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8. Foot and Ankle MCQs

Practice Set 56 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 1101

Topic: 8. Foot and Ankle

Which of the following statements regarding the assessment of the rheumatoid hindfoot is TRUE?

. Subtalar joint motion is primarily responsible for dorsiflexion and plantarflexion.
. The 'too many toes' sign specifically indicates forefoot abduction.
. Hindfoot valgus is less common than varus deformity in rheumatoid arthritis.
. Fixed hindfoot valgus can be effectively assessed by observing the heel in relation to the lower leg from posterior view while weightbearing.
. Ankle joint involvement is rare in patients with severe rheumatoid foot disease.

Correct Answer & Explanation

. Fixed hindfoot valgus can be effectively assessed by observing the heel in relation to the lower leg from posterior view while weightbearing.

Explanation

Correct Answer: DFixed hindfoot valgus is a common and debilitating deformity in rheumatoid arthritis, often due to collapse of the medial longitudinal arch and subtalar joint involvement. It is best assessed by observing the alignment of the heel relative to the lower leg from a posterior perspective during weightbearing. Subtalar joint motion primarily allows inversion and eversion, not dorsiflexion/plantarflexion (which is ankle motion). The 'too many toes' sign indicates hindfoot valgus (and compensatory forefoot abduction). Hindfoot valgus is more common than varus. Ankle joint involvement, while less frequent than midfoot/forefoot, can occur and significantly impact gait.

Question 1102

Topic: 8. Foot and Ankle

When evaluating a patient with severe rheumatoid forefoot deformity prior to surgical correction, the presence of a 'positive paper test' (unable to slide a thin piece of paper under the metatarsal heads) indicates:

. Flexible MTP joint contractures
. Significant plantar fat pad atrophy
. Fixed MTP joint dorsiflexion deformities or subluxation/dislocation
. Adequate plantar cushioning
. Early stage rheumatoid foot involvement

Correct Answer & Explanation

. Fixed MTP joint dorsiflexion deformities or subluxation/dislocation

Explanation

Correct Answer: CA 'positive paper test' indicates that the metatarsal heads are pressing firmly against the ground due to fixed MTP joint dorsiflexion, subluxation, or dislocation. This means the metatarsal heads are prominent plantarly and bear excessive weight, often leading to pain and callosities. It signifies a fixed deformity that is unlikely to correct with conservative measures and often requires surgical intervention.

Question 1103

Topic: 8. Foot and Ankle

A 35-year-old construction worker sustains a purely ligamentous Lisfranc injury after his foot gets trapped under a heavy object. Which of the following surgical treatments is associated with the best long-term functional outcomes and lowest reoperation rates for this specific injury pattern?

. Closed reduction and percutaneous pinning (CRPP)
. Open reduction and internal fixation (ORIF) with transarticular screws
. Primary partial tarsometatarsal arthrodesis
. Dorsal bridge plating without joint preparation
. Nonoperative management with prolonged cast immobilization

Correct Answer & Explanation

. Primary partial tarsometatarsal arthrodesis

Explanation

Primary arthrodesis of the medial column (1st, 2nd, and 3rd tarsometatarsal joints) is favored over ORIF for purely ligamentous Lisfranc injuries. Studies have shown primary arthrodesis yields better short- and medium-term functional outcomes and significantly lower hardware removal and reoperation rates compared to ORIF in these specific injuries.

Question 1104

Topic: 8. Foot and Ankle

A 55-year-old diabetic patient presents with an erythematous, profoundly swollen, and warm right foot without open ulcerations. Radiographs demonstrate periarticular osteopenia and early fragmentation of the tarsal navicular. Systemic inflammatory markers are normal. What is the most appropriate initial management?

. Intravenous antibiotics and surgical debridement
. Immediate open reduction and internal fixation of the midfoot
. Total contact casting and non-weight-bearing
. Prescription of custom accommodative orthotics
. Below-knee amputation

Correct Answer & Explanation

. Total contact casting and non-weight-bearing

Explanation

This patient is presenting with acute Stage I (fragmentation stage) Eichenholtz Charcot arthropathy. The mainstay of treatment in the acute, active phase of Charcot arthropathy is strict immobilization and offloading. Total contact casting is the gold standard to prevent further deformity and progression until the foot consolidates.

Question 1105

Topic: 8. Foot and Ankle
A 28-year-old male sustains a high-energy knee dislocation (Schenck KD III). In the emergency department, his foot is pulseless. After prompt closed reduction of the knee, his dorsalis pedis pulse returns, but his Ankle-Brachial Index (ABI) is 0.8. What is the most critical next step in management?
. Discharge with a knee immobilizer and close outpatient follow-up
. Immediate multi-ligament knee reconstruction
. Observation and repeat ABI in 24 hours
. CT angiography of the lower extremity
. Fasciotomy of the lower leg

Correct Answer & Explanation

. CT angiography of the lower extremity

Explanation

An Ankle-Brachial Index (ABI) less than 0.9 after a knee dislocation is highly suspicious for a vascular injury, even if pulses are palpable. A CT angiogram is the most appropriate next step to rule out a popliteal artery intimal tear or occlusion, which occurs in up to 18% of knee dislocations.

Question 1106

Topic: 8. Foot and Ankle

When comparing operative versus nonoperative management of acute Achilles tendon ruptures, modern literature indicates which of the following regarding functional rehabilitation protocols?

. Operative treatment has a significantly lower re-rupture rate even when early functional rehabilitation is used in the nonoperative group.
. Nonoperative treatment with early functional rehabilitation results in similar re-rupture rates compared to operative treatment.
. Operative treatment is associated with a lower rate of soft-tissue complications and infections.
. Nonoperative treatment guarantees superior plantarflexion strength compared to operative repair.
. Functional rehabilitation requires strict casting in equinus for 8 weeks before weight-bearing.

Correct Answer & Explanation

. Nonoperative treatment with early functional rehabilitation results in similar re-rupture rates compared to operative treatment.

Explanation

High-quality randomized controlled trials (e.g., Willits et al.) have demonstrated that when an early functional rehabilitation protocol is employed, nonoperative management of acute Achilles ruptures yields similar re-rupture rates and functional outcomes compared to operative repair. Operative repair carries a higher risk of wound complications.

Question 1107

Topic: Forefoot

A 45-year-old female presents with a painful bunion. Weight-bearing radiographs reveal a hallux valgus angle (HVA) of 45 degrees and an intermetatarsal angle (IMA) of 18 degrees. Clinical examination demonstrates significant hypermobility of the first tarsometatarsal (TMT) joint. Which surgical procedure is most appropriate?

. Distal chevron osteotomy
. Akin osteotomy alone
. McBride procedure
. Lapidus procedure (first TMT arthrodesis)
. Keller resection arthroplasty

Correct Answer & Explanation

. Lapidus procedure (first TMT arthrodesis)

Explanation

The Lapidus procedure (arthrodesis of the first tarsometatarsal joint) is specifically indicated for patients with moderate to severe hallux valgus (IMA > 15 degrees) accompanied by first TMT joint hypermobility. A distal chevron osteotomy is inadequate for this degree of deformity and does not address the TMT instability.

Question 1108

Topic: 8. Foot and Ankle

A 25-year-old male is 4 months postoperative from open reduction and internal fixation of a Weber C ankle fracture with placement of two cortical syndesmotic screws. The patient is asymptomatic but inquires if the screws must be removed. Based on current orthopedic evidence, what is the best advice regarding routine syndesmotic screw removal?

. Screws must be removed prior to weight-bearing to prevent devastating syndesmotic widening.
. Routine removal is mandatory at 12 weeks to prevent early ankle osteoarthritis.
. Routine removal is not required and does not significantly improve long-term functional outcomes.
. Only broken screws should be removed to prevent foreign body reactions.
. Screws must be removed to restore the medial clear space.

Correct Answer & Explanation

. Routine removal is not required and does not significantly improve long-term functional outcomes.

Explanation

Current literature shows that routine removal of syndesmotic screws is unnecessary. Retained screws, even if they loosen or break, do not lead to inferior functional outcomes compared to routinely removed screws. Removal should generally be reserved for patients who are symptomatic directly over the hardware.

Question 1109

Topic: 8. Foot and Ankle

A 24-year-old female presents with vague midfoot pain and swelling after forcefully plantarflexing her foot when stumbling on a stair. Non-weight-bearing radiographs appear entirely normal. If a subtle Lisfranc injury is suspected, what is the best next diagnostic step?

. Technetium-99m bone scan
. Bilateral weight-bearing radiographs of the feet
. Ultrasound of the midfoot
. Diagnostic injection of the tarsometatarsal joints
. Electromyography (EMG)

Correct Answer & Explanation

. Bilateral weight-bearing radiographs of the feet

Explanation

Weight-bearing radiographs are essential for identifying subtle diastasis in suspected Lisfranc injuries. Stress on the midfoot during weight-bearing helps reveal ligamentous instability that is frequently missed on non-weight-bearing films.

Question 1110

Topic: 8. Foot and Ankle

A 40-year-old male sustains an acute, closed midsubstance Achilles tendon rupture. When discussing operative repair versus functional non-operative management, the patient should be counseled that operative management is classically associated with:

. A lower risk of re-rupture but a higher risk of wound complications
. A higher risk of re-rupture but a lower risk of wound complications
. Superior plantarflexion strength but worse subjective outcome scores
. A higher rate of deep vein thrombosis
. Faster return to activities of daily living without any increased complication risk

Correct Answer & Explanation

. A lower risk of re-rupture but a higher risk of wound complications

Explanation

Historically, operative repair of the Achilles tendon offers a lower rate of re-rupture compared to traditional non-operative casting, but carries a higher risk of soft tissue complications such as infection. Modern functional rehab protocols have made re-rupture rates more comparable.

Question 1111

Topic: Midfoot & Hindfoot
A 55-year-old diabetic male with peripheral neuropathy presents with a deformed, painless, swollen foot. Radiographs display absorption of fine intra-articular debris, early fusion of large fracture fragments, and significant subchondral sclerosis. These findings correspond to which stage of the Eichenholtz classification for Charcot arthropathy?
. Stage I (Development)
. Stage II (Coalescence)
. Stage III (Reconstruction)
. Stage IV (Resolution)
. Stage 0 (High risk)

Correct Answer & Explanation

. Stage II (Coalescence)

Explanation

Eichenholtz Stage II (Coalescence) is characterized radiographically by absorption of fine debris, early fusion of adjacent large fragments, and sclerosis. Stage I features acute fragmentation and dislocation, while Stage III shows remodeling and rounded bone ends.

Question 1112

Topic: Ankle Trauma & Sports

During a Weber C ankle fracture, the distal tibiofibular syndesmosis is disrupted. Which of the following ligaments provides the greatest percentage of resistance against lateral displacement of the fibula?

. Anterior inferior tibiofibular ligament (AITFL)
. Posterior inferior tibiofibular ligament (PITFL)
. Interosseous ligament
. Anterior talofibular ligament
. Calcaneofibular ligament

Correct Answer & Explanation

. Posterior inferior tibiofibular ligament (PITFL)

Explanation

The posterior inferior tibiofibular ligament (PITFL) is the strongest component of the syndesmotic complex, providing approximately 42% of the resistance to lateral fibular displacement. The AITFL is the most commonly torn but provides less overall strength (approx. 35%).

Question 1113

Topic: Forefoot

A 40-year-old female presents with a painful bunion. Radiographs demonstrate a hallux valgus angle (HVA) of 26 degrees and an intermetatarsal angle (IMA) of 11 degrees. The first tarsometatarsal joint is stable without hypermobility. Which of the following is the most appropriate surgical option?

. First metatarsophalangeal arthrodesis
. Distal metatarsal osteotomy (Chevron)
. Proximal metatarsal crescentic osteotomy
. Lapidus procedure (First tarsometatarsal arthrodesis)
. Keller resection arthroplasty

Correct Answer & Explanation

. Distal metatarsal osteotomy (Chevron)

Explanation

A distal metatarsal osteotomy (e.g., Chevron) is indicated for mild-to-moderate hallux valgus deformities (HVA <30 degrees, IMA <13 degrees) in the absence of hypermobility. Severe deformity or hypermobility typically necessitates proximal osteotomies or a Lapidus procedure.

Question 1114

Topic: 8. Foot and Ankle

A 28-year-old male is brought to the trauma bay after a severe motorcycle accident. He has a clinically obvious knee dislocation that is quickly reduced. Post-reduction, his foot is warm with palpable pulses, but his Ankle-Brachial Index (ABI) is 0.85. What is the most appropriate next step in management?

. Immediate surgical exploration of the popliteal fossa
. CT angiography of the lower extremity
. Discharge with urgent outpatient orthopedic follow-up
. Recheck ABI in 24 hours
. Application of a hinged knee brace and weight-bearing as tolerated

Correct Answer & Explanation

. CT angiography of the lower extremity

Explanation

In the setting of a knee dislocation, an ABI less than 0.9 is highly suspicious for a popliteal artery injury. Even in the presence of palpable pulses, CT angiography must be obtained to definitively assess vascular integrity.

Question 1115

Topic: 8. Foot and Ankle
A 30-year-old male sustains a severe hyperdorsiflexion injury to his foot during a fall from a height. Radiographs reveal a Hawkins Type III talar neck fracture. Which of the following accurately describes the associated displacement and the risk of avascular necrosis (AVN)?
. Non-displaced fracture; AVN risk is 0-10%
. Subtalar dislocation only; AVN risk is 20-50%
. Tibiotalar and subtalar dislocation; AVN risk is 20-50%
. Subtalar, tibiotalar, and talonavicular dislocation; AVN risk approaches 100%
. Tibiotalar and subtalar dislocation; AVN risk approaches 100%

Correct Answer & Explanation

. Subtalar, tibiotalar, and talonavicular dislocation; AVN risk approaches 100%

Explanation

A Hawkins Type III fracture involves a talar neck fracture with dislocation of both the subtalar and tibiotalar joints. Because of the extensive disruption of the blood supply (artery of the tarsal canal, tarsal sinus branches, and deltoid branches), the risk of AVN approaches 90-100%.

Question 1116

Topic: 8. Foot and Ankle

A 24-year-old athlete sustains a midfoot injury. Weight-bearing radiographs show widening of the interval between the first and second metatarsal bases. The Lisfranc ligament connects which two structures?

. Medial cuneiform to the second metatarsal base
. Medial cuneiform to the first metatarsal base
. Intermediate cuneiform to the second metatarsal base
. Lateral cuneiform to the third metatarsal base
. Navicular to the medial cuneiform

Correct Answer & Explanation

. Medial cuneiform to the second metatarsal base

Explanation

The Lisfranc ligament is a stout interosseous ligament that connects the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. It is a critical stabilizer of the midfoot arch.

Question 1117

Topic: 8. Foot and Ankle

A 24-year-old semi-professional soccer player presents with recurrent right ankle 'giving way' sensation after multiple inversion injuries over 18 months. He has failed a comprehensive 6-month physiotherapy program including bracing and proprioceptive training. On examination, he has tenderness over the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) regions. Which of the following physical examination findings would most strongly indicate mechanical ankle instability and guide surgical consideration?

. Pain with palpation over the sinus tarsi
. A positive anterior drawer test with a 'clunk' and apprehension
. Generalized hypermobility on Beighton score
. Limited dorsiflexion range of motion
. Pain during a single-leg hop test

Correct Answer & Explanation

. A positive anterior drawer test with a 'clunk' and apprehension

Explanation

Correct Answer: BA positive anterior drawer test with a 'clunk' and apprehension is a key indicator of mechanical instability, specifically ATFL insufficiency, which is the most common cause of recurrent lateral ankle instability. The 'clunk' suggests significant talar translation, and apprehension indicates the patient's recognition of the instability. While other findings like sinus tarsi pain, hypermobility, limited dorsiflexion, and pain on hop test are relevant to chronic ankle problems, they do not directly demonstrate the mechanical laxity of the lateral ankle ligaments as strongly as a positive anterior drawer test in this context. Generalized hypermobility might suggest a need for a reconstructive rather than just a repair procedure, but the mechanical instability is primarily shown by the drawer test.

Question 1118

Topic: 8. Foot and Ankle

Which of the following ligaments is the primary static restraint to anterior translation of the talus relative to the tibia, particularly in plantarflexion?

. Posterior talofibular ligament (PTFL)
. Calcaneofibular ligament (CFL)
. Anterior inferior tibiofibular ligament (AITFL)
. Anterior talofibular ligament (ATFL)
. Deltoid ligament

Correct Answer & Explanation

. Anterior talofibular ligament (ATFL)

Explanation

Correct Answer: DThe anterior talofibular ligament (ATFL) is the weakest and most commonly injured of the lateral ankle ligaments. It primarily resists anterior translation of the talus and internal rotation, especially when the ankle is in plantarflexion, which is the position of typical inversion injury. The CFL primarily resists inversion in dorsiflexion, the PTFL resists posterior talar translation, the AITFL (part of the syndesmosis) stabilizes the distal tibiofibular joint, and the deltoid ligament stabilizes the medial ankle.

Question 1119

Topic: Ankle Trauma & Sports

In the context of chronic lateral ankle instability, what is the most common surgical procedure employed for primary repair?

. Chrisman-Snook reconstruction
. Watson-Jones tenodesis
. Modified Brostrom procedure (Brostrom-Gould)
. Anatomical reconstruction with allograft
. Peroneal tendon transfer

Correct Answer & Explanation

. Modified Brostrom procedure (Brostrom-Gould)

Explanation

Correct Answer: CThe Modified Brostrom procedure, often referred to as Brostrom-Gould, is the most common and gold standard surgical procedure for primary repair of chronic lateral ankle instability. It involves direct repair of the attenuated ATFL and CFL, often augmented with the inferior extensor retinaculum. Chrisman-Snook and Watson-Jones are older tenodesis procedures using peroneal tendons, which are non-anatomical reconstructions. Anatomical reconstruction with allograft is typically reserved for revision cases or patients with poor tissue quality/generalized laxity. Peroneal tendon transfer isn't a primary repair technique for instability.

Question 1120

Topic: Ankle Trauma & Sports

A patient presents with recurrent ankle sprains and complaints of the ankle 'giving way'. Clinically, you suspect chronic mechanical instability. Which of the following imaging modalities is most sensitive for evaluating the integrity of the ATFL and CFL?

. Plain radiographs (AP, lateral, mortise views)
. Stress radiographs (anterior drawer and talar tilt views)
. Computed Tomography (CT) scan
. Magnetic Resonance Imaging (MRI)
. Bone scintigraphy

Correct Answer & Explanation

. Magnetic Resonance Imaging (MRI)

Explanation

Correct Answer: DMagnetic Resonance Imaging (MRI) is the most sensitive imaging modality for evaluating the integrity of soft tissue structures like the ATFL and CFL. It can show attenuation, scarring, or complete tears of these ligaments. While stress radiographs are excellent for demonstrating functional mechanical instability by measuring talar tilt and anterior translation, they don't directly visualize the ligaments' integrity as well as MRI. Plain radiographs are for bony anatomy, and CT scans are superior for bony detail but less so for soft tissues.

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