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 1001
Topic: 8. Foot and Ankle
A patient with a distal third tibia fracture heals with a 12-degree valgus malunion. If left untreated, this malalignment most predictably leads to which of the following long-term complications?
Correct Answer & Explanation
. Lateral compartment ankle osteoarthritis.
Explanation
A valgus malunion of the distal tibia shifts the mechanical axis laterally. This alters the contact stresses within the ankle joint, predictably overloading the lateral structures and leading to lateral compartment ankle osteoarthritis.
Question 1002
Topic: 8. Foot and Ankle
A 42-year-old manual worker presents with chronic left ankle pain following a fracture 7 years prior, which was managed non-operatively. An AP weightbearing radiograph is obtained.
Based on the provided image and the candidate's initial description, which of the following is the most accurate radiographic interpretation?
Correct Answer & Explanation
. Joint space narrowing, subchondral sclerosis, previous fibula fracture superior to the syndesmosis, and varus angulation.
Explanation
Correct Answer: CThe candidate's description of the radiograph explicitly states: 'This is an AP weightbearing radiograph of a left ankle showing narrowing of the joint space and some subchondral sclerosis consistent with post-traumatic arthritis. There is evidence of a previous fibula fracture superior to the syndesmosis and varus angulation of the ankle.' This directly matches option C.Option A is incorrect as the description does not mention a trimalleolar fracture malunion or subtalar arthritis. Option B is incorrect as medial clear space widening is not noted; rather, varus angulation is described. Option D is incorrect as avascular necrosis of the talar dome and valgus deformity are not mentioned in the description. Option E is incorrect as the findings are consistent with post-traumatic arthritis, not inflammatory arthritis, and diffuse osteopenia or erosions are not described.
Question 1003
Topic: 8. Foot and Ankle
A 55-year-old patient is diagnosed with end-stage ankle arthritis. During counseling, the physician discusses the most common etiologies.
According to the provided case, which of the following is considered the most common cause of end-stage ankle arthritis?
Correct Answer & Explanation
. Post-traumatic arthritis
Explanation
Correct Answer: DThe case explicitly states: 'Primary osteoarthritis is thought to be relatively uncommon and the most common cause of ankle arthritis is probably post-traumatic arthritis. Other causes are inflammatory arthritis and septic arthritis.' Therefore, post-traumatic arthritis is the most common cause.Option A is incorrect because primary osteoarthritis is noted as relatively uncommon. Options B and C are incorrect as inflammatory and septic arthritis are listed as 'other causes' but not the most common. Option E, avascular necrosis of the talus, is a potential cause of ankle arthritis but is not listed in the case as one of the most common etiologies.
Question 1004
Topic: 8. Foot and Ankle
A 68-year-old low-demand patient with ankle arthritis is initiating conservative management. The patient has failed NSAIDs and activity modification. All of the following conservative management strategies are mentioned in the case as potentially beneficial for ankle arthritis, except:
Correct Answer & Explanation
. Footwear modification with a cushioned sole and rocker-bottom shoe
Explanation
The case discusses several conservative measures: 'optimize the patient’s analgesia adding in NSAIDs, and suggest activity modification. He could try footwear modification with a cushioned sole and rocker-bottom shoe which may improve his symptoms as may use of an ankle brace or AFO. Similarly an injection of intra-articular steroid or viscosupplementation may be of symptomatic benefit. Physiotherapy could be an adjunctive treatment in patients with symptoms of instability or weakness but may aggravate symptoms.' Long-term oral corticosteroids are not mentioned as a conservative management strategy for ankle arthritis in this context. Options A, B, C, and D are all explicitly mentioned as potential conservative treatments in the case.
Question 1005
Topic: 8. Foot and Ankle
A 35-year-old active patient with symptomatic ankle arthritis, not yet ready for definitive surgical treatment, is exploring options to 'buy time' before considering fusion or replacement.
Which of the following surgical options is described in the case as a temporizing measure for ankle arthritis?
Correct Answer & Explanation
. Distraction arthroplasty
Explanation
Correct Answer: CThe case clearly categorizes surgical options into 'temporizing measures' and 'definitive treatments'. It states: 'The temporizing measures are debridement of the joint which can be performed arthroscopically or open... The other option is distraction arthroplasty.' Therefore, distraction arthroplasty is a temporizing measure.Options A (Total ankle replacement) and B (Ankle arthrodesis) are described as 'definitive surgical options.' Options D (Supramalleolar osteotomy) and E (Subtalar fusion) are not mentioned in the case as either temporizing or definitive treatments for ankle arthritis.
Question 1006
Topic: 8. Foot and Ankle
The 42-year-old manual worker from the case, with post-traumatic ankle arthritis and varus angulation, insists on a total ankle replacement (TAR) despite being advised against it.
Based on the case discussion, which of the following is the primary contraindication for total ankle replacement in this specific patient?
Correct Answer & Explanation
. Manual worker and young age
Explanation
Correct Answer: CThe examiner specifically asks about the 42-year-old patient wanting an ankle replacement, and the candidate responds: 'He is a young patient, in a manual job. He wouldn’t be a candidate for total ankle replacement and I would explain to him that if his symptoms have failed to be controlled by non-operative measures and he requires definitive surgical treatment then an ankle fusion would be a better option for him.' This clearly identifies his young age and high-demand occupation as the primary contraindications.While varus angulation (Option B) is a contraindication if significant (>10 degrees), the case highlights the patient's age and activity level as the primary reasons for not being a candidate. A previous fibula fracture (Option A) and subchondral sclerosis (Option D) are findings associated with his post-traumatic arthritis but are not listed as primary contraindications for TAR in the same way age and activity level are. Option E is irrelevant to the surgical decision-making for this patient.
Question 1007
Topic: 8. Foot and Ankle
A patient with end-stage ankle arthritis is undergoing ankle arthrodesis.
According to the case, what is the ideal position for ankle fusion?
Correct Answer: BThe case explicitly states the ideal position for ankle fusion: 'The foot should be plantigrade with a physiological 5 of hindfoot valgus and 5 of external rotation.'Options A, C, D, and E describe various other positions that do not match the specific recommendations provided in the case for optimal ankle fusion.
Question 1008
Topic: 8. Foot and Ankle
A surgeon is discussing the evolution of total ankle replacement (TAR) designs with a resident.
The case mentions that most modern total ankle replacement designs are characterized by which of the following features?
Correct Answer: BThe case states: 'The earlier designs involved a two-component design such as the Agility total ankle replacement, which required fusion of the distal tibiofibular joint. Most modern designs are three-component uncemented mobile bearing prostheses.' This directly describes option B.Option A describes older, less common features. Option C describes earlier designs like the Agility, but not 'most modern designs.' Options D and E do not accurately reflect the description of modern TAR designs provided in the case.
Question 1009
Topic: 8. Foot and Ankle
A 45-year-old active patient with post-traumatic ankle arthritis, similar to the case patient, desires a total ankle replacement to maintain activity levels and avoid a stiff ankle, despite being counseled against it.
In this scenario, what is the most appropriate advice to give the patient regarding ankle fusion, as per the case?
Correct Answer & Explanation
. Ankle fusion provides a stable, pain-free ankle, allowing return to many activities, and preserves subtalar, midfoot, and forefoot movements.
Explanation
Correct Answer: CWhen the examiner presses the candidate about the patient still wanting a replacement to get back to hill walking and sports, the candidate explains: 'A fusion would provide a stable pain-free ankle that would allow him to return to the majority of activities that he wishes to do. I would explain that many patients return to sports after ankle fusion. I would also explain that an ankle fusion would only sacrifice the residual movement that he has at his ankle joint and that his subtalar, midfoot and forefoot movements would still be present.' This comprehensive explanation aligns perfectly with option C.Option A is incorrect because the case explicitly states that subtalar, midfoot, and forefoot movements are preserved, and many patients return to sports. Option B is incorrect as the case states fusion is still considered the 'gold standard' and is not outdated for all patients. Option D is incorrect as the case suggests fusion is suitable for active patients like the manual worker. Option E is incorrect; while adjacent joint arthritis is a known complication of fusion, the case does not state it's a higher risk than TAR, and the overall tone is that fusion is a better option for this patient.
Question 1010
Topic: 8. Foot and Ankle
Following a total knee arthroplasty for a severe valgus deformity, a 72-year-old patient experiences new-onset foot drop and numbness along the dorsum of the foot. Which of the following nerves is most likely affected?
Correct Answer & Explanation
. Option D: Peroneal nerve
Explanation
Correct Answer: DThe case explicitly warns: 'With correction of significant valgus deformity, one has to watch for peroneal nerve palsy in the postoperative period.' Foot drop and numbness along the dorsum of the foot are classic symptoms of peroneal nerve palsy, which can occur due to traction injury during significant valgus correction.Option A (Femoral nerve) is incorrect. Femoral nerve injury typically presents with quadriceps weakness and sensory loss over the anterior thigh and medial leg, not foot drop.Option B (Saphenous nerve) is incorrect. Saphenous nerve injury causes sensory loss along the medial aspect of the leg and foot, without motor deficits like foot drop.Option C (Tibial nerve) is incorrect. Tibial nerve injury typically affects plantarflexion and sensation on the sole of the foot, not dorsiflexion or sensation on the dorsum.Option E (Obturator nerve) is incorrect. Obturator nerve injury affects adduction of the thigh and sensation over the medial thigh, which is unrelated to foot drop.
Question 1011
Topic: 8. Foot and Ankle
A 65-year-old female presents with bilateral foot pain. The examiner provides the following clinical image of her feet.
Based on the provided image and the initial candidate's observations, which of the following is the MOST accurate initial observation regarding the patient's right foot?
Correct Answer & Explanation
. Hallux valgus with the hallux overriding the second toe.
Explanation
Correct Answer: CThe candidate's initial observation states, 'There is hallux valgus with the hallux over-riding the second toes.' The provided image (Figure 4.7, AP view) clearly depicts hallux valgus on the right foot, where the great toe is deviated laterally and appears to override the second toe. The case mentions the absence of the second toe on theleftfoot, not the right. Hallux varus is a medial deviation of the great toe, which is contrary to the image. Scars and specific surgical evidence are not definitively identifiable for the right foot from this initial clinical image alone.
Question 1012
Topic: 8. Foot and Ankle
A 65-year-old female presents with hallux valgus. The examiner asks about the value of plain radiographs. The candidate states they would measure the intermetatarsal angle (IMA), hallux valgus angle (HVA), and distal metatarsal articular angle (DMAA).
Which of the following represents the correct normal range for these angles as stated in the case?
Correct Answer & Explanation
. IMA < 9°, HVA < 15°, DMAA max 15°
Explanation
Correct Answer: BThe case explicitly states the normal ranges for these angles: 'The intermetatarsal angle is normally less than 9. The hallux valgus angle should be less than 15. The distal metatarsal articular angle is normally a maximum of 15 from perpendicular to the axis of the first metatarsal.' Therefore, option B accurately reflects these normal values.
Question 1013
Topic: Forefoot
The 65-year-old lady presents with a right foot deformity characterized by an intermetatarsal angle (IMA) of 15 degrees, a hallux valgus angle (HVA) of 35 degrees, and minimal passive correction of the hallux. Her first tarsometatarsal (TMT) joint is assessed as normal.
Based on these findings and the candidate's proposed management, which surgical approach would be MOST appropriate for her right foot?
Correct Answer & Explanation
. Scarf osteotomy with lateral release and possible Akin osteotomy.
Explanation
Correct Answer: CThe examiner presents a specific scenario: 'If this lady had an intermetatarsal angle of 15 on the right with a hallux valgus angle of 35 and minimal passive correction of the hallux, what surgery would you plan?' The candidate responds: 'If the first tarsometatarsal joint is normal, I would plan a scarf osteotomy combined with a lateral release and an Akin osteotomy of the proximal phalanx if necessary.' This directly matches option C. Chevron and Mitchell osteotomies are typically for less severe deformities or have disadvantages like shortening, as discussed later in the case. Arthrodesis is usually reserved for severe arthrosis or recurrent cases, especially with missing toes, and Keller is a salvage procedure.
Question 1014
Topic: 8. Foot and Ankle
Following the decision to perform a Scarf osteotomy for the patient's right foot, the examiner asks the candidate to justify this choice over simpler procedures.
Which of the following is a key advantage of the Scarf osteotomy, as described by the candidate, that makes it suitable for this patient's deformity?
Correct Answer & Explanation
. It provides stable fixation allowing early postoperative mobilization without a cast and offers versatility in correction.
Explanation
Correct Answer: CWhen asked 'Why would you choose a scarf osteotomy?', the candidate replies: 'It is a very versatile procedure with stable fixation allowing postoperative mobilization without a cast. It maintains length of the metatarsal but allows translation, angulation and depression of the metatarsal head as necessary.' This statement directly supports option C, highlighting stable fixation, early mobilization, and versatility. Options A and D are incorrect as Scarf is for moderate to severe deformities and is not necessarily 'simpler' than distal osteotomies. Option B is incorrect as Scarf maintains length or can even lengthen, unlike Mitchell. Option E is incorrect as arthrodesis is preferred for significant MTP arthritic change.
Question 1015
Topic: 8. Foot and Ankle
During the discussion of complications, the examiner specifically asks about the treatment of hallux varus, which is a potential complication of hallux valgus surgery.
According to the candidate, what is a reliable surgical option for hallux varus in the presence of significant stiffness or arthrosis?
Correct Answer & Explanation
. Arthrodesis of the first MTP joint.
Explanation
Correct Answer: CThe candidate states: 'Whilst soft tissue procedures such as abductor hallucis and medial capsular release or transfer of a slip of EHL are described for flexible deformity, arthrodesis of the first MTP joint is a reliable option in the presence of significant stiffness or arthrosis.' This directly identifies MTP joint arthrodesis as the reliable option for stiff or arthritic hallux varus. Other options are either not mentioned or are inappropriate for this specific indication.
Question 1016
Topic: 8. Foot and Ankle
After successfully treating the patient's right foot, the examiner asks if the same procedure would be performed on the left foot, given its presentation. The oblique view of the left foot is provided.
Considering the patient's left foot, as depicted in the image and described in the case (specifically the prior surgery), what is the MOST appropriate surgical plan for the hallux valgus recurrence?
Correct Answer & Explanation
. First MTP joint arthrodesis.
Explanation
Correct Answer: CThe examiner asks: 'So you have successfully treated this lady’s right foot and she is pleased with the result. Would you go ahead and do the same on the left?' The candidate responds: 'No. The absence of the second toe predisposes to recurrence and I would propose arthrodesis of the hallux MTP joint.' The image (Figure 4.8, oblique view) shows the left foot, which, as noted in the initial clinical description, has only three lesser toes due to the prior removal of the second toe. This unique anatomical situation on the left foot, predisposing to recurrence, makes MTP joint arthrodesis the preferred and most reliable option for long-term stability.
Question 1017
Topic: 8. Foot and Ankle
The examiner asks the candidate to describe their further assessment of the patient, beyond initial observations. The candidate outlines a comprehensive physical examination.
Which of the following is NOT a component of the physical examination specifically mentioned by the candidate for this patient?
Correct Answer & Explanation
. Measurement of ankle-brachial index (ABI).
Explanation
Correct Answer: CThe candidate details the physical examination: 'I would palpate for areas of tenderness, paying particular attention to the hallux MTP joint and lesser metatarsal heads. I would assess the degree of active and passive correction possible and the range of movement of the involved joints and look for gastrocnemius tightness. I would also perform a grind test to assess pain from loading the MTP joint. Neurovascular status must also be assessed.' While 'Neurovascular status must also be assessed' is mentioned, the specific 'Measurement of ankle-brachial index (ABI)' is not explicitly stated as part of the physical examination components by the candidate. All other options are directly mentioned.
Question 1018
Topic: 8. Foot and Ankle
The examiner challenges the candidate on why a simpler procedure like a Chevron or Mitchell osteotomy would not be chosen for the described deformity (IMA 15°, HVA 35°, minimal passive correction).
According to the candidate, what is a significant disadvantage of a Mitchell osteotomy for this patient's specific deformity?
Correct Answer & Explanation
. It produces shortening of the first metatarsal, potentially leading to transfer metatarsalgia.
Explanation
Correct Answer: CWhen asked 'Why not use a simpler procedure such as a chevron or Mitchell osteotomy?', the candidate responds: 'For the degree of deformity described, combined with the lack of passive correction of the hallux, I believe the correction that could be achieved with a distal osteotomy would be inadequate. A further disadvantage of a Mitchell osteotomy is that it produces shortening of the first metatarsal, which could lead to transfer metatarsalgia.' This statement directly supports option C as a significant disadvantage of the Mitchell osteotomy.
Question 1019
Topic: 8. Foot and Ankle
The examiner presents the clinical photographs (Figures 4.7 and 4.8) and asks the candidate to describe what they see.
Based on the candidate's initial description of the clinical photographs, which of the following observations is made regarding the patient's left foot?
Correct Answer & Explanation
. Only three lesser toes are visible, and there is a scar in the webspace lateral to the hallux.
Explanation
Correct Answer: CThe candidate's initial description of the clinical photographs (Figures 4.7 and 4.8) includes: 'I can only count three lesser toes on the left foot and there is a scar in the webspace lateral to the hallux.' This observation is clearly visible in the images, particularly Figure 4.8 (oblique view of the left foot), which shows the absence of the second toe and a scar. The case later confirms that the left second toe was removed years ago. Options A, B, D, and E are either inaccurate or not explicitly stated as initial observations for the left foot.
Question 1020
Topic: 8. Foot and Ankle
A 50-year-old manual laborer is undergoing an isolated tibiotalar arthrodesis for post-traumatic osteoarthritis. To optimize post-operative gait and minimize adjacent joint stress, what is the ideal alignment for the arthrodesis?
The optimal position for ankle arthrodesis is neutral dorsiflexion, 0 to 5 degrees of valgus, and 5 to 10 degrees of external rotation. This alignment best approximates normal gait mechanics and limits compensatory stress on the midfoot and subtalar joints.
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