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8. Foot and Ankle MCQs

Practice Set 78 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 1541

Topic: 8. Foot and Ankle

Figures 124a and 124b are the radiographs of a 30-year-old man who sustained an ankle injury and has swelling with lateral tenderness. The patient denies any previous ankle injuries. After 6 weeks of rest and use of a removable ankle brace, he continues to have swelling, lateral pain, and popping. An anterior drawer test reveals a solid end point. Recommended treatment should include which of the following?

. Ankle arthroscopy and debridement of an osteochondral lesion
. Peroneal retinacular reconstruction
. Brostrom-Gould lateral ligament reconstruction
. Immobilization in a walker boot in plantar flexion
. Ankle rehabilitation and physical therapy

Correct Answer & Explanation

. Ankle arthroscopy and debridement of an osteochondral lesion

Explanation

The radiographs and examination reveal peroneal tendon instability requiring surgical treatment for persistent symptoms and tendon instability. The radiographs demonstrate the "fleck sign," which is an avulsion of the posterior distal fibular ridge, and represents an injury to the superior peroneal retinaculum and probable peroneal dislocation. Peroneal tendon dislocations are typically present with vague lateral ankle findings associated with swelling and tenderness over the distal fibula. The tendons may be palpated as a ridge over the lateral fibula distally. Initial management of the acute injury with cast immobilization in plantar flexion/inversion with the use of a pad in the shape of a "U" or "J" is effective in 50% of patients; the rest will require surgical treatment. The indications for surgical treatment of peroneal dislocation/subluxation include continued pain and failure of nonsurgical management. Associated peroneal tendon tears can be found when performing retinacular reconstruction. Many techniques have been described including soft-tissue reconstructions, bone block procedures as well as fibular groove-deepening procedures. Radiographs do not reveal an osteochondral lesion. There is no evidenceof lateral ankle ligament instability. Ankle rehabilitation and physical therapy may further damage the unstable tendons.

Question 1542

Topic: 8. Foot and Ankle
A 12-year-old boy has had progressive pain and flatfeet for the past year. Pain is increased with weight-bearing activities. Examination reveals that subtalar motion is absent. On standing, the patient has obvious hindfoot valgus and loss of the normal arch bilaterally. Plain radiographs are shown in Figures 43a through 43c, and a CT scan is shown in Figure 43d. What is the most likely diagnosis?
. Peroneal spastic flatfoot
. Flexible flatfoot with a short Achilles tendon
. Calcaneonavicular coalition
. Talocalcaneal coalition
. Posterior tibial tendon dysfunction

Correct Answer & Explanation

. Talocalcaneal coalition

Explanation

DISCUSSION: The axial views show fusion of the talus and calcaneus at the medial facet (talocalcaneal coalition). Peroneal spastic flatfoot is a descriptive term applying to the symptoms of painful flatfoot associated with apparent peroneal spasm and is sometimes caused by tarsal coalition; however, this is not the most appropriate diagnosis for this patient. Flexible flatfoot with a short Achilles tendon often causes symptoms similar to the ones listed above, but subtalar motion should be normal. A diagnosis of calcaneonavicular coalition can be made based on plain oblique views of the foot but is not seen in these views. Posterior tibial tendon dysfunction in the absence of other pathology is uncommon in children.

Question 1543

Topic: 8. Foot and Ankle
You are asked to evaluate the patient whose current clinical photographs are shown in Figures 46a and 46b following aortic valve replacement 9 days ago. He is currently taking anticoagulation medication. He has no systemic signs of sepsis. What is the best management?
. Warming in a water or saline bath at 104 degrees F (40 degrees C) with no dressings
. Observation with possible late debridement
. Urgent arteriogram
. Reversal of anticoagulation, parenteral antibiotics, and debridement
. Reversal of anticoagulation, parenteral antibiotics, and open forefoot amputation

Correct Answer & Explanation

. Observation with possible late debridement

Explanation

DISCUSSION: These lesions are emboli related to the cardiac surgery, and the patient is already on anticoagulation medication. The foot reveals no signs consistent with gangrene or infection. Unless the patient shows local or systemic signs of sepsis, the best management is observation. It is unlikely that formal debridement will be necessary.

Question 1544

Topic: 8. Foot and Ankle
Following application of a short leg cast, a patient reports a complete foot drop. A compression injury of the peroneal nerve at the fibular neck is confirmed by electrical studies. Which of the following muscles is expected to be the last to recover function during the ensuing months?
. Extensor digitorum longus
. Flexor digitorum longus
. Peroneus longus
. Extensor hallucis longus
. Tibialis anterior

Correct Answer & Explanation

. Extensor hallucis longus

Explanation

DISCUSSION: The recovery process from peroneal nerve palsy may take many months as axonal regrowth occurs. Of the muscles listed, the extensor hallucis longus is innervated most distally by the peroneal nerve. The flexor digitorum longus is innervated by the tibial nerve.

Question 1545

Topic: 8. Foot and Ankle

Figures A through C are the radiograph and CT scans of a 42-year-old man who sustained an injury to both of his ankles and underwent surgical repair 2 weeks prior to presentation to your office. One ankle is healing well. On the contralateral side, he reports pain and restricted ankle range of motion. Management should consist of

. the addition of more aggressive physiotherapy.
. observation and continued non-weight-bearing.
. addition of an anteriorly directed "syndesmosis screw."
. loosening the syndesmotic screws from an overtightened position.
. removal of screws, re-reduction of the syndesmosis, and revision fixation.

Correct Answer & Explanation

. the addition of more aggressive physiotherapy.

Explanation

This patient has a malreduced syndesmosis. The CT scans clearly show the fibula to be subluxated posteriorly relative to the incisura; therefore, surgical revision is warranted. Revision surgery should include either removal of the current screws with accurate reduction of the syndesmosis and new screw placement or repair of the posterior malleolar fragment, which will in turn reduce the syndesmosis. Addition of an anteriorly directed screw to the current construct will not change the malalignment. Loosening the syndesmotic screws or addition of aggressive physiotherapy will not correct the malrotation of the distal fibula within the incisura which is seen on the CT scan. Outcomes after these injuries are related to the reduction of the ankle mortise.

Question 1546

Topic: 8. Foot and Ankle
The main advantage of surgical repair of an acute Achilles tendon rupture, when compared with nonsurgical management, is reduced:
. stiffness of the ankle joint.
. risk of deep venous thrombosis.
. risk of rerupture.
. cost of care.
. tendon healing time.

Correct Answer & Explanation

. risk of rerupture.

Explanation

DISCUSSION: The literature supports similar clinical outcomes after surgical and nonsurgical methods. The chief difference lies in the complications between the groups. Surgical patients experience more wound problems but a significantly lower rerupture rate. Although suturing the tendon allows earlier mobility, the tendon healing time is unchanged. Nonsurgical methods are less expensive to provide. REFERENCES: Maffulli N: Rupture of the Achilles tendon. J Bone Joint Surg Am 1999;81:1019-1036. Cetti R, Christensen SE, Ejsted R, Jensen NM, Jorgensen U: Operative versus nonoperative treatment of Achilles tendon rupture: A prospective randomized study and review of the literature. Am J Sports Med 1993;21:791-799. Nistor L: Surgical and non-surgical treatment of Achilles tendon rupture. J Bone Joint Surg Am 1981;63:394-399.

Question 1547

Topic: 8. Foot and Ankle
What is the most appropriate orthotic management for the lesion shown in Figure 6?
. Metatarsal pad
. Morton’s extension orthosis
. Medial longitudinal arch support
. Budin splint
. Viscoelastic heel lift

Correct Answer & Explanation

. Metatarsal pad

Explanation

DISCUSSION: The figure shows an intractable plantar keratosis (IPK). The keratoma usually forms beneath a bony prominence. This can occur under the sesamoids, most commonly the tibial sesamoid, or under the fibular condyle of a prominent metatarsal head. The initial treatment of an IPK consists of paring down the callused lesion and placing a metatarsal pad proximal to the lesion to provide posting to unload the bony prominence. REFERENCE: Rudicel SA: Intractable plantar keratoses, in Gould J (ed): Operative Foot Surgery. Philadelphia, PA, WB Saunders, 1994, p 70.

Question 1548

Topic: 8. Foot and Ankle
  • Which of the following procedures is associated with the highest risk of osteonecrosis of the metatarsal head?
. Distal chevron osteotomy with soft-tissue release
. Distal soft-tissue realignment only
. Closing wedge osteotomy (Aken) of the proximal phalanx
. Proximal first metatarsal osteotomy only
. Soft-tissue realignment with a proximal metatarsal osteotomy

Correct Answer & Explanation

. Distal chevron osteotomy with soft-tissue release

Explanation

1 – Complications of distal chevron osteotomy with soft tissue release are incomplete correction and avascular necrosis (1 – 2%). 2 – Complications of distal soft tissue realignment only are recurrence of deformity, inadequate lateral release, are hallux varus. 3 – Complications of the Aken procedure are an increase in the hallux valgus deformity. 4 ,5 – Complications of proximal first metatarsal osteotomy are hallux varus and shortening.

Question 1549

Topic: Forefoot
  • A 40-year old man has limited, painful motion in dorsiflexion at the metatarsophalangeal (MTP) joint of the right great toe, despite nonsurgical treatment. Radiographs show dorsal and medial osteophytes and minimal narrowing of the articular space. Treatment should consist of
. Arthrodesis of the MTP joint
. A Silastic implant of the MTP joint
. Resection arthroplasty of the MTP joint
. Cheilctomy of the MTP joint
. Osteotomy of the base of the proximal phalanx

Correct Answer & Explanation

. Arthrodesis of the MTP joint

Explanation

Cheilectomy, the excision of an irregular osseous rim that interferes with motion of a joint was performed on the distal part of the metatarsal of patients who had hallux rigidus. In this study by Mann, published in JBJS 1988, they were able to conclude that cheilectomy is a better method of treatment for hallux rigidus than arthrodesis, resection arthroplasty, or arthroplasty with the use of a flexible implant. In older adults who present late, with more severe X-Ray changes, Keller procedure is indicated.

Question 1550

Topic: 8. Foot and Ankle
Figure 28 is the radiograph of a 25-year-old soccer player who twisted her left ankle 1 week ago. She has pain and swelling over the anterolateral ankle and there is ecchymosis over the lateral ankle. She has these muscle group findings: anterior tibial tendon-right 5/5, left 5/5; posterior tibial tendon-right 5/5, left 5/5; peroneals-right 5/5, left 4/5; Achilles-right 5/5, left 5/5. What is the best next diagnostic or treatment step?
. Stress radiographs
. Surgical resection of the fragment with lateral ligament reconstruction
. Physical therapy for peroneal strengthening and proprioceptive training
. Ankle arthroscopy for debridement

Correct Answer & Explanation

. Physical therapy for peroneal strengthening and proprioceptive training

Explanation

In this case, a young athlete sprained her ankle. Her only area of tenderness is isolated to the anterior talofibular ligament. She also has associated weakness. The radiograph shows an os subfibulare; this is an entity that she likely was born with. There is no indication of bony pain, and it is too soon to test for instability; consequently, no further imaging is required. Considering the nature of the sprain and her weakness, physical therapy with proprioceptive training and peroneal strengthening would be most beneficial.

Question 1551

Topic: 8. Foot and Ankle
An active 48-year-old woman has had progressive retrocalcaneal pain for the past 2 years. She reports that an injection into the retrocalcaneal bursa 3 weeks ago provided relief, but she now has swelling and weakness after tripping on the stairs 3 days ago. The Thompson test is positive. A radiograph is shown in Figure 36. What is the next most appropriate step in management?
. MRI to rule out a complete rupture
. Ultrasound of the tendon apposition
. Open reduction and internal fixation of the calcaneal fracture
. Symptomatic care and physical therapy
. Surgical repair with tendon debridement and flexor hallucis longus transfer

Correct Answer & Explanation

. Surgical repair with tendon debridement and flexor hallucis longus transfer

Explanation

The patient’s long-standing symptoms and radiograph indicate a chronic insertional Achilles tendinopathy that has progressed to complete rupture. This situation is best treated with tendon debridement and repair, often requiring a supplementation graft from the flexor hallucis longus. MRI could provide additional information on the quality of the Achilles tendon, but neither MRI nor ultrasound is necessary to make a diagnosis or determine the surgical indication. Conservative management will be unpredictable with a chronic degenerative tendon injury.

Question 1552

Topic: 8. Foot and Ankle

Which one of the following lower extremity amputations requires a soft-tissue balancing procedure to prevent deformity following amputation? Review Topic

. Gritti-Stokes
. Transtibial
. Transmetatarsal
. Knee disarticulation
. Lisfranc

Correct Answer & Explanation

. Gritti-Stokes

Explanation

The Lisfranc level amputation removes the attachment of the peroneus brevis (base of the fifth metatarsal) and the peroneus longus (base of the first metatarsal), creating a varus deformity due to unopposed overpull by the tibialis anterior and posterior muscles. An anterior tibialis tendon transfer may be necessary. Other possible tissue balancing choices include posterior tibialis transfer and lengthening of the gastrocsoleus complex. Another option is to leave the base of the fifth metatarsal attached to preserve the eversion pull of the peroneus brevis. All the other amputations do not require soft-tissue balancing procedures to prevent deformities. However, adherence to the prescribed surgical techniques for reattachment of major muscle groups is important for optimizing limb strength and function.

Question 1553

Topic: 8. Foot and Ankle

A 19-year-old female field hockey player sustains a right ankle injury last night during a game. The patient is on crutches and reports that she has not been able to put any weight on her right ankle since the injury. She was running alongside with another player when her right ankle “gave out” and she twisted it, falling to the ground. Physical examination reveals discoloration similar to a hematoma and significant swelling around the lateral ankle area. Pain is elicited during palpation of the anterior talofibular ligament. What is the most appropriate course of action for this patient’s condition?

. Early mobilization and a guided proprioceptive and strengthening
. Extended immobilization in a cast
. Surgical intervention
. Weight bearing as tolerated in an ankle brace for 6 weeks

Correct Answer & Explanation

. Early mobilization and a guided proprioceptive and strengthening

Explanation

The anterior drawer test is performed with the ankle in 10° of plantar flexion, which results in the greatest amount of translation. The test investigates the integrity of the anterior talofibular ligament with a key distance of translation being 8 to 10 mm. While the patient is sitting and has her knees flexed over the edge of a table or bench, the physician uses one hand to stabilize the distal leg and with the other hand applies an anterior force to the heel in an attempt to gap the talus anteriorly from under the tibia. The anterior talofibular ligament and calcaneofibular ligament are both compromised based on the examination findings. The anterior drawer test result reflects injury to the anterior talofibular ligament and a possible injury to the calcaneofibular ligament. A lateral talar tilt test angle measurement >15° degrees reflects a rupture of both anterior talofibular ligament and calcaneofibular ligaments. Thediagnosis is a severe lateral ligament complex sprain. This is optimally managed with early mobilization and a guided rehabilitation program that emphasizes proprioceptive stability.

Question 1554

Topic: 8. Foot and Ankle
Figure 11 shows the radiograph of an 18-year-old soccer player who reports recurrent lateral foot pain after sustaining an inversion injury. History reveals that 6 months ago he had been treated in a non-weight-bearing cast for a fifth metatarsal fracture. Management should consist of
. intramedullary fixation.
. a brace or taping to limit inversion stress.
. a short leg walking cast or a fracture walker.
. a non-weight-bearing short leg cast.
. a rigid orthotic insole, with early motion exercises.

Correct Answer & Explanation

. intramedullary fixation.

Explanation

DISCUSSION: Fractures in this area of the fifth metatarsal have a high incidence of delayed union, nonunion, and recurrence with nonsurgical management. In an acute fracture, prolonged casting in a non-weight-bearing cast may allow for healing; however, in the presence of prolonged symptoms, recurrent fracture, and intramedullary sclerosis, surgical treatment is preferred. Surgery most commonly consists of intramedullary fixation or medullary curettage and bone grafting, followed by application of a non-weight-bearing cast. REFERENCES: Torg JS, Balduini FC, Zelko RR, Pavlov H, Peff TC, Das M: Fractures of the base of the fifth metatarsal distal to the tuberosity: Classification and guidelines for nonsurgical and surgical management. J Bone Joint Surg Am 1984;66:209-214. DeLee JC: Fractures and dislocations of the foot, in Mann R, Coughlin M (eds): Surgery of the Foot and Ankle, ed 6. St Louis, MO, Mosby, 1993, pp 1465-1503.

Question 1555

Topic: 8. Foot and Ankle

-Figures 3a and 3b are the clinical photographs of a 35-year-old man seen 3 months after repair of an acute Achilles tendon rupture. He has no constitutional symptoms and is unable to perform a single heelrise test. The most appropriate treatment is

. swab culture of the sinus tract and appropriate oral antibiotics for 6 weeks followed by Achilles reconstruction.
. excision of the distal Achilles tendon with flexor hallucis longus tendon transfer to thecalcaneus followed by culture-specific intravenous antibiotics for 12 weeks.
. debridement of the Achilles tendon followed by culture-specific intravenous antibiotics for 6 weeks.
. debridement of the Achilles tendon with free-flap application and culture-specific intravenous antibiotics for 6 weeks.
. debridement of the Achilles tendon with turndown procedure and culture-specific intravenous antibiotics for 12 weeks.

Correct Answer & Explanation

. swab culture of the sinus tract and appropriate oral antibiotics for 6 weeks followed by Achilles reconstruction.

Explanation

Question 1556

Topic: 8. Foot and Ankle
In the nonsurgical management of posterior tibial tendon dysfunction with flexible deformity, a common strategy is to prescribe an ankle-foot orthosis or a University of California Biomechanics Laboratory (UCBL) orthosis with medial posting. A high patient satisfaction rating and favorable outcome with this nonsurgical management is most likely in which of the following situations?
. Relatively young, active patient
. Patient with an inflammatory systemic disorder
. Elderly patient with a sedentary lifestyle
. Patient with severe arthritis of the ipsilateral hip or knee
. Patient with Parkinson’s disease

Correct Answer & Explanation

. Elderly patient with a sedentary lifestyle

Explanation

Most authors recommend an initial trial of nonsurgical management in the treatment of adult-acquired flatfoot deformity such as posterior tibial tendon dysfunction. Chao and associates found that there is high patient satisfaction with ankle-foot orthoses and UCBL-type inserts in elderly patients with a relatively sedentary lifestyle. Alternatively, there was a higher dissatisfaction rate in young active patients, those with balance and ambulation difficulties (Parkinson’s, severe arthritis of the hip or knee), and patients with inflammatory systemic disorders.

Question 1557

Topic: 8. Foot and Ankle
A 30-year-old woman injured her ankle playing soccer 3 months ago. She now reports popping and pain over the lateral side of her ankle. An MRI scan is shown in Figure 33. What structure needs to be repaired to alleviate the popping?
. Peroneal longus tendon
. Peroneal brevis tendon
. Superior peroneal retinaculum
. Anterior talofibular ligament
. Calcaneofibular ligament

Correct Answer & Explanation

. Superior peroneal retinaculum

Explanation

The symptoms and MRI scan indicate dislocated peroneal tendons. In this patient, the structure that needs to be repaired is the superior peroneal retinaculum. If the popping was coming from a torn peroneal tendon, repair would involve the peroneal longus or brevis tendon, but this is not shown in the MRI scan. The anterior talofibular ligament or the calcaneofibular ligament would need to be repaired if the patient had ankle instability due to an ankle sprain.

Question 1558

Topic: 8. Foot and Ankle
An active 60-year-old man is evaluated 4 years following surgical correction of a hallux valgus deformity. The patient reports that a hallux varus deformity developed rapidly following his initial surgery. Conservative management consisting of wider shoes, toe strapping, and anti-inflammatory drugs has failed to provide relief. Examination reveals a hallux varus deformity with restricted painful motion of the metatarsophalangeal joint and callus formation under the second metatarsal head. What is the next most appropriate step in management?
. Fascial arthroplasty
. Metatarsophalangeal joint arthrodesis
. Metatarsophalangeal joint Silastic arthroplasty
. Extensor tendon reconstruction
. Keller resection arthroplasty

Correct Answer & Explanation

. Metatarsophalangeal joint arthrodesis

Explanation

Hallux varus may occur as a complication following hallux valgus surgery. Conservative management is the initial treatment of choice; however, if unsuccessful, surgical options for reconstruction include soft-tissue reconstruction or metatarsophalangeal joint arthrodesis. The patient has evidence of joint arthrosis, making an arthrodesis the preferred method of reconstruction.

Question 1559

Topic: 8. Foot and Ankle
An 8-year-old boy with severe hemophilia A (factor VIII) and no inhibitor is averaging eight transfusions per month for bleeding into the right ankle. Examination shows synovial hypertrophy; range of motion consists of 0° of dorsiflexion and 20° of plantar flexion. The patient’s knees, elbows, and left ankle have no restriction of motion. Standing radiographs of the right ankle are shown in Figure 18. Management should consist of:
. Prophylactic transfusions three times per week
. Application of ankle-foot orthoses
. Ankle synovectomy
. Ankle arthrodesis performed with physeal protection
. Pantalar arthrodesis

Correct Answer & Explanation

. Ankle synovectomy

Explanation

The patient has bilateral hypertrophic synovitis that is causing repeated hemarthroses and progressive arthropathy. Ankle synovectomy in patients with hemophilia is effective in significantly reducing the rate of joint bleeding and in slowing the progression of the arthropathy; therefore, synovectomy is the treatment of choice.

Question 1560

Topic: 8. Foot and Ankle
Figure 8 shows the CT scan of an 11-year-old boy who has had a 1-year history of worsening painful flatfeet. He reports pain associated with physical education at school, especially with running and jumping. Management consisting of activity restriction, anti-inflammatory drugs, and casting has failed to provide relief. Treatment should now consist of:
. A subtalar arthroereisis with a titanium implant
. Triple arthrodesis
. Resection of the accessory navicular and advancement of the posterior tibial tendon bilaterally
. Resection of the talocalcaneal middle facet coalition in each foot
. Resection of the calcaneonavicular coalition in both feet

Correct Answer & Explanation

. Resection of the talocalcaneal middle facet coalition in each foot

Explanation

In most patients with symptomatic talocalcaneal coalition involving less than 50% of the subtalar joint, resection with fat graft interposition is preferred over a subtalar or triple arthrodesis, especially if reasonable range of motion can be achieved.

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