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8. Foot and Ankle MCQs

Practice Set 55 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 1081

Topic: 8. Foot and Ankle

A 7-year-old boy with Duchenne Muscular Dystrophy presents with a toe-walking gait. Clinical examination reveals 15 degrees of ankle equinus and intact passive knee extension. What is the primary biomechanical reason for equinus posturing during ambulation in early DMD?

. Primary contracture of the anterior tibialis
. Compensation for hip flexor weakness
. Compensation for progressive quadriceps weakness to maintain the knee in extension
. Secondary to isolated Achilles tendon tightness from a primary fascial defect
. Spasticity of the gastrocnemius-soleus complex

Correct Answer & Explanation

. Compensation for progressive quadriceps weakness to maintain the knee in extension

Explanation

In DMD, toe walking is initially a compensatory mechanism to keep the ground reaction force anterior to the knee. This locks the knee in extension and compensates for progressive quadriceps weakness.

Question 1082

Topic: 8. Foot and Ankle

An 11-year-old boy with Duchenne Muscular Dystrophy (DMD) is undergoing a fractional lengthening of his Achilles tendons. During induction of anesthesia, the anesthesiologist avoids the use of succinylcholine. Which of the following is the primary physiological reason for this contraindication?

. It induces severe intraoperative hypotension.
. It causes an unpredictable prolongation of neuromuscular blockade.
. It binds to acetylcholine receptors causing fatal anaphylaxis.
. It triggers massive extracellular potassium release leading to cardiac arrest.
. It precipitates acute hepatic failure due to abnormal metabolism.

Correct Answer & Explanation

. It triggers massive extracellular potassium release leading to cardiac arrest.

Explanation

Succinylcholine is contraindicated in patients with myopathies like DMD due to the upregulation of extrajunctional acetylcholine receptors. Depolarization by succinylcholine leads to massive potassium efflux, resulting in life-threatening hyperkalemia and cardiac arrest.

Question 1083

Topic: 8. Foot and Ankle

An 8-year-old ambulatory boy with Duchenne Muscular Dystrophy is evaluated in the clinic. His parents note he walks with an increasingly pronounced lumbar lordosis. This altered posture is primarily a compensatory mechanism for bilateral weakness in which of the following muscle groups?

. Hip extensors (Gluteus maximus)
. Hip flexors (Iliopsoas)
. Ankle plantarflexors (Gastrocnemius-soleus)
. Knee extensors (Quadriceps)
. Hip abductors (Gluteus medius)

Correct Answer & Explanation

. Hip extensors (Gluteus maximus)

Explanation

In early DMD, patients develop a hyperlordotic posture to keep their center of gravity posterior to the hip joint. This mechanically compensates for progressive weakness of the gluteus maximus (hip extensors).

Question 1084

Topic: 8. Foot and Ankle

A 26-year-old marathon runner is diagnosed with Chronic Exertional Compartment Syndrome strictly localized to the anterior compartment of the leg. During a severe symptomatic episode, which of the following physical examination findings is most likely to be present?

. Numbness over the lateral aspect of the foot
. Numbness in the first dorsal web space of the foot
. Weakness in active ankle plantarflexion
. Absent dorsalis pedis pulse
. Loss of the Achilles tendon reflex

Correct Answer & Explanation

. Numbness in the first dorsal web space of the foot

Explanation

The deep peroneal nerve runs within the anterior compartment of the leg. Elevated pressures in this compartment during exercise can compress the nerve, leading to paresthesias or numbness in its sensory distribution: the first dorsal web space.

Question 1085

Topic: 8. Foot and Ankle

A 10-year-old boy with Duchenne muscular dystrophy is scheduled for Achilles tendon lengthening. Which of the following anesthetic agents must be strictly avoided to prevent life-threatening hyperkalemia and rhabdomyolysis?

. Propofol
. Ketamine
. Succinylcholine
. Fentanyl
. Nitrous oxide

Correct Answer & Explanation

. Succinylcholine

Explanation

Succinylcholine, a depolarizing neuromuscular blocker, is strictly contraindicated in patients with DMD due to the risk of severe rhabdomyolysis and life-threatening hyperkalemia, which can cause sudden cardiac arrest.

Question 1086

Topic: 8. Foot and Ankle

In an ambulatory 8-year-old boy with Duchenne muscular dystrophy, which of the following lower extremity contracture patterns most commonly develops first?

. Knee extension and ankle dorsiflexion
. Hip extension and knee flexion
. Hip flexion, knee flexion, and ankle equinus
. Hip abduction and ankle valgus
. Knee valgus and ankle calcaneus

Correct Answer & Explanation

. Hip flexion, knee flexion, and ankle equinus

Explanation

Ambulatory DMD patients typically develop progressive hip flexion, knee flexion, and ankle equinus contractures. They compensate biomechanically with an increased lumbar lordosis and toe walking.

Question 1087

Topic: 8. Foot and Ankle

The Lisfranc ligament is a critical stabilizing structure of the midfoot that prevents lateral displacement of the lesser metatarsals. Which two osseous structures does the primary intra-articular component of this ligament connect?

. Medial cuneiform and second metatarsal base
. Middle cuneiform and second metatarsal base
. Medial cuneiform and first metatarsal base
. Navicular and medial cuneiform
. Cuboid and fourth metatarsal base

Correct Answer & Explanation

. Medial cuneiform and second metatarsal base

Explanation

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

Question 1088

Topic: 8. Foot and Ankle

Current evidence suggests that managing acute Achilles tendon ruptures non-operatively with an early functional rehabilitation protocol, compared to surgical repair, results in:

. Higher deep infection rates
. Lower rates of return to sport
. Significantly higher re-rupture rates but lower wound complications
. Similar re-rupture rates and lower wound complications
. Higher incidence of sural nerve neuroma

Correct Answer & Explanation

. Similar re-rupture rates and lower wound complications

Explanation

Recent high-quality studies show that early functional rehabilitation combined with non-operative management yields re-rupture rates similar to operative repair. However, surgical management carries a notably higher risk of wound healing complications and infections.

Question 1089

Topic: 8. Foot and Ankle

A "fleck sign" observed on an anteroposterior radiograph of a trauma patient's foot is highly suggestive of a Lisfranc injury. This osseous fragment typically represents an avulsion from which anatomical location?

. Lateral aspect of the medial cuneiform
. Medial aspect of the base of the second metatarsal
. Lateral aspect of the base of the second metatarsal
. Medial aspect of the middle cuneiform
. Plantar aspect of the cuboid

Correct Answer & Explanation

. Medial aspect of the base of the second metatarsal

Explanation

The "fleck sign" represents a bony avulsion of the Lisfranc ligament. While the ligament spans from the lateral aspect of the medial cuneiform to the medial base of the second metatarsal, the avulsion fracture almost universally occurs at the medial base of the second metatarsal.

Question 1090

Topic: 8. Foot and Ankle

A 24-year-old sustains a Lisfranc fracture-dislocation with lateral displacement of the 2nd through 5th metatarsals. Which structure is the primary stabilizing ligament of the normal Lisfranc joint complex?

. Dorsal ligament from the first cuneiform to the second metatarsal base
. Interosseous ligament from the medial cuneiform to the second metatarsal base
. Plantar ligament from the medial cuneiform to the first metatarsal base
. Transverse metatarsal ligament between the first and second metatarsal heads
. Spring ligament

Correct Answer & Explanation

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

Explanation

The Lisfranc ligament is the strongest and primary stabilizer of the midfoot, traveling from the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. There is no direct transverse ligamentous connection between the bases of the first and second metatarsals.

Question 1091

Topic: 8. Foot and Ankle

A 22-year-old football player sustains a midfoot injury. Radiographs show a "fleck sign" in the first intermetatarsal space. The disrupted ligament primarily connects which two anatomical structures?

. Medial cuneiform and second metatarsal base
. Medial cuneiform and first metatarsal base
. Middle cuneiform and second metatarsal base
. Lateral cuneiform and third metatarsal base
. Navicular and medial cuneiform

Correct Answer & Explanation

. Medial cuneiform and 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. The "fleck sign" represents a bony avulsion of this ligament.

Question 1092

Topic: Midfoot & Hindfoot

A 55-year-old diabetic patient presents with a swollen, erythematous, but painless foot. Radiographs show extensive bone fragmentation, joint subluxation, and debris. According to the Eichenholtz classification for Charcot arthropathy, which stage does this represent?

. Stage 0
. Stage 1
. Stage 2
. Stage 3
. Stage 4

Correct Answer & Explanation

. Stage 1

Explanation

Eichenholtz Stage 1 (Developmental/Fragmentation) of Charcot arthropathy is characterized clinically by a hot, swollen foot and radiographically by bone fragmentation, joint subluxation, and debris. Stage 2 is coalescence, and Stage 3 is consolidation.

Question 1093

Topic: 8. Foot and Ankle

During the initial inspection of a patient with rheumatoid arthritis presenting with foot pain, which of the following findings MOST reliably suggests active synovitis rather than fixed deformity?

. Fixed hallux valgus deformity
. Prominent bunionette deformity
. Warmth and erythema over the metatarsophalangeal joints
. Diffuse callosities on the plantar forefoot
. Subluxation of the lesser MTP joints with dorsal displacement

Correct Answer & Explanation

. Warmth and erythema over the metatarsophalangeal joints

Explanation

Correct Answer: CWarmth and erythema are cardinal signs of acute inflammation, indicative of active synovitis. Fixed hallux valgus, bunionette deformity, callosities, and MTPJ subluxation/dislocation are all consequences of chronic rheumatoid disease and represent fixed deformities or secondary skin changes, not necessarily active inflammation at the time of examination.

Question 1094

Topic: 8. Foot and Ankle

When performing a detailed palpation of the rheumatoid forefoot, which anatomical landmark is crucial for identifying early MTP joint synovitis, particularly in the lesser toes?

. The head of the first metatarsal
. The base of the fifth metatarsal
. The web spaces between the toes
. The dorsal aspect of the MTP joint capsule
. The plantar aspect of the MTP joint capsule

Correct Answer & Explanation

. The plantar aspect of the MTP joint capsule

Explanation

Correct Answer: EThe plantar aspect of the MTP joint capsule is often the most sensitive area for detecting early synovitis in the lesser toes. The synovium typically expands inferiorly, and gentle palpation with two fingers, one dorsally and one plantarly, can elicit tenderness and reveal a boggy sensation indicative of inflammation. Dorsal palpation can also be useful, but the plantar side often presents earlier and more prominently.

Question 1095

Topic: 8. Foot and Ankle

A patient with advanced rheumatoid arthritis presents with a severe forefoot deformity. On examination, you observe a 'telescoping' of the toes. This finding is MOST consistent with:

. Early hallux valgus deformity
. Lesser toe hammer toes
. Plantar fat pad migration
. Complete MTP joint dislocation with phalangeal overriding
. Flexible claw toe deformity

Correct Answer & Explanation

. Complete MTP joint dislocation with phalangeal overriding

Explanation

Correct Answer: D'Telescoping' of the toes, where the proximal phalanx appears to shorten into the metatarsal, is a classic sign of complete MTP joint dislocation with dorsal subluxation or dislocation of the phalanx relative to the metatarsal head. This leads to the characteristic 'cock-up' deformity and often involves the lesser toes. Plantar fat pad migration is a related but distinct consequence, and the other options describe less severe or different deformities.

Question 1096

Topic: 8. Foot and Ankle

During a gait assessment of a rheumatoid patient, you observe a 'toe-off' phase that is significantly limited or absent. This finding is MOST directly attributable to:

. Midfoot pronation leading to arch collapse
. Ankle equinus contracture
. Hindfoot valgus deformity
. Painful and stiff MTP joints, particularly the first MTP joint
. Subtalar joint arthritis

Correct Answer & Explanation

. Painful and stiff MTP joints, particularly the first MTP joint

Explanation

Correct Answer: DThe 'toe-off' phase of gait primarily relies on the push-off power generated by the MTP joints, especially the first MTP joint (hallux). Pain, stiffness, and deformity (e.g., hallux rigidus or MTP subluxation/dislocation) in these joints severely impair the ability to properly perform toe-off, leading to a propulsive gait pattern often described as an 'apathetic' or 'shuffle' gait. While other deformities can affect gait, this specific limitation points directly to forefoot pathology.

Question 1097

Topic: Midfoot & Hindfoot

Which of the following physical examination maneuvers is BEST for assessing the flexibility of a pes planovalgus deformity in a patient with rheumatoid arthritis?

. Checking the 'too many toes' sign while weightbearing
. Performing the Tarsal Tunnel compression test
. Observing the arch height while standing on toes (Jack's test equivalent)
. Palpating for tenderness over the posterior tibial tendon insertion
. Assessing subtalar joint range of motion in non-weightbearing

Correct Answer & Explanation

. Observing the arch height while standing on toes (Jack's test equivalent)

Explanation

Correct Answer: CObserving the arch height while standing on toes (a modification of the Jack's test or heel-rise test) is the most effective way to assess the flexibility of a pes planovalgus deformity. If the arch reconstitutes or significantly improves with a single heel-rise, the deformity is largely flexible. If the arch remains collapsed, it indicates a rigid deformity, which has significant implications for treatment planning. The 'too many toes' sign indicates hindfoot valgus but not flexibility. Tarsal Tunnel test is for nerve compression. Palpation of the posterior tibial tendon assesses tendon integrity but not overall arch flexibility.

Question 1098

Topic: 8. Foot and Ankle

A 55-year-old female with long-standing rheumatoid arthritis presents with chronic forefoot pain and difficulty wearing shoes. On examination, you note diffuse callosities under the metatarsal heads and migration of the plantar fat pad anteriorly. This fat pad migration primarily contributes to her symptoms by:

. Increasing the rigidity of her lesser toe deformities
. Exacerbating hallux valgus progression
. Reducing the natural cushioning under the metatarsal heads, leading to increased pressure
. Compressing the interdigital nerves, causing neuroma formation
. Impacting the stability of the ankle joint

Correct Answer & Explanation

. Reducing the natural cushioning under the metatarsal heads, leading to increased pressure

Explanation

Correct Answer: CPlantar fat pad migration is a common finding in advanced rheumatoid forefoot disease. As the MTP joints subluxate dorsally, the protective fat pad, which normally provides cushioning under the metatarsal heads, migrates distally, exposing the metatarsal heads directly to the ground during weightbearing. This loss of natural cushioning leads to significantly increased pressure, pain, and secondary callosity formation, which are major contributors to the patient's symptoms.

Question 1099

Topic: 8. Foot and Ankle

When examining the midfoot of a rheumatoid patient, persistent tenderness and swelling over the talonavicular joint, even without a significant pes planovalgus deformity, should raise suspicion for:

. Achilles tendinopathy
. Peroneal tendon pathology
. Early midfoot arthritis or synovitis
. Tarsal tunnel syndrome
. Plantar fasciitis

Correct Answer & Explanation

. Early midfoot arthritis or synovitis

Explanation

Correct Answer: CThe talonavicular joint is a key component of the midfoot and is frequently involved early in rheumatoid arthritis. Persistent tenderness and swelling directly over this joint are strong indicators of active synovitis or early arthritic changes. While other conditions can cause midfoot pain, localized tenderness and swelling specifically at the talonavicular joint points to its direct involvement. Achilles tendinopathy affects the hindfoot, peroneal tendon pathology is more lateral, tarsal tunnel syndrome involves nerve compression, and plantar fasciitis typically causes heel pain.

Question 1100

Topic: 8. Foot and Ankle

A 'pump bump' or Haglund's deformity is a bony prominence on the posterior calcaneus. In a rheumatoid patient, a similar posterior heel prominence associated with inflammation and tenderness suggests:

. Primary Achilles tendinosis
. Retrocalcaneal bursitis
. Plantar fasciitis insertionopathy
. Calcaneal stress fracture
. Subtalar joint arthritis

Correct Answer & Explanation

. Retrocalcaneal bursitis

Explanation

Correct Answer: BRetrocalcaneal bursitis is a common inflammatory condition in rheumatoid arthritis, characterized by inflammation of the bursa located between the Achilles tendon and the superior aspect of the calcaneus. This can cause pain, swelling, and tenderness at the posterior heel, mimicking aspects of a 'pump bump' but due to inflammation rather than purely bony prominence. While Achilles tendinosis can coexist, the inflammation points specifically to bursitis.

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