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8. Foot and Ankle MCQs

Practice Set 95 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 1881

Topic: 8. Foot and Ankle
What is the most common location for localized pigmented villonodular synovitis (PVNS) to occur?
. Ankle
. Anterior knee
. Posterior knee
. Hip
. Elbow

Correct Answer & Explanation

. Anterior knee

Explanation

DISCUSSION: Localized PVNS is a form of the disease in which synovial proliferation is restricted to one area of a joint and causes the formation of a small mass-like lesion. The true incidence of this is unknown but is probably less common than the diffuse form of the disease. PVNS presents as a usually painful discrete mass. The anterior compartment of the knee is the most common location.

Question 1882

Topic: 8. Foot and Ankle
Figures 89a through 89c are the radiographs of a 35-year-old woman who has had 7 years of progressive ankle pain. She experiences stiffness and pain despite the use of an ankle-foot orthosis. Examination reveals pain along the anterior tibiotalar joint without tenderness to the subtalar or talonavicular joints. What is the most appropriate surgical intervention?
. Total ankle arthroplasty (TAA)
. Ankle arthrodesis
. Tibiotalocalcaneal arthrodesis
. Anterior tibial exostectomy with Achilles lengthening

Correct Answer & Explanation

. Ankle arthrodesis

Explanation

DISCUSSION: This patient has isolated posttraumatic ankle arthritis with significantly decreased ankle range of motion that is best treated with an isolated ankle arthrodesis to eliminate pain. Because this patient is younger than 50 years of age and has limited presurgical range of motion, she is not a candidate for ankle arthroplasty. Additionally, TAA outcomes among patients who have a posttraumatic etiology are worse than for those with osteoarthritis. Tibiotalocalcaneal arthrodesis is suited for patients with associated subtalar arthritis or rigid hindfoot deformity that necessitates correction. Anterior tibial exostectomy will not resolve the underlying arthritic pain and is not indicated.

Question 1883

Topic: 8. Foot and Ankle

04 A pt wishes to return to driving after undergoing surgery for a displaced fibular fracture of the right ankle. A return to nml braking

. time can be expected how many weeks after surgery?
. IV - 9 wks

Correct Answer & Explanation

. IV - 9 wks

Explanation

Lower-Extremity Function for Driving an Automobile After Operative Treatment of Ankle Fracture. Kenneth A. Egol, MD et al JBJS 2003A computerized driving simulator was developed andtested. Eleven healthy volunteers were tested once to establishnormal mean values (Group I), and a group of thirty-one volunteerswith a fracture of the right ankle were tested at six, nine,and twelve weeks following operative repair (Group II). Thesubjects were tested with a series of driving scenarios (city,suburban, and highway). Scores on the Short Form MusculoskeletalAssessment were recorded at six, nine, and twelve weeks andwere compared with the results of the driving test. The effect of the time of the visit and of the testing conditionon the braking times was investigated.Conclusion: By nine weeks, the total braking time of patientswho have undergone fixation of a displaced right ankle fracturereturns to the normal, baseline value

Question 1884

Topic: Midfoot & Hindfoot

-What is the most common impediment to successful closed reduction of the injury seen in Figures 9aand 9b?

. Extensor retinaculum
. Talonavicular joint capsule
. Posterior tibial tendon
. Peroneus teritus tendon
. Flexor hallucis longus tendon

Correct Answer & Explanation

. Extensor retinaculum

Explanation

Question 1885

Topic: 8. Foot and Ankle
A 30-year-old male sustains a high-energy knee dislocation (KD-III). The knee is reduced in the ER. Ankle-brachial index (ABI) is measured at 0.85. What is the next most appropriate step in management?
. Immediate application of a spanning external fixator and discharge
. Serial clinical examinations for 24 hours
. CT angiography of the lower extremity
. Immediate surgical exploration by vascular surgery
. Discharge with a hinged knee brace and aspirin

Correct Answer & Explanation

. CT angiography of the lower extremity

Explanation

In a patient with a knee dislocation, vascular injury (popliteal artery) is a major concern. An ABI < 0.9 is a sensitive indicator of arterial injury and mandates further advanced vascular imaging, such as CT angiography. If there were hard signs of vascular ischemia (e.g., absent pulses after reduction, rapidly expanding hematoma, pulsatile bleeding), immediate surgical exploration would be indicated.

Question 1886

Topic: Midfoot & Hindfoot

A 28-year-old female runner presents with anterior knee pain, exacerbated by descending stairs. She is diagnosed with patellofemoral pain syndrome. Which of the following anatomical factors is most likely to increase the lateral force vector on the patella?

. Genu varum
. Internal tibial torsion
. Femoral anteversion
. Pes cavus
. Patella infera

Correct Answer & Explanation

. Femoral anteversion

Explanation

Increased femoral anteversion leads to internal rotation of the femur relative to the tibia. This, often combined with external tibial torsion and valgus knee alignment (the 'miserable malalignment syndrome'), increases the Q-angle. An increased Q-angle directly increases the lateral force vector on the patella, predisposing the patient to lateral patellar tracking and patellofemoral pain.

Question 1887

Topic: 8. Foot and Ankle

A 24-year-old healthy male collegiate sprinter complains of cramping calf pain and numbness in his foot that occurs only after sprinting 200 meters. Symptoms resolve with 10 minutes of rest. Resting ankle-brachial index (ABI) is 1.0. However, ABI drops to 0.6 with active plantar flexion of the ankle against resistance. What is the most likely anatomic etiology of his symptoms?

. Hypertrophy of the anterior compartment muscles
. Anomalous lateral deviation of the popliteal artery around the popliteus muscle
. Medial deviation of the popliteal artery around an anomalous medial head of the gastrocnemius
. Compression of the superficial peroneal nerve at the fibular neck
. Cystic adventitial disease of the popliteal artery

Correct Answer & Explanation

. Medial deviation of the popliteal artery around an anomalous medial head of the gastrocnemius

Explanation

Popliteal artery entrapment syndrome occurs most commonly in young athletes. It is caused by an anomalous relationship between the popliteal artery and the medial head of the gastrocnemius muscle (the artery typically deviates medially around or through an anomalous medial head). Symptoms are induced by active plantar flexion, which compresses the artery, leading to claudication-like symptoms and a drop in ABI.

Question 1888

Topic: 8. Foot and Ankle

A 20-year-old male is tackled during a football game with his knee flexed and foot internally rotated. He presents with prominent lateral knee deformity and inability to bear weight. Radiographs confirm an anterolateral dislocation of the proximal tibiofibular joint. Which nerve is most commonly at risk in this type of injury or during its surgical management?

. Tibial nerve
. Deep peroneal nerve
. Superficial peroneal nerve
. Common peroneal nerve
. Sural nerve

Correct Answer & Explanation

. Common peroneal nerve

Explanation

Proximal tibiofibular joint dislocations are most commonly anterolateral. The common peroneal nerve wraps around the fibular neck and is intimately associated with the joint. It is at high risk of stretch injury from the initial trauma (though more commonly in posteromedial dislocations) and is at significant risk iatrogenically during surgical reduction or reconstruction.

Question 1889

Topic: 8. Foot and Ankle

A 24-year-old male sustains an anterior knee dislocation that is reduced in the field. Upon arrival at the trauma bay, the knee is swollen but stable. Distal pulses are palpable but slightly asymmetric. The Ankle-Brachial Index (ABI) is calculated to be 0.85. What is the most appropriate next step in management?

. Discharge with a knee immobilizer
. Serial ABI measurements every 4 hours for 24 hours
. Immediate surgical exploration of the popliteal artery
. CT angiography of the lower extremity
. Duplex ultrasonography

Correct Answer & Explanation

. CT angiography of the lower extremity

Explanation

An ABI < 0.9 in the setting of a knee dislocation is highly suspicious for a significant popliteal artery injury. The appropriate next step in a patient with asymmetric pulses or an ABI < 0.9 is to obtain an advanced imaging study, typically CT angiography, to definitively evaluate for an intimal flap, occlusion, or other vascular injury before progressing to surgery.

Question 1890

Topic: 8. Foot and Ankle

A 30-year-old male presents with a grossly deformed knee after a motorcycle crash. After successful closed reduction of the knee dislocation, palpable distal pulses are present but weak. The Ankle-Brachial Index (ABI) is calculated to be 0.85. What is the most appropriate next step in management?

. Serial clinical examinations and pulse checks every 4 hours
. Immediate surgical exploration of the popliteal artery
. CT angiography of the lower extremity
. Duplex ultrasonography of the popliteal vein
. Application of a spanning external fixator before vascular workup

Correct Answer & Explanation

. CT angiography of the lower extremity

Explanation

An ABI < 0.90 in the setting of a knee dislocation is highly sensitive for vascular injury and warrants advanced imaging such as CT angiography. Patients with absent pulses or hard signs of ischemia (e.g., expanding hematoma) should proceed directly to surgical exploration.

Question 1891

Topic: 8. Foot and Ankle

A 32-year-old male sustains a high-velocity knee dislocation (KD-IV). After closed reduction, his ankle-brachial index (ABI) is measured at 0.85. The limb is warm and well-perfused. What is the next best step in management?

. Immediate surgical exploration of the popliteal artery
. CT angiography of the lower extremity
. Observation and repeat ABI in 4 hours
. Duplex ultrasound in 24 hours
. Application of a long leg cast

Correct Answer & Explanation

. Immediate surgical exploration of the popliteal artery

Explanation

An ABI < 0.9 in the setting of a knee dislocation is highly suspicious for a vascular injury. CT angiography is indicated to definitively evaluate the popliteal artery and guide further vascular intervention.

Question 1892

Topic: 8. Foot and Ankle
A 7-month-old girl has had a severe flatfoot deformity since birth. The talar head is prominent in the medial plantar arch of the foot. No other deformities of the spine or extremities are present. Motor and sensory examinations of the extremities are normal. Figures 37a through 37c show simulated weight-bearing AP and lateral radiographs and a plantar flexion lateral view. What is the most likely diagnosis?
. Pes calcaneovalgus
. Congenital vertical talus
. Flexible pes planus
. Peroneal spastic flatfoot
. Congenital short Achilles tendon

Correct Answer & Explanation

. Congenital vertical talus

Explanation

Congenital vertical talus is a fixed dorsal dislocation of the talonavicular joint with equinus of the ankle joint. The AP radiograph shows valgus of the midfoot and an increased talocalcaneal angle; the lateral radiograph shows a vertically positioned talus and equinus of the ankle joint, and the plantar flexion lateral view shows that the talonavicular joint does not reduce. A line drawn through the long axis of the talus passes below the long axis of the first metatarsal. Initial management should consist of serial casting to stretch the dorsal soft-tissue structures; surgery eventually will be required to reduce the talonavicular joint. The differential diagnosis of congenital vertical talus includes pes calcaneovalgus, flexible pes planus, and peroneal spastic flatfoot. Pes calcaneovalgus, flexible pes planus, congenital short Achilles tendon, and peroneal spastic flatfoot would not show resistant dorsal dislocation of the navicular on the plantar flexion view.

Question 1893

Topic: 8. Foot and Ankle

Figures 245a through 245e are the radiographs and MRI scans of a 50-year-old ice hockey referee with a 3-year history of progressive anterolateral ankle pain, a history of multiple ankle sprains, and a fibular fracture he sustained 30 years ago. Examination reveals mild bilateral pes planovalgus feet with passive ankle joint dorsiflexion range of motion of 10 degrees and plantar flexion of 45 degrees without pain. The physician should recommend

. ankle joint arthrodesis.
. ankle ligament reconstruction.
. supramalleolar osteotomy.
. total ankle joint arthroplasty.
. corticosteroid injection into the ankle.

Correct Answer & Explanation

. ankle joint arthrodesis.

Explanation

Question 1894

Topic: 8. Foot and Ankle
A newborn has been referred for evaluation of a deformed foot. Prenatal and birth history are unremarkable. Examination reveals a rocker bottom appearance to the foot, and a longitudinal arch cannot be created. A palpable lump is appreciated on the plantar medial surface. What is the best course of action?
. Parental education and reassurance
. Serial casting of the forefoot
. Complete peritalar release
. Lengthening of the Achilles tendon and soft-tissue balancing
. Reverse last shoes

Correct Answer & Explanation

. Complete peritalar release

Explanation

DISCUSSION: The patient has congenital vertical talus. The navicular is irreducibly dorsally dislocated on the talus with the talar head prominent on the plantar medial aspect of the foot. Initial management involves corrective casting for 3 months to stretch the dorsal tendons, skin, and neurovascular structures. Surgical reconstruction is often needed and is indicated when the patient is age 6 to 12 months. Reconstruction requires both bony and soft-tissue procedures.

Question 1895

Topic: 8. Foot and Ankle
A 46-year-old man sustains a calcaneal fracture in a fall off a scaffold. During surgical reconstruction using an extended lateral incision, the fracture is reduced and fixed with a plate and screws. One of the posterior facet screws is found to be 5 mm out of the bone on the Harris view. What structure is most likely at risk because of this finding?
. Posterior tibial tendon
. Flexor digitorum longus tendon
. Flexor hallucis longus tendon
. Posterior tibial neurovascular bundle
. Abductor hallucis muscle

Correct Answer & Explanation

. Flexor hallucis longus tendon

Explanation

The abductor hallucis muscle is the most medial structure. The posterior tibial tendon and the flexor digitorum longus tendon lie more cephalad to the sustentaculum tali. There is a groove under the sustentaculum for the flexor hallucis longus tendon. Subchondral lag screws placed across the posterior facet exit the medial side of the calcaneus in this groove. Just medial to the flexor hallucis longus tendon is the neurovascular bundle. A screw that is out of the bone a short distance can cause triggering of the flexor hallucis longus tendon. Patients will report loss of great toe excursion in the early postoperative period. Accurate measurement of subchondral lag screw length avoids this complication.

Question 1896

Topic: 8. Foot and Ankle
A 16-year-old girl has had pain and swelling along the medial arch of her left foot for the past 3 months. She also reports pain from shoe wear and while running. Nonsteroidal anti-inflammatory drugs have failed to provide relief. Radiographs are shown in Figures 40a through 40c. What is the next most appropriate step in management?
. Resection of the tarsal coalition
. Open reduction and internal fixation of the navicular fracture
. Surgical resection of the accessory navicular
. Corticosteroid injection
. Custom-molded orthosis

Correct Answer & Explanation

. Custom-molded orthosis

Explanation

DISCUSSION: Nonsurgical management of a symptomatic accessory navicular should be attempted prior to surgery. Good relief is often obtained with a semi-rigid orthosis with a medial arch support.

Question 1897

Topic: 8. Foot and Ankle
Which nerve is not included in a standard popliteal nerve block?
. Sural nerve
. Saphenous nerve
. Superficial peroneal nerve
. Deep peroneal nerve

Correct Answer & Explanation

. Saphenous nerve

Explanation

DISCUSSION: A standard popliteal nerve block is performed with the patient prone. The injection aims for the area at, or close to, the peroneal and tibial nerves. The sural nerve branches distal to the injection site, so this nerve and the superficial peroneal, deep peroneal, and tibial nerves are covered with the injection. The saphenous nerve is in an anteromedial location at knee level and is not close enough to the area covered by the posterior injection to be included in the analgesic effect.

Question 1898

Topic: 8. Foot and Ankle
A 57-year-old man with type II diabetes mellitus was successfully treated for a first occurrence forefoot full-thickness (Wagner II) diabetic foot ulcer underlying the third metatarsal head with associated hammertoe with a series of weight-bearing total contact casts. There was no evidence of osteomyelitis. The ulcer is now fully healed. He is insensate to the Semmes-Weinstein 5.07 (10 gm) monofilament. What is the next most appropriate step in management?
. No further treatment is advised unless a second ulcer develops
. Oxford shoes with a rubber sole
. Depth-inlay shoes with a custom accommodative foot orthosis
. Dorsiflexion third metatarsal osteotomy
. Achilles tendon lengthening

Correct Answer & Explanation

. Depth-inlay shoes with a custom accommodative foot orthosis

Explanation

This is the first occurrence of diabetic foot-specific morbidity. The patient has a foot deformity, a history of a diabetic foot ulcer, and is insensate to the monofilament. He is at moderate risk for the development of a recurrent ulcer. This is best avoided with therapeutic footwear. Commercially available depth-inlay shoes should be combined with a custom accommodative foot orthosis to accommodate the deformity.

Question 1899

Topic: Ankle Trauma & Sports

-A 30-year-old man sustained the injury seen in Figure 261. According to the Lauge-Hansen Classification System, the fracture should be classified as

. pronation-abduction.
. pronation-adduction.
. pronation-external rotation.
. supination-adduction.
. supination-external rotation.

Correct Answer & Explanation

. pronation-abduction.

Explanation

Question 1900

Topic: 8. Foot and Ankle
A 45-year-old diabetic woman with a gangrenous foot undergoes a Chopart amputation without tendon transfer or lengthening. Which type of deformity is the most likely complication of this procedure?
. Valgus deformity
. Varus deformity
. Equinus deformity
. Cavus deformity
. Planus deformity

Correct Answer & Explanation

. Equinus deformity

Explanation

DISCUSSION: The Chopart amputation is an amputation of the foot at the level of the calcaneocuboid and talonavicular level. Historically, its use has been criticized because an amputation at this level results in a muscular imbalance with flexor predominance and equinus deformity that eventually leads to stump breakdown. To prevent this complication it should be coupled with Achilles tenotomy (vs. lengthening) as well as transfer of the tibialis anterior insertion to the talar neck.

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