Menu

8. Foot and Ankle MCQs

Practice Set 317 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 6321

Topic: Forefoot

When comparing cheilectomy to MTP joint arthrodesis for hallux rigidus, which statement is TRUE?

. Arthrodesis provides greater motion but less pain relief than cheilectomy.
. Cheilectomy is preferred for Stage 4 disease, while arthrodesis is for Stage 2.
. Arthrodesis generally offers more predictable and complete pain relief for severe stages, sacrificing motion.
. Cheilectomy has a higher rate of transfer metatarsalgia.
. Arthrodesis has a faster return to full activity.

Correct Answer & Explanation

. Arthrodesis generally offers more predictable and complete pain relief for severe stages, sacrificing motion.

Explanation

Arthrodesis (fusion) of the first MTP joint is generally recognized as providing the most predictable and complete pain relief for severe (Stage 3-4) hallux rigidus, albeit at the cost of sacrificing all motion at that joint. Cheilectomy is a joint-preserving procedure for earlier stages (Stage 1-2) aiming to improve motion. Cheilectomy does not have a higher rate of transfer metatarsalgia than arthrodesis. Arthrodesis typically has a longer recovery and return to full activity due to the need for bone healing.

Question 6322

Topic: 8. Foot and Ankle

Which condition is a common differential diagnosis for early hallux rigidus symptoms, particularly given similar patient demographics?

. Plantar fasciitis
. Morton's neuroma
. Gouty arthritis
. Tarsal tunnel syndrome
. Achilles tendinopathy

Correct Answer & Explanation

. Gouty arthritis

Explanation

Gouty arthritis, especially 'podagra' (gout of the great toe), is a common differential diagnosis for early hallux rigidus, as both can cause pain and inflammation in the first MTP joint. However, gout typically presents with acute, severe, often nocturnal attacks of redness, swelling, and excruciating pain, while hallux rigidus has a more insidious onset of chronic pain and stiffness. Distinguishing between the two is crucial for appropriate treatment. The other options are foot conditions affecting different areas or with distinct presentations.

Question 6323

Topic: 8. Foot and Ankle

A 35-year-old with painful Stage 2 hallux rigidus and associated metatarsus primus elevatus. He desires a joint-sparing procedure. In addition to a cheilectomy, which other procedure would be most appropriate?

. Keller arthroplasty
. First MTP joint arthrodesis
. Moberg osteotomy (proximal phalanx)
. Lapidus procedure (TMT fusion)
. Weil osteotomy of the second metatarsal

Correct Answer & Explanation

. Moberg osteotomy (proximal phalanx)

Explanation

For Stage 2 hallux rigidus with metatarsus primus elevatus, a cheilectomy is often combined with a Moberg osteotomy. While metatarsus primus elevatus directly implies a dorsally elevated first metatarsal, a Moberg osteotomy (dorsal closing wedge osteotomy of the proximal phalanx) works by effectively plantarflexing the proximal phalanx, thereby increasing functional dorsiflexion and addressing the limited motion caused by the elevated metatarsal and impingement. A distal metatarsal shortening/plantarflexion osteotomy could also be an option for metatarsus primus elevatus, but Moberg is a very common concomitant procedure with cheilectomy to enhance dorsiflexion. Keller arthroplasty and arthrodesis are joint-sacrificing. Lapidus addresses instability at the TMT joint. Weil is for lesser metatarsals.

Question 6324

Topic: Forefoot

What type of imaging is most sensitive for detecting early articular cartilage damage in hallux rigidus, not typically visible on plain radiographs?

. Computed Tomography (CT) scan
. Bone scintigraphy
. Magnetic Resonance Imaging (MRI)
. Ultrasound
. Weight-bearing plain radiographs

Correct Answer & Explanation

. Magnetic Resonance Imaging (MRI)

Explanation

Magnetic Resonance Imaging (MRI) is the most sensitive imaging modality for detecting early articular cartilage damage, subchondral bone marrow edema, and subtle soft tissue changes (e.g., synovitis) associated with hallux rigidus that are not typically visible on plain radiographs. CT scans are excellent for bony detail but less so for cartilage. Bone scintigraphy shows metabolic activity but is non-specific. Ultrasound can assess superficial soft tissues but not deep articular cartilage well. Plain radiographs show advanced bony changes but miss early cartilage loss.

Question 6325

Topic: Forefoot

After a first MTP joint arthrodesis, a patient complains of a stiff, painful interphalangeal (IP) joint of the great toe. What is the most likely cause?

. Infection of the IP joint
. Developing hallux valgus deformity
. Pre-existing, undiagnosed IP joint arthritis exacerbated by increased demands post-fusion
. Transfer metatarsalgia to the IP joint
. Neuroma formation at the IP joint

Correct Answer & Explanation

. Pre-existing, undiagnosed IP joint arthritis exacerbated by increased demands post-fusion

Explanation

A stiff, painful IP joint after first MTP arthrodesis strongly suggests pre-existing, undiagnosed (or underestimated) arthritis in the IP joint. Once the MTP joint is fused, the IP joint becomes the primary mobile joint for the great toe, experiencing increased stress and compensatory motion. If it already has degenerative changes, these will likely become symptomatic. This highlights the importance of thorough IP joint assessment pre-operatively. Infection, hallux valgus, transfer metatarsalgia (which typically refers to lesser MTP joints), and neuroma are less likely to directly cause diffuse stiffness and pain within the IP joint itself.

Question 6326

Topic: Forefoot

Which of the following is a potential complication specific to a proximal phalangeal osteotomy (Moberg type) for hallux rigidus?

. Recurrence of dorsal osteophytes
. Nonunion or delayed union of the osteotomy site
. Transfer metatarsalgia
. Flail toe deformity
. Deep vein thrombosis

Correct Answer & Explanation

. Nonunion or delayed union of the osteotomy site

Explanation

Nonunion or delayed union of the osteotomy site is a specific complication to any osteotomy, including the Moberg osteotomy. While rare, failure of the osteotomy to heal properly can lead to persistent pain and require revision. Recurrence of dorsal osteophytes is typically a complication of cheilectomy alone. Transfer metatarsalgia and flail toe are more associated with resection arthroplasties (like Keller). DVT is a general surgical complication.

Question 6327

Topic: Forefoot

Which of the following is NOT typically considered a primary etiologic factor for the development of hallux rigidus?

. Trauma (e.g., turf toe injury)
. Metatarsus primus elevatus
. Hyperpronation of the foot
. Rheumatoid arthritis
. Genetics

Correct Answer & Explanation

. Rheumatoid arthritis

Explanation

Rheumatoid arthritis is an inflammatory arthritis that can affect the first MTP joint, but it is distinct from primary hallux rigidus, which is a degenerative osteoarthritic process. While rheumatoid arthritis can lead to MTP joint destruction, it is considered a secondary cause rather than a primary etiologic factor for the typical hallux rigidus presentation. Trauma, metatarsus primus elevatus, hyperpronation (altering biomechanics), and genetics are all considered primary or contributing etiologic factors for hallux rigidus.

Question 6328

Topic: Forefoot

When evaluating a patient with hallux rigidus, a positive 'grind test' at the first MTP joint indicates:

. Integrity of the plantar plate
. Inflammation of the sesamoids
. Cartilage degeneration and bone-on-bone articulation
. Presence of a neuroma
. Subluxation of the MTP joint

Correct Answer & Explanation

. Cartilage degeneration and bone-on-bone articulation

Explanation

A positive 'grind test' (axial compression and rotation of the MTP joint) that elicits pain and often crepitus is indicative of significant articular cartilage degeneration and bone-on-bone articulation within the joint. This test directly stresses the joint surfaces, making it a reliable indicator of the extent of arthritic changes in hallux rigidus. It is not primarily for plantar plate integrity, sesamoid inflammation (though they may be involved), neuroma, or subluxation (though subluxation can be part of advanced degeneration).

Question 6329

Topic: 8. Foot and Ankle

A patient presents with pain and swelling over the Achilles tendon. Histological examination reveals angiofibroblastic hyperplasia and disorganized collagen fibers, but no inflammatory cells. This pathology is most consistent with:

. Acute tendinitis
. Tendinosis
. Tenosynovitis
. Partial tendon rupture
. Gouty tendinopathy

Correct Answer & Explanation

. Tendinosis

Explanation

This description is classic for tendinosis (or tendinopathy), which is a degenerative process characterized by disorganized, degenerated collagen, increased ground substance, vascular proliferation (angiofibroblastic hyperplasia), and a notableabsenceof significant inflammatory cells. Acute tendinitis implies active inflammation. Tenosynovitis is inflammation of the tendon sheath. Partial rupture is a macroscopic tear. Gout involves urate crystal deposition.

Question 6330

Topic: Ankle Trauma & Sports

A 30-year-old male sustains a twisting injury to his ankle while playing basketball. He has significant pain and swelling over the lateral malleolus. X-rays show a spiral fracture of the distal fibula extending proximally, with widening of the medial clear space and an intact deltoid ligament on stress views. What is the most appropriate classification for this injury?

. Weber A
. Weber B
. Weber C
. Maisonneuve fracture
. Pilon fracture

Correct Answer & Explanation

. Maisonneuve fracture

Explanation

This describes a classic Maisonneuve fracture. It is an external rotation injury characterized by a spiral fracture of the proximal fibula (often extending into the shaft, as described by 'distal fibula extending proximally'), associated with disruption of the syndesmotic ligaments, and medial ankle injury (either a deltoid ligament rupture or medial malleolus fracture). The widening of the medial clear space indicates medial ankle instability. While the description mentions an 'intact deltoid ligament on stress views,' significant medial clear space widening implies functional compromise of the medial stabilizers, even if the main deltoid fibers are not overtly torn or it's a subtle injury combined with syndesmotic failure. The high fibula fracture is the key distinguishing feature differentiating it from Weber type ankle fractures which are limited to the distal fibula.

Question 6331

Topic: 8. Foot and Ankle

A 25-year-old athlete sustains a severe inversion injury to her ankle. She reports a 'pop' and significant swelling. Physical exam reveals gross instability of the ankle mortise on stress radiographs. Which ligament is most commonly injured in severe ankle inversion sprains?

. Deltoid ligament
. Calcaneofibular ligament
. Posterior talofibular ligament
. Anterior talofibular ligament
. Syndesmotic ligaments

Correct Answer & Explanation

. Anterior talofibular ligament

Explanation

The anterior talofibular ligament (ATFL) is the weakest and most commonly injured ligament in ankle inversion sprains, often as an isolated injury or as the first to rupture in a more severe injury. In severe inversion injuries leading to gross instability, the ATFL is almost certainly ruptured, frequently in conjunction with the calcaneofibular ligament (CFL) and sometimes the posterior talofibular ligament (PTFL). The deltoid ligament is on the medial side and is injured with eversion. Syndesmotic ligaments are injured with external rotation or high-energy trauma.

Question 6332

Topic: 8. Foot and Ankle

A 45-year-old runner complains of burning pain and numbness in her toes, particularly the plantar surface of the first three toes. Symptoms are exacerbated by prolonged standing and relieved by rest. Tinel's sign is positive behind the medial malleolus. Which nerve is most likely entrapped?

. Deep peroneal nerve
. Superficial peroneal nerve
. Sural nerve
. Saphenous nerve
. Tibial nerve

Correct Answer & Explanation

. Tibial nerve

Explanation

This constellation of symptoms is highly characteristic of tarsal tunnel syndrome, which results from compression of the tibial nerve (or its branches) as it passes through the tarsal tunnel behind the medial malleolus. The burning pain and numbness in the plantar surface of the toes, exacerbation with activity, and a positive Tinel's sign behind the medial malleolus are all classic findings for tibial nerve entrapment. Other nerves listed have different sensory distribution patterns.

Question 6333

Topic: Forefoot

A 65-year-old female presents with a painful bunion deformity (hallux valgus). She has failed conservative management. Clinical examination shows a painful hallux valgus angle of 35 degrees and an intermetatarsal angle of 18 degrees. What is the most appropriate surgical procedure for this deformity?

. McBride bunionectomy
. Akin osteotomy
. Cheilectomy
. Chevron osteotomy
. Proximal metatarsal osteotomy (e.g., Ludloff or scarf) combined with soft tissue release

Correct Answer & Explanation

. Proximal metatarsal osteotomy (e.g., Ludloff or scarf) combined with soft tissue release

Explanation

For moderate to severe hallux valgus deformities (typically Hallux Valgus Angle >30 degrees and Intermetatarsal Angle >15 degrees, as seen here with HVA 35 and IMA 18), a proximal first metatarsal osteotomy (such as a Ludloff, Scarf, or crescentic osteotomy) combined with a distal soft tissue release (McBride-type) is generally indicated. This combination allows for significant correction of both the intermetatarsal angle and the hallux valgus angle. A Chevron osteotomy (distal metatarsal osteotomy) is usually reserved for mild-to-moderate deformities (IMA <15 degrees). Akin osteotomy is a phalangeal osteotomy used for residual hallux valgus and is often combined with metatarsal osteotomies. Cheilectomy is for hallux rigidus.

Question 6334

Topic: 8. Foot and Ankle

A 45-year-old weekend warrior sustains a sudden, sharp pain in his calf while playing squash, feeling like he was 'shot in the leg.' He has a palpable gap in the Achilles tendon and a positive Thompson test. What is the most appropriate management for a complete Achilles tendon rupture in an active individual, aiming for early return to sport?

. Non-weight-bearing cast for 8 weeks
. Functional bracing with progressive weight-bearing
. Open surgical repair followed by rehabilitation
. Percutaneous repair followed by rehabilitation
. Corticosteroid injection and rest

Correct Answer & Explanation

. Open surgical repair followed by rehabilitation

Explanation

For active individuals with a complete Achilles tendon rupture who desire an early return to sport and wish to minimize the risk of re-rupture, surgical repair (open or percutaneous) followed by a structured rehabilitation protocol is generally preferred over non-operative management. Open surgical repair is often considered the gold standard for robust repair and offers a lower re-rupture rate, allowing for a more predictable and faster return to high-level activity. Functional bracing and progressive weight-bearing are components of the post-operative rehabilitation, not the primary treatment for the rupture itself in this context. Corticosteroid injections are contraindicated for tendon ruptures.

Question 6335

Topic: 8. Foot and Ankle

A 50-year-old male recreational athlete feels a sudden 'pop' in his right ankle while playing basketball. He experiences immediate pain and difficulty pushing off. Examination reveals a palpable gap approximately 5 cm proximal to the calcaneal insertion of the Achilles tendon. The Thompson test is positive. What is the most appropriate management for this acute injury?

. Non-weight bearing in a posterior splint for 2 weeks followed by physical therapy
. Surgical repair of the Achilles tendon
. Percutaneous repair with early range of motion exercises
. Long-leg cast immobilization for 8 weeks
. Oral corticosteroids and rest

Correct Answer & Explanation

. Surgical repair of the Achilles tendon

Explanation

An acute Achilles tendon rupture, as described by the sudden pop, palpable gap, and positive Thompson test, requires definitive management. For an active, relatively young recreational athlete, surgical repair (either open or percutaneous) is generally recommended to restore strength, minimize re-rupture risk, and facilitate an earlier return to sports. While non-operative treatment can be successful in select low-demand patients, surgical repair is often preferred in active individuals. Percutaneous repair can be an option to minimize wound complications, but open repair is often considered the gold standard for robust repair. Non-weight bearing in a splint alone is not definitive. A long-leg cast is overly restrictive and may lead to stiffness. Corticosteroids are contraindicated as they weaken tendons.

Question 6336

Topic: 8. Foot and Ankle

A 38-year-old male with a history of psoriasis presents with inflammatory back pain, bilateral sacroiliac joint pain, and enthesitis at the Achilles tendon insertions. Radiographs of the pelvis show sacroiliitis. Genetic testing reveals positivity for HLA-B27. What is the most likely associated orthopedic manifestation requiring close monitoring?

. Gouty arthritis of the first MTP joint
. Rheumatoid arthritis of the MCP joints
. Atlantoaxial subluxation
. Osteonecrosis of the femoral head
. Charcot arthropathy

Correct Answer & Explanation

. Atlantoaxial subluxation

Explanation

The patient's presentation (psoriasis, inflammatory back pain, sacroiliitis, enthesitis, HLA-B27 positivity) is highly characteristic of psoriatic arthritis (PsA) and other seronegative spondyloarthropathies, such as ankylosing spondylitis. Atlantoaxial subluxation is a serious orthopedic manifestation that can occur in these conditions, particularly in advanced cases, leading to cervical myelopathy if left untreated. Gout is characterized by monosodium urate crystal deposition. Rheumatoid arthritis typically involves small joints of the hands and feet, is often seropositive for RF/anti-CCP, and has a different systemic profile. Osteonecrosis can be associated with corticosteroid use, but not directly with PsA. Charcot arthropathy is neuropathic and related to loss of sensation.

Question 6337

Topic: 8. Foot and Ankle

A 58-year-old obese female presents with a progressive, painful flatfoot deformity of her right foot. She reports swelling and tenderness along the medial ankle, particularly posterior to the medial malleolus. Examination reveals a 'too many toes' sign, hindfoot valgus, and inability to perform a single-leg heel raise. The patient can actively invert her foot against resistance when non-weight-bearing, but loses the arch upon weight-bearing. What is the most likely diagnosis?

. Tarsal coalition
. Posterior tibial tendon dysfunction (PTTD)
. Charcot arthropathy
. Spring ligament rupture
. Plantar fasciitis

Correct Answer & Explanation

. Posterior tibial tendon dysfunction (PTTD)

Explanation

The patient's presentation of a progressive, painful flatfoot with 'too many toes' sign, hindfoot valgus, inability to perform a single-leg heel raise, and tenderness along the posterior tibial tendon are all hallmarks of adult acquired flatfoot deformity due to Posterior Tibial Tendon Dysfunction (PTTD). The ability to actively invert non-weight-bearing but collapse on weight-bearing suggests a flexible deformity. Spring ligament rupture can contribute to or result from PTTD. Tarsal coalition is usually diagnosed in childhood/adolescence as a rigid flatfoot. Charcot arthropathy is neuropathic. Plantar fasciitis causes heel pain, not typically a progressive flatfoot deformity with tendon dysfunction.

Question 6338

Topic: 8. Foot and Ankle

A 62-year-old male presents with a chronic, non-healing ulcer on his left heel. He has a history of type 2 diabetes with peripheral neuropathy. Examination reveals a deep, infected ulcer over the plantar aspect of the calcaneus with surrounding cellulitis. Radiographs show diffuse bony destruction and disorganization of the midfoot and hindfoot joints. What is the most appropriate management of the underlying bony pathology?

. Strict offloading with a total contact cast and long-term antibiotics
. Surgical debridement of the ulcer only
. Aggressive glycemic control and wound care
. Surgical reconstruction of the Charcot foot deformity and internal fixation
. Amputation below the knee

Correct Answer & Explanation

. Surgical reconstruction of the Charcot foot deformity and internal fixation

Explanation

The patient's history (diabetes, neuropathy), clinical presentation (non-healing ulcer, cellulitis), and radiographic findings (bony destruction and disorganization of midfoot/hindfoot joints) are classic for a Charcot arthropathy (neuropathic osteoarthropathy) complicated by infection. While strict offloading with a total contact cast and antibiotics are crucial for managing the acute infection and preventing progression, definitive management of the underlying bony pathology in a stable, non-infected Charcot foot often involves surgical reconstruction and internal fixation to stabilize the joints, correct deformity, and facilitate wound healing, especially when conservative measures fail or deformity is severe. Amputation is a salvage procedure. Surgical debridement of the ulcer alone does not address the underlying bony instability. Aggressive glycemic control is important but not a direct treatment for the structural foot deformity.

Question 6339

Topic: 8. Foot and Ankle
Which type of fracture pattern of the talar neck is associated with the highest risk of avascular necrosis (AVN) of the talar body?
. Hawkins Type I
. Hawkins Type II
. Hawkins Type III
. Hawkins Type IV
. Talar body fracture

Correct Answer & Explanation

. Hawkins Type III

Explanation

Hawkins classification for talar neck fractures is based on the degree of dislocation of the subtalar and ankle joints, and it correlates with the risk of avascular necrosis (AVN) of the talar body. Type III fractures (talar neck fracture with dislocation of the subtalar and ankle joints) have the highest risk of AVN, approaching 90-100%, because both major blood supplies to the talar body (from the tarsal sinus/canal and deltoid branch) are disrupted. Type I has no displacement (0-15% AVN), Type II has subtalar dislocation (20-50% AVN), and Type IV involves dislocation of the talonavicular joint in addition to Type III (also very high AVN risk, often grouped with Type III for highest risk).

Question 6340

Topic: 8. Foot and Ankle

Which of the following is the most appropriate indication for surgical stabilization of a chronically painful symptomatic os trigonum?

. Acute ankle sprain with associated os trigonum on X-ray
. Asymptomatic os trigonum found incidentally on imaging
. Chronic posterior ankle pain exacerbated by forced plantarflexion and failed conservative management
. Anterior ankle impingement symptoms
. Recurrent Achilles tendinitis

Correct Answer & Explanation

. Chronic posterior ankle pain exacerbated by forced plantarflexion and failed conservative management

Explanation

An os trigonum is an accessory ossicle posterior to the talus, usually fused by age 7-10. Symptomatic os trigonum, often causing posterior ankle impingement, typically presents with chronic posterior ankle pain exacerbated by forced plantarflexion (e.g., ballet dancers). Surgical excision is indicated only after failure of conservative management (rest, NSAIDs, injections). Acute ankle sprains might reveal an os trigonum, but it's not the primary pathology. Asymptomatic ossicles do not warrant surgery. Anterior ankle impingement involves anterior osteophytes. Recurrent Achilles tendinitis is a separate pathology, though it can co-exist.

Test Yourself

Switch to an interactive, timed exam simulation to truly master this topic.

On this Page