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8. Foot and Ankle MCQs

Practice Set 344 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 6861

Topic: 8. Foot and Ankle

A 22-year-old collegiate football player sustains a high-energy axial load and rotational injury to his plantarflexed foot. Weight-bearing radiographs demonstrate a 3 mm diastasis between the first and second metatarsal bases. What is the precise anatomical origin and insertion of the primary stabilizing ligament most likely injured in this scenario?

. Plantar-lateral aspect of the medial cuneiform to the plantar-medial aspect of the second metatarsal base
. Dorsal aspect of the medial cuneiform to the dorsal aspect of the second metatarsal base
. Plantar-medial aspect of the intermediate cuneiform to the plantar-lateral aspect of the second metatarsal base
. Lateral aspect of the medial cuneiform to the medial aspect of the intermediate cuneiform
. Plantar aspect of the medial cuneiform to the plantar aspect of the third metatarsal base

Correct Answer & Explanation

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

Explanation

The Lisfranc ligament is the strongest supporting structure of the first tarsometatarsal articulation. It courses from the plantar-lateral aspect of the medial cuneiform to the plantar-medial base of the second metatarsal.

Question 6862

Topic: 8. Foot and Ankle

A 65-year-old female undergoes a Lapidus procedure (first tarsometatarsal arthrodesis) for the treatment of severe hallux valgus with first ray hypermobility. To minimize the postoperative risk of transfer metatarsalgia, how should the first metatarsal optimally be positioned during the fusion?

. Dorsiflexed and inverted
. Slightly plantarflexed
. Neutral sagittal alignment with extreme adduction
. Slightly dorsiflexed with lengthening
. Significantly shortened and elevated

Correct Answer & Explanation

. Slightly plantarflexed

Explanation

During a Lapidus procedure, slight plantarflexion of the first metatarsal is necessary to restore the weight-bearing capability of the first ray. Failure to plantarflex the first ray can lead to elevation, resulting in secondary transfer metatarsalgia to the lesser metatarsals.

Question 6863

Topic: Midfoot & Hindfoot
A 55-year-old female presents with a progressive painful flatfoot deformity. On examination, she is unable to perform a single-leg heel raise on the right side. A Coleman block test is performed, and the patient's hindfoot valgus fails to correct. Based on these findings, what is the most appropriate surgical intervention?
. Flexor digitorum longus transfer to the navicular
. Medial displacement calcaneal osteotomy with FDL transfer
. Spring ligament reconstruction and lateral column lengthening
. Subtalar or triple arthrodesis
. Gastrocnemius recession and orthotic fitting

Correct Answer & Explanation

. Subtalar or triple arthrodesis

Explanation

The inability to correct hindfoot valgus during a Coleman block test indicates a rigid hindfoot deformity, classifying this as Stage III posterior tibial tendon dysfunction. The standard surgical treatment for Stage III rigid deformity is a hindfoot fusion (e.g., subtalar or triple arthrodesis).

Question 6864

Topic: 8. Foot and Ankle

A 30-year-old male complains of deep, aching ankle pain following a severe ankle sprain 8 months ago. MRI reveals a posteromedial osteochondral lesion of the talus (OCL). Compared to anterolateral talar OCLs, posteromedial lesions are classically described as:

. Shallow, wafer-shaped, and usually traumatic in origin
. Deep, cup-shaped, and less likely to have a clear traumatic etiology
. Highly responsive to conservative management with casting
. Associated predominantly with syndesmotic instability
. Easily accessible via standard anterior ankle arthroscopy without plantarflexion

Correct Answer & Explanation

. Deep, cup-shaped, and less likely to have a clear traumatic etiology

Explanation

Posteromedial talar osteochondral lesions are typically deeper, cup-shaped, and often insidious or atraumatic in nature (remembered by the mnemonic "DIAL a PIMP": Dorsiflexion Inversion for Anterolateral, Plantarflexion Inversion for Medial; Posteromedial = deep). Anterolateral lesions are usually shallow, wafer-shaped, and traumatic.

Question 6865

Topic: 8. Foot and Ankle

During open reduction and internal fixation of a joint-depression calcaneal fracture via an extensile lateral approach, the surgeon utilizes a specific bony fragment that remains anatomically aligned with the talus as the template for reconstructing the remaining calcaneus. Which anatomical structures tether this "constant" fragment?

. The Achilles tendon and plantar fascia
. The bifurcate ligament and anterior talofibular ligament
. The deltoid ligament and interosseous talocalcaneal ligament
. The calcaneofibular ligament and inferior extensor retinaculum
. The long plantar ligament and spring ligament

Correct Answer & Explanation

. The deltoid ligament and interosseous talocalcaneal ligament

Explanation

The "constant fragment" in a calcaneus fracture is the anteromedial fragment, which includes the sustentaculum tali. It remains firmly attached to the talus via the strong deltoid and interosseous talocalcaneal ligaments, serving as the anatomical foundation for fracture reduction.

Question 6866

Topic: 8. Foot and Ankle

A 25-year-old female undergoes syndesmotic screw fixation for a Weber C ankle fracture. Postoperative CT scan is obtained to assess reduction. According to current literature, what is the most common pattern of syndesmotic malreduction encountered postoperatively?

. Posterior translation of the fibula relative to the incisura
. Anterior translation of the fibula relative to the incisura
. Over-compression resulting in narrowing of the mortise
. Proximal migration of the fibula
. Lateral translation without sagittal plane malalignment

Correct Answer & Explanation

. Anterior translation of the fibula relative to the incisura

Explanation

Anterior translation of the fibula relative to the incisura fibularis is the most common pattern of syndesmotic malreduction. Using intraoperative clamping techniques, the fibula is frequently pushed anteriorly out of its anatomic groove.

Question 6867

Topic: Forefoot

A 50-year-old runner presents with dorsal midfoot pain. Examination reveals a dorsal exostosis at the first metatarsophalangeal joint with pain only at the extreme of dorsiflexion. Radiographs show a preserved joint space with mild dorsal osteophytes. What is the most appropriate surgical treatment if conservative measures fail?

. First MTP joint arthrodesis
. Silicone implant arthroplasty
. Cheilectomy
. Keller resection arthroplasty
. Lapidus procedure

Correct Answer & Explanation

. Cheilectomy

Explanation

This patient has early-stage hallux rigidus (Coughlin and Shurnas Grade 1 or 2) characterized by preserved joint space and pain primarily at the extremes of motion. Cheilectomy (removal of the dorsal osteophytes and the dorsal third of the metatarsal head) is the preferred initial surgical treatment.

Question 6868

Topic: 8. Foot and Ankle

A 14-year-old female presents with a unilateral cavovarus foot deformity. Neurological examination reveals marked weakness of the tibialis anterior muscle. Which antagonistic muscle's relatively preserved strength is the primary deforming force driving the plantarflexed first ray in this patient?

. Tibialis posterior
. Peroneus brevis
. Peroneus longus
. Extensor hallucis longus
. Flexor hallucis longus

Correct Answer & Explanation

. Peroneus longus

Explanation

In the development of a cavovarus foot (often seen in Charcot-Marie-Tooth disease), the peroneus longus overpowers the weak tibialis anterior, driving the first ray into profound plantarflexion. This leads to a forefoot-driven hindfoot varus deformity.

Question 6869

Topic: 8. Foot and Ankle

A 21-year-old collegiate cross-country runner is diagnosed with a stress fracture of the tarsal navicular. CT scanning confirms a fracture line located in the central third of the bone. What unique anatomical factor most directly contributes to the high risk of delayed union or nonunion in this specific region?

. Continuous tension from the posterior tibial tendon insertion
. Lack of medullary cavity within the navicular bone
. It represents an avascular watershed zone between dorsal and plantar arterial networks
. Proximity to the highly mobile talonavicular joint space
. Excessive compressive forces from the cuneiforms during heel strike

Correct Answer & Explanation

. It represents an avascular watershed zone between dorsal and plantar arterial networks

Explanation

The central third of the tarsal navicular is highly susceptible to stress fractures and nonunions because it is an avascular watershed zone. Blood supply enters the navicular from the dorsal and plantar surfaces, leaving the central core relatively ischemic.

Question 6870

Topic: 8. Foot and Ankle

A 45-year-old diabetic patient presents with unilateral burning heel pain. Tinel's sign is positive over the flexor retinaculum, and electrodiagnostic studies confirm Tarsal Tunnel Syndrome. The specific nerve responsible for the heel symptoms typically branches from the tibial nerve at what location relative to the tarsal tunnel?

. Distal to the bifurcation of the medial and lateral plantar nerves
. Proximal to or within the proximal aspect of the flexor retinaculum
. Deep to the abductor hallucis muscle fascia
. At the level of the master knot of Henry
. Directly from the sural nerve posterior to the lateral malleolus

Correct Answer & Explanation

. Proximal to or within the proximal aspect of the flexor retinaculum

Explanation

The medial calcaneal nerve provides sensation to the heel and typically branches from the tibial nerve proximal to or high within the tarsal tunnel (flexor retinaculum). Therefore, surgical release of the tarsal tunnel must extend proximally enough to decompress this branch.

Question 6871

Topic: 8. Foot and Ankle

A 15-year-old female gymnast complains of an insidious onset of forefoot pain primarily localized to the plantar aspect of the second metatarsal head. Radiographs show sclerosis, joint space widening, and flattening of the second metatarsal head. Which of the following best describes the pathogenesis of her condition?

. Traction apophysitis of the metatarsal base
. Avascular necrosis of the metatarsal head
. Repetitive stress fracture of the diaphyseal shaft
. Degenerative osteoarthritis secondary to hypermobility
. Osteochondroma formation at the physis

Correct Answer & Explanation

. Avascular necrosis of the metatarsal head

Explanation

Freiberg's infraction is an avascular necrosis of the metatarsal head, most commonly affecting the second metatarsal in adolescent females. Repetitive microtrauma and vascular compromise lead to the characteristic sclerosis and flattening of the articular surface.

Question 6872

Topic: Midfoot & Hindfoot
A 55-year-old female presents with progressive flattening of her left foot. Examination reveals a flexible flatfoot, inability to perform a single-leg heel raise, and >40% uncoverage of the talar head on AP radiographs. What is the most appropriate surgical management?
. Gastrocnemius recession, FDL transfer to the navicular, and medial displacement calcaneal osteotomy
. Gastrocnemius recession, FDL transfer to the navicular, and lateral column lengthening
. Subtalar arthrodesis with FHL transfer
. Triple arthrodesis
. Primary repair of the posterior tibial tendon

Correct Answer & Explanation

. Gastrocnemius recession, FDL transfer to the navicular, and lateral column lengthening

Explanation

Stage IIb posterior tibial tendon dysfunction is characterized by a flexible deformity with significant forefoot abduction (>40% talonavicular uncoverage). Lateral column lengthening is required to correct the forefoot abduction, alongside FDL transfer and calcaneal osteotomy.

Question 6873

Topic: Midfoot & Hindfoot

A 60-year-old diabetic male presents with a swollen, erythematous, warm, and painless right foot. Radiographs show periarticular fragmentation and debris at the tarsometatarsal joints. Infection has been ruled out. What is the most appropriate initial management?

. Intravenous antibiotics and serial debridement
. Immediate open reduction and internal fixation
. Total contact casting and strict non-weight-bearing
. Primary midfoot arthrodesis
. Charcot restraint orthotic walker (CROW) with weight-bearing as tolerated

Correct Answer & Explanation

. Total contact casting and strict non-weight-bearing

Explanation

The patient is in the acute fragmentation phase (Eichenholtz stage I) of Charcot arthropathy. The gold standard initial treatment is immobilization with total contact casting and strict non-weight-bearing to prevent further deformity until the acute phase resolves.

Question 6874

Topic: 8. Foot and Ankle
A 40-year-old roofer falls from a height, sustaining a Sanders type III displaced intra-articular calcaneus fracture. The surgeon opts for an extensile lateral approach. To minimize the risk of wound edge necrosis, which of the following surgical principles must be strictly adhered to?
. Incision directly over the sural nerve
. Creation of a subperiosteal full-thickness flap
. Early wound closure with high-tension sutures
. Dissection strictly subcutaneous without touching the periosteum
. Use of a tourniquet for a maximum of 3 hours

Correct Answer & Explanation

. Creation of a subperiosteal full-thickness flap

Explanation

A subperiosteal full-thickness flap is critical to minimizing flap necrosis in an extensile lateral approach. The flap must include the periosteum off the lateral wall of the calcaneus to protect the fragile vascular supply from the lateral calcaneal artery.

Question 6875

Topic: 8. Foot and Ankle

A 52-year-old male undergoes surgical treatment for chronic, refractory insertional Achilles tendinopathy. The procedure involves debridement of the degenerative tendon and resection of a Haglund's deformity. If more than 50% of the tendon insertion is detached during debridement, what is the most appropriate adjunctive procedure?

. Flexor digitorum longus (FDL) transfer
. Flexor hallucis longus (FHL) transfer
. Peroneus brevis transfer
. V-Y tendon lengthening
. Gastrocnemius recession

Correct Answer & Explanation

. Flexor hallucis longus (FHL) transfer

Explanation

When more than 50% of the Achilles tendon insertion requires detachment during debridement, an FHL transfer is indicated to provide structural support and a robust blood supply. The FHL is preferred due to its strength, proximity, and in-phase firing.

Question 6876

Topic: Forefoot

A 45-year-old female presents with a painful bunion. Weight-bearing radiographs demonstrate a hallux valgus angle (HVA) of 45 degrees, an intermetatarsal angle (IMA) of 18 degrees, and hypermobility of the first tarsometatarsal (TMT) joint. Which of the following procedures is most appropriate?

. Distal chevron osteotomy
. Proximal crescentic osteotomy with distal soft tissue release
. First TMT joint arthrodesis (Lapidus procedure)
. First metatarsophalangeal (MTP) joint arthrodesis
. Akin osteotomy alone

Correct Answer & Explanation

. First TMT joint arthrodesis (Lapidus procedure)

Explanation

A Lapidus procedure (first TMT arthrodesis) is indicated for severe hallux valgus combined with first ray hypermobility. It robustly corrects the severe intermetatarsal angle and stabilizes the hypermobile medial column.

Question 6877

Topic: 8. Foot and Ankle

A 12-year-old boy presents with a painful, rigid flatfoot and frequent ankle sprains. Radiographs reveal an "anteater nose" sign on the lateral view. Which of the following physical exam findings is most characteristic of this specific pathology?

. Inability to passively correct the hindfoot valgus during the Coleman block test
. Decreased subtalar motion and peroneal spasticity
. Lack of plantarflexion during the Thompson test
. Pain isolated to the medial malleolus
. Hyperdorsiflexion of the first MTP joint

Correct Answer & Explanation

. Inability to passively correct the hindfoot valgus during the Coleman block test

Explanation

The "anteater nose" sign is diagnostic of a calcaneonavicular coalition. Tarsal coalitions typically present with a rigid, painful flatfoot, severely restricted subtalar motion, and secondary peroneal muscle spasm.

Question 6878

Topic: 8. Foot and Ankle

A 26-year-old male sustains an external rotation ankle injury. Intraoperative fluoroscopy reveals an asymmetric ankle mortise and widening of the tibiofibular clear space. The surgeon decides to place a syndesmotic screw. Which of the following describes the correct trajectory for syndesmotic screw placement?

. Parallel to the ankle joint and angled 30 degrees anteriorly from the fibula to the tibia
. Parallel to the ankle joint and angled 30 degrees posteriorly from the fibula to the tibia
. Angled 10 degrees proximally and 20 degrees anteriorly
. Perpendicular to the fibular shaft and angled 45 degrees posteriorly
. Parallel to the ankle joint and driven purely horizontally without AP angulation

Correct Answer & Explanation

. Parallel to the ankle joint and angled 30 degrees anteriorly from the fibula to the tibia

Explanation

The lateral malleolus sits posterior to the center of the tibia in the axial plane. Therefore, a syndesmotic screw must be placed parallel to the ankle joint line and angled approximately 25-30 degrees anteriorly to accurately engage the center of the tibia.

Question 6879

Topic: Midfoot & Hindfoot

A 16-year-old female presents with bilateral progressive cavovarus deformities and weakness in ankle dorsiflexion. A Coleman block test demonstrates that the hindfoot varus corrects to neutral when the first ray is allowed to drop off the block. What is the primary driving force behind this flexible hindfoot varus?

. Overpull of the tibialis anterior relative to the peroneus longus
. Plantarflexed first ray driven by an overactive peroneus longus relative to a weak tibialis anterior
. Spasticity of the gastrocnemius-soleus complex
. Contracture of the posterior talofibular ligament
. Bony coalition of the subtalar joint

Correct Answer & Explanation

. Plantarflexed first ray driven by an overactive peroneus longus relative to a weak tibialis anterior

Explanation

In Charcot-Marie-Tooth disease, weakness of the tibialis anterior allows the strong peroneus longus to severely plantarflex the first ray. This rigid plantarflexed first ray acts as a kickstand, forcing the hindfoot into a compensatory, initially flexible varus.

Question 6880

Topic: Forefoot

A 28-year-old professional football player suffers a hyperdorsiflexion injury to his great toe. Examination shows gross instability of the first MTP joint, and a palpable defect proximal to the sesamoids. What is the most likely diagnosis and recommended management?

. Grade 1 Turf Toe; stiff-soled shoe and taping
. Grade 2 Turf Toe; walking boot for 4 weeks
. Grade 3 Turf Toe; surgical repair of the plantar plate
. Sesamoid fracture; excision of the fragmented sesamoid
. Hallux rigidus; cheilectomy

Correct Answer & Explanation

. Grade 3 Turf Toe; surgical repair of the plantar plate

Explanation

A hyperdorsiflexion injury with gross instability, a palpable defect, and proximal sesamoid migration indicates a Grade 3 turf toe (complete plantar plate rupture). In an elite athlete, surgical repair is indicated to restore joint stability and push-off strength.

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