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 681
Topic: 8. Foot and Ankle
A 30-year-old male sustains a Hawkins Type III talar neck fracture following a motor vehicle collision. Which of the following radiographic findings at 6 to 8 weeks post-injury would indicate a good prognosis regarding the vascularity of the talar body?
Correct Answer & Explanation
. Subchondral radiolucency in the talar dome
Explanation
Hawkins sign is a subchondral radiolucent band seen on the AP or mortise view of the ankle at 6 to 8 weeks post-injury. It indicates intact vascularity to the talar body with active bone resorption, making avascular necrosis unlikely.
Question 682
Topic: 8. Foot and Ankle
A 37-year-old male is diagnosed with a left L5/S1 paracentral disc prolapse. Based on the expected S1 nerve root compression, which combination of physical exam findings is most consistent with this diagnosis?
Correct Answer & Explanation
. Weakness in ankle plantarflexion, numbness over the lateral foot/heel, and diminished Achilles reflex.
Explanation
Correct Answer: CThe candidate's expected findings for an L5/S1 disc prolapse are explicitly stated: 'I would expect the pain, paraesthesia and numbness to be in an S1 distribution (posterior calf, heel and lateral border of the foot) on the left. There may be an associated subjective decreased sensation in the same distribution, a decreased ankle jerk on that side...' The S1 nerve root primarily innervates the muscles responsible for ankle plantarflexion and mediates the Achilles reflex (ankle jerk). Sensory distribution for S1 includes the posterior calf, heel, and lateral border of the foot. Therefore, weakness in ankle plantarflexion, numbness over the lateral foot/heel, and a diminished Achilles reflex are the classic findings for S1 radiculopathy.
Question 683
Topic: 8. Foot and Ankle
A 38-year-old woman presents with right lower extremity pain and weakness. Examination reveals weakness in right ankle dorsiflexion, great toe extension, and ankle inversion. Sensation is decreased over the dorsum of the foot. Which of the following pathologies is most likely responsible for her symptoms?
Correct Answer & Explanation
. Paracentral disc herniation at L4-L5
Explanation
Weakness in ankle dorsiflexion, toe extension, and importantly ankle inversion (tibialis posterior) localizes the lesion to the L5 nerve root. A paracentral disc herniation at L4-L5 compresses the traversing L5 nerve root. Peroneal nerve palsy would not affect ankle inversion.
Question 684
Topic: 8. Foot and Ankle
A 60-year-old female presents with progressive pain and deformity in her hindfoot, worse with activity. She has a flexible flatfoot deformity with abduction of the forefoot. Examination reveals tenderness along the medial ankle and inability to perform a single-leg heel raise. What is the most likely diagnosis?
Correct Answer & Explanation
. Posterior tibial tendon dysfunction (PTTD) stage II
Explanation
Correct Answer: CThis clinical picture is highly characteristic of Posterior Tibial Tendon Dysfunction (PTTD), specifically Stage II. Key features include an adult-acquired flexible flatfoot deformity, forefoot abduction (the 'too many toes' sign), pain and tenderness along the course of the posterior tibial tendon (medial ankle), and inability to perform a single-leg heel raise (indicating significant weakness of the posterior tibial tendon, which is crucial for dynamic arch support). While the spring ligament is often involved in the progression of the deformity, PTTD is the overarching diagnosis.
Question 685
Topic: Midfoot & Hindfoot
A 55-year-old diabetic patient presents with a red, hot, swollen unilateral foot. Peripheral pulses are bounding. Radiographs show soft tissue swelling but no fractures or dislocations. What is the most appropriate initial management for this suspected Eichenholtz "stage 0" Charcot arthropathy?
Correct Answer & Explanation
. Total contact casting and strict non-weight bearing
Explanation
Eichenholtz stage 0 Charcot arthropathy presents with acute inflammation but normal radiographs. It must be differentiated from infection. The standard of care to prevent catastrophic bony destruction is immediate offloading, typically with a total contact cast, until the acute inflammatory phase resolves.
Question 686
Topic: 8. Foot and Ankle
A 22-year-old female presents with a purely ligamentous Lisfranc injury. Weight-bearing radiographs demonstrate 4 mm of diastasis between the bases of the 1st and 2nd metatarsals. According to high-level orthopedic evidence, which surgical intervention provides the most reliable long-term outcome?
Correct Answer & Explanation
. Primary arthrodesis of the medial column tarsometatarsal (TMT) joints
Explanation
Level 1 evidence (e.g., Ly and Coetzee) has demonstrated that primary arthrodesis of the medial column (1st, 2nd, and 3rd TMT joints) yields better functional outcomes and fewer revision surgeries than ORIF for purely ligamentous Lisfranc injuries.
Question 687
Topic: 8. Foot and Ankle
A 55-year-old male with poorly controlled diabetes presents with a warm, swollen, erythematous left foot. His pedal pulses are bounding. Radiographs show fragmentation of the navicular and cuneiforms without any open ulcers. What is the most appropriate initial management?
Correct Answer & Explanation
. Total contact casting
Explanation
This presentation is classic for acute Eichenholtz stage I Charcot arthropathy. The gold standard initial treatment for an acute, non-ulcerated Charcot foot is strict offloading with a total contact cast to prevent progressive deformity.
Question 688
Topic: 8. Foot and Ankle
A 42-year-old weekend warrior feels a "pop" in his posterior ankle while playing basketball. Examination reveals a palpable gap and a positive Thompson test. He opts for non-operative management. What is the optimal initial bracing protocol?
Correct Answer & Explanation
. Functional bracing with the foot in resting equinus
Explanation
Non-operative management of acute Achilles tendon ruptures utilizes functional bracing. Initial immobilization places the foot in resting equinus to appose the tendon ends, followed by sequential decreases in plantarflexion over several weeks.
Question 689
Topic: Midfoot & Hindfoot
A 55-year-old male with poorly controlled diabetes presents with a swollen, erythematous, and warm right foot without open ulceration. Radiographs show acute fragmentation, periarticular debris, and subluxation at the tarsometatarsal joints. Inflammatory markers are mildly elevated. What is the most appropriate initial management?
Correct Answer & Explanation
. Total contact casting and non-weight-bearing
Explanation
The patient is in the acute, inflammatory phase (Eichenholtz stage I) of Charcot arthropathy. The gold standard for initial management is total contact casting and strict non-weight-bearing to arrest the inflammatory process and prevent progressive midfoot collapse.
Question 690
Topic: 8. Foot and Ankle
During a revision surgery for a failed ankle fusion, a surgeon attempts to re-insert a screw into a previously drilled hole. After initial resistance, the screw feels loose and does not achieve adequate purchase. This situation is most likely due to:
Correct Answer & Explanation
. C. Damage to the negative threads in the bone tissue from repeated withdrawal and reintroduction.
Explanation
Correct Answer: CThe case identifies 'repeated withdrawal and reintroduction of a screw causing damage to the negative threads in the bone tissue' as a surgeon factor that can reduce screw pull-out strength. When a screw is removed and reinserted, the bone threads (negative threads) can be stripped or damaged, leading to poor purchase and reduced pull-out strength upon reinsertion. Insufficient pilot hole depth (A) would typically lead to difficulty inserting the screw initially, not looseness after reinsertion. Over-tightening (B) could strip the threads on the first attempt, but the scenario describes re-insertion. An excessively fine pitch (D) would increase pull-out strength, not decrease it. The type of screw (E) is not the primary cause of this specific failure mode.
Question 691
Topic: 8. Foot and Ankle
A 42-year-old male, a self-described "weekend warrior," presents to the emergency department after experiencing a sudden "pop" in his right calf while playing recreational basketball. He reports immediate pain and difficulty pushing off his foot. On examination, a palpable gap is noted in the Achilles tendon, and the Thompson test is positive. Based on the epidemiology and anatomy described in the case, which of the following statements regarding this patient's injury is most accurate?
Correct Answer & Explanation
. The rupture is most commonly found in the hypovascular watershed zone, approximately 2-6 cm proximal to the calcaneal insertion.
Explanation
Correct Answer: CThe case describes the typical patient profile for an acute Achilles tendon rupture as a male, aged 30-50 years, often a "weekend warrior" involved in activities like basketball. The mechanism (sudden "pop," difficulty push-off) and clinical findings (palpable gap, positive Thompson test) are classic for an acute rupture. The text explicitly states, "The vast majority of acute ruptures occur within the mid-substance of the tendon, specifically in a region approximately 2-6 cm proximal to its calcaneal insertion. This region is critically important due to its relatively hypovascular nature, often referred to as the 'watershed zone' or 'critical zone'."Option A is incorrect because ruptures are most common in the mid-substance, not typically at the musculotendinous junction, and the mechanism involves eccentric load during dorsiflexion with knee extension, not just excessive knee extension. Option B is incorrect as his age and activity level perfectly match the typical patient profile. Option D is incorrect because the watershed zone receives its blood supply predominantly from the paratenon, with fewer direct penetrating vessels, making it hypovascular and prone to reduced healing capacity, not rapid healing from the osseotendinous junction. Option E is incorrect as the symptoms are highly consistent with an acute Achilles tendon rupture.
Question 692
Topic: 8. Foot and Ankle
A 38-year-old professional soccer player sustains an acute Achilles tendon rupture during a match. He undergoes open surgical repair. During the procedure, the surgeon meticulously identifies and protects the sural nerve. Post-operatively, the patient develops numbness and paresthesias along the lateral aspect of his foot. Based on the surgical anatomy described in the case, which statement best explains the course of the sural nerve and its susceptibility to injury?
Correct Answer & Explanation
. The sural nerve, a sensory nerve, courses subcutaneously along the posterior calf, often running close to the lateral border of the Achilles tendon, making it susceptible to iatrogenic injury during posterior approaches.
Explanation
Correct Answer: DThe case explicitly states, "Of particular surgical relevance is the sural nerve, a sensory nerve arising from the tibial and common peroneal nerves, which courses subcutaneously along the posterior calf, often running close to the lateral border of the Achilles tendon. It is highly susceptible to iatrogenic injury during posterior surgical approaches." This directly explains the patient's symptoms (numbness, paresthesias) and the nerve's anatomical vulnerability.Option A is incorrect; the sural nerve is sensory, and the triceps surae is innervated by the tibial nerve. Option B is incorrect; the sural nerve courses subcutaneously, not deep to the tendon. Option C is incorrect; the sural nerve arises from the tibial and common peroneal nerves, not the femoral nerve, and typically runs laterally, not medially, to the Achilles tendon. Option E is incorrect; the sural nerve is sensory, and ankle dorsiflexion is primarily by the deep peroneal nerve.
Question 693
Topic: 8. Foot and Ankle
A 55-year-old sedentary individual with a history of type 2 diabetes and peripheral vascular disease presents with a suspected Achilles tendon rupture. He reports no specific traumatic event, but rather a gradual onset of pain and weakness in his calf. Clinical examination reveals a small palpable gap (<1 cm) and a positive Thompson test. Given his comorbidities and the injury characteristics, which management strategy is most appropriate according to the case?
Correct Answer & Explanation
. Non-operative management with an accelerated functional rehabilitation protocol, due to high surgical risks and small gap.
Explanation
Correct Answer: C. The case outlines specific indications for non-operative management: 'Elderly or sedentary individuals,' 'Significant medical comorbidities: Patients with diabetes, peripheral vascular disease, immunosuppression, or other conditions that increase surgical risks (e.g., wound healing complications, infection, DVT),' and 'Small tendon gap (<1 cm) and good apposition.' This patient fits all these criteria, making non-operative management with an accelerated functional rehabilitation protocol the most appropriate choice to avoid the high surgical risks associated with his comorbidities. Option A is incorrect due to the high surgical risks (wound healing, infection) in a patient with diabetes and PVD. Option B, while aiming to reduce wound complications, still carries surgical risks and may not be necessary given the small gap and high comorbidity burden. Option D is incorrect; delayed repair is typically for chronic ruptures, not an initial strategy for acute cases, and would still carry high surgical risks. Option E is an augmentation technique typically reserved for chronic ruptures with significant tissue loss or reruptures, not an initial treatment for an acute rupture with a small gap, especially in a high-risk patient.
Question 694
Topic: 8. Foot and Ankle
A 32-year-old recreational runner presents with a chronic Achilles tendon rupture, 3 months after the initial injury. He initially attempted non-operative management but continued to experience significant weakness and inability to perform a single-leg heel raise. MRI reveals a 3 cm gap with significant retraction and poor tissue quality in the mid-substance. He is now scheduled for operative repair. During pre-operative planning, the surgeon considers augmentation. Which of the following augmentation options is most appropriate for this patient, given the details in the case?
Correct Answer & Explanation
. Flexor Hallucis Longus (FHL) transfer, especially given the significant retraction and poor tissue quality.
Explanation
Correct Answer: EThe case states, "For chronic ruptures, large gaps, poor tissue quality in the watershed zone, or reruptures, augmentation may be necessary." It then specifically mentions, "For chronic ruptures with significant retraction or tissue loss, FHL transfer is a robust option. The FHL tendon is harvested from the plantar foot or posteromedial ankle, released distally, rerouted through the calcaneus or through the Achilles tendon, and fixed with interference screws or sutures." Given the 3-month delay, 3 cm gap, and poor tissue quality, FHL transfer is a strong and appropriate augmentation choice.Option A and D (Gastrocnemius recession/V-Y lengthening) are procedures to gain length in chronic cases with contracture, but they are not augmentation techniques that add new tissue to bridge a gap or reinforce a repair with poor tissue quality. Option B (Plantaris tendon autograft) is mentioned as an augmentation option, but the case implies FHL transfer is a 'robust option' specifically for 'significant retraction or tissue loss' in chronic ruptures, which aligns better with a 3 cm gap and poor tissue quality. Option C (Allograft reconstruction) is mentioned as 'rarely used for acute ruptures, but can be considered for revision surgery or extensive defects,' implying it's less common than autograft options like FHL transfer for this scenario.
Question 695
Topic: 8. Foot and Ankle
A 48-year-old male undergoes open Achilles tendon repair for an acute rupture. Post-operatively, he is placed in a posterior splint with the ankle in 15 degrees of plantarflexion. At 2 weeks, sutures are removed, and he transitions to a CAM boot. According to the described rehabilitation protocols, what is the primary goal and expected progression during the subsequent 4-6 weeks (Phase 2)?
Correct Answer & Explanation
. Gradual restoration of range of motion, initiation of controlled partial weight-bearing, and maintenance of muscle function while in the CAM boot.
Explanation
Correct Answer: CPhase 2 of rehabilitation (Weeks 2/3 - 6/8) is described as "Graduated Protected Motion & Partial Weight-Bearing." The goals are to "Gradually restore range of motion (ROM), initiate controlled weight-bearing, maintain muscle function." The patient is in a CAM boot, with gradual increase from partial weight-bearing (PWB) to full weight-bearing (FWB) over 4-6 weeks, and gradual decrease in plantarflexion angle in the boot to allow incremental dorsiflexion.Option A is incorrect as Phase 2 involves gradual weight-bearing and motion, not strict NWB and maximal plantarflexion. Option B is incorrect; full weight-bearing without the boot and aggressive dorsiflexion stretching are too aggressive for Phase 2. Option D and E are incorrect; these activities (jogging, sport-specific drills, plyometrics) are reserved for Phase 4 (Months 4-6+).
Question 696
Topic: 8. Foot and Ankle
A 35-year-old patient presents with an acute Achilles tendon rupture. The surgeon plans an open repair. During pre-operative planning, the surgeon reviews the vascular supply to the Achilles tendon, particularly noting the "watershed zone." Which of the following statements accurately describes the vascularity of the Achilles tendon and the significance of the watershed zone?
Correct Answer & Explanation
. The paratenon provides the primary external blood supply to the tendon's mid-portion, but the watershed zone within this area is relatively hypovascular, receiving fewer direct penetrating vessels.
Explanation
Correct Answer: CThe case states, "The vascular supply to the Achilles tendon is complex and multifaceted... Critically, a relatively hypovascular zone, the 'watershed zone,' exists approximately 2-6 cm proximal to the calcaneal insertion. This region receives its blood supply predominantly from the paratenon, with fewer direct penetrating vessels compared to the proximal and distal ends." It further notes that the paratenon contains a "rich vascular network" and provides the "primary external blood supply" to the tendon's mid-portion.Option A is incorrect; while the osseotendinous junction has a supply, the paratenon is primary for the mid-substance. Option B is incorrect; the watershed zone is hypovascular, not richly supplied, and receives less direct supply. Option D is incorrect; the watershed zone, not the musculotendinous junction, is highlighted as the most hypovascular and common rupture site. Option E is incorrect; the text clearly describes a complex, multifaceted supply with a critical hypovascular zone, indicating non-uniformity and implications for healing.
Question 697
Topic: 8. Foot and Ankle
A 68-year-old female with a history of rheumatoid arthritis and long-term corticosteroid use presents with an acute Achilles tendon rupture. She is otherwise healthy and active for her age. The rupture is acute, with a 1.5 cm gap. The surgeon is considering operative versus non-operative management. Based on the case, what is the most significant relative contraindication to surgery in this patient?
Correct Answer & Explanation
. Long-term corticosteroid use, leading to extremely fragile or thin skin and increased risk of wound complications.
Explanation
Correct Answer: DThe case lists "Relative Contraindications for Surgery" including "Extremely fragile or thin skin (e.g., due to long-term corticosteroid use)." Long-term corticosteroid use significantly compromises skin integrity and wound healing, making it a major concern for surgical complications in this patient.Option A is incorrect; age is a factor, but not an absolute contraindication, and the case states operative management is 'favored' for young, but non-operative for elderly, implying it's a relative consideration, not an absolute contraindication. Option B is incorrect; acute ruptures can be managed operatively or non-operatively, and the decision is multifactorial. Option C is incorrect; a 1.5 cm gap is considered a 'large tendon gap (>1 cm)' which generally favors operative management. Option E is incorrect; rheumatoid arthritis is mentioned as a systemic condition that may compromise tendon integrity, but it is not listed as an absolute contraindication to surgery, though it would increase surgical risk.
Question 698
Topic: 8. Foot and Ankle
A 40-year-old male undergoes open Achilles tendon repair. The surgeon makes a lateral para-Achilles incision. During closure, the paratenon is carefully repaired. What is the primary rationale for repairing the paratenon, as described in the case?
Correct Answer & Explanation
. To provide a robust gliding layer and facilitate revascularization of the healing tendon, especially in the watershed zone.
Explanation
Correct Answer: BThe case states under 'Closure': "Carefully repair the paratenon with absorbable sutures... This provides an important gliding layer and helps to contain the repair, facilitating revascularization." It also highlights the paratenon's role in providing the primary external blood supply to the tendon's mid-portion, which is crucial for the hypovascular watershed zone.Option A is incorrect; the sural nerve runs subcutaneously, not within the paratenon. Option C is incorrect; the paratenon is a loose connective tissue sheath, not a primary load-bearing structure for tensile strength. Option D is incorrect; while it helps contain the repair, its primary role is not to prevent scar tissue by isolation. Option E is incorrect; the paratenon is not the primary load-bearing structure; the repaired tendon itself is.
Question 699
Topic: 8. Foot and Ankle
The Achilles tendon is composed predominantly of type I collagen fibers, arranged in a highly organized, parallel fashion. The fascicles within the Achilles tendon exhibit a characteristic spiraling course along its length. What is the biomechanical significance of this helical arrangement, as described in the case?
Correct Answer & Explanation
. It distributes stress evenly across the tendon during movement and contributes to its biomechanical efficiency.
Explanation
Correct Answer: CUnder 'Tendon Structure and Composition,' the case states: "The fascicles within the Achilles tendon exhibit a characteristic spiraling course along its length, undergoing up to 90 degrees of rotation from proximal to distal. This helical arrangement is thought to distribute stress evenly across the tendon during movement and contribute to its biomechanical efficiency."Option A is incorrect; while elasticity is important, the primary described function of the spiraling course is stress distribution. Option B is incorrect; the paratenon itself facilitates gliding, not the internal helical arrangement of fascicles. Option D is incorrect; the vascular supply is described as complex and multifaceted, not directly facilitated by the helical arrangement of collagen fibers. Option E is incorrect; the case explicitly states its biomechanical significance.
Question 700
Topic: 8. Foot and Ankle
A 38-year-old male sustains a pronation-external rotation ankle fracture with a displaced lateral malleolus. During open reduction, the surgeon encounters difficulty achieving anatomical reduction despite adequate exposure. The Extensor Digitorum Brevis (EDB) is identified as the interposing structure. Which of the following statements accurately describes the anatomical characteristics of the EDB relevant to its potential for interposition?
Correct Answer & Explanation
. Its medial tendon, often considered the Extensor Hallucis Brevis, inserts into the dorsal aspect of the proximal phalanx of the great toe.
Explanation
Correct Answer: CThe Extensor Digitorum Brevis (EDB) is a small, intrinsic muscle of the foot located on the dorsum. Its medial tendon, often larger and sometimes considered a separate muscle (Extensor Hallucis Brevis), inserts into the dorsal aspect of the proximal phalanx of the great toe. The other three tendons join the lateral three tendons of the Extensor Digitorum Longus (EDL) to insert into the middle and distal phalanges of the 2nd, 3rd, and 4th toes. This specific insertion pattern, particularly of the medial tendon, makes it susceptible to interposition in certain ankle fracture patterns.Option A is incorrect because the EDB is innervated by the deep peroneal nerve, not the superficial peroneal nerve. Option B is incorrect; its blood supply is from the dorsalis pedis artery (a continuation of the anterior tibial artery), not the posterior tibial artery. Option D is incorrect as the EDB is located on the dorsum of the foot, not in the deep posterior compartment of the leg. Option E is incorrect; the EDB originates from the superolateral surface of the calcaneus, anterior to the calcaneal sulcus, and from the lateral sinus tarsi, not the distal tibia.
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