Foot & Ankle Orthopedics MCQs | ABOS & OITE Board Review

Question 1

Which of the following best describes the epidemiological distribution of ankle fractures as highlighted in the provided text?

Explanation

Correct Answer: Bimodal distribution with peaks in young males and older females

Ankle fractures are among the most prevalent lower extremity injuries. They demonstrate a bimodal distribution, with a peak in young males (often due to high-energy trauma or sports-related injuries) and a second peak in older females (typically associated with lower-energy fragility fractures due to osteoporosis).

Question 2

During surgical reconstruction of the hindfoot, a resident is reviewing the muscular attachments of the tarsal bones. Which of the following muscles directly inserts onto the talus?

Explanation

Correct Answer: No muscles attach to this bone

The talus is a unique bone within the foot and ankle complex because it has no tendinous or muscular attachments. It serves as a keystone, transmitting forces from the leg to the foot, and relies entirely on its articular surfaces and ligamentous attachments for stability and blood supply.

Question 3

A 24-year-old athlete sustains an inversion injury to the ankle. Which ligament of the lateral collateral complex is most frequently injured in this scenario?

Explanation

Correct Answer: Anterior talofibular ligament (ATFL)

The lateral collateral ligament complex of the ankle includes the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), and posterior talofibular ligament (PTFL). The ATFL is the weakest of these ligaments and is the most commonly injured structure during a classic inversion and plantarflexion ankle sprain.

Question 4

When performing an anterolateral approach to the distal fibula for open reduction and internal fixation of a lateral malleolus fracture, which nerve is at greatest risk and must be meticulously identified and protected?

Explanation

Correct Answer: Superficial peroneal nerve

During the anterolateral approach to the distal fibula, the superficial peroneal nerve is at significant risk. It typically crosses the surgical field anteriorly within the subcutaneous tissue or superficial fascia. Meticulous dissection and protection of this nerve are essential to prevent painful neuromas or sensory deficits over the dorsum of the foot.

Question 5

The anterolateral approach to the distal fibula utilizes an internervous plane between muscles supplied by which of the following nerves?

Explanation

Correct Answer: Deep peroneal nerve and superficial peroneal nerve

The anterolateral approach to the fibula utilizes the internervous plane between the anterior compartment (innervated by the deep peroneal nerve) and the lateral compartment (innervated by the superficial peroneal nerve). This plane allows for safe exposure of the fibula while respecting the neurovascular supply of the leg.

Question 6

Which of the following best describes the primary kinematic function of the subtalar joint during the gait cycle?

Explanation

Correct Answer: Inversion and eversion to function as a mobile adaptor on uneven ground

The subtalar (talocalcaneal) joint is a complex articulation that primarily allows for inversion and eversion. This motion is critical during the gait cycle, as it allows the foot to act as a 'mobile adaptor' to accommodate uneven terrain and absorb shock during the initial contact and loading response phases.

Question 7

A 55-year-old female presents with progressive flattening of her medial longitudinal arch and pain posterior to the medial malleolus. Dysfunction of which of the following tendons is the most likely primary cause of her deformity?

Explanation

Correct Answer: Tibialis posterior

The posterior tibial tendon is the primary dynamic stabilizer of the medial longitudinal arch and the main invertor of the midfoot. Its dysfunction is the most common cause of adult-acquired flatfoot deformity, characterized by progressive arch collapse, hindfoot valgus, and forefoot abduction.

Question 8

Based on epidemiological data, what is the approximate prevalence of hallux valgus in the adult population over the age of 65?

Explanation

Correct Answer: Over 35%

Hallux valgus is a highly prevalent forefoot deformity. Epidemiological data indicates it affects approximately 23% of adults aged 18-65, and its prevalence increases significantly with age, affecting over 35% of individuals over the age of 65.

Question 9

To optimize surgical access to the lateral malleolus during open reduction and internal fixation in the supine position, which of the following positioning maneuvers is most commonly employed?

Explanation

Correct Answer: Placing a bump under the ipsilateral hip to internally rotate the operative leg

When fixing a lateral malleolus fracture with the patient in the supine position, placing a bump under the ipsilateral hip internally rotates the lower extremity. This brings the lateral malleolus anteriorly, significantly improving visualization and surgical access to the lateral aspect of the fibula.

Question 10

The deltoid ligament is a critical stabilizer of the medial ankle. Which of the following ligaments is a component of the deep layer of the deltoid ligament?

Explanation

Correct Answer: Deep anterior tibiotalar ligament

The deltoid ligament consists of superficial and deep layers. The superficial layer includes the tibiocalcaneal, tibionavicular, and superficial posterior tibiotalar ligaments. The deep layer, which is the primary restraint to lateral talar shift, includes the deep posterior tibiotalar and deep anterior tibiotalar ligaments.

Question 11

According to the provided epidemiological data, what is the approximate prevalence of hallux valgus in adults over the age of 65?

Explanation

Correct Answer: Greater than 35%

The text explicitly states that forefoot deformities such as hallux valgus affect approximately 23% of adults aged 18-65 and over 35% in those over 65. This highlights the increasing prevalence of this condition in the aging population.

Question 12

In addition to hindfoot eversion, what is the primary biomechanical function of the peroneus longus tendon as it traverses the foot?

Explanation

Correct Answer: Plantarflexion of the first ray

According to the text, the peroneus longus and brevis tendons are responsible for eversion, with the peroneus longus also contributing to plantarflexion of the first ray. This is a critical biomechanical function for forefoot stability during the push-off phase of gait.

Question 13

The spring ligament (plantar calcaneonavicular ligament) is a critical static stabilizer of the medial longitudinal arch. Which specific osseous structure does it directly support?

Explanation

Correct Answer: Talar head

The text notes that within the foot, the spring ligament (plantar calcaneonavicular ligament) supports the talar head and the medial longitudinal arch. Failure of this ligament contributes to adult-acquired flatfoot deformity.

Question 14

A patient presents with an inability to dorsiflex the ankle and numbness in the first dorsal web space. Based on the neurovascular anatomy described, which nerve is most likely injured?

Explanation

Correct Answer: Deep peroneal nerve

The text describes the deep peroneal nerve as providing sensation to the first web space and motor innervation to the anterior compartment muscles (which are responsible for ankle dorsiflexion and toe extension).

Question 15

When performing an anterolateral approach to the distal fibula, the surgeon utilizes an internervous plane between the anterior and lateral compartments. Which two nerves supply the musculature defining this interval?

Explanation

Correct Answer: Superficial peroneal nerve and deep peroneal nerve

The approach utilizes the interval between the anterior compartment (innervated by the deep peroneal nerve) and the lateral compartment (innervated by the superficial peroneal nerve). The text specifies this interval involves the tibialis anterior/extensors and the peroneus longus/brevis.

Question 16

The transverse tarsal joint allows the midfoot to lock into a rigid lever for propulsion or unlock for adaptability. Which two articulations comprise this joint?

Explanation

Correct Answer: Calcaneocuboid and talonavicular

The text explicitly defines the transverse tarsal joint as being composed of the calcaneocuboid and talonavicular joints. This joint complex is essential for transitioning the foot from a flexible shock absorber to a rigid lever during the gait cycle.

Question 17

During a standard anterolateral approach to the distal fibula, a longitudinal incision is made. Which nerve typically crosses the surgical field anteriorly and must be meticulously identified and protected?

Explanation

Correct Answer: Superficial peroneal nerve

The text highlights that during the anterolateral approach to the lateral malleolus, careful consideration must be given to the superficial peroneal nerve, which typically crosses the surgical field anteriorly and must be protected.

Question 18

While Magnetic Resonance Imaging (MRI) is preferred for evaluating soft tissue injuries like syndesmotic tears, which imaging modality is specifically indicated to assess syndesmotic integrity if dynamic instability is suspected?

Explanation

Correct Answer: Stress radiographs

According to the text, while MRI is preferred for evaluating soft tissue injuries, stress radiographs are specifically used to assess syndesmotic integrity if instability is suspected clinically but not apparent on static imaging.

Question 19

The deltoid ligament provides significant medial stability to the ankle. Which of the following ligaments is a component of the deep layer of the deltoid ligament?

Explanation

Correct Answer: Deep anterior tibiotalar ligament

The text divides the deltoid ligament into superficial and deep layers. The deep layer is composed of the deep posterior tibiotalar and deep anterior tibiotalar ligaments. The tibiocalcaneal, tibionavicular, and superficial posterior tibiotalar ligaments make up the superficial layer.

Question 20

During the surgical room setup and patient positioning for open reduction and internal fixation of a lateral malleolus fracture in the supine position, what is the primary rationale for placing a bump under the ipsilateral hip?

Explanation

Correct Answer: To internally rotate the leg and facilitate access to the lateral malleolus

The text states that a bump may be placed under the ipsilateral hip to internally rotate the leg, which facilitates access to the lateral malleolus during surgery in the supine position.

Question 21

Which of the following best describes the epidemiological distribution of ankle fractures as highlighted in the provided text?

Explanation

Correct Answer: B

According to the text, ankle fractures have an incidence of approximately 187 per 100,000 person-years and demonstrate a bimodal distribution. The peaks occur in young males (often due to high-energy trauma or sports injuries) and older females (typically related to osteoporotic fragility fractures). Understanding this epidemiological pattern is important for anticipating injury mechanisms and bone quality during surgical planning.

Question 22

During surgical exposure of the ankle and hindfoot, the surgeon must be aware of the unique anatomical characteristics of the tarsal bones. Which of the following statements regarding the talus is correct?

Explanation

Correct Answer: C

The talus is a unique bone in the human body because it has no muscular or tendinous attachments. It serves as a keystone in the ankle joint, transmitting forces from the tibia and fibula to the foot. Its stability and movement are entirely dependent on its articular geometry and the complex ligamentous structures attaching to it, such as the lateral collateral ligaments, deltoid ligament, and syndesmotic ligaments. The Achilles tendon attaches to the calcaneus, and the tibialis anterior attaches to the medial cuneiform and first metatarsal base.

Question 23

A patient presents with lateral ankle pain and weakness in eversion. During physical examination, the function of the peroneus longus is specifically tested. In addition to hindfoot eversion, what is the primary biomechanical function of the peroneus longus?

Explanation

Correct Answer: B

The peroneus longus and brevis are the primary evertors of the foot. However, the peroneus longus tendon courses under the cuboid and traverses the plantar aspect of the midfoot to insert on the plantar-lateral aspect of the medial cuneiform and the base of the first metatarsal. Because of this unique anatomical course, its contraction not only everts the hindfoot but also strongly plantarflexes the first ray, which is critical for stabilizing the medial column during the push-off phase of gait.

Question 24

A 45-year-old female presents with progressive flattening of her medial longitudinal arch and medial midfoot pain. Which of the following ligamentous structures is primarily responsible for supporting the talar head and the medial longitudinal arch?

Explanation

Correct Answer: D

The spring ligament, also known as the plantar calcaneonavicular ligament, is a critical static stabilizer of the medial longitudinal arch. It spans from the sustentaculum tali of the calcaneus to the navicular, forming a sling that supports the head of the talus. Failure or attenuation of the spring ligament is a key component in the pathophysiology of adult-acquired flatfoot deformity (posterior tibial tendon dysfunction).

Question 25

When performing an anterolateral approach for open reduction and internal fixation of a lateral malleolus fracture, the surgeon utilizes an internervous plane. Between which two muscle compartments does this plane lie, and which nerve is at greatest risk during the superficial dissection?

Explanation

Correct Answer: C

The anterolateral approach to the distal fibula utilizes the internervous plane between the anterior compartment (innervated by the deep peroneal nerve) and the lateral compartment (innervated by the superficial peroneal nerve). During the superficial dissection, the superficial peroneal nerve is at significant risk as it pierces the deep fascia to become subcutaneous, typically crossing the surgical field anteriorly from lateral to medial. It must be meticulously identified and protected.

Question 26

During the normal gait cycle, the foot must transition from a flexible structure to a rigid lever. Which joint complex is primarily responsible for allowing the midfoot to lock into a rigid lever for propulsion and unlock for adaptability?

Explanation

Correct Answer: B

The transverse tarsal joint, also known as Chopart's joint, consists of the talonavicular and calcaneocuboid articulations. Biomechanically, the axes of these two joints become parallel when the hindfoot is everted, making the midfoot flexible to accommodate uneven terrain. When the hindfoot inverts (as during the push-off phase of gait), the axes become divergent, locking the midfoot into a rigid lever to allow for efficient forward propulsion.

Question 27

A 25-year-old athlete sustains a twisting injury to the ankle. Plain radiographs are negative for fracture, but there is high clinical suspicion for a syndesmotic injury. According to the provided text, which of the following imaging modalities is preferred for evaluating the soft tissue integrity of the syndesmosis, and what is used to assess dynamic instability?

Explanation

Correct Answer: C

The text explicitly states that Magnetic Resonance Imaging (MRI) is the preferred modality for evaluating soft tissue injuries, including syndesmotic tears, deltoid ligament ruptures, and osteochondral lesions. However, to assess dynamic instability of the syndesmosis, stress radiographs (such as external rotation stress views) are indicated. CT scans are excellent for evaluating bony architecture and fracture comminution but are less sensitive for isolated soft tissue injuries compared to MRI.

Question 28

During the open reduction and internal fixation of a displaced lateral malleolus fracture, the surgeon meticulously restores the anatomical length of the fibula. What is the primary biomechanical rationale for this critical step?

Explanation

Correct Answer: B

Anatomical reduction of the fibula is paramount in ankle fracture surgery. The text highlights that restoration of fibular length is critical because it dictates the width of the ankle mortise. Shortening or malrotation of the fibula leads to lateral shift and external rotation of the talus within the mortise. Even a 1 mm lateral shift of the talus can significantly decrease the tibiotalar contact area, leading to altered biomechanics and early post-traumatic arthritis.

Question 29

A patient sustains a laceration to the anterior aspect of the lower leg, resulting in an isolated injury to the deep peroneal nerve. Which of the following clinical findings would be expected?

Explanation

Correct Answer: C

The common peroneal nerve bifurcates into the superficial and deep peroneal nerves. The deep peroneal nerve provides motor innervation to the muscles of the anterior compartment of the leg (tibialis anterior, extensor hallucis longus, extensor digitorum longus, and peroneus tertius), which are responsible for ankle and toe dorsiflexion. It also provides sensory innervation to the first web space of the foot. Therefore, an isolated injury to the deep peroneal nerve results in weakness in dorsiflexion (foot drop) and sensory loss in the first web space.

Question 30

Based on the provided text, what is the approximate prevalence of hallux valgus in the adult population over the age of 65?

Explanation

Correct Answer: D

According to the provided text, forefoot deformities such as hallux valgus are highly prevalent. They affect approximately 23% of adults aged 18-65 and over 35% in the population over the age of 65. This high prevalence underscores the significant burden of this condition, which often requires surgical correction due to pain and difficulty with shoe wear.

Question 31

According to epidemiological data, what is the approximate prevalence of hallux valgus in adults over the age of 65?

Explanation

Correct Answer: 35%

According to the provided text, forefoot deformities such as hallux valgus affect approximately 23% of adults aged 18-65 and over 35% in those over 65. This high prevalence often leads to pain and shoe wear difficulties, frequently requiring surgical correction.

Question 32

Which of the following tarsal bones is characterized by a complete absence of muscular attachments?

Explanation

Correct Answer: Talus

The talus is a unique bone in the foot and ankle complex because it has no muscular or tendinous attachments. It serves as a keystone, transmitting forces from the leg to the foot, and relies entirely on its articular congruency and ligamentous attachments for stability and blood supply.

Question 33

In addition to hindfoot eversion, what is the primary biomechanical function of the peroneus longus tendon during the gait cycle?

Explanation

Correct Answer: Plantarflexion of the first ray

The peroneus longus and brevis tendons are responsible for eversion of the foot. Additionally, because the peroneus longus tendon courses under the cuboid to insert on the base of the first metatarsal and medial cuneiform, it acts as a primary plantarflexor of the first ray, which is critical for stabilizing the medial column during the push-off phase of gait.

Question 34

When performing an anterolateral approach to the distal fibula for fracture fixation, the internervous plane lies between which two muscle compartments?

Explanation

Correct Answer: Anterior and lateral

The anterolateral approach to the distal fibula utilizes the internervous plane between the anterior compartment (containing the tibialis anterior and extensors, innervated by the deep peroneal nerve) and the lateral compartment (containing the peroneus longus and brevis, innervated by the superficial peroneal nerve).

Question 35

During the anterolateral approach to the lateral malleolus, which nerve is at greatest risk of iatrogenic injury and must be meticulously identified and protected?

Explanation

Correct Answer: Superficial peroneal nerve

During the anterolateral approach to the lateral malleolus, careful consideration must be given to the superficial peroneal nerve. This nerve typically crosses the surgical field anteriorly within the subcutaneous tissue or superficial fascia and must be identified and gently retracted to prevent iatrogenic injury.

Question 36

Which joint complex is primarily responsible for allowing the midfoot to transition between a flexible structure for shock absorption and a rigid lever for propulsion during gait?

Explanation

Correct Answer: Transverse tarsal joint

The transverse tarsal joint (Chopart's joint), which consists of the calcaneocuboid and talonavicular joints, works in concert with the subtalar joint. It allows the midfoot to unlock for adaptability and shock absorption during heel strike, and lock into a rigid lever for efficient propulsion during toe-off.

Question 37

Which of the following ligaments is a component of the deep layer of the deltoid ligament complex?

Explanation

Correct Answer: Deep anterior tibiotalar ligament

The deltoid ligament is a robust medial stabilizing structure composed of superficial and deep layers. The superficial layer includes the tibiocalcaneal, tibionavicular, and superficial posterior tibiotalar ligaments. The deep layer is composed of the deep posterior tibiotalar and deep anterior tibiotalar ligaments.

Question 38

While plain radiographs are the initial step in evaluating an ankle injury, which imaging modality is considered the preferred method for directly visualizing and diagnosing soft tissue injuries such as an acute syndesmotic tear or deltoid ligament rupture?

Explanation

Correct Answer: Magnetic Resonance Imaging (MRI)

According to the text, while CT scans are invaluable for assessing complex fractures and articular comminution, Magnetic Resonance Imaging (MRI) is the preferred modality for evaluating soft tissue injuries, including syndesmotic tears, deltoid ligament ruptures, osteochondral lesions, and tendon pathologies.

Question 39

Dysfunction of which of the following tendons is the primary driver in the pathogenesis of adult-acquired flatfoot deformity?

Explanation

Correct Answer: Posterior tibial tendon

The posterior tibial tendon is crucial for inversion of the foot and dynamic support of the medial longitudinal arch. Its dysfunction or rupture is the primary cause of adult-acquired flatfoot deformity, leading to progressive collapse of the arch and subsequent hindfoot valgus and forefoot abduction.

Question 40

During open reduction and internal fixation of a bimalleolar equivalent ankle fracture, why is the precise anatomical restoration of fibular length considered critical?

Explanation

Correct Answer: It dictates the width and stability of the ankle mortise

The lateral malleolus acts as a critical buttress for the talus. Restoration of fibular length, rotation, and alignment is paramount because it directly dictates the width of the ankle mortise. Shortening of the fibula leads to lateral talar shift, widening of the mortise, and significantly altered contact stresses, which can rapidly lead to post-traumatic osteoarthritis.

Question 41

According to the provided epidemiological data, what is the approximate prevalence of hallux valgus in adults over the age of 65?

Explanation

Correct Answer: C

The text explicitly states that forefoot deformities such as hallux valgus affect approximately 23% of adults aged 18-65 and over 35% in those over 65. This high prevalence often necessitates surgical correction due to pain and shoe wear difficulties.

Question 42

The deltoid ligament is a robust structure providing significant medial ankle stability. Which of the following ligaments is a component of the deep layer of the deltoid ligament?

Explanation

Correct Answer: D

The deltoid ligament is composed of superficial and deep layers. The superficial layer includes the tibiocalcaneal, tibionavicular, and superficial posterior tibiotalar ligaments. The deep layer consists of the deep posterior tibiotalar and deep anterior tibiotalar ligaments.

Question 43

In addition to its role in hindfoot eversion, what is the primary biomechanical function of the peroneus longus tendon in the foot?

Explanation

Correct Answer: B

The text notes that laterally, the peroneus longus and brevis tendons are responsible for eversion, with the peroneus longus also contributing to the plantarflexion of the first ray.

Question 44

A patient presents with an inability to dorsiflex the ankle and numbness isolated to the first web space of the foot. Which nerve is most likely injured?

Explanation

Correct Answer: B

The common peroneal nerve bifurcates into the superficial and deep peroneal nerves. The deep peroneal nerve provides motor innervation to the anterior compartment muscles (responsible for dorsiflexion) and sensory innervation to the first web space.

Question 45

Which two articulations comprise the transverse tarsal joint, allowing the midfoot to lock into a rigid lever for propulsion or unlock for adaptability?

Explanation

Correct Answer: B

The transverse tarsal joint, also known as Chopart's joint, consists of the calcaneocuboid and talonavicular joints. It plays a crucial biomechanical role in allowing the midfoot to lock into a rigid lever for propulsion during toe-off or unlock for adaptability on uneven surfaces.

Question 46

When performing an anterolateral approach to the distal fibula, the internervous plane utilized lies between muscles innervated by which two nerves?

Explanation

Correct Answer: A

The anterolateral approach utilizes the interval between the anterior compartment (tibialis anterior, extensors) and the lateral compartment (peroneus longus and brevis). The anterior compartment is innervated by the deep peroneal nerve, while the lateral compartment is innervated by the superficial peroneal nerve.

Question 47

During the anterolateral approach to the lateral malleolus, which nerve is at greatest risk of iatrogenic injury as it typically crosses the surgical field anteriorly?

Explanation

Correct Answer: C

When making a longitudinal incision over the distal fibula, careful consideration must be given to the superficial peroneal nerve. It typically crosses the surgical field anteriorly within the subcutaneous tissue or superficial fascia and must be meticulously identified and protected.

Question 48

The spring ligament is crucial for supporting the talar head and the medial longitudinal arch. Which two bony structures does this ligament connect?

Explanation

Correct Answer: C

The spring ligament is anatomically known as the plantar calcaneonavicular ligament. It connects the calcaneus to the navicular bone, forming a critical sling that supports the talar head and maintains the medial longitudinal arch.

Question 49

According to the provided text, which imaging modality is preferred for evaluating a suspected deltoid ligament rupture or an osteochondral lesion of the talus?

Explanation

Correct Answer: C

While CT scans are invaluable for assessing complex fractures and articular comminution, Magnetic Resonance Imaging (MRI) is the preferred modality for evaluating soft tissue injuries, including syndesmotic tears, deltoid ligament ruptures, osteochondral lesions, and tendon pathologies.

Question 50

During open reduction and internal fixation (ORIF) of a lateral malleolus fracture, why is the anatomical restoration of fibular length considered critical?

Explanation

Correct Answer: B

During fracture reduction of the fibula, it is crucial to restore length, rotation, and alignment. Restoration of fibular length is critical because it directly dictates the width of the ankle mortise, ensuring proper congruency and biomechanics of the ankle joint.

Question 51

A 35-year-old male sustains an acute Achilles tendon rupture. When discussing operative versus nonoperative management utilizing a functional rehabilitation protocol, which of the following statements regarding outcomes is most accurate?

Explanation

Current literature shows functional rehabilitation has comparable outcomes to surgery. Surgery traditionally lowers the re-rupture rate but carries a higher risk of wound complications and infection.

Question 52

A 22-year-old athlete sustains a purely ligamentous Lisfranc injury with 3 mm of diastasis between the medial and middle cuneiforms. Based on recent prospective studies, which of the following is the most appropriate surgical management?

Explanation

Primary arthrodesis is preferred for purely ligamentous Lisfranc injuries as it has been shown to reduce reoperation rates and hardware failure compared to ORIF.

Question 53

A 58-year-old patient with poorly controlled diabetes presents with a warm, erythematous, and swollen foot. Radiographs demonstrate periarticular debris, fragmentation, and subluxation of the midfoot joints. Which stage of Charcot neuroarthropathy does this represent?

Explanation

Eichenholtz Stage I (developmental/fragmentation phase) is characterized by clinical warmth, erythema, and radiographic findings of fragmentation, debris, and joint subluxation.

Question 54

Total ankle arthroplasty (TAA) is increasingly utilized for end-stage ankle arthritis. Which of the following is considered an absolute contraindication for primary TAA?

Explanation

Significant avascular necrosis of the talus (>50%) compromises the osseous support for the implant, making it an absolute contraindication due to high risk of subsidence and failure.

Question 55

A 21-year-old collegiate basketball player sustains a fracture at the metaphyseal-diaphyseal junction of the 5th metatarsal, extending into the fourth-fifth intermetatarsal articulation. What is the most appropriate management for this specific injury in a high-level athlete?

Explanation

This is a Zone 2 (Jones) fracture, which occurs in a vascular watershed area. High-level athletes are treated acutely with intramedullary screw fixation to expedite return to play and decrease nonunion risk.

Question 56

A 45-year-old female presents with severe bunion pain. Radiographs reveal a hallux valgus angle (HVA) of 45 degrees, an intermetatarsal angle (IMA) of 18 degrees, and significant hypermobility of the first tarsometatarsal (TMT) joint. Which of the following procedures is most appropriate?

Explanation

The Lapidus procedure is indicated for severe hallux valgus deformities (IMA >15 degrees) accompanied by first ray hypermobility, as it addresses the apex of the deformity and stabilizes the medial column.

Question 57

A 55-year-old female presents with a progressive flatfoot deformity. Examination reveals a flexible pes planovalgus and an inability to perform a single-limb heel rise. Which surgical intervention is the standard of care for this stage of adult acquired flatfoot deformity?

Explanation

Stage II posterior tibial tendon dysfunction involves a flexible flatfoot. It is treated with joint-sparing procedures, typically a medializing calcaneal osteotomy and FDL transfer to the navicular.

Question 58

A patient falls from a height and sustains a displaced fracture of the talar neck. Radiographs demonstrate dislocation of both the subtalar and tibiotalar joints. According to the Hawkins classification, what is the risk of avascular necrosis (AVN) associated with this injury?

Explanation

This describes a Hawkins III fracture (talar neck fracture with subtalar and tibiotalar dislocation). The blood supply to the talar body is severely disrupted, resulting in an AVN rate approaching 100%.

Question 59

Following operative management of a severely displaced intra-articular calcaneus fracture, what is the most common long-term complication experienced by the patient?

Explanation

Post-traumatic subtalar arthritis is the most common late complication after an intra-articular calcaneus fracture, regardless of whether it is managed operatively or nonoperatively.

Question 60

A 40-year-old female complains of burning pain in the plantar aspect of her forefoot, radiating to the third and fourth toes. Symptoms are exacerbated by wearing narrow shoes. Which anatomical structure is primarily responsible for compressing the affected nerve?

Explanation

Morton's neuroma is an entrapment neuropathy of the common digital nerve. It most commonly occurs in the 3rd webspace and is compressed by the deep transverse metatarsal ligament.

Question 61

During open reduction and internal fixation of a bimalleolar ankle fracture, syndesmotic instability is identified. When placing a syndesmotic screw, what is the optimal position of the ankle joint and why?

Explanation

The talar dome is wider anteriorly. Dorsiflexing the ankle during syndesmotic screw placement ensures the widest part is in the mortise, preventing overtightening and subsequent loss of dorsiflexion.

Question 62

A 38-year-old construction worker sustains a high-energy tibial pilon fracture with severe soft tissue swelling and fracture blisters circumferentially. What is the most appropriate initial management strategy?

Explanation

High-energy pilon fractures are fraught with soft tissue complications. A "span, scan, and plan" approach using an initial spanning external fixator allows soft tissue recovery before delayed definitive ORIF.

Question 63

When evaluating osteochondral lesions of the talus (OCL), which of the following statements correctly differentiates anterolateral lesions from posteromedial lesions?

Explanation

Remember "DIAL a PIMP": Dorsiflexion/Inversion causes Anterior/Lateral lesions (shallow, wafer-shaped, traumatic). Plantarflexion/Inversion causes Posterior/Medial lesions (deeper, cup-shaped, insidious).

Question 64

A patient presents with recurrent snapping over the lateral malleolus after an inversion injury. Examination reveals peroneal tendon subluxation. Which anatomical structure is the primary restraint to this pathology?

Explanation

The superior peroneal retinaculum is the primary dynamic and static restraint that keeps the peroneal tendons within the retromalleolar groove. Disruption leads to tendon subluxation.

Question 65

A 50-year-old male with chronic, recalcitrant plantar fasciitis undergoes a complete surgical release of the plantar fascia. Postoperatively, his heel pain improves, but he develops new-onset, severe pain along the outside of his midfoot. What is the most likely cause of his new pain?

Explanation

Complete release of the plantar fascia destroys the windlass mechanism, leading to a collapse of the medial longitudinal arch and resultant lateral column overload and pain.

Question 66

A 62-year-old male presents with severe pain in his great toe with walking. Radiographs show obliteration of the first metatarsophalangeal (MTP) joint space with large dorsal osteophytes (Coughlin and Shurnas Grade 4 Hallux Rigidus). Physical exam reveals pain at the mid-range of motion. What is the most reliable definitive surgical treatment?

Explanation

First MTP arthrodesis is the gold standard and most reliable treatment for advanced (Grade 3 or 4) hallux rigidus, especially when there is significant joint space narrowing and pain through the mid-range of motion.

Question 67

A collegiate football player sustains an acute hyperextension injury to his great toe. MRI reveals a complete tear of the plantar plate and capsuloligamentous complex with proximal migration of the sesamoids. What grade is this turf toe injury, and what is the recommended treatment?

Explanation

A complete tear of the plantar capsuloligamentous complex with gross instability is a Grade 3 turf toe injury. In high-level athletes, this often necessitates surgical repair to restore push-off strength.

Question 68

When performing a tibiotalar arthrodesis for end-stage ankle arthritis, achieving the optimal anatomical position is critical for a good functional outcome. What is the widely accepted optimal position for ankle fusion?

Explanation

The optimal position for ankle arthrodesis is neutral dorsiflexion (to prevent back knee thrust), 0-5 degrees of hindfoot valgus, and 5-10 degrees of external rotation (matching the contralateral side).

Question 69

A 13-year-old boy sustains an external rotation injury to his ankle. Radiographs show a Salter-Harris III fracture of the anterolateral distal tibial epiphysis. This avulsion fracture is caused by the pull of which ligament?

Explanation

A juvenile Tillaux fracture is avulsed by the AITFL. It occurs in adolescents because the distal tibial physis closes from central to medial, leaving the anterolateral physis open and vulnerable last.

Question 70

A 25-year-old female presents with a progressive bilateral cavovarus foot deformity. A Coleman block test is performed during the physical examination. What is the primary purpose of this specific test?

Explanation

The Coleman block test nullifies the effect of a rigidly plantarflexed first ray. If the hindfoot varus corrects when the first metatarsal is allowed to drop off the block, the hindfoot deformity is flexible.

Question 71

A 30-year-old sustains a Hawkins III talar neck fracture. Which of the following arteries provides the primary blood supply to the talar body, placing it at the highest risk for avascular necrosis upon disruption?

Explanation

The artery of the tarsal canal, a branch of the posterior tibial artery, supplies the majority of the talar body. A Hawkins III fracture disrupts this supply, along with contributions from the neck and sinus tarsi, leading to an extremely high risk of avascular necrosis.

Question 72

During an extensile lateral approach for open reduction and internal fixation of a displaced intra-articular calcaneus fracture, which of the following structures is at the greatest risk of iatrogenic injury if the full-thickness subperiosteal flap is not properly developed?

Explanation

The sural nerve crosses the lateral aspect of the hindfoot and is at the highest risk during the extensile lateral approach. A full-thickness subperiosteal "no touch" technique is crucial to minimize the risk of both wound complications and iatrogenic sural nerve injury.

Question 73

A 22-year-old football player sustains an axial load to a plantarflexed foot. Radiographs reveal a "fleck sign" in the midfoot. Between which two osseous structures does the primary ligament implicated in this injury attach?

Explanation

The Lisfranc ligament connects the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. The "fleck sign" represents an avulsion fracture of this ligament from the second metatarsal base, indicating a severe midfoot injury.

Question 74

When comparing operative versus nonoperative management of acute Achilles tendon ruptures using modern early functional rehabilitation protocols, operative management is specifically associated with which of the following?

Explanation

Modern randomized trials utilizing early functional rehabilitation show equivalent re-rupture rates between operative and nonoperative management. However, operative management is consistently associated with a significantly higher rate of wound complications and potential sural nerve injury.

Question 75

A 55-year-old woman presents with a flexible flatfoot deformity, inability to perform a single-leg heel raise, and >40% uncoverage of the talar head on AP standing radiographs. Which of the following surgical procedures is most appropriate to correct the transverse plane deformity?

Explanation

This patient has Stage IIb adult acquired flatfoot deformity characterized by significant forefoot abduction (transverse plane deformity). A lateral column lengthening (Evans osteotomy) is specifically indicated to address transverse plane uncoverage of the talar head.

Question 76

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 significant hypermobility at the first tarsometatarsal (TMT) joint. What is the most appropriate surgical intervention?

Explanation

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

Question 77

A 60-year-old male runner presents with dorsal first metatarsophalangeal (MTP) joint pain. Radiographs demonstrate dorsal osteophytes, <25% joint space remaining, and pain during the mid-arc of motion. According to the Coughlin and Shurnas classification, which of the following is the most reliable definitive treatment?

Explanation

This describes Coughlin and Shurnas Grade 3 hallux rigidus (significant joint space loss, pain with mid-arc of motion). First MTP arthrodesis remains the gold-standard and most reliable definitive treatment, providing excellent pain relief and functional outcomes in active patients.

Question 78

A 28-year-old sustains a Maisonneuve fracture. During syndesmotic fixation, at what distance proximal to the tibial plafond should the syndesmotic screws ideally be placed to maximize biomechanical stability without entering the joint?

Explanation

Biomechanical studies have demonstrated that syndesmotic screws placed 2 to 3 cm proximal to the tibiotalar joint line provide optimal stability. Placement too distal risks intra-articular penetration, while placing them too high provides inadequate stabilization.

Question 79

A 32-year-old skier presents with lateral ankle pain and a snapping sensation behind the lateral malleolus. Pathology of the superior peroneal retinaculum (SPR) is suspected. The primary osseous attachment of the SPR is the:

Explanation

The superior peroneal retinaculum prevents subluxation of the peroneal tendons and crucially inserts on the posterolateral fibrocartilaginous ridge of the lateral malleolus. Disruption of this periosteal attachment allows the tendons to dislocate anteriorly.

Question 80

A 55-year-old diabetic male presents with a red, hot, swollen foot without an ulcer. Radiographs show periarticular debris, fragmentation, and subluxation at the midfoot. Which of the following is the most appropriate initial management according to the Eichenholtz classification?

Explanation

This presentation describes Eichenholtz Stage I (Developmental/Fragmentation stage) of Charcot arthropathy. The gold standard for acute Charcot neuroarthropathy is strict immobilization and offloading, typically utilizing a total contact cast to arrest the destructive phase.

Question 81

A patient with Charcot-Marie-Tooth disease presents with a bilateral cavovarus foot deformity. A Coleman block test is performed and the hindfoot varus completely corrects to neutral. This finding indicates that the hindfoot deformity is primarily driven by which of the following?

Explanation

The Coleman block test distinguishes a flexible hindfoot driven by forefoot pathology from a rigid hindfoot deformity. If the hindfoot corrects when the first ray is allowed to drop off the block, it indicates the varus is secondary to a rigid, plantarflexed first ray.

Question 82

A 50-year-old female presents with pain at the plantar aspect of the second metatarsophalangeal (MTP) joint and a medial deviation of the second toe, creating a crossover toe deformity. Which of the following anatomical structures is most likely attenuated or ruptured?

Explanation

Crossover toe deformity typically results from sequential failure of the lateral collateral ligament and the plantar plate of the MTP joint. This structural incompetence leads to dorsal subluxation and medial deviation of the digit.

Question 83

A professional American football player sustains a forced hyperextension injury to the first metatarsophalangeal (MTP) joint. MRI confirms a complete tear of the plantar plate with proximal retraction of the sesamoids. What is the most appropriate management?

Explanation

A complete tear of the first MTP plantar plate with sesamoid retraction defines a Grade III turf toe injury. In high-demand professional athletes, this injury typically requires surgical repair of the plantar plate and capsuloligamentous complex to restore push-off strength.

Question 84

A 62-year-old diabetic patient presents with a chronic plantar ulcer under the first metatarsal head. Which of the following clinical findings or tests has the highest positive predictive value for diagnosing underlying osteomyelitis in this specific setting?

Explanation

A positive probe-to-bone test (palpating hard, gritty bone with a sterile blunt probe through an ulcer) has a remarkably high positive predictive value (approaching 90%) for underlying osteomyelitis in diabetic foot infections.

Question 85

A 40-year-old male sustains a closed, high-energy tibial pilon fracture. The soft tissues are significantly swollen with fracture blisters. What is the preferred strategy regarding the timing and sequence of definitive surgical fixation?

Explanation

High-energy pilon fractures are frequently associated with severe soft tissue compromise. The standard of care is a two-stage protocol: initial spanning external fixation to allow soft tissues to recover, followed by definitive internal fixation days to weeks later.

Question 86

A patient presents with burning medial heel pain and paresthesias radiating into the plantar foot. A positive Tinel's sign is elicited posterior to the medial malleolus. Within the tarsal tunnel, the posterior tibial nerve runs immediately posterior to which structure?

Explanation

The anatomical order of structures in the tarsal tunnel from anterior to posterior is: Tibialis posterior tendon, Flexor digitorum longus tendon, Posterior tibial Artery/Vein, posterior tibial Nerve, and Flexor hallucis longus tendon (Tom, Dick, AND a Very Nervous Harry).

Question 87

A 20-year-old collegiate sprinter presents with vague dorsal midfoot pain. A CT scan reveals a non-displaced stress fracture of the central third of the tarsal navicular. Why is this specific anatomical zone highly prone to delayed union and nonunion?

Explanation

The central third of the tarsal navicular is a recognized vascular watershed area, receiving only marginal blood supply from branches of the dorsalis pedis and medial plantar arteries. This avascularity puts stress fractures here at high risk for nonunion.

Question 88

A 55-year-old female presents with progressive flatfoot deformity. She has pain along the medial ankle and cannot perform a single-limb heel rise. Radiographs show a talonavicular uncoverage of 40%. The deformity is passively correctable. What is the most appropriate surgical management?

Explanation

This patient has Stage II posterior tibial tendon dysfunction, characterized by a flexible deformity and inability to perform a heel rise. The standard surgical treatment is a joint-sparing procedure such as an FDL transfer combined with a medial displacement calcaneal osteotomy.

Question 89

A 32-year-old male sustains a Hawkins type III talar neck fracture following a motor vehicle collision. Which of the following blood vessels provides the primary vascular supply to the talar body and is disrupted in this injury?

Explanation

The artery of the tarsal canal, a branch of the posterior tibial artery, is the dominant blood supply to the talar body. In a Hawkins type III fracture, all three primary blood supplies are disrupted, leading to a high rate of avascular necrosis.

Question 90

A 45-year-old female presents with symptomatic hallux valgus. Weight-bearing radiographs reveal a Hallux Valgus Angle (HVA) of 45 degrees, an Intermetatarsal Angle (IMA) of 18 degrees, and clinical hypermobility of the first tarsometatarsal joint. Which procedure is most appropriate?

Explanation

The Lapidus procedure (first TMT arthrodesis) is indicated for severe hallux valgus (IMA > 13 degrees, HVA > 40 degrees) associated with first ray hypermobility. Distal osteotomies are insufficient for correcting large intermetatarsal angles and do not address the proximal instability.

Question 91

A 22-year-old football player sustains a hyperplantarflexion injury to his midfoot. Weight-bearing radiographs demonstrate a 3 mm widening between the base of the first and second metatarsals. What is the primary stabilizing structure disrupted in this injury?

Explanation

The primary Lisfranc ligament is an interosseous ligament connecting the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. It is the largest and most critical stabilizer of the Lisfranc complex.

Question 92

During a percutaneous repair of an acute Achilles tendon rupture, the surgeon places a suture in the proximal stump passing from lateral to medial. Which neurological structure is at greatest risk of iatrogenic injury during this step?

Explanation

The sural nerve courses distally along the posterolateral aspect of the calf, crossing the lateral border of the Achilles tendon approximately 10 cm proximal to its insertion. It is highly susceptible to entrapment or laceration during percutaneous Achilles tendon repairs.

Question 93

A 40-year-old roofer falls from a ladder, sustaining a severely comminuted, intra-articular calcaneus fracture with profound soft tissue swelling. Surgical fixation via an extensile lateral approach is planned. To minimize wound complications, the surgical incision should be elevated as:

Explanation

The extensile lateral approach to the calcaneus requires creating a 'no-touch' full-thickness subperiosteal flap to preserve the delicate blood supply. Dissecting subcutaneously or splitting tissue layers significantly increases the risk of marginal skin necrosis and wound breakdown.

Question 94

A 60-year-old diabetic male presents with a swollen, erythematous, and warm left foot without systemic signs of infection. Radiographs show fragmentation of the midfoot, periarticular debris, and joint subluxation. Which Eichenholtz stage does this represent, and what is the optimal initial treatment?

Explanation

This presentation describes Eichenholtz Stage 1 (development/fragmentation) Charcot arthropathy, marked by acute inflammation and osseous fragmentation. The gold standard initial treatment is total contact casting and offloading until the acute inflammatory phase resolves.

Question 95

A 28-year-old male sustains an external rotation injury to his ankle resulting in a Maisonneuve fracture. Intraoperatively, the syndesmosis is reduced and pinned. Which radiographic parameter is the most reliable indicator of accurate syndesmotic reduction on a standard mortise view?

Explanation

On a mortise radiograph, the medial clear space should be equal to the superior clear space; widening indicates lateral talar shift and syndesmotic failure. Restoration of the medial clear space directly correlates with accurate talar reduction and better functional outcomes.

Question 96

A 48-year-old runner complains of chronic medial heel pain radiating into the plantar aspect of the foot, worsening with prolonged activity. Examination reveals maximal tenderness over the medial heel and a positive Tinel's sign posterior to the medial malleolus radiating distally. Entrapment of which nerve is the most likely diagnosis?

Explanation

The first branch of the lateral plantar nerve (Baxter's nerve) can become entrapped between the deep fascia of the abductor hallucis and the quadratus plantae. It typically presents with chronic heel pain mimicking plantar fasciitis but includes neurologic symptoms radiating laterally.

Question 97

A professional American football player sustains a hyperextension injury to his great toe. MRI demonstrates a complete tear of the plantar plate with significant proximal retraction of the sesamoids. What is the most appropriate management?

Explanation

A complete tear of the plantar plate with sesamoid retraction represents a high-grade (Anderson Grade III) Turf Toe injury. In elite athletes, surgical repair is indicated to restore push-off strength and prevent progressive hallux rigidus.

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

Foot & Ankle Orthopedics: Comprehensive Self-Assessment MCQs

Foot & Ankle Orthopedics: Comprehensive Self-Assessment MCQs

Chapter Index