8. Foot and Ankle MCQs

A 55-year-old male with long-standing, poorly controlled diabetes mellitus presents with a red, hot, and swollen right foot. He denies fevers, chills, or any open wounds. Pedal pulses are bounding. Radiographs demonstrate periarticular fragmentation, debris, and subluxation at the tarsometatarsal joints. His WBC count and ESR are within normal limits. What is the most appropriate initial management?

A 32-year-old male presents to the emergency department after a fall from a ladder, landing on his foot. He complains of severe midfoot pain and inability to bear weight. Initial non-weight-bearing radiographs are interpreted as normal. However, due to persistent pain and swelling, a weight-bearing AP radiograph is obtained, as shown below:

Based on the image and the case description, what is the most appropriate next step in management?

A 40-year-old male sustains a high-energy twisting injury to his foot. Clinical examination reveals significant midfoot swelling, ecchymosis, and tenderness over the tarsometatarsal joints. Radiographs show a subtle avulsion fracture from the plantar aspect of the second metatarsal base (fleck sign) and a 3mm diastasis between the medial cuneiform and the second metatarsal on a weight-bearing AP view. Which of the following statements regarding the anatomical and biomechanical significance of this injury is most accurate?

A 55-year-old male undergoes open reduction and internal fixation for a Lisfranc fracture-dislocation. Intraoperatively, after initial debridement, the surgeon begins the reduction sequence. The image below shows an intraoperative fluoroscopic view during the reduction process.

Based on the case description and the image, which of the following best describes the critical next step in achieving anatomical reduction and stability?

Following successful anatomical reduction of a Lisfranc injury, the surgeon proceeds with definitive internal fixation. The image below shows a post-operative radiograph.

Regarding the critical fixation of the second ray, which of the following statements is most consistent with the recommended technique and subsequent management?

A 48-year-old construction worker undergoes ORIF for a severe Lisfranc fracture-dislocation. Despite meticulous surgical technique and anatomical reduction, he develops persistent midfoot pain, swelling, and stiffness 18 months post-operatively. Radiographs show degenerative changes across the first, second, and third tarsometatarsal joints. Which of the following is the most common long-term complication of Lisfranc injuries, and what is the most likely salvage procedure for this patient?

A 35-year-old female undergoes ORIF for a Lisfranc injury. Post-operatively, she is placed in a well-padded splint. According to the typical rehabilitation protocol described in the case, which of the following statements accurately reflects the initial phase of her recovery?

A 60-year-old patient with a history of diabetes and pre-existing midfoot osteoarthritis presents with a severely comminuted Lisfranc fracture-dislocation that is irreducible with closed manipulation. Given the patient's comorbidities and the nature of the injury, the surgeon considers primary arthrodesis. Which of the following statements regarding primary arthrodesis for Lisfranc injuries is most accurate?

A 22-year-old collegiate football player sustains a Lisfranc injury. Despite undergoing meticulous anatomical reduction and stable internal fixation, he develops chronic pain and functional limitations. According to the key literature and guidelines, which factor is most strongly correlated with a poor long-term outcome and increased incidence of post-traumatic arthritis in Lisfranc injuries?

A 38-year-old male presents with a Lisfranc injury following a motor vehicle accident. Pre-operative imaging confirms a Type B2 injury according to the Myerson classification, with partial incongruity involving the second and third rays. During the surgical approach, the surgeon identifies the dorsalis pedis artery and deep peroneal nerve. Which of the following statements accurately describes the typical anatomical relationship of these structures relative to the surgical incisions for a Lisfranc repair?

A 7-year-old male with Paley Type 1B fibular deficiency presents with significant and progressive ankle valgus, making shoe wear difficult and causing a noticeable limp. Radiographs confirm severe talar tilt and a widened ankle mortise. The lateral malleolus is rudimentary and non-functional. The parents are seeking intervention to improve their child's ambulation and stability.

Based on the surgical anatomy and biomechanics described in the case, what is the primary biomechanical reason for the nearly universal ankle valgus deformity in fibular deficiency?

A 5-year-old child with fibular deficiency presents with a rigid foot deformity, characterized by severe equinovalgus and difficulty with ambulation. The child experiences pain with weight-bearing and struggles to find comfortable footwear. Radiographs are obtained to further characterize the foot pathology.

Which of the following foot deformities is a hallmark feature of fibular deficiency and often contributes significantly to rigidity, pain, and progressive deformity, as described in the case?

A 7-year-old male with Paley Type 1B fibular deficiency presents with a projected limb length discrepancy (LLD) of 8 cm at skeletal maturity. He exhibits a progressive gait abnormality, and his parents report increasing difficulty with compensatory shoe lifts. Clinical examination also reveals significant anterior-medial bowing of the tibia and progressive ankle valgus. The patient has no significant medical comorbidities.

Based on the indications for intervention described in the case, what is the most appropriate initial management strategy for this patient?

A surgical team is evaluating a 9-year-old for complex limb reconstruction for severe fibular deficiency. The proposed treatment involves multiple staged procedures, including limb lengthening with an external fixator, ankle stabilization, and foot reconstruction. During the counseling session, the family expresses significant doubts about their ability to manage the prolonged rehabilitation, daily pin site care, and frequent clinic visits required over several years. They are also concerned about the child's potential non-compliance with the demanding regimen.

Based on the contraindications for intervention described in the case, the family's expressed concerns represent which of the following in the context of limb reconstruction?

A 58-year-old male presents with a 2-year history of progressive pain and stiffness in his right great toe, particularly during push-off. He reports difficulty wearing dress shoes and has noticed a compensatory early heel-off during ambulation. Physical examination reveals tenderness and a palpable dorsal prominence at the first MTP joint, with passive dorsiflexion limited to 20 degrees and pain at the end range. Weight-bearing radiographs show moderate dorsal osteophytes, mild joint space narrowing, and subchondral sclerosis. Based on the provided case, which of the following biomechanical factors is most directly implicated in the patient's symptoms and the progression of his hallux rigidus?

A 35-year-old active runner presents with early-stage hallux rigidus, characterized by intermittent pain and mild dorsal osteophytes on radiographs, consistent with Coughlin and Shurnas Grade 1. He has failed a 3-month trial of NSAIDs and activity modification. During surgical planning for a cheilectomy, the surgeon emphasizes meticulous dissection in the dorsomedial aspect of the first MTP joint. Which neurovascular structure is at highest risk of iatrogenic injury during a standard dorsomedial approach to the first MTP joint?

A 62-year-old sedentary patient presents with severe, constant pain in her left great toe, significantly limiting her ability to walk even short distances. She has tried various conservative treatments, including orthotics, NSAIDs, and multiple corticosteroid injections over the past year, with only transient relief. Weight-bearing radiographs reveal severe joint space effacement, extensive dorsal and plantar osteophytes, subchondral sclerosis, and cyst formation at the first MTP joint. Based on the Coughlin and Shurnas classification system and the provided case, what is the most appropriate surgical recommendation for this patient?

A 40-year-old female presents with a 6-month history of intermittent pain in her right great toe, exacerbated by high-heeled shoes and prolonged walking. Clinical examination reveals mild dorsal tenderness and a slight restriction in passive dorsiflexion (approximately 45 degrees). Radiographs show minimal dorsal osteophytes with preserved joint space. She is diagnosed with early-stage hallux rigidus (Coughlin and Shurnas Grade 1). According to the case, which of the following non-operative treatment modalities should be the initial recommendation?

A 50-year-old male with Coughlin and Shurnas Grade 2 hallux rigidus undergoes a cheilectomy. During the procedure, after exposing the first MTP joint via a dorsomedial approach, the surgeon identifies significant dorsal osteophytes on both the metatarsal head and the proximal phalanx base. The image below depicts the removal of these osteophytes. What is the primary intraoperative goal of this specific step in the cheilectomy procedure?