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8. Foot and Ankle MCQs

Practice Set 57 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 1121

Topic: 8. Foot and Ankle

During an anterior drawer test of the ankle, which position of the ankle joint (in terms of plantarflexion/dorsiflexion) best isolates the ATFL?

. Neutral (0 degrees dorsiflexion/plantarflexion)
. Full dorsiflexion
. Slight dorsiflexion (10-15 degrees)
. Slight plantarflexion (10-20 degrees)
. Full plantarflexion

Correct Answer & Explanation

. Slight plantarflexion (10-20 degrees)

Explanation

Correct Answer: DThe anterior drawer test for the ankle is best performed with the ankle in slight plantarflexion (approximately 10-20 degrees). This position relaxes the CFL and PTFL, thereby isolating the ATFL, which is taut in plantarflexion and anterior translation. In dorsiflexion, the ATFL is relaxed, and the CFL becomes more taut, making assessment of the ATFL less specific.

Question 1122

Topic: 8. Foot and Ankle

What is the primary role of the calcaneofibular ligament (CFL) in ankle stability?

. Resisting internal rotation of the talus
. Preventing eversion of the hindfoot
. Resisting varus (inversion) stress, particularly in dorsiflexion
. Limiting anterior translation of the talus
. Stabilizing the syndesmosis

Correct Answer & Explanation

. Resisting varus (inversion) stress, particularly in dorsiflexion

Explanation

Correct Answer: CThe calcaneofibular ligament (CFL) is the primary static restraint to varus (inversion) stress of the ankle, particularly when the ankle is in a neutral or dorsiflexed position. While it also contributes to subtalar stability, its main role in ankle stability is resisting inversion. The ATFL limits anterior translation and internal rotation. The deltoid ligament prevents eversion, and syndesmotic ligaments stabilize the distal tibiofibular joint.

Question 1123

Topic: Ankle Trauma & Sports

A 35-year-old male with chronic lateral ankle instability undergoes a modified Brostrom-Gould procedure. Which structure is commonly imbricated with the repaired ATFL and CFL to augment the repair?

. Peroneus brevis tendon
. Inferior extensor retinaculum
. Peroneus longus tendon
. Spring ligament
. Superior peroneal retinaculum

Correct Answer & Explanation

. Inferior extensor retinaculum

Explanation

Correct Answer: BIn the modified Brostrom-Gould procedure, the attenuated ATFL and CFL are directly repaired and imbricated. The repair is then augmented by incorporating a flap of the inferior extensor retinaculum over the repaired ligaments. This provides additional strength and stability to the lateral ankle complex. The peroneal tendons are used in tenodesis procedures (e.g., Chrisman-Snook), not typically in a Brostrom-Gould repair. The spring ligament is on the medial side, and the superior peroneal retinaculum stabilizes the peroneal tendons.

Question 1124

Topic: 8. Foot and Ankle

What is the most common concomitant injury found in patients with chronic lateral ankle instability?

. Achilles tendon rupture
. Posterior tibial tendon dysfunction
. Osteochondral lesion of the talus
. Syndesmotic injury
. Tarsal tunnel syndrome

Correct Answer & Explanation

. Osteochondral lesion of the talus

Explanation

Correct Answer: COsteochondral lesions (OCLs) of the talus are the most common concomitant injury found in patients with chronic lateral ankle instability, occurring in up to 50% of cases. The repeated episodes of 'giving way' and abnormal biomechanics can lead to impaction injuries of the talar dome. While other conditions listed can occur, OCLs are specifically and highly associated with chronic ankle instability. It is crucial to evaluate for these lesions pre-operatively, often requiring an MRI.

Question 1125

Topic: Ankle Trauma & Sports

A 22-year-old dancer presents with chronic lateral ankle instability. Her Beighton score is 7/9, indicating generalized ligamentous laxity. Which surgical approach would be most appropriate given her hypermobility?

. Primary repair using a modified Brostrom-Gould technique.
. Non-anatomical reconstruction using the Watson-Jones technique.
. Anatomical reconstruction using an autograft or allograft.
. Arthroscopic debridement of the anterolateral gutter.
. An isolated posterior talofibular ligament repair.

Correct Answer & Explanation

. Anatomical reconstruction using an autograft or allograft.

Explanation

Correct Answer: CFor patients with generalized ligamentous laxity (like a high Beighton score) or poor tissue quality, a primary repair (like a modified Brostrom-Gould) may not provide sufficient long-term stability due to the inherent laxity. In such cases, an anatomical reconstruction using an autograft (e.g., gracilis, semitendinosus) or allograft is often preferred to provide a stronger and more durable repair. Non-anatomical reconstructions are generally less favored due to altered biomechanics. Arthroscopic debridement addresses impingement but not instability, and isolated PTFL repair is rare.

Question 1126

Topic: 8. Foot and Ankle

What is the recommended period of non-operative management (e.g., bracing, physiotherapy) before considering surgical intervention for chronic lateral ankle instability?

. 2-4 weeks
. 1-2 months
. 3-6 months
. Over 1 year
. Surgery is always the first-line treatment for chronic instability.

Correct Answer & Explanation

. 3-6 months

Explanation

Correct Answer: CMost guidelines recommend a minimum of 3 to 6 months of comprehensive non-operative management, including bracing, proprioceptive training, strengthening, and activity modification, before considering surgical intervention for chronic lateral ankle instability. A shorter trial may be considered in elite athletes or specific cases, but generally, conservative measures should be exhausted first.

Question 1127

Topic: 8. Foot and Ankle

In the assessment of a syndesmotic injury of the ankle, the primary restraint to anterior-posterior translation of the fibula relative to the tibia is the:

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

Correct Answer & Explanation

. Posterior inferior tibiofibular ligament (PITFL)

Explanation

The posterior inferior tibiofibular ligament (PITFL) provides the greatest resistance (approximately 42%) to posterior translation and overall stability of the syndesmosis. The AITFL contributes approximately 35%, and the interosseous ligament provides about 22%.

Question 1128

Topic: 8. Foot and Ankle

A 22-year-old athlete is diagnosed with a medial talar osteochondral lesion (OCL) following persistent pain after an ankle sprain. Compared to lateral talar OCLs, medial lesions are characteristically:

. Shallow, wafer-shaped, and usually have a clear history of trauma
. Deep, cup-shaped, and less frequently associated with a specific traumatic event
. Located entirely in the anterior half of the talar dome
. Highly responsive to conservative management with immobilization alone
. Best treated with primary ankle arthrodesis

Correct Answer & Explanation

. Deep, cup-shaped, and less frequently associated with a specific traumatic event

Explanation

Medial talar osteochondral lesions are typically deep and cup-shaped, located posteromedially, and are less often associated with a distinct traumatic event compared to lateral lesions. Lateral lesions are usually anterior, shallow, wafer-shaped, and strongly associated with a history of trauma.

Question 1129

Topic: 8. Foot and Ankle

During open reduction and internal fixation of a pronation-external rotation ankle fracture, the surgeon must address an unstable syndesmosis. Which of the following ligaments provides the greatest static resistance to lateral displacement of the fibula relative to the tibia?

. Anterior inferior tibiofibular ligament (AITFL)
. Posterior inferior tibiofibular ligament (PITFL)
. Interosseous membrane
. Transverse tibiofibular 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 and provides the greatest resistance (approximately 42%) to lateral displacement of the distal fibula. The AITFL is typically the first to tear but is structurally weaker.

Question 1130

Topic: 8. Foot and Ankle

During a minimally invasive or percutaneous repair of an acute Achilles tendon rupture using a specific jig, the surgeon must be mindful of local neurovascular anatomy. The sural nerve is at highest risk of iatrogenic injury at which of the following locations relative to the calcaneal insertion of the tendon?

. 2 to 4 cm proximally, as it crosses medial to the tendon
. 5 to 7 cm proximally, as it crosses medial to the tendon
. 10 to 12 cm proximally, as it crosses the lateral border of the tendon
. 15 to 18 cm proximally, as it runs anterior to the flexor hallucis longus
. Directly at the insertion point on the posterolateral calcaneus

Correct Answer & Explanation

. 10 to 12 cm proximally, as it crosses the lateral border of the tendon

Explanation

The sural nerve courses distally and crosses the lateral border of the Achilles tendon approximately 10 to 12 cm proximal to its calcaneal insertion. Sutures placed percutaneously in this region carry a high risk of nerve entrapment.

Question 1131

Topic: Ankle Trauma & Sports

During the operative fixation of a supination-external rotation (Weber B) ankle fracture, the surgeon performs a 'Cotton test' (lateral pull on the fibula) using a bone hook. Which of the following fluoroscopic findings definitively indicates syndesmotic instability necessitating screw or button fixation?

. Widening of the syndesmotic clear space by greater than 2 mm under stress
. An absolute medial clear space measurement of 3 mm on the unstressed AP view
. Talocrural angle of 83 degrees on the mortise view
. Tibiofibular overlap of 5 mm on the AP view
. Posterior subluxation of the fibula by 1 mm on the lateral view

Correct Answer & Explanation

. Widening of the syndesmotic clear space by greater than 2 mm under stress

Explanation

During intraoperative stress testing of the syndesmosis (the Cotton or Hook test), widening of the medial clear space or the tibiofibular clear space by greater than 2 mm compared to the unstressed state indicates syndesmotic instability requiring operative stabilization.

Question 1132

Topic: 8. Foot and Ankle

A 65-year-old diabetic male with end-stage post-traumatic ankle osteoarthritis presents for surgical consultation. He has a history of midfoot collapse, profound peripheral neuropathy, and a rigid, plantigrade foot. Which of the following represents an absolute contraindication to performing a total ankle arthroplasty (TAR) in this patient?

. Age younger than 70 years
. Active Charcot neuroarthropathy
. Mild coronal plane deformity of 5 degrees
. End-stage post-traumatic osteoarthritis
. History of a prior lateral ankle sprain

Correct Answer & Explanation

. Active Charcot neuroarthropathy

Explanation

Active Charcot neuroarthropathy, severe peripheral neuropathy, and lack of protective sensation are absolute contraindications for total ankle arthroplasty. These patients have an unacceptably high risk of catastrophic implant failure, subsidence, and deep infection, making arthrodesis the preferred procedure.

Question 1133

Topic: 8. Foot and Ankle

A 65-year-old male presents with end-stage post-traumatic ankle osteoarthritis and a rigid 18-degree varus coronal plane deformity. Why is ankle arthrodesis typically preferred over total ankle arthroplasty (TAA) in this specific clinical scenario?

. Significant rigid coronal plane deformity is a relative contraindication to standard TAA
. TAA is associated with a significantly higher rate of tibial nonunion
. Arthrodesis provides superior preservation of adjacent subtalar joint kinematics
. Total ankle arthroplasty is absolutely contraindicated in male patients over 60
. Ankle arthrodesis allows for immediate postoperative weight-bearing

Correct Answer & Explanation

. Significant rigid coronal plane deformity is a relative contraindication to standard TAA

Explanation

Severe, rigid coronal plane deformities (typically >10-15 degrees) are considered a relative contraindication to primary TAA due to the high risk of edge-loading, component subsidence, and early failure.

Question 1134

Topic: 8. Foot and Ankle

Following open reduction and internal fixation of a severe pronation-external rotation ankle fracture with syndesmotic disruption, which of the following imaging modalities provides the highest sensitivity and specificity for detecting postoperative syndesmotic malreduction?

. Weight-bearing anteroposterior radiograph
. Mortise radiograph with external rotation stress
. Magnetic resonance imaging (MRI)
. Axial computed tomography (CT)
. Dynamic diagnostic ultrasound

Correct Answer & Explanation

. Axial computed tomography (CT)

Explanation

Plain radiographs are notably inaccurate for assessing the distal tibiofibular syndesmosis. Axial CT is the most sensitive and specific imaging modality for evaluating syndesmotic reduction within the incisura fibularis.

Question 1135

Topic: 8. Foot and Ankle

A patient presents with midfoot pain after falling from a horse with the foot plantarflexed in the stirrup. AP radiographs show a small bony avulsion fragment in the space between the bases of the 1st and 2nd metatarsals ('fleck sign'). The disrupted ligament normally connects the base of the 2nd metatarsal to which of the following bones?

. First cuneiform (Medial cuneiform)
. Second cuneiform (Middle cuneiform)
. Third cuneiform (Lateral cuneiform)
. Cuboid
. Navicular

Correct Answer & Explanation

. First cuneiform (Medial cuneiform)

Explanation

The 'fleck sign' pathognomonic for a Lisfranc injury represents an avulsion of the Lisfranc ligament. This crucial stabilizing ligament originates from the lateral aspect of the medial cuneiform and inserts on the medial base of the second metatarsal.

Question 1136

Topic: 8. Foot and Ankle

A 24-year-old athlete sustains an axial load to a plantarflexed foot. Weight-bearing radiographs demonstrate a 3 mm widening between the base of the first and second metatarsals. The classic Lisfranc ligament injured in this scenario connects which two osseous structures?

. Medial cuneiform and the base of the first metatarsal
. Medial cuneiform and the base of the second metatarsal
. Middle cuneiform and the base of the second metatarsal
. Lateral cuneiform and the cuboid
. Navicular and the medial cuneiform

Correct Answer & Explanation

. Medial cuneiform and the base of the second metatarsal

Explanation

The Lisfranc ligament is a stout, oblique interosseous ligament that originates from the lateral aspect of the medial cuneiform and inserts onto the medial base of the second metatarsal. It is critical for the stability of the tarsometatarsal joint complex.

Question 1137

Topic: 8. Foot and Ankle

During your oral viva, the examiner asks you to discuss the potential complications of treating a displaced intra-articular calcaneus fracture. Which approach demonstrates the highest level of structured competence?

. Listing all the catastrophic complications first to show you understand the severity.
. Categorizing the complications sequentially into intra-operative, early post-operative, and late post-operative.
. Providing an exhaustive, detailed explanation of subtalar arthritis while ignoring minor complications.
. Asking the examiner which specific complication they would like you to focus on.
. Reciting a random list of complications as they come to mind to answer as quickly as possible.

Correct Answer & Explanation

. Categorizing the complications sequentially into intra-operative, early post-operative, and late post-operative.

Explanation

Structuring answers anatomically or chronologically (intra-operative, early, late) provides a clear, logical framework. It ensures comprehensive coverage of the topic and proves to the examiner that your thought process is organized and methodical.

Question 1138

Topic: 8. Foot and Ankle

A 24-year-old athlete sustains a midfoot injury. An AP radiograph of the foot reveals a 'fleck sign' in the first intermetatarsal space. This radiographic finding represents an avulsion of the Lisfranc ligament from which anatomical structure?

. Medial cuneiform.
. Intermediate cuneiform.
. Base of the first metatarsal.
. Base of the second metatarsal.
. Cuboid.

Correct Answer & Explanation

. Base of the second metatarsal.

Explanation

The Lisfranc ligament connects the medial cuneiform to the base of the second metatarsal. The 'fleck sign' represents a bony avulsion of this ligament specifically from its insertion on the base of the second metatarsal.

Question 1139

Topic: 8. Foot and Ankle

A 30-year-old male sustains a midfoot crush injury. The Lisfranc ligament complex is suspected to be torn. Anatomically, the primary oblique band of the Lisfranc ligament connects which two osseous structures?

. Base of the 1st metatarsal to the medial cuneiform
. Base of the 2nd metatarsal to the medial cuneiform
. Base of the 2nd metatarsal to the middle cuneiform
. Base of the 1st metatarsal to the base of the 2nd metatarsal
. Medial cuneiform to the middle cuneiform

Correct Answer & Explanation

. Base of the 2nd metatarsal to the medial cuneiform

Explanation

The true Lisfranc ligament is a strong intra-articular 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 1st and 2nd metatarsals.

Question 1140

Topic: Midfoot & Hindfoot

A 28-year-old runner sustains a purely ligamentous Lisfranc injury with 3 mm of widening between the medial and middle cuneiforms. What is the current recommended operative management?

. Closed reduction and cast application for 6 weeks
. Primary arthrodesis of the first, second, and third tarsometatarsal joints
. Open reduction and internal fixation (ORIF) with transarticular screws
. Flexible fixation with a suture button device only
. Midfoot amputation

Correct Answer & Explanation

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

Explanation

Recent literature supports primary arthrodesis for purely ligamentous Lisfranc injuries. It yields better functional outcomes and fewer reoperations compared to traditional ORIF.

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