Orthopedic Foot & Ankle 2026 MCQs: Part 4 Review

Question 1

A 50-year-old woman who underwent a joint replacement of the hallux metatarsophalangeal joint 6 months ago now has pain and swelling about the great toe. Radiographs are shown in Figures 39a and 39b. What is the next most appropriate step in management?

Explanation

39b The radiographs show displacement of the prosthesis, and there has been large amounts of bone resected to insert the implant. Arthrodesis is indicated with interposition bone graft to stabilize the joint and restore length to the first ray.

Question 2

What is the most common foot and ankle deformity in patients with arthrogryposis?

Explanation

Clubfoot (talipes equinovarus) in patients with arthrogryposis is a rigid and resistant deformity. However, multiple studies document limited success with nonsurgical management. Manipulation and casting are generally a preliminary treatment before surgery; successful correction will most like require a talectomy. Guidera KJ, Drennan JC: Foot and ankle deformities in arthrogryposis multiplex congenita. Clin Orthop 1985;194:93-98. Handelsman JE, Badalamente MA: Neuromuscular studies in clubfoot. J Pediatr Orthop 1981;1:23-32.

Question 3

A 16-year-old girl has had pain and swelling along the medial arch of her left foot for the past 3 months. She also reports pain from shoe wear and while running. Nonsteroidal anti-inflammatory drugs have failed to provide relief. Radiographs are shown in Figures 40a through 40c. What is the next most appropriate step in management?

Explanation

40b 40c Nonsurgical management of a symptomatic accessory navicular should be attempted prior to surgery. Good relief is often obtained with a semi-rigid orthosis with a medial arch support. Myerson MS: Foot and Ankle Disorders. Philadelphia, PA, WB Saunders, 2000, p 655.

Question 4

A 28-year-old man was shot in the foot with a .22 caliber handgun approximately 2 hours ago. Examination reveals an entrance wound dorsally and a plantar exit wound. The foot is neurovascularly intact. Radiographs reveal a nondisplaced fracture of the third metatarsal. Soft-tissue management for this injury should consist of

Explanation

The patient has sustained a low-velocity, low-caliber gunshot wound to the foot. Because the injury occurred within a period of 8 hours, this is classified as a type I wound. Several studies support the use of surface debridement, cleansing, and sterile dressings as the treatment of choice. More aggressive measures are reserved for high-velocity injuries and shotgun injuries. Brettler D, Sedlin ED, Mendes DG: Conservative treatment of low velocity gunshot wounds. Clin Orthop 1979;140:26-31. Hampton OD: The indications for debridement of gunshot bullet wounds of the extremities in civilian practice. J Trauma 1961;1:368-372.

Question 5

The photomicrograph seen in Figure 41 shows which of the following conditions?

Explanation

The photomicrograph shows a synovial cell sarcoma with a characteristic histology of a biphasic pattern of pleomorphic spindle cells and well-differentiated cuboidal to columnar cells forming gland-like spaces. The glandular zones contain mucous-like material that stains positively with periodic acid Schiff. Microscopic calcifications are usually found. Synovial cell sarcoma has a high rate of local recurrence as well as metastases. It is the most common malignancy found in the foot. Krall RA, Kostianovsky M, Patchefsky AS: Synovial sarcoma: A clinical, pathological and ultrastructural study of 26 cases supporting the recognition of a monophasic variant. Am J Surg Pathol 1981;5:137-151.

Question 6

A 33-year-old man had his foot run over by a forklift 1 hour ago. Examination reveals that the head of the fifth metatarsal is extruded through the plantar aspect of the foot. The foot is severely swollen and pale, there is no sensation in the toes, and the pulses are not palpable. Radiographs are shown in Figures 42a and 42b. Emergent management should consist of

Explanation

42b Following a severe crush injury, the patient has an acute compartment syndrome. Even though there is an open fracture, this is not sufficient to decompress the compartment syndrome. Therefore, splinting and observation are not appropriate. The surgical treatment of choice is fasciotomy with fixation of the multiple fractures. A primary amputation is not indicated because there is potential for salvage of this devastating injury. Fakhouri AJ, Manoli A II: Acute foot compartment syndromes. J Orthop Trauma 1992;6:223-228. Myerson MS: Management of compartment syndromes of the foot. Clin Orthop 1991;271:239-248.

Question 7

A 2-year-old boy has been referred for musculoskeletal evaluation. Examination reveals shortened proximal limbs, hip and knee flexion contractures, an abducted thumb, and ear abnormalities. His parents are concerned about his deformed feet. What is the most common foot deformity associated with this patient's diagnosis?

Explanation

The patient has diastrophic dysplasia. Affected individuals have rhizomelic short stature, cauliflower ears, severe joint contractures (especially knees and hips), hitchhiker's thumb, and a cleft palate. The most common foot abnormality is a rigid equinovarus deformity. Surgical results are poorer than those for idiopathic clubfeet and often require bony procedures or talectomy. Ryoppy S, Poussa M, Merikanto J, Marttinen E, Kaitila I: Foot deformities in diastrophic dysplasia: An analysis of 102 patients. J Bone Joint Surg Br 1992;74:441-444.

Question 8

A 31-year-old woman has a history of a painful ankle that has failed to respond to conservative management. She has associated night pain that is relieved with nonsteroidal anti-inflammatory drugs. MRI and technetium Tc 99m scans are consistent with an osteoid osteoma. Management should now consist of

Explanation

Surgical curettage or en bloc resection is the treatment of choice for osteoid osteoma. Night pain and relief of symptoms with nonsteroidal anti-inflammatory drugs are classic findings for osteoid osteoma. Donley BG, Philbin T, Rosenberg GA, Schils JP, Recht M: Percutaneous CT guided resection of osteoid osteoma of the tibial plafond. Foot Ankle Int 2000;21:596-598. Kenzora JE, Abrams RC: Problems encountered in the diagnosis and treatment of osteoid osteoma of the talus. Foot Ankle 1981;2:172-178.

Question 9

A 13-year-old girl has had pain in her ankle and difficulty with sporting activities for the past 6 months. Nonsteroidal anti-inflammatory drugs and use of a short leg cast have provided minimal relief. A radiograph and MRI scan are shown in Figures 43a and 43b. What is the next most appropriate step in treatment?

Explanation

43b The MRI scan shows an obvious talocalcaneal coalition of the medial facet. Because nonsurgical management has failed, surgical resection of the coalition is indicated. Arthrodesis would be indicated only if resection fails to relieve pain or if advanced degeneration of the hindfoot joints is present. McCormack TJ, Olney B, Asher M: Talocalcaneal coalition resection: A 10-year follow-up. J Pediatr Orthop 1997;17:13-15.

Question 10

A 16-year-old female dancer has persistent posterior ankle pain, particularly after a vigorous dancing schedule. Examination reveals tenderness both posteromedially and posterolaterally. MRI scans are seen in Figures 44a and 44b. What is the most likely diagnosis?

Explanation

44b Posterior ankle impingement or os trigonum syndrome is well described in dancers, and it is often associated with flexor hallucis longus tendinitis. High-quality MRI imaging will reveal the inflammation about the os trigonum and flexor hallucis longus tendinitis. Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont IL, American Academy of Orthopaedic Surgeons, 1998, pp 315-332.

Question 11

Which of the following nerves is most commonly injured during ankle arthroscopy?

Explanation

The superficial peroneal nerve, which is adjacent to the location of the lateral arthroscopic portal is most commonly injured. Ferkel RD, Heath DD, Guhl JF: Neurological complications of ankle arthroscopy. Arthroscopy 1996;12:200-208.

Question 12

An obese 56-year-old woman with hypertension has had posterior heel pain for the past 6 months. She also notes some enlargement over the posterior aspect of the heel. Examination reproduces pain with palpation at the insertion of the Achilles tendon. A lateral radiograph is shown in Figure 45. What is the most likely diagnosis?

Explanation

The lateral radiograph shows a traction spur consistent with tendinopathy of the Achilles tendon. There is no displacement of the spur to suggest a rupture of the Achilles tendon, and os trigonum is not seen on the radiograph. The examination findings are not consistent with nerve entrapment. Schepsis AA, Wagner C, Leach RE: Surgical management of Achilles tendon overuse injuries: A long-term follow-up study. Am J Sports Med 1994;22:611-619.

Question 13

A 42-year-old woman has a history of nontraumatic ankle swelling with tenderness over the Achilles tendon and plantar fascia. She reports that while vacationing in Connecticut 2 months ago she noted the presence of a "red bull's eye" rash. Management should consist of

Explanation

The most likely diagnosis is Lyme disease because of the patient's recent vacation in an area with a high risk of exposure. The most effective treatment is doxycycline. Neu HC: A perspective on therapy of Lyme infection. Ann NY Acad Sci 1988;539:314-316.

Question 14

A 50-year-old woman has a painful hallux valgus and a painful callus beneath the second metatarsal head. A radiograph is shown in Figure 46. To correct these problems, treatment of the great toe deformity should consist of

Explanation

The patient has a significant hallux valgus and instability of the first ray, causing transfer metatarsalgia to the second metatarsal head. Therefore, the best procedure is fusion of the metatarsal cuneiform joint with soft-tissue realignment of the first metatarsophalangeal joint. This procedure provides the best chance of relieving symptoms under the second metatarsal head, as well as correcting the hallux valgus.

Question 15

The lower extremity motor dysfunction in Charcot-Marie-Tooth disease most commonly involves which of the following muscles?

Explanation

The motor dysfunction in Charcot-Marie-Tooth disease involves the tibialis anterior muscle. Charcot-Marie-Tooth disorders most commonly cause distal motor dysfunction in the foot intrinsics, anterior compartment musculature, and peroneals. There is evidence that the peroneus brevis is affected selectively and the peroneus longus is spared. This is based on clinical muscle testing, muscle cross-sections on MRI, and electrodiagnostic testing. Mann RA, Missirian J: Pathophysiology of Charcot-Marie-Tooth disease. Clin Orthop 1988;234:221-228.

Question 16

Fixed hyperextension of the metatarsophalangeal joint is associated with

Explanation

Claw toe and hammer toe deformities are associated with dorsal subluxation of the interossei, which can no longer serve to flex the metatarsophalangeal joint. The extensor digitorum longus then loses its tenodesing effect on the proximal interphalangeal and distal interphalangeal joints and works unopposed to extend the metatarsophalangeal joint and the proximal phalanx. Without the antagonistic action of the extensor digitorum longus, the extrinsic flexors become unopposed flexors of the proximal and distal interphalangeal joints. Marks RM: Anatomy and pathophysiology of lesser toe deformities. Foot Ankle Clin 1998;3:199-213.

Question 17

The orthosis shown in Figure 47 is commonly used for

Explanation

The orthosis shown is a carbon reinforced Morton's extension, and it is commonly used for hallux rigidus. It decreases motion of the first metatarsophalangeal joint and subsequently decreases pain.

Question 18

A 14-year-old boy has medial ankle pain, progressive unilateral flatfoot deformity, and pain with most activities of daily living. He denies any recent injury. His parents recall that at age 7 years he sustained an injury that was treated as a sprain. Examination reveals valgus deformity with painless, unrestricted passive motion of the ankle. He has grossly equal limb lengths. A radiograph of the affected ankle is shown in Figure 48a, and the contralateral ankle is shown in Figure 48b. Management should consist of

Explanation

48b Angular deformities of the ankle can occur following physeal injury. While an orthosis may be beneficial, the deformity is at the level of the ankle rather than the hindfoot. An epiphysiodesis or physeal bar resection would not be indicated as the growth plates are closed. Correction of the angular deformity should level the ankle joint and normalize the weight-bearing stresses on the ankle. This is most easily achieved with a closing wedge distal tibial osteotomy with or without concomitant osteotomy of the fibula. Thompson DM, Calhoun JH: Advanced techniques in foot and ankle reconstruction. Foot Ankle Clin 2000;5:417-442. Ting AJ, Tarr RR, Sarmiento A, Wagner K, Resnick C: The role of subtalar motion and ankle contact pressure changes from angular deformities of the tibia. Foot Ankle 1987;7:290-299.

Question 19

What is the most common organism found following a nail puncture wound through tennis shoes in a host without immunocompromise?

Explanation

The association of a nail puncture wound with a gram-negative infection (Pseudomonas aeruginosa) has been attributed to the local environmental factors in shoes. Osteomyelitis is rare, occurring only in about 1% of patients. Tetanus prophylaxis should be given if it is not up to date. While the remaining organisms listed are periodically involved, they are more common in patients who are immunocompromised or who have diabetes mellitus. Therefore, obtaining a culture of the infected wound is appropriate in such individuals because of the multifactorial nature of the infection. Green NE, Bruno J III: Pseudomonas infections of the foot after puncture wounds. South Med J 1980;73:146-149.

Question 20

Examination of a 28-year-old woman reveals a moderate hallux valgus deformity and a prominence of the medial eminence. She reports that she can participate in all activities, wear 3-inch heels with minimal discomfort, and walk in a 1-inch heel with no pain. However, she is concerned that the deformity will get worse and requests recommendations regarding surgical correction. What is the best course of action?

Explanation

Because the patient is essentially asymptomatic, the most appropriate course of action is observation. Prophylactic hallux valgus surgery is not medically indicated. Steroid injection would only risk infection, as well as joint and capsule damage. There are no data to support the use of a custom orthosis to delay the progression of a hallux valgus deformity. Special shoe wear or an extra-depth shoe is not necessary and is unlikely to be accepted by the patient. Donley BG, Tisdel CL, Sferra JJ, Hall JO: Diagnosing and treating hallux valgus: A conservative approach for a common problem. Cleve Clin J Med 1997;64:469-474.

Question 21

A 25-year-old man has ankle instability and a lateral foot callosity. Radiographs are shown in Figures 49a through 49c. Management options are best determined by the

Explanation

49b 49c The patient has a cavovarus deformity that has resulted in lateral foot overload and stressing of the lateral ligaments. Further treatment depends on the ability to correct the deformity. The Coleman block test indicates whether a deformity is fixed or supple. A supple deformity will respond to orthotic management or soft-tissue procedures, while a fixed deformity requires corrective osteotomy or fusion. Physical therapy, casting, and injection will not address the underlying pathophysiology. There is no indication that this is a neuropathic problem.

Question 22

A 17-year-old boy underwent open reduction and internal fixation of a navicular fracture 5 days ago. A follow-up examination now reveals a tensely swollen foot with erythema and multiple skin bullae. The patient is febrile and has marked pain with palpation of the entire forefoot and hindfoot. What is the next step in management?

Explanation

Necrotizing fasciitis is a rapidly progressive soft-tissue infection with the potential to threaten both life and limb. Patients who are immunocompromised (HIV infection, diabetes mellitus, alcohol abuse) are at increased risk. However, any patient in the immediate postoperative phase is susceptible to wound infection. Early detection is the key. Necrotizing fasciitis is primarily a surgical problem that requires urgent debridement and broad-spectrum IV antibiotics. Rapid diagnosis and prompt treatment help to reduce mortality, which may approach 30%. Debridement of the bullae and observation are not indicated. Although elevation and close follow-up may be warranted early on, in this patient, surgical debridement is the next step. Ault MJ, Geiderman J, Sokolov R: Rapid identification of group A streptococcus as the cause of necrotizing fasciitis. Ann Emerg Med 1996;28:227-230.

Question 23

A 14-year-old girl has had mild pain and nail deformity of the great toe for the past 4 months. A radiograph is shown in Figure 50. What is the most likely etiology of the lesion?

Explanation

The lesion is typical of a subungual exostosis, which is most often found on the medial aspect of the great toe in children and young adults. The diagnosis is confirmed on radiographs and usually requires excision for relief. Lokiec F, Ezra E, Krasin E, Keret D, Wientraub S: A simple and efficient surgical technique for subungual exostosis. J Pediatr Orthop 2001;21:76-79. Letts M, Davidson D, Nizalik E: Subungual exostosis: Diagnosis and treatment in children. J Trauma 1998;44:346-349.

Question 24

The third plantar intrinsic muscle layer of the foot consists of which of the following structures?

Explanation

The plantar intrinsic muscles are divided into four layers with respect to depth from the plantar fascia. They are (from superficial to deep): 1) abductor hallucis, flexor digitorum brevis, abductor digiti minimi; 2) quadratus plantae, lumbricals; 3) flexor digiti minimi, flexor hallucis brevis, adductor hallucis brevis; and 4) dorsal and plantar interosseous muscles. The flexor hallucis brevis and adductor hallucis brevis originate from the midtarsal bones, encompass the sesamoids, and insert into the base of the proximal phalanx. The adductor hallucis brevis consists of two muscle bellies forming a conjoined tendon and inserting into the lateral portion of the proximal phalanx and the lateral sesamoid. The adductor hallucis brevis is stronger than the abductor hallucis brevis, which may contribute to hallux valgus. The flexor digitorum minimi travels under the fifth metatarsal, arising at the base and inserting into the lateral base of the fifth proximal phalanx.

Question 25

Which of the following results cannot be achieved with an in-shoe orthosis?

Explanation

Depending on the type of materials used, an orthotic can be fabricated to achieve a variety of results. While a rigid fixed deformity can be stabilized or cushioned, an orthotic will not correct a deformity that is not passively correctable. Mizel MS, Miller RA, Scioli MW (eds): Orthopaedic Knowledge Update: Foot and Ankle 2. Rosemont, IL, American Academy of Orthopaedic Surgeons, 1998, pp 55-64. Bono CM, Berberian WS: Orthotic devices: Degenerative disorders of the foot and ankle. Foot Ankle Clin 2001;6:329-340.

Question 26

A 55-year-old woman presents with progressive medial ankle pain and the inability to perform a single-leg heel raise. Examination reveals a flexible hindfoot valgus and severe forefoot abduction. Radiographs show greater than 40% talonavicular uncoverage. What is the most appropriate surgical management for this stage IIb adult-acquired flatfoot deformity?

Explanation

Stage IIb posterior tibial tendon dysfunction involves flexible hindfoot valgus with significant forefoot abduction (>40% talonavicular uncoverage). Surgical correction requires an FDL transfer, medial displacement calcaneal osteotomy, and a lateral column lengthening to correct the forefoot abduction.

Question 27

A 35-year-old man undergoes acute repair of an Achilles tendon rupture. What is the most significant advantage of early functional rehabilitation compared to prolonged immobilization?

Explanation

Early functional rehabilitation after Achilles tendon repair allows for improved functional outcomes, earlier return to work, and improved patient satisfaction without significantly increasing the re-rupture rate.

Question 28

A 24-year-old athlete sustains an external rotation injury to the ankle. Weight-bearing radiographs are normal. MRI shows a partial tear of the anterior inferior tibiofibular ligament (AITFL). What is the next most appropriate step in management?

Explanation

Stable syndesmotic injuries (without diastasis on stress or weight-bearing radiographs) are treated nonoperatively with a period of immobilization followed by progressive rehabilitation. Operative fixation is reserved for unstable injuries.

Question 29

A 14-year-old boy presents with a painful, rigid flatfoot and a history of recurrent ankle sprains. Radiographs demonstrate a "C-sign". What is the most likely diagnosis?

Explanation

The C-sign on a lateral radiograph is formed by the medial outline of the talar dome and the posterior outline of the sustentaculum tali, strongly indicating a talocalcaneal (subtalar) coalition.

Question 30

A 28-year-old equestrian falls from a horse, catching her foot in the stirrup. She has midfoot pain and plantar ecchymosis. Radiographs show widening of the space between the first and second metatarsal bases. What is the primary stabilizing structure of this joint?

Explanation

The Lisfranc ligament is a strong plantar interosseous ligament extending from the medial cuneiform to the base of the second metatarsal, providing critical stability to the midfoot.

Question 31

A 55-year-old woman has a painful bunion. Radiographs reveal a hallux valgus angle of 45 degrees and an intermetatarsal angle of 18 degrees. There is clinically evident hypermobility at the first tarsometatarsal joint. Which procedure is most appropriate?

Explanation

A Lapidus procedure is indicated for severe hallux valgus combined with first tarsometatarsal joint hypermobility. It corrects the deformity and provides stabilization of the medial column.

Question 32

A 60-year-old woman presents with medial ankle pain and a progressive flatfoot. She can perform a single-limb heel rise but it is weak and painful. The deformity is fully correctable passively. Which surgical intervention is most appropriate if conservative measures fail?

Explanation

Stage II adult-acquired flatfoot deformity is characterized by a flexible deformity. The standard surgical treatment includes a medializing calcaneal osteotomy and FDL transfer to the navicular.

Question 33

A 22-year-old man with Charcot-Marie-Tooth disease presents with a symptomatic bilateral cavovarus foot deformity. A Coleman block test normalizes the hindfoot varus. What does this test indicate?

Explanation

The Coleman block test evaluates hindfoot flexibility. If hindfoot varus corrects when the first ray drops off the block, the varus is flexible and driven by a plantarflexed first ray.

Question 34

A 30-year-old man sustains a Hawkins Type III talar neck fracture following a motor vehicle accident. What is the approximate rate of avascular necrosis (AVN) of the talar body associated with this injury?

Explanation

Hawkins Type III talar neck fractures disrupt the three major blood supplies to the talus, carrying an AVN rate of approximately 75-100%.

Question 35

A 45-year-old man undergoes an extensile lateral approach for open reduction and internal fixation of a displaced intra-articular calcaneus fracture. What is the most common complication of this specific surgical approach?

Explanation

The extensile lateral approach to the calcaneus has a high rate of wound healing complications and dehiscence due to the tenuous vascular supply of the lateral skin flap.

Question 36

A 21-year-old football player sustains a hyperextension injury to his first metatarsophalangeal (MTP) joint. MRI demonstrates a complete tear of the plantar plate with proximal retraction of the sesamoids. What is the most appropriate treatment?

Explanation

A complete rupture of the plantar plate with sesamoid retraction in a competitive athlete requires primary surgical repair to restore push-off strength and joint stability.

Question 37

A 28-year-old woman has persistent anterolateral ankle pain after a severe sprain 6 months ago. MRI shows a 12-mm osteochondral lesion of the anterolateral talar dome with intact cartilage but subchondral cystic changes. After failed conservative treatment, what is the best surgical option?

Explanation

Arthroscopic microfracture is the standard initial surgical treatment for symptomatic, small to medium-sized (<1.5 cm diameter) osteochondral lesions of the talus.

Question 38

A 65-year-old man with a BMI of 25 presents with end-stage post-traumatic ankle osteoarthritis. He has minimal deformity and well-preserved subtalar joint motion. He wishes to maintain mobility for walking and golfing. What is the most appropriate surgical treatment?

Explanation

Total ankle arthroplasty is an excellent option for older, non-obese patients with end-stage ankle arthritis, minimal deformity, and a desire to preserve motion for low-impact activities.

Question 39

A 40-year-old woman complains of burning pain in the plantar aspect of her forefoot, radiating into the third and fourth toes. Symptoms worsen with tight shoes. A Mulder's click is positive. The affected nerve is typically formed by branches from which two nerves?

Explanation

Morton's neuroma most commonly affects the third web space. The third common digital nerve is typically formed by communicating branches from both the medial and lateral plantar nerves.

Question 40

A 50-year-old runner has chronic posterior heel pain exacerbated by running. Examination reveals a prominent posterosuperior calcaneal tuberosity and pain at the Achilles insertion. MRI shows tendinosis involving 60% of the tendon width. Operative intervention is planned. What must be included in the procedure?

Explanation

For severe insertional Achilles tendinosis with a Haglund's deformity, treatment requires excision of the prominent bone (ostectomy), debridement of the diseased tendon, and reattachment if >50% of the tendon is detached.

Question 41

A 58-year-old man presents with pain and stiffness in his right great toe. Examination shows restricted dorsiflexion with a palpable dorsal exostosis. Radiographs show joint space narrowing primarily in the dorsal half and a large dorsal osteophyte (Grade 2). He wants to preserve joint motion. What is the most appropriate surgery?

Explanation

A cheilectomy (removal of the dorsal osteophyte and the dorsal third of the metatarsal head) is indicated for mild to moderate hallux rigidus (Grades 1 and 2) in patients who wish to preserve motion.

Question 42

A 25-year-old professional basketball player complains of lateral foot pain for 4 weeks. Radiographs show a transverse fracture at the metaphyseal-diaphyseal junction of the fifth metatarsal with intramedullary sclerosis. What is the most appropriate treatment?

Explanation

This is a Jones fracture with signs of delayed union (intramedullary sclerosis) in an elite athlete. Intramedullary screw fixation is recommended to ensure healing and expedite return to play.

Question 43

A 20-year-old track athlete has vague midfoot pain for 3 months. Plain radiographs are normal. MRI confirms a non-displaced navicular stress fracture in the middle third of the bone. What is the initial recommended treatment?

Explanation

Uncomplicated, non-displaced navicular stress fractures are initially treated with strict non-weight-bearing immobilization in a cast for 6 to 8 weeks due to the high risk of nonunion from the avascular central third.

Question 44

A 55-year-old patient with poorly controlled diabetes presents with a red, hot, swollen foot. Radiographs show fragmentation, periarticular debris, and subluxation at the tarsometatarsal joints. There are no ulcers. What is the most appropriate initial management?

Explanation

This patient is in the acute fragmentation phase (Eichenholtz stage I) of Charcot arthropathy. The mainstay of initial treatment is total contact casting and offloading to prevent further deformity.

Question 45

A 48-year-old overweight man has classic plantar fasciitis symptoms for 12 months that have failed nonoperative management. He elects to proceed with surgery. Which specific structure must be protected during a plantar fascia release?

Explanation

The first branch of the lateral plantar nerve (Baxter's nerve) courses deep to the abductor hallucis and is at risk during plantar fascial release. Entrapment of this nerve can also be a concurrent cause of heel pain.

Question 46

A 55-year-old woman with a progressive flatfoot deformity complains of medial ankle pain and an inability to perform a single-limb heel rise. Weight-bearing radiographs show >30% uncovering of the talonavicular joint. What is the most appropriate surgical management?

Explanation

Stage IIb adult acquired flatfoot deformity is characterized by >30% forefoot abduction (talonavicular uncovering). Management requires a lateral column lengthening in addition to MDCO and FDL transfer to correct the abduction.

Question 47

A 25-year-old man presents with midfoot pain after a twisting injury. Weight-bearing radiographs reveal a 3 mm diastasis between the base of the first and second metatarsals without any fractures. What is the most appropriate management?

Explanation

Purely ligamentous Lisfranc injuries have poor healing potential and high rates of post-traumatic arthritis. Primary arthrodesis of the medial column (1st, 2nd, and 3rd TMT joints) is associated with better functional outcomes than ORIF in purely ligamentous injuries.

Question 48

A 45-year-old female presents with a painful bunion. Clinical exam reveals severe hallux valgus and first ray hypermobility. Radiographs show a hallux valgus angle of 45 degrees and an intermetatarsal angle of 18 degrees. What is the most appropriate surgical management?

Explanation

The Lapidus procedure (first TMT arthrodesis) is indicated for severe hallux valgus with first ray hypermobility. It provides powerful correction and stabilizes the medial column to prevent recurrence.

Question 49

A 55-year-old male with poorly controlled diabetes presents with a red, hot, swollen right foot for 3 weeks. There is no history of ulceration or open wounds. Radiographs show periarticular debris, fragmentation, and subluxation at the tarsometatarsal joints. What is the most appropriate initial management?

Explanation

This patient has Eichenholtz stage I (fragmentation) Charcot arthropathy. The mainstay of initial treatment is offloading with total contact casting to prevent further deformity until the active inflammatory phase resolves.

Question 50

A 35-year-old male undergoes open reduction and internal fixation of a displaced intra-articular calcaneus fracture via an extensile lateral approach. Which of the following is the most significant modifiable risk factor for wound complications postoperatively?

Explanation

Smoking is the most significant modifiable risk factor for wound healing complications following the extensile lateral approach for calcaneus fractures. Delayed surgery until soft tissue swelling subsides actually decreases wound complication rates.

Question 51

A 28-year-old male sustains a Hawkins type III fracture of the talar neck. Open reduction and internal fixation is performed. Which of the following radiographic signs at 6 to 8 weeks postoperatively indicates intact vascularity to the talar body?

Explanation

Hawkins sign is characterized by subchondral radiolucency of the talar dome on the mortise radiograph at 6-8 weeks. It indicates intact vascularity and active bone resorption, making the development of avascular necrosis unlikely.

Question 52

A 22-year-old male with Charcot-Marie-Tooth disease presents with a progressive bilateral cavovarus foot deformity. The Coleman block test demonstrates that the hindfoot varus corrects to neutral when the first metatarsal is allowed to plantarflex off the block. What does this finding indicate regarding surgical planning?

Explanation

A flexible hindfoot varus that corrects on a Coleman block test indicates the deformity is driven by a rigidly plantarflexed first ray. Treatment should focus on correcting the forefoot with a first metatarsal dorsiflexion osteotomy.

Question 53

A 30-year-old male sustains a purely ligamentous Lisfranc injury. Weight-bearing radiographs show 3 mm of widening between the base of the first and second metatarsals. What is the most appropriate definitive management?

Explanation

Purely ligamentous Lisfranc injuries have a high rate of hardware failure and post-traumatic arthritis with ORIF. Primary arthrodesis of the first, second, and third tarsometatarsal joints yields superior functional outcomes.

Question 54

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

Explanation

Operative management of acute Achilles tendon ruptures has historically been associated with a lower rerupture rate, though it carries a higher risk of soft tissue complications and sural nerve injury.

Question 55

A 20-year-old collegiate basketball player sustains an acute, minimally displaced fracture at the metaphyseal-diaphyseal junction of the fifth metatarsal (Jones fracture). He wishes to return to play as soon as safely possible. What is the recommended treatment?

Explanation

Intramedullary screw fixation is recommended for acute Jones fractures in high-level athletes. It significantly decreases the risk of nonunion and allows for a faster return to play compared to nonoperative management.

Question 56

A 60-year-old male with end-stage post-traumatic ankle osteoarthritis is considering surgical intervention. He has a history of avascular necrosis of the talus with significant collapse. Which procedure is most appropriate?

Explanation

In the presence of significant talar body collapse due to avascular necrosis, total ankle arthroplasty and isolated ankle arthrodesis are contraindicated due to inadequate talar bone stock. A TTC arthrodesis is the appropriate salvage procedure.

Question 57

A 14-year-old boy presents with frequent ankle sprains and a rigid flatfoot. Radiographs show an elongated lateral process of the talus and a prominent "C-sign". What is the most likely diagnosis?

Explanation

A rigid flatfoot and a "C-sign" on the lateral radiograph are pathognomonic for a talocalcaneal coalition. This most commonly affects the middle facet of the subtalar joint.

Question 58

A 55-year-old woman presents with medial ankle pain and a progressively flattening arch. She has a flexible flatfoot, cannot perform a single-leg heel rise, and has tenderness over the posterior tibial tendon. Nonoperative management has failed. What is the most appropriate surgical procedure?

Explanation

This patient has Stage II (flexible) adult-acquired flatfoot deformity. The standard joint-sparing surgical treatment utilizes an FDL transfer and a medial displacement calcaneal osteotomy (MDCO) to restore the arch.

Question 59

A 25-year-old male undergoes arthroscopic evaluation for an osteochondral lesion of the medial talar dome. The lesion is 12 mm x 10 mm. The articular cartilage is completely intact but soft upon probing. What is the recommended treatment?

Explanation

For a relatively small osteochondral lesion of the talus with an intact cartilaginous surface, retrograde drilling is indicated. It promotes subchondral bone healing without violating the native articular cartilage.

Question 60

A 60-year-old man presents with pain and stiffness in his right great toe, especially with push-off. Radiographs show dorsal osteophytes and joint space narrowing of the first metatarsophalangeal joint, but the plantar joint space is well preserved. He desires to maintain motion. What is the most appropriate surgical option?

Explanation

For mild to moderate hallux rigidus with preserved plantar joint space, a cheilectomy is highly effective. Removing the dorsal osteophytes and the dorsal one-third of the metatarsal head relieves impingement while preserving motion.

Question 61

A 26-year-old professional athlete sustains an external rotation injury to his ankle. Intraoperative stress testing confirms syndesmotic instability after fixing the associated fibula fracture. Which syndesmotic fixation strategy has been shown to allow the most physiologic motion?

Explanation

Flexible fixation with a suture button construct allows for more physiologic motion of the syndesmosis. It reduces the risk of hardware breakage and often eliminates the need for routine hardware removal.

Question 62

A 15-year-old female dancer presents with insidious onset of pain in her forefoot. Examination reveals localized swelling and tenderness over the second metatarsophalangeal joint. Radiographs show flattening and sclerosis of the second metatarsal head. What is the most likely diagnosis?

Explanation

Freiberg's infraction is avascular necrosis of the metatarsal head, most commonly affecting the second metatarsal in adolescent females. Radiographs typically demonstrate flattening, sclerosis, and fragmentation.

Question 63

A 55-year-old female presents with progressive flattening of her left foot, pain along the medial ankle, and an inability to perform a single-leg heel raise. Examination reveals abduction of the forefoot with 'too many toes' visible from behind. Weight-bearing radiographs show significant uncovering of the talonavicular joint. What is the most appropriate surgical management?

Explanation

This patient has Stage IIb adult-acquired flatfoot deformity characterized by flexible hindfoot valgus and significant forefoot abduction. Surgical reconstruction requires addressing the medial tendon dysfunction and correcting both hindfoot valgus and forefoot abduction using an FDL transfer, medial calcaneal osteotomy, and a lateral column lengthening procedure.

Question 64

A 32-year-old man sustains a Hawkins type III talar neck fracture. Radiographs at 8 weeks post-ORIF show a subchondral lucency in the talar dome. What does this radiographic finding indicate?

Explanation

The Hawkins sign is a subchondral radiolucent band in the talar dome typically seen 6-8 weeks post-injury. It indicates intact vascularity and active bone resorption, demonstrating that the talar body is viable and not undergoing avascular necrosis.

Question 65

A 45-year-old runner presents with chronic, aching heel pain that is worse at the end of the day. Examination reveals maximal tenderness over the medial calcaneal tuberosity and an inability to abduct the fifth toe. Compression of which of the following nerves is the most likely cause?

Explanation

Baxter's nerve is the first branch of the lateral plantar nerve and provides motor innervation to the abductor digiti minimi. Entrapment commonly causes chronic heel pain and weakness in abducting the fifth toe, mimicking plantar fasciitis.

Question 66

A 24-year-old elite rugby player presents with midfoot pain after a hyperplantarflexion injury. Weight-bearing radiographs show 3 mm of diastasis between the first and second metatarsal bases without fracture. What is the most appropriate management?

Explanation

Subtle, purely ligamentous Lisfranc injuries with diastasis greater than 2 mm on weight-bearing films in young athletes require surgical stabilization. ORIF or flexible suture-button fixation restores anatomy and stability, whereas nonoperative treatment leads to chronic pain and midfoot collapse.

Question 67

A 65-year-old woman with end-stage ankle osteoarthritis complains of severe pain. She has a history of severe peripheral neuropathy and prior deep infection in the ipsilateral leg. Which of the following is an absolute contraindication to total ankle arthroplasty (TAR) in this patient?

Explanation

Absolute contraindications to total ankle arthroplasty include active infection, severe peripheral neuropathy (e.g., Charcot arthropathy), and absent lower extremity sensation. These conditions significantly increase the risk of implant failure, collapse, and perioperative wound complications.

Question 68

A 28-year-old man with Charcot-Marie-Tooth disease presents with a bilateral cavovarus foot deformity. A Coleman block test is performed and the hindfoot varus corrects to a neutral alignment. What does this finding indicate regarding surgical planning?

Explanation

A flexible hindfoot that corrects to neutral on a Coleman block test indicates that the varus deformity is primarily driven by a rigid, plantarflexed first ray. Surgical reconstruction should focus on a first metatarsal dorsiflexion osteotomy and soft-tissue balancing rather than a rigid hindfoot fusion.

Question 69

A 55-year-old woman undergoes a calcaneal lengthening osteotomy (Evans procedure), FDL transfer, and medial displacement calcaneal osteotomy for Stage IIb adult-acquired flatfoot deformity. Postoperatively, she develops new-onset, deep aching pain over the lateral aspect of the midfoot. What is the most likely cause of this complication?

Explanation

The Evans lateral column lengthening procedure increases joint reactive forces across the calcaneocuboid (CC) joint. This commonly leads to CC joint subluxation or postoperative arthritis, which is a leading cause of lateral midfoot pain after this surgery.

Question 70

A 42-year-old woman presents with symptomatic hallux valgus. Radiographs demonstrate a hallux valgus angle (HVA) of 30 degrees, an intermetatarsal angle (IMA) of 13 degrees, and a distal metatarsal articular angle (DMAA) of 25 degrees. To avoid postoperative hallux valgus recurrence or joint incongruity, which surgical step is essential?

Explanation

An abnormally high DMAA (greater than 15 degrees) indicates an incongruent joint surface orientation. A standard metatarsal osteotomy without addressing the DMAA leaves the articular cartilage laterally deviated, so a biplanar osteotomy is required to rotate the articular surface medially.

Question 71

A 22-year-old collegiate track athlete presents with insidious onset dorsal midfoot pain. A CT scan reveals an incomplete, non-displaced stress fracture of the tarsal navicular involving the dorsal cortex. What is the most appropriate initial management?

Explanation

Non-displaced, incomplete navicular stress fractures are initially treated with strict non-weight-bearing in a cast for 6-8 weeks due to the high risk of nonunion from the avascular central third of the bone. Surgical fixation is reserved for displaced fractures, complete fractures, or symptomatic nonunions.

Question 72

A 26-year-old skier presents with lateral ankle pain and a snapping sensation behind the lateral malleolus when dorsiflexing and everting the foot. MRI confirms an intact superior peroneal retinaculum (SPR) that has avulsed from its fibular insertion, creating a false pouch. What is the most appropriate surgical intervention?

Explanation

The patient has a Grade I peroneal tendon subluxation with an SPR avulsion. The standard of care is deepening of the fibular groove and anatomical repair or reefing of the superior peroneal retinaculum to the periosteum of the posterolateral fibular ridge.

Question 73

When counseling a 35-year-old recreational athlete regarding non-operative versus operative management of an acute Achilles tendon rupture, which of the following statements is most supported by recent level I evidence utilizing early functional rehabilitation?

Explanation

Recent level I trials demonstrate that when early functional rehabilitation (weight-bearing and ROM) is utilized, the re-rupture rates between non-operative and operative management of Achilles ruptures are equivalent. Operative management does, however, carry a higher risk of wound complications and nerve injury.

Question 74

A 56-year-old man with poorly controlled diabetes mellitus presents with a swollen, red, and warm right foot. Radiographs show periarticular fragmentation, bone debris, and subluxation of the midfoot without signs of consolidation. He is afebrile with normal inflammatory markers. What Eichenholtz stage does this represent and what is the best initial treatment?

Explanation

Eichenholtz Stage I (Development/Fragmentation) is characterized by acute inflammation, osteopenia, bone fragmentation, and joint subluxation. The standard initial treatment is strict offloading with a total contact cast to prevent further deformity until the active inflammatory phase resolves.

Question 75

A 25-year-old soccer player has persistent ankle pain following a sprain 1 year ago. MRI demonstrates an osteochondral lesion on the medial talar dome measuring 1.8 square cm. Previous conservative management has failed. Which of the following is the most appropriate surgical management?

Explanation

For large osteochondral lesions of the talus (typically >1.5 square cm) or cystic lesions, simple bone marrow stimulation has high failure rates. Osteochondral autograft transfer (OATS) or fresh allograft is the preferred treatment to restore the structural contour and hyaline cartilage surface.

Question 76

A 40-year-old roofer falls and sustains a closed, displaced, intra-articular joint-depression calcaneus fracture. The surgeon elects to perform an open reduction and internal fixation via an extensile lateral approach. Which of the following vascular structures must be protected within the full-thickness flap?

Explanation

The lateral calcaneal artery provides the primary blood supply to the corner of the skin flap used in the extensile lateral approach to the calcaneus. The flap must be full-thickness, subperiosteal, and handled atraumatically to minimize the high risk of tip necrosis and wound breakdown.

Question 77

A 29-year-old professional football player sustains an ankle fracture-dislocation with a confirmed complete syndesmotic disruption. He is treated with open reduction and flexible suture-button fixation. Compared to traditional rigid screw fixation, what is a recognized advantage of flexible syndesmotic fixation?

Explanation

Flexible suture-button constructs provide sufficient stability while allowing physiologic micro-motion at the syndesmosis during gait. They significantly reduce the need for routine hardware removal and decrease the risk of hardware breakage compared to rigid syndesmotic screws.

Question 78

A 45-year-old woman complains of sharp, burning pain in the ball of her foot radiating into the third and fourth toes. Examination reveals a positive Mulder's click. After failing non-operative management, she is scheduled for surgical excision via a dorsal approach. Which structure must be transected to adequately resect the neuroma?

Explanation

When excising a Morton's neuroma (commonly found in the 3rd intermetatarsal space) through a dorsal approach, the deep transverse metatarsal ligament must be released. This allows adequate visualization and proximal retraction of the nerve to resect it in healthy tissue.

Question 79

A 21-year-old college basketball player sustains an acute fracture of the fifth metatarsal at the metaphyseal-diaphyseal junction (Zone 2) during a game. He wishes to return to play as quickly as possible. What is the recommended treatment?

Explanation

Zone 2 fractures (Jones fractures) have a higher risk of delayed union or nonunion due to a vascular watershed area. In elite or high-demand athletes seeking early return to play, intramedullary screw fixation is recommended to reduce nonunion risk and accelerate functional recovery.

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

Orthopedic Foot & Ankle 2026 MCQs: Board Review Questions & Answers (Part 4)

Key Takeaway

Orthopedic Foot & Ankle 2026 MCQs: Board Review Questions & Answers (Part 4)

Chapter Index