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8. Foot and Ankle MCQs

Practice Set 39 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 761

Topic: 8. Foot and Ankle

A 48-year-old patient with Coughlin and Shurnas Grade 2 hallux rigidus undergoes a cheilectomy. Intraoperatively, after adequate dorsal osteophyte resection, the surgeon notes that functional dorsiflexion remains limited, particularly when the hallux is loaded. The patient's pre-operative radiographs also showed a subtle metatarsus primus elevatus. Based on the case, which additional procedure would be most appropriate to functionally increase dorsiflexion by reorienting the proximal phalanx?

. A. Watermann osteotomy of the distal metatarsal.
. B. Interposition arthroplasty with a synthetic spacer.
. C. Moberg osteotomy of the proximal phalanx.
. D. First MTP joint arthrodesis.
. E. Microfracture of the articular cartilage.

Correct Answer & Explanation

. C. Moberg osteotomy of the proximal phalanx.

Explanation

Correct Answer: CThe case describes the Moberg osteotomy as 'Often combined with cheilectomy for Grade 1-3 hallux rigidus, particularly when functional hallux limitus persists despite adequate cheilectomy or when a metatarsus primus elevatus is present. It functionally increases dorsiflexion of the hallux by reorienting the proximal phalanx.' The patient's scenario of persistent limited dorsiflexion after cheilectomy and pre-existing metatarsus primus elevatus directly aligns with the indications for a Moberg osteotomy.A. A Watermann osteotomy is a dorsal closing wedge osteotomy of the distal metatarsal that shortens and plantarflexes the metatarsal head. While it can address metatarsus primus elevatus, the question specifically asks for a procedure that reorients the proximal phalanx to increase dorsiflexion, which is the direct effect of a Moberg osteotomy.B. Interposition arthroplasty is for Grade 3-4 HR and aims to preserve motion by inserting a graft or spacer, not to reorient the phalanx for functional dorsiflexion in a Grade 2 case.D. Arthrodesis is the gold standard for end-stage (Grade 4) HR and involves fusion, sacrificing motion, which is not the goal for a Grade 2 patient where motion preservation is still desired.E. Microfracture is for focal cartilage defects in younger patients, not for addressing persistent functional hallux limitus or metatarsus primus elevatus after cheilectomy.

Question 762

Topic: 8. Foot and Ankle

A 70-year-old patient with end-stage hallux rigidus (Coughlin and Shurnas Grade 4) undergoes a first MTP joint arthrodesis. During the procedure, after preparing the joint surfaces, the surgeon meticulously positions the joint for fixation. According to the case, what is the ideal position for fusion of the first MTP joint to facilitate comfortable shoe wear and optimize the push-off phase of gait?

. A. 0 degrees dorsiflexion, 0 degrees valgus, and neutral rotation.
. B. 25-30 degrees dorsiflexion, 5 degrees varus, and slight internal rotation.
. C. 10-20 degrees dorsiflexion relative to the plantar aspect of the foot, 10-15 degrees valgus, and slight external rotation.
. D. 5-10 degrees plantarflexion, 10-15 degrees valgus, and neutral rotation.
. E. 15-20 degrees dorsiflexion relative to the first metatarsal shaft, 0 degrees valgus, and slight internal rotation.

Correct Answer & Explanation

. C. 10-20 degrees dorsiflexion relative to the plantar aspect of the foot, 10-15 degrees valgus, and slight external rotation.

Explanation

Correct Answer: CUnder 'Arthrodesis Fusion - Technique,' the case explicitly states: 'The ideal position for fusion is typically 10-20 degrees of dorsiflexion relative to the plantar aspect of the foot (or 5-10 degrees relative to the first metatarsal shaft), 10-15 degrees of valgus, and slight external rotation. This position facilitates comfortable shoe wear and optimizes the push-off phase of gait despite the loss of motion.'A. 0 degrees dorsiflexion would make push-off difficult and shoe wear uncomfortable.B. 25-30 degrees dorsiflexion is generally considered excessive and can lead to transfer metatarsalgia or difficulty with shoe wear. 5 degrees varus is also incorrect; valgus is preferred.D. 5-10 degrees plantarflexion would severely impair push-off and make walking very difficult.E. While 15-20 degrees dorsiflexion is within the range, 'relative to the first metatarsal shaft' is a different reference point, and 0 degrees valgus and slight internal rotation are not the ideal parameters described in the text.

Question 763

Topic: 8. Foot and Ankle

A 55-year-old male undergoes a first MTP joint arthrodesis for severe hallux rigidus. Six months post-operatively, he presents with persistent pain under his second and third metatarsal heads, particularly with ambulation. Radiographs confirm a solid fusion of the first MTP joint in an appropriate position. Based on the case, what is the most likely complication this patient is experiencing, and what is the typical initial management?

. A. Nonunion of the arthrodesis; revision arthrodesis with bone graft.
. B. Malunion of the arthrodesis; corrective osteotomy.
. C. Transfer metatarsalgia; accommodative orthotics and shoe modifications.
. D. Hardware irritation; hardware removal.
. E. Avascular necrosis of the metatarsal head; debridement or conversion to another arthrodesis.

Correct Answer & Explanation

. C. Transfer metatarsalgia; accommodative orthotics and shoe modifications.

Explanation

Correct Answer: CThe patient's symptoms of 'persistent pain under his second and third metatarsal heads' after a solid first MTP joint arthrodesis, even in an appropriate position, are classic for 'Transfer Metatarsalgia.' The case explicitly lists this as a complication: 'Altered weight-bearing mechanics leading to pain under lesser metatarsals (often after cheilectomy due to shortening or arthrodesis).' The recommended management is 'accommodative orthotics, shoe modifications, metatarsal pads. Rarely, lesser metatarsal osteotomies.'A. Nonunion is ruled out by the statement 'Radiographs confirm a solid fusion.' If it were nonunion, the management would be revision arthrodesis.B. Malunion is ruled out by 'solid fusion... in an appropriate position.' If it were malunion, a corrective osteotomy might be considered if symptomatic.D. Hardware irritation typically presents as localized pain over the hardware, not specifically under the lesser metatarsal heads. While hardware removal is a management option, it's not the most likely cause of this specific pain pattern.E. Avascular necrosis (AVN) is rare and typically affects the metatarsal head, leading to joint collapse and accelerated arthritis, not pain under the lesser metatarsals after a successful fusion.

Question 764

Topic: Forefoot

A 42-year-old patient undergoes a cheilectomy and Moberg osteotomy for Coughlin and Shurnas Grade 2 hallux rigidus. Which of the following post-operative rehabilitation instructions is most consistent with the goals of this specific procedure, as outlined in the case?

. A. Strict non-weight-bearing in a short leg cast for 6 weeks to ensure bone healing.
. B. Immediate, gentle active and passive range of motion exercises for the first MTP joint.
. C. No active or passive ROM exercises for the first MTP joint for 12 weeks.
. D. Gradual progression to weight-bearing in a CAM boot only after radiographic confirmation of osteotomy union at 8 weeks.
. E. Avoidance of any MTP joint motion for 4 weeks, followed by passive stretching only.

Correct Answer & Explanation

. B. Immediate, gentle active and passive range of motion exercises for the first MTP joint.

Explanation

Correct Answer: BThe case, under 'Post-Operative Rehabilitation Protocols - Cheilectomy and Moberg Osteotomy,' states: 'These procedures aim to restore and maintain motion, so early mobilization is typically encouraged.' Specifically, for 'Immediately Post-operative (Day 0 - 2 weeks),' it instructs: 'Range of Motion (ROM): Crucial. Initiate immediate, gentle active and passive ROM exercises for the first MTP joint, focusing on dorsiflexion and plantarflexion. Patients are instructed to perform these exercises frequently throughout the day to prevent stiffness and scar tissue formation.'A. Strict non-weight-bearing in a cast for 6 weeks is typical for arthrodesis, not for cheilectomy/Moberg osteotomy, which allows for weight-bearing as tolerated in a surgical shoe.C. No active or passive ROM for 12 weeks is contrary to the goal of motion preservation and would lead to stiffness.D. Gradual progression to weight-bearing after radiographic confirmation of union at 8 weeks is characteristic of arthrodesis protocols, not cheilectomy/Moberg osteotomy, which allows earlier weight-bearing.E. Avoidance of MTP joint motion for 4 weeks is incorrect; early motion is emphasized to prevent stiffness.

Question 765

Topic: Forefoot

A 68-year-old patient with a history of rheumatoid arthritis and severe, painful hallux rigidus (Coughlin and Shurnas Grade 4) is considering surgical options. She expresses a strong desire to preserve some motion in her great toe, if possible, but her primary goal is reliable pain relief. Based on the provided case, which statement accurately reflects the current understanding of motion-preserving arthroplasty options versus arthrodesis for end-stage hallux rigidus?

. A. Metallic hemiarthroplasty offers superior long-term pain relief and durability compared to arthrodesis for end-stage disease.
. B. Interposition arthroplasty using autograft provides more predictable outcomes and motion preservation than arthrodesis.
. C. Arthrodesis is considered the gold standard for end-stage hallux rigidus, providing the most reliable and durable pain relief, despite sacrificing motion.
. D. Silicone implants are now the preferred choice for arthroplasty due to their excellent long-term results and low complication rates.
. E. Cartilage restoration techniques like microfracture are highly effective for diffuse, end-stage arthritis in older patients seeking motion preservation.

Correct Answer & Explanation

. C. Arthrodesis is considered the gold standard for end-stage hallux rigidus, providing the most reliable and durable pain relief, despite sacrificing motion.

Explanation

Correct Answer: CThe case, under 'Summary of Key Literature and Guidelines - Arthrodesis,' explicitly states: 'Fusion of the first MTP joint is widely considered the 'gold standard' for end-stage hallux rigidus (Coughlin and Shurnas Grade 4), providing the most reliable and durable pain relief. Fusion rates typically range from 90% to 98%, with high patient satisfaction despite the sacrifice of motion.' This directly addresses the patient's primary goal of reliable pain relief for end-stage disease.A. The case states regarding metallic hemiarthroplasty: 'Long-term comparative studies against arthrodesis often show superior pain relief and durability for fusion in severe cases.' This contradicts the option.B. Regarding interposition arthroplasty, the case notes: 'these procedures generally have less predictable outcomes than fusion, with variable rates of pain relief and maintenance of motion.' This contradicts the option.D. The case states: 'Silicone implants: Largely abandoned due to concerns regarding particulate synovitis and implant failure.' This contradicts the option.E. The case states regarding cartilage restoration: 'their application in diffuse, advanced hallux rigidus is limited, and long-term data specific to the first MTP joint is still evolving.' This contradicts the option, especially for an older patient with diffuse, end-stage arthritis.

Question 766

Topic: 8. Foot and Ankle

The Lisfranc ligament is a primary stabilizer of the midfoot. Which of the following accurately describes its anatomic origin and insertion?

. Medial cuneiform to the base of the 1st metatarsal
. Medial cuneiform to the base of the 2nd metatarsal
. Intermediate cuneiform to the base of the 2nd metatarsal
. Lateral cuneiform to the base of the 3rd metatarsal
. Cuboid to the base of the 4th metatarsal

Correct Answer & Explanation

. Medial cuneiform to the base of the 2nd metatarsal

Explanation

The Lisfranc ligament is a strong interosseous ligament that originates on the lateral aspect of the medial cuneiform and inserts on the medial aspect of the base of the second metatarsal. There is no direct ligamentous connection between the bases of the first and second metatarsals.

Question 767

Topic: Midfoot & Hindfoot

A 38-year-old female sustains a purely ligamentous Lisfranc injury. Studies have shown that primary arthrodesis yields superior functional outcomes for this specific injury pattern compared to open reduction internal fixation (ORIF). Which joints are typically included in this primary arthrodesis?

. 1st, 2nd, and 3rd tarsometatarsal joints
. 2nd, 3rd, and 4th tarsometatarsal joints
. 4th and 5th tarsometatarsal joints only
. Naviculocuneiform joints
. All five tarsometatarsal joints

Correct Answer & Explanation

. 1st, 2nd, and 3rd tarsometatarsal joints

Explanation

Primary arthrodesis for purely ligamentous Lisfranc injuries typically involves the medial and middle columns (1st, 2nd, and 3rd TMT joints). The lateral column (4th and 5th TMT joints) should be stabilized with flexible fixation (e.g., K-wires) to preserve essential mobility.

Question 768

Topic: Forefoot

A 55-year-old male presents with dorsal pain and stiffness in his right great toe. Radiographs demonstrate dorsal osteophytes and mild joint space narrowing at the first metatarsophalangeal (MTP) joint consistent with Grade 2 hallux rigidus. Which of the following shoe modifications is most appropriate for initial conservative management?

. Flexible, thin-soled minimalist shoe
. Shoe with a flexible toe box and high heel
. Stiff-soled shoe with a Morton extension
. Shoe with a medial heel wedge
. UCBL orthosis

Correct Answer & Explanation

. Stiff-soled shoe with a Morton extension

Explanation

The mainstay of non-operative treatment for hallux rigidus is limiting dorsiflexion of the first MTP joint. A stiff-soled shoe with a Morton extension (a rigid plate under the first MTP) accomplishes this and effectively reduces pain.

Question 769

Topic: 8. Foot and Ankle

During surgical stabilization of a severe Lisfranc fracture-dislocation involving all five tarsometatarsal joints, the surgeon places rigid screw fixation across the 1st, 2nd, and 3rd TMT joints. How should the 4th and 5th TMT joints be optimally managed?

. Rigid screw fixation
. Dorsal bridge plating
. Primary arthrodesis
. Closed reduction and Kirschner wire fixation
. No fixation is required if the medial and middle columns are stable

Correct Answer & Explanation

. Closed reduction and Kirschner wire fixation

Explanation

The lateral column of the foot (4th and 5th TMT joints) requires mobility to accommodate uneven terrain during gait. It should be stabilized temporarily with flexible K-wires, which are removed later, rather than with rigid screws or arthrodesis.

Question 770

Topic: 8. Foot and Ankle

A 62-year-old female with Grade 4 hallux rigidus undergoes a first metatarsophalangeal joint arthrodesis. To optimize her postoperative gait and prevent adjacent joint arthritis, what is the ideal position for the arthrodesis?

. Neutral dorsiflexion, 0 degrees of valgus
. 10-15 degrees of dorsiflexion relative to the floor, 10-15 degrees of valgus
. 25-30 degrees of dorsiflexion relative to the floor, 5 degrees of varus
. 5 degrees of plantarflexion, 10-15 degrees of valgus
. 10-15 degrees of dorsiflexion relative to the first metatarsal shaft, neutral valgus

Correct Answer & Explanation

. 10-15 degrees of dorsiflexion relative to the floor, 10-15 degrees of valgus

Explanation

The optimal position for a 1st MTP joint arthrodesis is approximately 10 to 15 degrees of dorsiflexion relative to the floor (or 25-30 degrees relative to the first metatarsal shaft) and 10 to 15 degrees of valgus, with neutral rotation.

Question 771

Topic: 8. Foot and Ankle

In the open reduction and internal fixation of a classic divergent Lisfranc injury, what is the proper sequence of reduction and fixation?

. 1st TMT joint, followed by the 2nd TMT joint, followed by the 3rd TMT joint
. 2nd TMT joint, followed by the 1st TMT joint, followed by the 3rd TMT joint
. Lateral column (4th/5th TMT), followed by the 2nd TMT joint
. 3rd TMT joint, followed by the 2nd TMT joint
. The sequence does not affect functional outcomes as long as all joints are reduced

Correct Answer & Explanation

. 2nd TMT joint, followed by the 1st TMT joint, followed by the 3rd TMT joint

Explanation

The second metatarsal acts as the keystone of the midfoot arch. Standard surgical sequence dictates reducing and fixing the 2nd TMT joint first (often with a homing screw from the medial cuneiform), followed by the 1st TMT, and then the 3rd TMT joint.

Question 772

Topic: 8. Foot and Ankle

A 45-year-old runner with early-stage hallux rigidus fails conservative management and elects to undergo a dorsal cheilectomy. What is the primary biomechanical goal of this procedure?

. Decompression of the plantar fascia
. Excision of the plantar sesamoids
. Removal of the dorsal 30% of the metatarsal head to increase dorsiflexion
. Realigning the first ray into a more varus position
. Arthrodesis of the first MTP joint

Correct Answer & Explanation

. Removal of the dorsal 30% of the metatarsal head to increase dorsiflexion

Explanation

A dorsal cheilectomy involves the removal of the dorsal osteophytes and the dorsal 20% to 30% of the first metatarsal head. This functionally decompresses the joint and increases first MTP dorsiflexion impingement-free.

Question 773

Topic: 8. Foot and Ankle

In a patient with severe congenital fibular deficiency, which of the following clinical findings strongly favors early Syme amputation over attempts at limb lengthening?

. Mild anteromedial tibial bowing
. A functional, plantigrade foot with 4 rays
. A predicted limb length discrepancy of 3 cm at maturity
. A non-plantigrade foot with only 2 rays and an unstable ankle
. The presence of an associated anterior cruciate ligament deficiency

Correct Answer & Explanation

. A non-plantigrade foot with only 2 rays and an unstable ankle

Explanation

Severe foot deformities, such as absent lateral rays (<3 toes), a non-plantigrade position, and an unstable or rigid foot, are strong indications for early amputation (Syme or Boyd) rather than extensive limb lengthening procedures.

Question 774

Topic: 8. Foot and Ankle

A 24-year-old athlete sustains a midfoot injury. A weight-bearing AP radiograph shows a small bony fragment in the space between the medial cuneiform and the base of the second metatarsal. This "fleck sign" represents an avulsion of the Lisfranc ligament from which structure?

. Base of the 1st metatarsal
. Base of the 2nd metatarsal
. Medial cuneiform
. Intermediate cuneiform
. Navicular

Correct Answer & Explanation

. Base of the 2nd metatarsal

Explanation

The "fleck sign" is pathognomonic for a Lisfranc injury. It represents a bony avulsion of the Lisfranc ligament, typically from its insertion site at the medial base of the second metatarsal.

Question 775

Topic: 8. Foot and Ankle

A 78-year-old low-demand female undergoes a Keller excision arthroplasty for severe hallux rigidus. Postoperatively, she complains of a new deformity of her great toe and pain under the second metatarsal head. Which of the following is the most likely complication responsible for her symptoms?

. Nonunion of the MTP joint
. Loss of flexor hallucis brevis function leading to a cock-up deformity and transfer metatarsalgia
. Avascular necrosis of the first metatarsal head
. Rupture of the extensor hallucis longus
. Hallux varus from over-tightening of the medial capsule

Correct Answer & Explanation

. Loss of flexor hallucis brevis function leading to a cock-up deformity and transfer metatarsalgia

Explanation

The Keller procedure involves resection of the base of the proximal phalanx. This detaches the intrinsic flexors (flexor hallucis brevis), which can lead to a "cock-up" deformity of the hallux and subsequent transfer metatarsalgia to the lesser rays.

Question 776

Topic: 8. Foot and Ankle

During physical examination of a patient with a suspected subtle midfoot injury, the presence of plantar ecchymosis is noted. This finding is highly specific for an injury to which of the following?

. Spring ligament complex
. Tarsometatarsal joint complex
. Plantar fascia
. Achilles tendon
. Tibialis posterior tendon

Correct Answer & Explanation

. Tarsometatarsal joint complex

Explanation

Plantar ecchymosis in the midfoot following trauma is considered pathognomonic for a Lisfranc (tarsometatarsal) injury until proven otherwise. It reflects tearing of the plantar ligaments and capsules of the TMT joints.

Question 777

Topic: 8. Foot and Ankle

The Lisfranc ligament is a primary stabilizer of the midfoot. Which of the following best describes its anatomical origin and insertion?

. Lateral margin of the medial cuneiform to the medial aspect of the base of the second metatarsal
. Medial margin of the lateral cuneiform to the medial base of the third metatarsal
. Plantar aspect of the navicular to the dorsal base of the second metatarsal
. Dorsal aspect of the medial cuneiform to the dorsal base of the first metatarsal
. Plantar aspect of the medial cuneiform to the plantar base of the first metatarsal

Correct Answer & Explanation

. Lateral margin of the medial cuneiform to the medial aspect of the base of the second metatarsal

Explanation

The Lisfranc ligament is an oblique interosseous ligament that originates from the lateral aspect of the medial cuneiform and inserts onto the medial aspect of the base of the second metatarsal. There is no direct intermetatarsal ligament between the bases of the first and second metatarsals, making this ligament critical for stability.

Question 778

Topic: Midfoot & Hindfoot

A 45-year-old male presents with severe midfoot pain after a misstep off a curb. MRI confirms a complete, purely ligamentous rupture of the Lisfranc complex with associated diastasis on weight-bearing films, but no fractures. Based on recent literature, which of the following treatments provides the lowest rate of hardware failure and subsequent revision surgeries for this specific injury pattern?

. Cast immobilization for 8 weeks
. ORIF with transarticular solid screws
. Primary arthrodesis of the medial column (1st, 2nd, and 3rd TMT joints)
. Primary arthrodesis of the lateral column (4th and 5th TMT joints)
. Open reduction without internal fixation

Correct Answer & Explanation

. Primary arthrodesis of the medial column (1st, 2nd, and 3rd TMT joints)

Explanation

Evidence suggests that for purely ligamentous Lisfranc injuries, primary arthrodesis of the medial column (1st, 2nd, and 3rd TMT joints) yields comparable or superior long-term functional outcomes and significantly lower rates of revision surgery compared to ORIF.

Question 779

Topic: 8. Foot and Ankle

The Lisfranc ligament is a crucial stabilizing structure of the midfoot. Which of the following accurately describes its anatomic origin and insertion?

. Lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal
. Medial aspect of the middle cuneiform to the medial aspect of the base of the second metatarsal
. Plantar aspect of the medial cuneiform to the plantar aspect of the first metatarsal
. Plantar aspect of the cuboid to the base of the fourth and fifth metatarsals
. Dorsal aspect of the middle cuneiform to the dorsal base of the third metatarsal

Correct Answer & Explanation

. Lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal

Explanation

The Lisfranc ligament is an interosseous ligament connecting the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. It is the primary stabilizer of the second tarsometatarsal joint.

Question 780

Topic: 8. Foot and Ankle

A 24-year-old professional athlete sustains a purely ligamentous Lisfranc injury. Weight-bearing radiographs demonstrate 3 mm of diastasis between the first and second metatarsals. What is the most evidence-based surgical management for this specific injury pattern to minimize the need for future reoperation?

. Open reduction and internal fixation (ORIF) with dorsal bridge plating
. Closed reduction and percutaneous pinning (CRPP)
. Primary arthrodesis of the first, second, and third tarsometatarsal joints
. Open reduction and internal fixation (ORIF) with transarticular screws
. Isolated ligamentous repair with anchor fixation

Correct Answer & Explanation

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

Explanation

Recent literature demonstrates that primary arthrodesis for purely ligamentous Lisfranc injuries yields better functional outcomes and significantly lower reoperation rates compared to ORIF. ORIF is generally preferred for purely bony fracture-dislocations.

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