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8. Foot and Ankle MCQs

Practice Set 59 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 1161

Topic: 8. Foot and Ankle

The examiner asks about the normal range of key radiographic angles in hallux valgus. Based on the AP radiograph and the case discussion, which statement accurately describes the normal values for the intermetatarsal angle (IMA), hallux valgus angle (HVA), and distal metatarsal articular angle (DMAA)?

. A. IMA < 12°, HVA < 20°, DMAA max 10°.
. B. IMA < 9°, HVA < 15°, DMAA max 15°.
. C. IMA < 15°, HVA < 25°, DMAA max 20°.
. D. IMA < 9°, HVA < 20°, DMAA max 10°.
. E. IMA < 10°, HVA < 15°, DMAA max 20°.

Correct Answer & Explanation

. B. 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.'Options A, C, D, and Epresent incorrect combinations or values for the normal ranges as stated in the case.

Question 1162

Topic: Forefoot

The candidate emphasizes obtaining a detailed history, including questioning about relevant conditions. Which of the following conditions is NOT specifically mentioned in the case as a relevant condition to inquire about during the history for a patient presenting with hallux valgus?

. A. Diabetes.
. B. Inflammatory arthritis.
. C. Vascular disease.
. D. Gout.
. E. Neuropathy.

Correct Answer & Explanation

. D. Gout.

Explanation

Correct Answer: DThe candidate states: 'I would complete the history, including questioning about relevant conditions such as diabetes, inflammatory arthritis, vascular disease and neuropathy...'Options A, B, C, and Eare all explicitly mentioned in the case as relevant conditions to inquire about during the history.Option D (Gout)is a common condition that can affect the MTP joint and mimic or exacerbate hallux valgus symptoms, and would typically be part of a comprehensive history. However, it is not explicitly listed in the specific conditions mentioned by the candidate in this teaching case, making it the correct answer to the question 'NOT specifically mentioned'.

Question 1163

Topic: 8. Foot and Ankle

The candidate describes securing the Scarf osteotomy with two headless compression screws. Which of the following statements accurately describes a key mechanical advantage or characteristic of the Scarf osteotomy, as discussed in the case?

. A. It primarily achieves correction through shortening of the first metatarsal.
. B. It is a simple distal osteotomy, limiting its application to mild deformities.
. C. It provides unstable fixation, necessitating prolonged cast immobilization.
. D. It allows for translation, angulation, and depression of the metatarsal head while maintaining metatarsal length.
. E. Its main benefit is the ability to lengthen the first metatarsal without affecting other planes of correction.

Correct Answer & Explanation

. D. It allows for translation, angulation, and depression of the metatarsal head while maintaining metatarsal length.

Explanation

Correct Answer: DThe case describes the Scarf osteotomy as '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. It can also be used to shorten or even lengthen the metatarsal.'Option A (Primarily achieves correction through shortening)is incorrect. The case emphasizes that it 'maintains length' and avoids the shortening seen with procedures like Mitchell osteotomy.Option B (Simple distal osteotomy, limiting application to mild deformities)is incorrect. The case highlights its versatility and suitability for more severe deformities, contrasting it with distal osteotomies that would be 'inadequate' for the described deformity.Option C (Provides unstable fixation, necessitating prolonged cast immobilization)is incorrect. The case states it provides 'stable fixation allowing postoperative mobilization without a cast.'Option E (Its main benefit is the ability to lengthen the first metatarsal without affecting other planes of correction)is partially correct in that itcanlengthen, but the primary benefit highlighted is its versatility in allowing translation, angulation, and depression whilemaintaininglength, which is a more comprehensive description of its advantages for correction.

Question 1164

Topic: 8. Foot and Ankle

A patient presents with a painful, rigid hallux varus deformity 1 year after a distal chevron osteotomy and lateral soft tissue release for hallux valgus. What is the most likely iatrogenic cause?

. Under-resection of the medial eminence
. Failure to release the adductor hallucis
. Excessive lateral translation of the capital fragment
. Staking the metatarsal head
. Nonunion of the osteotomy

Correct Answer & Explanation

. Staking the metatarsal head

Explanation

Iatrogenic hallux varus is most commonly caused by over-resection of the medial eminence (staking the head) combined with over-release of the lateral soft tissues. Staking removes the vital medial bony support for the proximal phalanx.

Question 1165

Topic: Forefoot

A 45-year-old female presents with severe hallux valgus, an intermetatarsal angle of 18 degrees, and obvious hypermobility of the first tarsometatarsal (TMT) joint. Which of the following is the most appropriate surgical intervention?

. Proximal crescentic osteotomy
. Scarf osteotomy
. Distal chevron osteotomy
. First TMT joint arthrodesis (Lapidus)
. First MTP joint arthrodesis

Correct Answer & Explanation

. First TMT joint arthrodesis (Lapidus)

Explanation

The Lapidus procedure (first TMT arthrodesis) is indicated for severe hallux valgus (IMA > 15 degrees) associated with first ray hypermobility or symptomatic TMT arthritis. It provides powerful deformity correction and stabilizes the medial column.

Question 1166

Topic: 8. Foot and Ankle

A patient has a hallux valgus deformity with a distal metatarsal articular angle (DMAA) of 20 degrees. Which of the following procedures is most appropriate to correct this specific angular deformity?

. Ludloff osteotomy
. Akin osteotomy
. Biplanar chevron osteotomy
. Keller arthroplasty
. Weil osteotomy

Correct Answer & Explanation

. Biplanar chevron osteotomy

Explanation

An abnormally increased DMAA requires a procedure that alters the distal articular orientation. A biplanar chevron or Reverdin osteotomy specifically derotates the articular cartilage to correct the DMAA while simultaneously treating the valgus deformity.

Question 1167

Topic: 8. Foot and Ankle

When performing a distal metatarsal osteotomy for hallux valgus correction, carefully preserving the soft tissue attachments in which specific area minimizes the risk of avascular necrosis of the metatarsal head?

. Dorsomedial capsule
. Plantar-lateral capsule
. Dorsolateral capsule
. Plantar aponeurosis
. Interosseous membrane

Correct Answer & Explanation

. Plantar-lateral capsule

Explanation

The primary blood supply to the first metatarsal head is from the first dorsal metatarsal artery, which enters the plantar-lateral aspect of the head. Aggressive lateral release combined with a distal osteotomy significantly increases AVN risk if this area is stripped.

Question 1168

Topic: 8. Foot and Ankle

A surgeon performs a distal chevron osteotomy for hallux valgus. Intraoperatively, after fully correcting the intermetatarsal angle, the hallux remains in clinical valgus due to an intrinsic deformity within the proximal phalanx. Which procedure should be added?

. Proximal closing wedge osteotomy of the first metatarsal
. Distal soft tissue release only
. Excision of the medial eminence
. Medial closing wedge osteotomy of the proximal phalanx (Akin)
. First MTP fusion

Correct Answer & Explanation

. Medial closing wedge osteotomy of the proximal phalanx (Akin)

Explanation

An Akin osteotomy is a medial closing wedge osteotomy of the proximal phalanx. It is specifically indicated for hallux valgus interphalangeus (HVI) or residual clinical valgus after the first metatarsal alignment has been fully corrected.

Question 1169

Topic: 8. Foot and Ankle

A 68-year-old female undergoes a distal chevron osteotomy with a lateral soft tissue release for hallux valgus. Postoperatively, she develops avascular necrosis (AVN) of the first metatarsal head. Which of the following anatomical structures was most likely compromised?

. Medial plantar artery
. Dorsalis pedis artery
. First dorsal metatarsal artery and plantar-lateral capsular vessels
. Deep plantar arch
. Lateral tarsal artery

Correct Answer & Explanation

. First dorsal metatarsal artery and plantar-lateral capsular vessels

Explanation

The primary blood supply to the first metatarsal head enters through the plantar-lateral capsule. Combining a distal metatarsal osteotomy (like a chevron) with an extensive lateral capsular release significantly increases the risk of AVN.

Question 1170

Topic: Forefoot

A 45-year-old female presents with severe bunion pain. Weight-bearing radiographs reveal a Hallux Valgus Angle (HVA) of 42 degrees, an Intermetatarsal Angle (IMA) of 19 degrees, and clinical evidence of first tarsometatarsal (TMT) joint hypermobility. What is the most appropriate surgical intervention?

. Distal chevron osteotomy
. Akin osteotomy alone
. First TMT arthrodesis (Lapidus procedure)
. Keller resection arthroplasty
. Proximal phalanx osteotomy

Correct Answer & Explanation

. First TMT arthrodesis (Lapidus procedure)

Explanation

The Lapidus procedure (first TMT arthrodesis) is indicated for severe hallux valgus (IMA > 15-20 degrees) especially in the presence of first ray hypermobility. Distal osteotomies cannot adequately correct an IMA of this magnitude.

Question 1171

Topic: 8. Foot and Ankle

During a hallux valgus correction, the surgeon aggressively resects the medial eminence of the first metatarsal head, removing bone lateral to the sagittal sulcus. This error most directly predisposes the patient to which of the following postoperative complications?

. Hallux rigidus
. Avascular necrosis of the metatarsal head
. Hallux varus
. Nonunion of the metatarsal
. Transfer metatarsalgia

Correct Answer & Explanation

. Hallux varus

Explanation

Over-resection of the medial eminence (staking the head) removes the bony support for the medial collateral ligament and proximal phalanx. This leads to medial subluxation of the proximal phalanx, resulting in iatrogenic hallux varus.

Question 1172

Topic: 8. Foot and Ankle

A 55-year-old female presents with a symptomatic bunion. Radiographs show an HVA of 14 degrees, an IMA of 8 degrees, and a Distal Metatarsal Articular Angle (DMAA) of 25 degrees. The joint is incongruent. What is the most appropriate surgical correction?

. First TMT arthrodesis
. Proximal crescentic osteotomy
. Biplanar chevron osteotomy or Reverdin procedure
. McBride soft tissue procedure
. First MTP arthrodesis

Correct Answer & Explanation

. Biplanar chevron osteotomy or Reverdin procedure

Explanation

An abnormally high DMAA (> 15 degrees) indicates an increased lateral slope of the distal articular surface. A biplanar chevron or a Reverdin (distal medial closing wedge) osteotomy corrects this articular orientation while treating the mild deformity.

Question 1173

Topic: 8. Foot and Ankle

A 35-year-old patient undergoes a proximal crescentic osteotomy for a severe hallux valgus deformity. Postoperatively, she develops intractable pain under the second metatarsal head. What is the most likely technical error responsible for this complication?

. Plantarflexion malunion of the first metatarsal
. Dorsiflexion malunion (elevation) of the first metatarsal
. Over-shortening of the proximal phalanx
. Inadequate lateral capsular release
. Excessive medial translation of the distal fragment

Correct Answer & Explanation

. Dorsiflexion malunion (elevation) of the first metatarsal

Explanation

Dorsiflexion (elevation) of the first metatarsal head is a common complication of proximal osteotomies. This unloads the first ray during the terminal stance phase of gait, transferring weight-bearing forces to the lesser metatarsals and causing transfer metatarsalgia.

Question 1174

Topic: Forefoot

A patient presents for bunion correction. Radiographs demonstrate an HVA of 20 degrees, an IMA of 8 degrees, and a Hallux Valgus Interphalangeus (HVI) angle of 18 degrees.

Which of the following procedures is most appropriate to address the interphalangeal deformity?

. Proximal crescentic osteotomy
. Akin osteotomy
. Scarf osteotomy
. Chevron osteotomy
. Lapidus arthrodesis

Correct Answer & Explanation

. Akin osteotomy

Explanation

An Akin osteotomy is a medial closing wedge osteotomy of the proximal phalanx. It is specifically indicated for correcting Hallux Valgus Interphalangeus or as an adjunct procedure when the great toe remains in valgus despite correcting the first MTP joint.

Question 1175

Topic: Forefoot

A 60-year-old female with profound rheumatoid arthritis presents with a severe hallux valgus deformity, complete destruction of the first MTP joint cartilage, and multiple lesser toe deformities. What is the surgical treatment of choice for her first ray?

. First MTP joint silicone arthroplasty
. Keller resection arthroplasty
. First MTP joint arthrodesis
. Ludloff osteotomy
. Distal chevron osteotomy

Correct Answer & Explanation

. First MTP joint arthrodesis

Explanation

First MTP joint arthrodesis is the gold standard for severe hallux valgus in the setting of inflammatory arthritis (like RA) with joint destruction. It provides reliable pain relief, permanent deformity correction, and restores medial column weight-bearing.

Question 1176

Topic: 8. Foot and Ankle

Which of the following is a known risk associated with a Scarf osteotomy (a diaphyseal Z-step cut) for hallux valgus correction in a patient with osteoporotic bone?

. Troughing of the metatarsal shaft
. Premature physeal closure
. Hypertrophy of the medial eminence
. Spontaneous arthrodesis of the MTP joint
. Excessive dorsiflexion of the distal phalanx

Correct Answer & Explanation

. Troughing of the metatarsal shaft

Explanation

Troughing occurs when the harder cortical bone of one fragment sinks into the softer cancellous bone of the other fragment after a Scarf osteotomy. This can lead to loss of fixation, loss of elevation, and transfer metatarsalgia, particularly in osteoporotic bone.

Question 1177

Topic: Forefoot

Which of the following is an absolute contraindication to performing a Keller resection arthroplasty for hallux valgus?

. Patient age greater than 75 years
. Severe first MTP joint osteoarthritis
. Active, high-demand lifestyle in a young patient
. Previous failed chevron osteotomy
. Presence of a lesser toe hammer toe deformity

Correct Answer & Explanation

. Active, high-demand lifestyle in a young patient

Explanation

A Keller arthroplasty involves excising the base of the proximal phalanx, which destabilizes the first MTP joint and weakens push-off strength. It is contraindicated in young, active, high-demand patients due to the resultant loss of toe purchase and push-off power.

Question 1178

Topic: Forefoot

A 45-year-old female presents with a painful bunion. Radiographs show a hallux valgus angle (HVA) of 45 degrees, an intermetatarsal angle (IMA) of 18 degrees, and hypermobility of the first tarsometatarsal (TMT) joint. What is the most appropriate surgical intervention?

. Distal chevron osteotomy
. Proximal crescentic osteotomy
. First TMT arthrodesis (Lapidus)
. First MTP arthrodesis
. Keller arthroplasty

Correct Answer & Explanation

. First TMT arthrodesis (Lapidus)

Explanation

The Lapidus procedure (first TMT arthrodesis) is indicated for severe hallux valgus (IMA >15-20 degrees) combined with first ray hypermobility. Distal osteotomies are insufficient for large IMAs, and MTP fusion is usually reserved for arthritis or severe deformity in older, low-demand patients.

Question 1179

Topic: Forefoot

A 55-year-old female presents with a progressively painful, medially deviated great toe 1 year after a modified McBride bunionectomy and distal chevron osteotomy. Clinical exam reveals a flexible first MTP joint. Which of the following is the most appropriate treatment?

. First MTP arthrodesis
. Extensor hallucis brevis tenodesis
. Extensor hallucis longus transfer (Jones procedure)
. Keller arthroplasty
. Closing wedge osteotomy of the proximal phalanx

Correct Answer & Explanation

. Extensor hallucis brevis tenodesis

Explanation

Iatrogenic hallux varus with a flexible MTP joint can be treated with soft tissue reconstruction, such as EHB tenodesis or EHL transfer, often combined with medial capsule release. If the joint were rigid or arthritic, an MTP arthrodesis would be indicated.

Question 1180

Topic: 8. Foot and Ankle

A 32-year-old female undergoes a proximal crescentic osteotomy and distal soft tissue release for hallux valgus. Postoperatively, her HVA is corrected, but she has a prominent medial eminence and the articular surface of the metatarsal head is laterally deviated. Which of the following was likely missed preoperatively?

. High intermetatarsal angle (IMA)
. Hypermobile first ray
. Increased distal metatarsal articular angle (DMAA)
. First MTP arthritis
. Metatarsus adductus

Correct Answer & Explanation

. Increased distal metatarsal articular angle (DMAA)

Explanation

An increased DMAA indicates a laterally directed articular surface of the first metatarsal head. Failure to address this (usually with a biplanar or distal osteotomy like a Reverdin) leaves the joint incongruent when the toe is straightened, risking recurrence or subluxation.

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