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8. Foot and Ankle MCQs

Practice Set 63 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 1241

Topic: 8. Foot and Ankle

Based on the "Summary of Key Literature / Guidelines" section, which of the following statements best reflects the current consensus regarding the surgical management of symptomatic second MTPJ instability with a significant plantar plate tear?

. Non-operative management is effective for advanced cases with irreducible subluxation.
. A plantar approach is preferred for direct visualization and repair of the plantar plate.
. Direct plantar plate repair alone is sufficient, and concomitant Weil osteotomy is rarely indicated.
. MRI is the gold standard for diagnosing plantar plate tears and correlating with clinical instability.
. Long-term outcomes are generally poor due to high recurrence rates and persistent pain.

Correct Answer & Explanation

. MRI is the gold standard for diagnosing plantar plate tears and correlating with clinical instability.

Explanation

Correct Answer: DThe 'Summary of Key Literature / Guidelines' section explicitly states: 'advancements in imaging, especially MRI, have confirmed the high prevalence of plantar plate tears as the primary pathology... The strong correlation between clinical instability, radiographic dorsal subluxation, and MRI-confirmed plantar plate pathology is well-established.' It also reiterates: 'MRI: The gold standard for assessing soft tissue structures, particularly the plantar plate.'Let's evaluate the other options:A) Non-operative management is effective for advanced cases with irreducible subluxation:This is incorrect. The text states non-operative measures 'often fail to address the underlying structural instability in advanced cases' and that surgery is indicated for 'irreducible dorsal subluxation.'B) A plantar approach is preferred for direct visualization and repair of the plantar plate:This is incorrect. The text states: 'The dorsal approach is the most common, offering good visualization of the joint and allowing for concomitant procedures.'C) Direct plantar plate repair alone is sufficient, and concomitant Weil osteotomy is rarely indicated:This is incorrect. The text notes: 'Concomitant Weil osteotomy of the second metatarsal is frequently performed, especially in cases with a long second metatarsal or significant dorsal subluxation. It serves to shorten the metatarsal, decompress the MTPJ, and facilitate plantar plate repair.'E) Long-term outcomes are generally poor due to high recurrence rates and persistent pain:This is incorrect. The text states: 'The long-term outcomes of successful plantar plate repair combined with appropriate adjunct procedures show high patient satisfaction, significant pain reduction, and functional improvement, with recurrence rates ranging from 10-20%.' While recurrence can occur, overall outcomes are generally good.

Question 1242

Topic: 8. Foot and Ankle

What is the most common complication following a standard Weil distal metatarsal shortening osteotomy performed for second MTP joint instability?

. Avascular necrosis of the metatarsal head
. Nonunion of the osteotomy
. Transfer metatarsalgia to the adjacent ray
. Floating toe deformity
. Flexor tendon rupture

Correct Answer & Explanation

. Floating toe deformity

Explanation

A "floating toe" is the most common complication of a Weil osteotomy. It occurs because shortening the metatarsal alters the center of rotation and relaxes the intrinsic muscles, shifting their mechanical advantage from MTP flexors to extensors.

Question 1243

Topic: 8. Foot and Ankle
A 45-year-old woman complains of forefoot pain localized to the plantar aspect of the second metatarsophalangeal (MTP) joint, describing a sensation of "walking on a marble." Which of the following physical examination maneuvers is most sensitive for diagnosing the suspected pathology?
. Mulder's click test
. Squeeze test of the metatarsal heads
. Dorsal drawer (Lachman) test of the MTP joint
. Silfverskiöld test
. Windlass test

Correct Answer & Explanation

. Dorsal drawer (Lachman) test of the MTP joint

Explanation

The patient's symptoms suggest a plantar plate tear with MTP joint instability. The dorsal drawer (Lachman) test of the MTP joint is the most sensitive and specific physical examination maneuver for evaluating plantar plate integrity and MTP instability.

Question 1244

Topic: 8. Foot and Ankle

A 60-year-old female undergoes a Weil osteotomy of the second metatarsal and a plantar plate repair for a rigid crossover toe deformity. Postoperatively, she develops a "floating toe" complication. What biomechanical consequence of the Weil osteotomy primarily contributes to this complication?

. Lengthening of the metatarsal with excessive tension on the extensor tendons
. Plantar translation of the metatarsal head changing the axis of rotation
. Elevation of the metatarsal head leading to loss of flexor tendon tension
. Iatrogenic transection of the lumbrical tendon
. Over-tightening of the plantar plate repair

Correct Answer & Explanation

. Plantar translation of the metatarsal head changing the axis of rotation

Explanation

The Weil osteotomy is an intra-articular osteotomy parallel to the plantar aspect of the foot. Because it shifts the metatarsal head proximally and plantarly, it alters the axis of rotation relative to the interossei, making them act as extensors and contributing to a floating toe.

Question 1245

Topic: 8. Foot and Ankle

A 55-year-old female presents with severe pain and a crossover deformity of the second toe. Imaging and exam confirm a complete plantar plate tear. She is scheduled for a direct plantar plate repair and a Weil osteotomy. What is the primary mechanical purpose of adding the Weil osteotomy in this setting?

. To correct the medial deviation by shortening the lateral collateral ligament
. To shift the metatarsal head plantarly to restore weight-bearing
. To decompress the MTP joint and allow tension-free repair of the plantar plate
. To elevate the metatarsal head and transfer pressure to the first ray
. To induce a bony fusion of the MTP joint

Correct Answer & Explanation

. To decompress the MTP joint and allow tension-free repair of the plantar plate

Explanation

A Weil osteotomy (a distal oblique intra-articular metatarsal shortening osteotomy) decompresses the MTP joint. This shortens the ray, relaxing the contracted soft tissues and allowing a tension-free repair of the plantar plate.

Question 1246

Topic: 8. Foot and Ankle

A 21-year-old triathlete reports anterior shin pain and numbness in the first dorsal webspace of his foot after running 2 miles. The symptoms resolve with 20 minutes of rest. Which compartment is affected, and what conservative intervention is most likely to lower its exertional pressures?

. Anterior compartment; Transitioning from a forefoot-strike to a heel-strike running pattern
. Anterior compartment; Transitioning from a heel-strike to a forefoot-strike running pattern
. Lateral compartment; Transitioning from a heel-strike to a forefoot-strike running pattern
. Deep posterior compartment; Use of orthotics with a medial post
. Deep posterior compartment; Transitioning from a forefoot-strike to a heel-strike running pattern

Correct Answer & Explanation

. Anterior compartment; Transitioning from a heel-strike to a forefoot-strike running pattern

Explanation

The deep peroneal nerve resides in the anterior compartment and supplies the first webspace. Transitioning from a heel-strike to a forefoot-strike running pattern has been shown to significantly reduce anterior compartment pressures.

Question 1247

Topic: 8. Foot and Ankle

A 60-year-old female undergoes a Weil osteotomy of the second metatarsal for chronic MTP joint instability. At her 6-month follow-up, she complains of a "floating toe" that does not touch the ground when standing. What biomechanical alteration caused this complication?

. Dorsal translation of the interossei axis of pull relative to the MTP joint
. Over-lengthening of the metatarsal shaft
. Iatrogenic disruption of the extensor digitorum longus
. Plantarflexion of the metatarsal head
. Over-tightening of the plantar plate repair

Correct Answer & Explanation

. Dorsal translation of the interossei axis of pull relative to the MTP joint

Explanation

A Weil osteotomy shifts the center of rotation of the metatarsal head proximally and plantarward. This moves the intrinsic muscles (interossei) dorsal to the axis of rotation, converting them from plantarflexors to extensors, causing a floating toe.

Question 1248

Topic: 8. Foot and Ankle

A normal sagittal plane mechanical axis of the lower extremity is evaluated by dropping a plumb line from the center of the femoral head to the center of the ankle. In a normal individual standing with full knee extension, where does this line pass in relation to the knee joint center?

. Directly through the center of rotation of the knee
. Posterior to the center of the knee by 1-2 cm
. Anterior to the center of the knee
. Through the fibular head
. Through the posterior cruciate ligament footprint

Correct Answer & Explanation

. Anterior to the center of the knee

Explanation

The sagittal mechanical axis (plumb line) normally passes anterior to the center of rotation of the knee joint. This anterior position helps maintain passive knee extension during stance, reducing the energy requirement of the quadriceps.

Question 1249

Topic: 8. Foot and Ankle

A patient with a distal femoral recurvatum deformity (mPDFA 98°) also demonstrates a compensatory deformity to maintain a horizontal foot flat during stance. What is the most likely ipsilateral compensatory bony deformity?

. Proximal femoral procurvatum
. Distal tibial recurvatum
. Proximal tibial procurvatum
. Proximal tibial recurvatum
. Calcaneal pitch increase

Correct Answer & Explanation

. Proximal tibial procurvatum

Explanation

To keep the foot flat on the ground and the trunk upright, a recurvatum (apex posterior) deformity of the femur is typically compensated by a procurvatum (apex anterior) deformity of the tibia, effectively 'Z-ing' the limb.

Question 1250

Topic: 8. Foot and Ankle

An adult patient presents with a 'back-knee' (recurvatum) gait thrust. Upon clinical examination, the patient's knee anatomy is entirely normal, but they lack active and passive ankle dorsiflexion past neutral. What is the mechanism of this compensatory knee recurvatum?

. Weakness of the quadriceps forcing knee locking
. Ankle equinus contracture forcing the tibia posteriorly during stance
. Hamstring spasticity
. Posterior capsular hyperlaxity of the knee
. Anterior pelvic tilt

Correct Answer & Explanation

. Ankle equinus contracture forcing the tibia posteriorly during stance

Explanation

An ankle equinus contracture prevents normal forward progression of the tibia over the foot during the stance phase of gait. To keep the foot flat on the ground, the knee is forced into compensatory hyperextension (recurvatum).

Question 1251

Topic: 8. Foot and Ankle

A 28-year-old patient has undergone a double-level Pelvic Support Osteotomy for a chronically dislocated hip. Postoperative radiographs are being reviewed to assess the success of the correction.

Referring to the provided image (specifically diagram 'g') and the principles outlined in the case, what is the ultimate goal of the double-level osteotomy regarding the mechanical axis?

. To ensure the mechanical axis passes through the anatomical center of the absent femoral head.
. To create a severe valgus deformity at the knee to enhance stability.
. To ensure the final mechanical axis, drawn from the new pelvic pivot point to the ankle center, passes directly through the center of the knee.
. To achieve a mLDFA of 95 degrees to maximize abductor tension.
. To create a parallel shift of the mechanical axis laterally to offload the medial compartment of the knee.

Correct Answer & Explanation

. To ensure the final mechanical axis, drawn from the new pelvic pivot point to the ankle center, passes directly through the center of the knee.

Explanation

Correct Answer: CThe case emphasizes the importance of Mechanical Axis Deviation (MAD) analysis in the absence of a femoral head. It states: 'The entire goal of the double-level osteotomy is to ensure the final mechanical axis—drawn from this new pivot point to the ankle center—passes directly through the center of the knee.' Diagram 'g' in the provided image visually depicts this ideal final alignment, where the mechanical axis (red line) runs perfectly from the new proximal pivot point, through the knee center, to the ankle center. Option A is incorrect because the femoral head is absent. Option B describes the historical failure of single-level osteotomies. Option D is incorrect; the mLDFA should be 87° (± 3°), not 95°. Option E describes an undesirable outcome that would lead to lateral compartment knee arthritis.

Question 1252

Topic: 8. Foot and Ankle

A patient undergoing extensive tibial and femoral limb lengthening via a circular external fixator develops a severe, rigid equinus contracture of the ankle despite aggressive physical therapy and splinting. What is the most appropriate next step to manage this complication?

. Stop distraction and perform immediate open Achilles tendon lengthening
. Increase the rate of distraction to stretch the triceps surae
. Inject botulinum toxin directly into the gastrocnemius
. Extend the external fixator frame across the ankle joint
. Perform an isolated gastrocnemius recession immediately

Correct Answer & Explanation

. Extend the external fixator frame across the ankle joint

Explanation

If conservative measures fail to control an equinus contracture during lower extremity lengthening, the gold standard mechanical solution is to extend the external fixator across the ankle joint, maintaining the foot in a neutral plantigrade position while lengthening continues.

Question 1253

Topic: 8. Foot and Ankle

Review the provided imaging concepts related to deformity planning.

When analyzing mechanical axis deviation (MAD) of the lower extremity, a shift of the mechanical axis line lateral to the center of the knee joint indicates which of the following?

. Varus deformity
. Valgus deformity
. Procurvatum deformity
. Recurvatum deformity
. Normal alignment

Correct Answer & Explanation

. Valgus deformity

Explanation

A mechanical axis line (drawn from the center of the femoral head to the center of the ankle) that passes lateral to the center of the knee joint defines a valgus mechanical axis deviation. This indicates excessive lateral compartment loading and overall valgus malalignment.

Question 1254

Topic: 8. Foot and Ankle

During a 5 cm tibial lengthening procedure utilizing a circular external fixator, the patient gradually develops an equinus contracture of the ankle. What is the most appropriate primary prevention strategy for this complication?

. Botulinum toxin injection to the tibialis anterior
. Extending the external fixator frame to include the foot
. Prophylactic Achilles tendon lengthening prior to frame application
. Slowing the lengthening rate to 0.25 mm per day
. Performing a concurrent proximal fibular osteotomy

Correct Answer & Explanation

. Extending the external fixator frame to include the foot

Explanation

Lengthening of the tibia increases tension on the gastrocnemius-soleus complex, leading to equinus. Extending the fixator to the foot maintains the ankle in a neutral position, acting as a primary prevention strategy.

Question 1255

Topic: 8. Foot and Ankle

A 30-year-old patient with known internal tibial torsion requires a standing AP long-leg radiograph to accurately assess frontal plane knee alignment. The radiography technologist is preparing to position the patient.

To obtain a true AP view of the knee for accurate alignment assessment, how should the limb be positioned?

. With the foot pointing straight forward, irrespective of patella position
. With the patella centered on the femoral condyles, irrespective of foot position
. With the hip internally rotated to align the foot forward
. With the hip externally rotated to align the patella forward
. With the ankle joint in a neutral dorsiflexion position

Correct Answer & Explanation

. With the patella centered on the femoral condyles, irrespective of foot position

Explanation

Correct Answer: BThe text explicitly states that for a true AP view of the knee, the correct method is to orient the patella forward, irrespective of the foot position. This ensures that the knee's frontal plane (or the plane of the knee flexion-extension axis, which is approximately 3° externally rotated to the frontal plane) is perpendicular to the X-ray beam. If the foot is positioned forward in a patient with internal tibial torsion, the patella will point inward, leading to an inaccurate assessment of knee alignment (as shown in Fig. 3-1a and Fig. 3-2a). Palpating the patella and rotating the foot until the patella points forward is the described technique (Fig. 3-2b). Options A, C, D, and E describe incorrect or less accurate positioning methods for assessing true frontal plane knee alignment in the presence of torsional deformities.

Question 1256

Topic: 8. Foot and Ankle

A surgeon is performing a comprehensive deformity analysis of a patient's lower limb using the Mechanical Axis Test (MAT).

Which of the following deformities is *least reliably* identified by the Mechanical Axis Test (MAT)?

. Distal femoral varus
. Proximal tibial valgus
. Knee joint subluxation
. Ankle joint malorientation
. Medial compartment cartilage loss

Correct Answer & Explanation

. Medial compartment cartilage loss

Explanation

Correct Answer: DThe text explicitly states that 'Malorientation of the ankle or hip joints usually leads to minimal or no MAD because the deformity apex is at or near the ends of the mechanical axis of the lower limb (center points of ankle and hip) (~Fig. 2-5). Therefore, the MAT does not reliably identify the presence of tibial and femoral deformities around the ankle or hip, respectively.' The MAT is primarily a malorientation test (MOT) of the knee. Distal femoral varus (Option A), proximal tibial valgus (Option B), knee joint subluxation (Option C), and medial compartment cartilage loss (Option E) are all directly assessed or inferred by the various steps of the MAT (mLDFA, MPTA, Addendum 1, and JLCA, respectively).

Question 1257

Topic: 8. Foot and Ankle

A 28-year-old patient presents with chronic ankle pain and a suspected deformity. As part of a comprehensive deformity analysis, the orientation of the ankle joint is being assessed.

What is the normal range for the Lateral Distal Tibial Angle (LDTA) when measured relative to the tibial mechanical axis?

. 80° ± 3°
. 84° ± 5°
. 89° ± 3°
. 90° ± 5°
. 130° ± 6°

Correct Answer & Explanation

. 89° ± 3°

Explanation

Correct Answer: CThe text specifies the normal orientation of the ankle joint in the frontal plane. It states that 'The LDTA is normally 89±3° to these axes (~Fig. 2-6a).' This angle measures the orientation of the ankle joint line to the tibial mechanical and anatomic axes. Options A, B, D, and E represent incorrect values or refer to other angles (e.g., LPFA, MPFA, MNSA for the hip).

Question 1258

Topic: 8. Foot and Ankle

A patient with a complex hindfoot deformity requires a radiographic assessment of the calcaneus-tibia alignment in the frontal plane. The surgeon wants a view that clearly shows the body of the calcaneus relative to the tibial diaphysis.

Which specialized radiographic view is described as having the X-ray beam angled 45° to the X-ray plate and foot (with the foot at 90° to the tibia) to achieve this visualization?

. Mortise view
. Lateral view
. Long axial view
. Saltzman view
. Oblique view

Correct Answer & Explanation

. Long axial view

Explanation

Correct Answer: CThe text describes the 'long axial' view for assessing the alignment of the calcaneus to the tibia in the frontal plane. It states: 'To obtain this radiograph, the beam is angled 45° to the tibia with the foot at 90° to the tibia (~Fig. 3-16). The 'long axial' view can be obtained with the patient supine (~Fig. 3-16a) or standing (~Fig. 3-16b).' This view projects the tibial shaft onto the film, allowing measurement of the calcaneal axis relative to the tibial mid-diaphyseal line (Fig. 3-15). The Saltzman view (Option D) is an alternative method with a 20° beam and cassette inclination, which shows the ankle joint better but may foreshorten the calcaneus. Mortise (Option A) and Lateral (Option B) views are standard ankle views that do not provide this specific calcaneus-tibia alignment. Oblique view (Option E) is a general term for angled views but not specific to this technique.

Question 1259

Topic: 8. Foot and Ankle

A 55-year-old patient presents with a tibial deformity primarily located in the proximal metaphysis. The distal tibia appears grossly straight on the full-length standing radiograph. When planning the Distal Tibial Mechanical Axis (DMA), the surgeon initially draws a line from the center of the ankle joint, extending proximally, parallel to the mid-diaphyseal line of the distal segment. What crucial additional step, as highlighted in the case, must the surgeon perform even if the distal tibia appears straight, and why?

. Measure the bone length to ensure no limb length discrepancy, as this affects the DMA.
. Perform a Malorientation Test (MOT) of the ankle by measuring the Lateral Distal Tibial Angle (LDTA) to detect a hidden juxta-articular deformity.
. Confirm the patient's weight-bearing status, as non-weight-bearing films alter the DMA.
. Assess the fibula's alignment, as fibular deformity can indirectly affect the tibial DMA.
. Draw the anatomic axis of the distal tibia to compare it with the mechanical axis for any divergence.

Correct Answer & Explanation

. Perform a Malorientation Test (MOT) of the ankle by measuring the Lateral Distal Tibial Angle (LDTA) to detect a hidden juxta-articular deformity.

Explanation

Correct Answer: BThe case specifically includes a "Surgical Pearl" under Scenario A for drawing the Distal Tibial Mechanical Axis (DMA): "Even if the distal tibia looks perfectly straight to the naked eye, youmustperform the Malorientation Test (MOT) of the ankle. Draw the ankle plafond line and measure the LDTA. If it falls outside the 86-92° range, a hidden juxta-articular deformity is lurking, and your mid-diaphyseal line will lead to a malaligned ankle post-operatively." This emphasizes that a visually straight diaphysis does not preclude a subtle, but critical, juxta-articular deformity.Option A is incorrect. While limb length discrepancy is important, it's not the specific additional step required for accurate DMA drawing in this context.Option C is incorrect. The prerequisite forallplanning is a full-length standing weight-bearing film, so this is assumed to be already done.Option D is incorrect. While fibular alignment can be relevant in some complex cases, the immediate and crucial step for tibial DMA accuracy is the ankle MOT.Option E is incorrect. In the tibia, the mechanical and anatomic axes are considered parallel, so comparing them for divergence is not the primary concern here; the concern is the joint orientation itself.

Question 1260

Topic: 8. Foot and Ankle

A 48-year-old patient presents with a long-standing varus deformity of the right lower extremity. To accurately plan the correction, the orthopedic surgeon requires a specific type of radiograph. Which of the following is the absolute prerequisite for accurate Mechanical Axis Deviation (MAD) calculation and overall frontal plane planning?

. A supine, short knee-to-ankle AP radiograph.
. A full-length, standing, weight-bearing AP radiograph of both lower extremities.
. A lateral radiograph of the affected limb.
. A CT scan of the entire lower extremity.
. An MRI of the knee joint to assess cartilage damage.

Correct Answer & Explanation

. A full-length, standing, weight-bearing AP radiograph of both lower extremities.

Explanation

Correct Answer: BThe case explicitly states this as a "Crucial Prerequisite" for the step-by-step masterclass: "This process must be performed meticulously on a high-quality, full-length, standing, weight-bearing AP radiograph of both lower extremities. Supine films or short knee-to-ankle films are entirely useless for accurate MAD calculation, as they eliminate the effect of gravity, ligamentous laxity, and the hip joint's contribution to alignment."Option A is incorrectbecause the case specifically states these are "entirely useless" for accurate MAD calculation.Option C is incorrect. A lateral radiograph is essential for sagittal plane planning but not for frontal plane MAD calculation.Option D is incorrect. While a CT scan can provide detailed bony anatomy, it is typically performed supine and is not the primary or initial prerequisite for global frontal plane mechanical axis planning, which relies on weight-bearing films.Option E is incorrect. An MRI is excellent for soft tissue and cartilage assessment but does not provide the full-length bony alignment required for mechanical axis planning.

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