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8. Foot and Ankle MCQs

Practice Set 79 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 1561

Topic: 8. Foot and Ankle
A 42-year-old female undergoes a subtalar bone block distraction arthrodesis as sequelae of a nonoperatively treated calcaneus fracture ten years prior. This procedure addresses which of the following issues?
. Hindfoot valgus
. Midfoot supination
. Sinus tarsi impingement
. Anterior ankle impingement
. Hammertoe deformity

Correct Answer & Explanation

. Anterior ankle impingement

Explanation

DISCUSSION: The subtalar fusion technique involves distraction of the subtalar joint, insertion of a bone block, fusion, and rigid screw fixation. The distraction allows correction of the talocalcaneal relationship. Based on the literature, this procedure ultimately addresses the lost hindfoot height, subtalar arthritis, ankle impingement (improvement of the talus-first metatarsal axis), and peroneal impingement. It does not address hindfoot valgus; the deformity after a calcaneus fracture is usually from lateral wall blowout and hindfoot varus.

Question 1562

Topic: 8. Foot and Ankle

A patient falls off a roof and sustains the fracture shown in Figure 29. What is the most likely complication that results from injury to the structure that is located at the arrow?

. Paresthesias on the plantar aspect of the foot
. Pain or popping with great toe flexion
. Loss of the arch
. Inability to flex the lesser toes
. Spring ligament rupture

Correct Answer & Explanation

. Paresthesias on the plantar aspect of the foot

Explanation

The arrow points to the sustentaculum tali, which is fractured off the tuberosity of the calcaneus. The flexor hallucis longus (FHL) tendon runs directly under this structure. An injury to this structure could cause stenosis around the FHL tendon which would cause pain with great toe flexion. Paresthesias on the plantar aspect of the foot refers to the medial plantar nerve. Loss of the arch refers to the plantar fascia which attaches at the calcaneal tuberosity. Inability to flex the lesser toes refers to the flexor digitorum longus tendon which runs superior to the sustentaculum. The spring ligament runs from the navicular to the calcaneus, but does not attach under the sustentaculum tali.

Question 1563

Topic: 8. Foot and Ankle
A 14-year-old boy with a history of cerebral palsy has a clawed hallux, cavus foot deformity, and associated pain. Examination reveals pain under the first metatarsal head and a rigid first tarsometatarsal joint. Treatment should consist of:
. transfer of the extensor hallucis longus to the neck of the first metatarsal with first metatarsal osteotomy.
. extensor hallucis longus lengthening.
. midfoot osteotomy.
. first metatarsal osteotomy.
. transfer of the extensor hallucis longus to the neck of the first metatarsal.

Correct Answer & Explanation

. transfer of the extensor hallucis longus to the neck of the first metatarsal with first metatarsal osteotomy.

Explanation

In a retrospective study for clawing of the hallux with associated cavus foot deformities, the modified Robert Jones tendon transfer was shown to be effective in relieving symptoms related to clawing of the hallux in 90% of patients but was not reliable in relieving pain under the first metatarsal head. The return of symptoms in these cases is the result of stretching of the muscle and tendon of the extensor hallucis longus by the more powerful peroneus longus. Basal dorsal wedge osteotomy at the time of the modified Robert Jones procedure is recommended.

Question 1564

Topic: 8. Foot and Ankle
What is the most common metatarsal fracture in a 3-year-old?
. Proximal first metatarsal
. Proximal fifth metatarsal
. Distal second metatarsal
. Distal fifth metatarsal

Correct Answer & Explanation

. Proximal first metatarsal

Explanation

In children 5 years of age and younger, the proximal first metatarsal is the most common site for metatarsal fractures; the fractures are usually caused by a fall. In children older than age 5, injury to the fifth metatarsal is most common and is sustained during play or sports. Many fractures in children under age 5 are not initially visible on radiograph. Knowing where to look for common injuries is mandatory when treating young children and nonverbal patients.

Question 1565

Topic: 8. Foot and Ankle
A 42-year-old woman has a history of nontraumatic ankle swelling with tenderness over the Achilles tendon and plantar fascia. She reports that while vacationing in Connecticut 2 months ago she noted the presence of a “red bull’s eye” rash. Management should consist of
. physical therapy.
. doxycycline.
. ciprofloxacin.
. nonsteroidal anti-inflammatory drugs.
. gentamicin.

Correct Answer & Explanation

. doxycycline.

Explanation

The most likely diagnosis is Lyme disease because of the patient’s recent vacation in an area with a high risk of exposure. The most effective treatment is doxycycline.

Question 1566

Topic: 8. Foot and Ankle
Which of the following is most important to achieve a good outcome following a Syme amputation?
. trimming any dog ears
. a viable and stable heel pad
. achilles tendon lengthening
. preserving the malleoli
. tenodesing the extensor digitorum longus to the tibial shaft

Correct Answer & Explanation

. a viable and stable heel pad

Explanation

A Syme amputation is effectively a tibiotalar disarticulation, which provides an end-bearing stump that could potentially allow ambulation without a prosthesis over short distances. It works better for tumor and trauma, but the heel pad must be viable. The two most common problems are 1) skin sloughing from compromised vascular supply and 2) migration of the heel pad due to instability. A hypermobile heel pad can cause difficulty with prosthesis wear and damage to the soft tissues which can eventually lead to failure.

Question 1567

Topic: 8. Foot and Ankle
A 35-year-old runner has pain beneath the second metatarsophalangeal joint. He reports that he has significantly decreased his running distance since the onset of the pain. He denies any history of trauma or injury to the foot. A radiograph is shown in Figure 14. Initial management should consist of
. resectional arthroplasty.
. metatarsophalangeal joint arthrodesis.
. dorsal closing wedge osteotomy.
. physical therapy.
. a rigid steel shank shoe with a rocker bottom sole.

Correct Answer & Explanation

. a rigid steel shank shoe with a rocker bottom sole.

Explanation

DISCUSSION: The presence of the relatively long second metatarsal, along with the close approximation of the second and third metatarsal heads, are consistent with second metatarsophalangeal tenosynovitis. The hallmark of initial management is conservative. Modalities include taping, nonsteroidal anti-inflammatory drugs, metatarsal pads, and cortisone injections. Trepman and Yeo combined the use of a cortisone injection with a rocker bottom sole. Mizel and Michelson reported their results using an extended rigid steel shank shoe along with a cortisone injection.

Question 1568

Topic: 8. Foot and Ankle
An eversion mechanism of injury is associated with which of the following ankle conditions?
. Peroneal tendon splits
. Osteochondral talar dome fracture
. Superficial peroneal nerve palsy
. Anterolateral soft-tissue impingement
. Fracture of the anterior colliculus

Correct Answer & Explanation

. Fracture of the anterior colliculus

Explanation

DISCUSSION: A fracture of the anterior colliculus is typically the result of an eversion mechanism resulting in a bony avulsion of the deltoid ligament from the anterior colliculus of the medial malleolus. An inversion ankle injury typically involves ligamentous damage to the lateral ligaments of the ankle to include the anterior talofibular ligament and calcaneofibular ligament. Acute and particularly chronic ankle sprains also can have associated injuries. The inversion mechanism has been implicated in osteochondral and transchondral talar dome lesions, producing splits in the peroneus tendons, and in the development of meniscoid and soft-tissue impingement lesions in the anterolateral ankle. An inversion mechanism can also stretch the superficial peroneal nerve, leading to pain and paresthesias along its distribution.

Question 1569

Topic: 8. Foot and Ankle

During open reduction and internal fixation of a Lisfranc injury, the surgeon must anatomically restore the Lisfranc ligament to ensure proper midfoot stability. What is the precise anatomic attachment of the primary band of the Lisfranc ligament?

. Plantar-lateral aspect of the medial cuneiform to the plantar-medial aspect of the second metatarsal base
. Dorsal-medial aspect of the medial cuneiform to the dorsal aspect of the second metatarsal base
. Plantar aspect of the intermediate cuneiform to the plantar aspect of the third metatarsal base
. Plantar-lateral aspect of the medial cuneiform to the plantar-lateral aspect of the third metatarsal base
. Plantar aspect of the navicular to the plantar aspect of the second metatarsal base

Correct Answer & Explanation

. Plantar-lateral aspect of the medial cuneiform to the plantar-medial aspect of the second metatarsal base

Explanation

The Lisfranc ligament is an interosseous ligament composed of up to three bands, with the primary and strongest being the plantar band. It attaches from the plantar-lateral aspect of the medial cuneiform to the plantar-medial aspect of the base of the second metatarsal. There is no direct ligamentous connection between the first and second metatarsal bases, making the Lisfranc ligament crucial for stabilizing the second metatarsal in the 'keystone' position.

Question 1570

Topic: Midfoot & Hindfoot
A 45-year-old female presents with a painful, progressive flatfoot deformity. Examination reveals an inability to perform a single-leg heel rise, flexible hindfoot valgus, and uncovering of the talar head of >40% on AP weight-bearing foot radiographs. Which of the following surgical interventions is most appropriate for this stage of deformity?
. Medial displacement calcaneal osteotomy and flexor digitorum longus (FDL) transfer
. Lateral column lengthening, medial displacement calcaneal osteotomy, and FDL transfer
. Isolated triple arthrodesis
. Subtalar arthrodesis combined with a Cobb procedure
. Isolated primary repair of the spring ligament

Correct Answer & Explanation

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

Explanation

The patient's clinical and radiographic presentation is consistent with Stage IIB adult-acquired flatfoot deformity (posterior tibial tendon dysfunction). Stage IIB is distinguished from IIA by significant forefoot abduction (uncovering of the talonavicular joint >30%). Therefore, in addition to an FDL transfer and a medial displacement calcaneal osteotomy (MDCO) to correct hindfoot valgus, a lateral column lengthening (e.g., Evans osteotomy) is required to correct the severe forefoot abduction.

Question 1571

Topic: 8. Foot and Ankle

A 24-year-old professional rugby player undergoes dynamic fluoroscopy revealing isolated syndesmotic instability without a fibular fracture. He is treated with dynamic suture button fixation. Compared to traditional trans-syndesmotic screw fixation, what is the primary biomechanical advantage of dynamic suture button fixation?

. Superior resistance to pure sagittal translation of the fibula
. Maintenance of physiological tibiofibular micromotion during ankle dorsiflexion
. Increased rigid compression across the incisura fibularis
. Elimination of the need for concurrent medial deltoid ligament repair
. Absolute prevention of proximal fibular migration

Correct Answer & Explanation

. Maintenance of physiological tibiofibular micromotion during ankle dorsiflexion

Explanation

The primary biomechanical advantage of dynamic suture button fixation for syndesmotic injuries is that it allows for the maintenance of physiologic tibiofibular micromotion. Specifically, it permits the normal external rotation and slight proximal/lateral translation of the fibula that occurs when the wider anterior dome of the talus engages the mortise during ankle dorsiflexion. Rigid screw fixation eliminates this physiologic motion.

Question 1572

Topic: 8. Foot and Ankle

A 22-year-old collegiate basketball player sustains a Zone II (Jones) fracture of the proximal fifth metatarsal. The high rate of delayed union or non-union in this specific region is directly attributed to its vascular anatomy. Which of the following describes the arterial supply to this watershed area?

. It is supplied solely by the nutrient artery arising from the medial plantar artery
. It relies strictly on metaphyseal branches from the lateral plantar artery
. It represents a watershed zone between the retrograde intramedullary diaphyseal supply and the proximal metaphyseal supply
. It is supplied entirely by an extraosseous periosteal network from the dorsalis pedis
. It depends entirely on direct branches from the deep plantar arch

Correct Answer & Explanation

. It represents a watershed zone between the retrograde intramedullary diaphyseal supply and the proximal metaphyseal supply

Explanation

The base of the 5th metatarsal has two primary blood supplies: the metaphyseal arteries supplying the proximal tuberosity, and the main nutrient artery entering the medial cortex of the diaphysis, which supplies the shaft via intramedullary branches running in a retrograde fashion. Zone II (the metaphyseal-diaphyseal junction, or Jones fracture site) is a relative watershed area between these two distinct vascular supplies, rendering it prone to non-union.

Question 1573

Topic: Forefoot

A 55-year-old active male presents with advanced hallux rigidus (Coughlin and Shurnas Grade 3) and severe pain. He wishes to maintain maximum walking activity levels without pain. Which surgical procedure offers the most reliable, long-term functional outcome?

. Cheilectomy
. Proximal phalanx (Moberg) osteotomy
. Metatarsophalangeal (MTP) joint arthrodesis
. Silicone interposition arthroplasty
. Hemiarthroplasty of the proximal phalanx

Correct Answer & Explanation

. Cheilectomy

Explanation

First MTP joint arthrodesis is the gold standard for advanced (Grade 3 and 4) hallux rigidus. It provides the most reliable long-term pain relief and restores excellent functional push-off for active patients.

Question 1574

Topic: 8. Foot and Ankle

A 22-year-old basketball player undergoes intramedullary screw fixation for a Zone 2 proximal fifth metatarsal fracture (Jones fracture). Which anatomical characteristic dictates that the correct entry point must be high and medial on the fifth metatarsal base?

. The lateral and plantar bowing of the fifth metatarsal shaft
. The broad attachment footprint of the peroneus brevis tendon
. The close proximity and risk of entrapment of the sural nerve
. The location of the primary nutrient artery foramen
. The articular facet orientation for the cuboid

Correct Answer & Explanation

. The lateral and plantar bowing of the fifth metatarsal shaft

Explanation

The fifth metatarsal has a natural lateral and plantar bow. To safely place a straight intramedullary screw without breaching the medial or plantar cortices, the starting point must be located high (dorsal) and medial on the base.

Question 1575

Topic: 8. Foot and Ankle
A 35-year-old roofer falls from a height and sustains a Sanders type III calcaneus fracture. An extensile lateral approach is planned for open reduction and internal fixation. To minimize the risk of wound slough and flap necrosis, the full-thickness flap must be elevated in a subperiosteal plane. Which of the following arterial branches is the primary vascular supply to this lateral flap?
. Medial calcaneal artery
. Lateral calcaneal artery
. Dorsalis pedis artery
. Anterior lateral malleolar artery
. Sural artery

Correct Answer & Explanation

. Lateral calcaneal artery

Explanation

The lateral calcaneal artery, a branch of the peroneal artery, provides the primary blood supply to the lateral flap of the calcaneus. The flap must be elevated full-thickness subperiosteally to preserve this delicate vascular network and prevent apical necrosis.

Question 1576

Topic: Forefoot

A 45-year-old female presents with severe bunion pain. 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. Which of the following surgical procedures is most appropriate?

. Distal chevron osteotomy
. Proximal crescentic osteotomy
. First tarsometatarsal arthrodesis (Lapidus procedure)
. Metatarsophalangeal arthrodesis
. Akin osteotomy alone

Correct Answer & Explanation

. Distal chevron osteotomy

Explanation

The Lapidus procedure (1st TMT arthrodesis) is indicated for severe hallux valgus (IMA > 15 degrees) combined with first ray hypermobility. Distal or proximal osteotomies alone fail to address the apex of deformity at the unstable TMT joint in this specific presentation.

Question 1577

Topic: Midfoot & Hindfoot

A 55-year-old diabetic male presents with an acutely swollen, warm, erythematous foot without ulceration. Radiographs show periarticular fragmentation and dorsal subluxation of the midfoot. Which of the following is the most appropriate initial management?

. Immediate surgical arthrodesis of the midfoot
. Total contact casting and non-weight-bearing
. Intravenous antibiotics and bone biopsy
. Open reduction and internal fixation of the Lisfranc joint
. Amputation at the transmalleolar level

Correct Answer & Explanation

. Immediate surgical arthrodesis of the midfoot

Explanation

This patient is in Eichenholtz Stage I (developmental/fragmentation) of Charcot neuroarthropathy. The gold standard initial treatment is strict offloading and immobilization using a total contact cast to arrest the inflammatory cascade and prevent further collapse.

Question 1578

Topic: 8. Foot and Ankle

An extensile lateral approach is utilized for open reduction and internal fixation of a joint-depressed calcaneus fracture. Which of the following neurovascular structures is at greatest risk of iatrogenic injury during the inferior aspect of this surgical exposure?

. Superficial peroneal nerve
. Deep peroneal nerve
. Sural nerve
. Medial plantar nerve
. Posterior tibial artery

Correct Answer & Explanation

. Superficial peroneal nerve

Explanation

The sural nerve courses along the lateral border of the foot, posterior to the lateral malleolus. It is highly vulnerable to transection, traction injury, or neuroma formation during the inferior subperiosteal dissection of the standard extensile lateral approach to the calcaneus.

Question 1579

Topic: 8. Foot and Ankle

Recent randomized controlled trials comparing operative versus modern functional rehabilitation (non-operative) protocols for acute Achilles tendon ruptures have predominantly demonstrated which of the following outcomes?

. Significantly higher re-rupture rates in the non-operative group regardless of protocol
. Significantly greater long-term plantar flexion strength in the operative group
. Similar re-rupture rates between groups, but higher wound complication rates in the operative group
. Similar wound complication rates, but higher deep vein thrombosis rates in the non-operative group
. Non-operative treatment guarantees a zero percent risk of re-rupture

Correct Answer & Explanation

. Significantly higher re-rupture rates in the non-operative group regardless of protocol

Explanation

With the advent of early functional weight-bearing rehabilitation protocols, the historically higher re-rupture rate of non-operative management has dropped, becoming comparable to operative treatment. However, operative management still carries a significantly higher risk of complications such as infection and wound breakdown.

Question 1580

Topic: Forefoot

A 40-year-old female presents with a severe hallux valgus deformity (Intermetatarsal Angle = 18 degrees, Hallux Valgus Angle = 45 degrees). Clinical examination reveals profound multiplanar hypermobility of the first tarsometatarsal (TMT) joint. Which of the following surgical procedures is most strongly indicated?

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

Correct Answer & Explanation

. Distal chevron osteotomy

Explanation

The Lapidus procedure involves an arthrodesis of the first tarsometatarsal joint. It is the gold standard for correcting moderate-to-severe hallux valgus deformities when concurrent first ray hypermobility is present, as it provides definitive stabilization and powerful triplanar correction.

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