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8. Foot and Ankle MCQs

Practice Set 333 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 6641

Topic: 8. Foot and Ankle

A patient with a malunited calcaneus fracture presents with anterior ankle impingement and limited dorsiflexion. A weight-bearing lateral radiograph demonstrates a talar declination angle of 10 degrees. Which of the following procedures is most appropriate to reestablish normal ankle mechanics and eliminate the anterior impingement?

. Anterior ankle arthroscopy with osteophyte excision
. In situ subtalar arthrodesis
. Subtalar distraction bone block arthrodesis
. Tibiotalocalcaneal arthrodesis
. Lateral wall ostectomy of the calcaneus

Correct Answer & Explanation

. Subtalar distraction bone block arthrodesis

Explanation

Correct Answer: CA malunited calcaneus fracture often results in loss of heel height, a decreased talar declination angle (normal is >20 degrees), and subsequent anterior ankle impingement due to a horizontal talus. A subtalar distraction bone block arthrodesis restores heel height and reestablishes the normal declination of the talus, thereby eliminating the anterior ankle impingement and improving dorsiflexion mechanics. In situ fusion or osteophyte excision alone would not correct the underlying mechanical derangement.

Question 6642

Topic: 8. Foot and Ankle

A 28-year-old man presents with progressive lateral ankle pain 15 years after undergoing a triple arthrodesis for a tarsal coalition. Weight-bearing radiographs demonstrate a valgus-supination malunion with lateral subfibular impingement. Which of the following surgical interventions is most appropriate to address this specific deformity?

. Lateral column lengthening and heel cord lengthening
. Ankle arthrodesis with retrograde intramedullary nail fixation
. Medial displacement calcaneal osteotomy and transverse tarsal derotational osteotomy
. Ankle arthroscopy and lateral ligament reconstruction
. Total ankle arthroplasty

Correct Answer & Explanation

. Medial displacement calcaneal osteotomy and transverse tarsal derotational osteotomy

Explanation

Correct Answer: CA valgus-supination triple arthrodesis malunion results in excessive hindfoot valgus (causing subfibular impingement) and forefoot supination. The most appropriate management to correct this complex multiplanar deformity while preserving the ankle joint is a medial displacement calcaneal osteotomy (to correct the hindfoot valgus) combined with a transverse tarsal derotational osteotomy (to correct the forefoot supination). Ankle arthrodesis or arthroplasty is not indicated as the primary pathology is the malunited hindfoot, not the ankle joint itself.

Question 6643

Topic: 8. Foot and Ankle

A 14-year-old girl presents with a painful hallux valgus deformity. Radiographs demonstrate an increased first-second intermetatarsal angle, a congruent metatarsophalangeal joint, and an abnormal distal metatarsal articular angle (DMAA). If surgical intervention is pursued, which of the following combinations is required to fully correct the deformity?

. Proximal first metatarsal osteotomy and lateral soft tissue release
. Distal first metatarsal osteotomy and medial eminence excision
. Proximal and distal first metatarsal osteotomies
. First metatarsocuneiform arthrodesis and Akin osteotomy
. Metatarsophalangeal joint arthrodesis

Correct Answer & Explanation

. Proximal and distal first metatarsal osteotomies

Explanation

Correct Answer: C. Proximal and distal first metatarsal osteotomiesIn a juvenile bunion presenting with an increased intermetatarsal angle and an abnormal DMAA with a congruent joint, a double osteotomy is required. A proximal osteotomy is necessary to correct the large intermetatarsal angle, while a distal osteotomy is required to correct the abnormal DMAA and maintain joint congruency.

Question 6644

Topic: 8. Foot and Ankle

A patient presents with progressive hindfoot pain and anterior ankle impingement two years after a comminuted calcaneus fracture. A lateral weight-bearing radiograph demonstrates a talar declination angle of 10 degrees. Which of the following procedures is most appropriate to reestablish normal ankle mechanics and eliminate the anterior impingement?

. In situ subtalar arthrodesis
. Anterior distal tibial osteophyte excision
. Subtalar distraction bone block arthrodesis
. Tibiotalocalcaneal arthrodesis
. Lateral wall ostectomy of the calcaneus

Correct Answer & Explanation

. Subtalar distraction bone block arthrodesis

Explanation

Correct Answer: C. Subtalar distraction bone block arthrodesisLoss of heel height after a calcaneus fracture leads to a decreased talar declination angle (normal is > 20 degrees), resulting in anterior ankle impingement and limited dorsiflexion. A subtalar distraction bone block arthrodesis restores heel height and normal talar declination, thereby resolving the anterior impingement and addressing the subtalar arthrosis.

Question 6645

Topic: 8. Foot and Ankle

A 32-year-old man sustains a displaced fracture of the talar neck. He is at high risk for osteonecrosis of the talar body. The main blood supply to the lateral two-thirds of the talar body is derived from which of the following vessels?

. Artery of the tarsal canal
. Artery of the tarsal sinus
. Anterior tibial artery
. Peroneal artery
. Dorsalis pedis artery

Correct Answer & Explanation

. Artery of the tarsal canal

Explanation

Correct Answer: AThe main blood supply to the lateral two-thirds of the talar body is derived from the artery of the tarsal canal, which is a branch of the posterior tibial artery. The artery of the sinus tarsi supplies the intrasinus structures and is formed by anastomoses from the peroneal and anterior tibial arteries. The anterior tibial artery supplies the superior surface of the talar head.

Question 6646

Topic: 8. Foot and Ankle

A 15-year-old girl presents with a painful bunion deformity that has failed conservative management. Radiographs demonstrate an increased first-second intermetatarsal angle and an abnormal distal metatarsal articular angle (DMAA) with a congruent metatarsophalangeal joint. Which of the following surgical strategies is most appropriate to correct both the intermetatarsal angle and the DMAA?

. Proximal metatarsal osteotomy and Akin osteotomy
. Distal chevron osteotomy alone
. Proximal and distal first metatarsal osteotomies
. Lapidus procedure and Akin osteotomy
. Metatarsophalangeal joint arthrodesis

Correct Answer & Explanation

. Proximal and distal first metatarsal osteotomies

Explanation

Correct Answer: CThe radiograph reveals an increased first-second intermetatarsal angle and a congruent metatarsophalangeal joint with an abnormal distal metatarsal articular angle (DMAA). Correction of both of these specific abnormalities in a juvenile or adolescent bunion requires a double osteotomy approach: a proximal first metatarsal osteotomy to correct the intermetatarsal angle, and a distal first metatarsal osteotomy to correct the DMAA.

Question 6647

Topic: 8. Foot and Ankle

A patient with a history of a calcaneus fracture presents with anterior ankle pain and limited dorsiflexion. A lateral radiograph demonstrates loss of heel height and subtalar arthrosis. Anterior ankle impingement in this setting is suggested when the talar declination angle falls below what value?

. 10 degrees
. 15 degrees
. 20 degrees
. 25 degrees
. 30 degrees

Correct Answer & Explanation

. 20 degrees

Explanation

Correct Answer: CThe talar declination angle is measured by drawing a line through the longitudinal axis of the talus and the plane of support of the foot on a weight-bearing lateral radiograph. Anterior impingement is suggested with any value below 20 degrees. By performing a distraction arthrodesis through the subtalar joint, the normal declination of the talus is reestablished, eliminating the anterior ankle impingement.

Question 6648

Topic: 8. Foot and Ankle

A 32-year-old man sustains a displaced talar neck fracture. The primary blood supply to the lateral two-thirds of the talar body is at risk. This blood supply is derived from the artery of the tarsal canal, which is a branch of which of the following vessels?

. Anterior tibial artery
. Posterior tibial artery
. Peroneal artery
. Dorsalis pedis artery
. Medial plantar artery

Correct Answer & Explanation

. Posterior tibial artery

Explanation

Correct Answer: BThe main blood supply to the lateral two-thirds of the talar body is derived from the artery of the tarsal canal, which is a branch of the posterior tibial artery. The peroneal artery helps form a vascular plexus over the posterior tubercle, and the anterior tibial artery sends branches to the superior surface of the talar head.

Question 6649

Topic: 8. Foot and Ankle

When reconstructing a chronic Achilles tendon rupture with a large insertional gap, transfer of the flexor hallucis longus (FHL) tendon is often utilized. Which of the following anatomic characteristics makes the FHL particularly advantageous for this transfer?

. It lies medial to the tibial nerve, avoiding neurovascular crossing.
. Its muscle belly extends distally, providing excellent blood supply to the reconstruction.
. It is a direct antagonist to the Achilles tendon, allowing for immediate postoperative weight-bearing.
. It originates from the medial cuneiform, providing a robust anchor point.
. It is innervated by the deep peroneal nerve, which is easily mobilized during the approach.

Correct Answer & Explanation

. Its muscle belly extends distally, providing excellent blood supply to the reconstruction.

Explanation

Correct Answer: BThe flexor hallucis longus (FHL) tendon provides the best, most direct route of transfer for filling Achilles tendon gaps. The FHL tendon has a muscle belly that extends distally on the tendon itself, often beyond the actual tibiotalar joint. When the tendon is transferred, this muscle belly brings excellent blood supply to the anterior portion of the reconstruction. It also lies lateral to the neurovascular structures, making it safe for harvest without crossing them.

Question 6650

Topic: 8. Foot and Ankle

In a 14-year-old patient presenting with a painful hallux valgus deformity, radiographic evaluation demonstrates an increased first-second intermetatarsal angle, a congruent metatarsophalangeal joint, and an abnormal distal metatarsal articular angle. Which of the following surgical strategies is most appropriate to address all components of this deformity?

. Distal soft-tissue realignment alone
. Proximal first metatarsal osteotomy with distal soft-tissue realignment
. Distal first metatarsal osteotomy with distal soft-tissue realignment
. Combined proximal and distal first metatarsal osteotomies
. First metatarsophalangeal joint arthrodesis

Correct Answer & Explanation

. Combined proximal and distal first metatarsal osteotomies

Explanation

Correct Answer: DThe presence of an increased intermetatarsal angle combined with an abnormal distal metatarsal articular angle (DMAA) and a congruent joint in a juvenile bunion requires a double osteotomy. A proximal osteotomy corrects the intermetatarsal angle, while a distal osteotomy corrects the DMAA. Soft-tissue realignment alone or a single osteotomy would fail to address the complex multi-apical nature of this specific deformity.

Question 6651

Topic: 8. Foot and Ankle

Which of the following arteries provides the primary blood supply to the lateral two-thirds of the talar body?

. Artery of the tarsal sinus
. Artery of the tarsal canal
. Anterior lateral malleolar artery
. Peroneal artery
. Dorsalis pedis artery

Correct Answer & Explanation

. Artery of the tarsal canal

Explanation

Correct Answer: BThe artery of the tarsal canal, a branch of the posterior tibial artery, provides the main blood supply to the lateral two-thirds of the talar body. The artery of the sinus tarsi supplies the intrasinus structures and the anterolateral aspect of the talar body. The anterior tibial artery supplies the superior aspect of the talar head and neck.

Question 6652

Topic: 8. Foot and Ankle

When reconstructing a chronic Achilles tendon rupture with a large insertional gap, transfer of the flexor hallucis longus (FHL) tendon is frequently utilized. Which of the following anatomic characteristics makes the FHL particularly advantageous for this transfer?

. It lies medial to the neurovascular bundle, allowing for a safe harvest.
. Its muscle belly extends distally, providing excellent blood supply to the anterior portion of the reconstruction.
. It is the strongest plantar flexor of the foot, fully replacing the strength of the gastrocnemius-soleus complex.
. It crosses superficial to the neurovascular structures, minimizing the risk of nerve injury during transfer.
. It has a dual innervation, preventing complete denervation during harvest.

Correct Answer & Explanation

. Its muscle belly extends distally, providing excellent blood supply to the anterior portion of the reconstruction.

Explanation

Correct Answer: BThe FHL tendon is ideal for Achilles tendon reconstruction because its muscle belly extends far distally, often beyond the tibiotalar joint. When transferred, this muscle belly brings a robust blood supply to the anterior aspect of the poorly vascularized Achilles reconstruction site. Additionally, it lies lateral to the neurovascular bundle, making harvest safe and providing a direct route to the calcaneus.

Question 6653

Topic: Midfoot & Hindfoot

A 22-year-old rugby player sustains a purely ligamentous Lisfranc injury with dynamic instability demonstrated on weight-bearing radiographs. Which surgical intervention is associated with the best long-term functional outcome for purely ligamentous variants?

. Closed reduction and percutaneous pinning with K-wires
. Open reduction and internal fixation with transarticular screws
. Primary arthrodesis of the first, second, and third tarsometatarsal joints
. Dorsal bridge plating spanning the midfoot
. Ligamentous reconstruction using a plantaris autograft

Correct Answer & Explanation

. Primary arthrodesis of the first, second, and third tarsometatarsal joints

Explanation

Evidence suggests that primary arthrodesis yields superior long-term outcomes and lower revision rates compared to open reduction and internal fixation (ORIF) for purely ligamentous Lisfranc injuries. ORIF is generally preferred for purely bony variants.

Question 6654

Topic: 8. Foot and Ankle

In the initial correction of an idiopathic clubfoot utilizing the Ponseti casting technique, what is the critical first maneuver?

. Abduction of the forefoot while counter-pressuring the calcaneus
. Dorsiflexion of the entire foot to stretch the Achilles tendon
. Supination of the forefoot and elevation of the first ray to correct cavus
. Pronation of the midfoot to unlock the transverse tarsal joint
. Eversion of the hindfoot to correct varus

Correct Answer & Explanation

. Supination of the forefoot and elevation of the first ray to correct cavus

Explanation

The Ponseti method follows the CAVE sequence (Cavus, Adductus, Varus, Equinus). The very first step is to correct the cavus deformity by supinating the forefoot and elevating the first ray, effectively aligning the forefoot with the hindfoot.

Question 6655

Topic: 8. Foot and Ankle

When counseling a 35-year-old active male regarding the treatment options for an acute Achilles tendon rupture, how do the complication profiles of operative versus nonoperative management typically compare?

. Operative treatment has a higher rerupture rate but lower infection rate
. Nonoperative treatment has a lower rerupture rate and lower infection rate
. Operative treatment has a lower rerupture rate but higher risk of superficial and deep infection
. Both treatments have identical rerupture and infection rates
. Nonoperative treatment is associated with a higher risk of sural nerve injury

Correct Answer & Explanation

. Operative treatment has a lower rerupture rate but higher risk of superficial and deep infection

Explanation

Surgical repair of Achilles tendon ruptures significantly decreases the rerupture rate compared to traditional nonoperative management. However, it introduces surgical risks, notably superficial and deep wound infections, as well as potential sural nerve injury depending on the technique.

Question 6656

Topic: 8. Foot and Ankle

A 25-year-old male sustains a severe axial load to a plantarflexed foot. Weight-bearing radiographs reveal widening between the medial and middle cuneiforms and a "fleck sign" in the first intermetatarsal space. The injured primary stabilizing structure normally connects which of the following bones?

. The medial cuneiform to the base of the second metatarsal
. The medial cuneiform to the middle cuneiform
. The base of the first metatarsal to the base of the second metatarsal
. The navicular to the medial cuneiform
. The calcaneus to the navicular

Correct Answer & Explanation

. The medial cuneiform to the base of the second metatarsal

Explanation

The Lisfranc ligament is the strongest interosseous ligament stabilizing the midfoot and connects the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. A "fleck sign" represents a bony avulsion of this ligament.

Question 6657

Topic: 8. Foot and Ankle

A newborn is noted to have severe micromelia, rigid clubfeet, and "hitchhiker" thumbs. Clinical examination also reveals prominent swelling of the bilateral pinnae. What is the underlying mechanism of this skeletal dysplasia?

. Defective type IX collagen synthesis
. Defective type X collagen synthesis
. Impaired intracellular sulfate transport
. Gain of function in fibroblast growth factor receptor
. Defective degradation of mucopolysaccharides

Correct Answer & Explanation

. Impaired intracellular sulfate transport

Explanation

Diastrophic dysplasia is an autosomal recessive disorder caused by a mutation in the SLC26A2 (DTDST) gene, leading to defective sulfate transport. Classic physical findings include cauliflower ears, hitchhiker thumbs, and rigid equinovarus foot deformities.

Question 6658

Topic: 8. Foot and Ankle

A 60-year-old woman presents with medial ankle pain and a progressive flatfoot deformity. Examination reveals an inability to perform a single-limb heel rise. The primary dynamic stabilizer of the medial longitudinal arch is implicated. Which of the following best describes the primary insertion site and action of this tendon?

. Base of the first metatarsal; plantarflexion and eversion
. Navicular tuberosity; plantarflexion and inversion
. Medial cuneiform; dorsiflexion and inversion
. Base of the fifth metatarsal; plantarflexion and eversion
. Sustentaculum tali; dorsiflexion and eversion

Correct Answer & Explanation

. Navicular tuberosity; plantarflexion and inversion

Explanation

Correct Answer: Navicular tuberosity; plantarflexion and inversionThe posterior tibial tendon (PTT) is the primary dynamic stabilizer of the medial longitudinal arch. It originates from the posterior surfaces of the tibia and fibula and the interosseous membrane. It passes posterior to the medial malleolus and has a broad insertion, primarily on the navicular tuberosity, but also sends slips to the cuneiforms, cuboid, and bases of the 2nd-4th metatarsals. Its primary action is plantarflexion and inversion of the foot. Dysfunction of the PTT leads to adult acquired flatfoot deformity, characterized by loss of the medial arch, hindfoot valgus, and forefoot abduction.

Question 6659

Topic: Midfoot & Hindfoot
A 62-year-old woman with a history of medial ankle pain presents with a rigid, non-reducible flatfoot deformity. She has severe pain in the subfibular region. Radiographs demonstrate talonavicular and subtalar arthritis with severe talonavicular uncoverage. Conservative management has failed. What is the most appropriate surgical intervention?
. Flexor digitorum longus transfer and medial displacement calcaneal osteotomy
. Lateral column lengthening and gastrocnemius recession
. Triple arthrodesis
. Subtalar arthrodesis
. Spring ligament reconstruction

Correct Answer & Explanation

. Triple arthrodesis

Explanation

The patient presents with Stage III posterior tibial tendon dysfunction (PTTD), which is characterized by a rigid, non-reducible flatfoot deformity and degenerative changes in the subtalar and/or talonavicular joints. The presence of subfibular pain indicates lateral impingement due to severe hindfoot valgus. The appropriate surgical management for a rigid deformity with arthritic changes is a triple arthrodesis (fusion of the subtalar, talonavicular, and calcaneocuboid joints) to correct the deformity and relieve pain. FDL transfer and calcaneal osteotomy are indicated for Stage II (flexible) deformity without significant arthritis.

Question 6660

Topic: 8. Foot and Ankle

A 70-year-old woman presents with pain and deformity of her great toe 2 years after a bunionectomy. Examination reveals a rigid hallux varus deformity. Which of the following intraoperative errors is the most likely cause of this complication?

. Under-resection of the medial eminence
. Failure to release the adductor hallucis tendon
. Excessive lateral release and over-resection of the medial eminence
. Plantarflexion of the first metatarsal during osteotomy fixation
. Inadequate medial capsulorrhaphy

Correct Answer & Explanation

. Excessive lateral release and over-resection of the medial eminence

Explanation

Correct Answer: Excessive lateral release and over-resection of the medial eminenceHallux varus is a known complication of bunion surgery (hallux valgus correction). It is most commonly iatrogenic, resulting from over-correction. The classic cause is 'staking the metatarsal head' (excessive resection of the medial eminence past the sagittal sulcus), combined with an overzealous lateral soft tissue release (release of the adductor hallucis and lateral capsule) and over-plication of the medial capsule. This disrupts the dynamic balance of the first MTP joint, leading to a medial deviation of the proximal phalanx.

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