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8. Foot and Ankle MCQs

Practice Set 80 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 1581

Topic: 8. Foot and Ankle

During an extensile lateral approach for open reduction and internal fixation of a displaced intra-articular calcaneus fracture, the sural nerve is at significant risk. At the level of the lateral malleolus, what is the predictable anatomic relationship of the sural nerve to the tip of the fibula?

. 1.5 to 2.0 cm posterior and inferior
. Directly anterior to the anterior talofibular ligament
. 3.0 cm superior to the fibular tip
. Directly superficial to the peroneal tubercle
. Passes medial to the Achilles tendon insertion

Correct Answer & Explanation

. 1.5 to 2.0 cm posterior and inferior

Explanation

The sural nerve courses distally in the posterolateral leg and predictably passes approximately 1.5 to 2.0 cm posterior and inferior to the tip of the lateral malleolus. Knowledge of this anatomy is critical when making the vertical limb of the extensile lateral approach to avoid painful neuromas.

Question 1582

Topic: Forefoot

A 55-year-old female presents with severe hallux valgus (HVA 45 degrees, IMA 19 degrees) and demonstrable clinical hypermobility of the first tarsometatarsal (TMT) joint. Which surgical procedure is most appropriate to address her deformity and prevent long-term recurrence?

. Distal chevron osteotomy
. Proximal crescentic osteotomy with distal soft tissue release
. First tarsometatarsal joint arthrodesis (Lapidus procedure)
. First metatarsophalangeal joint arthrodesis
. Akin osteotomy alone

Correct Answer & Explanation

. Distal chevron osteotomy

Explanation

The Lapidus procedure (1st TMT arthrodesis) is specifically indicated for patients with moderate to severe hallux valgus coupled with first ray hypermobility. It uniquely restores medial column stability and provides robust correction of the intermetatarsal angle.

Question 1583

Topic: 8. Foot and Ankle

Recent randomized controlled trials comparing operative versus non-operative management of acute Achilles tendon ruptures, when utilizing aggressive early functional rehabilitation protocols, have most consistently demonstrated which of the following outcomes?

. Significantly lower re-rupture rates in the operative group across all demographics
. Similar re-rupture rates between groups, but higher complication rates (e.g., infection) in the operative group
. Markedly improved peak plantarflexion strength in the non-operative group
. Higher incidence of deep vein thrombosis in the non-operative group
. Lower return-to-sport rates in the operative group

Correct Answer & Explanation

. Significantly lower re-rupture rates in the operative group across all demographics

Explanation

Current high-level evidence indicates that with early functional weight-bearing rehabilitation, non-operative management yields re-rupture rates similar to operative repair. However, operative management carries a higher risk of complications, such as surgical site infections and sural nerve injury.

Question 1584

Topic: 8. Foot and Ankle
What neurologic structure is most at risk when performing intramedullary screw fixation of a fifth metatarsal base fracture?
. Saphenous nerve
. First branch of the lateral plantar nerve
. Superficial peroneal nerve
. Sural nerve
. Deep peroneal nerve

Correct Answer & Explanation

. Sural nerve

Explanation

The sural nerve and its terminal branches course through the lateral hindfoot and midfoot area and are directly at risk in surgeries involving the peroneal tendon complex and the fifth metatarsal. The first branch of the lateral plantar nerve originates in the tarsal tunnel region and courses across the plantar heel area to innervate the abductor digiti minimi; it is not at direct risk with fifth metatarsal surgery.

Question 1585

Topic: 8. Foot and Ankle
Which of the following methods best aids in the diagnosis of an interdigital neuroma?
. Ultrasound
. MRI
. Web space injection
. Electromyography and nerve conduction velocity studies
. History and physical examination

Correct Answer & Explanation

. History and physical examination

Explanation

History and physical examination are still the gold standard for diagnosis of an interdigital neuroma. Ultrasound and MRI may be helpful adjuncts but are dependent on equipment and operator expertise. Web space injection may be helpful for diagnostic and therapeutic purposes. Electromyography and nerve conduction velocity studies are of little benefit for distal lesions.

Question 1586

Topic: 8. Foot and Ankle
A 14-year-old girl has a painful hallux valgus deformity that has not responded to shoe modifications. Figure 21 shows a standing AP radiograph. What is the most appropriate surgical procedure?
. Distal soft-tissue realignment
. Distal first metatarsal osteotomy with distal soft-tissue realignment
. Proximal first metatarsal osteotomy with distal soft-tissue realignment
. Proximal and distal first metatarsal osteotomy
. Osteotomy of the proximal phalanx

Correct Answer & Explanation

. Proximal and distal first metatarsal osteotomy

Explanation

DISCUSSION: The radiograph reveals an increased first-second intermetatarsal angle and a congruent metatarsophalangeal joint with an abnormal distal metatarsal articular angle. Correction of both of these abnormalities requires a proximal and distal first metatarsal osteotomy. REFERENCES: Coughlin M: Juvenile bunions, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 6. St Louis, MO, Mosby, 1993, pp 297-339. Peterson HA, Newman SR: Adolescent bunion treated with double osteotomy and longitudinal pin fixation of the first ray. J Pediatr Orthop 1993;13:80-84.

Question 1587

Topic: 8. Foot and Ankle

A 16-year-old snowboarder has significant pain and is still unable to bear weight after sustaining a lateral ankle injury in a fall 1 week ago. Examination reveals swelling and tenderness in the sinus tarsi. AP, lateral, and mortise radiographs of the ankle are unremarkable. Management should consist of

. an elastic bandage, cold packs, and weight bearing as tolerated.
. non-weight-bearing and a CT scan of the talus.
. cast immobilization for 10 days, followed by progressive rehabilitation.
. cast immobilization for 6 weeks, followed by progressive rehabilitation.
. stirrup splinting, cold packs, and aggressive rehabilitation.

Correct Answer & Explanation

. an elastic bandage, cold packs, and weight bearing as tolerated.

Explanation

DISCUSSION: Because there is a significant possibility that the patient may have a fracture of the lateral process of the talus, there is some disagreement as to the best radiographic study to identify this injury.  A CT scan is an appropriate diagnostic tool to visualize the fracture and identify any displacement.  Displaced lateral process fractures are best treated surgically.REFERENCES: Kirkpatrick DP, Hunter RE, Janes PC, Mastrangelo J, Nicholas RA: The snowboarder’s foot and ankle.  Am J Sports Med 1998;26:271-277.Ebraheim NA, Skie MC, Podeszwa DA, Jackson WT: Evaluation of process fractures of the talus using computed tomography.  J Orthop Trauma 1994;8:332-337.

Question 1588

Topic: 8. Foot and Ankle

Surgical treatment of an adult cavovarus foot with fixed forefoot valgus that does not correct on Coleman block testing should consist of Review Topic

. lateral column lengthening through the calcaneal anterior process.
. a medial displacement calcaneal osteotomy.
. first metatarsal-cuneiform fusion in increased plantar flexion.
. dorsiflexion osteotomy of the first metatarsal and a medial displacement calcaneal osteotomy.
. dorsiflexion osteotomy of the first metatarsal and a lateral displacement calcaneal osteotomy.

Correct Answer & Explanation

. lateral column lengthening through the calcaneal anterior process.

Explanation

Cavovarus feet are characterized by plantar flexion of the first metatarsal and hindfoot varus. A rigid cavovarus hindfoot does not correct on Coleman block testing. Correction of these rigid deformities requires either lateral displacement or lateral closing wedge osteotomies of the calcaneus and dorsiflexion osteotomies of the involved metatarsals. Lateral column lengthening procedures are used to correct painful flatfoot deformities.

Question 1589

Topic: 8. Foot and Ankle

Figures 34a and 34b show the clinical photographs of a 46-year-old woman who has a painful deformity of the second toe. Surgical treatment consisting of metatarsophalangeal capsulotomy and proximal interphalangeal joint resection arthroplasty resulted in satisfactory correction, but the toe remains unstable at the metatarsophalangeal joint. What is the next most appropriate step?

. Flexor digitorum longus tenotomy
. Resection of the metatarsal head and pin fixation
. Transfer of the flexor digitorum longus to the extensor tendon
. Excision at the base of the proximal phalanx and syndactyly with the third toe
. Arthrodesis of the second metatarsophalangeal joint

Correct Answer & Explanation

. Flexor digitorum longus tenotomy

Explanation

DISCUSSION: Crossover second toes are attributed to attenuation or rupture of the plantar plate and lateral collateral ligament and are associated with varying degrees of instability.  Flexor-to-extensor transfer (Girdlestone/Taylor procedure) can provide intrinsic stability to the toe.  Although plantar metatarsal head condylectomy can increase stability by resulting in scarring of the plantar plate, excision of the entire second metatarsal head carries a high risk of transfer metatarsalgia.  Removal of the base of the proximal phalanx destabilizes the toe and should be reserved as a salvage procedure.  Simple flexor tenotomy alone will not improve stability, and arthrodesis of the second metatarsophalangeal joint will limit motion and impair function.REFERENCES: Coughlin MJ: Crossover second toe deformity.  Foot Ankle 1987;8:29-39.Thompson FM, Deland JT: Flexor tendon transfer for metatarsophalangeal instability of the second toe.  Foot Ankle 1993;14:385-388.

Question 1590

Topic: 8. Foot and Ankle

What is a risk factor for interdigital neuroma?

. Female gender
. Increased mobility between the third and fourth rays
. Achilles tendon contracture
. Prolonged standing at work

Correct Answer & Explanation

. Female gender

Explanation

DISCUSSIONThe only proven risk factor for development of an interdigital neuroma is female gender, which likely is related to the use of fashionable shoes that force plantar flexion of the metatarsal heads and secondary hyperdorsiflexion of the metatarsophalangeal joints. The other factors listed have not been proven to cause interdigital neuroma, as well as mediolateral compression of the forefoot.RECOMMENDED READINGSHill KJ. Peripheral nerve disorder. In: Pinzur MS, ed. Orthopaedic Knowledge Update: Foot and Ankle 4. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2008:307-327.Schon LC, Mann RA. Diseases of the nerves. In: Coughlin MJ, Mann RA, Saltzman CL, eds. Surgery of the Foot and Ankle. 8th ed. Philadelphia, PA: Mosby-Elsevier; 2007:613-686.

Question 1591

Topic: 8. Foot and Ankle

A 10-year-old boy who is active in soccer has had activity-related heel pain for the past 3 months. Examination reveals tenderness over the posterior heel and a tight Achilles tendon. Radiographs demonstrate a 2-cm cyst in the anterior body of the calcaneus. His physes have not closed. Based on these findings, what is the most appropriate management?

. Bone scan
. Curettage and bone grafting of the cyst
. Cast immobilization
. Observation with reduced activity
. Skeletal survey

Correct Answer & Explanation

. Bone scan

Explanation

DISCUSSION: The most likely diagnosis is Sever’s disease, which is considered either an apophysitis or a para-apophyseal stress fracture.  It is common in athletic children and is associated with a tight Achilles tendon.  Cast immobilization may be necessary if activity reduction fails.  Calcaneal cysts are quite common and do not require any further diagnostic testing or treatment unless they occupy the full width of the calcaneus or one third of the length of the calcaneus.REFERENCES: Ogden JA, Ganey TM, Hill JD, et al: Sever’s injury: A stress fracture of the immature calcaneal metaphysis.  J Ped Orthop 2004;24:488-492.Pogoda P, Priemel M, Linhart W, et al: Clinical relevance of calcaneal bone cysts: A study of 50 cysts in 47 patients.  Clin Orthop Relat Res 2004;424:202-210.

Question 1592

Topic: 8. Foot and Ankle

A 28-year-old woman has a moderate hallux valgus deformity and a prominence of the medial eminence. She can participate in all activities and reports that she could wear 3-inch heels in the past, but she now notes medial eminence pain even while wearing a soft leather flat shoe with a cushioned sole. She requests recommendations regarding surgical correction. Examination reveals a 1-2 intermetatarsal angle of 10 degrees. A clinical photograph and radiograph are shown in Figures 13a and 13b. What is the best course of action?

. Chevron osteotomy to correct hallux valgus
. Custom orthosis to prevent further deformity
. Observation only
. Steroid injection to decrease inflammation
. Extra-depth shoes

Correct Answer & Explanation

. Chevron osteotomy to correct hallux valgus

Explanation

DISCUSSION: Based on her symptoms and prior shoe wear modifications, the treatment of choice is surgical correction of the hallux valgus with a chevron osteotomy.  There are no data to support the use of a custom orthosis to delay the progression of a hallux valgus deformity.  Steroid injection would only risk infection, as well as joint and capsule damage.  Extra-depth shoes are an option; however, the patient is interested in surgical options.REFERENCES: Chou LB, Mann RA, Casillas MM: Biplanar chevron osteotomy.  Foot Ankle Int 1998;19:579-584.Coughlin MJ: Roger A. Mann Award: Juvenile hallux valgus. Etiology and treatment.  Foot Ankle Int 1995;16:682-697.Pochatko DJ, Schlehr FJ, Murphey MD, Hamilton JJ: Distal chevron osteotomy with lateral release for treatment of hallux valgus deformity.  Foot Ankle Int 1994;15:457-461.

Question 1593

Topic: 8. Foot and Ankle

Which of the following changes in the parameters of the gait cycle occurs in the transition from normal walking to running?

. Increased time in stance and swing phase
. Addition of a double leg float phase
. Decreased vertical ground reaction forces
. Decreased arc of motion in the hip, knee, and ankle
. Decreased joint reaction forces in the hip, knee, and ankle

Correct Answer & Explanation

. Increased time in stance and swing phase

Explanation

The same basic mechanisms that have been described for the biomechanics of the foot and ankle are not significantly altered during running. The major differences observed during running are that the gait cycle is altered considerably; the amount of force generated, as measured by force plated data, is markedly increased; the range of motion of the joints of the lower extremities is increased; and the phasic activity of the muscles of the lower extremities is altered. During walking one foot is always in contact with the ground; as the speed of gait increases a float phase incorporated into the gait cycle, during which time both feet are off the ground. There also is no longer a period of double limb support. As the speed of gait continues to increase, the time the foot spends on the ground, both in real time and in percentage of cycle, decreases considerably.Question 71 -Examination of a 5-year-old child who has fibular hemimelia reveals the foot has two rays and is stiff in equinus and valgus. The level of the foot is just proximal to the midshaft of the contralateral tibia, and the knee has full active flexion and extension, but slight valgus. Treatment should includeAmputation through the midshaft of the tibiaCorrection of the foot deformity and lengthening with a ring fixatorKnee disarticulationAnkle disarticulationAnkle disarticulation and contralateral epiphyseodesis of the proximal tibia Answer: 4Congenital absence of the fibula, also called fibula hemimelia, has several manifestations. These range from complete absence of the fibula with missing lateral rays of the foot (i.e. terminal longitudinal deficiency) to absence of only a portion of the fibula without foot involvement (i.e. intercalary longitudinal; deficiency). Congenital fibular deficiency usually occurs sporadically without a known cause. The child with complete absence of the fibula presents clinically with an anterolateral bow of the tibia, an equinovalgus deformity of the foot, and a tarsal coalition. The talotibial joint is usually malformed, with the fused talocalcaneus having a flat upper surface that articulates with the tibia in a valgus and equinus position. The foot may be missing one or two lateral rays. There is always significant shortening of the epsilateral femur. Treatment: There is a reasonable consensus that complete fibular hemimelia is best treated by performing an ankle disarticulation in early childhood and fitting a Syme-type prosthesis. Children with lesser (<5cm) at birth may be a candidate for lengthening procedures, but the exact indications and results of these procedures have not been well defined. Children with large discrepancies (>5cm) at birth and those with major foot deformities are better managed with amputation.

Question 1594

Topic: 8. Foot and Ankle

What significant structure is most at risk during a posterior approach of the Achilles tendon near its musculotendinous junction?

. Saphenous vein
. Saphenous nerve
. Posterior tibial nerve
. Sural nerve
. Plantaris muscle

Correct Answer & Explanation

. Saphenous vein

Explanation

DISCUSSION: The sural nerve crosses near the midline at the level of the musculotendinous junction before descending to its more lateral location distally.  The saphenous nerve and vein are further medial and at less risk.  The posterior tibial nerve is at risk only during deep dissection, such as harvesting flexor hallucis longus tendon graft.  The plantaris muscle lies in this area but is of little clinical significance.REFERENCES: Webb J, Moorjani N, Radford M: Anatomy of the sural nerve and its relation to the Achilles tendon.  Foot Ankle Int 2000;21:475-477.Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 101-111.

Question 1595

Topic: 8. Foot and Ankle

What is the most common surgical cause of the foot deformity shown in Figure 9?

. Medial tibial sesamoid subluxation
. Overcorrection of the intermetatarsal angle
. Excessive postoperative dressing application
. Excessive medial eminence resection
. Excessive lateral soft-tissue release and lateral sesamoidectomy

Correct Answer & Explanation

. Medial tibial sesamoid subluxation

Explanation

DISCUSSION: The radiograph shows a hallux varus deformity.  Iatrogenically acquired hallux varus is most often the result of excessive lateral soft-tissue release, sesamoidectomy, or both.  It also can be caused by a medial tibial sesamoid subluxation in conjunction with excessive postoperative dressing application, overcorrection of the intermetatarsal angle, or excessive medial eminence resection.REFERENCES: Donley BG: Acquired hallux varus.  Foot Ankle Int 1997;18:586-592.Myerson MS, Komenda GA: Results of hallux varus correction using an extensor brevis tenodesis.  Foot Ankle Int 1996;17:21-27.

Question 1596

Topic: 8. Foot and Ankle

A patient sustained a puncture wound to the plantar aspect of his foot. He was wearing shoes and socks at the time of the injury. Systemic antibiotic administration with specific coverage for which bacterial species (in addition to Staphylococcus aureus) should be instituted?

. Escherichia coli
. Mycobacterium marinum
. Pseudomonas
. Clostridium

Correct Answer & Explanation

. Escherichia coli

Explanation

DISCUSSIONPuncture wounds sustained through a shoe and sock increase risk for Pseudomonas infection. Clostridium are associated with soil-contaminated wounds. Mycobacterium marinum is associated with injuries sustained within water.RECOMMENDED READINGSDeCoster TA, Miller RA. Management of Traumatic Foot Wounds. J Am Acad Orthop Surg. 1994 Jul;2(4):226-230. PubMed PMID: 10709013.View Abstract at PubMedRaikin SM. Common infections of the foot. In: Richardson EG, ed. Orthopaedic Knowledge Update: Foot and Ankle 3. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2004:199-205.

Question 1597

Topic: 8. Foot and Ankle

Triple arthrodesis in a reduced position

. Open reduction of the vertical talus
. Open reduction of the vertical talus will most likely prevent problems.
. With observation only, the patient is likely to stand or walk and develop pressure problems. Talectomy will not produce the most usable foot.
. Achilles tenotomy will not produce significant correction by itself. Triple arthrodesis will concentrate stress and lead to ulcers.

Correct Answer & Explanation

. Open reduction of the vertical talus

Explanation

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Question 1598

Topic: 8. Foot and Ankle

What are the five major compartments of the foot?

. Medial, lateral, central, interosseous, and calcaneal
. Medial, lateral, central, interosseous, and dorsal
. Medial, lateral, central, dorsal, and calcaneal
. Medial, lateral, dorsal, interosseous, and calcaneal
. Dorsal, lateral, central, interosseous, and calcaneal

Correct Answer & Explanation

. Medial, lateral, central, interosseous, and calcaneal

Explanation

DISCUSSION: The five major compartments of the foot are medial, lateral, central, interosseous, and calcaneal.  There is no dorsal compartment in the foot.REFERENCES: Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2.  Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 262-264.Shereff MJ: Compartment syndromes of the foot.  Instr Course Lect 1990;39:127-132.

Question 1599

Topic: 8. Foot and Ankle

A 37-year-old man with a history of congenital flatfoot reports worsening pain on the medial aspect of his ankle for the past year. The pain is worse with weight bearing and is better with rest and the use of an ankle brace. What findings are shown on the MRI scans shown in Figures 18a through 18c?

. The flexor digitorum longus tendon is ruptured.
. The posterior tibial tendon has a normal appearance.
. The posterior tibial tendon has a physiologic amount of fluid in its sheath.
. The posterior tibial tendon is completely ruptured and retracted (type III tear).
. The posterior tibial tendon has a chronic longitudinal split with enlargement (type II tear).

Correct Answer & Explanation

. The flexor digitorum longus tendon is ruptured.

Explanation

DISCUSSION: The MRI scans reveal an enlarged posterior tibial tendon, with degenerative signal within the tendon and an excessive amount of fluid in its sheath.  This is a type II tear, as noted by Conti and associates, which is the most commonly seen tear.REFERENCES: Slovenkai MP: Clinical and radiographic evaluation (Adult flatfoot: Posterior tibial tendon dysfunction).  Foot Ankle Clin 1997;2:241-260.Conti S, Michelson J, Jahss M: Clinical significance of magnetic resonance imaging in preoperative planning for reconstruction of posterior tibial tendon ruptures.  Foot Ankle 1992;13:208-214.

Question 1600

Topic: 8. Foot and Ankle

Figure 25 shows the clinical photograph of a 48-year-old man who has had a forefoot ulcer for the past 4 months. History reveals that he has had type II diabetes mellitus for the past 10 years. Examination reveals sensory and motor neuropathy, with weak ankle dorsiflexion. The ankle cannot be passively dorsiflexed past a neutral position. Initial management should consist of

. an extra-depth shoe with an accommodative orthosis.
. surgical debridement and metatarsal head resection.
. posterior tibial tendon transfer through the interosseous membrane.
. Achilles tendon lengthening and total contact casting.
. hyperbaric oxygen therapy.

Correct Answer & Explanation

. an extra-depth shoe with an accommodative orthosis.

Explanation

DISCUSSION: Foot deformity and decreased joint motion have been associated with increased plantar pressures and an increased risk of ulceration.  In a partial-thickness ulcer without exposed bone or tendon, total contact casting is highly effective.  Concomitant Achilles tendon lengthening increases the likelihood that healing of the ulcer can be obtained and perhaps more importantly, maintained.REFERENCES: Lin SS, Lee TH, Wapner KL: Plantar forefoot ulceration with equinus deformity of the ankle in diabetic patients: The effect of tendo-Achilles lengthening and total contact casting.  Orthopedics 1996;19:465-475.Armstrong DG, Stacpoole-Shea S, Nguyen H, Harkless LB: Lengthening of the Achilles tendon in diabetic patients who are at high risk for ulceration of the foot.  J Bone Joint Surg Am 1999;81:535-538.

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