Orthopedic Foot & Ankle MCQs: 2026 Board Review

Question 1

The main advantage of surgical repair of an acute Achilles tendon rupture, when compared with nonsurgical management, is reduced

Explanation

The literature supports similar clinical outcomes after surgical and nonsurgical methods. The chief difference lies in the complications between the groups. Surgical patients experience more wound problems but a significantly lower rerupture rate. Although suturing the tendon allows earlier mobility, the tendon healing time is unchanged. Nonsurgical methods are less expensive to provide. Maffulli N: Rupture of the Achilles tendon. J Bone Joint Surg Am 1999;81:1019-1036. Cetti R, Christensen SE, Ejsted R, Jensen NM, Jorgensen U: Operative versus nonoperative treatment of Achilles tendon rupture: A prospective randomized study and review of the literature. Am J Sports Med 1993;21:791-799.

Question 2

A 25-year-old farm worker sustained a grade III open fracture of the midshaft of the left tibia after falling from a ladder. Which of the following antibiotic regimens is best for this patient?

Explanation

Patients who sustain grade III open fractures that are related to a farm environment require ampicillin or penicillin for Clostridium coverage. Holton PD, Mader J, Nelson CL, Osmon DR, Patzakis MJ: Antibiotics for the practicing orthopaedic surgeon. Instr Course Lect 2000;341:36-42.

Question 3

A 60-year-old man reports that he has had shoe pressure pain over his right great toe for several years but has minimal discomfort when barefoot or in sandals. A clinical photograph and radiographs are shown in Figures 1a through 1c. Management should consist of

Explanation

1b 1c Some patients have minimal symptoms associated with hallux rigidus despite significant radiographic evidence of osteoarthritis. This patient's symptoms are primarily related to shoe pressure from the exostosis and can be managed with extra-depth shoe wear. Smith RW, Katchis SD, Ayson LC: Outcomes in hallux rigidus patients treated nonoperatively: A long-term follow-up study. Foot Ankle Int 2000;21:906-913.

Question 4

A 45-year-old man is seeking evaluation of an injury sustained in a motor vehicle accident 10 weeks ago. Current radiographs are shown in Figures 2a and 2b. Based on the radiographic findings, what is the most likely diagnosis?

Explanation

2b An increased density of the talar body compared to the distal tibia following fracture of the talar neck is highly suggestive of vascular compromise of the talar body. Subchondral osteopenia of the talus at 6 to 8 weeks (Hawkins sign) is a favorable sign but does not eliminate the possibility of osteonecrosis. Elgafy H, Ebraheim NA, Tile M, Stephen D, Kase J: Fractures of the talus: Experience of two level 1 trauma centers. Foot Ankle Int 2000;21:1023-1029.

Question 5

A 28-year-old woman who is training for the New York Marathon reports pain in the posteromedial aspect of her right ankle. Examination reveals tenderness just posterior to the medial malleolus. Radiographs are normal. An MRI scan is shown in Figure 3. What is the most likely diagnosis?

Explanation

Any of the above conditions is credible with a limited history. The MRI scan unequivocally shows the stress fracture in the distal tibia. Most tibial stress fractures can be managed with rest and immobilization. Boden BP, Osbahr DC: High risk stress fractures: Evaluation and treatment. J Am Acad Orthop Surg 2000;8:344-353.

Question 6

A 50-year-old laborer sustained an isolated closed injury to his heel after falling 11 feet off a wall. A radiograph and a CT scan are shown in Figures 4a and 4b. To minimize the patient's temporary disability and allow him to return to work most rapidly, management should consist of

Explanation

4b With a severe articular injury to the calcaneus, the ability to achieve satisfactory results with open reduction and internal fixation diminishes. An arthrodesis is often needed to allow a person who works as a laborer to return to work. Recent literature suggests that this can be successfully performed primarily, improving the odds of an earlier return to the labor force at 1 year. Huefner T, Thermann H, Geerling J, Pape HC, Pohlemann T: Primary subtalar arthrodesis of calcaneal fractures. Foot Ankle Int 2001;22:9-14. Coughlin MJ: Calcaneal fractures in the industrial patient. Foot Ankle Int 2000;21:896-905.

Question 7

Figures 5a and 5b show the clinical photograph and radiograph of a patient who has difficulty wearing shoes and has persistent symptoms medially and laterally at the first and fifth metatarsophalangeal joints. Because shoe modifications have failed to provide relief, management should now consist of

Explanation

5b A significant bunionette deformity that fails to respond to conservative management is best addressed surgically, in this case with the bunion deformity. The radiograph reveals a prominent lateral condyle at the fifth metatarsal head without a significant increase in the intermetatarsal angle. Simple exostectomy is preferred with less risk of complications. Complete excision would risk transfer lesions to the medial metatarsals. Mann RA, Coughlin MJ: Adult hallux valgus, in Coughlin MJ, Mann RA (eds): Surgery of the Foot and Ankle, ed 7. St Louis, MO, Mosby, 1999, pp 415-435.

Question 8

What is the most appropriate orthotic management for the lesion shown in Figure 6?

Explanation

The figure shows an intractable plantar keratosis (IPK). The keratoma usually forms beneath a bony prominence. This can occur under the sesamoids, most commonly the tibial sesamoid, or under the fibular condyle of a prominent metatarsal head. The initial treatment of an IPK consists of paring down the callused lesion and placing a metatarsal pad proximal to the lesion to provide posting to unload the bony prominence.

Question 9

Examination of a 45-year-old man with Charcot-Marie-Tooth disease reveals a cavus foot, a tight Achilles tendon, and forefoot callus formation. Radiographs reveal advanced degenerative changes in the hindfoot. Shoe wear modifications have failed to provide relief. Treatment should now consist of

Explanation

The patient has the typical end stage residuals from long-standing Charcot-Marie-Tooth disease. Initial management consisting of shoe wear modifications and orthotic devices is preferred, but these are not successful when the disease process has progressed. Surgical correction with calcaneal osteotomy or Achilles tendon lengthening and Steindler stripping is not indicated in the presence of significant hindfoot arthritis. Because this patient has findings consistent with hindfoot arthritis, a triple arthrodesis with correction of the cavus deformity is the preferred treatment. Roper BA, Tibrewal SB: Soft tissue surgery in Charcot-Marie-Tooth disease. J Bone Joint Surg Br 1989;71:17-20.

Question 10

A Canale view best visualizes which of the following structures?

Explanation

The Canale view, which visualizes the talar neck, is taken with the ankle in maximum plantar flexion and the foot pronated 15 degrees. The radiograph is directed at a 75 degree angle from the horizontal plane in the anteroposterior plane. The Broden view, which is different from the Canale view, is best for imaging the posterior facet of the subtalar joint. Canale ST, Kelly FB Jr: Fractures of the neck of the talus: Long-term evaluation of seventy-one cases. J Bone Joint Surg Am 1978;60:143-156.

Question 11

A 45-year-old woman with a long-standing history of diabetes mellitus has a large draining plantar ulcer of the right foot. Examination reveals some local cellulitis and erythema surrounding the ulcer. A clinical photograph is shown in Figure 7. Based on these findings, what is the most appropriate antibiotic?

Explanation

Combination drugs with activity against both aerobic and anaerobic organisms have been determined to be the best approach. The first-generation cephalosporins do not provide adequate coverage for gram-negative and anaerobic organisms. Gentamicin alone would not provide adequate activity against anaerobes, and there is the risk of renal and auditory toxicity. Pinzur MS, Slovenkai MD, Trepman E: Guidelines for diabetic foot care. Foot Ankle Int 1999;20:695-702.

Question 12

A 35-year-old man reports forefoot pain with weight-bearing activities. He reports that he has had high arches since adolescence but has never been treated. Examination reveals stiff cavus feet. He has no plantar callus or hammer toe formation. The ankle can be passively dorsiflexed 10 degrees. Initial management should consist of

Explanation

The patient has cavus feet with minimal clinical symptoms. At this stage, conservative management is preferred. The use of a molded orthosis will allow better support of the midfoot and provide cushioning of the forefoot. This will most likely result in long-term relief. In more advanced cases with forefoot callus formation, Achilles tendon lengthening or calcaneal osteotomy and Steindler stripping are effective in correcting the cavus deformity. In the presence of arthritic changes in the hindfoot, a triple arthrodesis with corrective bone resection may be necessary. Janisse DJ: Indications and prescriptions for orthoses in sports. Orthop Clin North Am 1994;25:95-107.

Question 13

A 70-year-old woman had poliomyelitis as a young child, and the residual weakness she has as an adult principally involves the lower extremities. She now notes progressive weakness in both legs and she tires easily. What is the best course of action?

Explanation

The most likely diagnosis is postpolio syndrome, which is characterized by increasing weakness in both the paretic and previously normal muscles. Fatigability, joint pain, muscle atrophy, respiratory insufficiency, dysphagia, and sleep apnea are also seen. Gentle exercise and modification in lifestyle demands are generally recommended. Vigorous rehabilitation is likely to be detrimental in this condition. Further diagnostic work-up is not indicated at this time. Dalakas MC, Elder G, Hallett M, et al: A long-term follow-up study of patients with post-poliomyelitis neuromuscular symptoms. N Eng J Med 1986;314:959-963.

Question 14

A patient with Charcot-Marie-Tooth disease has a progressively rigid cavovarus foot deformity. The patient states that the pain is restricted to the forefoot, where rigid claw toe deformities have developed. Which of the following structures is primarily involved in creation of a claw toe deformity?

Explanation

Diseases such as Charcot-Marie-Tooth result in spasticity to the extrinsic flexor tendons. This results in hyperflexion of the proximal and distal interphalangeal joints of the involved toe, as well as hyperextension at the metatarsophalangeal joint. The tendon often becomes contracted with progressive equinus of the ankle. Correction of ankle equinus exaggerates the claw toe deformity. The interosseous tendon plays no role in the etiology of a claw toe but may become contracted in later stages of the disease. Laxity of the volar plate may precipitate a claw toe deformity in a nonspastic situation. In patients with a head injury, claw toe deformities are generally the result of overactivity of the extensor tendons. Keenan MA, Gorai AP, Smith CW, Garland DE: Intrinsic toe flexion deformity following correction of spastic equinovarus deformity in adults. Foot Ankle 1987;7:333-337. Pichney GA, Derner R, Lauf E: Digital "V" arthrodesis. J Foot Ankle Surg 1993;32:473-479.

Question 15

A 45-year-old man who underwent an ankle arthrodesis reports that for the first 6 years he had significant pain relief after the fusion healed. However, he now has increasing pain in the sinus tarsi. AP and lateral radiographs are shown in Figures 8a and 8b. What is the most likely cause of the patient's symptoms?

Explanation

8b The patient has a solid ankle fusion radiographically. With a tibiotalar arthrodesis, the adjacent joints (subtalar and transverse tarsal) take additional stress. Over time, progressive degenerative arthritis will occur in these adjacent joints, often necessitating further surgery. Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 613-631.

Question 16

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

Explanation

The radiograph shows a hallux varus deformity. Iatrogenically acquired hallux varus is most often the result of excessive lateral soft-tissue release, sesamoidectomy, or both. It also can be caused by a medial tibial sesamoid subluxation in conjunction with excessive postoperative dressing application, overcorrection of the intermetatarsal angle, or excessive medial eminence resection. Donley BG: Acquired hallux varus. Foot Ankle Int 1997;18:586-592.

Question 17

What is the reported failure rate for surgical treatment of a Morton's neuroma?

Explanation

The reported failure rate is in the range of 15%, which may be the result of incorrect diagnosis, improper web space selection, or formation of a stump neuroma. Therefore, the procedure should be approached with caution, measures should be taken to ensure that the diagnosis is accurate, and nonsurgical options should be exhausted. Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 101-111. Beskin JL: Nerve entrapment syndromes of the foot and ankle. J Am Acad Orthop Surg 1997;5:261-269.

Question 18

A 35-year-old woman who runs long distance has had posterior calf tenderness for the past 3 months. A clinical photograph is shown in Figure 10a, and MRI scans are shown in Figures 10b and 10c. Management at this point should consist of

Explanation

10b 10c The initial treatment for peritendinitis should consist of calf stretching in an eccentric mode and physical therapy. In a recent study, this treatment has been found superior to surgical debridement in nonextensive peritendinitis and pantendinitis. A non-weight-bearing cast, while useful in reducing inflammation, will result in calf atrophy and poorly organized collagen repair. Cortisone is contraindicated because of the danger of tendon damage. Tendon debridement at this stage is not indicated. Alfredson H, Pietila T, Jansson P, Lorentzon R: Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med 1998;26:360-366.

Question 19

A 35-year-old laborer who sustained a forefoot injury 10 years ago has returned to work but reports a progressively painful deformity of the hallux and continued midfoot pain that is aggravated by weight-bearing activities. Shoe wear modifications have failed to provide relief. Direct palpation reveals no pain at the first metatarsocuneiform joint. A radiograph is shown in Figure 11. What is the next most appropriate step in management?

Explanation

The patient has nonunions of the metatarsal fractures and a hallux valgus deformity with arthritic changes. To address all of the findings, management should consist of open treatment of the metatarsal nonunions and hallux metatarsophalangeal arthrodesis. Cast immobilization and a bone stimulator are unlikely to be beneficial at this time. Isolated correction of the hallux valgus deformity will not address the metatarsal nonunions or the arthritis at the hallux metatarsophalangeal joint. Kitaoka HB, Patzer GL: Arthrodesis versus resection arthroplasty for failed hallux valgus operations. Clin Orthop 1998;347:208-214. McGarvey WC, Braly WG: Bone graft in hindfoot arthrodesis: Allograft vs autograft. Orthopedics 1996;19:389-394.

Question 20

The use of posting (a wedge added to the medial or lateral side of an insole) is useful to balance forefoot or hindfoot malalignment. Assuming normal subtalar joint pronation, what is the maximum amount of recommended hindfoot posting?

Explanation

Generally, patients cannot tolerate more than 5 degrees of hindfoot posting. Donatelli RA, Hurlbert C, Conaway D, et al: Biomechanics foot orthotics: A retrospective study. J Orthop Sports Phys Ther 1988;10:205-212. Michaud TM: Foot Orthoses and Other Forms of Conservative Foot Care. Baltimore, MD, Williams & Wilkins, 1993, pp 61-65, 186.

Question 21

A 40-year-old woman has a symptomatic mass on the anterior aspect of the ankle. She reports no constitutional symptoms. An MRI scan is shown in Figure 12. What is the most likely diagnosis?

Explanation

The MRI scan reveals a lobular mass that is below the vitamin E tablet marker taped to the skin. This is juxtaposed to the tibialis anterior tendon. It is slightly more enhanced than the surrounding subcutaneous fat and is consistent with a ganglion. Osteosarcoma, aneurysmal bone cyst, or unicameral bone cyst all would demonstrate enhancement or pathology in the bone. This is clearly a well-defined soft-tissue mass. Gouty tophi show low to intermediate signal on T1- and T2-weighted images. Kransdorf MJ, Jelinek JS, Moser RP Jr, et al: Soft tissue masses: Diagnosis using MR imaging. Am J Roentgenol 1989;153:541-547. Wetzel LH, Levine E: Soft-tissue tumors of the foot: Value of MR imaging for specific diagnosis. Am J Roentgenol 1990;155:1025-1030.

Question 22

A 35-year-old woman who is training for a triathlon has had a 2-month history of heel pain with weight bearing and is unable to run. History reveals that she is amenorrheic. Examination reveals that she is thin and has pain over the heel that is exacerbated with medial and lateral compression. Range of motion and motor and sensory function are normal. Radiographs are normal. What is the most likely diagnosis?

Explanation

The most likely diagnosis is a stress fracture of the calcaneus and is supported by the history of running, female gender, and amenorrhea. Reproducing pain with medial and lateral compression of the heel also supports the diagnosis. A bone scan or MRI would most likely confirm the diagnosis. Plantar fasciitis would result in pain on the bottom of the heel with point tenderness. The lack of other areas of involvement or other symptoms does not support a seronegative inflammatory arthritis. Tarsal tunnel syndrome and peripheral neuropathy are unlikely because of the normal neurologic examination. Beaty JH (ed): Orthopaedic Knowledge Update 6. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1999, pp 597-612.

Question 23

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

Explanation

13b Based on her symptoms and prior shoe wear modifications, the treatment of choice is surgical correction of the hallux valgus with a chevron osteotomy. There are no data to support the use of a custom orthosis to delay the progression of a hallux valgus deformity. Steroid injection would only risk infection, as well as joint and capsule damage. Extra-depth shoes are an option; however, the patient is interested in surgical options. Chou LB, Mann RA, Casillas MM: Biplanar chevron osteotomy. Foot Ankle Int 1998;19:579-584. Coughlin MJ: Roger A. Mann Award: Juvenile hallux valgus. Etiology and treatment. Foot Ankle Int 1995;16:682-697.

Question 24

A 20-year-old woman has lateral foot and ankle pain after sustaining an inversion injury of the ankle while playing soccer 3 months ago. Activity modifications and physical therapy have failed to provide relief. She describes burning pain that extends from the anterior aspect of the ankle to the foot and lateral two toes. The pain is often worse at night. Plain radiographs, a bone scan, and an MRI scan are normal. Stress examination reveals no instability. What is the most likely diagnosis?

Explanation

Persistent pain following an ankle sprain can present a diagnostic dilemma. All of the injuries listed should be considered in the differential diagnosis. The superficial peroneal nerve courses in the lateral compartment and exits the crural fascia 12 to 15 cm above the level of the ankle. Muscle herniation through the fascial defect has been reported to be associated with entrapment of this nerve. The fascial hiatus also may serve as a potential tether in cases of inversion injuries causing injury to the superficial peroneal nerve. Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 101-111.

Question 25

A 35-year-old runner has pain beneath the second metatarsophalangeal joint. He reports that he has significantly decreased his running distance since the onset of the pain. He denies any history of trauma or injury to the foot. A radiograph is shown in Figure 14. Initial management should consist of

Explanation

The presence of the relatively long second metatarsal, along with the close approximation of the second and third metatarsal heads, are consistent with second metatarsophalangeal tenosynovitis. The hallmark of initial management is conservative. Modalities include taping, nonsteroidal anti-inflammatory drugs, metatarsal pads, and cortisone injections. Trepman and Yeo combined the use of a cortisone injection with a rocker bottom sole. Mizel and Michelson reported their results using an extended rigid steel shank shoe along with a cortisone injection. Trepman E, Yeo SJ: Nonoperative treatment of metatarsophalangeal joint synovitis. Foot Ankle Int 1995;16:771-777.

Question 26

A 25-year-old athlete sustains a forced plantar flexion injury to his midfoot. Weight-bearing radiographs show 3 mm of widening between the base of the first and second metatarsals. What is the primary stabilizing structure injured in this scenario?

Explanation

The 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 primary stabilizer of the second tarsometatarsal joint and its disruption leads to midfoot instability.

Question 27

A 32-year-old man falls from a height and sustains a Hawkins type III talar neck fracture. Which of the following best describes the disruption of blood supply leading to the high rate of avascular necrosis in this injury?

Explanation

A Hawkins type III fracture involves subluxation or dislocation of both the subtalar and tibiotalar joints. This disrupts the three major blood supplies to the talar body: the artery of the tarsal canal, the deltoid branch, and the capsular branches from the dorsalis pedis.

Question 28

A 16-year-old girl presents with progressive bilateral foot deformities and frequent ankle sprains. Examination reveals a rigid hindfoot varus that corrects with a Coleman block test. Which of the following muscle imbalances is the primary driver of the forefoot-driven cavovarus deformity?

Explanation

In Charcot-Marie-Tooth disease, a plantarflexed first ray is driven by a strong peroneus longus overpulling a weak tibialis anterior. This causes a forefoot-driven hindfoot varus which is initially flexible (corrects on Coleman block test) but can become rigid over time.

Question 29

A 65-year-old man with end-stage post-traumatic ankle osteoarthritis is considering surgical intervention. Which of the following is an absolute contraindication to a total ankle arthroplasty (TAA)?

Explanation

Absolute contraindications to total ankle arthroplasty include active infection, Charcot neuroarthropathy, absent lower extremity sensation, and avascular necrosis of the talus (>50%). Age, moderate obesity, and prior trauma without active infection are not absolute contraindications.

Question 30

A 22-year-old professional soccer player sustains an acute Zone 2 fifth metatarsal base fracture. He wishes to return to play as soon as possible. What is the most appropriate surgical treatment?

Explanation

Zone 2 fractures (Jones fractures) in elite athletes are best treated with intramedullary screw fixation to minimize nonunion risk and expedite return to play. The screw threads must cross the fracture site completely for adequate compression.

Question 31

A 55-year-old woman presents with medial foot pain and a progressive flatfoot deformity. Examination shows a flexible hindfoot valgus and inability to perform a single-leg heel raise. Radiographs demonstrate >40% talonavicular uncoverage. What is the most appropriate surgical management?

Explanation

This patient has Stage IIb adult acquired flatfoot deformity (flexible, >40% talonavicular uncoverage indicating severe forefoot abduction). Treatment requires FDL transfer, MDCO, and a lateral column lengthening (e.g., Evans osteotomy) to correct the forefoot abduction.

Question 32

During the extensile lateral approach for open reduction and internal fixation of a displaced intra-articular calcaneus fracture, what structure is at highest risk of iatrogenic injury when elevating the full-thickness flap?

Explanation

The sural nerve is at high risk of injury during the extensile lateral approach to the calcaneus. A meticulous "no-touch" subperiosteal full-thickness flap dissection is essential to protect the nerve and the fragile skin flap's blood supply.

Question 33

A 45-year-old woman complains of a painful bunion. Weight-bearing radiographs show a hallux valgus angle of 45 degrees and an intermetatarsal angle (IMA) of 16 degrees. The first tarsometatarsal joint is hypermobile. What is the most appropriate surgical procedure?

Explanation

A Lapidus procedure (first tarsometatarsal arthrodesis) is indicated for severe hallux valgus (IMA >15 degrees, HVA >40 degrees), particularly in the presence of first TMT joint hypermobility. Distal osteotomies are insufficient for large intermetatarsal angles.

Question 34

A 28-year-old football running back injures his great toe during a forceful push-off on artificial turf. He has severe pain at the first MTP joint. Radiographs show proximal migration of the medial sesamoid compared to the lateral sesamoid. What is the diagnosis?

Explanation

Turf toe is a hyperextension injury of the first MTP joint leading to sprain or tear of the plantar plate complex. Proximal migration of the sesamoid indicates a complete (Grade 3) rupture of the plantar plate/sesamoid complex requiring operative repair in elite athletes.

Question 35

A 24-year-old man presents with persistent deep ankle pain 8 months after a severe ankle sprain. MRI demonstrates a 1.8 square centimeter osteochondral lesion on the medial talar dome with subchondral cystic changes. After failing conservative management, what is the most appropriate surgical treatment?

Explanation

Osteochondral lesions of the talus larger than 1.5 cm2 or those with significant subchondral cysts are best treated with osteochondral autograft transfer (OATS) or allograft. Microfracture has high failure rates in lesions larger than 1.5 cm2.

Question 36

A 58-year-old man with poorly controlled type 2 diabetes presents with an ulcer under the first metatarsal head. The ulcer extends to the bone, and a sterile probe easily touches the metatarsal head, which feels gritty. There is surrounding erythema and purulent drainage. According to the Wagner classification, what grade is this lesion?

Explanation

The Wagner classification grades diabetic foot ulcers. Grade 3 denotes a deep ulcer with osteomyelitis, deep abscess, or joint sepsis. Probing to bone strongly correlates with clinical osteomyelitis.

Question 37

A 21-year-old skier presents with lateral ankle pain and a snapping sensation behind the lateral malleolus after a twisting fall. Examination reveals subluxation of the peroneal tendons over the fibula during active eversion. Which structure is compromised in this condition?

Explanation

Peroneal tendon subluxation is caused by injury to or incompetence of the superior peroneal retinaculum (SPR). Surgical treatment typically involves SPR repair and may require deepening of the retromalleolar fibular groove.

Question 38

A 52-year-old man with peripheral neuropathy presents with a swollen, erythematous, and warm right foot. Radiographs reveal prominent soft tissue swelling, fragmentation of the navicular and cuboid, and periarticular debris without frank dislocation. Inflammatory markers are normal. According to the Eichenholtz classification, what stage is this?

Explanation

Eichenholtz Stage 1 (Developmental/Fragmentation) is characterized by joint edema, radiolucency, bony fragmentation, and debris. Treatment requires strict immobilization in a total contact cast to prevent further collapse.

Question 39

A 35-year-old construction worker falls from a scaffold, sustaining a severe high-energy comminuted tibial plafond (pilon) fracture with severe soft tissue swelling and fracture blisters. What is the most widely accepted initial management strategy?

Explanation

High-energy pilon fractures are associated with massive soft tissue injury. The standard of care is a staged protocol: initial spanning external fixation until the soft tissue envelope recovers (typically 10-14 days), followed by definitive ORIF.

Question 40

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. What is the most appropriate surgical treatment?

Explanation

First TMT arthrodesis (Lapidus procedure) is indicated for moderate to severe hallux valgus with 1st ray hypermobility to correct the intermetatarsal angle and stabilize the medial column.

Question 41

A 55-year-old diabetic male presents with a swollen, erythematous, warm, and painless left foot. Radiographs reveal fragmentation of the navicular and cuneiforms with joint subluxation. What is the most appropriate initial management?

Explanation

This patient is in the acute fragmentation phase (Eichenholtz stage I) of Charcot arthropathy. The gold standard initial management is immobilization and offloading, typically with a total contact cast, until the inflammatory phase resolves.

Question 42

A 60-year-old male presents with chronic Achilles tendinopathy and a 5 cm defect following a spontaneous rupture 3 months ago. An FHL transfer is planned. To minimize morbidity, which function is most important to evaluate postoperatively regarding the donor tendon?

Explanation

The flexor hallucis longus (FHL) provides flexion at the interphalangeal (IP) joint of the great toe. Harvesting the FHL for Achilles reconstruction can lead to a loss of active IP joint flexion, though functional deficit is usually minimal.

Question 43

A 22-year-old male presents with bilateral cavovarus feet. A Coleman block test is performed by placing the heel and lateral foot on a block while the first metatarsal hangs off. The hindfoot varus corrects to neutral. What does this finding indicate?

Explanation

A flexible hindfoot varus that corrects during the Coleman block test indicates that the deformity is forefoot-driven, typically due to a plantarflexed first ray. Management should primarily target the first ray, such as a dorsiflexing osteotomy.

Question 44

A 24-year-old professional football player sustains an acute Jones fracture (Zone 2) of the fifth metatarsal. Which of the following is the most appropriate management?

Explanation

In high-level athletes, intramedullary screw fixation of acute Zone 2 fifth metatarsal fractures (Jones fractures) is recommended to decrease nonunion risk and expedite return to play compared to conservative management.

Question 45

A 50-year-old female presents with a painful, progressive flatfoot. She can perform a single leg heel rise but it is painful and incomplete. Examination shows a flexible hindfoot valgus. What is the most appropriate surgical intervention if conservative measures fail?

Explanation

The patient has Stage II adult-acquired flatfoot deformity (flexible hindfoot, PTT insufficiency). Joint-sparing surgery with FDL transfer and a medializing calcaneal osteotomy corrects the deformity and restores tendon function.

Question 46

A 30-year-old male sustains a Hawkins type III talar neck fracture following a motor vehicle accident. What is the expected rate of avascular necrosis (AVN) of the talar body?

Explanation

A Hawkins type III fracture is a talar neck fracture with subtalar and tibiotalar dislocation, disrupting all three major blood supplies to the talar body. The risk of AVN is exceptionally high, approaching 75-100%.

Question 47

A 28-year-old rugby player sustains a hyper-dorsiflexion injury to his right great toe. MRI demonstrates a complete disruption of the plantar plate and proximal retraction of the sesamoids. What is the most appropriate management?

Explanation

This represents a Grade III turf toe injury with a complete tear of the plantar plate and sesamoid retraction. In a competitive athlete, primary surgical repair is indicated to restore push-off strength and joint stability.

Question 48

A 35-year-old female falls from a horse, injuring her midfoot. Radiographs show a 3 mm diastasis between the base of the first and second metatarsals, with dorsal subluxation on the lateral view. Which of the following ligaments is primarily injured?

Explanation

The Lisfranc ligament is an interosseous ligament that runs from the plantar-lateral aspect of the medial cuneiform to the plantar-medial base of the second metatarsal. It is the primary stabilizer of the second TMT joint.

Question 49

A 65-year-old male with end-stage post-traumatic ankle arthritis has severe pain. He is an avid golfer and walker. Examination reveals a well-aligned hindfoot and functional adjacent joints. He has no history of infection or severe neuropathy. Which of the following is an absolute contraindication to total ankle arthroplasty (TAA)?

Explanation

Significant avascular necrosis (typically >50%) of the talar body compromises the bony support required for the talar component. This makes it an absolute contraindication to total ankle arthroplasty due to high risk of implant subsidence.

Question 50

A 40-year-old roofer falls 15 feet, sustaining a closed, displaced, intra-articular calcaneal fracture with loss of Böhler's angle and widening of the heel. If open reduction and internal fixation via an extensile lateral approach is planned, what is the most significant risk associated with this surgical approach?

Explanation

The extensile lateral approach to the calcaneus carries a high risk of wound healing complications (up to 25%). This includes edge necrosis and deep infection, due to the tenuous vascular supply of the lateral heel flap.

Question 51

A 42-year-old female presents with burning pain and tingling in the plantar aspect of her foot, which worsens at night and after prolonged standing. Tinel's sign is positive posterior to the medial malleolus. Which nerve is compressed?

Explanation

Tarsal tunnel syndrome results from the compression of the posterior tibial nerve or its branches. This occurs as it passes through the fibro-osseous tunnel beneath the flexor retinaculum, posterior to the medial malleolus.

Question 52

A 22-year-old football player sustains a rotational injury to his midfoot. Radiographs demonstrate widening between the 1st and 2nd metatarsal bases with a "fleck sign". The primary ligament injured in this condition connects which of the following structures?

Explanation

The Lisfranc ligament is an intra-articular ligament that connects the lateral aspect of the medial cuneiform to the medial base of the second metatarsal. Disruption leads to midfoot instability and requires anatomic reduction.

Question 53

During an extensile lateral approach for the open reduction and internal fixation of a displaced intra-articular calcaneus fracture, the surgeon must carefully identify and protect which of the following nerves in the superior and posterior aspect of the flap?

Explanation

The sural nerve courses along the lateral aspect of the hindfoot and is at high risk of iatrogenic injury during the extensile lateral approach to the calcaneus. Retracting it within the full-thickness soft tissue flap protects it.

Question 54

A 35-year-old man falls from a height and sustains a Hawkins type III fracture of the talar neck. What is the approximate reported rate of avascular necrosis (AVN) of the talar body associated with this specific injury pattern?

Explanation

A Hawkins type III talar neck fracture involves subluxation or dislocation of both the subtalar and tibiotalar joints. This severe displacement disrupts the major blood supply to the talar body, leading to an AVN rate of 80% to 100%.

Question 55

A 55-year-old woman presents with a flexible flatfoot deformity, lateral hindfoot pain, and an inability to perform a single-leg heel rise. Radiographs show uncovering of the talonavicular joint. What is the most widely accepted initial surgical management for stage IIb posterior tibial tendon dysfunction?

Explanation

Stage IIb PTTD denotes a flexible flatfoot with forefoot abduction. Surgical reconstruction typically involves an FDL tendon transfer to substitute for the PTT, combined with a medializing calcaneal osteotomy and lateral column lengthening to correct the forefoot abduction.

Question 56

An elite collegiate basketball player sustains an acute Zone 2 fracture of the proximal fifth metatarsal. To minimize the risk of nonunion and expedite his return to play, which of the following treatments is most appropriate?

Explanation

Zone 2 fractures (Jones fractures) occur at the metaphyseal-diaphyseal junction, a watershed vascular area prone to nonunion. In high-level athletes, early intramedullary screw fixation is recommended to reduce nonunion rates and accelerate return to sport.

Question 57

A 48-year-old woman has a severe hallux valgus deformity with a hallux valgus angle of 45 degrees and an intermetatarsal angle of 18 degrees. Clinical examination reveals gross hypermobility of the first tarsometatarsal (TMT) joint. Which of the following procedures is most indicated?

Explanation

The Lapidus procedure (first TMT joint arthrodesis) is the procedure of choice for severe hallux valgus associated with first ray hypermobility. Distal osteotomies are insufficient for high intermetatarsal angles combined with TMT instability.

Question 58

A 60-year-old patient with long-standing poorly controlled diabetes presents with a red, hot, swollen right foot. Radiographs demonstrate fragmentation and periarticular debris at the tarsometatarsal joints. What is the most appropriate initial management?

Explanation

This presentation is classic for Eichenholtz Stage I (fragmentation phase) Charcot neuroarthropathy. The mainstay of initial treatment is immobilization and offloading, most effectively achieved with a total contact cast until the acute inflammatory phase resolves.

Question 59

A 68-year-old man with end-stage post-traumatic tibiotalar arthritis is considering surgical intervention. He has concomitant severe subtalar osteoarthritis but no significant coronal plane deformity. Which of the following is a primary indication for total ankle arthroplasty over an ankle arthrodesis in this patient?

Explanation

Advanced adjacent joint arthritis (e.g., subtalar or talonavicular joints) is a major indication for total ankle arthroplasty. Preserving tibiotalar motion prevents accelerated wear and worsening pain in the already arthritic adjacent hindfoot joints.

Question 60

A wide receiver injures his great toe while being tackled on an artificial turf field. MRI confirms a complete tear of the plantar plate and sesamoid complex of the first metatarsophalangeal (MTP) joint. What is the most common mechanism of this injury?

Explanation

Classic 'turf toe' is caused by an acute, forced hyperextension of the first MTP joint, leading to sprain or rupture of the plantar capsuloligamentous complex. It is highly associated with flexible artificial turf and lightweight athletic footwear.

Question 61

A patient with Charcot-Marie-Tooth disease presents with a significant cavovarus foot deformity. Upon performing a Coleman block test, the hindfoot varus deformity corrects entirely to neutral. This clinical finding indicates that the hindfoot varus is primarily driven by:

Explanation

The Coleman block test nullifies the effect of a plantarflexed first ray by allowing it to drop off the block. If the hindfoot varus corrects to neutral, the deformity is forefoot-driven and the subtalar joint remains flexible.

Question 62

A 55-year-old runner is undergoing surgical debridement for severe insertional Achilles tendinopathy with a Haglund's deformity. Intraoperatively, the surgeon notes that more than 50% of the Achilles tendon insertion must be detached to thoroughly resect the diseased tissue. Which of the following transfers is most appropriate for augmentation?

Explanation

When greater than 50% of the Achilles tendon insertion is compromised during debridement, augmentation is necessary to restore plantarflexion strength and prevent rupture. The FHL tendon is the gold standard transfer due to its strength, proximity, and in-phase firing.

Question 63

A 28-year-old woman has chronic medial ankle pain after an inversion injury 1 year ago. MRI demonstrates an 8-mm isolated osteochondral lesion of the posteromedial talar dome. Nonoperative management has failed. What is the most appropriate initial surgical treatment?

Explanation

For primary osteochondral lesions of the talus that are smaller than 1.5 cm in diameter, arthroscopic debridement and marrow stimulation (microfracture) is the most appropriate and effective initial surgical treatment.

Question 64

A 45-year-old factory worker complains of burning pain and tingling in the plantar aspect of his foot that worsens after long shifts. Tinel's sign is positive posterior to the medial malleolus. Compression of which of the following nerves is the most likely cause of his symptoms?

Explanation

Tarsal tunnel syndrome is caused by the entrapment of the posterior tibial nerve (or its branches) as it passes beneath the flexor retinaculum posterior to the medial malleolus. Symptoms typically include plantar foot numbness and pain.

Question 65

A 24-year-old downhill skier sustains a forced dorsiflexion and inversion injury to his ankle. He subsequently reports a painful snapping sensation over his lateral malleolus during ambulation. Incompetence of which of the following structures is the primary cause of his pathology?

Explanation

The superior peroneal retinaculum is the primary restraint to peroneal tendon subluxation. Forced dorsiflexion and inversion can strip or tear the retinaculum from the fibula, leading to recurrent peroneal tendon dislocation.

Question 66

A 19-year-old track athlete presents with insidious onset of vague midfoot pain that worsens with sprinting. Imaging reveals a stress fracture of the tarsal navicular. This fracture most commonly occurs in which anatomic region of the bone?

Explanation

Tarsal navicular stress fractures predominantly occur in the central third of the bone in the sagittal plane. This area represents a relatively avascular watershed zone, making it highly susceptible to fatigue failure and nonunion.

Question 67

A 38-year-old construction worker falls from scaffolding, sustaining a high-energy comminuted tibial pilon fracture with severe fracture blisters and massive soft tissue edema. What is the most appropriate initial management?

Explanation

High-energy pilon fractures are fraught with severe soft-tissue complications if operated on acutely. The standard of care is a staged protocol: initial spanning external fixation to allow soft tissues to recover, followed by definitive ORIF 1 to 3 weeks later.

Question 68

A 42-year-old woman presents with severe burning pain in her forefoot that radiates into her toes, particularly when wearing narrow dress shoes. Examination reveals a palpable click when compressing the metatarsal heads while applying plantar pressure to the web space. Which web space is most commonly affected by this condition?

Explanation

The clinical presentation describes a Morton's neuroma, with a positive Mulder's click. It most frequently occurs in the third interdigital space, where the medial and lateral plantar nerves anastomose, creating a thicker nerve more prone to tethering.

Question 69

A 30-year-old man undergoes ORIF for a Weber C ankle fracture. After fibular fixation, the surgeon suspects a concomitant syndesmotic injury. Which of the following intraoperative tests is most reliable for dynamically assessing the integrity of the distal tibiofibular syndesmosis?

Explanation

The Cotton test is performed intraoperatively by placing a bone hook around the fibula and applying a lateral traction force. Widening of the syndesmosis under fluoroscopy confirms syndesmotic instability requiring fixation.

Question 70

A 22-year-old elite collegiate basketball player presents with acute midfoot pain after a cutting maneuver. Radiographs demonstrate a fracture at the metaphyseal-diaphyseal junction of the fifth metatarsal, extending into the fourth-fifth intermetatarsal articulation. What is the most appropriate management for this patient to minimize the risk of nonunion and expedite return to play?

Explanation

This is a Zone 2 (Jones) fracture. In elite athletes, early intramedullary screw fixation is recommended to significantly decrease the time to union and lower the high rate of nonunion associated with conservative management.

Question 71

A 55-year-old woman presents with a painful, flexible acquired flatfoot deformity. She is unable to perform a single-leg heel rise. Radiographs demonstrate uncovering of the talonavicular joint of 45% and significant forefoot abduction. Which of the following surgical interventions is most appropriate if conservative management fails?

Explanation

This represents a Stage IIb posterior tibial tendon dysfunction (PTTD), characterized by >30% talonavicular uncovering and forefoot abduction. Appropriate treatment requires FDL transfer combined with lateral column lengthening to correct the abduction deformity.

Question 72

A 35-year-old man is 8 weeks post-operative from open reduction and internal fixation of a Hawkins Type II talar neck fracture. Radiographs obtained at this visit demonstrate a subchondral radiolucent band in the dome of the talus. This radiographic finding indicates which of the following?

Explanation

The presence of a subchondral radiolucent band in the talar dome at 6 to 8 weeks is known as the Hawkins sign. It represents subchondral osteopenia secondary to bone resorption, which confirms intact vascularity and a low risk of avascular necrosis.

Question 73

A 28-year-old male sustains a hyperplantarflexion injury to his foot. Non-weight-bearing radiographs appear normal. On clinical exam, he has midfoot swelling, pain with midfoot pronation/abduction, and ecchymosis on the plantar aspect of the midfoot. What is the next best step in management?

Explanation

Plantar ecchymosis is highly suspicious for a Lisfranc injury. When non-weight-bearing radiographs are normal, weight-bearing radiographs are the essential next step to evaluate for dynamic instability of the tarsometatarsal joints.

Question 74

A 58-year-old male with long-standing, poorly controlled diabetes presents with a swollen, erythematous, warm, and relatively painless foot. Pulses are palpable. Radiographs reveal early fragmentation and subluxation of the tarsometatarsal joints. What is the most appropriate initial management?

Explanation

This presentation is classic for acute Eichenholtz stage I Charcot neuroarthropathy. The mainstay of initial management is offloading the foot with total contact casting until the acute inflammatory phase (warmth and erythema) resolves.

Question 75

A 45-year-old female presents with a painful bunion. Clinical examination reveals hypermobility of the first tarsometatarsal (TMT) joint with primarily sagittal plane instability. Radiographs show a hallux valgus angle of 38 degrees and an intermetatarsal angle of 18 degrees. Which of the following surgical procedures is most appropriate?

Explanation

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

Question 76

When evaluating a patient with end-stage ankle osteoarthritis, which of the following is considered an absolute contraindication to a total ankle arthroplasty (TAA)?

Explanation

Active infection, Charcot neuroarthropathy, and severe avascular necrosis of the talus with collapse are absolute contraindications for total ankle arthroplasty. Advanced age and inflammatory arthritis are typical indications for TAA.

Question 77

A 32-year-old runner complains of chronic retromalleolar lateral ankle pain. MRI reveals a longitudinal split tear of the peroneus brevis tendon, with an intact peroneus longus. Intraoperatively, the tear involves 30% of the cross-sectional area of the tendon. What is the best surgical management?

Explanation

For isolated peroneus brevis tears involving less than 50% of the tendon cross-section, the standard of care is debridement of the torn segment followed by tubularization. Tears >50% often necessitate tenodesis to the peroneus longus.

Question 78

A professional football player presents with severe pain in the first metatarsophalangeal (MTP) joint after a forced hyperextension injury. Examination demonstrates marked swelling, ecchymosis, and a positive Lachman test of the MTP joint. Radiographs show proximal migration of the sesamoids. What is the grade of this injury and the most appropriate management?

Explanation

This is a Grade III turf toe, characterized by a complete tear of the plantar plate complex (evident by MTP instability and sesamoid retraction). In high-level athletes, surgical repair is recommended to restore push-off strength and prevent chronic deformity.

Question 79

A 45-year-old male presents with chronic posterior heel pain. Radiographs show a prominent posterosuperior calcaneal tuberosity and an enthesophyte. MRI shows insertional Achilles tendinosis involving 60% of the tendon insertion. Which surgical approach is most appropriate?

Explanation

For insertional Achilles tendinopathy requiring detachment and debridement of >50% of the tendon footprint, augmentation with a Flexor Hallucis Longus (FHL) transfer is recommended to maintain plantarflexion strength and protect the repair.

Question 80

What is the most common long-term complication following open reduction and internal fixation of a displaced intra-articular calcaneus fracture?

Explanation

Subtalar post-traumatic arthritis is the most frequent long-term complication following intra-articular calcaneal fractures, regardless of whether they are treated operatively or non-operatively, often eventually requiring a subtalar arthrodesis.

Question 81

A diabetic patient presents with a chronic plantar ulcer under the first metatarsal head. There is no systemic toxicity. Which clinical finding has the highest positive predictive value for underlying osteomyelitis?

Explanation

A positive probe-to-bone test (feeling a hard, gritty surface) in the presence of a chronic diabetic foot ulcer is highly predictive of underlying osteomyelitis, often confirming the diagnosis without the immediate need for an MRI.

Question 82

When evaluating an ankle mortise radiograph for a suspected syndesmotic injury, which of the following radiographic parameters is the most reliable indicator of syndesmotic diastasis?

Explanation

A tibiofibular clear space greater than 5 mm (measured 1 cm proximal to the tibial plafond) is the most reliable radiographic parameter for detecting syndesmotic widening on both AP and mortise views.

Question 83

A 40-year-old female complains of burning pain in the plantar aspect of her forefoot that radiates into her third and fourth toes, worsening with tight shoes. Examination reveals a painful click when the metatarsal heads are compressed laterally while applying plantar pressure to the interspace. The pathology most commonly involves which of the following nerves?

Explanation

The clinical presentation and positive Mulder's sign are classic for a Morton's neuroma, which most frequently involves the third common digital nerve located in the third web space.

Question 84

A 25-year-old male suffers an acute inversion ankle sprain. On clinical examination, he demonstrates a positive anterior drawer test of the ankle, but the talar tilt test is firmly negative. Which ligament is primarily injured?

Explanation

The ATFL is the primary restraint to anterior translation of the talus, assessed by the anterior drawer test. A negative talar tilt test indicates that the calcaneofibular ligament (CFL) remains intact.

Question 85

Which of the following ligaments is considered the strongest and primary stabilizer of the second tarsometatarsal joint?

Explanation

The interosseous Lisfranc ligament connects the medial cuneiform to the base of the second metatarsal. It is the strongest and most important stabilizing structure of the Lisfranc complex.

Question 86

A 55-year-old patient with poorly controlled diabetes presents with a swollen, erythematous, and warm foot without a wound or fever. Radiographs show fragmentation and periarticular debris around the midfoot. What is the most appropriate initial management?

Explanation

This presentation describes Eichenholtz stage I (fragmentation phase) Charcot neuroarthropathy. The gold standard initial treatment is immediate offloading with a total contact cast to prevent further destructive deformity.

Question 87

A 45-year-old woman presents with painful hallux valgus. Examination and weight-bearing radiographs reveal an intermetatarsal angle (IMA) of 12 degrees and a hallux valgus angle (HVA) of 28 degrees. The first tarsometatarsal joint is stable without hypermobility. What is the most appropriate surgical intervention?

Explanation

A distal chevron osteotomy is indicated for mild to moderate hallux valgus deformities (IMA < 13 degrees, HVA < 30 degrees) without hypermobility. The Lapidus procedure is reserved for more severe deformities or when first TMT hypermobility is present.

Question 88

A 48-year-old runner presents with chronic posterior heel pain. MRI shows insertional Achilles tendinosis involving 60% of the tendon footprint. Following failed conservative management, surgical intervention includes excision of the Haglund prominence and extensive tendon debridement. What additional procedure is strongly recommended?

Explanation

When more than 50% of the Achilles tendon insertion requires debridement for insertional tendinopathy, an FHL transfer is recommended. The FHL augments the repair and provides robust local blood supply to aid in healing.

Question 89

A 62-year-old woman presents with medial ankle pain and a progressively flattening arch. She can perform a single-leg heel raise but it is weak and painful. Radiographs show a talonavicular uncoverage of 30%. What is the standard surgical treatment for this condition?

Explanation

This patient has Stage II adult-acquired flatfoot deformity (flexible flatfoot secondary to posterior tibial tendon dysfunction). The standard surgical approach combines a soft tissue reconstruction (FDL transfer) with a bony corrective procedure (MDCO).

Question 90

Which of the following radiographic parameters on a standard mortise ankle radiograph is the most reliable direct indicator of a syndesmotic injury?

Explanation

A tibiofibular clear space greater than 6 mm, measured 1 cm proximal to the joint line on AP and mortise views, is a reliable direct radiographic indicator of syndesmotic widening. Normal tibiofibular clear space is < 6 mm.

Question 91

A 22-year-old collegiate football player sustains a forceful hyper-dorsiflexion injury to his great toe. Examination reveals marked tenderness plantar to the first MTP joint and profound weakness with active plantar flexion of the hallux. What structure is most likely disrupted?

Explanation

Turf toe is a severe sprain or complete tear of the plantar plate and capsuloligamentous complex of the first MTP joint. Loss of push-off strength directly implicates compromise of the sesamoid-plantar plate mechanism.

Question 92

According to the Hawkins classification of talar neck fractures, which of the following injury patterns carries a risk of avascular necrosis (AVN) to the talar body approaching 100%?

Explanation

Hawkins Type IV fractures involve disruption of the subtalar, tibiotalar, and talonavicular joints. Because all three major sources of retrograde blood supply to the talar body are severed, the AVN risk is practically 100%.

Question 93

A 19-year-old elite collegiate basketball player complains of lateral foot pain after a cutting maneuver. A radiograph is shown.

What is the recommended treatment to minimize nonunion and expedite return to play?

Explanation

The clinical scenario and typical imaging describe a true Jones fracture (Zone 2 of the 5th metatarsal base). In high-demand athletes, early intramedullary screw fixation is recommended to reduce nonunion risk and allow faster return to sport.

Question 94

A 16-year-old female dancer presents with chronic pain and swelling over the dorsal aspect of the second metatarsophalangeal joint. Radiographs show flattening, sclerosis, and fragmentation of the second metatarsal head. What is the most likely diagnosis?

Explanation

Freiberg infraction is an avascular necrosis of the metatarsal head, most frequently affecting the second metatarsal in adolescent females. It presents with localized dorsal forefoot pain exacerbated by weight-bearing.

Question 95

A 26-year-old skier presents with lateral ankle pain and a painful snapping sensation behind the lateral malleolus when actively everting and dorsiflexing the foot. Which structure is most likely injured or attenuated?

Explanation

Peroneal tendon subluxation or dislocation is typically caused by an injury or stripping of the superior peroneal retinaculum (SPR). The classic mechanism is sudden forceful dorsiflexion and inversion.

Question 96

A 42-year-old man presents with burning pain and tingling radiating into the plantar aspect of his foot, worse after standing. Tinel's sign is strongly positive posterior to the medial malleolus. Entrapment of which nerve is causing these symptoms?

Explanation

Tarsal tunnel syndrome is a compressive neuropathy of the tibial nerve (or its medial/lateral plantar branches) as it passes beneath the flexor retinaculum posterior to the medial malleolus.

Question 97

A 35-year-old construction worker falls from a ladder and sustains the heel injury seen in the lateral radiograph.

Which of the following statements regarding the typical morphologic changes in a displaced intra-articular calcaneus fracture is true?

Explanation

In displaced intra-articular calcaneus fractures, the lateral wall blows out, causing the calcaneus to become shortened and widened. Böhler's angle is characteristically decreased or flattened, while the angle of Gissane is often increased.

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

Orthopedic Foot & Ankle 2026 MCQs: Board Review Questions & Answers (Part 1)

Key Takeaway

Orthopedic Foot & Ankle 2026 MCQs: Board Review Questions & Answers (Part 1)

Chapter Index