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8. Foot and Ankle MCQs

Practice Set 350 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 6981

Topic: Forefoot

A 45-year-old female presents with a painful bunion. Weight-bearing radiographs show a hallux valgus angle (HVA) of 45 degrees, an intermetatarsal angle (IMA) of 18 degrees, and significant hypermobility at the first tarsometatarsal (TMT) joint. What is the most appropriate surgical intervention?

. Distal chevron osteotomy
. Proximal crescentic osteotomy
. First TMT arthrodesis (Lapidus procedure)
. Metatarsophalangeal joint arthrodesis
. Akin osteotomy alone

Correct Answer & Explanation

. First TMT arthrodesis (Lapidus procedure)

Explanation

A first TMT arthrodesis (Lapidus procedure) is the treatment of choice for severe hallux valgus (IMA >15, HVA >40) associated with first ray hypermobility. It corrects the deformity at its apex and robustly stabilizes the medial column.

Question 6982

Topic: Forefoot
A 60-year-old male runner presents with dorsal first metatarsophalangeal (MTP) joint pain. Radiographs demonstrate dorsal osteophytes, <25% joint space remaining, and pain during the mid-arc of motion. According to the Coughlin and Shurnas classification, which of the following is the most reliable definitive treatment?
. First MTP joint cheilectomy
. First MTP joint arthrodesis
. First TMT joint arthrodesis
. First MTP joint arthroplasty
. Moberg osteotomy

Correct Answer & Explanation

. First MTP joint arthrodesis

Explanation

This describes Coughlin and Shurnas Grade 3 hallux rigidus (significant joint space loss, pain with mid-arc of motion). First MTP arthrodesis remains the gold-standard and most reliable definitive treatment, providing excellent pain relief and functional outcomes in active patients.

Question 6983

Topic: Ankle Trauma & Sports

A 28-year-old sustains a Maisonneuve fracture. During syndesmotic fixation, at what distance proximal to the tibial plafond should the syndesmotic screws ideally be placed to maximize biomechanical stability without entering the joint?

. 0.5 to 1.0 cm
. 2.0 to 3.0 cm
. 5.0 to 6.0 cm
. 7.0 to 8.0 cm
. 10.0 cm

Correct Answer & Explanation

. 2.0 to 3.0 cm

Explanation

Biomechanical studies have demonstrated that syndesmotic screws placed 2 to 3 cm proximal to the tibiotalar joint line provide optimal stability. Placement too distal risks intra-articular penetration, while placing them too high provides inadequate stabilization.

Question 6984

Topic: 8. Foot and Ankle

A 32-year-old skier presents with lateral ankle pain and a snapping sensation behind the lateral malleolus. Pathology of the superior peroneal retinaculum (SPR) is suspected. The primary osseous attachment of the SPR is the:

. Posterior border of the lateral malleolus
. Anterior border of the lateral malleolus
. Lateral process of the talus
. Calcaneal tuberosity
. Base of the fifth metatarsal

Correct Answer & Explanation

. Posterior border of the lateral malleolus

Explanation

The superior peroneal retinaculum prevents subluxation of the peroneal tendons and crucially inserts on the posterolateral fibrocartilaginous ridge of the lateral malleolus. Disruption of this periosteal attachment allows the tendons to dislocate anteriorly.

Question 6985

Topic: Midfoot & Hindfoot

A 55-year-old diabetic male presents with a red, hot, swollen foot without an ulcer. Radiographs show periarticular debris, fragmentation, and subluxation at the midfoot. Which of the following is the most appropriate initial management according to the Eichenholtz classification?

. Immediate open reduction and internal fixation
. Total contact casting and non-weight bearing
. Intravenous antibiotics and surgical debridement
. Midfoot arthrodesis with a superconstruct
. Custom orthotic shoe wear

Correct Answer & Explanation

. Total contact casting and non-weight bearing

Explanation

This presentation describes Eichenholtz Stage I (Developmental/Fragmentation stage) of Charcot arthropathy. The gold standard for acute Charcot neuroarthropathy is strict immobilization and offloading, typically utilizing a total contact cast to arrest the destructive phase.

Question 6986

Topic: 8. Foot and Ankle

A patient with Charcot-Marie-Tooth disease presents with a bilateral cavovarus foot deformity. A Coleman block test is performed and the hindfoot varus completely corrects to neutral. This finding indicates that the hindfoot deformity is primarily driven by which of the following?

. Rigid subtalar joint contracture
. Plantarflexed first ray
. Tight Achilles tendon
. Weakness of the tibialis anterior
. Overactivity of the tibialis posterior

Correct Answer & Explanation

. Plantarflexed first ray

Explanation

The Coleman block test distinguishes a flexible hindfoot driven by forefoot pathology from a rigid hindfoot deformity. If the hindfoot corrects when the first ray is allowed to drop off the block, it indicates the varus is secondary to a rigid, plantarflexed first ray.

Question 6987

Topic: 8. Foot and Ankle

A 50-year-old female presents with pain at the plantar aspect of the second metatarsophalangeal (MTP) joint and a medial deviation of the second toe, creating a crossover toe deformity. Which of the following anatomical structures is most likely attenuated or ruptured?

. Medial collateral ligament of the 2nd MTP joint
. Extensor digitorum brevis
. Lateral collateral ligament and plantar plate of the 2nd MTP joint
. Flexor digitorum longus tendon
. Deep transverse metatarsal ligament

Correct Answer & Explanation

. Lateral collateral ligament and plantar plate of the 2nd MTP joint

Explanation

Crossover toe deformity typically results from sequential failure of the lateral collateral ligament and the plantar plate of the MTP joint. This structural incompetence leads to dorsal subluxation and medial deviation of the digit.

Question 6988

Topic: 8. Foot and Ankle

A patient presents with burning medial heel pain and paresthesias radiating into the plantar foot. A positive Tinel's sign is elicited posterior to the medial malleolus. Within the tarsal tunnel, the posterior tibial nerve runs immediately posterior to which structure?

. Tibialis posterior tendon
. Flexor digitorum longus tendon
. Posterior tibial artery
. Flexor hallucis longus tendon
. Achilles tendon

Correct Answer & Explanation

. Flexor hallucis longus tendon

Explanation

The anatomical order of structures in the tarsal tunnel from anterior to posterior is: Tibialis posterior tendon, Flexor digitorum longus tendon, Posterior tibial Artery/Vein, posterior tibial Nerve, and Flexor hallucis longus tendon (Tom, Dick, AND a Very Nervous Harry).

Question 6989

Topic: Midfoot & Hindfoot

A 55-year-old female presents with progressive flatfoot deformity. She has pain along the medial ankle and cannot perform a single-limb heel rise. Radiographs show a talonavicular uncoverage of 40%. The deformity is passively correctable. What is the most appropriate surgical management?

. Isolated subtalar fusion
. Flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy
. Triple arthrodesis
. Spring ligament repair alone
. Tibiotalocalcaneal arthrodesis

Correct Answer & Explanation

. Flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy

Explanation

This patient has Stage II posterior tibial tendon dysfunction, characterized by a flexible deformity and inability to perform a heel rise. The standard surgical treatment is a joint-sparing procedure such as an FDL transfer combined with a medial displacement calcaneal osteotomy.

Question 6990

Topic: 8. Foot and Ankle
A 32-year-old male sustains a Hawkins type III talar neck fracture following a motor vehicle collision. Which of the following blood vessels provides the primary vascular supply to the talar body and is disrupted in this injury?
. Artery of the tarsal canal
. Dorsalis pedis artery
. Artery of the tarsal sinus
. Deltoid artery
. Peroneal artery

Correct Answer & Explanation

. Artery of the tarsal canal

Explanation

The artery of the tarsal canal, a branch of the posterior tibial artery, is the dominant blood supply to the talar body. In a Hawkins type III fracture, all three primary blood supplies are disrupted, leading to a high rate of avascular necrosis.

Question 6991

Topic: Forefoot

A 45-year-old female presents with symptomatic hallux valgus. Weight-bearing radiographs reveal a Hallux Valgus Angle (HVA) of 45 degrees, an Intermetatarsal Angle (IMA) of 18 degrees, and clinical hypermobility of the first tarsometatarsal joint. Which procedure is most appropriate?

. Distal chevron osteotomy
. Proximal crescentic osteotomy with distal soft tissue release
. First tarsometatarsal joint arthrodesis (Lapidus procedure)
. Metatarsophalangeal joint arthrodesis
. Keller resection arthroplasty

Correct Answer & Explanation

. First tarsometatarsal joint arthrodesis (Lapidus procedure)

Explanation

The Lapidus procedure (first TMT arthrodesis) is indicated for severe hallux valgus (IMA > 13 degrees, HVA > 40 degrees) associated with first ray hypermobility. Distal osteotomies are insufficient for correcting large intermetatarsal angles and do not address the proximal instability.

Question 6992

Topic: 8. Foot and Ankle

A 22-year-old football player sustains a hyperplantarflexion injury to his midfoot. Weight-bearing radiographs demonstrate a 3 mm widening between the base of the first and second metatarsals. What is the primary stabilizing structure disrupted in this injury?

. Dorsal Lisfranc ligament
. Plantar ligament connecting the medial cuneiform to the second metatarsal base
. Plantar ligament connecting the medial and intermediate cuneiforms
. Interosseous ligament connecting the medial cuneiform to the second metatarsal base
. Dorsal ligament connecting the lateral cuneiform to the cuboid

Correct Answer & Explanation

. Interosseous ligament connecting the medial cuneiform to the second metatarsal base

Explanation

The primary Lisfranc ligament is an interosseous ligament connecting the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. It is the largest and most critical stabilizer of the Lisfranc complex.

Question 6993

Topic: 8. Foot and Ankle

During a percutaneous repair of an acute Achilles tendon rupture, the surgeon places a suture in the proximal stump passing from lateral to medial. Which neurological structure is at greatest risk of iatrogenic injury during this step?

. Tibial nerve
. Superficial peroneal nerve
. Deep peroneal nerve
. Sural nerve
. Saphenous nerve

Correct Answer & Explanation

. Sural nerve

Explanation

The sural nerve courses distally along the posterolateral aspect of the calf, crossing the lateral border of the Achilles tendon approximately 10 cm proximal to its insertion. It is highly susceptible to entrapment or laceration during percutaneous Achilles tendon repairs.

Question 6994

Topic: 8. Foot and Ankle

A 40-year-old roofer falls from a ladder, sustaining a severely comminuted, intra-articular calcaneus fracture with profound soft tissue swelling. Surgical fixation via an extensile lateral approach is planned. To minimize wound complications, the surgical incision should be elevated as:

. A subcutaneous flap, dissecting the skin off the underlying peroneal fascia
. A split-thickness flap directly over the lateral malleolus
. A full-thickness subperiosteal flap incorporating the sural nerve and peroneal tendons
. An oblique incision across the angiosomes of the lateral foot
. A dual-incision technique splitting the peroneal tendons

Correct Answer & Explanation

. A full-thickness subperiosteal flap incorporating the sural nerve and peroneal tendons

Explanation

The extensile lateral approach to the calcaneus requires creating a 'no-touch' full-thickness subperiosteal flap to preserve the delicate blood supply. Dissecting subcutaneously or splitting tissue layers significantly increases the risk of marginal skin necrosis and wound breakdown.

Question 6995

Topic: Midfoot & Hindfoot

A 60-year-old diabetic male presents with a swollen, erythematous, and warm left foot without systemic signs of infection. Radiographs show fragmentation of the midfoot, periarticular debris, and joint subluxation. Which Eichenholtz stage does this represent, and what is the optimal initial treatment?

. Stage 0; urgent surgical debridement
. Stage 1; total contact casting and non-weight bearing
. Stage 2; custom accommodating orthotics
. Stage 3; midfoot arthrodesis
. Stage 1; immediate open reduction and internal fixation

Correct Answer & Explanation

. Stage 1; total contact casting and non-weight bearing

Explanation

This presentation describes Eichenholtz Stage 1 (development/fragmentation) Charcot arthropathy, marked by acute inflammation and osseous fragmentation. The gold standard initial treatment is total contact casting and offloading until the acute inflammatory phase resolves.

Question 6996

Topic: 8. Foot and Ankle

A 28-year-old male sustains an external rotation injury to his ankle resulting in a Maisonneuve fracture. Intraoperatively, the syndesmosis is reduced and pinned. Which radiographic parameter is the most reliable indicator of accurate syndesmotic reduction on a standard mortise view?

. Tibiofibular overlap greater than 1 mm
. Tibiofibular clear space less than 5 mm
. Medial clear space equal to the superior clear space
. Talar tilt less than 2 degrees
. Restoration of Shenton's line of the ankle

Correct Answer & Explanation

. Medial clear space equal to the superior clear space

Explanation

On a mortise radiograph, the medial clear space should be equal to the superior clear space; widening indicates lateral talar shift and syndesmotic failure. Restoration of the medial clear space directly correlates with accurate talar reduction and better functional outcomes.

Question 6997

Topic: Midfoot & Hindfoot

A 48-year-old runner complains of chronic medial heel pain radiating into the plantar aspect of the foot, worsening with prolonged activity. Examination reveals maximal tenderness over the medial heel and a positive Tinel's sign posterior to the medial malleolus radiating distally. Entrapment of which nerve is the most likely diagnosis?

. Medial plantar nerve
. First branch of the lateral plantar nerve
. Sural nerve
. Medial calcaneal nerve
. Deep peroneal nerve

Correct Answer & Explanation

. First branch of the lateral plantar nerve

Explanation

The first branch of the lateral plantar nerve (Baxter's nerve) can become entrapped between the deep fascia of the abductor hallucis and the quadratus plantae. It typically presents with chronic heel pain mimicking plantar fasciitis but includes neurologic symptoms radiating laterally.

Question 6998

Topic: 8. Foot and Ankle

An 18-year-old male with multiple hereditary exostoses (MHE) is evaluated. He has multiple bony prominences around his knees and ankles. The genetic mutation associated with this condition primarily affects the synthesis of which of the following?

. Type I collagen
. Heparan sulfate
. Fibroblast growth factor receptor 3
. Chondroitin sulfate
. Core binding factor alpha 1

Correct Answer & Explanation

. Heparan sulfate

Explanation

MHE is an autosomal dominant disorder caused by mutations in the EXT1 or EXT2 genes. These genes encode glycosyltransferases essential for the biosynthesis of heparan sulfate, which regulates chondrocyte proliferation and differentiation.

Question 6999

Topic: 8. Foot and Ankle

An 18-year-old male presents with a painless, hard bony mass extending from the proximal lateral fibula. He recently developed a foot drop and decreased sensation over the dorsum of his foot. Compression of which nerve is most likely responsible for his symptoms?

. Deep peroneal nerve
. Tibial nerve
. Saphenous nerve
. Sural nerve
. Common peroneal nerve

Correct Answer & Explanation

. Common peroneal nerve

Explanation

An osteochondroma located at the proximal lateral fibula can cause extrinsic compression of the common peroneal nerve as it wraps around the fibular neck. This results in foot drop and sensory loss over the lateral leg and dorsum of the foot.

Question 7000

Topic: 8. Foot and Ankle

During the Ponseti method for correcting idiopathic clubfoot, the cavus deformity must be addressed first. Which of the following describes the correct initial manipulation?

. Plantarflexion of the first ray with simultaneous supination of the forefoot
. Dorsiflexion of the first ray to align the forefoot with the hindfoot
. Eversion of the calcaneus with forefoot abduction
. Dorsiflexion of the entire midfoot against a stabilized talus
. Abduction of the metatarsals while maintaining equinus

Correct Answer & Explanation

. Plantarflexion of the first ray with simultaneous supination of the forefoot

Explanation

The cavus deformity is driven by relative pronation of the forefoot compared to the hindfoot. It is corrected by elevating (dorsiflexing) the first ray to supinate the forefoot, bringing it into proper alignment with the hindfoot before subsequent abduction maneuvers.

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