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8. Foot and Ankle MCQs

Practice Set 75 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 1481

Topic: 8. Foot and Ankle

A 24-year-old elite athlete sustains a purely ligamentous Lisfranc injury with 3 mm of widening between the medial cuneiform and the base of the second metatarsal. Based on prospective randomized data comparing open reduction internal fixation (ORIF) to primary arthrodesis for this specific injury pattern, primary arthrodesis is associated with which of the following?

. Higher rates of hardware failure and unplanned reoperation
. Decreased midfoot stability in the sagittal plane
. Inferior American Orthopaedic Foot and Ankle Society (AOFAS) scores at 2 years
. A lower rate of secondary surgical procedures and superior functional outcomes
. Increased rates of complex regional pain syndrome (CRPS)

Correct Answer & Explanation

. A lower rate of secondary surgical procedures and superior functional outcomes

Explanation

In purely ligamentous Lisfranc injuries (without associated large bony fractures), primary arthrodesis of the medial column (TMT 1-3) has been shown to yield superior functional outcomes and lower rates of secondary surgeries (such as hardware removal or conversion to fusion due to post-traumatic arthritis) compared to ORIF. This was classically demonstrated in the prospective randomized study by Ly and Coetzee (JBJS 2006).

Question 1482

Topic: Midfoot & Hindfoot
A 52-year-old male with long-standing, poorly controlled type 2 diabetes presents with a red, hot, and severely swollen left foot. He is afebrile and has normal white blood cell counts. Radiographs show extensive bone fragmentation, subluxation of the tarsometatarsal joints, and osseous debris, with no distinct fracture lines. According to the Eichenholtz classification, what is the stage of this Charcot arthropathy and what is the most appropriate initial management?
. Stage 0; Intravenous antibiotics
. Stage I; Total contact casting and non-weight-bearing
. Stage II; Urgent open reduction and internal fixation
. Stage III; Custom accommodative footwear
. Stage I; Primary midfoot arthrodesis

Correct Answer & Explanation

. Stage I; Total contact casting and non-weight-bearing

Explanation

The patient is in Eichenholtz Stage I (Developmental/Fragmentation phase) of Charcot neuroarthropathy, characterized clinically by a red, hot, swollen foot and radiographically by bone fragmentation, joint subluxation/dislocation, and debris. The gold standard initial management to halt progression and prevent further deformity is immobilization with a total contact cast (TCC) and restricted weight-bearing until the acute inflammatory phase resolves and the bones begin to coalesce (Stage II).

Question 1483

Topic: Forefoot

A 45-year-old female presents with hallux rigidus. She complains of dorsal impingement pain at the first metatarsophalangeal (MTP) joint, specifically with forced dorsiflexion. Clinical exam shows she has 40 degrees of dorsiflexion. Radiographs reveal dorsal osteophytes, but the joint space is generally preserved and there are no large cystic changes. According to the Coughlin and Shurnas classification, what is her grade and most appropriate surgical treatment if conservative measures fail?

. Grade 1; First MTP arthrodesis
. Grade 2; Dorsal cheilectomy
. Grade 3; Silastic joint replacement
. Grade 3; First MTP arthrodesis
. Grade 4; Keller resection arthroplasty

Correct Answer & Explanation

. Grade 2; Dorsal cheilectomy

Explanation

The patient has Coughlin and Shurnas Grade 2 hallux rigidus (mild-to-moderate joint space narrowing, dorsal osteophytes, dorsiflexion >30 degrees but pain at the end of range). The treatment of choice for symptomatic Grade 1 and 2 hallux rigidus that fails conservative management is a dorsal cheilectomy (excision of the dorsal osteophytes and the dorsal one-third of the metatarsal head).

Question 1484

Topic: 8. Foot and Ankle

A 15-year-old male with Charcot-Marie-Tooth disease presents with a rigid cavovarus foot deformity. During the Coleman block test, placing the lateral heel on a block and allowing the first metatarsal to drop off significantly corrects the hindfoot varus to neutral. This finding indicates that the primary deforming force driving the hindfoot varus is the plantarflexed first ray. Which muscle imbalance is directly responsible for this plantarflexed first ray?

. Overactivity of the tibialis posterior relative to the peroneus brevis
. Overactivity of the peroneus longus relative to the tibialis anterior
. Weakness of the flexor hallucis longus relative to the extensor hallucis longus
. Overactivity of the tibialis anterior relative to the peroneus longus
. Contracture of the Achilles tendon overpowering the ankle dorsiflexors

Correct Answer & Explanation

. Overactivity of the peroneus longus relative to the tibialis anterior

Explanation

In a classic cavovarus foot (frequently seen in CMT), the hallmark early muscle imbalance is the overactivity of the peroneus longus muscle relative to a weak tibialis anterior. The strong peroneus longus forcefully plantarflexes the first ray. When the foot hits the ground, this rigid plantarflexed first ray acts as a kickstand, driving the hindfoot into compensatory varus. The Coleman block test confirms if the hindfoot varus is driven by this forefoot pathology.

Question 1485

Topic: 8. Foot and Ankle

A 45-year-old male requires surgical reconstruction for a chronic Achilles tendon rupture with a 6-cm defect. A flexor hallucis longus (FHL) tendon transfer is planned. Which of the following represents a biomechanical advantage of the FHL transfer over a flexor digitorum longus (FDL) transfer for this indication?

. The FHL has a smaller cross-sectional area, reducing donor site morbidity
. The FHL fires in a different phase of gait, allowing for antagonistic balancing
. The FHL possesses a significantly larger physiologic cross-sectional area and a more coaxial line of pull
. The FHL tendon is shorter, allowing for greater tensioning across the defect
. The FHL does not require detachment from the midfoot, preserving toe flexion

Correct Answer & Explanation

. The FHL possesses a significantly larger physiologic cross-sectional area and a more coaxial line of pull

Explanation

The FHL is the preferred transfer for chronic Achilles tendon defects because it is the second strongest plantarflexor of the foot (behind the triceps surae), possessing a physiologic cross-sectional area nearly twice that of the FDL. Furthermore, its anatomical position allows for an axis of pull that is highly coaxial with the Achilles tendon, and it fires in phase with the gastrosoleus complex.

Question 1486

Topic: Midfoot & Hindfoot

A 55-year-old female with Stage IIb Adult Acquired Flatfoot Deformity (AAFD) is planned for reconstruction. The surgeon intends to perform a medializing calcaneal osteotomy and a flexor digitorum longus (FDL) transfer to the navicular. What specific radiographic finding is the primary indication to add a lateral column lengthening (Evans osteotomy) to this surgical construct?

. Talonavicular uncoverage of 20%
. Meary's angle of 5 degrees
. Hindfoot valgus of 10 degrees
. Talonavicular uncoverage greater than 40%
. Calcaneal pitch of 15 degrees

Correct Answer & Explanation

. Talonavicular uncoverage greater than 40%

Explanation

Stage IIb AAFD denotes a flexible flatfoot with significant forefoot abduction. Forefoot abduction is assessed radiographically on the AP view of the foot via talonavicular uncoverage. When talonavicular uncoverage exceeds 40%, a lateral column lengthening (Evans calcaneal osteotomy) is indicated to restore the length of the lateral column and swing the forefoot out of abduction, pivoting around the intact plantar medial calcaneonavicular (spring) ligament complex.

Question 1487

Topic: 8. Foot and Ankle

During the physical examination of a patient with a cavovarus foot deformity, the Coleman block test is performed. The patient stands with the heel and lateral border of the foot on a 1-inch block, allowing the first metatarsal to drop freely off the medial edge. If the hindfoot varus corrects to neutral during this test, what is the primary driver of the hindfoot deformity?

. Contracture of the Achilles tendon
. Rigid subtalar joint arthritis
. Spasticity of the tibialis posterior
. Plantarflexed first ray
. Weakness of the peroneus brevis

Correct Answer & Explanation

. Plantarflexed first ray

Explanation

The Coleman block test evaluates the flexibility of the hindfoot and differentiates forefoot-driven from hindfoot-driven varus. If placing the foot on a lateral block (which eliminates the effect of the plantarflexed first ray by allowing it to drop) causes the hindfoot varus to correct, the deformity is flexible and is driven by the rigid plantarflexed first ray. A dorsiflexion osteotomy of the 1st metatarsal is generally required.

Question 1488

Topic: 8. Foot and Ankle
A 58-year-old diabetic patient presents with a swollen, erythematous, and warm foot without an open ulcer. Laboratory markers (WBC, ESR, CRP) are within normal limits. Radiographs demonstrate periarticular debris, subluxation of the tarsometatarsal joints, and early fragmentation. According to the Eichenholtz classification, what stage is this, and what is the standard initial treatment?
. Stage I; Total contact casting and non-weight bearing
. Stage II; Immediate midfoot arthrodesis
. Stage III; Custom accommodative orthoses
. Stage I; Intravenous antibiotics and surgical debridement
. Stage II; Intravenous antibiotics and surgical debridement

Correct Answer & Explanation

. Stage I; Total contact casting and non-weight bearing

Explanation

The clinical picture represents Eichenholtz Stage I (Development/Fragmentation) of Charcot neuroarthropathy, characterized clinically by the 'red, hot, swollen' foot and radiographically by fragmentation, debris, and subluxation. Infection must be ruled out (which is likely here given normal labs and no ulcer). The gold standard of care during the active Stage I phase is immobilization and offloading, typically utilizing a total contact cast (TCC), to prevent progressive deformity.

Question 1489

Topic: Midfoot & Hindfoot
A 55-year-old female presents with progressive foot pain and flattening of her medial longitudinal arch. On examination, she is unable to perform a single-limb heel rise. Weight-bearing radiographs demonstrate >50% uncovering of the talonavicular joint. Examination confirms the hindfoot deformity remains flexible. What is the most appropriate surgical intervention?
. Gastrocnemius recession and medial displacement calcaneal osteotomy alone
. Subtalar arthrodesis and flexor digitorum longus (FDL) transfer
. Triple arthrodesis
. FDL transfer, medial displacement calcaneal osteotomy, and lateral column lengthening
. Spring ligament repair and isolated subtalar arthroereisis

Correct Answer & Explanation

. FDL transfer, medial displacement calcaneal osteotomy, and lateral column lengthening

Explanation

This patient has a Stage IIB adult-acquired flatfoot deformity (flexible, >50% TN uncovering/forefoot abduction). Treatment requires soft tissue reconstruction (FDL transfer) combined with both a medial displacement calcaneal osteotomy and lateral column lengthening to correct the severe forefoot abduction.

Question 1490

Topic: 8. Foot and Ankle

A 25-year-old male sustains a purely ligamentous Lisfranc injury. Based on high-level randomized controlled trials comparing open reduction internal fixation (ORIF) to primary partial midfoot arthrodesis for this specific injury pattern, which of the following is true regarding primary arthrodesis?

. It results in an increased rate of complex regional pain syndrome.
. It is associated with higher rates of hardware failure and implant breakage.
. It yields inferior long-term American Orthopaedic Foot and Ankle Society (AOFAS) scores.
. It results in a lower reoperation rate and higher functional outcomes.
. It requires a significantly longer period of non-weight-bearing postoperatively.

Correct Answer & Explanation

. It results in a lower reoperation rate and higher functional outcomes.

Explanation

Randomized controlled trials have demonstrated that primary arthrodesis for purely ligamentous Lisfranc injuries leads to lower reoperation rates (primarily avoiding hardware removal) and equal or superior functional outcomes compared to ORIF.

Question 1491

Topic: 8. Foot and Ankle

A 52-year-old male with long-standing poorly controlled diabetes presents with a unilaterally swollen, erythematous, and warm foot. He denies recent trauma or pain. Pulses are bounding. Radiographs demonstrate periarticular debris, fragmentation, and subluxation at the tarsometatarsal joints. What is the most appropriate initial treatment?

. Total contact casting and strict non-weight-bearing
. Urgent open reduction and internal fixation of the tarsometatarsal joints
. Intravenous antibiotics and surgical debridement
. Primary midfoot arthrodesis with a rigid plantar plate
. Custom orthotic shoe wear and weight-bearing as tolerated

Correct Answer & Explanation

. Total contact casting and strict non-weight-bearing

Explanation

The patient is presenting with acute Eichenholtz Stage I (fragmentation stage) Charcot neuroarthropathy. The gold standard for initial management of the acute, active phase is offloading and immobilization using a total contact cast to prevent further deformity.

Question 1492

Topic: 8. Foot and Ankle

A 45-year-old recreational runner fails 6 months of conservative management for severe insertional Achilles tendinopathy and a large Haglund's deformity. Surgical intervention is planned, involving detachment of the Achilles tendon, resection of the bursa and prominent bone, and reattachment. What is the generally accepted maximum percentage of the Achilles insertion that can be detached before a flexor hallucis longus (FHL) transfer is required for augmentation?

. 25%
. 33%
. 50%
. 75%
. 90%

Correct Answer & Explanation

. 50%

Explanation

During debridement for insertional Achilles tendinopathy, up to 50% of the tendon insertion can be detached and primarily repaired using suture anchors. If >50% is compromised, augmentation with an FHL transfer is generally recommended.

Question 1493

Topic: 8. Foot and Ankle

A 58-year-old male with end-stage post-traumatic ankle osteoarthritis is scheduled for an open ankle arthrodesis. To optimize postoperative gait mechanics and minimize adjacent joint arthritis, what is the most appropriate target position for the fusion?

. 5 degrees of plantarflexion, neutral coronal alignment, neutral rotation
. Neutral dorsiflexion, 0 to 5 degrees of valgus, 5 to 10 degrees of external rotation
. 5 degrees of dorsiflexion, 5 degrees of varus, neutral rotation
. Neutral dorsiflexion, 5 degrees of varus, 15 degrees of external rotation
. 10 degrees of plantarflexion, 0 to 5 degrees of valgus, internal rotation matched to the contralateral side

Correct Answer & Explanation

. Neutral dorsiflexion, 0 to 5 degrees of valgus, 5 to 10 degrees of external rotation

Explanation

The optimal position for ankle arthrodesis is neutral dorsiflexion (0 degrees), 0 to 5 degrees of hindfoot valgus, and external rotation matching the contralateral side (typically 5 to 10 degrees) to facilitate normal rollover during gait.

Question 1494

Topic: Forefoot

A 65-year-old female presents with severe pain and stiffness in her first metatarsophalangeal (MTP) joint. Examination reveals less than 10 degrees of total dorsiflexion and severe pain in the mid-arc of motion. Radiographs demonstrate diffuse joint space narrowing, large dorsal osteophytes, and subchondral sclerosis. What is the most reliable, gold-standard surgical treatment for this condition?

. Extracorporeal shockwave therapy
. Dorsal cheilectomy with Moberg osteotomy
. First MTP arthrodesis
. Silicone implant arthroplasty
. Keller resection arthroplasty

Correct Answer & Explanation

. First MTP arthrodesis

Explanation

This patient has Grade 3/4 hallux rigidus (diffuse arthritis, severe restriction of motion, pain in mid-arc). The gold standard treatment providing the most reliable pain relief and functional improvement is a first MTP arthrodesis.

Question 1495

Topic: 8. Foot and Ankle

A 32-year-old female with Charcot-Marie-Tooth disease presents with severe, progressive bilateral cavovarus foot deformities. On examination, a Coleman block test is performed; the hindfoot varus does not correct when the first metatarsal is allowed to drop off the block. Which of the following procedures is absolutely required as part of her surgical reconstruction?

. Dorsiflexion osteotomy of the first metatarsal
. Transfer of the peroneus longus to the peroneus brevis
. Plantar fascia release
. Subtalar or triple arthrodesis
. Medial displacement calcaneal osteotomy

Correct Answer & Explanation

. Subtalar or triple arthrodesis

Explanation

A positive Coleman block test (hindfoot remains in varus) indicates a rigid, structural hindfoot deformity. While soft tissue releases and forefoot osteotomies may be adjuncts, a rigid hindfoot varus requires a bony fusion (subtalar or triple arthrodesis) for adequate correction.

Question 1496

Topic: 8. Foot and Ankle
A 12-year-old girl with foot pain who has been diagnosed with hereditary motor sensory neuropathy is seen for the foot deformity shown in Figure 59a. A “block test” is performed and shown in Figure 59b. What is the most appropriate management for this patient?
. Observation
. Corrective shoes
. Plantar release with first metatarsal osteotomy and possible tendon transfers
. Calcaneal osteotomy
. Triple arthrodesis

Correct Answer & Explanation

. Plantar release with first metatarsal osteotomy and possible tendon transfers

Explanation

The hindfoot varus in this individual with a cavovarus deformity is nonstructural as shown by the “block test”. Therefore, surgical procedures directed at correcting the hindfoot deformity are not necessary. Observation is not in order and shoe modifications have not been shown to be effective in managing this problem. The patient is symptomatic; therefore, the treatment of choice is plantar release with first metatarsal osteotomy and possible tendon transfers.

Question 1497

Topic: 8. Foot and Ankle

Figures 191a and 191b are the radiographs of an 18-year-old man who had an ankle fracture requiring open reduction and internal fixation 2 years ago. He has a progressive symptomatic ankle deformity.Surgical intervention should consist of

. ankle arthrodesis.
. total ankle arthroplasty.
. supramalleolar tibial osteotomy.
. valgus-producing calcaneal osteotomy.
. epiphyseodesis of the distal tibial physis.

Correct Answer & Explanation

. ankle arthrodesis.

Explanation

Question 1498

Topic: 8. Foot and Ankle
A 60-year-old man reports increasing pain in his right foot with limited ankle dorsiflexion and anterior ankle pain after sustaining a fracture of the calcaneus in a fall several years ago. Bracing, nonsteroidal anti-inflammatory drugs, and cortisone injections have failed to provide significant relief. Radiographs are shown in Figures 19a and 19b. What is the next most appropriate step in management?
. Subtalar distraction arthrodesis
. Subtalar arthroscopy with debridement
. Custom orthotics
. Ankle arthrodesis
. Calcaneal osteotomy

Correct Answer & Explanation

. Subtalar distraction arthrodesis

Explanation

DISCUSSION: Following a calcaneal fracture, the patient has severe subtalar arthritis with loss of talar declination and shortening of the heel; therefore, the treatment of choice is subtalar distraction arthrodesis. Orthotics will not provide significant relief as bracing has failed. Ankle arthrodesis will not be beneficial because the arthritis is in the subtalar joint. Subtalar arthroscopy would only be helpful for a small area of arthrosis, and calcaneal osteotomy would not be beneficial given the extent of the arthritis of the subtalar joint. REFERENCE: Robinson TF, Murphy GA: Arthrodesis as salvage for calcaneal avulsions. Foot Ankle Clin 2002;7:107-120.

Question 1499

Topic: Forefoot
A 48-year-old man has had pain and swelling of the hallux metatarsophalangeal joint for the past 9 months. A rocker bottom stiff-soled shoe has failed to provide relief; however, two cortisone injections have temporarily alleviated his symptoms. The radiographs shown in Figures 20a and 20b reveal diffuse arthritis of the entire hallux metatarsophalangeal joint. What is the most definitive surgical treatment?
. Dorsal cheilectomy
. Keller resection arthroplasty
. Silastic joint replacement
. Hallux metatarsophalangeal arthrodesis
. Hallux valgus correction

Correct Answer & Explanation

. Hallux metatarsophalangeal arthrodesis

Explanation

DISCUSSION: Because the radiographs demonstrate severe arthritis, hallux metatarsophalangeal arthrodesis is the treatment of choice. Cheilectomy alone will not relieve pain because the entire joint is degenerative. Joint replacement has not been shown to be a long-term solution. Keller resection arthroplasty is not indicated in younger active patients. Hallux valgus correction will not address arthritis of the joint and could stiffen the joint further. REFERENCES: Smith RW, Joanis TL, Maxwell PD: Great toe metatarsophalangeal joint arthrodesis: A user-friendly technique. Foot Ankle 1992;13:367-377. Mann RA: Hallux rigidus. Instr Course Lect 1990;39:15-21.

Question 1500

Topic: 8. Foot and Ankle
What is the optimum position of immobilization of the foot and ankle immediately after Achilles tendon repair to maximize skin perfusion?
. Ten degrees of dorsiflexion
. Ten degrees of plantar flexion
. Twenty degrees of plantar flexion
. Neutral
. Resting equinus

Correct Answer & Explanation

. Twenty degrees of plantar flexion

Explanation

DISCUSSION: Achilles tendon tension is not affected by knee position when the ankle is in 20° to 25° of plantar flexion. Skin perfusion overlying the Achilles tendon is maximal in 20° of plantar flexion and is reduced beyond 20° of plantar flexion. Neutral flexion or any amount of dorsiflexion compromises the repair. REFERENCE: Poynton AR, O’Rourke K: An analysis of skin perfusion over the Achilles tendon in varying degrees of plantar flexion. Foot Ankle Int 2001;22:572-574.

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