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8. Foot and Ankle MCQs

Practice Set 318 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 6341

Topic: Forefoot

Which of the following is the primary indication for surgical intervention in patients with hallux valgus deformity?

. Radiographic hallux valgus angle (HVA) greater than 20 degrees
. Presence of a painful bunion
. Associated hammertoe deformity
. Patient's desire for cosmetic improvement
. Difficulty finding shoes that fit

Correct Answer & Explanation

. Presence of a painful bunion

Explanation

The primary indication for surgical correction of hallux valgus (bunion deformity) is symptomatic pain that significantly interferes with daily activities or shoe wear, and has failed conservative management. While radiographic angles (HVA, IMA) and shoe-fitting difficulties are important considerations, pain is the overarching factor that drives the decision for surgery. Cosmetic improvement alone is generally not considered a primary indication for elective orthopedic surgery due to potential complications. Hammertoe is an associated deformity but not the primary indication for bunion surgery.

Question 6342

Topic: 8. Foot and Ankle

You are asked to explain the biomechanics of a walking boot (cam walker). What is the main principle of its function that an examiner would expect you to articulate?

. It keeps the foot warm.
. It is simply a comfortable shoe.
. It provides immobilization and protection for the foot/ankle, allows for controlled weight-bearing (if indicated), and reduces range of motion at the ankle to facilitate healing of specific injuries (e.g., stable ankle fractures, severe sprains, post-op).
. It actively corrects deformities.
. It only works for non-weight-bearing injuries.

Correct Answer & Explanation

. It provides immobilization and protection for the foot/ankle, allows for controlled weight-bearing (if indicated), and reduces range of motion at the ankle to facilitate healing of specific injuries (e.g., stable ankle fractures, severe sprains, post-op).

Explanation

The primary biomechanical principles of a walking boot are immobilization and protection of the injured foot/ankle. It effectively reduces painful motion and stress on healing tissues, while often allowing for controlled or protected weight-bearing, which is crucial for functional recovery and reducing complications associated with complete non-weight-bearing. Articulating these functions demonstrates an understanding of conservative management tools.

Question 6343

Topic: 8. Foot and Ankle

You are discussing the post-operative management of a patient who underwent Achilles tendon repair. The examiner asks, 'What is the rationale behind early functional rehabilitation (e.g., controlled ankle motion, early weight-bearing) versus traditional prolonged immobilization after Achilles repair?'

. Early functional rehabilitation primarily aims to reduce the risk of deep vein thrombosis (DVT).
. Traditional prolonged immobilization leads to a higher rate of re-rupture due to delayed healing.
. Early functional rehabilitation promotes collagen fiber alignment, improves tendon strength, reduces adhesion formation, and leads to faster return to activity without increasing the risk of re-rupture when carefully controlled.
. Early functional rehabilitation is solely for patient comfort and psychological well-being.
. There is no significant difference in outcomes; the choice is purely surgeon preference.

Correct Answer & Explanation

. Early functional rehabilitation promotes collagen fiber alignment, improves tendon strength, reduces adhesion formation, and leads to faster return to activity without increasing the risk of re-rupture when carefully controlled.

Explanation

The rationale for early functional rehabilitation after Achilles tendon repair is multifactorial and evidence-based. It promotes better collagen fiber alignment and maturation, improves tendon strength by stimulating mechanoreceptors, reduces the formation of adhesions that can restrict motion, and facilitates a faster return to activity. Modern protocols show that controlled early motion and weight-bearing, when carefully implemented, do not increase the risk of re-rupture compared to prolonged immobilization, and often lead to superior functional outcomes. While DVT prevention (A) is a benefit, it's not the primary rationale for tendon healing. Option B is incorrect; prolonged immobilization can lead to tendon weakening, but not necessarily higher re-rupture rates if protected. Options D and E are incomplete or incorrect.

Question 6344

Topic: 8. Foot and Ankle

An examiner asks you to describe your approach to a chronic non-healing ulcer on the foot of a diabetic patient. You outline history, examination, and initial investigations. The examiner then asks, 'What is the most critical first-line investigation to perform in ALL diabetic foot ulcers that will significantly guide further management?'

. Plain radiographs of the foot to rule out osteomyelitis.
. Blood tests including HbA1c and inflammatory markers.
. An Ankle-Brachial Index (ABI) and potentially toe pressures to assess peripheral arterial disease (PAD).
. Swab cultures for microbiology to identify pathogens.
. Electromyography (EMG) to assess for peripheral neuropathy.

Correct Answer & Explanation

. An Ankle-Brachial Index (ABI) and potentially toe pressures to assess peripheral arterial disease (PAD).

Explanation

For any chronic non-healing diabetic foot ulcer, assessing peripheral arterial disease (PAD) is paramount as adequate blood supply is essential for wound healing. An Ankle-Brachial Index (ABI) and/or toe pressures are critical first-line investigations. Without adequate perfusion, aggressive wound care, antibiotics, or even surgery will likely fail. While radiographs (A) for osteomyelitis, blood tests (B) for glycemic control and infection, cultures (D) for targeted antibiotics, and EMG (E) for neuropathy are all important, addressing perfusion (C) is often the most critical initial step impacting the entire management pathway.

Question 6345

Topic: 8. Foot and Ankle

You are discussing the indications for total ankle arthroplasty (TAA) versus ankle fusion. The examiner asks, 'What is the primary contraindication for total ankle arthroplasty that would strongly favor ankle fusion?'

. Patient age greater than 65 years old.
. Patient preference for quicker recovery.
. Active or recurrent infection in the ankle joint, severe deformity that is non-correctable, significant bone loss, or severe peripheral vascular disease.
. History of a prior ankle sprain.
. Presence of moderate obesity.

Correct Answer & Explanation

. Active or recurrent infection in the ankle joint, severe deformity that is non-correctable, significant bone loss, or severe peripheral vascular disease.

Explanation

The primary contraindications for total ankle arthroplasty (TAA) that would strongly favor ankle fusion include active or recurrent infection, severe deformity that cannot be corrected, significant bone loss that precludes stable implant placement, severe peripheral vascular disease (compromising healing), Charcot arthropathy, and neuropathic joints. These conditions significantly increase the risk of TAA failure, infection, and poor outcomes. Age (A) is a relative, not absolute, contraindication. Patient preference (B) is important but doesn't override absolute contraindications. Prior sprain (D) is irrelevant. Moderate obesity (E) is a relative contraindication, not absolute.

Question 6346

Topic: Ankle Trauma & Sports

You are presenting a case of recurrent instability of the distal tibiofibular syndesmosis after initial operative fixation. The examiner asks, 'What are the two most common reasons for recurrent instability after syndesmotic fixation?'

. Inadequate post-operative rehabilitation and early weight-bearing.
. Failure to address concomitant medial ankle instability and patient non-compliance.
. Malreduction of the syndesmosis during the initial surgery and/or hardware failure/loosening.
. Development of deep vein thrombosis and subsequent swelling.
. Over-tightening of the syndesmotic screw leading to fusion.

Correct Answer & Explanation

. Malreduction of the syndesmosis during the initial surgery and/or hardware failure/loosening.

Explanation

The two most common reasons for recurrent instability of the distal tibiofibular syndesmosis after initial operative fixation are malreduction of the syndesmosis during the primary surgery (often leading to persistent diastasis or impingement) and/or hardware failure or loosening (e.g., screw breakage, loosening of suture button). Correct anatomical reduction is paramount for long-term stability. While inadequate rehab (A) and non-compliance (B) can contribute, technical errors in reduction or hardware problems are often the primary culprits. DVT (D) is a complication, not a cause of instability. Over-tightening (E) can cause stiffness and pain but typically doesn't lead torecurrent instabilityas the primary issue.

Question 6347

Topic: 8. Foot and Ankle

You are asked about the surgical management of hallux valgus deformity. The examiner asks, 'What is the primary rationale for performing an osteotomy (e.g., Chevron or Scarf) in the management of moderate to severe hallux valgus, rather than just a bunionectomy?'

. To excise the prominent medial eminence and reduce pain from shoe wear.
. To realign the first metatarsal head and shaft to correct the metatarsus primus varus deformity, thereby addressing the underlying biomechanical cause and reducing recurrence.
. To shorten the first metatarsal to relieve pressure on the forefoot.
. To lengthen the adductor hallucis tendon and release the lateral capsule.
. To fuse the first metatarsophalangeal joint to ensure permanent correction.

Correct Answer & Explanation

. To realign the first metatarsal head and shaft to correct the metatarsus primus varus deformity, thereby addressing the underlying biomechanical cause and reducing recurrence.

Explanation

The primary rationale for performing an osteotomy (e.g., Chevron, Scarf, or Ludloff) in moderate to severe hallux valgus is to address the underlying metatarsus primus varus deformity by realigning the first metatarsal head and shaft. Simple bunionectomy (excision of the medial eminence) only addresses the symptomatic prominence and does not correct the pathological angulation, leading to a high recurrence rate. Osteotomies allow for accurate biomechanical correction, which is crucial for long-term success. Shortening (C) is a potential consequence or specific indication for some osteotomies, not the primary rationale. Lengthening the adductor hallucis (D) and capsular release are soft tissue procedures, often adjuncts. Fusion (E) is reserved for severe deformity, revision, or arthritic joints.

Question 6348

Topic: 8. Foot and Ankle

You are asked about surgical indications for hallux rigidus (osteoarthritis of the great toe MTP joint). The examiner asks, 'In a young, active patient with early to moderate hallux rigidus, what surgical procedure would you typically consider first, and what is its primary goal?'

. Arthrodesis (fusion) of the MTP joint to eliminate all pain.
. Cheilectomy, with the primary goal of decompressing the MTP joint by removing dorsal osteophytes and often part of the dorsal metatarsal head, thereby improving range of motion and reducing impingement pain.
. Resection arthroplasty (Keller procedure) to create a pseudoarthrosis.
. Total MTP joint replacement to restore full range of motion.
. Proximal phalangeal osteotomy (Moberg osteotomy) alone.

Correct Answer & Explanation

. Cheilectomy, with the primary goal of decompressing the MTP joint by removing dorsal osteophytes and often part of the dorsal metatarsal head, thereby improving range of motion and reducing impingement pain.

Explanation

For young, active patients with early to moderate hallux rigidus, a cheilectomy is typically the first-line surgical procedure. Its primary goal is to decompress the first metatarsophalangeal (MTP) joint by excising dorsal osteophytes and often a portion of the dorsal metatarsal head, thereby improving dorsiflexion range of motion and reducing pain from impingement. This procedure aims to preserve joint motion. Arthrodesis (A) is for severe disease. Keller procedure (C) is reserved for older, less active patients. Joint replacement (D) has variable results and is typically not first-line. Moberg osteotomy (E) can be an adjunct to increase dorsiflexion, but cheilectomy is fundamental for decompression.

Question 6349

Topic: 8. Foot and Ankle

A 25-year-old athlete presents with midfoot pain and plantar ecchymosis. Weight-bearing radiographs demonstrate a 3 mm diastasis between the first and second metatarsal bases. In a purely ligamentous injury of this type, which of the following treatments provides the most predictable long-term outcome?

. Non-weight bearing cast for 6 weeks
. Closed reduction and percutaneous pinning
. Primary arthrodesis of the first, second, and third tarsometatarsal joints
. Corticosteroid injection into the TMT joint
. Open reduction and internal fixation with flexible implants

Correct Answer & Explanation

. Primary arthrodesis of the first, second, and third tarsometatarsal joints

Explanation

Purely ligamentous Lisfranc injuries have a high rate of hardware failure and post-traumatic arthritis with ORIF. Primary arthrodesis of the medial columns (1st, 2nd, and 3rd TMT joints) provides superior long-term outcomes and reduces reoperation rates.

Question 6350

Topic: Midfoot & Hindfoot

A 55-year-old female presents with a progressive, painful flatfoot deformity. Examination reveals inability to perform a single-leg heel rise and excessive forefoot abduction. Radiographs demonstrate greater than 40% talonavicular uncoverage but flexible hindfoot and forefoot joints. What is the most appropriate surgical intervention?

. Total contact casting
. Flexor digitorum longus (FDL) transfer, medial displacement calcaneal osteotomy, and lateral column lengthening
. Triple arthrodesis
. Isolated repair of the spring ligament
. Isolated subtalar arthrodesis

Correct Answer & Explanation

. Flexor digitorum longus (FDL) transfer, medial displacement calcaneal osteotomy, and lateral column lengthening

Explanation

This is a Stage IIb adult acquired flatfoot deformity (flexible, with significant forefoot abduction). Treatment requires addressing both the medial column (FDL transfer, medial osteotomy) and the lateral column lengthening to correct the forefoot abduction.

Question 6351

Topic: 8. Foot and Ankle

A 25-year-old athlete presents with midfoot pain after a twisting injury. Non-weight-bearing radiographs are normal. What is the most appropriate next step to diagnose a subtle Lisfranc injury?

. CT scan of the midfoot
. Weight-bearing bilateral foot radiographs
. MRI of the midfoot
. Technetium bone scan
. Ultrasound of the Lisfranc ligament

Correct Answer & Explanation

. Weight-bearing bilateral foot radiographs

Explanation

Weight-bearing radiographs are essential for evaluating subtle Lisfranc injuries as they can reveal diastasis between the first and second metatarsals. If weight-bearing films are normal but clinical suspicion remains high, MRI or weight-bearing CT may be indicated.

Question 6352

Topic: 8. Foot and Ankle
A 32-year-old male sustains a Hawkins Type III talar neck fracture. Which of the following best describes the disruption of blood supply associated with this injury?
. Artery of the tarsal canal only
. Artery of the tarsal canal and tarsal sinus only
. Artery of the tarsal canal, tarsal sinus, and deltoid branches
. Dorsalis pedis branches only
. Posterior tibial artery main trunk

Correct Answer & Explanation

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

Explanation

A Hawkins Type III fracture involves dislocation of the talar body from both the subtalar and tibiotalar joints. This disrupts all three major sources of blood supply to the talus: the artery of the tarsal canal, artery of the tarsal sinus, and deltoid branches.

Question 6353

Topic: Midfoot & Hindfoot

A 55-year-old diabetic patient presents with a red, hot, swollen foot without an ulcer. Radiographs show fragmentation and subluxation of the midfoot. What is the most appropriate initial management?

. Intravenous antibiotics and surgical debridement
. Total contact casting and non-weight-bearing
. Immediate midfoot arthrodesis
. Custom orthotics with arch support
. Aspiration of the midfoot joints

Correct Answer & Explanation

. Total contact casting and non-weight-bearing

Explanation

This patient is in Eichenholtz Stage I (fragmentation) of Charcot arthropathy. The gold standard for initial management is immobilization with a total contact cast to prevent further deformity while the acute inflammatory phase resolves.

Question 6354

Topic: 8. Foot and Ankle

During a minimally invasive repair of an acute Achilles tendon rupture, the surgeon places percutaneous sutures in the proximal stump. Which neurological structure is at greatest risk during this step?

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

Correct Answer & Explanation

. Sural nerve

Explanation

The sural nerve crosses from medial to lateral, typically running about 1 to 2 cm lateral to the lateral border of the Achilles tendon in the proximal aspect. It is at high risk of entrapment or injury during percutaneous or minimally invasive Achilles repairs.

Question 6355

Topic: Midfoot & Hindfoot
A 45-year-old female presents with a flexible flatfoot deformity, unable to perform a single-leg heel rise, and >40% uncovering of the talonavicular joint on weight-bearing AP radiographs. What surgical procedure is specifically indicated to correct the forefoot abduction?
. Medial displacement calcaneal osteotomy
. Lateral column lengthening (Evans osteotomy)
. Spring ligament repair only
. Triple arthrodesis
. Isolated subtalar arthrodesis

Correct Answer & Explanation

. Lateral column lengthening (Evans osteotomy)

Explanation

This patient has Stage IIb posterior tibial tendon dysfunction, characterized by forefoot abduction (>30-40% talonavicular uncovering). A lateral column lengthening (Evans osteotomy) is indicated to specifically address and correct the forefoot abduction component.

Question 6356

Topic: Forefoot

A 40-year-old female presents with a painful bunion. Weight-bearing radiographs reveal a Hallux Valgus Angle (HVA) of 42 degrees and an Intermetatarsal Angle (IMA) of 18 degrees. Which of the following is the most appropriate surgical option?

. Distal chevron osteotomy
. Akin osteotomy alone
. Proximal metatarsal osteotomy or Lapidus procedure
. Keller resection arthroplasty
. First metatarsophalangeal joint arthrodesis

Correct Answer & Explanation

. Proximal metatarsal osteotomy or Lapidus procedure

Explanation

An IMA of >15 degrees and HVA >40 degrees defines a severe hallux valgus deformity. Proximal osteotomies or a first tarsometatarsal fusion (Lapidus) provide the necessary corrective power, whereas distal osteotomies are insufficient for this degree of deformity.

Question 6357

Topic: 8. Foot and Ankle

A 35-year-old male undergoes open reduction and internal fixation of a displaced intra-articular calcaneus fracture via a lateral extensile approach. What is the most common complication associated with this specific surgical approach?

. Sural nerve injury
. Subtalar arthritis
. Wound edge necrosis and dehiscence
. Peroneal tendon subluxation
. Deep vein thrombosis

Correct Answer & Explanation

. Wound edge necrosis and dehiscence

Explanation

The lateral extensile approach for calcaneus fractures relies on a full-thickness flap whose blood supply is tenuous (primarily the lateral calcaneal artery). Wound complications, particularly edge necrosis and dehiscence, occur in up to 10-25% of cases.

Question 6358

Topic: 8. Foot and Ankle

An MRI of a 28-year-old male with chronic ankle pain reveals a deep, cup-shaped osteochondral lesion on the posteromedial aspect of the talar dome. What is the typical mechanism of injury leading to this specific lesion?

. Inversion and dorsiflexion
. Inversion and plantarflexion
. Eversion and dorsiflexion
. Eversion and plantarflexion
. Direct axial load in neutral position

Correct Answer & Explanation

. Inversion and plantarflexion

Explanation

Posteromedial osteochondral lesions of the talus are typically deeper and cup-shaped, caused by an inversion and plantarflexion injury. Anterolateral lesions are typically shallower, wafer-shaped, and caused by inversion and dorsiflexion (DIAL a PIMP mnemonic).

Question 6359

Topic: 8. Foot and Ankle

A patient with Charcot-Marie-Tooth disease presents with a bilateral cavovarus foot deformity. A Coleman block test is performed, and the hindfoot corrects to neutral. What does this physical examination finding indicate?

. The hindfoot deformity is rigid and requires a triple arthrodesis.
. The forefoot deformity is driven by a rigid plantarflexed first ray.
. The Achilles tendon is over-lengthened.
. A lateralizing calcaneal osteotomy is mandatory.
. The tibialis posterior is ruptured.

Correct Answer & Explanation

. The forefoot deformity is driven by a rigid plantarflexed first ray.

Explanation

The Coleman block test evaluates hindfoot flexibility in a cavovarus foot. If the hindfoot varus corrects when the first ray is allowed to drop off the block, the hindfoot is flexible, indicating the varus deformity is driven by a rigid plantarflexed first ray.

Question 6360

Topic: 8. Foot and Ankle

A 45-year-old female complains of burning pain in the third web space of her foot. Non-operative management has failed. During surgical excision through a dorsal approach, which structure must be transected to adequately access the neuroma?

. Plantar aponeurosis
. Deep transverse metatarsal ligament
. Flexor digitorum brevis tendon
. Lumbrical tendon
. Plantar interosseous muscle

Correct Answer & Explanation

. Deep transverse metatarsal ligament

Explanation

When excising a Morton's neuroma via a dorsal approach, the deep transverse metatarsal ligament must be transected to expose the neuroma, which lies plantar to this structure. This helps prevent recurrence by releasing the compression point.

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