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8. Foot and Ankle MCQs

Practice Set 349 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 6961

Topic: 8. Foot and Ankle

During open reduction and internal fixation (ORIF) of a lateral malleolus fracture, why is the anatomical restoration of fibular length considered critical?

. It prevents post-operative superficial peroneal nerve entrapment.
. It dictates the width of the ankle mortise.
. It restores the pull of the Achilles tendon.
. It prevents subluxation of the peroneal tendons.
. It ensures adequate blood supply to the talus.

Correct Answer & Explanation

. It dictates the width of the ankle mortise.

Explanation

Correct Answer: BDuring fracture reduction of the fibula, it is crucial to restore length, rotation, and alignment. Restoration of fibular length is critical because it directly dictates the width of the ankle mortise, ensuring proper congruency and biomechanics of the ankle joint.

Question 6962

Topic: 8. Foot and Ankle

A 35-year-old male sustains an acute Achilles tendon rupture. When discussing operative versus nonoperative management utilizing a functional rehabilitation protocol, which of the following statements regarding outcomes is most accurate?

. Operative treatment yields significantly higher plantarflexion strength at 2 years.
. Nonoperative treatment has historically been associated with a slightly higher re-rupture rate, but fewer wound complications.
. Operative treatment has a higher rate of sural nerve injury with open techniques compared to percutaneous techniques.
. Nonoperative treatment requires a longer period of strict immobilization in equinus cast.
. Operative treatment is associated with a higher rate of deep vein thrombosis.

Correct Answer & Explanation

. Nonoperative treatment has historically been associated with a slightly higher re-rupture rate, but fewer wound complications.

Explanation

Current literature shows functional rehabilitation has comparable outcomes to surgery. Surgery traditionally lowers the re-rupture rate but carries a higher risk of wound complications and infection.

Question 6963

Topic: Midfoot & Hindfoot

A 22-year-old athlete sustains a purely ligamentous Lisfranc injury with 3 mm of diastasis between the medial and middle cuneiforms. Based on recent prospective studies, which of the following is the most appropriate surgical management?

. Open reduction and internal fixation with screws across the involved joints
. Primary arthrodesis of the first, second, and third tarsometatarsal joints
. Closed reduction and percutaneous K-wire fixation
. Dorsal bridge plating spanning the tarsometatarsal joints
. Nonoperative management in a non-weight-bearing cast for 6 weeks

Correct Answer & Explanation

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

Explanation

Primary arthrodesis is preferred for purely ligamentous Lisfranc injuries as it has been shown to reduce reoperation rates and hardware failure compared to ORIF.

Question 6964

Topic: Midfoot & Hindfoot
A 58-year-old patient with poorly controlled diabetes presents with a warm, erythematous, and swollen foot. Radiographs demonstrate periarticular debris, fragmentation, and subluxation of the midfoot joints. Which stage of Charcot neuroarthropathy does this represent?
. Eichenholtz Stage 0
. Eichenholtz Stage I
. Eichenholtz Stage II
. Eichenholtz Stage III
. Eichenholtz Stage IV

Correct Answer & Explanation

. Eichenholtz Stage I

Explanation

Eichenholtz Stage I (developmental/fragmentation phase) is characterized by clinical warmth, erythema, and radiographic findings of fragmentation, debris, and joint subluxation.

Question 6965

Topic: 8. Foot and Ankle

Total ankle arthroplasty (TAA) is increasingly utilized for end-stage ankle arthritis. Which of the following is considered an absolute contraindication for primary TAA?

. Patient age greater than 70 years
. Concomitant subtalar arthritis
. Avascular necrosis involving greater than 50% of the talar body
. Inflammatory arthritis (e.g., Rheumatoid arthritis)
. Coronal plane deformity of 5 degrees

Correct Answer & Explanation

. Avascular necrosis involving greater than 50% of the talar body

Explanation

Significant avascular necrosis of the talus (>50%) compromises the osseous support for the implant, making it an absolute contraindication due to high risk of subsidence and failure.

Question 6966

Topic: Forefoot

A 45-year-old female presents with severe bunion pain. Radiographs reveal a hallux valgus angle (HVA) of 45 degrees, an intermetatarsal angle (IMA) of 18 degrees, and significant hypermobility of the first tarsometatarsal (TMT) joint. Which of the following procedures is most appropriate?

. Distal chevron osteotomy
. Akin osteotomy alone
. Lapidus procedure (1st TMT arthrodesis)
. Keller resection arthroplasty
. Proximal phalangeal osteotomy

Correct Answer & Explanation

. Lapidus procedure (1st TMT arthrodesis)

Explanation

The Lapidus procedure is indicated for severe hallux valgus deformities (IMA >15 degrees) accompanied by first ray hypermobility, as it addresses the apex of the deformity and stabilizes the medial column.

Question 6967

Topic: Midfoot & Hindfoot

A 55-year-old female presents with a progressive flatfoot deformity. Examination reveals a flexible pes planovalgus and an inability to perform a single-limb heel rise. Which surgical intervention is the standard of care for this stage of adult acquired flatfoot deformity?

. Flexor digitorum longus (FDL) transfer to the navicular alone
. FDL transfer combined with a medializing calcaneal osteotomy
. Triple arthrodesis
. Isolated subtalar arthrodesis
. Gastrocnemius recession as an isolated procedure

Correct Answer & Explanation

. FDL transfer combined with a medializing calcaneal osteotomy

Explanation

Stage II posterior tibial tendon dysfunction involves a flexible flatfoot. It is treated with joint-sparing procedures, typically a medializing calcaneal osteotomy and FDL transfer to the navicular.

Question 6968

Topic: 8. Foot and Ankle

Following operative management of a severely displaced intra-articular calcaneus fracture, what is the most common long-term complication experienced by the patient?

. Post-traumatic subtalar arthritis
. Sural nerve entrapment
. Peroneal tendon subluxation
. Heel pad avulsion
. Tibial nerve palsy

Correct Answer & Explanation

. Post-traumatic subtalar arthritis

Explanation

Post-traumatic subtalar arthritis is the most common late complication after an intra-articular calcaneus fracture, regardless of whether it is managed operatively or nonoperatively.

Question 6969

Topic: 8. Foot and Ankle

A 40-year-old female complains of burning pain in the plantar aspect of her forefoot, radiating to the third and fourth toes. Symptoms are exacerbated by wearing narrow shoes. Which anatomical structure is primarily responsible for compressing the affected nerve?

. Deep transverse metatarsal ligament
. Superficial transverse metatarsal ligament
. Plantar aponeurosis
. Flexor digitorum brevis tendon
. Lumbrical musculature

Correct Answer & Explanation

. Deep transverse metatarsal ligament

Explanation

Morton's neuroma is an entrapment neuropathy of the common digital nerve. It most commonly occurs in the 3rd webspace and is compressed by the deep transverse metatarsal ligament.

Question 6970

Topic: 8. Foot and Ankle

During open reduction and internal fixation of a bimalleolar ankle fracture, syndesmotic instability is identified. When placing a syndesmotic screw, what is the optimal position of the ankle joint and why?

. Maximal dorsiflexion, because the widest portion of the talus engages the mortise, preventing overtightening.
. Maximal plantarflexion, to relax the Achilles tendon and allow optimal fibular reduction.
. Neutral rotation and slight varus, to restore the correct fibular length.
. Slight plantarflexion, because the narrowest portion of the talus engages the mortise, allowing rigid fixation.
. Maximal inversion, to properly tension the calcaneofibular ligament.

Correct Answer & Explanation

. Maximal dorsiflexion, because the widest portion of the talus engages the mortise, preventing overtightening.

Explanation

The talar dome is wider anteriorly. Dorsiflexing the ankle during syndesmotic screw placement ensures the widest part is in the mortise, preventing overtightening and subsequent loss of dorsiflexion.

Question 6971

Topic: 8. Foot and Ankle

When evaluating osteochondral lesions of the talus (OCL), which of the following statements correctly differentiates anterolateral lesions from posteromedial lesions?

. Anterolateral lesions are typically deeper, cup-shaped, and less likely to be caused by trauma.
. Anterolateral lesions are typically shallow, wafer-shaped, and usually have a history of trauma.
. Posteromedial lesions are typically shallow, wafer-shaped, and have a high association with acute trauma.
. Anterolateral lesions rarely require surgical debridement compared to posteromedial lesions.
. Posteromedial lesions almost always heal spontaneously without intervention.

Correct Answer & Explanation

. Posteromedial lesions are typically shallow, wafer-shaped, and have a high association with acute trauma.

Explanation

Remember "DIAL a PIMP": Dorsiflexion/Inversion causes Anterior/Lateral lesions (shallow, wafer-shaped, traumatic). Plantarflexion/Inversion causes Posterior/Medial lesions (deeper, cup-shaped, insidious).

Question 6972

Topic: 8. Foot and Ankle

A 50-year-old male with chronic, recalcitrant plantar fasciitis undergoes a complete surgical release of the plantar fascia. Postoperatively, his heel pain improves, but he develops new-onset, severe pain along the outside of his midfoot. What is the most likely cause of his new pain?

. Sural nerve entrapment in the surgical scar
. Lateral column overload due to loss of the medial longitudinal arch
. Stress fracture of the fifth metatarsal base
. Cuboid syndrome from a secondary trauma
. Complex regional pain syndrome

Correct Answer & Explanation

. Lateral column overload due to loss of the medial longitudinal arch

Explanation

Complete release of the plantar fascia destroys the windlass mechanism, leading to a collapse of the medial longitudinal arch and resultant lateral column overload and pain.

Question 6973

Topic: Forefoot

A 62-year-old male presents with severe pain in his great toe with walking. Radiographs show obliteration of the first metatarsophalangeal (MTP) joint space with large dorsal osteophytes (Coughlin and Shurnas Grade 4 Hallux Rigidus). Physical exam reveals pain at the mid-range of motion. What is the most reliable definitive surgical treatment?

. Dorsal cheilectomy
. First MTP joint arthrodesis
. First MTP joint hemiarthroplasty
. Moberg osteotomy
. Extensor hallucis longus lengthening

Correct Answer & Explanation

. First MTP joint arthrodesis

Explanation

First MTP arthrodesis is the gold standard and most reliable treatment for advanced (Grade 3 or 4) hallux rigidus, especially when there is significant joint space narrowing and pain through the mid-range of motion.

Question 6974

Topic: 8. Foot and Ankle

When performing a tibiotalar arthrodesis for end-stage ankle arthritis, achieving the optimal anatomical position is critical for a good functional outcome. What is the widely accepted optimal position for ankle fusion?

. Neutral dorsiflexion, 0-5 degrees of valgus, and 5-10 degrees of external rotation
. 10 degrees of plantarflexion, 5 degrees of varus, and neutral rotation
. 5 degrees of dorsiflexion, neutral hindfoot coronal alignment, and 15 degrees of internal rotation
. Neutral dorsiflexion, 5 degrees of varus, and 5-10 degrees of external rotation
. 5 degrees of plantarflexion, 5 degrees of valgus, and neutral rotation

Correct Answer & Explanation

. Neutral dorsiflexion, 0-5 degrees of valgus, and 5-10 degrees of external rotation

Explanation

The optimal position for ankle arthrodesis is neutral dorsiflexion (to prevent back knee thrust), 0-5 degrees of hindfoot valgus, and 5-10 degrees of external rotation (matching the contralateral side).

Question 6975

Topic: Ankle Trauma & Sports
A 13-year-old boy sustains an external rotation injury to his ankle. Radiographs show a Salter-Harris III fracture of the anterolateral distal tibial epiphysis. This avulsion fracture is caused by the pull of which ligament?
. Anterior inferior tibiofibular ligament (AITFL)
. Posterior inferior tibiofibular ligament (PITFL)
. Anterior talofibular ligament (ATFL)
. Calcaneofibular ligament (CFL)
. Deltoid ligament

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament (AITFL)

Explanation

A juvenile Tillaux fracture is avulsed by the AITFL. It occurs in adolescents because the distal tibial physis closes from central to medial, leaving the anterolateral physis open and vulnerable last.

Question 6976

Topic: 8. Foot and Ankle

A 25-year-old female presents with a progressive bilateral cavovarus foot deformity. A Coleman block test is performed during the physical examination. What is the primary purpose of this specific test?

. To assess for occult tightness of the Achilles tendon.
. To differentiate between a flexible and rigid hindfoot varus driven by a plantarflexed first ray.
. To evaluate the isolated strength of the posterior tibialis muscle.
. To determine the degree of subtalar joint arthritis.
. To diagnose the presence of a calcaneonavicular coalition.

Correct Answer & Explanation

. To differentiate between a flexible and rigid hindfoot varus driven by a plantarflexed first ray.

Explanation

The Coleman block test nullifies the effect of a rigidly plantarflexed first ray. If the hindfoot varus corrects when the first metatarsal is allowed to drop off the block, the hindfoot deformity is flexible.

Question 6977

Topic: 8. Foot and Ankle
A 30-year-old sustains a Hawkins III talar neck fracture. Which of the following arteries provides the primary blood supply to the talar body, placing it at the highest risk for avascular necrosis upon disruption?
. Artery of the tarsal canal
. Artery of the tarsal sinus
. Dorsalis pedis artery
. Deltoid 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, supplies the majority of the talar body. A Hawkins III fracture disrupts this supply, along with contributions from the neck and sinus tarsi, leading to an extremely high risk of avascular necrosis.

Question 6978

Topic: 8. Foot and Ankle

A 22-year-old football player sustains an axial load to a plantarflexed foot. Radiographs reveal a "fleck sign" in the midfoot. Between which two osseous structures does the primary ligament implicated in this injury attach?

. Medial cuneiform and first metatarsal base
. Medial cuneiform and second metatarsal base
. Middle cuneiform and second metatarsal base
. Lateral cuneiform and third metatarsal base
. Navicular and medial cuneiform

Correct Answer & Explanation

. Medial cuneiform and second metatarsal base

Explanation

The Lisfranc ligament connects the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. The "fleck sign" represents an avulsion fracture of this ligament from the second metatarsal base, indicating a severe midfoot injury.

Question 6979

Topic: 8. Foot and Ankle

When comparing operative versus nonoperative management of acute Achilles tendon ruptures using modern early functional rehabilitation protocols, operative management is specifically associated with which of the following?

. Higher rate of re-rupture
. Lower rate of sural nerve injury
. Higher rate of wound complications
. Equivalent rate of deep vein thrombosis
. Lower return to sport rate

Correct Answer & Explanation

. Higher rate of wound complications

Explanation

Modern randomized trials utilizing early functional rehabilitation show equivalent re-rupture rates between operative and nonoperative management. However, operative management is consistently associated with a significantly higher rate of wound complications and potential sural nerve injury.

Question 6980

Topic: Midfoot & Hindfoot
A 55-year-old woman presents with a flexible flatfoot deformity, inability to perform a single-leg heel raise, and >40% uncoverage of the talar head on AP standing radiographs. Which of the following surgical procedures is most appropriate to correct the transverse plane deformity?
. Medial displacement calcaneal osteotomy (MDCO)
. Lateral column lengthening (Evans osteotomy)
. Subtalar arthrodesis
. Triple arthrodesis
. Spring ligament repair alone

Correct Answer & Explanation

. Lateral column lengthening (Evans osteotomy)

Explanation

This patient has Stage IIb adult acquired flatfoot deformity characterized by significant forefoot abduction (transverse plane deformity). A lateral column lengthening (Evans osteotomy) is specifically indicated to address transverse plane uncoverage of the talar head.

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