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8. Foot and Ankle MCQs

Practice Set 325 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 6481

Topic: Ankle Trauma & Sports

A 28-year-old female skier presents with acute ankle pain after forced dorsiflexion and eversion. Radiographs reveal a small bony avulsion flake arising from the lateral ridge of the distal fibula. What pathology does this 'fleck sign' typically represent?

. Avulsion of the anterior talofibular ligament (ATFL)
. Avulsion of the superior peroneal retinaculum (SPR)
. Avulsion of the calcaneofibular ligament (CFL)
. Osteochondral lesion of the talar dome
. Avulsion of the anterior inferior tibiofibular ligament (AITFL)

Correct Answer & Explanation

. Avulsion of the superior peroneal retinaculum (SPR)

Explanation

A fleck of bone off the lateral ridge of the distal fibula represents an avulsion of the superior peroneal retinaculum (SPR), which is pathognomonic for acute peroneal tendon subluxation or dislocation.

Question 6482

Topic: Midfoot & Hindfoot

A 30-year-old construction worker falls from a ladder and sustains an injury to his midfoot. Radiographs show a purely ligamentous Lisfranc injury with widening of the first intermetatarsal space. According to recent literature, what is the preferred surgical treatment to maximize long-term functional outcome?

. Closed reduction and percutaneous pinning (CRPP)
. Open reduction and internal fixation (ORIF) with transarticular screws
. Primary partial midfoot arthrodesis (TMT joints 1-3)
. Dorsal bridge plating spanning the entire midfoot
. Flexible fixation with suture buttons only across all TMT joints

Correct Answer & Explanation

. Primary partial midfoot arthrodesis (TMT joints 1-3)

Explanation

Recent studies, including classic prospective trials, demonstrate that purely ligamentous Lisfranc injuries treated with primary arthrodesis of the first three TMT joints have better functional outcomes and lower reoperation rates compared to ORIF.

Question 6483

Topic: Ankle Trauma & Sports
A 14-year-old boy presents with an ankle injury after an external rotation force. Radiographs show a Salter-Harris III fracture of the anterolateral aspect of the distal tibia. Which ligament is responsible for the avulsion of this bony fragment?
. Anterior talofibular ligament (ATFL)
. Posterior inferior tibiofibular ligament (PITFL)
. Anterior inferior tibiofibular ligament (AITFL)
. Deltoid ligament
. Calcaneofibular ligament (CFL)

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament (AITFL)

Explanation

A juvenile Tillaux fracture is an SH III fracture of the anterolateral distal tibia. The fragment is avulsed by the intact anterior inferior tibiofibular ligament (AITFL) during an external rotation injury.

Question 6484

Topic: 8. Foot and Ankle

A 25-year-old snowboarder is diagnosed with a 'snowboarder's fracture' after reporting persistent lateral ankle pain following a crash. Which anatomic structure is fractured in this injury?

. Posterior process of the talus
. Anterior process of the calcaneus
. Lateral process of the talus
. Base of the fifth metatarsal
. Cuboid

Correct Answer & Explanation

. Lateral process of the talus

Explanation

A 'snowboarder's fracture' refers to a fracture of the lateral process of the talus. It is caused by an axial load on a dorsiflexed, everted foot and is often misdiagnosed as a lateral ankle sprain.

Question 6485

Topic: 8. Foot and Ankle

A patient with Charcot-Marie-Tooth (CMT) disease presents with a progressive cavovarus foot deformity. A Coleman block test is performed, and the hindfoot varus corrects to neutral when the first ray drops off the block. What does this indicate regarding the primary deforming force and hindfoot flexibility?

. The hindfoot is rigid, requiring a triple arthrodesis.
. The primary deformity is a rigid equinus driven by the Achilles tendon.
. The hindfoot is flexible, and the deformity is driven by a plantarflexed first ray.
. The forefoot is entirely flexible, driven by tibialis posterior overactivity.
. The hindfoot varus is fixed, requiring a lateral displacement calcaneal osteotomy.

Correct Answer & Explanation

. The hindfoot is flexible, and the deformity is driven by a plantarflexed first ray.

Explanation

Correction of hindfoot varus during a Coleman block test indicates a flexible hindfoot. The deformity is primarily forefoot-driven by a rigid plantarflexed first ray, typically due to peroneus longus overpull.

Question 6486

Topic: 8. Foot and Ankle

During surgical release for Tarsal Tunnel Syndrome, the flexor retinaculum is divided to decompress the posterior tibial nerve. In the region of the medial malleolus, what is the anatomical relationship of the nerve to the adjacent tendons and vessels (from anterior/medial to posterior/lateral)?

. Tibialis posterior, Flexor digitorum longus, Artery, Nerve, Flexor hallucis longus
. Tibialis posterior, Artery, Nerve, Flexor digitorum longus, Flexor hallucis longus
. Flexor digitorum longus, Tibialis posterior, Nerve, Artery, Flexor hallucis longus
. Flexor hallucis longus, Nerve, Artery, Flexor digitorum longus, Tibialis posterior
. Artery, Nerve, Tibialis posterior, Flexor digitorum longus, Flexor hallucis longus

Correct Answer & Explanation

. Tibialis posterior, Flexor digitorum longus, Artery, Nerve, Flexor hallucis longus

Explanation

The order of structures passing behind the medial malleolus is Tom, Dick, AND Harry: Tibialis posterior, flexor digitorum longus, Artery (posterior tibial), Nerve (posterior tibial), and flexor hallucis longus.

Question 6487

Topic: 8. Foot and Ankle

A 50-year-old obese male presents with non-insertional Achilles tendinosis. Conservative management has failed. MRI shows mucoid degeneration involving 60% of the cross-sectional area of the tendon. If surgical debridement is performed, what additional procedure is highly recommended?

. Flexor hallucis longus (FHL) tendon transfer
. Gastrocnemius recession only
. Primary end-to-end repair without augmentation
. Peroneus brevis tendon transfer
. Plantaris tendon harvest and weaving

Correct Answer & Explanation

. Flexor hallucis longus (FHL) tendon transfer

Explanation

When debridement of the Achilles tendon requires resection of >50% of the diseased tendon, an FHL transfer is indicated to provide vascularity and adequate plantarflexion strength.

Question 6488

Topic: 8. Foot and Ankle

A 42-year-old roofer falls from a height and sustains a displaced intra-articular calcaneus fracture. An extensile lateral approach is planned. Which of the following nerves is at greatest risk of iatrogenic injury during the inferior and posterior aspects of the incision?

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

Correct Answer & Explanation

. Sural nerve

Explanation

The sural nerve is at significant risk during the extensile lateral approach to the calcaneus, particularly at the posterior and inferior limbs of the incision. It courses posterior to the lateral malleolus and provides sensation to the lateral foot.

Question 6489

Topic: 8. Foot and Ankle

A 24-year-old male presents with a progressive unilateral cavovarus foot deformity. A Coleman block test is performed, which corrects the hindfoot varus to a neutral alignment. What does this physical examination finding indicate?

. The hindfoot varus is rigid and requires a subtalar arthrodesis.
. The deformity is primarily driven by a plantarflexed first ray and the hindfoot is flexible.
. The Achilles tendon is contracted and requires lengthening.
. There is a rigid fixed deformity of the calcaneocuboid joint.
. The tibialis posterior tendon is ruptured.

Correct Answer & Explanation

. The deformity is primarily driven by a plantarflexed first ray and the hindfoot is flexible.

Explanation

The Coleman block test evaluates hindfoot flexibility in cavovarus deformities. If the hindfoot varus corrects when the first metatarsal is allowed to drop off the block, the deformity is forefoot-driven (plantarflexed first ray) and the hindfoot remains flexible.

Question 6490

Topic: Midfoot & Hindfoot

A 55-year-old overweight female presents with acquired flatfoot deformity. Examination shows a flexible hindfoot, but radiographs reveal greater than 40% talonavicular uncoverage indicating significant forefoot abduction. What is the most appropriate surgical management for this Stage IIb posterior tibial tendon dysfunction?

. Flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy alone
. Triple arthrodesis
. FDL transfer, medial displacement calcaneal osteotomy, and lateral column lengthening
. Talonavicular arthrodesis
. Isolated spring ligament repair

Correct Answer & Explanation

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

Explanation

Stage IIb PTTD is characterized by a flexible hindfoot with significant forefoot abduction (talonavicular uncoverage >40%). Optimal treatment includes an FDL transfer, medial displacement calcaneal osteotomy, and a lateral column lengthening (e.g., Evans osteotomy) to correct the abduction.

Question 6491

Topic: 8. Foot and Ankle

Following an ankle sprain, a 28-year-old male has persistent ankle pain. MRI reveals an osteochondral lesion of the talus. Based on classic morphologic principles, what is the typical mechanism and shape of a posteromedial talar dome lesion?

. Dorsiflexion-inversion; shallow and wafer-shaped
. Plantarflexion-inversion; deep and cup-shaped
. Plantarflexion-eversion; shallow and anterior
. Dorsiflexion-eversion; deep and lateral
. Direct axial load; central and fragmented

Correct Answer & Explanation

. Plantarflexion-inversion; deep and cup-shaped

Explanation

Posteromedial talar lesions classically result from Plantarflexion and Inversion, and are morphologically deep and cup-shaped. Anterolateral lesions result from Dorsiflexion and Inversion, and are anterior, shallow, and wafer-shaped.

Question 6492

Topic: Midfoot & Hindfoot

A 58-year-old male with poorly controlled diabetes mellitus and severe peripheral neuropathy presents with a red, hot, swollen foot without skin ulceration. Radiographs show periarticular debris, fragmentation, and subluxation at the tarsometatarsal joints. What is the most appropriate initial management?

. Immediate open reduction and internal fixation
. Total contact casting (TCC) and non-weight-bearing
. Intravenous antibiotics for 6 weeks
. Midfoot arthrodesis with autograft
. Below-knee amputation

Correct Answer & Explanation

. Total contact casting (TCC) and non-weight-bearing

Explanation

The patient is in Eichenholtz Stage I (fragmentation/development) of Charcot arthropathy. The gold standard initial treatment to prevent further deformity is strict offloading, typically achieved with total contact casting (TCC).

Question 6493

Topic: 8. Foot and Ankle

A 65-year-old male with end-stage post-traumatic ankle osteoarthritis is considering a total ankle arthroplasty (TAA). Which of the following conditions represents an absolute contraindication to performing a TAA?

. Contralateral knee osteoarthritis
. Body Mass Index (BMI) of 32
. Charcot neuroarthropathy with complete loss of protective sensation
. Mild ipsilateral subtalar arthritis
. Age greater than 60 years

Correct Answer & Explanation

. Charcot neuroarthropathy with complete loss of protective sensation

Explanation

Charcot neuroarthropathy and absent protective sensation are absolute contraindications to total ankle arthroplasty due to the extremely high risk of implant failure, collapse, and severe complications. Ankle arthrodesis is the preferred surgical option in neuropathic patients.

Question 6494

Topic: 8. Foot and Ankle

A professional American football player sustains a "turf toe" injury after a tackle. Which of the following best describes the pathoanatomy and mechanism of this injury?

. Hyperflexion injury causing a dorsal capsular tear at the first MTP joint
. Hyperextension injury resulting in disruption of the plantar plate at the first MTP joint
. Varus stress causing lateral collateral ligament rupture of the hallux
. Direct axial load resulting in a first metatarsal head impaction fracture
. Hyperextension injury causing isolated avulsion of the extensor hallucis longus

Correct Answer & Explanation

. Hyperextension injury resulting in disruption of the plantar plate at the first MTP joint

Explanation

Turf toe is characterized by a severe hyperextension injury to the first metatarsophalangeal (MTP) joint. This mechanism stretches or tears the plantar plate and the sesamoid complex, leading to instability and pain.

Question 6495

Topic: 8. Foot and Ankle
A 55-year-old female presents with progressive flattening of her left foot, medial ankle pain, and difficulty performing a single-leg heel rise. Radiographs demonstrate >50% uncovering of the talonavicular joint on the AP view and a significant decrease in the calcaneal pitch. Which of the following is the most appropriate surgical management for this flexible deformity?
. Medial displacement calcaneal osteotomy (MDCO) and FDL transfer alone
. Gastrocnemius recession and spring ligament repair
. Lateral column lengthening, MDCO, and FDL transfer
. Triple arthrodesis
. Tibiotalocalcaneal (TTC) arthrodesis

Correct Answer & Explanation

. Lateral column lengthening, MDCO, and FDL transfer

Explanation

This patient has Stage IIb Adult Acquired Flatfoot Deformity (AAFD), characterized by a flexible deformity with significant forefoot abduction (>50% talonavicular uncoverage). Treatment requires addressing both the hindfoot valgus and the severe forefoot abduction with a lateral column lengthening, in addition to an MDCO and FDL transfer.

Question 6496

Topic: 8. Foot and Ankle

A 40-year-old male undergoes open reduction and internal fixation of a displaced intra-articular calcaneus fracture via an extensile lateral approach. Postoperatively, he develops full-thickness wound necrosis at the apex of the L-shaped incision. The blood supply to this specific vulnerable angiosome is predominantly provided by which of the following arteries?

. Lateral tarsal artery
. Anterior tibial artery
. Posterior tibial artery
. Peroneal artery
. Medial plantar artery

Correct Answer & Explanation

. Peroneal artery

Explanation

The extensile lateral approach to the calcaneus relies on the lateral calcaneal artery, which is a terminal branch of the peroneal artery. Compromise of this angiosome is responsible for the high rate of apical wound necrosis seen in this approach.

Question 6497

Topic: 8. Foot and Ankle

A 25-year-old athlete sustains a pronation-external rotation ankle fracture. Following rigid fixation of the malleoli, the intraoperative Cotton test reveals widening of the syndesmosis. A syndesmotic screw is planned. According to recent orthopedic literature, what is the optimal position of the ankle during screw placement to prevent postoperative loss of dorsiflexion?

. Maximal plantarflexion
. Neutral (0 degrees)
. Maximal dorsiflexion
. 15 degrees of internal rotation
. Foot position does not significantly affect postoperative dorsiflexion

Correct Answer & Explanation

. Foot position does not significantly affect postoperative dorsiflexion

Explanation

Recent high-level evidence demonstrates that the position of the ankle (dorsiflexion vs. plantarflexion) during syndesmotic screw fixation does not significantly affect postoperative dorsiflexion or clinical outcomes. This refutes the historical teaching that the ankle must be maximally dorsiflexed to accommodate the wider anterior talar dome.

Question 6498

Topic: 8. Foot and Ankle

A 60-year-old poorly controlled diabetic male presents with a markedly swollen, erythematous, and warm right foot. He denies fevers or systemic symptoms. Radiographs show fragmentation, osteopenia, and early subluxation of the tarsometatarsal joints. What is the most appropriate initial management?

. Immediate midfoot arthrodesis with rigid internal fixation
. Intravenous antibiotics and surgical debridement
. Total contact casting and strict non-weight bearing
. Custom Charcot Restraint Orthotic Walker (CROW) boot with full weight-bearing
. Excision of the fragmented bone

Correct Answer & Explanation

. Total contact casting and strict non-weight bearing

Explanation

This patient presents with acute Eichenholtz Stage I (developmental/fragmentation) Charcot neuroarthropathy. The mainstay of initial treatment for acute Charcot is immediate offloading and immobilization, most effectively achieved with a total contact cast (TCC) to prevent further deformity.

Question 6499

Topic: 8. Foot and Ankle

Which of the following statements accurately compares functional rehabilitation with early weight-bearing in the non-operative management of acute Achilles tendon ruptures to surgical repair?

. Non-operative management has a significantly higher re-rupture rate.
. Non-operative management results in a higher rate of sural nerve injury.
. Non-operative management with early functional rehab yields similar re-rupture rates but lower soft-tissue complication rates.
. Surgical repair results in significantly greater plantarflexion strength at 2-year follow-up.
. Non-operative management results in a slower return to activities of daily living.

Correct Answer & Explanation

. Non-operative management with early functional rehab yields similar re-rupture rates but lower soft-tissue complication rates.

Explanation

Current AAOS guidelines and meta-analyses show that non-operative management utilizing early functional rehabilitation and weight-bearing provides equivalent functional outcomes and similar re-rupture rates compared to operative repair, while completely avoiding surgical soft-tissue complications.

Question 6500

Topic: 8. Foot and Ankle

A 22-year-old soccer player presents with chronic anterolateral ankle pain. MRI reveals an osteochondral lesion of the talus (OCL). Which of the following best describes the typical etiology and morphology of this specific lesion compared to posteromedial talar dome lesions?

. Traumatic etiology; shallow and wafer-shaped
. Insidious etiology; deep and cup-shaped
. Traumatic etiology; deep and cup-shaped
. Insidious etiology; shallow and wafer-shaped
. Atraumatic etiology; large cystic changes

Correct Answer & Explanation

. Traumatic etiology; shallow and wafer-shaped

Explanation

Anterolateral talar osteochondral lesions are typically traumatic in origin and morphologically shallow/wafer-shaped (remember the mnemonic DIAL: Dorsiflexion Inversion, AnteroLateral). Posteromedial lesions are usually non-traumatic (or insidious) and deep/cup-shaped (PIMP: Plantarflexion Inversion, Medial Posterior).

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