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8. Foot and Ankle MCQs

Practice Set 316 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 6301

Topic: 8. Foot and Ankle

In the context of hallux rigidus, what does 'metatarsus primus elevatus' refer to?

. A condition where the first metatarsal is abnormally short
. An excessively abducted first metatarsal, leading to bunion formation
. A condition where the first metatarsal is dorsally angulated or elevated relative to the lesser metatarsals
. An increased intermetatarsal angle between the first and second metatarsals
. A congenital fusion of the first metatarsal and medial cuneiform

Correct Answer & Explanation

. A condition where the first metatarsal is dorsally angulated or elevated relative to the lesser metatarsals

Explanation

Metatarsus primus elevatus describes a condition where the first metatarsal is dorsally angulated or elevated relative to the lesser metatarsals and the ground. This elevation reduces the functional arc of dorsiflexion at the first MTP joint, as the metatarsal head impinges earlier against the base of the proximal phalanx. It is considered a predisposing factor or contributing mechanical cause for hallux rigidus. It is distinct from shortening, abduction, or increased intermetatarsal angle.

Question 6302

Topic: 8. Foot and Ankle

What is the primary biomechanical effect of a successful first MTP joint arthrodesis on the gait cycle?

. Increased pronation of the subtalar joint
. Loss of the 'windlass mechanism' for push-off
. Enhanced shock absorption during heel strike
. Increased dorsiflexion of the ankle joint
. Improved intrinsic muscle strength

Correct Answer & Explanation

. Loss of the 'windlass mechanism' for push-off

Explanation

A successful first MTP joint arthrodesis eliminates motion at this critical joint. This directly leads to a loss of the 'windlass mechanism,' which relies on passive dorsiflexion of the MTP joint to tighten the plantar fascia and create a rigid lever for propulsion during the toe-off phase of gait. While patients learn to compensate, the inherent mechanism is lost. It does not primarily affect subtalar pronation, shock absorption at heel strike, or ankle dorsiflexion, nor does it inherently improve intrinsic muscle strength.

Question 6303

Topic: 8. Foot and Ankle

Which of the following interventions is most likely to reduce symptoms in early-stage hallux rigidus by limiting MTP joint motion and thereby reducing impingement?

. Daily stretching exercises for the great toe
. Wearing shoes with a wide toe box and soft soles
. Custom orthotics with a rigid forefoot extension or carbon fiber plate
. Regular corticosteroid injections every 3 months
. Physical therapy focusing on strengthening intrinsic foot muscles

Correct Answer & Explanation

. Custom orthotics with a rigid forefoot extension or carbon fiber plate

Explanation

Custom orthotics with a rigid forefoot extension, a stiff-soled shoe, or a carbon fiber plate are highly effective in early-stage hallux rigidus. By limiting dorsiflexion at the first MTP joint, they reduce the painful dorsal impingement that characterizes the condition, thus providing symptomatic relief during weight-bearing and propulsion. Stretching exercises might exacerbate pain. Soft-soled shoes offer little support. Regular corticosteroid injections are not a first-line mechanical solution, and strengthening intrinsic muscles, while beneficial for overall foot health, does not directly address the mechanical impingement causing pain in hallux rigidus.

Question 6304

Topic: Forefoot

In a patient presenting with hallux rigidus, why is the term 'hallux limitus' sometimes used, and what does it typically refer to?

. It refers to an earlier stage of the disease where motion is merely limited, not completely rigid.
. It describes a variant where the great toe is fused at birth.
. It is an old term for hallux valgus with limited motion.
. It indicates stiffness of the interphalangeal joint of the great toe.
. It is a misnomer, and the term 'hallux rigidus' should always be used.

Correct Answer & Explanation

. It refers to an earlier stage of the disease where motion is merely limited, not completely rigid.

Explanation

'Hallux limitus' is often used interchangeably with or to describe an earlier stage of hallux rigidus. It refers to a condition where there is a significant limitation of motion (particularly dorsiflexion) at the first MTP joint, but the joint is not yet 'rigid' or completely fused/ankylosed. It represents a continuum where the degenerative process has started, leading to restricted motion, but full-blown osteoarthritis with severe rigidity may not yet be present. Essentially, hallux limitus progresses to hallux rigidus.

Question 6305

Topic: 8. Foot and Ankle

Which surgical technique, usually performed in conjunction with a cheilectomy, aims to elevate the plantar aspect of the first metatarsal head, thereby decompressing the MTP joint?

. Moberg osteotomy
. Keller arthroplasty
. Closing wedge osteotomy of the proximal phalanx
. Dorsal closing wedge osteotomy of the first metatarsal (e.g., Watermann osteotomy)
. Lapidus procedure

Correct Answer & Explanation

. Dorsal closing wedge osteotomy of the first metatarsal (e.g., Watermann osteotomy)

Explanation

A dorsal closing wedge osteotomy of the first metatarsal, such as the Watermann osteotomy or a modified version, aims to elevate the plantar aspect of the metatarsal head. This effectively dorsiflexes the metatarsal head relative to the shaft, thereby decompressing the first MTP joint by lowering the articular surface and creating more space for dorsiflexion. This is distinct from a Moberg osteotomy (proximal phalanx plantarflexion), Keller arthroplasty (resection), or Lapidus (TMT fusion). Closing wedge of the proximal phalanx is another term for Moberg, which does not elevate the metatarsal head.

Question 6306

Topic: 8. Foot and Ankle

Which of the following is considered a primary contraindication to a Keller arthroplasty for hallux rigidus?

. Low demand, elderly patient
. Severe Stage 4 hallux rigidus
. Long first metatarsal (Morton's toe)
. Presence of a significant hallux valgus deformity
. Patient concern about a flail toe or transfer metatarsalgia

Correct Answer & Explanation

. Patient concern about a flail toe or transfer metatarsalgia

Explanation

A Keller arthroplasty, involving resection of the base of the proximal phalanx, historically resulted in high rates of a 'flail toe' (unstable, weak toe) and transfer metatarsalgia (pain under the lesser metatarsal heads due to altered weight distribution). Therefore, patient concern about these specific complications, which are inherent to the procedure, would be a strong contraindication or at least a significant counseling point against it. While elderly, low-demand patients might tolerate it, and it can be used for Stage 4, its complications make it largely obsolete. A long first metatarsal or hallux valgus are not primary contraindications, though they might influence the extent of resection or concomitant procedures.

Question 6307

Topic: Forefoot

A patient presents with pain and stiffness in the first MTP joint, but physical exam reveals a painful and restricted MTP joint that is fixed in 10 degrees of plantarflexion. Radiographs confirm joint space narrowing and osteophytes. This specific fixed deformity is known as:

. Hallux valgus
. Hallux varus
. Hallux saltans
. Hallux extensus
. Hallux flexus

Correct Answer & Explanation

. Hallux flexus

Explanation

Hallux flexus refers to a painful and rigid deformity of the great toe MTP joint where it is fixed in plantarflexion. This is a less common presentation of hallux rigidus, as the typical restriction is in dorsiflexion, but it can occur and cause similar pain and functional limitations. Hallux valgus and varus refer to transverse plane deformities. Hallux saltans refers to a snapping toe. Hallux extensus would imply fixed dorsiflexion, which is not the case here.

Question 6308

Topic: 8. Foot and Ankle
What is the primary goal of the Regnauld classification for hallux rigidus?
. To guide non-operative management strategies
. To specifically categorize the location and size of dorsal osteophytes
. To assess the degree of sesamoid involvement
. To correlate clinical symptoms with radiographic findings for surgical planning
. To describe the three types of degenerative changes within the joint

Correct Answer & Explanation

. To describe the three types of degenerative changes within the joint

Explanation

The Regnauld classification for hallux rigidus describes three types of degenerative changes within the joint: Type I (degenerative changes in the phalanx), Type II (degenerative changes in the metatarsal head), and Type III (diffuse degenerative changes throughout the joint). It focuses on the primary sites of arthrosis within the joint components. While it indirectly informs surgical planning, its primary goal is to characterize the pattern of degeneration. The Coughlin & Shurnas classification is more commonly used for overall staging and guiding management.

Question 6309

Topic: 8. Foot and Ankle

Which of the following factors is most likely to predispose a patient to juvenile hallux rigidus?

. Excessive pronation of the foot
. Tarsal coalition
. Hypertrophy of the sesamoids
. Metatarsus primus elevatus
. Juvenile rheumatoid arthritis

Correct Answer & Explanation

. Metatarsus primus elevatus

Explanation

Metatarsus primus elevatus, where the first metatarsal is congenitally or developmentally dorsally angulated, is a strong predisposing factor for juvenile hallux rigidus. This anatomical variant reduces the functional arc of dorsiflexion at the first MTP joint, leading to early impingement and degenerative changes. While excessive pronation or hypertrophy of sesamoids can contribute to foot pathology, metatarsus primus elevatus is specifically linked to the early onset of hallux rigidus. Tarsal coalition affects hindfoot motion, and juvenile rheumatoid arthritis is an inflammatory condition distinct from primary hallux rigidus.

Question 6310

Topic: Forefoot

After a cheilectomy, a patient reports continued pain localized to the dorsal medial aspect of the great toe, particularly with light touch or shoe wear. What is the most likely iatrogenic complication?

. Infection
. Neuroma of the medial dorsal cutaneous nerve
. Recurrent osteophyte formation
. Plantar plate tear
. Deep vein thrombosis

Correct Answer & Explanation

. Neuroma of the medial dorsal cutaneous nerve

Explanation

Pain with light touch (allodynia) or direct pressure over a nerve distribution, particularly following surgery in that area, is highly suggestive of a neuroma. The medial dorsal cutaneous nerve, a branch of the superficial fibular nerve, courses dorsally over the first MTP joint and is at risk of injury or entrapment during approaches for cheilectomy, leading to neuroma formation. Recurrent osteophyte formation would typically present with mechanical impingement symptoms rather than neuropathic pain. Infection would have signs of inflammation, and DVT and plantar plate tears are unrelated to this specific presentation.

Question 6311

Topic: Forefoot

In which stage of Coughlin and Shurnas classification for hallux rigidus is a cheilectomy alone typically considered insufficient, often requiring a concomitant osteotomy or moving towards arthroplasty/arthrodesis?

. Stage 0
. Stage 1
. Stage 2
. Stage 3
. Stage 4

Correct Answer & Explanation

. Stage 3

Explanation

In Stage 3 hallux rigidus, there is significant osteophyte formation, moderate-to-severe joint space narrowing, and subchondral sclerosis affecting greater than 50% of the articular surface. At this stage, a cheilectomy alone is often insufficient to restore adequate motion and provide lasting pain relief due to the extensive articular damage. It is frequently combined with a Moberg osteotomy (proximal phalangeal plantarflexion osteotomy) to enhance dorsiflexion, or considered for salvage procedures like arthroplasty or arthrodesis if symptoms are severe and cartilage loss is extensive. Stage 0, 1, and 2 are more amenable to isolated cheilectomy.

Question 6312

Topic: 8. Foot and Ankle

What is the primary mechanism by which a Moberg osteotomy improves function in hallux rigidus?

. It shortens the first metatarsal bone.
. It rotates the proximal phalanx into relative plantarflexion, increasing functional dorsiflexion at the MTP joint.
. It directly removes dorsal osteophytes.
. It stabilizes the sesamoid apparatus.
. It lengthens the plantar fascia.

Correct Answer & Explanation

. It rotates the proximal phalanx into relative plantarflexion, increasing functional dorsiflexion at the MTP joint.

Explanation

A Moberg osteotomy (dorsal closing wedge osteotomy of the proximal phalanx) works by rotating the proximal phalanx into a relatively more plantarflexed position. This effectively shifts the arc of motion, allowing for greater functional dorsiflexion at the MTP joint before impingement occurs, without actually increasing the anatomical range of motion of the MTP joint itself. It is a joint-preserving procedure that aims to improve toe-off. It does not shorten the metatarsal, remove osteophytes (that's cheilectomy), stabilize sesamoids, or lengthen the plantar fascia.

Question 6313

Topic: 8. Foot and Ankle

Which type of metatarsal osteotomy is specifically designed to treat metatarsus primus elevatus by plantarflexing the first metatarsal head?

. Cheilectomy
. Austin bunionectomy
. Closing wedge osteotomy of the first metatarsal (e.g., Green-Watermann, Watermann)
. Lapidus fusion
. Weil osteotomy

Correct Answer & Explanation

. Closing wedge osteotomy of the first metatarsal (e.g., Green-Watermann, Watermann)

Explanation

Closing wedge osteotomies of the first metatarsal, such as the Green-Watermann or Watermann osteotomy, are specifically designed to address metatarsus primus elevatus. These procedures involve removing a dorsal wedge from the metatarsal neck or shaft to effectively plantarflex the distal segment, thereby lowering the first metatarsal head relative to the ground and reducing the effective dorsal impingement at the MTP joint. Cheilectomy removes osteophytes. Austin bunionectomy is for hallux valgus correction. Lapidus is for TMT fusion. Weil osteotomy is a shortening osteotomy of lesser metatarsals.

Question 6314

Topic: Forefoot

A patient with Stage 4 hallux rigidus presents with severe pain and a desire to remain active, including hiking. Considering their desire for activity, which surgical procedure is most likely to provide a durable, pain-free outcome?

. Keller arthroplasty
. Silicone MTP joint implant
. First MTP joint arthrodesis
. Interpositional arthroplasty with soft tissue
. Dorsal cheilectomy with Moberg osteotomy

Correct Answer & Explanation

. First MTP joint arthrodesis

Explanation

For Stage 4 hallux rigidus in an active patient, first MTP joint arthrodesis (fusion) is the most reliable option for providing a durable, pain-free, and stable platform. While it eliminates motion, the stability it provides is excellent for high-demand activities. Keller arthroplasty and silicone implants are associated with high failure rates, instability, and transfer metatarsalgia in active individuals. Interpositional arthroplasty is less predictable for stability in high-demand settings. Cheilectomy with Moberg osteotomy is reserved for earlier stages with more preserved joint cartilage.

Question 6315

Topic: Forefoot

Which non-operative treatment for hallux rigidus specifically targets inflammation within the joint capsule?

. Rocker-bottom shoes
. Carbon fiber plate inserts
. First MTP joint corticosteroid injection
. Activity modification to avoid aggravating activities
. Use of toe spacers

Correct Answer & Explanation

. First MTP joint corticosteroid injection

Explanation

A first MTP joint corticosteroid injection directly delivers an anti-inflammatory agent into the joint space, targeting the synovitis and inflammation within the joint capsule that contributes to pain in hallux rigidus. Rocker-bottom shoes, carbon fiber plates, and activity modification are mechanical solutions that limit motion. Toe spacers address interdigital pressure or alignment, not joint inflammation directly.

Question 6316

Topic: Forefoot

A patient with hallux rigidus undergoes a cheilectomy and Moberg osteotomy. Six weeks post-operatively, they complain of persistent stiffness and pain with dorsiflexion. On examination, the MTP joint is still restricted. What is the most likely reason for this persistent stiffness?

. Early arthrodesis of the joint
. Transfer metatarsalgia to the lesser toes
. Inadequate bone resection during cheilectomy or insufficient Moberg correction
. Fracture of the proximal phalanx
. Complex Regional Pain Syndrome (CRPS)

Correct Answer & Explanation

. Inadequate bone resection during cheilectomy or insufficient Moberg correction

Explanation

Persistent stiffness and pain with dorsiflexion after a cheilectomy and Moberg osteotomy strongly suggest inadequate bone resection or insufficient correction. If the osteophytes were not fully removed or the Moberg osteotomy did not provide enough relative plantarflexion of the phalanx, impingement will persist. Early arthrodesis implies complete fusion, which is not the goal. Transfer metatarsalgia is pain in lesser toes. Fracture would cause acute pain and instability. CRPS would present with a constellation of neurovascular symptoms, not just mechanical stiffness.

Question 6317

Topic: Forefoot

When advising on footwear for a patient with early-stage hallux rigidus, which feature is most important?

. High heels for aesthetic purposes
. Flexible sole to allow maximal toe motion
. Tight-fitting toe box to immobilize the joint
. Rigid sole, often with a rocker-bottom design, and a wide, deep toe box
. Open-toed sandals exclusively

Correct Answer & Explanation

. Rigid sole, often with a rocker-bottom design, and a wide, deep toe box

Explanation

For early-stage hallux rigidus, the most important footwear features are a rigid sole (often with a rocker-bottom or rigid shank) to minimize motion at the first MTP joint during gait, and a wide, deep toe box to prevent compression and irritation of the dorsal osteophytes. Flexible soles exacerbate pain by allowing painful dorsiflexion. High heels and tight toe boxes increase pressure and pain. Open-toed sandals may be comfortable for some but don't offer the necessary rigidity.

Question 6318

Topic: Forefoot

Which clinical test specifically assesses the functional range of dorsiflexion at the first MTP joint in a weight-bearing scenario, which is often limited in hallux rigidus?

. Lachman test
. Thomson test
. Hubscher's maneuver (Jack's Test)
. Anterior drawer test
. Tinel's sign

Correct Answer & Explanation

. Hubscher's maneuver (Jack's Test)

Explanation

Hubscher's maneuver, also known as Jack's Test, is a clinical test performed in a weight-bearing patient. The examiner dorsiflexes the great toe, which should lead to elevation of the medial longitudinal arch if the windlass mechanism is intact. In hallux rigidus, due to limited MTP dorsiflexion, this maneuver will be painful, restricted, and the arch may not elevate, indicating impaired functional dorsiflexion and a compromised windlass mechanism. The other tests are for different anatomical regions or pathologies.

Question 6319

Topic: 8. Foot and Ankle

A 40-year-old with a high arch (pes cavus) and Stage 2 hallux rigidus presents for evaluation. How might the pes cavus foot type contribute to the development or exacerbation of hallux rigidus?

. It typically leads to increased flexibility of the first MTP joint.
. It causes hyperpronation, which offloads the first ray.
. The rigid nature of the cavus foot often results in a fixed plantarflexed first metatarsal, increasing MTP joint compression.
. It promotes transfer metatarsalgia to the medial forefoot, protecting the great toe.
. It leads to a functional shortening of the first metatarsal, reducing joint stress.

Correct Answer & Explanation

. The rigid nature of the cavus foot often results in a fixed plantarflexed first metatarsal, increasing MTP joint compression.

Explanation

A rigid pes cavus foot, particularly when associated with a fixed plantarflexed first metatarsal (often seen in cavus feet), increases the load and compression across the first MTP joint. This increased stress and decreased effective dorsiflexion contribute to accelerated degenerative changes and the development or exacerbation of hallux rigidus. It does not increase flexibility, cause hyperpronation, or functionally shorten the metatarsal. The rigid nature works against the normal shock absorption and adaptability of the foot.

Question 6320

Topic: Forefoot

Which of the following describes the purpose of a dorsiflexion-plantarflexion stress radiograph of the first MTP joint in the evaluation of hallux rigidus?

. To measure the intermetatarsal angle.
. To assess the integrity of the collateral ligaments.
. To quantify the true range of motion and identify the point of impingement.
. To determine the extent of sesamoidopathy.
. To evaluate midfoot collapse.

Correct Answer & Explanation

. To quantify the true range of motion and identify the point of impingement.

Explanation

Dorsiflexion-plantarflexion stress radiographs (often a lateral view) are used to dynamically assess the first MTP joint's range of motion and pinpoint the exact position and degree of bony impingement. This helps in surgical planning, especially for cheilectomy, to determine the amount of bone resection required to achieve adequate motion. It provides more functional information than static radiographs. It is not for intermetatarsal angle, collateral ligaments, sesamoidopathy, or midfoot collapse.

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