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8. Foot and Ankle MCQs

Practice Set 323 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 6441

Topic: 8. Foot and Ankle
A 35-year-old male sustains a Hawkins Type III talus neck fracture. Which of the following best describes the blood supply to the talar body that is disrupted in this injury?
. Artery of the tarsal canal only
. Artery of the tarsal sinus only
. Deltoid branch, artery of the tarsal sinus, and artery of the tarsal canal
. Dorsalis pedis branches only
. Peroneal artery perforators

Correct Answer & Explanation

. Deltoid branch, artery of the tarsal sinus, and artery of the tarsal canal

Explanation

A Hawkins Type III talus neck fracture involves displacement at both the subtalar and tibiotalar joints, thereby disrupting the three main sources of blood supply to the talar body: the artery of the tarsal canal (from posterior tibial), the artery of the tarsal sinus (from perforating peroneal and dorsalis pedis), and the deltoid branches. This results in a nearly 100% risk of avascular necrosis.

Question 6442

Topic: 8. Foot and Ankle

The Lisfranc ligament is essential for midfoot stability. Which of the following accurately describes its precise anatomic attachments?

. Lateral aspect of the medial cuneiform to the medial aspect of the 2nd metatarsal base
. Medial aspect of the medial cuneiform to the medial aspect of the 1st metatarsal base
. Lateral aspect of the middle cuneiform to the medial aspect of the 2nd metatarsal base
. Anterior aspect of the lateral cuneiform to the dorsal aspect of the 3rd metatarsal base
. Medial aspect of the cuboid to the lateral aspect of the 4th metatarsal base

Correct Answer & Explanation

. Lateral aspect of the medial cuneiform to the medial aspect of the 2nd metatarsal base

Explanation

The Lisfranc ligament is a strong interosseous ligament that originates from the lateral aspect of the medial cuneiform and inserts onto the medial aspect of the base of the second metatarsal. It is the strongest of the tarsometatarsal ligaments and its disruption is the hallmark of a Lisfranc injury.

Question 6443

Topic: Forefoot

A 45-year-old female presents with a painful bunion. Radiographs reveal a hallux valgus angle (HVA) of 42 degrees, an intermetatarsal angle (IMA) of 18 degrees, and clinical examination demonstrates significant hypermobility of the first tarsometatarsal (TMT) joint. What is the most appropriate surgical intervention?

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

Correct Answer & Explanation

. First TMT arthrodesis (Lapidus procedure)

Explanation

A first TMT arthrodesis (Lapidus procedure) is indicated for patients with moderate to severe hallux valgus (IMA > 15 degrees) accompanied by hypermobility of the first TMT joint. Distal osteotomies do not correct large IMA angles or address TMT hypermobility, leading to high recurrence rates in these specific patients.

Question 6444

Topic: Midfoot & Hindfoot

A 55-year-old female presents with a flexible acquired flatfoot deformity. Standing radiographs reveal 45% talonavicular uncoverage. She is diagnosed with Stage IIB posterior tibial tendon dysfunction. Which of the following surgical strategies is most appropriate?

. Medial displacement calcaneal osteotomy (MDCO) and FDL transfer alone
. FDL transfer, MDCO, and lateral column lengthening
. Triple arthrodesis
. Isolated talonavicular arthrodesis
. Isolated gastrocnemius recession

Correct Answer & Explanation

. FDL transfer, MDCO, and lateral column lengthening

Explanation

Stage IIB posterior tibial tendon dysfunction is characterized by a flexible deformity with significant forefoot abduction (typically >40% talonavicular uncoverage on AP radiograph). Treatment requires addressing both the valgus hindfoot and the forefoot abduction. Therefore, a lateral column lengthening (e.g., Evans osteotomy) is required in addition to an MDCO and FDL transfer to adequately correct the severe abduction deformity.

Question 6445

Topic: 8. Foot and Ankle
A 28-year-old male with Charcot-Marie-Tooth disease presents with a cavovarus foot deformity. A Coleman block test is performed, and the hindfoot varus corrects to neutral. This finding dictates which of the following regarding surgical management?
. The hindfoot deformity is rigid and requires a subtalar or triple arthrodesis
. The hindfoot deformity is driven by a plantarflexed first ray, and a dorsiflexion osteotomy of the first metatarsal is required
. The deformity is driven by a tight Achilles tendon requiring aggressive lengthening
. A lateralizing calcaneal osteotomy must be performed as the primary bony procedure
. An isolated split anterior tibial tendon transfer (SPLATT) will fully correct the deformity

Correct Answer & Explanation

. The hindfoot deformity is driven by a plantarflexed first ray, and a dorsiflexion osteotomy of the first metatarsal is required

Explanation

The Coleman block test evaluates the flexibility of the hindfoot in a cavovarus foot. By dropping the first ray off the block, a flexible hindfoot will correct to neutral or valgus. This indicates that the hindfoot varus is compensatory and driven by a rigidly plantarflexed first ray. Surgical treatment should therefore target the forefoot (e.g., first metatarsal dorsiflexion osteotomy) rather than relying primarily on hindfoot arthrodesis.

Question 6446

Topic: 8. Foot and Ankle

A 35-year-old roofer falls and sustains a displaced intra-articular calcaneus fracture. He undergoes open reduction and internal fixation via an extensile lateral approach. Postoperatively, he complains of numbness and neuropathic pain along the lateral aspect of his foot. Which nerve is most likely injured, and what is its typical anatomical location at risk during this approach?

. Superficial peroneal nerve crossing the anterior ankle joint
. Sural nerve coursing posterior to the lateral malleolus and superficially over the lateral calcaneal wall
. Deep peroneal nerve in the first web space
. Lateral plantar nerve running deep to the abductor hallucis
. Saphenous nerve coursing near the medial malleolus

Correct Answer & Explanation

. Sural nerve coursing posterior to the lateral malleolus and superficially over the lateral calcaneal wall

Explanation

The sural nerve is at high risk during the extensile lateral approach to the calcaneus. It courses posterior to the lateral malleolus and runs superficially over the peroneal tendons and lateral calcaneal wall. Retraction, excessive tension, or direct injury during flap elevation can lead to lateral foot numbness and neuropathic pain.

Question 6447

Topic: 8. Foot and Ankle

Which of the following statements most accurately reflects current evidence regarding the comparison of operative versus non-operative management of acute Achilles tendon ruptures when modern early functional rehabilitation protocols are utilized?

. Operative management significantly reduces the re-rupture rate compared to non-operative management
. Non-operative management results in significantly greater permanent plantarflexion weakness compared to operative management
. There is no statistically significant difference in re-rupture rates, but operative management has a higher risk of complications such as infection
. Non-operative management leads to a significantly faster return to full competitive athletic activities
. Operative management eliminates the risk of sural nerve injury

Correct Answer & Explanation

. There is no statistically significant difference in re-rupture rates, but operative management has a higher risk of complications such as infection

Explanation

Modern high-quality randomized controlled trials (e.g., Willits et al.) have demonstrated that when early functional rehabilitation (early weight-bearing and active ROM) is employed, the re-rupture rates between operative and non-operative groups are statistically similar. However, operative management carries a higher risk of soft-tissue and wound complications.

Question 6448

Topic: 8. Foot and Ankle

During fixation of a pronation-external rotation ankle fracture with syndesmotic instability, you elect to place a syndesmotic screw. Based on anatomical and biomechanical studies, what is the optimal trajectory for this screw?

. Angled 30 degrees posteriorly from the fibula to the tibia
. Parallel to the coronal plane of the ankle joint
. Angled 30 degrees anteriorly from the fibula to the tibia
. Angled 15 degrees superiorly from the fibula to the tibia
. Directly transverse from lateral to medial without angulation

Correct Answer & Explanation

. Angled 30 degrees anteriorly from the fibula to the tibia

Explanation

The fibula sits slightly posterior to the midline of the tibia in the incisura fibularis. To accurately capture the center of the tibia and avoid eccentrically pushing the fibula, a syndesmotic screw should be directed approximately 20 to 30 degrees anteriorly from the lateral fibula toward the tibia.

Question 6449

Topic: 8. Foot and Ankle
A 58-year-old diabetic male presents with a red, hot, swollen right foot mimicking cellulitis, but without open wounds. Radiographs reveal periarticular debris, fragmentation, and subluxation at the tarsometatarsal joints. According to the Eichenholtz classification, what is the stage and the most appropriate initial treatment?
. Stage 0; rigid custom orthoses
. Stage I (Developmental/Fragmentation); Total contact casting and non-weight bearing
. Stage II (Coalescence); Surgical midfoot arthrodesis
. Stage III (Consolidation); Total contact casting
. Stage I; Immediate open reduction and internal fixation

Correct Answer & Explanation

. Stage I (Developmental/Fragmentation); Total contact casting and non-weight bearing

Explanation

The clinical and radiographic picture (erythema, swelling, bony fragmentation, debris, joint subluxation) describes Eichenholtz Stage I (developmental/fragmentation stage) of Charcot neuroarthropathy. The gold standard initial treatment in the acute, active stage is strict offloading, typically achieved with a total contact cast, until the inflammation subsides. Surgery is generally contraindicated in the acute phase due to severe bone softening and high complication rates.

Question 6450

Topic: 8. Foot and Ankle

A 30-year-old skier experiences a snapping sensation at the lateral aspect of her ankle during a forceful dorsiflexion and eversion injury. Examination reveals active subluxation of the peroneal tendons over the lateral malleolus. This injury pattern most commonly involves pathology of which anatomic structure?

. Inferior extensor retinaculum
. Superior peroneal retinaculum
. Calcaneofibular ligament
. Anterior talofibular ligament
. Peroneus brevis tendon rupture

Correct Answer & Explanation

. Superior peroneal retinaculum

Explanation

Peroneal tendon subluxation is most commonly caused by stripping or avulsion of the superior peroneal retinaculum (SPR) from its insertion on the posterolateral aspect of the fibula. This typically occurs during a sudden, forceful dorsiflexion and eversion of the foot, which violently contracts the peroneal muscles against the retinaculum.

Question 6451

Topic: 8. Foot and Ankle

Total ankle arthroplasty (TAA) is increasingly utilized for end-stage ankle osteoarthritis. Which of the following is considered an absolute contraindication to performing a primary TAA?

. Patient age greater than 65 years
. Concomitant subtalar arthritis
. Severe, uncorrectable hindfoot malalignment (e.g., >15 degrees varus)
. History of a highly comminuted ankle fracture 20 years ago without current signs of infection
. Moderate obesity (BMI 32)

Correct Answer & Explanation

. Severe, uncorrectable hindfoot malalignment (e.g., >15 degrees varus)

Explanation

Absolute contraindications to total ankle arthroplasty (TAA) include active or recent deep infection, severe avascular necrosis of the talus, Charcot arthropathy, absent motor function, and severe uncorrectable malalignment (coronal plane deformities >15 degrees that cannot be surgically balanced). Concomitant subtalar arthritis is actually a relative indication for TAA rather than arthrodesis, as TAA preserves adjacent joint motion.

Question 6452

Topic: 8. Foot and Ankle

A 15-year-old female gymnast presents with chronic pain and swelling over the dorsal aspect of the forefoot. Radiographs demonstrate sclerosis, fragmentation, and flattening of the second metatarsal head. Which of the following is the most likely diagnosis?

. Sever's disease
. Kohler's disease
. Freiberg's infarction
. Morton's neuroma
. Iselin's disease

Correct Answer & Explanation

. Freiberg's infarction

Explanation

Freiberg's infarction is an avascular necrosis of the metatarsal head, most commonly affecting the second metatarsal. It typically presents in adolescent females who participate in activities involving repetitive microtrauma or mechanical overload to the forefoot, such as gymnastics or ballet.

Question 6453

Topic: Midfoot & Hindfoot

The calcaneonavicular (spring) ligament complex is a critical static stabilizer of the longitudinal arch and is often attenuated in adult acquired flatfoot deformity. Which of the following describes its most robust and clinically critical fascicle for supporting the talonavicular joint?

. Superomedial calcaneonavicular ligament
. Inferior calcaneonavicular ligament
. Bifurcate ligament
. Long plantar ligament
. Plantar aponeurosis

Correct Answer & Explanation

. Superomedial calcaneonavicular ligament

Explanation

The spring ligament complex consists of three main fascicles. The superomedial calcaneonavicular ligament is the most robust, widest, and most clinically important fascicle. It acts as a sling under the talar head, and its failure is a hallmark of progressive adult acquired flatfoot deformity associated with posterior tibial tendon dysfunction.

Question 6454

Topic: 8. Foot and Ankle

A 45-year-old runner with refractory insertional Achilles tendinopathy and a prominent Haglund's deformity undergoes surgical debridement. During the procedure, the surgeon notes that greater than 50% of the Achilles tendon insertion must be detached to adequately resect the calcaneal exostosis and debride the diseased tendon. What is the most appropriate next step?

. Repair the remaining Achilles tendon directly to bone with suture anchors and cast in equinus
. Perform a flexor hallucis longus (FHL) tendon transfer to augment the repair
. Harvest a semitendinosus autograft to bridge the defect
. Perform a gastrocnemius recession only
. Perform a V-Y advancement flap of the proximal Achilles tendon

Correct Answer & Explanation

. Perform a flexor hallucis longus (FHL) tendon transfer to augment the repair

Explanation

When debridement of insertional Achilles tendinopathy requires detachment of greater than 50% of the tendon insertion, the residual construct is significantly weakened. Augmentation is recommended to prevent postoperative rupture and restore plantarflexion power. The flexor hallucis longus (FHL) tendon transfer is the procedure of choice due to its proximity, strength, and in-phase firing with the gastrocnemius-soleus complex.

Question 6455

Topic: Midfoot & Hindfoot
A 55-year-old female presents with medial ankle pain and an inability to perform a single-leg heel rise. Clinical examination reveals a flexible hindfoot valgus, with no significant forefoot abduction (too-many-toes sign is negative). Radiographs show a preserved subtalar joint without arthritis. Which of the following is the most appropriate surgical management for this patient?
. Isolated flexor digitorum longus (FDL) transfer to the navicular
. Flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy (MDCO)
. Triple arthrodesis
. FDL transfer, MDCO, and lateral column lengthening
. Subtalar arthrodesis

Correct Answer & Explanation

. Flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy (MDCO)

Explanation

This patient presents with Stage IIA Adult Acquired Flatfoot Deformity (Posterior Tibial Tendon Dysfunction). Stage II denotes a flexible deformity. Stage IIA involves hindfoot valgus without significant forefoot abduction. The gold standard surgical management for Stage IIA is a Flexor Digitorum Longus (FDL) tendon transfer to the navicular combined with a Medial Displacement Calcaneal Osteotomy (MDCO) to correct the hindfoot valgus axis. Lateral column lengthening (Evans osteotomy) is typically added for Stage IIB, where clinically significant forefoot abduction is present. Triple arthrodesis is reserved for Stage III (rigid deformity).

Question 6456

Topic: 8. Foot and Ankle
A 60-year-old male with a 15-year history of poorly controlled type 2 diabetes mellitus presents with a red, hot, and swollen right foot. He denies any trauma. His pedal pulses are bounding. Initial radiographs were interpreted as normal, but repeat radiographs 3 weeks later reveal periarticular fragmentation and dorsal subluxation at the tarsometatarsal joints. What is the most appropriate initial management?
. Immediate open reduction and internal fixation of the midfoot
. Intravenous antibiotics and emergent surgical debridement
. Non-weight bearing in a total contact cast
. Midfoot arthrodesis with autogenous bone grafting
. Application of a Charcot Restraint Orthotic Walker (CROW) boot

Correct Answer & Explanation

. Non-weight bearing in a total contact cast

Explanation

This clinical scenario is classic for an acute Charcot arthropathy (Eichenholtz Stage I: Developmental/Fragmentation stage), characterized by a red, hot, swollen foot mimicking infection, but with bounding pulses and characteristic radiographic progression (fragmentation, debris, subluxation). The mainstay of treatment in the acute fragmentation phase is immobilization and strict offloading, ideally with non-weight bearing in a total contact cast (TCC) to prevent further deformity until the foot reaches the coalescence and consolidation phases (Stages II and III). Surgery during the acute inflammatory phase is generally contraindicated due to poor bone quality and high failure rates.

Question 6457

Topic: 8. Foot and Ankle

A 35-year-old male undergoes a percutaneous minimally invasive repair of an acute Achilles tendon rupture. Postoperatively, he complains of numbness and paresthesias along the lateral aspect of his foot. Which of the following anatomic structures was most likely injured during the procedure?

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

Correct Answer & Explanation

. Sural nerve

Explanation

The sural nerve is at highest risk during percutaneous or minimally invasive Achilles tendon repair, particularly when placing sutures in the proximal stump. The sural nerve crosses the lateral border of the Achilles tendon approximately 9 to 12 cm proximal to its insertion on the calcaneus. Injury to the sural nerve results in sensory deficits along the lateral hindfoot and lateral border of the foot.

Question 6458

Topic: 8. Foot and Ankle

A 25-year-old professional athlete sustains a rotational ankle injury. Intra-operative stress testing confirms syndesmotic instability requiring fixation. Which of the following ligamentous structures provides the greatest biomechanical resistance to lateral translation of the fibula relative to the tibia?

. Anterior inferior tibiofibular ligament (AITFL)
. Posterior inferior tibiofibular ligament (PITFL)
. Interosseous ligament
. Deltoid ligament
. Anterior talofibular ligament

Correct Answer & Explanation

. Posterior inferior tibiofibular ligament (PITFL)

Explanation

The ankle syndesmosis consists of the AITFL, PITFL, interosseous ligament, and the transverse tibiofibular ligament. Biomechanical studies have demonstrated that the Posterior Inferior Tibiofibular Ligament (PITFL) is the strongest of the syndesmotic ligaments and provides the greatest resistance (approximately 42%) to lateral displacement of the fibula, followed by the AITFL (35%) and the interosseous ligament (22%).

Question 6459

Topic: Forefoot
A 62-year-old male complains of worsening pain and stiffness in his right great toe, particularly during the toe-off phase of gait. Radiographs demonstrate severe joint space narrowing (>50%), extensive dorsal osteophytosis, and subchondral sclerosis at the first metatarsophalangeal (MTP) joint. On examination, dorsiflexion is limited to 10 degrees and elicits significant pain. According to the Coughlin and Shurnas classification, what is the most definitive and reliable surgical treatment for this condition?
. First MTP joint arthrodesis
. Dorsal cheilectomy
. Keller resection arthroplasty
. Synthetic hemiarthroplasty
. Proximal phalanx osteotomy (Moberg)

Correct Answer & Explanation

. First MTP joint arthrodesis

Explanation

The patient has Grade 3 hallux rigidus (Coughlin and Shurnas classification), characterized by significant pain at the extremes of motion, >50% joint space narrowing, and extensive osteophytes. While a dorsal cheilectomy is highly successful for Grade 1 and 2 hallux rigidus, Grade 3 and 4 disease is best treated with a first MTP joint arthrodesis, which is the gold standard and provides the most reliable long-term pain relief and functional restoration.

Question 6460

Topic: 8. Foot and Ankle
A 40-year-old male sustains a Sanders Type III intra-articular calcaneus fracture and undergoes Open Reduction and Internal Fixation (ORIF) via a standard extensile lateral approach. Which of the following is the most frequent early postoperative complication associated with this surgical approach?
. Sural nerve neuroma
. Post-traumatic subtalar arthritis
. Wound edge necrosis and dehiscence
. Malunion with severe varus deformity
. Flexor hallucis longus entrapment

Correct Answer & Explanation

. Wound edge necrosis and dehiscence

Explanation

The standard extensile lateral approach to the calcaneus involves creating a full-thickness fasciocutaneous flap. The blood supply to the apex of this flap relies critically on the lateral calcaneal artery, a branch of the peroneal artery. Compromise of this vascular supply, compounded by postoperative swelling, makes wound edge necrosis and dehiscence the most common early postoperative complication, occurring in 10% to 25% of cases.

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