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8. Foot and Ankle MCQs

Practice Set 319 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 6361

Topic: 8. Foot and Ankle

A 52-year-old male presents with dorsal foot pain and restricted first MTP joint dorsiflexion. Radiographs show dorsal osteophytes with joint space preservation on the plantar half of the first MTP joint. Which treatment is most appropriate after failed conservative care?

. Keller arthroplasty
. First MTP joint arthrodesis
. Cheilectomy
. Silicone joint replacement
. Proximal phalanx osteotomy (Moberg)

Correct Answer & Explanation

. Cheilectomy

Explanation

The patient has Coughlin and Shurnas Grade 2 hallux rigidus (dorsal osteophytes, preserved plantar joint space). A cheilectomy (removal of the dorsal third of the metatarsal head and osteophytes) is the surgical treatment of choice, providing pain relief and improved dorsiflexion.

Question 6362

Topic: Midfoot & Hindfoot
A 35-year-old male sustains a Hawkins type III talar neck fracture. Which of the following describes the anatomical displacement and the associated rate of avascular necrosis (AVN)?
. Displacement of the subtalar joint only; 20-30% AVN
. Displacement of the subtalar and tibiotalar joints; 50% AVN
. Displacement of the subtalar, tibiotalar, and talonavicular joints; nearly 100% AVN
. Displacement of the subtalar and tibiotalar joints; nearly 100% AVN
. Displacement of the talonavicular joint only; 10% AVN

Correct Answer & Explanation

. Displacement of the subtalar and tibiotalar joints; nearly 100% AVN

Explanation

A Hawkins type III fracture involves displacement of both the subtalar and tibiotalar joints. The risk of avascular necrosis in these injuries is nearly 100% due to the disruption of the artery of the tarsal canal, deltoid branches, and dorsalis pedis branches.

Question 6363

Topic: 8. Foot and Ankle

Recent randomized controlled trials comparing operative versus non-operative management of acute Achilles tendon ruptures using early functional rehabilitation protocols have demonstrated which of the following?

. Significantly higher rerupture rates in the non-operative group
. Significantly higher rates of deep infection in the operative group
. No clinically important differences in rerupture rates between the groups
. Superior plantar flexion strength at 2 years in the non-operative group
. Higher rates of sural nerve injury in the non-operative group

Correct Answer & Explanation

. No clinically important differences in rerupture rates between the groups

Explanation

When employing an early functional rehabilitation protocol with weight-bearing in a functional brace, studies show no clinically important differences in rerupture rates between operative and non-operative management. Operative management is, however, associated with a higher risk of soft tissue complications and infection.

Question 6364

Topic: 8. Foot and Ankle

A 55-year-old diabetic female presents with a warm, swollen, erythematous left foot. Radiographs show periarticular fragmentation, subluxation, and joint debris at the tarsometatarsal joints. According to the Eichenholtz classification, what is the appropriate initial management?

. Immediate midfoot arthrodesis
. Total contact casting and non-weight-bearing
. Oral antibiotics and immediate weight-bearing
. Intravenous antibiotics and surgical debridement
. Achilles tendon lengthening and rocker-bottom shoe

Correct Answer & Explanation

. Total contact casting and non-weight-bearing

Explanation

The clinical and radiographic findings describe Eichenholtz stage I (fragmentation/developmental phase) of Charcot arthropathy. The gold standard of initial management is offloading with a total contact cast to prevent further deformity while the acute inflammatory phase resolves.

Question 6365

Topic: Forefoot

A 45-year-old female presents with symptomatic hallux valgus. Radiographs demonstrate a hallux valgus angle (HVA) of 45 degrees, an intermetatarsal angle (IMA) of 16 degrees, and hypermobility of the first tarsometatarsal (TMT) joint. Which surgical procedure is most appropriate?

. Distal chevron osteotomy
. Proximal crescentic osteotomy with distal soft tissue procedure
. First tarsometatarsal arthrodesis (Lapidus procedure)
. First metatarsophalangeal arthrodesis
. Akin osteotomy alone

Correct Answer & Explanation

. First tarsometatarsal arthrodesis (Lapidus procedure)

Explanation

The patient has a severe hallux valgus deformity combined with first TMT joint hypermobility. A modified Lapidus procedure (first TMT arthrodesis) is the most appropriate operation to correct the deformity and stabilize the medial column.

Question 6366

Topic: Midfoot & Hindfoot

A 60-year-old female presents with a flexible flatfoot deformity, unable to perform a single-leg heel raise. Radiographs show a talonavicular uncoverage of 40% but no arthritic changes in the subtalar, talonavicular, or calcaneocuboid joints. What is the most appropriate surgical intervention after failed conservative care?

. Flexor digitorum longus (FDL) transfer to the navicular and medializing calcaneal osteotomy
. Triple arthrodesis
. Subtalar arthrodesis
. Gastrocnemius recession alone
. Isolated talonavicular arthrodesis

Correct Answer & Explanation

. Flexor digitorum longus (FDL) transfer to the navicular and medializing calcaneal osteotomy

Explanation

This patient has Stage II adult-acquired flatfoot deformity. Joint-sparing procedures, such as an FDL transfer combined with a medializing calcaneal osteotomy, are indicated since there is no fixed deformity or arthritis.

Question 6367

Topic: 8. Foot and Ankle

Which of the following radiographic findings is most sensitive for diagnosing a subtle Lisfranc injury on a weight-bearing AP radiograph of the foot?

. Fleck sign adjacent to the base of the first metatarsal
. More than 2 mm of diastasis between the bases of the first and second metatarsals
. Dorsal displacement of the second metatarsal base on the lateral view
. Medial shift of the third metatarsal relative to the lateral cuneiform
. Avulsion fracture of the navicular tuberosity

Correct Answer & Explanation

. More than 2 mm of diastasis between the bases of the first and second metatarsals

Explanation

A diastasis of greater than 2 mm between the base of the first and second metatarsals on a weight-bearing AP view is highly indicative of a Lisfranc ligament disruption. While the "fleck sign" is pathognomonic, it is less commonly seen than the diastasis gap.

Question 6368

Topic: 8. Foot and Ankle

A 14-year-old male presents with recurrent ankle sprains and rigid flatfeet. A "C-sign" is noted on the lateral radiograph. Which of the following physical exam findings is most characteristic of this condition?

. Inability to passively dorsiflex the great toe
. Pain with compression of the heel
. Decreased subtalar motion and peroneal spasticity
. Lack of sensation in the first web space
. A positive Mulder's click

Correct Answer & Explanation

. Decreased subtalar motion and peroneal spasticity

Explanation

The "C-sign" on a lateral radiograph is indicative of a talocalcaneal coalition. Patients classically present with a rigid flatfoot, decreased subtalar motion, and peroneal spasticity acting as a protective mechanism against painful joint movement.

Question 6369

Topic: 8. Foot and Ankle

Which of the following is considered an absolute contraindication to a total ankle arthroplasty in a patient with end-stage tibiotalar osteoarthritis?

. Age greater than 70 years
. Concomitant subtalar arthritis
. Active Charcot neuroarthropathy of the ankle
. Coronal plane deformity of 10 degrees
. Prior medial malleolus fracture

Correct Answer & Explanation

. Active Charcot neuroarthropathy of the ankle

Explanation

Active Charcot neuroarthropathy is an absolute contraindication to total ankle arthroplasty due to the high risk of implant subsidence, failure, and severe complications in a dysvascular, insensate limb. Concomitant subtalar arthritis is often a relative indication for arthroplasty to preserve hindfoot motion.

Question 6370

Topic: 8. Foot and Ankle

A 28-year-old skier presents with lateral ankle pain and a snapping sensation posterior to the fibula after acute forced dorsiflexion and inversion. Physical examination reveals subluxation of the peroneal tendons with resisted eversion. Which anatomic structure is primarily compromised?

. Calcaneofibular ligament
. Superior peroneal retinaculum
. Inferior peroneal retinaculum
. Anterior talofibular ligament
. Bifurcate ligament

Correct Answer & Explanation

. Superior peroneal retinaculum

Explanation

Peroneal tendon subluxation or dislocation is primarily caused by an injury or incompetence of the superior peroneal retinaculum. It frequently occurs during acute forced dorsiflexion of the inverted foot.

Question 6371

Topic: 8. Foot and Ankle

A 45-year-old female presents with midfoot pain after a fall from a horse. Weight-bearing radiographs and subsequent MRI demonstrate a purely ligamentous Lisfranc injury with 3 mm of diastasis between the first and second metatarsals. What is the most appropriate surgical management?

. Open reduction and internal fixation with transarticular screws
. Primary arthrodesis of the first, second, and third tarsometatarsal joints
. Percutaneous Kirschner wire fixation
. Dorsal bridge plating of the first and second TMT joints
. Suture button fixation between the medial cuneiform and second metatarsal

Correct Answer & Explanation

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

Explanation

Purely ligamentous Lisfranc injuries have a high failure rate when treated with open reduction and internal fixation (ORIF). Primary arthrodesis of the medial column (1st, 2nd, and 3rd TMT joints) is recommended as it provides superior outcomes and lower revision rates in these specific injuries.

Question 6372

Topic: Forefoot

A 55-year-old female presents with severe bunion pain. Radiographs reveal a hallux valgus angle (HVA) of 45 degrees, an intermetatarsal angle (IMA) of 19 degrees, and clinical hypermobility of the first ray in the sagittal plane. Which procedure is most appropriate?

. Distal chevron osteotomy
. Proximal crescentic osteotomy
. First tarsometatarsal joint arthrodesis (Lapidus procedure)
. Akin osteotomy alone
. Keller resection arthroplasty

Correct Answer & Explanation

. First tarsometatarsal joint arthrodesis (Lapidus procedure)

Explanation

The Lapidus procedure (first TMT arthrodesis) is indicated for moderate to severe hallux valgus (IMA >15 degrees) associated with first ray hypermobility. It definitively corrects the deformity at the apex (TMT joint) and stabilizes the medial column.

Question 6373

Topic: 8. Foot and Ankle

A 50-year-old male with long-standing, poorly controlled diabetes presents with a warm, swollen, and erythematous right foot. He denies fevers or systemic symptoms. Radiographs reveal fragmentation and subluxation of the midfoot joints without osteomyelitis. Which of the following is the most appropriate initial treatment?

. Total contact casting with strict non-weight-bearing
. Immediate midfoot arthrodesis with robust hardware
. Intravenous antibiotics and surgical debridement
. Charcot Restraint Orthotic Walker (CROW) boot with full weight-bearing
. Amputation of the affected limb

Correct Answer & Explanation

. Total contact casting with strict non-weight-bearing

Explanation

This patient is presenting with acute Eichenholtz Stage I Charcot neuroarthropathy. The gold standard for initial management of the acute, inflammatory phase is total contact casting to immobilize the foot, reduce edema, and prevent further joint destruction.

Question 6374

Topic: Midfoot & Hindfoot
A 58-year-old female presents with adult-acquired flatfoot deformity. Examination shows a flexible hindfoot valgus, inability to perform a single-leg heel raise, and forefoot abduction with >40% talonavicular uncoverage on radiographs. What is the most appropriate surgical intervention?
. Isolated flexor digitorum longus (FDL) transfer to the navicular
. Triple arthrodesis
. Gastrocnemius recession and subtalar arthrodesis
. Medializing calcaneal osteotomy alone
. FDL transfer, medializing calcaneal osteotomy, and lateral column lengthening

Correct Answer & Explanation

. FDL transfer, medializing calcaneal osteotomy, and lateral column lengthening

Explanation

This is a Stage IIb posterior tibial tendon dysfunction (flexible deformity with significant forefoot abduction). The recommended treatment addresses all deformity planes: FDL transfer (tendon substitution), medializing calcaneal osteotomy (hindfoot valgus correction), and lateral column lengthening (forefoot abduction correction).

Question 6375

Topic: 8. Foot and Ankle

A 45-year-old male sustains a displaced intra-articular calcaneus fracture. The surgeon is planning an extensile lateral approach for open reduction and internal fixation. Which of the following patient factors is the strongest independent predictor of postoperative wound complications?

. Body mass index of 30
. Age greater than 40 years
. History of deep vein thrombosis
. Cigarette smoking
. Use of non-steroidal anti-inflammatory drugs

Correct Answer & Explanation

. Cigarette smoking

Explanation

Cigarette smoking is the most significant independent risk factor for wound breakdown and infection following an extensile lateral approach to the calcaneus. Patients who smoke have vastly higher rates of flap necrosis and deep infection.

Question 6376

Topic: 8. Foot and Ankle

In a patient with Charcot-Marie-Tooth disease presenting with a classic cavovarus foot deformity, which of the following muscle imbalances is the primary driver of the plantarflexed first ray?

. Overpowering of the tibialis anterior by the peroneus longus
. Overpowering of the peroneus brevis by the tibialis posterior
. Weakness of the intrinsic foot musculature alone
. Overpowering of the Achilles tendon by the anterior tibialis
. Spasticity of the flexor hallucis longus

Correct Answer & Explanation

. Overpowering of the tibialis anterior by the peroneus longus

Explanation

In CMT, the peroneus longus retains its strength while the tibialis anterior weakens. The unopposed pull of the peroneus longus strongly plantarflexes the first ray, contributing significantly to the cavus deformity and subsequent hindfoot varus.

Question 6377

Topic: Forefoot

A 60-year-old male presents with severe pain and stiffness in the first metatarsophalangeal (MTP) joint. Examination reveals pain throughout the entire arc of motion and less than 10 degrees of dorsiflexion. Radiographs show complete loss of the joint space, subchondral cysts, and large dorsal osteophytes (Grade 3 hallux rigidus). What is the gold standard surgical treatment?

. Aggressive dorsal cheilectomy
. Moberg osteotomy
. First TMT arthrodesis
. First metatarsophalangeal joint arthrodesis
. Keller resection arthroplasty

Correct Answer & Explanation

. First metatarsophalangeal joint arthrodesis

Explanation

First MTP joint arthrodesis is the gold standard for advanced (Grade 3 or 4) hallux rigidus characterized by significant joint space narrowing and mid-arc pain. Cheilectomy is generally reserved for Grade 1 or 2 disease with pain only at the extremes of dorsiflexion.

Question 6378

Topic: 8. Foot and Ankle

A 45-year-old runner presents with chronic medial heel pain that is worse at the end of the day and non-responsive to plantar fasciitis treatments. Tinel's sign is positive over the medial heel, and MRI shows fatty atrophy of the abductor digiti minimi. Where is the most likely anatomic site of entrapment for the involved nerve?

. Posterior to the medial malleolus beneath the flexor retinaculum
. Between the two heads of the gastrocnemius
. Between the deep fascia of the abductor hallucis and the quadratus plantae
. At the level of the deep transverse metatarsal ligament
. Underneath the superior extensor retinaculum

Correct Answer & Explanation

. Between the deep fascia of the abductor hallucis and the quadratus plantae

Explanation

The patient has Baxter's nerve entrapment (first branch of the lateral plantar nerve). It most commonly becomes entrapped between the deep fascia of the abductor hallucis and the medial aspect of the quadratus plantae, leading to denervation of the abductor digiti minimi.

Question 6379

Topic: Ankle Trauma & Sports

During open reduction and internal fixation of a pronation-external rotation (Weber C) ankle fracture, what is a critical technical prerequisite before utilizing a clamp to anatomically reduce the syndesmosis?

. The medial malleolus must be fixed to allow lateral compression.
. Fibular length must be anatomically restored prior to syndesmosis reduction.
. The anterior inferior tibiofibular ligament must be directly repaired.
. The foot must be held in maximal plantar flexion.
. A deltoid ligament repair must be completed first.

Correct Answer & Explanation

. Fibular length must be anatomically restored prior to syndesmosis reduction.

Explanation

Restoring anatomical fibular length and rotation is an absolute prerequisite before clamping and fixing the syndesmosis. Failure to restore fibular length will result in proximal migration of the fibula and a malreduced syndesmosis.

Question 6380

Topic: Forefoot

A professional football player sustains a forced hyperextension injury to his great toe. MRI reveals a complete rupture of the plantar plate and joint capsule with proximal retraction of the sesamoids (Grade 3 Turf Toe). What is the recommended management?

. Carbon fiber shoe insert and play as tolerated
. Walking boot for 2 weeks followed by aggressive physical therapy
. Corticosteroid injection into the MTP joint
. Excision of the sesamoids
. Operative repair of the plantar plate and capsule

Correct Answer & Explanation

. Operative repair of the plantar plate and capsule

Explanation

Grade 3 turf toe injuries (complete disruption of the plantar plate complex) in elite athletes usually require operative repair to restore the push-off mechanism and prevent chronic instability, progressive hallux valgus, or hallux rigidus.

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