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8. Foot and Ankle MCQs

Practice Set 324 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 6461

Topic: 8. Foot and Ankle

A 12-year-old boy presents with a painful, rigid flatfoot and a history of recurrent ankle sprains. Subtalar motion is markedly decreased. A lateral radiograph of the foot reveals a continuous, solid bony bridge forming a 'C-sign' outline around the posterior talus and the sustentaculum tali. Which anatomical location is most commonly involved in this specific type of coalition?

. Anterior facet
. Middle facet
. Posterior facet
. Sinus tarsi
. Calcaneocuboid joint

Correct Answer & Explanation

. Middle facet

Explanation

The 'C-sign' on a lateral radiograph of the foot is highly indicative of a talocalcaneal coalition. Talocalcaneal coalitions most frequently involve the middle facet of the subtalar joint (between the medial talus and the sustentaculum tali). Conversely, the 'anteater nose' sign on a lateral oblique radiograph is pathognomonic for a calcaneonavicular coalition.

Question 6462

Topic: Midfoot & Hindfoot

A 45-year-old avid distance runner presents with chronic, intractable medial plantar heel pain that radiates laterally. The pain has failed to improve after 6 months of physical therapy, orthotics, and corticosteroid injections. MRI of the hindfoot demonstrates isolated fatty atrophy of the abductor digiti minimi muscle. Entrapment of which of the following nerves is the most likely cause of this patient's symptoms?

. Medial plantar nerve
. Sural nerve
. Medial calcaneal nerve
. First branch of the lateral plantar nerve
. Deep peroneal nerve

Correct Answer & Explanation

. First branch of the lateral plantar nerve

Explanation

The first branch of the lateral plantar nerve, also known as Baxter's nerve, provides sensory innervation to the calcaneal periosteum and motor innervation to the abductor digiti minimi (ADM) muscle. Entrapment commonly occurs between the deep fascia of the abductor hallucis and the medial margin of the quadratus plantae. Chronic compression leads to denervation and subsequent fatty atrophy of the ADM on MRI, a pathognomonic finding for Baxter's nerve entrapment.

Question 6463

Topic: 8. Foot and Ankle
A 42-year-old roofer falls from a height and sustains a Sanders Type III calcaneus fracture. He undergoes open reduction and internal fixation via an extensile lateral approach. Which of the following neurovascular structures is at greatest risk of iatrogenic injury during the full-thickness flap elevation?
. Superficial peroneal nerve
. Deep peroneal nerve
. Sural nerve
. Lateral plantar nerve
. Medial calcaneal nerve

Correct Answer & Explanation

. Sural nerve

Explanation

The sural nerve is at significant risk during the extensile lateral approach to the calcaneus. Retraction of the full-thickness flap must be done carefully using "no-touch" techniques with K-wires to minimize tension on the skin edge and protect the nerve.

Question 6464

Topic: 8. Foot and Ankle

A 14-year-old male presents with recurrent ankle sprains and a rigid, painful flatfoot. Radiographs demonstrate an elongated anterior process of the calcaneus. A "C-sign" is absent. What is the most appropriate initial surgical management if non-operative measures fail?

. Talocalcaneal joint arthrodesis
. Resection of the calcaneonavicular coalition with fat graft interposition
. Resection of the talocalcaneal coalition with FHL interposition
. Subtalar arthroereisis
. Triple arthrodesis

Correct Answer & Explanation

. Resection of the calcaneonavicular coalition with fat graft interposition

Explanation

The patient has a calcaneonavicular coalition, suggested by the "anteater sign" (elongated anterior calcaneal process). If conservative treatment fails, resection of the bar with fat or muscle (EDB) interposition is the standard initial surgical treatment.

Question 6465

Topic: 8. Foot and Ankle

A 55-year-old woman presents with progressive flattening of her left foot. She has pain along the medial ankle and is unable to perform a single-leg heel raise. Hindfoot valgus is passively correctable. Which of the following is the most appropriate surgical treatment?

. Gastrocnemius recession, flexor digitorum longus (FDL) transfer to the navicular, and medial displacement calcaneal osteotomy
. Triple arthrodesis
. Isolated talonavicular arthrodesis
. Subtalar arthrodesis
. Kidner procedure

Correct Answer & Explanation

. Gastrocnemius recession, flexor digitorum longus (FDL) transfer to the navicular, and medial displacement calcaneal osteotomy

Explanation

This is a Stage II Adult Acquired Flatfoot Deformity (correctable hindfoot, posterior tibial tendon insufficiency). Joint-sparing procedures, such as FDL transfer combined with a calcaneal osteotomy (and often a gastrocnemius recession), are indicated.

Question 6466

Topic: 8. Foot and Ankle

A 38-year-old male undergoes percutaneous repair of an acute Achilles tendon rupture. Post-operatively, he complains of numbness along the lateral aspect of his foot. Which of the following structures was most likely injured during the procedure?

. Saphenous nerve
. Sural nerve
. Tibial nerve
. Superficial peroneal nerve
. Lateral plantar nerve

Correct Answer & Explanation

. Sural nerve

Explanation

The sural nerve crosses from medial to lateral across the Achilles tendon, typically 9-12 cm proximal to its insertion. It is at particularly high risk during percutaneous or minimally invasive Achilles repairs.

Question 6467

Topic: 8. Foot and Ankle

A 45-year-old marathon runner complains of chronic medial heel pain that radiates to the plantar aspect of the foot. Examination reveals a positive Tinel's sign over the tarsal tunnel and maximum tenderness over the first branch of the lateral plantar nerve. What muscle's atrophy is most commonly associated with this nerve entrapment?

. Abductor hallucis
. Abductor digiti minimi
. Flexor hallucis brevis
. Adductor hallucis
. Extensor digitorum brevis

Correct Answer & Explanation

. Abductor digiti minimi

Explanation

Entrapment of the first branch of the lateral plantar nerve (Baxter's nerve) often causes chronic heel pain mimicking plantar fasciitis. Chronic compression leads to denervation and atrophy of the abductor digiti minimi muscle.

Question 6468

Topic: Forefoot

A 60-year-old male presents with dorsal foot pain and restricted toe dorsiflexion. Radiographs show severe joint space narrowing, large dorsal osteophytes, and subchondral sclerosis at the first metatarsophalangeal joint (Coughlin and Shurnas Grade 3). What is the gold standard surgical treatment?

. Cheilectomy
. Moberg osteotomy
. First MTP joint arthrodesis
. Keller resection arthroplasty
. Silicone implant arthroplasty

Correct Answer & Explanation

. First MTP joint arthrodesis

Explanation

For advanced hallux rigidus (Grade 3 or 4) with diffuse joint space loss and significant pain, first MTP joint arthrodesis is the gold standard procedure. It provides reliable pain relief and functional improvement.

Question 6469

Topic: 8. Foot and Ankle

Which of the following is considered an absolute contraindication for a total ankle arthroplasty (TAA) in a patient with end-stage ankle osteoarthritis?

. Age greater than 70 years
. Contralateral ankle arthrodesis
. Avascular necrosis of more than 50% of the talar body
. Concomitant subtalar arthritis
. Body mass index (BMI) of 28

Correct Answer & Explanation

. Avascular necrosis of more than 50% of the talar body

Explanation

Significant avascular necrosis of the talus (more than 50%) precludes adequate component fixation and is an absolute contraindication for TAA. These patients are better served with an ankle or tibiotalocalcaneal arthrodesis.

Question 6470

Topic: 8. Foot and Ankle

During an open reduction and internal fixation of a pronation-external rotation ankle fracture, the syndesmosis is evaluated. The "Cotton test" is performed. Which of the following intraoperative findings best confirms a syndesmotic injury requiring fixation?

. More than 2 mm of lateral displacement of the fibula on the AP view with lateral hook traction
. Medial clear space greater than 4 mm on the mortise view with lateral hook traction
. Tibiofibular overlap less than 1 mm on the AP view
. Talocrural angle less than 83 degrees
. Talar tilt of 2 degrees

Correct Answer & Explanation

. Medial clear space greater than 4 mm on the mortise view with lateral hook traction

Explanation

The Cotton test involves applying lateral traction to the fibula using a bone hook. Widening of the syndesmosis or a medial clear space greater than 4-5 mm on fluoroscopy confirms syndesmotic instability requiring stabilization.

Question 6471

Topic: 8. Foot and Ankle
A 55-year-old diabetic patient presents with a swollen, erythematous, and warm painless right foot. Radiographs show fragmentation, debris, and subluxation at the tarsometatarsal joints. Which Eichenholtz stage does this represent, and what is the optimal initial management?
. Stage 0; Intravenous antibiotics
. Stage I; Total contact casting and non-weight-bearing
. Stage II; Open reduction and internal fixation
. Stage III; Custom orthotic footwear
. Stage I; Immediate midfoot arthrodesis

Correct Answer & Explanation

. Stage I; Total contact casting and non-weight-bearing

Explanation

Eichenholtz Stage I (Development/Fragmentation) is characterized by acute inflammation, joint debris, and subluxation. The mainstay of treatment is immobilization and offloading, typically utilizing a total contact cast until the acute phase resolves.

Question 6472

Topic: 8. Foot and Ankle

A 28-year-old female presents with chronic deep ankle pain following an inversion injury 2 years ago. MRI demonstrates an 8 mm osteochondral lesion of the talus. Based on typical injury patterns, where is this trauma-induced lesion most likely located and what is its morphologic characteristic?

. Anterolateral talar dome; shallow and wafer-shaped
. Anterolateral talar dome; deep and cup-shaped
. Posteromedial talar dome; shallow and wafer-shaped
. Posteromedial talar dome; deep and cup-shaped
. Central talar dome; cystic and expansile

Correct Answer & Explanation

. Anterolateral talar dome; shallow and wafer-shaped

Explanation

Anterolateral osteochondral lesions of the talus are typically traumatic in origin, shallow, and wafer-shaped. Posteromedial lesions are often deeper, cup-shaped, and usually have an insidious or non-traumatic etiology.

Question 6473

Topic: 8. Foot and Ankle

A 42-year-old male sustains a displaced intra-articular calcaneus fracture and undergoes Open Reduction Internal Fixation (ORIF) via an extensile lateral approach. Postoperatively, he develops altered sensation along the lateral aspect of his foot. Which nerve is most likely at risk during the distal extension of this surgical approach?

. Superficial peroneal nerve
. Deep peroneal nerve
. Sural nerve
. Saphenous nerve
. Lateral plantar nerve

Correct Answer & Explanation

. Sural nerve

Explanation

The sural nerve is highly vulnerable during the extensile lateral approach to the calcaneus, particularly at the distal limb of the incision. Injury results in numbness along the lateral foot.

Question 6474

Topic: 8. Foot and Ankle

A 38-year-old weekend warrior sustains an acute Achilles tendon rupture. When comparing nonoperative management utilizing early functional rehabilitation to operative repair, which of the following statements regarding outcomes is most accurate?

. Operative repair has a significantly higher rerupture rate.
. Nonoperative management with early functional rehab yields similar rerupture rates but fewer wound complications.
. Operative repair demonstrates inferior long-term plantarflexion strength.
. Nonoperative management has a higher risk of sural nerve injury.
. Nonoperative management requires strict cast immobilization for 12 weeks to achieve equivalence.

Correct Answer & Explanation

. Nonoperative management with early functional rehab yields similar rerupture rates but fewer wound complications.

Explanation

Recent high-level evidence shows that nonoperative treatment with early functional rehabilitation offers similar rerupture rates to surgical repair while avoiding surgical complications like wound necrosis or infection.

Question 6475

Topic: Midfoot & Hindfoot
A 55-year-old female presents with Stage IIb Adult Acquired Flatfoot Deformity (posterior tibial tendon dysfunction). Clinical examination reveals a flexible hindfoot valgus and significant forefoot abduction (>30%). Which surgical reconstruction is most appropriate?
. FDL transfer to the navicular and medial displacement calcaneal osteotomy alone
. Triple arthrodesis
. FDL transfer, medial displacement calcaneal osteotomy, and lateral column lengthening
. Isolated subtalar arthrodesis
. Gastrocnemius recession and spring ligament repair alone

Correct Answer & Explanation

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

Explanation

Stage IIb features forefoot abduction (uncovering of the talonavicular joint). It requires an FDL transfer, medial displacement calcaneal osteotomy, and a lateral column lengthening (e.g., Evans osteotomy) to correct the abduction.

Question 6476

Topic: 8. Foot and Ankle

A 22-year-old elite track athlete complains of vague, aching midfoot pain that worsens with sprinting. Imaging reveals a stress fracture of the tarsal navicular. Why is this specific fracture prone to nonunion or delayed union?

. High tensile forces from the Achilles tendon
. Poor osteogenic potential of the talonavicular joint fluid
. A relatively avascular zone in the central third of the bone
. Constant dynamic pull of the peroneus brevis
. Excessive subtalar motion during toe-off

Correct Answer & Explanation

. A relatively avascular zone in the central third of the bone

Explanation

The central third of the tarsal navicular is a vascular watershed area supplied by branches of the dorsalis pedis and medial plantar arteries. This limited blood supply predisposes stress fractures in this region to nonunion.

Question 6477

Topic: 8. Foot and Ankle
A 60-year-old diabetic patient presents with a swollen, erythematous, and warm left foot. Radiographs show soft tissue swelling but no osseous destruction. Which clinical test is most helpful in differentiating acute Charcot arthropathy from a deep soft-tissue infection?
. Dependent rubor test
. Leg elevation for 10 minutes
. Tinel's sign at the tarsal tunnel
. Silfverskiöld test
. Ankle-brachial index measurement

Correct Answer & Explanation

. Leg elevation for 10 minutes

Explanation

Elevating the leg for 5 to 10 minutes will typically cause the erythema and swelling to resolve or significantly improve in acute Charcot arthropathy, whereas cellulitis or infection will remain erythematous.

Question 6478

Topic: Forefoot

A 65-year-old male with severe hallux rigidus (Coughlin and Shurnas Grade 3) complains of persistent pain and inability to wear normal shoes despite conservative management. He desires a definitive surgical procedure with the lowest risk of recurrence. What is the gold standard treatment?

. Dorsal cheilectomy
. Moberg osteotomy
. Keller resection arthroplasty
. First metatarsophalangeal (MTP) joint arthrodesis
. First MTP total joint replacement

Correct Answer & Explanation

. First metatarsophalangeal (MTP) joint arthrodesis

Explanation

First MTP joint arthrodesis is the gold standard for advanced (Grade 3 or 4) hallux rigidus, providing reliable pain relief, durable functional outcomes, and the lowest recurrence rate.

Question 6479

Topic: 8. Foot and Ankle

Total ankle arthroplasty (TAA) has become an increasingly popular option for end-stage ankle arthritis. Which of the following is considered an absolute contraindication to this procedure?

. Age greater than 70 years
. Active Charcot neuroarthropathy of the ankle
. Prior medial malleolar fracture treated with ORIF
. Mild to moderate obesity (BMI 32)
. Osteoarthritis isolated to the tibiotalar joint

Correct Answer & Explanation

. Active Charcot neuroarthropathy of the ankle

Explanation

Active or neuropathic joint destruction (Charcot arthropathy) is an absolute contraindication to total ankle arthroplasty due to the extremely high risk of premature catastrophic failure.

Question 6480

Topic: 8. Foot and Ankle

A 24-year-old professional football player sustains an acute Zone 2 fracture of the proximal fifth metatarsal (Jones fracture). Given his desire for a rapid return to play, intramedullary screw fixation is planned. Which anatomical factor must be strictly respected to avoid complication during screw placement?

. The screw must engage the medial cuneiform to provide rigid stability.
. The guidewire must enter high and medial on the base to avoid penetrating the medial cortex due to the lateral bow of the diaphysis.
. The medullary canal narrows significantly at the distal third, requiring a minimum 6.5 mm screw.
. The sural nerve crosses directly over the tuberosity and must be transected.
. The screw must strictly bypass the metaphyseal-diaphyseal junction.

Correct Answer & Explanation

. The guidewire must enter high and medial on the base to avoid penetrating the medial cortex due to the lateral bow of the diaphysis.

Explanation

The fifth metatarsal has a lateral and plantar bow. The starting point must be high and medial on the tuberosity to safely pass down the straight medullary canal and avoid medial cortical perforation.

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