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8. Foot and Ankle MCQs

Practice Set 42 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 821

Topic: 8. Foot and Ankle

A 13-year-old male presents with acute right ankle pain after a soccer injury. An anteroposterior radiograph of his ankle is shown in . Which of the following answers correctly pairs the eponym commonly used to describe this injury with the affected anatomic structure?

. Tillaux fracture; ATFL (anterior talofibular ligament)
. Tillaux fracture; AITFL (anterior inferior tibiofibular ligament)
. Chopart fracture; ATFL (anterior talofibular ligament)
. Chopart fracture; AITFL (anterior inferior tibiofibular ligament)
. Chaput fracture; ATFL (anterior talofibular ligament)

Correct Answer & Explanation

. Tillaux fracture; AITFL (anterior inferior tibiofibular ligament)

Explanation

Correct Answer: BThe radiograph depicts a Tillaux fracture, which is a transitional ankle fracture in adolescents involving an avulsion of the anterolateral distal tibial epiphysis. This fragment remains attached to the anterior inferior tibiofibular ligament (AITFL), which is one of the primary syndesmotic ligaments of the ankle. Chopart injuries involve the midtarsal joint, not the distal tibia. The Chaput fragment is another eponym for the same fracture piece attached to the AITFL, but it is more commonly used in adult ankle fractures. The anterior talofibular ligament (ATFL) is the most commonly injured ligament in lateral ankle sprains, not typically involved in a Tillaux fracture.

Question 822

Topic: 8. Foot and Ankle
A patient presents with a grossly dislocated knee (Schenck KD-III). Following closed reduction, the Ankle-Brachial Index (ABI) is calculated to be 0.8. What is the most appropriate next step in management?
. Immediate surgical exploration of the popliteal artery
. CT angiography of the lower extremity
. Observation and repeat ABI in 4 hours
. Duplex ultrasonography
. Fasciotomies of the lower leg

Correct Answer & Explanation

. CT angiography of the lower extremity

Explanation

An ABI < 0.9 after a knee dislocation is highly suspicious for a vascular injury, most commonly to the popliteal artery. The gold standard for further evaluation in a hemodynamically stable patient with an abnormal ABI is a CT angiogram.

Question 823

Topic: 8. Foot and Ankle

A 21-year-old athlete sustains an acute knee dislocation. Following rapid closed reduction in the emergency department, the foot is warm with palpable pulses, but the Ankle-Brachial Index (ABI) is calculated to be 0.8. What is the next most appropriate step?

. Immediate surgical exploration of the popliteal artery
. CT Angiography of the lower extremity
. Observation with repeat ABI measurements every 4 hours
. Duplex ultrasonography
. Application of a hinged knee brace and discharge

Correct Answer & Explanation

. CT Angiography of the lower extremity

Explanation

In the setting of a knee dislocation, an ABI of less than 0.9 strongly suggests an underlying vascular injury, even if pulses are palpable. CT angiography is the gold-standard diagnostic step to define the injury and guide surgical intervention.

Question 824

Topic: 8. Foot and Ankle
A 28-year-old male is brought to the trauma bay after a motorcycle accident with an anterior knee dislocation (Schenck KD-III). The joint is urgently reduced. Post-reduction, he has palpable dorsalis pedis and posterior tibial pulses. His ankle-brachial index (ABI) is measured at 1.1. What is the most appropriate next step in vascular management?
. Immediate surgical exploration of the popliteal artery
. Computed tomography angiography (CTA) of the lower extremity
. Magnetic resonance angiography (MRA) of the lower extremity
. Serial physical examinations for 24 to 48 hours
. Prophylactic fasciotomies of the lower leg

Correct Answer & Explanation

. Serial physical examinations for 24 to 48 hours

Explanation

For knee dislocations, an ABI greater than 0.9 with normal palpable pulses indicates a very low likelihood of a flow-limiting vascular injury. The standard of care is admission for serial physical and neurovascular examinations for 24 to 48 hours.

Question 825

Topic: 8. Foot and Ankle

A 13-year-old male presents with acute right ankle pain after a soccer match. Radiographs, including the AP view shown below, reveal a transitional ankle fracture.

Which of the following answers correctly pairs the eponym commonly used to describe this injury with the affected anatomic structure?

. Tillaux fracture; ATFL (anterior talofibular ligament)
. Tillaux fracture; AITFL (anterior inferior tibiofibular ligament)
. Chopart fracture; ATFL (anterior talofibular ligament)
. Chopart fracture; AITFL (anterior inferior tibiofibular ligament)
. Chaput fracture; ATFL (anterior talofibular ligament)

Correct Answer & Explanation

. Tillaux fracture; AITFL (anterior inferior tibiofibular ligament)

Explanation

Correct Answer: Tillaux fracture; AITFL (anterior inferior tibiofibular ligament)The radiograph displays a Tillaux fracture, which is a specific type of transitional ankle fracture seen in adolescents. It involves an avulsion fracture of the anterolateral distal tibial epiphysis. The anterior inferior tibiofibular ligament (AITFL), a key syndesmotic ligament, inserts onto this fragment. The injury typically occurs due to external rotation forces on the foot, causing the AITFL to avulse a piece of the epiphysis.Tillaux fracture; ATFL (anterior talofibular ligament):The ATFL is the most commonly injured ligament in lateral ankle sprains but is not directly involved in a Tillaux fracture.Chopart fracture; ATFL (anterior talofibular ligament):Chopart injuries involve the midtarsal joint (talonavicular and calcaneocuboid joints) and are distinct from distal tibial physeal fractures.Chopart fracture; AITFL (anterior inferior tibiofibular ligament):This option incorrectly combines the Chopart injury with the AITFL.Chaput fracture; ATFL (anterior talofibular ligament):A Chaput fracture is another eponym for an avulsion fracture of the anterior inferior tibial tubercle, which is essentially the same anatomical injury as a Tillaux fracture but is more commonly used in adult ankle fracture classifications. However, it is associated with the AITFL, not the ATFL.

Question 826

Topic: 8. Foot and Ankle

A 13-year-old male is diagnosed with a triplane ankle fracture. You decide to perform a closed reduction and long-leg splint application. Which of the following best describes the primary reduction maneuver for this injury?

. Traction, internal rotation of the foot, and dorsiflexion of the ankle
. Traction, internal rotation of the foot, and plantarflexion of the ankle
. Traction, external rotation of the foot, and dorsiflexion of the ankle
. Traction, external rotation of the foot, and plantarflexion of the ankle
. Traction, abduction of the foot, and plantarflexion of the ankle

Correct Answer & Explanation

. Traction, internal rotation of the foot, and dorsiflexion of the ankle

Explanation

Correct Answer: Traction, internal rotation of the foot, and dorsiflexion of the ankleThe classic reduction maneuver for triplane ankle fractures involves sustained axial traction to disimpact the fragments, followed by maximal internal rotation and supination of the foot, combined with dorsiflexion of the ankle. This maneuver aims to reverse the typical external rotation and pronation mechanism of injury and to achieve anatomical reduction of the articular surface.Traction, internal rotation of the foot, and plantarflexion of the ankle:Plantarflexion would not help reduce the fracture and may even exacerbate displacement.Traction, external rotation of the foot, and dorsiflexion of the ankle:External rotation is typically the mechanism of injury, so applying external rotation would worsen the displacement.Traction, external rotation of the foot, and plantarflexion of the ankle:Both external rotation and plantarflexion are incorrect for reduction.Traction, abduction of the foot, and plantarflexion of the ankle:Abduction and plantarflexion are not the correct components of the reduction maneuver for this fracture.

Question 827

Topic: 8. Foot and Ankle

A 49-year-old female presents to the emergency department after falling down stairs, complaining of severe left foot pain, swelling, and inability to bear weight. Initial assessment reveals ecchymosis and tenderness over the midfoot. The following radiographs are obtained:

Which of the following radiographic findings is MOST indicative of a Lisfranc injury in this patient?

. A. Fracture of the cuboid bone.
. B. Widening of the space between the navicular and cuneiform bones.
. C. Diastasis of > 2 mm between the base of the first and second metatarsals.
. D. Avulsion fracture from the lateral malleolus.
. E. Subtalar joint dislocation.

Correct Answer & Explanation

. C. Diastasis of > 2 mm between the base of the first and second metatarsals.

Explanation

Correct Answer: CThe case explicitly states, 'There is diastasis of > 2 mm between the base of the first and second metatarsals, features suggestive of Lisfranc tarsometatarsal fracture dislocation. There is a small avulsed fragment of bone in that interval. This avulsion fracture could be from the insertion of the Lisfranc ligament into the base of the second metatarsal, called a โ€˜fleck signโ€™.' This diastasis is a hallmark radiographic sign of a Lisfranc injury, indicating disruption of the Lisfranc ligament complex.Option A (Fracture of the cuboid bone)is incorrect. While cuboid fractures can occur in foot trauma, they are not the primary diagnostic feature of a Lisfranc injury.Option B (Widening of the space between the navicular and cuneiform bones)is incorrect. While midfoot widening is a general sign of trauma, the specific diastasis between the first and second metatarsal bases is more characteristic of a Lisfranc injury, reflecting disruption at the tarsometatarsal joint complex.Option D (Avulsion fracture from the lateral malleolus)is incorrect. An avulsion fracture of the lateral malleolus is indicative of an ankle injury, not a midfoot Lisfranc injury.Option E (Subtalar joint dislocation)is incorrect. Subtalar joint dislocation is a hindfoot injury and presents differently from a Lisfranc injury, which affects the midfoot.

Question 828

Topic: 8. Foot and Ankle
A 35-year-old male presents with midfoot pain after a motor vehicle accident. Initial AP and oblique radiographs of the foot are equivocal for a Lisfranc injury, showing only subtle widening of the first-second metatarsal space. The patient's pain is disproportionate to the radiographic findings, and he has tenderness over the tarsometatarsal joints. Based on the case discussion, what would be the most appropriate next step in imaging to definitively diagnose or rule out a Lisfranc injury?
. Repeat AP and oblique radiographs in 24 hours.
. Obtain a bone scan.
. Perform stress views and a CT scan.
. Order a weight-bearing lateral ankle radiograph.
. Administer a local anesthetic injection and re-examine.

Correct Answer & Explanation

. Perform stress views and a CT scan.

Explanation

Stress views can reveal instability not apparent on static radiographs, and a CT scan provides detailed bony anatomy, crucial for identifying subtle fractures, displacement, and joint incongruity in the complex midfoot region. Delaying definitive diagnosis can lead to worse outcomes for Lisfranc injuries.

Question 829

Topic: 8. Foot and Ankle

A 40-year-old construction worker undergoes open reduction and internal fixation for a Lisfranc fracture-dislocation. During the postoperative course, he develops persistent midfoot pain, stiffness, and difficulty returning to his previous activity level despite appropriate rehabilitation. Based on the prognosis discussed in the case, which of the following is the MOST likely long-term complication this patient is experiencing?

. A. Avascular necrosis of the talus.
. B. Chronic ankle instability.
. C. Post-traumatic osteoarthritis.
. D. Stress fracture of the fifth metatarsal.
. E. Tarsal tunnel syndrome.

Correct Answer & Explanation

. C. Post-traumatic osteoarthritis.

Explanation

Correct Answer: CThe case explicitly states regarding prognosis: 'This is a serious injury with potentially a poor outcome. Post-traumatic osteoarthritis may occur in more than 50% of cases despite surgical intervention. Residual pain and stiff foot are not uncommon complications of this injury.' The patient's symptoms of persistent pain and stiffness are highly consistent with the development of post-traumatic osteoarthritis in the tarsometatarsal joints, which is a common and significant long-term complication of Lisfranc injuries.Option A (Avascular necrosis of the talus)is incorrect. Avascular necrosis of the talus is a complication associated with talar neck fractures or severe ankle dislocations, not typically Lisfranc injuries.Option B (Chronic ankle instability)is incorrect. Lisfranc injuries affect the midfoot, and while they can alter foot mechanics, chronic ankle instability is not a direct or primary long-term complication of a Lisfranc injury itself.Option D (Stress fracture of the fifth metatarsal)is incorrect. While stress fractures can occur in the foot, they are not a direct long-term complication of a Lisfranc injury, especially after ORIF and rehabilitation.Option E (Tarsal tunnel syndrome)is incorrect. Tarsal tunnel syndrome involves compression of the posterior tibial nerve and can cause foot pain, but it is not listed as a common long-term complication of Lisfranc injuries in the case, nor is it as prevalent as post-traumatic osteoarthritis.

Question 830

Topic: 8. Foot and Ankle

A 49-year-old female with a Lisfranc injury develops acute compartment syndrome of the foot. She is taken to the operating theatre for emergency decompression. Based on the candidate's description in the case, how many incisions are typically used to decompress the nine compartments of the foot, and where are they located?

. A. One incision, located medially along the arch.
. B. Two incisions, one dorsal and one plantar.
. C. Three incisions: two dorsal over the second and third metatarsals, and one medial just under the medial border of the first metatarsal.
. D. Four incisions: two dorsal and two plantar.
. E. Five incisions: one for each metatarsal space.

Correct Answer & Explanation

. C. Three incisions: two dorsal over the second and third metatarsals, and one medial just under the medial border of the first metatarsal.

Explanation

Correct Answer: CThe case explicitly details the surgical approach for foot compartment syndrome: 'There is more than one technique described to decompress compartment syndrome of the foot, but I have been trained to decompress the nine compartments of the foot through three incisions, two dorsal over the second and third metatarsals and one on the medial side, just under the medial border of the first metatarsal.' This describes a common and effective approach to decompress all nine compartments of the foot.Option A (One incision, located medially along the arch)is incorrect. A single incision is insufficient to decompress all nine compartments of the foot.Option B (Two incisions, one dorsal and one plantar)is incorrect. While some techniques use dorsal and plantar approaches, the specific description in the case involves three incisions with precise locations.Option D (Four incisions: two dorsal and two plantar)is incorrect. This is not the technique described in the case, which specifies three incisions.Option E (Five incisions: one for each metatarsal space)is incorrect. This would be excessive and is not the standard approach described for foot fasciotomy.

Question 831

Topic: Midfoot & Hindfoot

A 28-year-old athlete sustains a low-energy twisting injury to the foot while playing basketball. Initial radiographs are interpreted as normal. However, due to persistent midfoot pain and swelling, a follow-up MRI is performed, which reveals a subtle disruption of the Lisfranc ligament without significant bony displacement. Based on the case discussion, what is the MOST appropriate initial non-operative management for this stable Lisfranc sprain?

. A. Immediate weight-bearing as tolerated with a supportive shoe.
. B. Non-weightbearing cast for 6 weeks with regular clinical and radiological review.
. C. Partial weight-bearing in a walking boot for 2-3 weeks.
. D. Aggressive physical therapy focusing on strengthening and flexibility.
. E. Corticosteroid injection into the tarsometatarsal joint.

Correct Answer & Explanation

. B. Non-weightbearing cast for 6 weeks with regular clinical and radiological review.

Explanation

Correct Answer: BThe case states: 'There is a role for non-operative management of an undisplaced stable injury or sprain which includes a non-weightbearing cast for 6 weeks and regular clinical and radiological review.' Even a stable Lisfranc sprain involves disruption of critical ligaments and requires a period of strict non-weightbearing immobilization to allow for healing and prevent progression to instability. Regular review is essential to ensure stability is maintained.Option A (Immediate weight-bearing as tolerated with a supportive shoe)is incorrect. This would place undue stress on the healing ligaments and could lead to chronic instability and pain.Option C (Partial weight-bearing in a walking boot for 2-3 weeks)is incorrect. This duration and level of activity are insufficient for a Lisfranc sprain, which requires longer non-weightbearing to heal adequately.Option D (Aggressive physical therapy focusing on strengthening and flexibility)is incorrect. While physical therapy is crucial after immobilization, aggressive therapy too early would jeopardize ligament healing.Option E (Corticosteroid injection into the tarsometatarsal joint)is incorrect. Corticosteroid injections are generally not indicated for acute ligamentous injuries and could potentially weaken the healing tissue.

Question 832

Topic: 8. Foot and Ankle

A 49-year-old female presents with a Lisfranc injury. The candidate in the case mentions the 'fleck sign' as an avulsed fragment of bone from the insertion of the Lisfranc ligament. Which specific anatomical structure is the Lisfranc ligament primarily connecting, and what is its biomechanical significance?

. A. Connects the navicular to the cuboid, stabilizing the transverse arch.
. B. Connects the calcaneus to the cuboid, supporting the lateral column.
. C. Connects the medial cuneiform to the base of the second metatarsal, providing critical midfoot stability.
. D. Connects the talus to the navicular, forming part of the talonavicular joint capsule.
. E. Connects the first metatarsal to the medial cuneiform, preventing hallux valgus.

Correct Answer & Explanation

. C. Connects the medial cuneiform to the base of the second metatarsal, providing critical midfoot stability.

Explanation

Correct Answer: CThe Lisfranc ligament is a critical stabilizer of the midfoot. The case mentions the 'fleck sign' as an avulsion fracture from the insertion of the Lisfranc ligament into the base of the second metatarsal. This ligament primarily connects the medial cuneiform to the base of the second metatarsal. It is the strongest ligament in the tarsometatarsal joint complex and prevents dorsal and lateral displacement of the metatarsals relative to the tarsus, thus providing crucial stability to the midfoot arch.Option A (Connects the navicular to the cuboid, stabilizing the transverse arch)is incorrect. This describes ligaments within the midtarsal joint, not the Lisfranc ligament.Option B (Connects the calcaneus to the cuboid, supporting the lateral column)is incorrect. This describes the calcaneocuboid ligaments, part of the Chopart joint.Option D (Connects the talus to the navicular, forming part of the talonavicular joint capsule)is incorrect. This describes ligaments of the talonavicular joint, part of the hindfoot.Option E (Connects the first metatarsal to the medial cuneiform, preventing hallux valgus)is incorrect. While there are ligaments connecting the first metatarsal to the medial cuneiform, the Lisfranc ligament specifically refers to the connection between the medial cuneiform and the second metatarsal base, and its primary role is midfoot stability, not directly preventing hallux valgus.

Question 833

Topic: Midfoot & Hindfoot

A 25-year-old professional athlete sustains a purely ligamentous Lisfranc injury. According to recent literature, what is the primary advantage of performing a primary arthrodesis of the first, second, and third tarsometatarsal joints rather than open reduction and internal fixation (ORIF)?

. Shorter initial non-weight-bearing duration
. Decreased rate of subsequent surgeries and hardware removal
. Superior restoration of the medial longitudinal arch height
. Reduced risk of adjacent segment disease at the midtarsal joints
. Lower incidence of superficial wound infections

Correct Answer & Explanation

. Decreased rate of subsequent surgeries and hardware removal

Explanation

Primary arthrodesis for purely ligamentous Lisfranc injuries has been shown to yield similar or slightly better functional outcomes compared to ORIF, primarily due to a significantly decreased need for subsequent surgeries such as hardware removal.

Question 834

Topic: 8. Foot and Ankle

A patient develops unrecognized compartment syndrome of the foot following a severe crush injury mechanism. Which of the following deformities is the classic late complication characteristic of this missed diagnosis?

. Pes planovalgus deformity
. Fixed equinovarus contracture
. Claw toe deformity
. Hallux rigidus
. Drop foot

Correct Answer & Explanation

. Claw toe deformity

Explanation

Missed foot compartment syndrome leads to ischemic necrosis and contracture of the intrinsic muscles of the foot. This intrinsic-minus state typically results in the classic clinical presentation of claw toe deformities.

Question 835

Topic: 8. Foot and Ankle

The Lisfranc ligament is an intra-articular structure crucial for midfoot stability. It originates on the lateral aspect of the medial cuneiform and inserts directly onto which of the following structures?

. Medial aspect of the first metatarsal base
. Medial aspect of the second metatarsal base
. Lateral aspect of the second metatarsal base
. Plantar aspect of the third metatarsal base
. Dorsal aspect of the intermediate cuneiform

Correct Answer & Explanation

. Medial aspect of the second metatarsal base

Explanation

The Lisfranc ligament is an interosseous ligament that connects the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. There is no direct ligamentous connection between the bases of the first and second metatarsals.

Question 836

Topic: 8. Foot and Ankle

A 65-year-old poorly controlled diabetic patient with peripheral neuropathy requires surgical fixation for an unstable bimalleolar ankle fracture. To minimize the high risk of Charcot arthropathy and hardware failure, which surgical strategy is most recommended?

. Use of bioabsorbable fixation hardware
. Augmented rigid fixation (e.g., multiple syndesmotic screws or hindfoot nail) with prolonged immobilization
. Minimally invasive percutaneous pinning without internal plates
. Early weight-bearing and aggressive range of motion at 2 weeks
. Primary total ankle arthroplasty

Correct Answer & Explanation

. Augmented rigid fixation (e.g., multiple syndesmotic screws or hindfoot nail) with prolonged immobilization

Explanation

Diabetic patients with neuropathy are at a severe risk for Charcot arthropathy and catastrophic hardware failure. Augmented, ultra-rigid fixation combined with prolonged non-weight-bearing (often double the standard duration) is the recommended strategy.

Question 837

Topic: 8. Foot and Ankle

A dual dorsal incision approach (with incisions placed over the 2nd and 4th metatarsals) to the foot for fasciotomy is primarily designed to directly access and decompress which of the following fascial compartments?

. Superficial central and calcaneal compartments
. Interosseous compartments
. Medial and lateral compartments only
. Adductor and quadratus plantae compartments
. The superficial dorsal compartment only

Correct Answer & Explanation

. Interosseous compartments

Explanation

The classic dual dorsal incisions provide direct and easy access to release the four interosseous compartments of the foot. Reaching the deeper central and calcaneal compartments from a strictly dorsal approach requires extensive and potentially dangerous dissection.

Question 838

Topic: 8. Foot and Ankle

What ligament provides the primary structural stability to the Lisfranc complex?

. Plantar ligament between the medial cuneiform and first metatarsal base
. Dorsal ligament between the medial cuneiform and second metatarsal base
. Interosseous ligament between the medial cuneiform and second metatarsal base
. Plantar ligament between the intermediate cuneiform and second metatarsal base
. Interosseous ligament between the lateral cuneiform and third metatarsal base

Correct Answer & Explanation

. Interosseous ligament between the medial cuneiform and second metatarsal base

Explanation

The Lisfranc ligament is a strong interosseous ligament connecting the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. It is critical for the stability of the midfoot arch.

Question 839

Topic: Midfoot & Hindfoot

A 24-year-old athlete is diagnosed with a purely ligamentous Lisfranc injury involving the first, second, and third tarsometatarsal joints. Which of the following is the most appropriate definitive management for the medial columns?

. Non-weight-bearing cast immobilization for 8 weeks
. Closed reduction and percutaneous pinning
. Open reduction and internal fixation with transarticular screws
. Primary arthrodesis of the first, second, and third tarsometatarsal joints
. Open reduction and internal fixation with dorsal bridge plating

Correct Answer & Explanation

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

Explanation

Current evidence demonstrates that pure ligamentous Lisfranc injuries have better functional outcomes and lower reoperation rates when treated with primary arthrodesis of the medial three rays compared to open reduction and internal fixation.

Question 840

Topic: 8. Foot and Ankle

According to the Lauge-Hansen classification, which structure is the first to be injured in a Supination-External Rotation (SER) ankle fracture?

. Anterior inferior tibiofibular ligament (AITFL)
. Posterior inferior tibiofibular ligament (PITFL)
. Lateral malleolus (short oblique fracture)
. Deltoid ligament
. Interosseous membrane

Correct Answer & Explanation

. Anterior inferior tibiofibular ligament (AITFL)

Explanation

In an SER injury, the sequence begins anteriorly and progresses clockwise. Stage I is a rupture of the anterior inferior tibiofibular ligament (AITFL).

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