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8. Foot and Ankle MCQs

Practice Set 328 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 6541

Topic: 8. Foot and Ankle

A 40-year-old weekend warrior sustains an acute Achilles tendon rupture. The tear occurs in the typical 'watershed' region. This area of relative hypovascularity is located approximately how far proximal to the calcaneal insertion?

. 0 - 1 cm
. 2 - 6 cm
. 7 - 9 cm
. At the musculotendinous junction
. Distal to the retrocalcaneal bursa

Correct Answer & Explanation

. 2 - 6 cm

Explanation

The 'watershed' area of the Achilles tendon, which is most susceptible to rupture due to decreased vascularity, is located approximately 2 to 6 cm proximal to its insertion on the calcaneus.

Question 6542

Topic: 8. Foot and Ankle

A 22-year-old football player sustains a hyperplantarflexion injury to his midfoot. Weight-bearing radiographs show a 3 mm widening between the base of the first and second metatarsals. What is the precise anatomic attachment of the 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 cuboid
. Navicular to the medial cuneiform

Correct Answer & Explanation

. Medial cuneiform to the base of the second metatarsal

Explanation

The Lisfranc ligament is a strong interosseous ligament that connects the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. It is critical for the structural stability of the midfoot.

Question 6543

Topic: 8. Foot and Ankle

A 30-year-old male sustains a hyperplantarflexion injury to his midfoot. Radiographs demonstrate a widening of the space between the 1st and 2nd metatarsal bases with a small avulsion fragment ('fleck sign'). The disrupted ligament in this injury originates from which bone?

. Medial cuneiform
. Intermediate cuneiform
. Lateral cuneiform
. Navicular
. Cuboid

Correct Answer & Explanation

. Medial cuneiform

Explanation

The Lisfranc ligament is a stout interosseous ligament that anchors the second metatarsal to the midfoot. It originates on the lateral surface of the medial cuneiform and inserts onto the medial base of the second metatarsal.

Question 6544

Topic: 8. Foot and Ankle

The Lisfranc ligament is crucial for maintaining the stability of the midfoot-forefoot articulation. Between which two osseous structures does the primary, strongest band of the Lisfranc ligament course?

. Plantar aspect of the medial cuneiform to the base of the second metatarsal
. Dorsal aspect of the middle cuneiform to the base of the second metatarsal
. Plantar aspect of the medial cuneiform to the base of the first metatarsal
. Base of the first metatarsal to the base of the second metatarsal
. Plantar aspect of the lateral cuneiform to the cuboid

Correct Answer & Explanation

. Plantar aspect of the medial cuneiform to the base of the second metatarsal

Explanation

The Lisfranc ligament is an intra-articular interosseous ligament that connects the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. Its strongest component is the plantar band. Notably, there is no direct ligamentous connection between the bases of the first and second metatarsals, making the Lisfranc ligament the critical stabilizer of the second metatarsal base (the 'keystone' of the tarsometatarsal joint).

Question 6545

Topic: Forefoot

A 45-year-old female presents with a painful bunion. Weight-bearing radiographs demonstrate a Hallux Valgus Angle (HVA) of 36 degrees and an Intermetatarsal Angle (IMA) of 17 degrees. The 1st MTP joint shows no arthritic changes. Which of the following surgical procedures is most appropriate to achieve correction?

. Distal chevron osteotomy
. Akin osteotomy alone
. Proximal metatarsal osteotomy
. Keller arthroplasty
. 1st MTP arthrodesis

Correct Answer & Explanation

. Proximal metatarsal osteotomy

Explanation

An intermetatarsal angle (IMA) greater than 15 degrees and a hallux valgus angle (HVA) greater than 30 degrees classify as severe hallux valgus. Distal osteotomies (like a distal Chevron) cannot adequately translate the metatarsal head to correct an IMA >15 degrees. A proximal metatarsal osteotomy (e.g., Ludloff, Crescentic) or a Lapidus procedure (1st TMT fusion) is required to correct this magnitude of deformity.

Question 6546

Topic: 8. Foot and Ankle

A meta-analysis comparing operative versus non-operative management of acute Achilles tendon ruptures utilizing modern early functional rehabilitation protocols is most likely to demonstrate which of the following?

. Operative management has a substantially lower re-rupture rate
. Non-operative management has a substantially higher re-rupture rate
. No significant difference in re-rupture rate, but operative management has a higher complication rate
. Operative management restores significantly greater plantarflexion power at 1 year
. Non-operative management is strictly indicated only for sedentary patients

Correct Answer & Explanation

. No significant difference in re-rupture rate, but operative management has a higher complication rate

Explanation

Recent high-quality meta-analyses demonstrate that when early functional rehabilitation and early weight-bearing protocols are utilized, there is no statistically significant difference in re-rupture rates between operative and non-operative management of acute Achilles tendon ruptures. However, operative management consistently carries a higher risk of soft-tissue complications, including infection, wound breakdown, and sural nerve injury.

Question 6547

Topic: 8. Foot and Ankle

In the surgical evaluation of midfoot trauma, identifying a disruption of the Lisfranc ligament is critical. Anatomically, the primary robust band 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
. Lateral cuneiform to the base of the 3rd metatarsal
. Cuboid to the base of the 4th metatarsal

Correct Answer & Explanation

. Medial cuneiform to the base of the 1st metatarsal

Explanation

The Lisfranc ligament is an oblique, strong intra-articular ligament that originates on the lateral aspect of the medial cuneiform and inserts onto the medial aspect of the base of the second metatarsal. It is a critical stabilizer of the midfoot, especially because there is no direct transverse intermetatarsal ligament connecting the bases of the first and second metatarsals.

Question 6548

Topic: 8. Foot and Ankle

A 58-year-old diabetic male with peripheral neuropathy presents with a warm, swollen, erythematous left foot. Radiographs reveal fragmentation of the midfoot joints, collapse of the arch, and subluxation of the talonavicular joint. He reports no acute trauma but has had increasing difficulty with shoe wear and ambulation. What is the most appropriate initial management for this patient?

. Immediate surgical correction of the deformity with internal fixation
. Non-weight-bearing in a total contact cast (TCC) to offload the foot and promote healing
. Aggressive intravenous antibiotic therapy for suspected osteomyelitis
. Amputation of the forefoot to prevent further progression
. Immediate initiation of a structured physical therapy program

Correct Answer & Explanation

. Non-weight-bearing in a total contact cast (TCC) to offload the foot and promote healing

Explanation

This patient's presentation (diabetic with neuropathy, warm/swollen/erythematous foot, radiographic changes of joint fragmentation and arch collapse) is classic for acute Charcot neuroarthropathy (Rockwood Stage 1 or Eichenholtz Stage 1). The most appropriate initial management is non-weight-bearing immobilization using a total contact cast (TCC) or a removable cast walker. The goal is to offload the foot, reduce inflammation, and prevent further joint destruction and deformity. Surgical correction is typically reserved for stable, chronic deformities that are refractory to conservative treatment or for those with severe instability/ulceration that cannot be accommodated by bracing. While osteomyelitis can complicate Charcot, the initial presentation points strongly to acute Charcot itself, and antibiotics are not indicated unless infection is proven. Amputation is a last resort. Physical therapy is contraindicated during the acute inflammatory phase.

Question 6549

Topic: 8. Foot and Ankle

A 35-year-old female presents with midfoot pain after a twisting injury. Weight-bearing radiographs show 3 mm of widening between the base of the first and second metatarsals. What is the anatomic attachment of the primary ligament injured?

. 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 uniquely connects the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. It is critical for the stability of the tarsometatarsal joint complex.

Question 6550

Topic: 8. Foot and Ankle
A 28-year-old male falls from a height and sustains a Hawkins Type III fracture of the talar neck. Which of the following best describes the vascular supply compromise and the expected rate of avascular necrosis (AVN) in this injury?
. Disruption of the artery of the tarsal canal alone; 20-30% AVN rate
. Disruption of the artery of the tarsal canal and deltoid branches; 50% AVN rate
. Disruption of blood supply from the tarsal canal, sinus tarsi, and deltoid branches; nearly 100% AVN rate
. Disruption of the anterior tibial artery branches; 10% AVN rate
. Disruption of the calcaneal branches; 80% AVN rate

Correct Answer & Explanation

. Disruption of blood supply from the tarsal canal, sinus tarsi, and deltoid branches; nearly 100% AVN rate

Explanation

A Hawkins Type III fracture involves subluxation or dislocation of the talar body from both the subtalar and tibiotalar joints. This typically tears all three major blood supplies (tarsal canal, sinus tarsi, and deltoid branches), leading to an AVN rate approaching 100%.

Question 6551

Topic: 8. Foot and Ankle

A 40-year-old male sustains an acute Achilles tendon rupture. After discussing treatment options, he elects for non-operative management. Compared to open surgical repair, which of the following is true regarding non-operative management utilizing early functional rehabilitation?

. Higher rate of deep infection
. Significantly higher rate of re-rupture
. Equivalent re-rupture rates but higher risk of iatrogenic nerve injury
. Similar re-rupture rates with lower wound complication risks
. Greater long-term plantar flexion strength

Correct Answer & Explanation

. Similar re-rupture rates with lower wound complication risks

Explanation

Recent high-quality studies show that non-operative management with early functional rehabilitation yields re-rupture rates similar to operative repair. It also avoids the surgical risks of wound breakdown and infection associated with open repair.

Question 6552

Topic: Midfoot & Hindfoot

A 55-year-old diabetic male presents with a swollen, erythematous, but painless foot. Radiographs show acute fragmentation and subluxation of the tarsometatarsal joints. What is the most appropriate initial management?

. Intravenous antibiotics for presumed osteomyelitis
. Total contact casting and strictly non-weight-bearing
. Open reduction and internal fixation of the midfoot
. Below-knee amputation
. Intra-articular corticosteroid injection

Correct Answer & Explanation

. Total contact casting and strictly non-weight-bearing

Explanation

The patient is in the acute, inflammatory phase (Eichenholtz Stage I) of Charcot arthropathy. The standard initial treatment is rigorous offloading and immobilization, most commonly achieved with a total contact cast, until the acute phase resolves.

Question 6553

Topic: 8. Foot and Ankle

A 24-year-old professional athlete sustains an axial loading and twisting injury to his midfoot. Weight-bearing radiographs show 3 mm of widening between the base of the first and second metatarsals without any evidence of fractures. What is the most appropriate definitive management for this purely ligamentous injury to optimize return to function?

. Non-weight-bearing in a short leg cast for 8 weeks followed by progressive rehabilitation
. Open reduction and internal fixation with transarticular solid cortical screws
. Primary arthrodesis of the medial column tarsometatarsal joints
. Closed reduction and percutaneous pinning of the first, second, and third rays
. Immediate return to play utilizing a custom rigid carbon-fiber shoe insert

Correct Answer & Explanation

. Primary arthrodesis of the medial column tarsometatarsal joints

Explanation

Purely ligamentous Lisfranc injuries exhibit a high rate of chronic instability and predictable post-traumatic arthritis when treated with open reduction and internal fixation. Current evidence indicates that primary arthrodesis of the involved medial column joints yields superior long-term functional outcomes and lower reoperation rates.

Question 6554

Topic: 8. Foot and Ankle
A 35-year-old man sustains an Achilles tendon rupture and undergoes surgical repair. During the remodeling phase of tendon healing, which of the following collagen transitions primarily occurs to increase the tensile strength of the repair site?
. Type I replaces Type II
. Type II replaces Type I
. Type III replaces Type I
. Type I replaces Type III
. Type IV replaces Type I

Correct Answer & Explanation

. Type I replaces Type III

Explanation

Tendon healing progresses through inflammatory, proliferative, and remodeling phases. In the early proliferative phase, fibroblasts primarily synthesize Type III collagen. During the remodeling phase, Type I collagen replaces Type III collagen, aligning along the lines of tension to increase the tissue's mechanical strength.

Question 6555

Topic: 8. Foot and Ankle
A 55-year-old female presents with stage IIB adult acquired flatfoot deformity (posterior tibial tendon dysfunction). Her deformity is flexible but demonstrates >30% uncoverage of the talar head on AP foot radiographs. Along with a flexor digitorum longus (FDL) transfer, which of the following bony procedures is most biomechanically appropriate to address her specific multiplanar deformity?
. Medial displacement calcaneal osteotomy alone
. Lateral column lengthening (e.g., Evans osteotomy) and medial displacement calcaneal osteotomy
. Isolated subtalar arthrodesis
. Triple arthrodesis
. First tarsometatarsal joint arthrodesis (Lapidus) alone

Correct Answer & Explanation

. Lateral column lengthening (e.g., Evans osteotomy) and medial displacement calcaneal osteotomy

Explanation

Stage IIB adult acquired flatfoot deformity is characterized by a flexible deformity with significant forefoot abduction (>30% talonavicular uncoverage). A medial displacement calcaneal osteotomy (MDCO) primarily addresses hindfoot valgus, but a lateral column lengthening is necessary to correct the severe forefoot abduction. Combined MDCO and lateral column lengthening (often with FDL transfer) is standard for Stage IIB.

Question 6556

Topic: 8. Foot and Ankle

The Lisfranc ligament is essential for the stability of the tarsometatarsal joint complex. Which of the following accurately describes the precise anatomical origin and insertion of this critical ligament?

. Plantar aspect of the medial cuneiform to the base of the first metatarsal
. Plantar-lateral aspect of the medial cuneiform to the plantar-medial base of the second metatarsal
. Dorsal aspect of the intermediate cuneiform to the base of the second metatarsal
. Dorsal aspect of the medial cuneiform to the base of the third metatarsal
. Cuboid to the base of the fourth and fifth metatarsals

Correct Answer & Explanation

. Plantar-lateral aspect of the medial cuneiform to the plantar-medial base of the second metatarsal

Explanation

The Lisfranc ligament is an intra-articular ligament that extends from the plantar-lateral aspect of the medial cuneiform to the plantar-medial base of the second metatarsal. There is no direct ligamentous connection between the bases of the first and second metatarsals, making the Lisfranc ligament the critical primary stabilizer linking the medial and middle columns.

Question 6557

Topic: 8. Foot and Ankle

During the normal human gait cycle, the tibialis anterior muscle exhibits its peak electromyographic activity immediately following heel strike. What type of contraction is it performing, and what is its primary biomechanical function during this phase?

. Concentric; to actively dorsiflex the ankle for toe clearance
. Eccentric; to decelerate plantarflexion and prevent foot slap
. Isometric; to rigidly stabilize the subtalar joint
. Isotonic; to accelerate the lower limb into the swing phase
. Plyometric; to absorb vertical shock at the knee joint

Correct Answer & Explanation

. Eccentric; to decelerate plantarflexion and prevent foot slap

Explanation

Immediately following heel strike (initial contact), the ankle moves toward foot flat. The tibialis anterior contracts eccentrically (lengthening under tension) to control the rate of plantarflexion, slowly lowering the forefoot to the ground and preventing an audible "foot slap."

Question 6558

Topic: 8. Foot and Ankle

In the radiographic evaluation of a suspected subtle Lisfranc injury, weight-bearing views are critical. Which of the following radiographic relationships is the most reliable indicator of a normal Lisfranc joint complex on the standard anteroposterior (AP) view?

. Medial border of the 2nd metatarsal aligning with the medial border of the middle cuneiform
. Lateral border of the 1st metatarsal aligning with the lateral border of the medial cuneiform
. Medial border of the 3rd metatarsal aligning with the medial border of the lateral cuneiform
. Medial border of the 4th metatarsal aligning with the medial border of the cuboid
. Lateral border of the 2nd metatarsal aligning with the lateral border of the middle cuneiform

Correct Answer & Explanation

. Medial border of the 2nd metatarsal aligning with the medial border of the middle cuneiform

Explanation

On the AP view of the foot, the medial border of the base of the 2nd metatarsal should align perfectly with the medial border of the middle cuneiform. On the oblique view, the medial border of the 3rd metatarsal should align with the medial border of the lateral cuneiform.

Question 6559

Topic: Midfoot & Hindfoot
A 55-year-old diabetic male presents with a swollen, erythematous, and warm foot without skin ulceration. Radiographs show osteopenia, prominent periarticular fragmentation, subluxation of the tarsometatarsal joints, and bony debris. According to the Eichenholtz classification of Charcot arthropathy, which stage does this represent?
. Stage 0 (Prodromal)
. Stage I (Developmental/Fragmentation)
. Stage II (Coalescence)
. Stage III (Reconstruction/Consolidation)
. Stage IV (Ulceration)

Correct Answer & Explanation

. Stage I (Developmental/Fragmentation)

Explanation

Eichenholtz Stage I (Developmental or Fragmentation stage) is characterized clinically by an acute inflammatory response (erythema, swelling, warmth mimicking infection) and radiographically by osteopenia, bony fragmentation, joint subluxation/dislocation, and intra-articular debris. Stage II (Coalescence) shows absorption of fine debris and early fusion. Stage III (Reconstruction) shows mature bony remodeling.

Question 6560

Topic: 8. Foot and Ankle

A 60-year-old diabetic patient presents with a warm, swollen, and erythematous foot. Radiographs reveal fragmentation of the tarsal bones, subluxation of the tarsometatarsal joints, and significant bony debris. According to the Eichenholtz classification of Charcot arthropathy, what is the current stage and the most appropriate initial management?

. Stage 0; Intravenous antibiotics and urgent surgical debridement
. Stage 1; Total contact casting and strict non-weight bearing
. Stage 2; Custom orthosis and weight-bearing as tolerated
. Stage 3; Arthrodesis of the midfoot with rigid internal fixation
. Stage 1; Immediate open reduction and internal fixation to restore anatomy

Correct Answer & Explanation

. Stage 1; Total contact casting and strict non-weight bearing

Explanation

The patient is in Eichenholtz Stage 1 (Development/Fragmentation phase) of Charcot arthropathy, characterized by clinical inflammation (warmth, erythema, swelling) and radiographic findings of osteopenia, fragmentation, joint subluxation, and bony debris. The standard of care for acute Charcot arthropathy (Stage 1) is strict immobilization and offloading, which is most effectively achieved with a total contact cast (TCC) to prevent further structural collapse until the acute inflammatory phase resolves (Stage 2/3).

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