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8. Foot and Ankle MCQs

Practice Set 320 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 6381

Topic: 8. Foot and Ankle

A diabetic patient with peripheral neuropathy presents with a chronic, recurrent plantar ulcer directly beneath the first metatarsal head. He has failed total contact casting and orthotic management. Physical examination reveals an inability to dorsiflex the ankle past neutral with the knee extended, but 15 degrees of dorsiflexion is achieved when the knee is flexed. What surgical adjunct is most likely to heal the ulcer and prevent recurrence?

. First MTP joint arthrodesis
. First metatarsal neck osteotomy
. Gastrocnemius recession or Achilles tendon lengthening
. Plantar fasciotomy
. Tibialis anterior tendon transfer

Correct Answer & Explanation

. Gastrocnemius recession or Achilles tendon lengthening

Explanation

The patient has a positive Silfverskiold test, indicating isolated gastrocnemius tightness (equinus contracture). This contracture dramatically increases forefoot plantar pressures. Gastrocnemius recession or Achilles lengthening reduces this pressure, promoting ulcer healing and preventing recurrence.

Question 6382

Topic: Forefoot

A 55-year-old female presents with pain at the plantar aspect of the second metatarsophalangeal (MTP) joint and a new onset of the second toe crossing over the hallux. A positive dorsal drawer test of the second MTP joint is elicited. What is the most likely diagnosis?

. Morton's neuroma
. Freiberg's infraction
. Sesamoiditis
. Plantar plate tear
. Flexor digitorum longus rupture

Correct Answer & Explanation

. Plantar plate tear

Explanation

A positive dorsal drawer test at the MTP joint, localized plantar pain, and crossover toe deformity are hallmark clinical signs of a plantar plate attenuation or tear. Morton's neuroma usually presents with web space pain and a positive Mulder's click, without joint instability.

Question 6383

Topic: 8. Foot and Ankle

A 65-year-old patient with end-stage ankle osteoarthritis is evaluated for a total ankle replacement (TAR). Which of the following is considered an absolute contraindication to modern total ankle arthroplasty?

. Patient age greater than 60 years
. Coronal plane deformity of 5 degrees
. Mild to moderate obesity (BMI 32)
. Concomitant subtalar arthritis
. History of Charcot neuroarthropathy

Correct Answer & Explanation

. History of Charcot neuroarthropathy

Explanation

Charcot neuroarthropathy, active infection, severe talar avascular necrosis (>50%), and loss of protective sensation are absolute contraindications to total ankle replacement due to exceptionally high failure rates. Ankle arthrodesis is preferred in these scenarios.

Question 6384

Topic: 8. Foot and Ankle

A 15-year-old female dancer complains of insidious pain and swelling isolated to the dorsal aspect of the second metatarsal head. Radiographs demonstrate flattening, sclerosis, and fragmentation of the second metatarsal head. What is the underlying pathology?

. Avascular necrosis of the second metatarsal head
. Stress fracture of the metatarsal shaft
. Osteosarcoma of the metatarsal
. Inflammatory crystalline arthropathy
. Traction apophysitis

Correct Answer & Explanation

. Avascular necrosis of the second metatarsal head

Explanation

The clinical scenario and radiographic findings of flattening and sclerosis of the second metatarsal head in a young, active female are classic for Freiberg's infraction, which is avascular necrosis of the metatarsal head.

Question 6385

Topic: Midfoot & Hindfoot

A 45-year-old female presents with progressive flattening of her left arch. She cannot perform a single-leg heel raise. Radiographs demonstrate an uncovered talar head of 45% and a talonavicular uncoverage angle of 25 degrees. She has pain over the lateral hindfoot but a passively correctable hindfoot valgus. What is the most appropriate surgical treatment?

. Medial calcaneal displacement osteotomy and FDL transfer
. Lateral column lengthening, FDL transfer, and medial calcaneal displacement osteotomy
. Subtalar arthrodesis
. Triple arthrodesis
. Tibiotalocalcaneal arthrodesis

Correct Answer & Explanation

. Lateral column lengthening, FDL transfer, and medial calcaneal displacement osteotomy

Explanation

This describes Stage IIb posterior tibial tendon dysfunction (PTTD), characterized by a flexible deformity with >40% talonavicular uncoverage (forefoot abduction). Treatment requires lateral column lengthening to correct the forefoot abduction, in addition to FDL transfer and medial calcaneal slide.

Question 6386

Topic: 8. Foot and Ankle

Which of the following is an absolute contraindication to a total ankle arthroplasty (TAA)?

. Age less than 50 years
. Prior ankle intra-articular fracture
. Charcot neuroarthropathy
. Hemophilia-induced arthropathy
. End-stage primary osteoarthritis

Correct Answer & Explanation

. Charcot neuroarthropathy

Explanation

Charcot neuroarthropathy is an absolute contraindication to total ankle arthroplasty due to the loss of protective sensation, poor bone quality, and high failure rates. Ankle arthrodesis or tibiotalocalcaneal (TTC) fusion is the preferred surgical option for end-stage Charcot ankle arthropathy.

Question 6387

Topic: Forefoot

A 28-year-old female presents with a painful bunion deformity. Examination reveals a hallux valgus angle of 45 degrees, an intermetatarsal angle of 18 degrees, and clinical hypermobility of the 1st tarsometatarsal (TMT) joint. What is the most appropriate surgical procedure?

. Distal chevron osteotomy
. Proximal crescentic osteotomy with distal soft tissue release
. First TMT arthrodesis (Lapidus procedure)
. First MTP arthrodesis
. Keller resection arthroplasty

Correct Answer & Explanation

. First TMT arthrodesis (Lapidus procedure)

Explanation

The Lapidus procedure (first TMT arthrodesis) is indicated for severe hallux valgus deformities (IMA > 15 degrees) associated with 1st ray hypermobility. It provides powerful correction and addresses the apex of the deformity at the TMT joint.

Question 6388

Topic: Midfoot & Hindfoot
A 40-year-old male sustains a Hawkins Type III talar neck fracture. Which of the following best describes this injury and its associated risk of avascular necrosis (AVN)?
. Undisplaced fracture; 0-10% AVN risk
. Displaced fracture with subtalar subluxation; 20-50% AVN risk
. Displaced fracture with subtalar and tibiotalar dislocation; nearly 100% AVN risk
. Displaced fracture with talonavicular dislocation; 10% AVN risk
. Comminuted fracture of the talar body; 50% AVN risk

Correct Answer & Explanation

. Displaced fracture with subtalar and tibiotalar dislocation; nearly 100% AVN risk

Explanation

A Hawkins Type III talar neck fracture involves displacement of the talar neck with dislocation of both the subtalar and tibiotalar joints. The risk of avascular necrosis (AVN) in Type III fractures is extremely high, approaching 90-100%.

Question 6389

Topic: 8. Foot and Ankle

A 55-year-old male with diabetes presents with a red, hot, swollen foot without systemic signs of infection. Radiographs reveal fragmentation and periarticular debris at the midfoot. Which of the following is the gold standard initial treatment?

. Intravenous antibiotics and surgical debridement
. Total contact casting
. Immediate midfoot arthrodesis
. Custom orthotic shoe inserts
. Below-knee amputation

Correct Answer & Explanation

. Total contact casting

Explanation

The clinical presentation is classic for acute (Eichenholtz Stage I) Charcot neuroarthropathy. The gold standard initial treatment is offloading with a total contact cast (TCC) to prevent further deformity while the acute inflammatory process subsides.

Question 6390

Topic: 8. Foot and Ankle

A 42-year-old female complains of persistent dorsal midfoot pain 6 months after a seemingly minor twisting injury. Weight-bearing radiographs demonstrate a 3 mm diastasis between the base of the 1st and 2nd metatarsals. What is the most likely diagnosis?

. Navicular stress fracture
. Lisfranc injury
. Cuboid syndrome
. Anterior tibial tendon rupture
. Tarsal coalition

Correct Answer & Explanation

. Lisfranc injury

Explanation

A diastasis >2 mm between the base of the 1st and 2nd metatarsals on weight-bearing radiographs is diagnostic of a Lisfranc injury. Subtle Lisfranc injuries frequently present with persistent midfoot pain and require weight-bearing films for accurate diagnosis.

Question 6391

Topic: 8. Foot and Ankle

A 60-year-old female undergoes surgical release of the plantar fascia for recalcitrant plantar fasciitis. Postoperatively, she develops new-onset lateral midfoot pain. What is the most likely cause of this complication?

. Sural nerve injury
. Lateral column overload
. Tarsal tunnel syndrome
. Calcaneal stress fracture
. Recurrent plantar fasciitis

Correct Answer & Explanation

. Lateral column overload

Explanation

Surgical release of the plantar fascia, especially if >50% is released, can result in a loss of the medial longitudinal arch and subsequent lateral column overload. This biomechanical shift often manifests as new lateral midfoot pain postoperatively.

Question 6392

Topic: 8. Foot and Ankle

A 15-year-old boy presents with a rigid flatfoot and frequent ankle sprains. Radiographs reveal an elongated anterior process of the calcaneus resembling an "anteater's nose" on the lateral view. Which of the following is the most likely diagnosis?

. Talocalcaneal coalition
. Calcaneonavicular coalition
. Naviculocuneiform coalition
. Accessory navicular
. Peroneal spastic flatfoot due to trauma

Correct Answer & Explanation

. Calcaneonavicular coalition

Explanation

The "anteater sign" on a lateral foot radiograph is pathognomonic for a calcaneonavicular tarsal coalition. Tarsal coalitions typically present in adolescence with a rigid flatfoot and recurrent ankle sprains due to altered hindfoot mechanics.

Question 6393

Topic: 8. Foot and Ankle

A 35-year-old recreational athlete sustains an acute complete rupture of the Achilles tendon. He opts for nonoperative management. Which of the following is true regarding nonoperative versus operative management for this injury?

. Nonoperative management has a significantly higher risk of sural nerve injury.
. Operative management has a higher re-rupture rate.
. Nonoperative management utilizing early functional rehabilitation has a similar re-rupture rate to operative management.
. Operative management is strictly contraindicated in recreational athletes.
. Nonoperative management results in significantly greater plantar flexion strength.

Correct Answer & Explanation

. Nonoperative management utilizing early functional rehabilitation has a similar re-rupture rate to operative management.

Explanation

Recent literature shows that nonoperative management with early functional rehabilitation (weight-bearing in equinus) yields re-rupture rates comparable to operative repair (around 3-5%). Operative management carries a higher risk of soft tissue complications, such as infection and wound breakdown.

Question 6394

Topic: 8. Foot and Ankle
A 50-year-old female presents with a painful bunionette deformity. Radiographs show a normal 4-5 intermetatarsal angle but a lateral bowing of the 5th metatarsal shaft. What is the most appropriate surgical management?
. Condylectomy of the 5th metatarsal head
. Distal chevron osteotomy of the 5th metatarsal
. Diaphyseal (midshaft) osteotomy of the 5th metatarsal
. 5th MTP joint arthrodesis
. Proximal basilar osteotomy

Correct Answer & Explanation

. Diaphyseal (midshaft) osteotomy of the 5th metatarsal

Explanation

Bunionette deformities with lateral bowing of the 5th metatarsal shaft (Type III) are best addressed with a diaphyseal osteotomy to correct the structural bowing. Distal osteotomies or condylectomies are insufficient for shaft deformities.

Question 6395

Topic: 8. Foot and Ankle

A 29-year-old male sustains an inversion ankle injury resulting in a "popping" sensation behind the lateral malleolus. Examination reveals retromalleolar pain and snapping of the tendons with resisted dorsiflexion and eversion. Which of the following structures is most likely injured?

. Anterior talofibular ligament
. Calcaneofibular ligament
. Superior peroneal retinaculum
. Inferior extensor retinaculum
. Flexor retinaculum

Correct Answer & Explanation

. Superior peroneal retinaculum

Explanation

Snapping of the peroneal tendons over the lateral malleolus with resisted dorsiflexion and eversion indicates peroneal tendon subluxation or dislocation. This occurs secondary to an injury or avulsion of the superior peroneal retinaculum (SPR).

Question 6396

Topic: 8. Foot and Ankle

Which of the following physical exam findings is most specific for a complete rupture of the anterior tibial tendon?

. Inability to plantarflex the ankle
. Absent Achilles reflex
. Loss of eversion strength
. "Slapping" foot gait and inability to walk on heels
. Inability to invert the foot while plantarflexed

Correct Answer & Explanation

. "Slapping" foot gait and inability to walk on heels

Explanation

The anterior tibial tendon is the primary dorsiflexor of the ankle. A complete rupture results in a drop foot, characterized by a "slapping" gait during the heel-strike phase and a clinical inability to walk on the heels.

Question 6397

Topic: 8. Foot and Ankle

A 55-year-old female presents with pain in her forefoot. She notes a feeling of "walking on a marble." Compression of the forefoot reproduces a painful click. Which interdigital space is most commonly affected by this condition?

. First web space
. Second web space
. Third web space
. Fourth web space
. Fifth web space

Correct Answer & Explanation

. Third web space

Explanation

The clinical presentation (Mulder's click) is characteristic of a Morton's neuroma. This compressive neuropathy most commonly affects the common digital nerve in the third web space (between the 3rd and 4th metatarsal heads).

Question 6398

Topic: 8. Foot and Ankle

A 40-year-old male sustains an acute, closed Achilles tendon rupture. He is treated non-operatively with an early functional rehabilitation protocol. Compared to surgical repair, which of the following outcomes is most closely associated with this management strategy?

. Higher rate of deep infection
. Significantly higher rate of re-rupture
. Equivalent rate of re-rupture
. Significantly decreased plantar flexion strength
. Higher risk of sural nerve injury

Correct Answer & Explanation

. Equivalent rate of re-rupture

Explanation

Recent high-quality studies show that early functional rehabilitation for acute Achilles tendon ruptures yields equivalent re-rupture rates compared to surgical repair. Surgical repair carries a higher risk of soft tissue complications and nerve injury without providing a clinically significant improvement in rupture rates.

Question 6399

Topic: 8. Foot and Ankle

A 58-year-old poorly controlled diabetic presents with a swollen, erythematous, and warm but painless right foot. Radiographs demonstrate periarticular debris, subchondral cyst formation, and fragmentation of the midfoot. According to the Eichenholtz classification, what stage does this represent?

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

Correct Answer & Explanation

. Stage 1

Explanation

Eichenholtz Stage 1 (Development/Fragmentation) is characterized by joint edema, erythema, periarticular debris, fragmentation, and subluxation. Stage 2 involves coalescence (absorption of debris), and Stage 3 is reconstruction/consolidation.

Question 6400

Topic: 8. Foot and Ankle

During an extensile lateral approach for open reduction and internal fixation of a displaced intra-articular calcaneus fracture, the full-thickness flap is elevated. Which of the following structures is contained within this flap and must be protected?

. Medial plantar nerve
. Deep peroneal nerve
. Sural nerve
. Posterior tibial artery
. Saphenous nerve

Correct Answer & Explanation

. Sural nerve

Explanation

The extensile lateral approach to the calcaneus involves creating a full-thickness subperiosteal flap. The sural nerve and lesser saphenous vein are included within this flap to protect them from direct injury and optimize flap vascularity.

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