Orthopedic Board Review: 100 Foot & Ankle Mock MCQs

Question 1

A 25-year-old athlete presents with midfoot pain and plantar ecchymosis. Weight-bearing radiographs demonstrate a 3 mm diastasis between the first and second metatarsal bases. In a purely ligamentous injury of this type, which of the following treatments provides the most predictable long-term outcome?

Explanation

Purely ligamentous Lisfranc injuries have a high rate of hardware failure and post-traumatic arthritis with ORIF. Primary arthrodesis of the medial columns (1st, 2nd, and 3rd TMT joints) provides superior long-term outcomes and reduces reoperation rates.

Question 2

A 55-year-old female presents with a progressive, painful flatfoot deformity. Examination reveals inability to perform a single-leg heel rise and excessive forefoot abduction. Radiographs demonstrate greater than 40% talonavicular uncoverage but flexible hindfoot and forefoot joints. What is the most appropriate surgical intervention?

Explanation

This is a Stage IIb adult acquired flatfoot deformity (flexible, with significant forefoot abduction). Treatment requires addressing both the medial column (FDL transfer, medial osteotomy) and the lateral column lengthening to correct the forefoot abduction.

Question 3

A 25-year-old athlete presents with midfoot pain after a twisting injury. Non-weight-bearing radiographs are normal. What is the most appropriate next step to diagnose a subtle Lisfranc injury?

Explanation

Weight-bearing radiographs are essential for evaluating subtle Lisfranc injuries as they can reveal diastasis between the first and second metatarsals. If weight-bearing films are normal but clinical suspicion remains high, MRI or weight-bearing CT may be indicated.

Question 4

A 32-year-old male sustains a Hawkins Type III talar neck fracture. Which of the following best describes the disruption of blood supply associated with this injury?

Explanation

A Hawkins Type III fracture involves dislocation of the talar body from both the subtalar and tibiotalar joints. This disrupts all three major sources of blood supply to the talus: the artery of the tarsal canal, artery of the tarsal sinus, and deltoid branches.

Question 5

A 55-year-old diabetic patient presents with a red, hot, swollen foot without an ulcer. Radiographs show fragmentation and subluxation of the midfoot. What is the most appropriate initial management?

Explanation

This patient is in Eichenholtz Stage I (fragmentation) of Charcot arthropathy. The gold standard for initial management is immobilization with a total contact cast to prevent further deformity while the acute inflammatory phase resolves.

Question 6

During a minimally invasive repair of an acute Achilles tendon rupture, the surgeon places percutaneous sutures in the proximal stump. Which neurological structure is at greatest risk during this step?

Explanation

The sural nerve crosses from medial to lateral, typically running about 1 to 2 cm lateral to the lateral border of the Achilles tendon in the proximal aspect. It is at high risk of entrapment or injury during percutaneous or minimally invasive Achilles repairs.

Question 7

A 45-year-old female presents with a flexible flatfoot deformity, unable to perform a single-leg heel rise, and >40% uncovering of the talonavicular joint on weight-bearing AP radiographs. What surgical procedure is specifically indicated to correct the forefoot abduction?

Explanation

This patient has Stage IIb posterior tibial tendon dysfunction, characterized by forefoot abduction (>30-40% talonavicular uncovering). A lateral column lengthening (Evans osteotomy) is indicated to specifically address and correct the forefoot abduction component.

Question 8

A 40-year-old female presents with a painful bunion. Weight-bearing radiographs reveal a Hallux Valgus Angle (HVA) of 42 degrees and an Intermetatarsal Angle (IMA) of 18 degrees. Which of the following is the most appropriate surgical option?

Explanation

An IMA of >15 degrees and HVA >40 degrees defines a severe hallux valgus deformity. Proximal osteotomies or a first tarsometatarsal fusion (Lapidus) provide the necessary corrective power, whereas distal osteotomies are insufficient for this degree of deformity.

Question 9

A 22-year-old professional soccer player sustains an acute fracture at the metaphyseal-diaphyseal junction of the fifth metatarsal. Which of the following is the recommended treatment to minimize the risk of nonunion and allow early return to play?

Explanation

Fractures at the metaphyseal-diaphyseal junction (Jones fractures, Zone 2) occur in a vascular watershed area with a high risk of nonunion. In elite athletes, intramedullary screw fixation is recommended to reduce nonunion rates and accelerate return to sport.

Question 10

A 35-year-old male undergoes open reduction and internal fixation of a displaced intra-articular calcaneus fracture via a lateral extensile approach. What is the most common complication associated with this specific surgical approach?

Explanation

The lateral extensile approach for calcaneus fractures relies on a full-thickness flap whose blood supply is tenuous (primarily the lateral calcaneal artery). Wound complications, particularly edge necrosis and dehiscence, occur in up to 10-25% of cases.

Question 11

An MRI of a 28-year-old male with chronic ankle pain reveals a deep, cup-shaped osteochondral lesion on the posteromedial aspect of the talar dome. What is the typical mechanism of injury leading to this specific lesion?

Explanation

Posteromedial osteochondral lesions of the talus are typically deeper and cup-shaped, caused by an inversion and plantarflexion injury. Anterolateral lesions are typically shallower, wafer-shaped, and caused by inversion and dorsiflexion (DIAL a PIMP mnemonic).

Question 12

A patient with Charcot-Marie-Tooth disease presents with a bilateral cavovarus foot deformity. A Coleman block test is performed, and the hindfoot corrects to neutral. What does this physical examination finding indicate?

Explanation

The Coleman block test evaluates hindfoot flexibility in a cavovarus foot. If the hindfoot varus corrects when the first ray is allowed to drop off the block, the hindfoot is flexible, indicating the varus deformity is driven by a rigid plantarflexed first ray.

Question 13

A 45-year-old female complains of burning pain in the third web space of her foot. Non-operative management has failed. During surgical excision through a dorsal approach, which structure must be transected to adequately access the neuroma?

Explanation

When excising a Morton's neuroma via a dorsal approach, the deep transverse metatarsal ligament must be transected to expose the neuroma, which lies plantar to this structure. This helps prevent recurrence by releasing the compression point.

Question 14

A 52-year-old male presents with dorsal foot pain and restricted first MTP joint dorsiflexion. Radiographs show dorsal osteophytes with joint space preservation on the plantar half of the first MTP joint. Which treatment is most appropriate after failed conservative care?

Explanation

The patient has Coughlin and Shurnas Grade 2 hallux rigidus (dorsal osteophytes, preserved plantar joint space). A cheilectomy (removal of the dorsal third of the metatarsal head and osteophytes) is the surgical treatment of choice, providing pain relief and improved dorsiflexion.

Question 15

A 35-year-old male sustains a Hawkins type III talar neck fracture. Which of the following describes the anatomical displacement and the associated rate of avascular necrosis (AVN)?

Explanation

A Hawkins type III fracture involves displacement of both the subtalar and tibiotalar joints. The risk of avascular necrosis in these injuries is nearly 100% due to the disruption of the artery of the tarsal canal, deltoid branches, and dorsalis pedis branches.

Question 16

Recent randomized controlled trials comparing operative versus non-operative management of acute Achilles tendon ruptures using early functional rehabilitation protocols have demonstrated which of the following?

Explanation

When employing an early functional rehabilitation protocol with weight-bearing in a functional brace, studies show no clinically important differences in rerupture rates between operative and non-operative management. Operative management is, however, associated with a higher risk of soft tissue complications and infection.

Question 17

A 55-year-old diabetic female presents with a warm, swollen, erythematous left foot. Radiographs show periarticular fragmentation, subluxation, and joint debris at the tarsometatarsal joints. According to the Eichenholtz classification, what is the appropriate initial management?

Explanation

The clinical and radiographic findings describe Eichenholtz stage I (fragmentation/developmental phase) of Charcot arthropathy. The gold standard of initial management is offloading with a total contact cast to prevent further deformity while the acute inflammatory phase resolves.

Question 18

A 45-year-old female presents with symptomatic hallux valgus. Radiographs demonstrate a hallux valgus angle (HVA) of 45 degrees, an intermetatarsal angle (IMA) of 16 degrees, and hypermobility of the first tarsometatarsal (TMT) joint. Which surgical procedure is most appropriate?

Explanation

The patient has a severe hallux valgus deformity combined with first TMT joint hypermobility. A modified Lapidus procedure (first TMT arthrodesis) is the most appropriate operation to correct the deformity and stabilize the medial column.

Question 19

A 22-year-old elite collegiate basketball player sustains an acute Zone 2 fracture of the proximal fifth metatarsal. What is the recommended treatment to minimize the risk of nonunion and expedite return to play?

Explanation

Zone 2 fractures (Jones fractures) involve the metaphyseal-diaphyseal junction, a watershed vascular area prone to nonunion. In elite athletes, early intramedullary screw fixation is recommended to decrease nonunion rates and allow a faster return to competitive sports.

Question 20

A 60-year-old female presents with a flexible flatfoot deformity, unable to perform a single-leg heel raise. Radiographs show a talonavicular uncoverage of 40% but no arthritic changes in the subtalar, talonavicular, or calcaneocuboid joints. What is the most appropriate surgical intervention after failed conservative care?

Explanation

This patient has Stage II adult-acquired flatfoot deformity. Joint-sparing procedures, such as an FDL transfer combined with a medializing calcaneal osteotomy, are indicated since there is no fixed deformity or arthritis.

Question 21

Which of the following radiographic findings is most sensitive for diagnosing a subtle Lisfranc injury on a weight-bearing AP radiograph of the foot?

Explanation

A diastasis of greater than 2 mm between the base of the first and second metatarsals on a weight-bearing AP view is highly indicative of a Lisfranc ligament disruption. While the "fleck sign" is pathognomonic, it is less commonly seen than the diastasis gap.

Question 22

A 40-year-old male roofer falls from a height and sustains a closed, displaced intra-articular calcaneus fracture. CT scan shows a Sanders Type III fracture. Which of the following factors is most strongly associated with poor clinical outcomes following open reduction and internal fixation (ORIF)?

Explanation

While smoking increases wound complication rates, orthopedic literature consistently shows that Worker's compensation claims and ongoing litigation are the most significant predictors of poor functional outcomes following operative treatment of calcaneus fractures.

Question 23

A 25-year-old female presents with persistent deep ankle pain following an inversion sprain 6 months ago. MRI reveals a 12 mm x 10 mm anterolateral osteochondral lesion of the talar dome with intact overlying cartilage. What is the most appropriate initial surgical management after failed conservative therapy?

Explanation

For primary osteochondral lesions of the talus smaller than 1.5 cm squared, arthroscopic bone marrow stimulation is the recommended first-line surgical treatment. OATS or ACI are typically reserved for larger lesions or failures of primary microfracture.

Question 24

A 14-year-old male presents with recurrent ankle sprains and rigid flatfeet. A "C-sign" is noted on the lateral radiograph. Which of the following physical exam findings is most characteristic of this condition?

Explanation

The "C-sign" on a lateral radiograph is indicative of a talocalcaneal coalition. Patients classically present with a rigid flatfoot, decreased subtalar motion, and peroneal spasticity acting as a protective mechanism against painful joint movement.

Question 25

Which of the following is considered an absolute contraindication to a total ankle arthroplasty in a patient with end-stage tibiotalar osteoarthritis?

Explanation

Active Charcot neuroarthropathy is an absolute contraindication to total ankle arthroplasty due to the high risk of implant subsidence, failure, and severe complications in a dysvascular, insensate limb. Concomitant subtalar arthritis is often a relative indication for arthroplasty to preserve hindfoot motion.

Question 26

A 28-year-old skier presents with lateral ankle pain and a snapping sensation posterior to the fibula after acute forced dorsiflexion and inversion. Physical examination reveals subluxation of the peroneal tendons with resisted eversion. Which anatomic structure is primarily compromised?

Explanation

Peroneal tendon subluxation or dislocation is primarily caused by an injury or incompetence of the superior peroneal retinaculum. It frequently occurs during acute forced dorsiflexion of the inverted foot.

Question 27

A professional football player sustains a hyperextension injury to his first metatarsophalangeal (MTP) joint. MRI shows complete rupture of the plantar plate and proximal migration of the sesamoids. What is the most appropriate management?

Explanation

A complete rupture of the plantar plate with proximal migration of the sesamoids represents a Grade 3 Turf Toe injury. In competitive athletes, Grade 3 injuries typically require primary surgical repair to restore the push-off strength and stability of the first MTP joint.

Question 28

A 45-year-old male sustains a high-energy closed tibial pilon fracture with severe soft tissue swelling and fracture blisters. What is the most appropriate initial management strategy?

Explanation

High-energy pilon fractures are associated with significant soft tissue trauma. The standard of care is a staged approach utilizing a spanning external fixator initially, followed by definitive fixation once the soft tissue envelope has adequately healed.

Question 29

A 20-year-old track athlete complains of vague, aching dorsal midfoot pain that worsens with running. Radiographs are normal, but a CT scan reveals an incomplete, non-displaced stress fracture of the tarsal navicular in the sagittal plane. What is the most appropriate initial treatment?

Explanation

Non-displaced navicular stress fractures have a high risk of nonunion due to the watershed vascular supply of the central third of the bone. Strict non-weight-bearing in a cast for 6 to 8 weeks is the gold standard initial treatment to achieve union.

Question 30

A 32-year-old recreational athlete sustains an acute Achilles tendon rupture. He is considering operative versus non-operative management. According to recent high-level evidence utilizing early functional rehabilitation, what is the most accurate statement regarding outcomes?

Explanation

Recent high-level studies show that when early functional rehabilitation protocols are utilized, the rerupture rates and functional outcomes between operative and non-operative management of acute Achilles tendon ruptures are statistically similar. Operative treatment carries a higher risk of soft-tissue complications.

Question 31

A 45-year-old female presents with midfoot pain after a fall from a horse. Weight-bearing radiographs and subsequent MRI demonstrate a purely ligamentous Lisfranc injury with 3 mm of diastasis between the first and second metatarsals. What is the most appropriate surgical management?

Explanation

Purely ligamentous Lisfranc injuries have a high failure rate when treated with open reduction and internal fixation (ORIF). Primary arthrodesis of the medial column (1st, 2nd, and 3rd TMT joints) is recommended as it provides superior outcomes and lower revision rates in these specific injuries.

Question 32

A 55-year-old female presents with severe bunion pain. Radiographs reveal a hallux valgus angle (HVA) of 45 degrees, an intermetatarsal angle (IMA) of 19 degrees, and clinical hypermobility of the first ray in the sagittal plane. Which procedure is most appropriate?

Explanation

The Lapidus procedure (first TMT arthrodesis) is indicated for moderate to severe hallux valgus (IMA >15 degrees) associated with first ray hypermobility. It definitively corrects the deformity at the apex (TMT joint) and stabilizes the medial column.

Question 33

A 50-year-old male with long-standing, poorly controlled diabetes presents with a warm, swollen, and erythematous right foot. He denies fevers or systemic symptoms. Radiographs reveal fragmentation and subluxation of the midfoot joints without osteomyelitis. Which of the following is the most appropriate initial treatment?

Explanation

This patient is presenting with acute Eichenholtz Stage I Charcot neuroarthropathy. The gold standard for initial management of the acute, inflammatory phase is total contact casting to immobilize the foot, reduce edema, and prevent further joint destruction.

Question 34

A 58-year-old female presents with adult-acquired flatfoot deformity. Examination shows a flexible hindfoot valgus, inability to perform a single-leg heel raise, and forefoot abduction with >40% talonavicular uncoverage on radiographs. What is the most appropriate surgical intervention?

Explanation

This is a Stage IIb posterior tibial tendon dysfunction (flexible deformity with significant forefoot abduction). The recommended treatment addresses all deformity planes: FDL transfer (tendon substitution), medializing calcaneal osteotomy (hindfoot valgus correction), and lateral column lengthening (forefoot abduction correction).

Question 35

A 21-year-old collegiate basketball player sustains a fracture at the metaphyseal-diaphyseal junction of the fifth metatarsal (Zone 2). To ensure the highest chance of union and fastest return to play, what is the best treatment option?

Explanation

Zone 2 (Jones) fractures in elite athletes are best treated with intramedullary screw fixation to minimize the risk of nonunion and accelerate return to play. The fracture occurs in a vascular watershed area, making it prone to delayed union with conservative management.

Question 36

A 30-year-old male is recovering from an operatively treated Hawkins Type II talar neck fracture. At 8 weeks post-operation, an AP radiograph of the ankle demonstrates a subchondral radiolucent band in the talar dome. What does this finding signify?

Explanation

This finding is known as the Hawkins sign. The subchondral radiolucency indicates that the bone is undergoing disuse osteopenia, which requires an intact blood supply, thereby prognosticating against the development of complete avascular necrosis.

Question 37

A 45-year-old male sustains a displaced intra-articular calcaneus fracture. The surgeon is planning an extensile lateral approach for open reduction and internal fixation. Which of the following patient factors is the strongest independent predictor of postoperative wound complications?

Explanation

Cigarette smoking is the most significant independent risk factor for wound breakdown and infection following an extensile lateral approach to the calcaneus. Patients who smoke have vastly higher rates of flap necrosis and deep infection.

Question 38

In a patient with Charcot-Marie-Tooth disease presenting with a classic cavovarus foot deformity, which of the following muscle imbalances is the primary driver of the plantarflexed first ray?

Explanation

In CMT, the peroneus longus retains its strength while the tibialis anterior weakens. The unopposed pull of the peroneus longus strongly plantarflexes the first ray, contributing significantly to the cavus deformity and subsequent hindfoot varus.

Question 39

A 60-year-old male presents with severe pain and stiffness in the first metatarsophalangeal (MTP) joint. Examination reveals pain throughout the entire arc of motion and less than 10 degrees of dorsiflexion. Radiographs show complete loss of the joint space, subchondral cysts, and large dorsal osteophytes (Grade 3 hallux rigidus). What is the gold standard surgical treatment?

Explanation

First MTP joint arthrodesis is the gold standard for advanced (Grade 3 or 4) hallux rigidus characterized by significant joint space narrowing and mid-arc pain. Cheilectomy is generally reserved for Grade 1 or 2 disease with pain only at the extremes of dorsiflexion.

Question 40

A 45-year-old runner presents with chronic medial heel pain that is worse at the end of the day and non-responsive to plantar fasciitis treatments. Tinel's sign is positive over the medial heel, and MRI shows fatty atrophy of the abductor digiti minimi. Where is the most likely anatomic site of entrapment for the involved nerve?

Explanation

The patient has Baxter's nerve entrapment (first branch of the lateral plantar nerve). It most commonly becomes entrapped between the deep fascia of the abductor hallucis and the medial aspect of the quadratus plantae, leading to denervation of the abductor digiti minimi.

Question 41

During open reduction and internal fixation of a pronation-external rotation (Weber C) ankle fracture, what is a critical technical prerequisite before utilizing a clamp to anatomically reduce the syndesmosis?

Explanation

Restoring anatomical fibular length and rotation is an absolute prerequisite before clamping and fixing the syndesmosis. Failure to restore fibular length will result in proximal migration of the fibula and a malreduced syndesmosis.

Question 42

A professional football player sustains a forced hyperextension injury to his great toe. MRI reveals a complete rupture of the plantar plate and joint capsule with proximal retraction of the sesamoids (Grade 3 Turf Toe). What is the recommended management?

Explanation

Grade 3 turf toe injuries (complete disruption of the plantar plate complex) in elite athletes usually require operative repair to restore the push-off mechanism and prevent chronic instability, progressive hallux valgus, or hallux rigidus.

Question 43

A 20-year-old elite track athlete complains of insidious onset midfoot pain. A CT scan reveals a non-displaced, incomplete stress fracture involving the dorsal cortex of the tarsal navicular. What is the most appropriate initial management?

Explanation

For non-displaced and incomplete navicular stress fractures, conservative management consisting of 6 weeks of strict non-weight-bearing in a cast is highly successful and remains the first-line treatment. Weight-bearing casts or boots have unacceptably high failure rates.

Question 44

A 25-year-old male presents with lateral ankle pain and a snapping sensation behind the lateral malleolus when the ankle is actively dorsiflexed and everted. Radiographs demonstrate a small bony "fleck" lateral to the distal fibula. What is the anatomic basis of this pathology?

Explanation

The patient has peroneal tendon subluxation. The "fleck sign" on an AP ankle radiograph represents a bony avulsion of the superior peroneal retinaculum (SPR) from the lateral malleolus. Surgical treatment typically involves SPR repair and potential fibular groove deepening.

Question 45

A diabetic patient with peripheral neuropathy presents with a chronic, recurrent plantar ulcer directly beneath the first metatarsal head. He has failed total contact casting and orthotic management. Physical examination reveals an inability to dorsiflex the ankle past neutral with the knee extended, but 15 degrees of dorsiflexion is achieved when the knee is flexed. What surgical adjunct is most likely to heal the ulcer and prevent recurrence?

Explanation

The patient has a positive Silfverskiold test, indicating isolated gastrocnemius tightness (equinus contracture). This contracture dramatically increases forefoot plantar pressures. Gastrocnemius recession or Achilles lengthening reduces this pressure, promoting ulcer healing and preventing recurrence.

Question 46

A 55-year-old female presents with pain at the plantar aspect of the second metatarsophalangeal (MTP) joint and a new onset of the second toe crossing over the hallux. A positive dorsal drawer test of the second MTP joint is elicited. What is the most likely diagnosis?

Explanation

A positive dorsal drawer test at the MTP joint, localized plantar pain, and crossover toe deformity are hallmark clinical signs of a plantar plate attenuation or tear. Morton's neuroma usually presents with web space pain and a positive Mulder's click, without joint instability.

Question 47

A 65-year-old patient with end-stage ankle osteoarthritis is evaluated for a total ankle replacement (TAR). Which of the following is considered an absolute contraindication to modern total ankle arthroplasty?

Explanation

Charcot neuroarthropathy, active infection, severe talar avascular necrosis (>50%), and loss of protective sensation are absolute contraindications to total ankle replacement due to exceptionally high failure rates. Ankle arthrodesis is preferred in these scenarios.

Question 48

A 40-year-old male sustains a high-energy, severely displaced pilon fracture (OTA 43-C3) with massive soft tissue swelling and fracture blisters. A spanning external fixator is placed on the day of injury. What is the primary reason to delay definitive open reduction and internal fixation?

Explanation

Definitive ORIF of pilon fractures is staged primarily to allow the severe soft tissue envelope swelling to subside. Operating through compromised, swollen soft tissue dramatically increases the risk of wound dehiscence and deep infection. The reappearance of skin wrinkles indicates appropriate timing.

Question 49

A 15-year-old female dancer complains of insidious pain and swelling isolated to the dorsal aspect of the second metatarsal head. Radiographs demonstrate flattening, sclerosis, and fragmentation of the second metatarsal head. What is the underlying pathology?

Explanation

The clinical scenario and radiographic findings of flattening and sclerosis of the second metatarsal head in a young, active female are classic for Freiberg's infraction, which is avascular necrosis of the metatarsal head.

Question 50

A 24-year-old professional football player sustains a hyperdorsiflexion injury to his first metatarsophalangeal (MTP) joint. Exam reveals profound ecchymosis and a lack of push-off strength. MRI confirms a complete tear of the plantar plate with proximal retraction of the sesamoids. What is the most appropriate management?

Explanation

This is a Grade 3 turf toe injury with complete disruption of the plantar plate and proximal sesamoid migration. In a high-level athlete with a complete tear, primary surgical repair is indicated to restore push-off strength and joint stability.

Question 51

A 45-year-old female presents with progressive flattening of her left arch. She cannot perform a single-leg heel raise. Radiographs demonstrate an uncovered talar head of 45% and a talonavicular uncoverage angle of 25 degrees. She has pain over the lateral hindfoot but a passively correctable hindfoot valgus. What is the most appropriate surgical treatment?

Explanation

This describes Stage IIb posterior tibial tendon dysfunction (PTTD), characterized by a flexible deformity with >40% talonavicular uncoverage (forefoot abduction). Treatment requires lateral column lengthening to correct the forefoot abduction, in addition to FDL transfer and medial calcaneal slide.

Question 52

Which of the following is an absolute contraindication to a total ankle arthroplasty (TAA)?

Explanation

Charcot neuroarthropathy is an absolute contraindication to total ankle arthroplasty due to the loss of protective sensation, poor bone quality, and high failure rates. Ankle arthrodesis or tibiotalocalcaneal (TTC) fusion is the preferred surgical option for end-stage Charcot ankle arthropathy.

Question 53

A 19-year-old collegiate runner presents with midfoot pain. MRI confirms a stress fracture of the navicular involving the central third with a 1 mm gap and no sclerosis. What is the recommended initial management?

Explanation

Navicular stress fractures carry a high risk of nonunion due to the relatively avascular central third. Initial conservative management for nondisplaced fractures requires strict non-weight-bearing in a short leg cast for 6 to 8 weeks.

Question 54

A 32-year-old male sustains a closed, highly comminuted, displaced tibial pilon fracture (OTA/AO 43-C3) with severe soft tissue swelling and fracture blisters. What is the most appropriate initial management?

Explanation

High-energy pilon fractures with severe soft tissue compromise should be managed with the "span, scan, and plan" approach. A spanning external fixator stabilizes the fracture and allows soft tissue recovery before delayed definitive open reduction and internal fixation.

Question 55

A 28-year-old female presents with a painful bunion deformity. Examination reveals a hallux valgus angle of 45 degrees, an intermetatarsal angle of 18 degrees, and clinical hypermobility of the 1st tarsometatarsal (TMT) joint. What is the most appropriate surgical procedure?

Explanation

The Lapidus procedure (first TMT arthrodesis) is indicated for severe hallux valgus deformities (IMA > 15 degrees) associated with 1st ray hypermobility. It provides powerful correction and addresses the apex of the deformity at the TMT joint.

Question 56

In the Sanders classification for intra-articular calcaneal fractures, the primary coronal CT image used to determine the classification is located at which anatomic landmark?

Explanation

The Sanders classification is based on coronal CT images through the widest portion of the posterior facet of the calcaneus. It categorizes fractures based on the number and location of articular fragments, which guides surgical decision-making.

Question 57

A 40-year-old male sustains a Hawkins Type III talar neck fracture. Which of the following best describes this injury and its associated risk of avascular necrosis (AVN)?

Explanation

A Hawkins Type III talar neck fracture involves displacement of the talar neck with dislocation of both the subtalar and tibiotalar joints. The risk of avascular necrosis (AVN) in Type III fractures is extremely high, approaching 90-100%.

Question 58

A 22-year-old basketball player lands awkwardly on another player's foot and complains of lateral foot pain. Radiographs demonstrate a fracture at the diaphyseal-metaphyseal junction of the fifth metatarsal. He wishes to return to play as soon as possible. What is the most appropriate treatment?

Explanation

This is a Zone 2 (Jones) fracture. In high-level athletes, early intramedullary screw fixation is recommended to decrease the time to union, minimize the risk of nonunion, and expedite return to play.

Question 59

A 55-year-old male with diabetes presents with a red, hot, swollen foot without systemic signs of infection. Radiographs reveal fragmentation and periarticular debris at the midfoot. Which of the following is the gold standard initial treatment?

Explanation

The clinical presentation is classic for acute (Eichenholtz Stage I) Charcot neuroarthropathy. The gold standard initial treatment is offloading with a total contact cast (TCC) to prevent further deformity while the acute inflammatory process subsides.

Question 60

A 42-year-old female complains of persistent dorsal midfoot pain 6 months after a seemingly minor twisting injury. Weight-bearing radiographs demonstrate a 3 mm diastasis between the base of the 1st and 2nd metatarsals. What is the most likely diagnosis?

Explanation

A diastasis >2 mm between the base of the 1st and 2nd metatarsals on weight-bearing radiographs is diagnostic of a Lisfranc injury. Subtle Lisfranc injuries frequently present with persistent midfoot pain and require weight-bearing films for accurate diagnosis.

Question 61

A 60-year-old female undergoes surgical release of the plantar fascia for recalcitrant plantar fasciitis. Postoperatively, she develops new-onset lateral midfoot pain. What is the most likely cause of this complication?

Explanation

Surgical release of the plantar fascia, especially if >50% is released, can result in a loss of the medial longitudinal arch and subsequent lateral column overload. This biomechanical shift often manifests as new lateral midfoot pain postoperatively.

Question 62

A 15-year-old boy presents with a rigid flatfoot and frequent ankle sprains. Radiographs reveal an elongated anterior process of the calcaneus resembling an "anteater's nose" on the lateral view. Which of the following is the most likely diagnosis?

Explanation

The "anteater sign" on a lateral foot radiograph is pathognomonic for a calcaneonavicular tarsal coalition. Tarsal coalitions typically present in adolescence with a rigid flatfoot and recurrent ankle sprains due to altered hindfoot mechanics.

Question 63

During evaluation of a patient with an acute ankle sprain, a positive external rotation stress test is elicited. On the AP radiograph, what is the normal expected tibiofibular overlap measured 1 cm proximal to the joint line?

Explanation

In a normal ankle, the tibiofibular overlap on an AP radiograph should be >6 mm (or >1 mm on the mortise view). Decreased overlap indicates a syndesmotic injury (distal tibiofibular diastasis) which may require surgical stabilization.

Question 64

A 35-year-old recreational athlete sustains an acute complete rupture of the Achilles tendon. He opts for nonoperative management. Which of the following is true regarding nonoperative versus operative management for this injury?

Explanation

Recent literature shows that nonoperative management with early functional rehabilitation (weight-bearing in equinus) yields re-rupture rates comparable to operative repair (around 3-5%). Operative management carries a higher risk of soft tissue complications, such as infection and wound breakdown.

Question 65

A 50-year-old female presents with a painful bunionette deformity. Radiographs show a normal 4-5 intermetatarsal angle but a lateral bowing of the 5th metatarsal shaft. What is the most appropriate surgical management?

Explanation

Bunionette deformities with lateral bowing of the 5th metatarsal shaft (Type III) are best addressed with a diaphyseal osteotomy to correct the structural bowing. Distal osteotomies or condylectomies are insufficient for shaft deformities.

Question 66

A 29-year-old male sustains an inversion ankle injury resulting in a "popping" sensation behind the lateral malleolus. Examination reveals retromalleolar pain and snapping of the tendons with resisted dorsiflexion and eversion. Which of the following structures is most likely injured?

Explanation

Snapping of the peroneal tendons over the lateral malleolus with resisted dorsiflexion and eversion indicates peroneal tendon subluxation or dislocation. This occurs secondary to an injury or avulsion of the superior peroneal retinaculum (SPR).

Question 67

Which of the following physical exam findings is most specific for a complete rupture of the anterior tibial tendon?

Explanation

The anterior tibial tendon is the primary dorsiflexor of the ankle. A complete rupture results in a drop foot, characterized by a "slapping" gait during the heel-strike phase and a clinical inability to walk on the heels.

Question 68

A 55-year-old female presents with pain in her forefoot. She notes a feeling of "walking on a marble." Compression of the forefoot reproduces a painful click. Which interdigital space is most commonly affected by this condition?

Explanation

The clinical presentation (Mulder's click) is characteristic of a Morton's neuroma. This compressive neuropathy most commonly affects the common digital nerve in the third web space (between the 3rd and 4th metatarsal heads).

Question 69

A 40-year-old male sustains an acute, closed Achilles tendon rupture. He is treated non-operatively with an early functional rehabilitation protocol. Compared to surgical repair, which of the following outcomes is most closely associated with this management strategy?

Explanation

Recent high-quality studies show that early functional rehabilitation for acute Achilles tendon ruptures yields equivalent re-rupture rates compared to surgical repair. Surgical repair carries a higher risk of soft tissue complications and nerve injury without providing a clinically significant improvement in rupture rates.

Question 70

A 24-year-old soccer player sustains an inversion ankle injury. Weight-bearing radiographs reveal a 5 mm medial clear space, which increases to 8 mm on external rotation stress views. The fibula is intact. What is the most appropriate definitive management?

Explanation

This patient has a purely ligamentous syndesmotic injury with instability, demonstrated by widening of the medial clear space on stress views. Operative fixation with syndesmotic screws or suture-button devices is required to restore and maintain the mortise.

Question 71

A 58-year-old poorly controlled diabetic presents with a swollen, erythematous, and warm but painless right foot. Radiographs demonstrate periarticular debris, subchondral cyst formation, and fragmentation of the midfoot. According to the Eichenholtz classification, what stage does this represent?

Explanation

Eichenholtz Stage 1 (Development/Fragmentation) is characterized by joint edema, erythema, periarticular debris, fragmentation, and subluxation. Stage 2 involves coalescence (absorption of debris), and Stage 3 is reconstruction/consolidation.

Question 72

A 30-year-old male sustains a talar neck fracture with subluxation of both the subtalar and tibiotalar joints following a motor vehicle accident. What is his estimated risk of developing avascular necrosis (AVN) of the talar body?

Explanation

This describes a Hawkins Type III talar neck fracture (fracture with dislocation of the subtalar and tibiotalar joints). The risk of AVN in Hawkins Type III fractures is historically reported to be between 70-100% due to the disruption of the tenuous retrograde blood supply.

Question 73

During an extensile lateral approach for open reduction and internal fixation of a displaced intra-articular calcaneus fracture, the full-thickness flap is elevated. Which of the following structures is contained within this flap and must be protected?

Explanation

The extensile lateral approach to the calcaneus involves creating a full-thickness subperiosteal flap. The sural nerve and lesser saphenous vein are included within this flap to protect them from direct injury and optimize flap vascularity.

Question 74

A 45-year-old female presents with a painful bunion. Weight-bearing 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 options is most appropriate?

Explanation

A Lapidus procedure (first TMT arthrodesis) is indicated for severe hallux valgus (HVA >40, IMA >15) associated with first TMT joint hypermobility. It corrects the deformity at the apex and stabilizes the medial column.

Question 75

A professional football player hyperextends his great toe on artificial turf. MRI confirms a complete tear of the plantar plate with proximal retraction of the medial sesamoid. What is the recommended management?

Explanation

This is a Grade III turf toe injury with sesamoid retraction indicating gross instability of the MTP joint. Surgical repair of the plantar plate and soft tissue structures is recommended for high-level athletes with complete, retracted tears to restore push-off strength.

Question 76

A 22-year-old collegiate basketball player complains of lateral foot pain after an awkward landing. Radiographs reveal a transverse fracture at the metaphyseal-diaphyseal junction of the fifth metatarsal. Which of the following is the most appropriate management to optimize his return to sport?

Explanation

Fractures at the metaphyseal-diaphyseal junction of the fifth metatarsal (Zone 2/Jones fracture) are at a high risk of nonunion due to a watershed blood supply. Intramedullary screw fixation is the standard of care for elite athletes to minimize nonunion and expedite return to sport.

Question 77

A 65-year-old male with end-stage post-traumatic ankle osteoarthritis is being evaluated for a total ankle arthroplasty. Which of the following is considered an absolute contraindication to this procedure?

Explanation

Absolute contraindications for total ankle arthroplasty include Charcot neuroarthropathy, active infection, severe avascular necrosis of the talar body, and profound neuropathy. Age >60 and bilateral disease are general indications rather than contraindications.

Question 78

A 35-year-old male sustains a high-energy closed tibial pilon fracture. The soft tissues are severely swollen with fracture blisters present. Which of the following defines the optimal timing for definitive open reduction and internal fixation?

Explanation

High-energy pilon fractures are typically managed with a two-staged approach (span, scan, and plan). Definitive fixation is delayed until the soft tissue envelope improves, indicated by the "wrinkle sign" and healing of fracture blisters, typically 10-21 days post-injury.

Question 79

A 28-year-old skier presents with posterolateral ankle pain and a snapping sensation behind the lateral malleolus. Physical examination reveals subluxation of the peroneal tendons with resisted eversion. Pathology involves disruption of which of the following structures?

Explanation

Peroneal tendon subluxation or dislocation is caused by an injury to the superior peroneal retinaculum (SPR), often occurring with sudden, forceful dorsiflexion and eversion. Surgical repair and potential fibular groove deepening is often required for symptomatic instability.

Question 80

A 29-year-old male suffers a severe crush injury to his foot. Compartment syndrome is suspected. How many distinct fascial compartments are generally recognized in the foot for the purpose of surgical decompression?

Explanation

There are 9 distinct fascial compartments in the foot: 4 interosseous, 3 central (superficial, deep, and adductor), 1 medial, and 1 lateral. Complete decompression requires dual dorsal incisions or an extensive medial approach.

Question 81

A 14-year-old boy presents with a rigid, painful flatfoot and a history of recurrent ankle sprains. Radiographs show an elongated anterior process of the calcaneus resembling an anteater's nose on the lateral view. What is the most likely diagnosis?

Explanation

The "anteater sign" on a lateral radiograph is highly indicative of a calcaneonavicular coalition. Talocalcaneal coalitions, conversely, typically present with a "C-sign" on lateral radiographs.

Question 82

A 30-year-old male sustains a Hawkins Type III talar neck fracture. Six weeks post-operatively, an AP radiograph of the ankle reveals a subchondral radiolucent band in the talar dome. What does this finding indicate?

Explanation

The presence of a subchondral radiolucent band at 6 to 8 weeks is known as the Hawkins sign. It represents subchondral osteopenia secondary to hyperemia, indicating intact vascularity and ruling out avascular necrosis.

Question 83

A 45-year-old female presents with a painful bunion. Clinical exam reveals a hypermobile first tarsometatarsal (TMT) joint. Radiographs show a hallux valgus angle of 35 degrees and an intermetatarsal angle of 16 degrees. Which of the following procedures is most appropriate?

Explanation

A Lapidus procedure (first TMT arthrodesis) is indicated for moderate-to-severe hallux valgus associated with first ray hypermobility. It corrects the intermetatarsal angle and stabilizes the medial column, preventing recurrence.

Question 84

A 65-year-old male with end-stage ankle osteoarthritis is evaluated for a total ankle arthroplasty (TAA). Which of the following is considered an absolute contraindication to TAA?

Explanation

Charcot neuroarthropathy, active infection, and severe avascular necrosis of the talus are absolute contraindications to total ankle arthroplasty due to unacceptably high failure rates. Ankle arthrodesis is the preferred surgical treatment in these patients.

Question 85

A 24-year-old football player presents with lateral ankle pain and a snapping sensation behind the lateral malleolus when circumducting the foot. Radiographs demonstrate a small bony avulsion off the posterolateral aspect of the distal fibula. What is the most appropriate surgical treatment?

Explanation

The clinical presentation and "fleck sign" on radiographs indicate a superior peroneal retinaculum (SPR) avulsion leading to peroneal tendon subluxation. Surgical treatment involves SPR repair and often fibular groove deepening to stabilize the tendons.

Question 86

A 40-year-old roofer falls from a height and sustains a severely comminuted, displaced intra-articular calcaneus fracture (Sanders Type III). A lateral extensile approach is planned for open reduction and internal fixation. Which nerve is at greatest risk of iatrogenic injury during the surgical approach?

Explanation

The sural nerve crosses the lateral aspect of the hindfoot and is at highest risk during the standard lateral extensile approach to the calcaneus. Careful full-thickness flap elevation is required to protect it and the vascular supply to the flap.

Question 87

A 38-year-old male sustains an acute, closed mid-substance Achilles tendon rupture. After discussing treatment options, he elects for nonoperative management with a functional rehabilitation protocol. Compared to operative repair, nonoperative management with early functional rehab is associated with which of the following?

Explanation

Recent literature shows that nonoperative management utilizing early functional weight-bearing rehabilitation has similar re-rupture rates compared to operative repair, while completely avoiding surgical wound complications. Operative repair has historically shown lower re-rupture rates only when compared to prolonged cast immobilization.

Question 88

A 22-year-old collegiate basketball player sustains a zone 2 fracture of the proximal fifth metatarsal. Intramedullary screw fixation is planned. To minimize the risk of lateral cortex penetration and hardware failure, the starting point for the screw should be:

Explanation

To avoid penetrating the laterally bowed cortex of the fifth metatarsal, the ideal starting point for an intramedullary screw is high (dorsal) and medial on the tuberosity. This trajectory aligns best with the straight intramedullary canal.

Question 89

A 26-year-old professional football player suffers an acute hyperextension injury to his first MTP joint. MRI reveals a complete rupture of the plantar plate with 4 mm of proximal retraction of the sesamoids. What is the most appropriate management?

Explanation

Grade 3 turf toe injuries with complete plantar plate rupture, gross instability, or sesamoid retraction >3 mm in high-demand athletes warrant surgical repair. Nonoperative management in this demographic usually leads to chronic pain and push-off weakness.

Question 90

A 14-year-old boy presents with repeated ankle sprains and a rigid, flatfoot deformity. Radiographs show an elongated anterior process of the calcaneus (anteater sign). CT confirms a calcaneonavicular coalition. After 6 months of failed conservative treatment, what is the best surgical option?

Explanation

For a symptomatic calcaneonavicular coalition failing nonoperative management without advanced degenerative changes, the gold standard is resection with interposition of the EDB muscle or fat graft to prevent recurrence. Arthrodesis is reserved for cases with severe arthritis or failed resections.

Question 91

A 20-year-old cross-country runner reports 2 months of vague dorsal midfoot pain. Plain radiographs are normal, but an MRI demonstrates a stress fracture in the central third of the navicular without displacement. What is the recommended initial management?

Explanation

The central third of the navicular is a vascular watershed area prone to delayed healing and nonunion. The standard initial management for a nondisplaced navicular stress fracture is strict non-weight-bearing in a cast for 6 to 8 weeks.

Question 92

A 55-year-old diabetic patient presents with a swollen, erythematous, and warm left foot. Radiographs demonstrate severe periarticular fragmentation, debris, and subluxation of the midfoot joints. According to the Eichenholtz classification, what stage does this represent and what is the primary treatment?

Explanation

Eichenholtz Stage 1 (Developmental/Fragmentation) is characterized by clinical erythema, swelling, and radiographic fragmentation and debris. The gold standard treatment in this active phase is immobilization and offloading, typically with a total contact cast, until the joints coalesce.

Question 93

During open reduction and internal fixation of a pronation-external rotation (PER-4) ankle fracture, the surgeon assesses the syndesmosis using the external rotation stress test. Which radiographic parameter on the mortise view most reliably indicates syndesmotic instability requiring fixation?

Explanation

An increase in the medial clear space (>4 mm) with external rotation stress is the most reliable radiographic indicator of deep deltoid ligament insufficiency and syndesmotic instability. The tibiofibular clear space is less reproducible due to variability in rotational positioning.

AAOS & ABOS Foot & Ankle Board Review MCQs (Set 2): Ankle Fractures, Lisfranc, Diabetic Foot

Orthopedic Board Review: Mock Exam Set 574 - 100 High-Yield MCQs (Foot & Ankle Focus)

Key Takeaway

Orthopedic Board Review: Mock Exam Set 574 - 100 High-Yield MCQs (Foot & Ankle Focus)

Chapter Index