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 6521
Topic: 8. Foot and Ankle
A patient sustains a high-energy fracture-dislocation of the midfoot involving the tarsometatarsal joints. Which ligament is primarily responsible for maintaining the structural stability of the second metatarsal base to the medial cuneiform?
Correct Answer & Explanation
. Lisfranc ligament
Explanation
The Lisfranc ligament connects the medial cuneiform directly to the base of the second metatarsal. It lacks an intermetatarsal ligament between the first and second rays, making this specific ligament critical for midfoot stability.
Question 6522
Topic: 8. Foot and Ankle
A 28-year-old male sustains a Hawkins Type III fracture of the talar neck. Which of the following sources of blood supply to the talus is most likely to remain intact in this specific injury pattern?
Correct Answer & Explanation
. None, all are consistently disrupted
Explanation
A Hawkins Type III fracture involves a talar neck fracture with dislocation of both the subtalar and tibiotalar (ankle) joints. This pattern severely disrupts all three major blood supplies (artery of the tarsal canal, sinus tarsi, and deltoid branch), leading to a near 100% rate of avascular necrosis. None remain consistently intact.
Question 6523
Topic: Midfoot & Hindfoot
A 52-year-old patient with poorly controlled diabetes presents with a swollen, warm, and erythematous right foot. Radiographs reveal fragmentation, periarticular debris, and joint subluxation at the tarsometatarsal joints. According to the Eichenholtz classification for Charcot neuroarthropathy, what stage does this represent?
Correct Answer & Explanation
. Stage I
Explanation
The Eichenholtz classification divides Charcot arthropathy into stages: Stage 0 (prodromal, normal x-rays), Stage I (development/fragmentation, characterized by debris, subluxation, and fragmentation), Stage II (coalescence, absorption of fine debris, early fusion), and Stage III (reconstruction, consolidation, remodeling).
Question 6524
Topic: Midfoot & Hindfoot
A 30-year-old male sustains a displaced Hawkins type III talar neck fracture. Which of the following best describes the anatomical disruption associated with this specific classification?
Correct Answer & Explanation
. Talar neck fracture with subtalar and tibiotalar dislocations
Explanation
A Hawkins type III fracture is a displaced talar neck fracture accompanied by dislocation of both the subtalar and tibiotalar joints. This pattern carries an exceptionally high risk of avascular necrosis of the talar body.
Question 6525
Topic: 8. Foot and Ankle
A 25-year-old male injures his midfoot. Weight-bearing radiographs show widening between the first and second metatarsal bases. The primary stabilizing Lisfranc ligament connects which two osseous structures?
Correct Answer & Explanation
. Second metatarsal and medial cuneiform
Explanation
The true Lisfranc ligament is an oblique intra-articular ligament that connects the lateral aspect of the medial cuneiform to the base of the second metatarsal. It is the keystone stabilizer of the midfoot arch.
Question 6526
Topic: 8. Foot and Ankle
The Lisfranc ligament complex is critical for maintaining midfoot stability. Which of the following best describes the anatomic attachment of the primary and strongest band of the Lisfranc ligament?
Correct Answer & Explanation
. Plantar aspect of the medial cuneiform to the plantar base of the second metatarsal
Explanation
The true Lisfranc ligament spans from the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. Its plantar band is the thickest and biomechanically strongest component of the complex.
Question 6527
Topic: 8. Foot and Ankle
A 14-year-old girl presents with bilateral cavovarus foot deformities. Family history is positive for similar foot shapes. Genetic testing reveals a duplication of the PMP22 gene. Which physical exam finding is most likely to be present?
Correct Answer & Explanation
. Weakness of the peroneus brevis and anterior tibialis
Explanation
The duplication of PMP22 causes Charcot-Marie-Tooth (CMT) disease type 1A, a hereditary motor and sensory neuropathy. The characteristic cavovarus deformity is driven by an imbalance where the anterior tibialis and peroneus brevis become weak early, while the posterior tibialis and peroneus longus remain relatively strong. Deep tendon reflexes are typically decreased or absent, not hyperactive.
Question 6528
Topic: 8. Foot and Ankle
A 55-year-old diabetic male with a history of peripheral neuropathy presents with a red, swollen, and warm midfoot. Radiographs show disorganization and fragmentation of the tarsometatarsal joints with a 'rocker-bottom' deformity. His WBC count is normal, and there are no open wounds. What is the most appropriate initial management strategy?
Correct Answer & Explanation
. Non-weight bearing in a total contact cast or controlled ankle motion (CAM) boot.
Explanation
The patient's presentation (diabetic neuropathy, red/swollen/warm midfoot, radiographic changes of disorganization and fragmentation, 'rocker-bottom' deformity) is classic for acute Charcot neuroarthropathy. In the acute (Eichenholtz Stage I - fragmentation and disorganization) phase, the primary management is strict non-weight bearing and immobilization in a total contact cast or CAM boot to protect the foot from further collapse and allow for bone consolidation. Surgical fusion is generally reserved for the chronic (Stage III - coalescence/consolidation) phase, or for severe deformity that cannot be accommodated by bracing and leads to recurrent ulceration, and is not an initial treatment for acute Charcot. Systemic antibiotics are not indicated unless there is a confirmed infection, and the normal WBC and absence of open wounds make infection less likely as the primary issue. Corticosteroids are not a standard treatment. Amputation is a last resort for uncontrolled infection or severe deformity with intractable ulceration.
Question 6529
Topic: 8. Foot and Ankle
A 40-year-old male develops severe, burning pain, allodynia, hyperalgesia, swelling, and changes in skin temperature and color in his left foot 3 weeks after an ankle fracture. Radiographs show no abnormalities beyond the healing fracture. Nerve conduction studies are normal. Which of the following non-pharmacological interventions has demonstrated the most consistent efficacy in the early management of this condition?
Correct Answer & Explanation
. Mirror therapy.
Explanation
The patient's symptoms are highly suggestive of Complex Regional Pain Syndrome (CRPS) Type 1. In the early stages of CRPS, a multidisciplinary approach is crucial, involving pain management, physical therapy, and psychological support. Among the non-pharmacological interventions, mirror therapy has demonstrated consistent efficacy, particularly in early CRPS, by addressing the cortical reorganization thought to be involved in the pathophysiology. Graded motor imagery is also effective. While sympathetic nerve blocks can provide pain relief, they are more invasive and not typically theinitialnon-pharmacological intervention of choice. Spinal cord stimulators are reserved for refractory chronic CRPS. TENS has limited evidence for CRPS.
Question 6530
Topic: 8. Foot and Ankle
A 25-year-old football player presents with midfoot pain after his foot was axially loaded while plantarflexed. Non-weight-bearing radiographs appear normal. What is the most sensitive initial radiographic view or study to identify an occult Lisfranc injury in this patient?
Correct Answer & Explanation
. Weight-bearing AP and lateral foot X-rays
Explanation
Weight-bearing radiographs are critical for diagnosing occult Lisfranc injuries as the stress reveals widening of the interval between the first and second metatarsal bases. If weight-bearing X-rays are equivocal, an MRI or weight-bearing CT is often the next step.
Question 6531
Topic: 8. Foot and Ankle
A 22-year-old football player sustains a hyperplantarflexion injury to his foot. Radiographs reveal widening of the space between the medial and middle cuneiforms, and a small bony avulsion in the first intermetatarsal space. What ligament is primarily injured?
Correct Answer & Explanation
. Lisfranc ligament
Explanation
The injury described is a Lisfranc injury, involving disruption of the tarsometatarsal joint complex. The Lisfranc ligament connects the medial cuneiform to the base of the second metatarsal; the 'fleck sign' represents an avulsion fracture at its attachment.
Question 6532
Topic: Midfoot & Hindfoot
A 55-year-old poorly controlled diabetic male presents with a swollen, erythematous, warm, and painless right foot. Radiographs show early subluxation of the midfoot joints but no open ulcers. What is the most appropriate initial management?
Correct Answer & Explanation
. Total contact casting
Explanation
The patient is presenting with acute Eichenholtz Stage I Charcot arthropathy. In the absence of ulceration or systemic infection, the gold standard initial treatment is offloading and immobilization with a total contact cast.
Question 6533
Topic: 8. Foot and Ankle
A 24-year-old football player sustains a hyperplantarflexion injury to his midfoot. Radiographs demonstrate widening of the space between the medial cuneiform and the base of the second metatarsal, accompanied by a small bony "fleck sign". The ruptured ligament responsible for this pathognomonic finding connects which two osseous structures?
Correct Answer & Explanation
. Medial cuneiform to the base of the second metatarsal
Explanation
The Lisfranc ligament is an intra-articular ligament that extends from the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. Avulsion of this critical stabilizing structure often produces the pathognomonic "fleck sign" on AP foot radiographs.
Question 6534
Topic: 8. Foot and Ankle
A 28-year-old male sustains a purely ligamentous Lisfranc injury. He undergoes evaluation for operative treatment. Compared to open reduction and internal fixation (ORIF), primary arthrodesis for this specific injury pattern has been shown to result in:
Correct Answer & Explanation
. Better functional outcomes at 2 years
Explanation
For purely ligamentous Lisfranc injuries, multiple studies have demonstrated that primary arthrodesis of the 1st, 2nd, and 3rd tarsometatarsal joints yields better functional outcomes and a significantly lower reoperation rate compared to ORIF.
Question 6535
Topic: 8. Foot and Ankle
Recent high-level evidence regarding acute Achilles tendon ruptures comparing operative to non-operative management utilizing early functional rehabilitation protocols has shown which of the following?
Correct Answer & Explanation
. Non-operative management with early functional rehab has a re-rupture rate similar to operative management
Explanation
Landmark studies (such as the Willits trial) have demonstrated that when a dynamic, early functional rehabilitation protocol is employed, non-operative management of acute Achilles tendon ruptures has functional outcomes and re-rupture rates that are statistically similar to operative management, while avoiding surgical complications.
Question 6536
Topic: Midfoot & Hindfoot
The Eichenholtz classification is used to stage Charcot arthropathy. Which of the following clinical and radiographic findings is characteristic of the Stage 1 phase?
Correct Answer & Explanation
. Clinical erythema, osteopenia, subluxation, and periarticular debris
Explanation
Eichenholtz Stage 1 (Development/Fragmentation) is characterized by a red, hot, swollen extremity. Radiographs show osteopenia, periarticular debris, fragmentation, and subluxation. Stage 2 (Coalescence) shows absorption of debris and sclerosis. Stage 3 (Reconstruction/Consolidation) shows remodeling and decreased sclerosis.
Question 6537
Topic: Midfoot & Hindfoot
A 55-year-old poorly controlled diabetic patient presents with a swollen, warm, erythematous foot. Radiographs show periarticular fragmentation, subluxation, and bony debris in the midfoot. According to the Eichenholtz classification, this presentation best represents which stage of Charcot arthropathy?
Correct Answer & Explanation
. Stage I (Fragmentation)
Explanation
Eichenholtz Stage I is the developmental or fragmentation phase, characterized by joint effusion, bone fragmentation, subluxation, and joint debris. Clinically, the foot is warm, red, and swollen. Stage II is coalescence (absorption of debris), and Stage III is consolidation (remodeling with mature bony architecture).
Question 6538
Topic: Midfoot & Hindfoot
A 55-year-old male with poorly controlled type II diabetes presents with a unilaterally swollen, warm, and erythematous foot without ulceration. Radiographs show periarticular fragmentation, bony debris, and early subluxation of the midfoot joints, but no significant sclerosis or consolidation. According to the Eichenholtz classification, what is the stage and the most appropriate initial management?
Correct Answer & Explanation
. Stage 1 / Total contact casting and non-weight bearing
Explanation
The patient is presenting with acute Charcot arthropathy. The clinical and radiographic findings of fragmentation, debris, and subluxation characterize Eichenholtz Stage 1 (Developmental/Fragmentation stage). Stage 0 (prodromal) has clinical swelling but normal radiographs. Stage 2 (Coalescence) shows early healing and sclerosis. Stage 3 (Reconstruction) shows consolidation and remodeling. The gold standard initial treatment for acute Stage 1 Charcot is immobilization with a total contact cast (TCC) to prevent further deformity until the acute inflammatory phase resolves.
Question 6539
Topic: Forefoot
A 45-year-old female presents with a painful bunion. Weight-bearing radiographs reveal a Hallux Valgus Angle (HVA) of 42 degrees and an Intermetatarsal Angle (IMA) of 18 degrees. Clinical examination reveals no hypermobility at the first tarsometatarsal (TMT) joint. What is the most appropriate surgical intervention for this deformity?
Correct Answer & Explanation
. Proximal metatarsal osteotomy with a distal soft tissue reconstruction
Explanation
This patient has a severe hallux valgus deformity, defined by an HVA > 40 degrees and an IMA > 15 degrees. Distal osteotomies (like the Chevron) cannot achieve enough translation to correct an IMA > 15 degrees. For severe deformities without TMT hypermobility or degenerative arthritis, a proximal metatarsal osteotomy (e.g., Ludloff, proximal crescentic) combined with a distal soft tissue release (modified McBride) is the most appropriate procedure. A Lapidus is favored if there is documented TMT hypermobility or arthritis.
Question 6540
Topic: 8. Foot and Ankle
A 25-year-old athlete sustains a midfoot injury. Radiographs reveal a 'fleck sign.' The ligament whose avulsion creates this radiographic finding originates on which bone and inserts onto which bone?
Correct Answer & Explanation
. Originates on medial cuneiform, inserts on base of 2nd metatarsal
Explanation
The Lisfranc ligament is an interosseous ligament that connects the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. A 'fleck sign' represents a bony avulsion of this ligament, usually from the base of the 2nd metatarsal, and indicates a severe Lisfranc injury.
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