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8. Foot and Ankle MCQs

Practice Set 326 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 6501

Topic: 8. Foot and Ankle

When evaluating a patient with end-stage post-traumatic ankle osteoarthritis, which of the following is considered an absolute contraindication to performing a Total Ankle Arthroplasty (TAA)?

. Advanced patient age (>70 years)
. Charcot neuroarthropathy with severe sensory neuropathy
. Concomitant subtalar arthritis
. Bilateral ankle arthritis
. Previous ankle fracture treated with open reduction internal fixation

Correct Answer & Explanation

. Charcot neuroarthropathy with severe sensory neuropathy

Explanation

Charcot neuroarthropathy with lack of protective sensation is an absolute contraindication to Total Ankle Arthroplasty due to the unacceptably high risk of catastrophic implant failure, peri-prosthetic fracture, and progressive deformity. These patients are better managed with a tibiotalocalcaneal arthrodesis if surgical intervention is necessary.

Question 6502

Topic: 8. Foot and Ankle

A 28-year-old skier presents with lateral ankle pain and a snapping sensation behind the lateral malleolus after an acute dorsiflexion-inversion injury. Examination reveals subluxation of the lateral tendons over the fibula with resisted active eversion. Injury to which of the following structures is the primary cause of this pathology?

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

Correct Answer & Explanation

. Superior peroneal retinaculum

Explanation

Peroneal tendon subluxation or dislocation is primarily caused by an injury to the superior peroneal retinaculum (SPR), which normally acts to restrain the tendons in the retromalleolar groove. This classically occurs during forceful dorsiflexion and inversion, such as catching a ski tip.

Question 6503

Topic: 8. Foot and Ankle

A 42-year-old male sustains an acute Achilles tendon rupture while playing basketball. He is discussing operative versus non-operative treatment with his orthopedic surgeon. If a modern, accelerated functional rehabilitation protocol is utilized, what is the primary consensus finding regarding the outcomes of non-operative compared to operative management?

. Non-operative management has a significantly higher rate of deep vein thrombosis.
. Operative management provides significantly greater ultimate plantar flexion strength.
. With functional bracing, rerupture rates between the two groups are statistically similar.
. Operative management eliminates the risk of elongation of the tendon.
. Non-operative management is contraindicated in tears gap larger than 1 cm.

Correct Answer & Explanation

. With functional bracing, rerupture rates between the two groups are statistically similar.

Explanation

Recent high-quality evidence shows that when acute Achilles tendon ruptures are treated with functional bracing and early weight-bearing protocols, the rerupture rates are comparable to operative repair, while avoiding surgical wound complications.

Question 6504

Topic: 8. Foot and Ankle

In a purely ligamentous Lisfranc injury, what is the exact anatomical attachment of the primary intact Lisfranc ligament?

. Medial cuneiform to the base of the first metatarsal
. Medial cuneiform to the base of the second metatarsal
. Middle cuneiform to the base of the second metatarsal
. Lateral cuneiform to the base of the third metatarsal
. Cuboid to the base of the fourth metatarsal

Correct Answer & Explanation

. Medial cuneiform to the base of the second metatarsal

Explanation

The Lisfranc ligament is a strong interosseous ligament that connects the medial cuneiform to the base of the second metatarsal. It is critical for the stability of the midfoot. There is no direct ligamentous connection between the bases of the first and second metatarsals.

Question 6505

Topic: 8. Foot and Ankle

The Lisfranc ligament is crucial for midfoot stability. Anatomically, this ligament originates from the medial cuneiform and inserts onto which of the following structures?

. Base of the first metatarsal
. Base of the second metatarsal
. Base of the third metatarsal
. Middle cuneiform
. Navicular

Correct Answer & Explanation

. Base of the second metatarsal

Explanation

The Lisfranc ligament is an interosseous ligament that connects the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. It is the strongest and primary stabilizer of the tarsometatarsal joint.

Question 6506

Topic: 8. Foot and Ankle

When counseling a patient on the management of an acute Achilles tendon rupture, which of the following is the primary established advantage of operative repair compared to modern non-operative functional rehabilitation?

. Lower risk of deep vein thrombosis
. Decreased risk of sural nerve injury
. Statistically lower rate of tendon re-rupture
. Faster return to independent ambulation
. Lower risk of wound complications

Correct Answer & Explanation

. Statistically lower rate of tendon re-rupture

Explanation

Operative repair historically provides a lower rate of re-rupture compared to non-operative management, particularly in younger, active patients. However, operative management carries a higher risk of wound complications and infection.

Question 6507

Topic: 8. Foot and Ankle

A 25-year-old football player sustains a hyperplantarflexion injury to his midfoot. Radiographs show widening between the bases of the 1st and 2nd metatarsals and a tiny bony avulsion fragment in this interval. What ligament is primarily injured?

. Plantar calcaneonavicular (spring) ligament
. Dorsal tarsometatarsal ligament
. Interosseous ligament connecting the medial cuneiform to the second metatarsal base
. Bifurcate ligament
. Long plantar ligament

Correct Answer & Explanation

. Interosseous ligament connecting the medial cuneiform to the second metatarsal base

Explanation

The Lisfranc ligament is a crucial interosseous ligament running from the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. A 'fleck sign' in this interval represents an avulsion fracture of this essential stabilizing structure.

Question 6508

Topic: 8. Foot and Ankle

The primary blood supply to the body of the talus, which is at the highest risk of disruption resulting in avascular necrosis following a displaced talar neck fracture, is derived from which of the following vessels?

. Artery of the tarsal canal
. Artery of the tarsal sinus
. Dorsalis pedis artery
. Deltoid branch of the posterior tibial artery
. Anterior tibial artery

Correct Answer & Explanation

. Artery of the tarsal canal

Explanation

The artery of the tarsal canal, a branch of the posterior tibial artery, is the dominant blood supply to the talar body. It provides retrograde flow to the body, making it highly susceptible to injury in talar neck fractures.

Question 6509

Topic: 8. Foot and Ankle

Which of the following vessels provides the major blood supply to the body of the talus, placing it at high risk for avascular necrosis following a displaced talar neck fracture?

. Artery of the tarsal canal
. Artery of the tarsal sinus
. Dorsalis pedis artery
. Deltoid artery
. Lateral tarsal artery

Correct Answer & Explanation

. Artery of the tarsal canal

Explanation

The artery of the tarsal canal, a branch of the posterior tibial artery, provides the major blood supply to the body of the talus. Displaced talar neck fractures often disrupt this antegrade intraosseous supply, leading to a high rate of avascular necrosis. The deltoid artery supplies the medial aspect of the body and is often the only remaining supply after a displaced neck fracture.

Question 6510

Topic: Midfoot & Hindfoot

Which of the following theories best explains the neurovascular pathophysiology underlying the active phase of Charcot arthropathy in patients with diabetes mellitus?

. Decreased blood flow leading to avascular necrosis
. Repetitive microtrauma due to sensory loss alone
. Autonomic neuropathy causing arteriovenous shunting and bone resorption
. Chronic deep space infection spreading to the joint
. Reduced osteoclast activity leading to brittle, non-compliant bone

Correct Answer & Explanation

. Autonomic neuropathy causing arteriovenous shunting and bone resorption

Explanation

The neurovascular theory of Charcot arthropathy postulates that autonomic neuropathy leads to a loss of sympathetic vascular tone, causing continuous arteriovenous shunting and hyperemia. This hyperemia increases osteoclastic bone resorption. The weakened, osteopenic bone, combined with loss of protective sensation (neurotraumatic theory), leads to repetitive microtrauma, fracture, and severe joint destruction.

Question 6511

Topic: 8. Foot and Ankle

The structural integrity of the midfoot is highly dependent on the Lisfranc ligament complex. The primary interosseous component of the Lisfranc ligament connects which two osseous structures?

. Medial cuneiform to the base of the 1st metatarsal
. Medial cuneiform to the base of the 2nd metatarsal
. Middle cuneiform to the base of the 2nd metatarsal
. Navicular to the base of the 1st metatarsal
. Cuboid to the base of the 4th metatarsal

Correct Answer & Explanation

. Medial cuneiform to the base of the 2nd metatarsal

Explanation

The Lisfranc ligament is an interosseous ligament that runs obliquely from the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. It is the primary stabilizer of the second tarsometatarsal joint.

Question 6512

Topic: 8. Foot and Ankle
A 55-year-old male with poorly controlled diabetes mellitus presents with a swollen, erythematous, and warm unilateral foot. Radiographs demonstrate periarticular bony debris, fragmentation, and subluxation at the tarsometatarsal joints. According to the Eichenholtz classification, what stage is this patient in, and what is the gold standard initial treatment?
. Stage 0; Intravenous antibiotics
. Stage I; Total contact casting and non-weight bearing
. Stage II; Open reduction internal fixation
. Stage III; Midfoot arthrodesis
. Stage I; Immediate below-knee amputation

Correct Answer & Explanation

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

Explanation

The patient is presenting with acute Charcot neuroarthropathy. Radiographs showing fragmentation, debris, and subluxation represent Eichenholtz Stage I (Development/Fragmentation). The gold standard initial management in the acute phase is strict immobilization and offloading, most effectively achieved with a total contact cast (TCC).

Question 6513

Topic: 8. Foot and Ankle

A 55-year-old diabetic male presents with a warm, swollen, erythematous foot. Radiographs show periarticular osteopenia, fragmentation, and subluxation at the tarsometatarsal joint. According to the Eichenholtz classification, what stage does this represent, and what is the most appropriate initial management?

. Stage 0; immediate arthrodesis
. Stage 1 (Developmental); total contact cast and non-weight bearing
. Stage 2 (Coalescence); custom orthotic footwear
. Stage 3 (Reconstruction); Charcot restraint orthotic walker (CROW)
. Stage 1 (Developmental); intravenous antibiotics for osteomyelitis

Correct Answer & Explanation

. Stage 1 (Developmental); total contact cast and non-weight bearing

Explanation

Eichenholtz Stage 1 (Developmental/Fragmentation) presents with an acutely inflamed foot, radiographic fragmentation, debris, and subluxation. The mainstay of initial treatment is offloading and immobilization via a total contact cast (TCC) to prevent further deformity until the acute inflammatory phase resolves (progression to coalescence).

Question 6514

Topic: 8. Foot and Ankle

A 40-year-old male sustains an acute Achilles tendon rupture while playing basketball. He opts for non-operative management utilizing a strict functional rehabilitation protocol. Based on modern randomized controlled trials, how do the outcomes of this non-operative protocol compare to traditional open surgical repair?

. Significantly higher re-rupture rate with non-operative treatment
. Higher incidence of deep vein thrombosis with non-operative treatment
. Equivalent functional outcomes and similar re-rupture rates
. Increased risk of sural nerve injury with non-operative treatment
. Faster return to competitive athletics with non-operative treatment

Correct Answer & Explanation

. Equivalent functional outcomes and similar re-rupture rates

Explanation

Recent high-quality studies and meta-analyses have demonstrated that when non-operative management of acute Achilles tendon ruptures is paired with an early functional rehabilitation protocol (early weight-bearing and functional mobilization in an orthosis), the functional outcomes and re-rupture rates are statistically equivalent to operative repair, while successfully avoiding surgical complications such as wound breakdown or infection.

Question 6515

Topic: 8. Foot and Ankle
A 28-year-old athlete sustains a high-energy multiligamentous knee injury (KD-III). On examination, the foot is warm, and dorsalis pedis and posterior tibial pulses are palpable and symmetrical to the contralateral limb. An ankle-brachial index (ABI) is measured at 0.85. What is the most appropriate next step in management regarding the patient's vascular status?
. Immediate surgical exploration of the popliteal artery
. Observation with serial clinical neurovascular checks every 4 hours
. Perform a CT angiography (CTA) of the lower extremity
. Application of a long leg cast and discharge
. Fasciotomies of the lower leg

Correct Answer & Explanation

. Perform a CT angiography (CTA) of the lower extremity

Explanation

In the assessment of knee dislocations, an ABI should be routinely performed. An ABI less than 0.9, even in the presence of palpable pulses, is highly suspicious for a vascular intimal injury of the popliteal artery and necessitates further advanced imaging, typically a CT angiogram (CTA). Immediate exploration is reserved for 'hard signs' of arterial injury (e.g., absent pulses, expanding hematoma).

Question 6516

Topic: Midfoot & Hindfoot

A 55-year-old diabetic patient presents with a red, hot, swollen right foot. He is afebrile and his WBC count is normal. Radiographs reveal fragmentation of the tarsometatarsal joints, subchondral debris, and subluxation. Based on the Eichenholtz classification of Charcot arthropathy, which stage is this patient in, and what is the gold standard initial treatment?

. Stage 0; Intravenous antibiotics and I&D
. Stage 1; Total contact casting (TCC)
. Stage 2; Custom orthotic footwear
. Stage 3; Arthrodesis of the midfoot
. Stage 1; Immediate midfoot reconstructive arthrodesis

Correct Answer & Explanation

. Stage 1; Total contact casting (TCC)

Explanation

The patient is in Eichenholtz Stage 1 (Developmental/Fragmentation stage) of Charcot arthropathy, characterized clinically by a red, hot, swollen foot and radiographically by bone fragmentation, joint dislocation, and debris. The gold standard for initial management during this active phase is immobilization and offloading using a Total Contact Cast (TCC) to prevent further deformity until the active inflammatory phase subsides (transitioning to Stage 2 - Coalescence).

Question 6517

Topic: 8. Foot and Ankle

According to the Ponseti method for the correction of idiopathic clubfoot, the sequence of deformity correction is critical. Which of the following best describes the very first manipulation and casting step?

. Dorsiflexion of the ankle to correct the equinus
. Pronation of the forefoot to stretch the plantar fascia
. Abduction of the foot with counter-pressure on the calcaneocuboid joint
. Supination of the forefoot and elevation of the first ray to align with the hindfoot
. External rotation of the tibia to correct internal tibial torsion

Correct Answer & Explanation

. Supination of the forefoot and elevation of the first ray to align with the hindfoot

Explanation

The Ponseti method follows the acronym CAVE (Cavus, Adductus, Varus, Equinus) for the sequence of correction. The first step addresses the Cavus. Because the cavus is caused by pronation of the forefoot relative to the hindfoot (a dropped first metatarsal), the correct initial maneuver is to elevate the first ray and supinate the forefoot, aligning it with the hindfoot. Subsequent casts abduct the foot around the fixed head of the talus.

Question 6518

Topic: 8. Foot and Ankle
A 55-year-old patient with long-standing uncontrolled diabetes presents with a profoundly swollen, warm, and erythematous left foot. Radiographs demonstrate severe periarticular debris, fragmentation of the tarsal bones, and joint subluxation. There is no open wound. According to the Eichenholtz classification of Charcot arthropathy, what stage does this represent?
. Stage 0
. Stage I (Development/Fragmentation)
. Stage II (Coalescence)
. Stage III (Reconstruction/Consolidation)
. Stage IV

Correct Answer & Explanation

. Stage I (Development/Fragmentation)

Explanation

The Eichenholtz classification describes the natural history of Charcot arthropathy. Stage 0 is the acute inflammatory phase (normal radiographs or mild osteopenia). Stage I (Fragmentation) is characterized by acute inflammation, joint laxity, subluxation, and radiographic evidence of bone fragmentation and periarticular debris. Stage II (Coalescence) shows decreased inflammation, absorption of fine debris, and early fusion.

Question 6519

Topic: Midfoot & Hindfoot

Compared to baseline ambulation in an able-bodied individual, which of the following lower extremity amputations theoretically requires the greatest increase in energy expenditure during ambulation?

. Unilateral transtibial
. Bilateral transtibial
. Unilateral transfemoral
. Syme amputation
. Chopart amputation

Correct Answer & Explanation

. Unilateral transfemoral

Explanation

Energy expenditure increases significantly as the level of lower extremity amputation moves proximally, largely due to the loss of the knee joint. A unilateral transtibial amputation increases energy cost by roughly 25%, and bilateral transtibial by roughly 40%. A unilateral transfemoral amputation increases energy cost by 60-70%, making it more energetically demanding than a bilateral transtibial amputation.

Question 6520

Topic: 8. Foot and Ankle

A 7-year-old boy with spastic diplegic cerebral palsy develops an iatrogenic 'crouch gait', characterized by excessive hip flexion, knee flexion, and ankle dorsiflexion during the stance phase. Which of the following prior surgical interventions is the most common iatrogenic cause of this specific gait pattern?

. Bilateral adductor tenotomies
. Hamstring fractional lengthening
. Over-lengthening of the Achilles tendon
. Iliopsoas recession
. Derotational femoral osteotomies

Correct Answer & Explanation

. Over-lengthening of the Achilles tendon

Explanation

Over-lengthening of the Achilles tendon (tendo-Achilles lengthening) in a patient with spastic diplegia weakens the critical plantarflexion-knee extension couple. Without competent plantarflexors to control the forward progression of the tibia over the foot during stance, the tibia falls forward, causing the knee to buckle into flexion. This leads to an iatrogenic, highly disabling crouch gait.

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