast, non-weight-bearing, and pain/swelling control.

Explanation

The initial rehabilitation phase (typically 0-2 weeks) after a modified Brostrom-Gould repair focuses on protecting the surgical repair. This involves immobilization in a boot or cast (or combination of both), non-weight-bearing to protect the suture lines, and controlling pain and swelling. Aggressive motion, strengthening, or plyometrics are deferred to later phases to allow for initial soft tissue healing.

Question 6282

Topic: 8. Foot and Ankle

Which of the following is considered the gold standard for diagnosis of lateral ankle ligament tears and associated pathologies?

. Plain radiographs
. Stress radiographs
. Clinical examination
. Magnetic Resonance Imaging (MRI)
. Ultrasound

Correct Answer & Explanation

. Magnetic Resonance Imaging (MRI)

Explanation

While clinical examination and stress radiographs are crucial for diagnosing functional and mechanical instability, Magnetic Resonance Imaging (MRI) is considered the gold standard for directly visualizing the integrity of the lateral ankle ligaments (ATFL, CFL, PTFL) and identifying associated soft tissue and bone pathologies, such as osteochondral lesions, synovitis, or peroneal tendon tears. Plain radiographs are for bone, and ultrasound has operator dependency.

Question 6283

Topic: 8. Foot and Ankle

A 55-year-old active individual presents with chronic lateral ankle pain and instability after multiple sprains. He has significant hindfoot varus and clinical evidence of subtalar instability. What is the typical surgical management strategy for combined ankle and subtalar instability with a cavovarus foot?

. Isolated modified Brostrom-Gould repair.
. Non-anatomical tenodesis with peroneal tendon transfer.
. Combined lateral ankle ligament reconstruction and a calcaneal osteotomy.
. Arthroscopic debridement alone.
. Fusion of the subtalar joint only.

Correct Answer & Explanation

. Combined lateral ankle ligament reconstruction and a calcaneal osteotomy.

Explanation

For patients with combined ankle and subtalar instability along with a significant cavovarus foot deformity, an isolated lateral ankle ligament repair is likely to fail due to the underlying biomechanical malalignment. The preferred surgical strategy involves addressing both the ligamentous instability (e.g., anatomical reconstruction) and correcting the hindfoot alignment through a calcaneal osteotomy (e.g., lateralizing calcaneal osteotomy) to unload the lateral structures and neutralize the foot. Non-anatomical repairs are generally less favored, arthroscopic debridement is insufficient, and subtalar fusion is a salvage procedure typically for severe arthritis, not primary instability management.

Question 6284

Topic: 8. Foot and Ankle

When using an extramedullary guide for tibial resection, what is the most important anatomical landmark for achieving correct coronal alignment?

. Lateral malleolus
. Medial malleolus
. Tibial tubercle
. Center of the talus
. Center of the femoral head

Correct Answer & Explanation

. Center of the talus

Explanation

When using an extramedullary guide for tibial resection, the center of the talus (or the midpoint between the malleoli) is the critical distal reference point. The goal is to align the tibial cut perpendicular to the mechanical axis, which passes from the center of the knee to the center of the talus. The tibial tubercle is a rotational reference, and the malleoli define the ankle, but the center of the talus represents the mechanical axis origin in the ankle.

Question 6285

Topic: 8. Foot and Ankle

In a patient presenting with hallux rigidus, which of the following physical examination findings is most indicative of advanced disease (Stage 3 or 4)?

. Tenderness to palpation over the medial cuneiform
. Restricted and painful passive dorsiflexion, often less than 20 degrees, with crepitus
. Presence of a bunionette deformity
. Pain primarily relieved by wearing rigid-soled shoes
. Positive anterior drawer test of the ankle

Correct Answer & Explanation

. Restricted and painful passive dorsiflexion, often less than 20 degrees, with crepitus

Explanation

Advanced hallux rigidus is characterized by severe joint degeneration. Restricted and painful passive dorsiflexion, typically less than 20 degrees, often accompanied by crepitus, indicates significant loss of articular cartilage and osteophyte formation leading to bone-on-bone impingement. While rigid-soled shoes can provide some relief in earlier stages by reducing MTP joint motion, persistent pain with severe motion restriction and crepitus points to advanced pathology. Tenderness over the medial cuneiform, bunionette deformity (fifth MTP joint), and a positive ankle anterior drawer test are unrelated to hallux rigidus severity.

Question 6286

Topic: 8. Foot and Ankle

Which radiographic view is essential for evaluating the first MTP joint in hallux rigidus, particularly to visualize dorsal osteophytes and joint space narrowing?

. AP foot view
. Lateral foot view
. Oblique foot view
. Harris axial view
. Weight-bearing AP ankle view

Correct Answer & Explanation

. Lateral foot view

Explanation

A weight-bearing lateral foot view is crucial for evaluating hallux rigidus. It best demonstrates the dorsal osteophytes on the first metatarsal head and proximal phalanx, assesses the degree of joint space narrowing in the sagittal plane, and helps to visualize any subchondral sclerosis or cysts. While AP and oblique views provide information about the transverse plane and overall alignment, the lateral view is paramount for assessing the primary pathology of dorsal impingement and degenerative changes.

Question 6287

Topic: 8. Foot and Ankle

A patient undergoes a dorsal cheilectomy for Stage 2 hallux rigidus. Postoperatively, they develop significant swelling and pain that is disproportionate to the expected recovery. Examination reveals cool, clammy skin, allodynia, and trophic changes in the great toe. Which complication should be highest on your differential diagnosis?

. Superficial wound infection
. Deep vein thrombosis
. Complex Regional Pain Syndrome (CRPS) Type I
. Neuroma formation of the medial dorsal cutaneous nerve
. Failure of osteophyte resection

Correct Answer & Explanation

. Complex Regional Pain Syndrome (CRPS) Type I

Explanation

The constellation of disproportionate pain, swelling, cool/clammy skin, allodynia (pain from non-noxious stimuli), and trophic changes (skin/nail changes) strongly suggests Complex Regional Pain Syndrome (CRPS) Type I, also known as reflex sympathetic dystrophy. This is a severe, debilitating complication that can occur after trauma or surgery, particularly in the foot and ankle. While superficial infection, DVT, and neuroma are possible surgical complications, they do not typically present with the full spectrum of sympathetic nervous system dysfunction seen in CRPS. Failure of osteophyte resection would manifest as persistent mechanical symptoms, not these neurovascular changes.

Question 6288

Topic: 8. Foot and Ankle

When considering non-operative management for early to moderate hallux rigidus, which of the following orthotic modifications is most beneficial?

. Soft, cushioned insoles for shock absorption
. A rigid-soled shoe or carbon fiber plate to limit MTP joint motion
. Arch support to correct pes planus
. Custom orthotics with a medial heel wedge
. Toe spacers to separate the great toe from the second toe

Correct Answer & Explanation

. A rigid-soled shoe or carbon fiber plate to limit MTP joint motion

Explanation

For hallux rigidus, the primary goal of non-operative management, especially with orthotics, is to limit painful motion at the first MTP joint. A rigid-soled shoe, a rocker-bottom sole, or a carbon fiber plate inserted into the shoe achieves this by reducing the stresses on the MTP joint during the push-off phase of gait. Soft cushioned insoles provide comfort but do not restrict motion. Arch support and heel wedges are for other foot pathologies, and toe spacers are typically for interdigital problems or hallux valgus.

Question 6289

Topic: Forefoot

A 28-year-old active female presents with Stage 1 hallux rigidus. She has tried conservative measures, including orthotics and NSAIDs, but continues to have activity-related pain. She is keen to avoid surgery if possible. What would be the most appropriate next step in her non-operative management plan?

. Immediately proceed to dorsal cheilectomy
. Recommend a first MTP joint arthrodesis
. Consider a corticosteroid injection into the first MTP joint
. Prescribe a short course of oral corticosteroids
. Advise complete immobilization for 6 weeks

Correct Answer & Explanation

. Consider a corticosteroid injection into the first MTP joint

Explanation

For Stage 1 hallux rigidus, where conservative management has been partially effective but pain persists, a corticosteroid injection into the first MTP joint can be a valuable adjunctive treatment. It can help reduce inflammation and pain, potentially offering a period of relief and delaying surgical intervention. While it is not a cure, it can be a useful diagnostic and therapeutic tool. Surgical intervention like cheilectomy is typically reserved for those who fail multiple conservative measures. Arthrodesis is for advanced stages. Oral corticosteroids are generally not used for chronic localized joint pain, and complete immobilization is rarely indicated and can lead to stiffness.

Question 6290

Topic: Forefoot

Which of the following describes a key differentiating feature between hallux rigidus and gout affecting the first MTP joint?

. Presence of hyperuricemia
. Pain and stiffness worsened with activity
. Acute onset of severe pain, redness, and swelling
. Radiographic evidence of joint space narrowing
. Response to NSAIDs

Correct Answer & Explanation

. Acute onset of severe pain, redness, and swelling

Explanation

While both hallux rigidus and gout can affect the first MTP joint and respond to NSAIDs, the presentation differs significantly. Gout typically presents with an acute, often sudden, onset of excruciating pain, redness, and swelling (podagra), commonly waking the patient from sleep. Hallux rigidus, in contrast, usually has an insidious onset with chronic pain and stiffness that worsens with activity. Hyperuricemia is a risk factor for gout, not hallux rigidus. Both can eventually show joint space narrowing on radiographs in later stages.

Question 6291

Topic: 8. Foot and Ankle

The 'cheater's view' or dorsiflexion lateral radiograph of the first MTP joint is sometimes used to assess what specific aspect of hallux rigidus?

. The presence of an os intermetatarseum
. The degree of sesamoid subluxation
. The extent of dorsal impingement and remaining dorsiflexion range
. The alignment of the talonavicular joint
. The integrity of the plantar plate

Correct Answer & Explanation

. The extent of dorsal impingement and remaining dorsiflexion range

Explanation

The 'cheater's view' or stress dorsiflexion lateral radiograph of the first MTP joint helps to dynamically assess the extent of dorsal impingement between the metatarsal head and the proximal phalanx, and to visualize the maximal dorsiflexion achieved before bone-on-bone contact. This can be useful in surgical planning for cheilectomy, demonstrating the amount of bone that needs to be resected to restore functional motion. It is not primarily for assessing sesamoid subluxation (which is better seen on axial views), os intermetatarseum, talonavicular alignment, or plantar plate integrity (which would require MRI).

Question 6292

Topic: 8. Foot and Ankle

What is the primary mechanism of pain in early-stage hallux rigidus?

. Chronic inflammation of the sesamoids
. Dorsal impingement of osteophytes during dorsiflexion
. Subluxation of the first MTP joint
. Ischemic necrosis of the metatarsal head
. Compression neuropathy of the deep fibular nerve

Correct Answer & Explanation

. Dorsal impingement of osteophytes during dorsiflexion

Explanation

In early-stage hallux rigidus, the primary mechanism of pain is dorsal impingement. As the first metatarsal head develops osteophytes, these bony prominences collide with the base of the proximal phalanx during dorsiflexion, causing pain and restricting motion. While inflammation, degenerative changes, and mechanical stress contribute to the overall pathology, direct bone-on-bone impingement of the dorsal osteophytes is the leading cause of pain in the early stages.

Question 6293

Topic: Forefoot

A patient undergoing first MTP joint arthrodesis for severe hallux rigidus requires internal fixation. Which of the following is generally considered the most biomechanically stable fixation construct?

. A single K-wire crossing the joint
. A dorsal compression plate with an interfragmentary screw
. Two divergent cancellous screws
. An external fixator alone
. Intramedullary K-wires

Correct Answer & Explanation

. A dorsal compression plate with an interfragmentary screw

Explanation

For first MTP joint arthrodesis, a dorsal compression plate with an interfragmentary screw is generally considered the most biomechanically stable and preferred fixation construct. The plate provides robust dorsal tension band fixation, while the interfragmentary screw provides compression across the fusion site, promoting primary bone healing. Two divergent cancellous screws are also a common and effective method, but a plate-and-screw construct often offers superior rigidity. A single K-wire is insufficient for stable fusion. External fixators are typically reserved for complex cases or infected fusions. Intramedullary K-wires are not commonly used for MTP fusions due to lack of compression and rotational instability.

Question 6294

Topic: 8. Foot and Ankle

Which of the following is considered a key risk factor for the development and progression of hallux rigidus?

. History of rheumatoid arthritis
. Systemic lupus erythematosus
. Genetic predisposition and family history
. Wearing high-heeled shoes regularly
. Pes planus (flatfoot) deformity

Correct Answer & Explanation

. Genetic predisposition and family history

Explanation

Genetic predisposition and a family history of hallux rigidus are strong risk factors, suggesting an inherited component to the condition. While other factors like trauma, abnormal foot mechanics (e.g., hypermobility, pes planus, or pes cavus), and certain inflammatory conditions can contribute, a clear genetic link has been identified. Rheumatoid arthritis and systemic lupus erythematosus are inflammatory arthropathies, distinct from the primary osteoarthritic process of hallux rigidus, though they can affect the joint. High-heeled shoes can exacerbate symptoms but are not considered a primary etiologic factor for the development of the condition itself. Pes planus can alter biomechanics but is not as strong a primary risk factor as genetics.

Question 6295

Topic: Forefoot

Following a successful cheilectomy for hallux rigidus, what is the expected timeline for return to full activity, including sports, assuming an uncomplicated recovery?

. Immediately, with no restrictions
. 2-4 weeks
. 6-8 weeks
. 3-4 months
. 6-12 months

Correct Answer & Explanation

. 3-4 months

Explanation

After an uncomplicated dorsal cheilectomy, patients typically progress to full weight-bearing in a rigid-soled shoe or post-op shoe fairly quickly (within a few days to 2 weeks). However, return to full, unrestricted activity, including sports, usually takes around 3-4 months. This allows for soft tissue healing, resolution of swelling, and regaining full range of motion and strength. Earlier return risks exacerbating symptoms or impeding recovery. Immediately or 2-4 weeks is too aggressive for full activity, while 6-12 months is generally too long unless complications arise.

Question 6296

Topic: 8. Foot and Ankle

Which of the following describes the anatomical structure most commonly impinging dorsally in hallux rigidus, leading to pain and restricted motion?

. The sesamoids against the metatarsal head
. The base of the proximal phalanx against the dorsal aspect of the first metatarsal head
. The medial cuneiform against the first metatarsal base
. The navicular against the talar head
. The fibular sesamoid against the lateral aspect of the first metatarsal head

Correct Answer & Explanation

. The base of the proximal phalanx against the dorsal aspect of the first metatarsal head

Explanation

The primary anatomical impingement in hallux rigidus occurs dorsally at the first MTP joint. Specifically, as dorsiflexion is attempted, the dorsal aspect of the base of the proximal phalanx collides with the dorsal osteophyte and/or the dorsal articular margin of the first metatarsal head. This bone-on-bone contact causes pain and progressively limits the range of motion. Sesamoids can be affected by the degenerative process but are not the primary dorsal impingement point. The other options describe different anatomical regions or pathologies.

Question 6297

Topic: 8. Foot and Ankle

What is the primary goal of an interpositional arthroplasty for hallux rigidus, often utilizing autologous tissue or synthetic spacer?

. To achieve complete pain relief by fusing the joint
. To remove all osteophytes and restore full joint motion
. To maintain some joint motion while providing pain relief, without the risks of an implant
. To shorten the first metatarsal and decompress the joint
. To replace the entire first MTP joint with a prosthetic device

Correct Answer & Explanation

. To maintain some joint motion while providing pain relief, without the risks of an implant

Explanation

Interpositional arthroplasty aims to maintain some motion at the first MTP joint while alleviating pain, serving as an alternative to arthrodesis for patients who are unwilling to sacrifice motion or who are poor candidates for implant arthroplasty. It involves resecting a portion of the articular surface and interposing a layer of tissue (e.g., joint capsule, fat, allograft, or synthetic material) to create a pseudoarthrosis and prevent bone-on-bone impingement. It does not achieve full motion restoration, nor does it fuse the joint or replace it entirely with a conventional implant, but rather creates a 'spacer' effect.

Question 6298

Topic: 8. Foot and Ankle

A 58-year-old patient with Stage 3 hallux rigidus presents with a long first metatarsal (Morton's toe) and diffuse pain in the first MTP joint. In addition to a cheilectomy, which concomitant osteotomy might be considered to offload the first metatarsal head and potentially improve symptoms?

. Akin osteotomy
. Weil osteotomy of the second metatarsal
. Distal metatarsal osteotomy (e.g., shortening osteotomy like a modified Reverdin or Ludloff)
. Lelievre osteotomy
. Kessel-Bonney osteotomy

Correct Answer & Explanation

. Distal metatarsal osteotomy (e.g., shortening osteotomy like a modified Reverdin or Ludloff)

Explanation

For Stage 3 hallux rigidus, especially when associated with a long first metatarsal (Morton's toe), a distal metatarsal shortening osteotomy (e.g., modified Reverdin, Ludloff, or oblique shortening osteotomy) can be performed in conjunction with a cheilectomy. The purpose of the shortening osteotomy is to decompress the first MTP joint by reducing pressure on the metatarsal head, particularly in cases of metatarsus primus elevatus or a relatively long first metatarsal. Akin osteotomy is for hallux valgus interphalangeus. Weil osteotomy is for lesser metatarsal shortening. Lelievre and Kessel-Bonney are other osteotomies with different indications, not typically for first metatarsal shortening in hallux rigidus.

Question 6299

Topic: Forefoot

What is the typical age range for onset of symptoms in primary hallux rigidus?

. Adolescence (10-18 years)
. Young adults (18-30 years)
. Middle age (30-60 years)
. Elderly (>70 years)
. Congenital at birth

Correct Answer & Explanation

. Middle age (30-60 years)

Explanation

Primary hallux rigidus, which is degenerative in nature, typically presents with the onset of symptoms in middle age, generally between 30 and 60 years. While some individuals may experience earlier onset (juvenile hallux rigidus, often associated with specific anatomical factors like metatarsus primus elevatus), the vast majority of cases present in the middle-aged population, progressing with time. It is not congenital.

Question 6300

Topic: 8. Foot and Ankle

Which classification system for hallux rigidus focuses on the degree of radiographic degeneration and subchondral changes?

. Coughlin and Shurnas
. Hattrup and Johnson
. Regnauld
. Manchester-Oxford Foot Questionnaire (MOXFQ)
. American Orthopaedic Foot & Ankle Society (AOFAS) scoring system

Correct Answer & Explanation

. Coughlin and Shurnas

Explanation

The Coughlin and Shurnas classification system is widely adopted for hallux rigidus and focuses on the radiographic severity of the disease, categorizing it into four stages (0-4) based on osteophyte formation, joint space narrowing, and subchondral changes. Hattrup and Johnson and Regnauld are older or less commonly used classifications. MOXFQ and AOFAS are patient-reported outcome measures, not classification systems for disease severity.

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