Multiple Choice Questions
Foot & Ankle
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37. This patient is a 17-year-old athlete who presents for treatment of a feeling of giving way of the ankle. The inversion clinical stress is demonstrated below (Slide).
Which statement concerning the image presented below is correct:
A) Ankle instability is present
B) Subtalar instability is present.
C) Ankle and subtalar instability are present.
D) Generalized ligamentous laxity is present.
E) No determination of instability can be made from this picture
36. A 33-year-old recreational athlete presents for treatment of chronic ankle pain. He recalls multiple ankle sprains that occurred 10 years ago. He has not undergone any surgical treatment. On examination, his ankle is stable, there is no crepitus on range of motion, and pain is present to palpation of the posterior ankle. A computerized axial tomography is presented (Slide).
The surgical procedure most consistent with a rapid recovery and predictable outcome is:
A) Ankle arthrodesis
B) Arthroscopy of the ankle with drilling of the osteochondral defect
C) Osteoarticular autograft procedure
D) Cartilage cell harvest with staged debridement of the talus and cartilage cell implantation
E) Osteoarticular allograft procedure
35. A 57-year-old woman presents for treatment of a painful flatfoot deformity. She says that her foot has been painful for 4 years, but she does not recall any injury to the foot. The opposite foot is not bothersome. Upon examination, she has pain in the midfoot and hindfoot. Resisted inversion is strong and painful. She is able to perform a single and repetitive heel rise test.
The most likely diagnosis is:
A) An unrecognized Lisfranc injury
B) Posterior tibial tendon rupture
C) Rupture of the spring ligament
D) Idiopathic tarsometatarsal arthritis
E) Calcaneonavicular tarsal coalition
34. Which of the following structures is disrupted in patients with an acute medial subtalar dislocation:
A) Lisfranc ligament
B) Long plantar ligament C) Talocalcaneal ligament
D) Calcaneonavicular ligament
E) Anterior talofibular ligament
33. A foot is maximally dorsiflexed during this point of the gait cycle:
C) Toe off
E) First one-third of stance
32. A patient sustains a fracture of the anterior process of the calcaneus.
What ligament is responsible for avulsion of this bone:
A) Short plantar
B) Long plantar
C) Anterior talofibular
31. After surgery to the hallux, a patient complains of burning and numbness along the medial aspect of the first metatarsal. The numbness extends from the medial cuneiform distally to the midportion of the first metatarsal and junction of the plantar and dorsal skin.
The nerve involved with the pain is the:
A) Intermediate dorsal cutaneous branch superficial peroneal
B) Medial cutaneous branch deep peroneal
C) Medial cutaneous branch superficial peroneal
D) Dorsal cutaneous branch medial plantar
E) Intermediate cutaneous branch deep peroneal
30. A 65-year-old woman presents for treatment of a painful flatfoot condition. On examination, the hindfoot is in marked valgus and a rupture of the posterior tibial tendon is noted. The recommended treatment is a transfer of the flexor digitorum longus tendon and a medial translational osteotomy of the calcaneus.
The rationale for the osteotomy includes all of the following except:
A) To increase the ground reaction forces medially
B) ) To make the Achilles tendon vector lateral to the axis of the subtalar joint
C) To improve the weight bearing tripod effect of the foot
D) To augment the flexor transfer medially
E) To decrease the valgus force of the gastrocnemius on the hindfoot
29. A 49-year-old woman has had swelling in the posterior aspect of the ankle for 5 years (Slide). The pain is focal and does not radiate. She notes that pain is worse with activity, exercise, and shoe wear. Which of the following is not an acceptable treatment for this patient:
A) Short leg cast immobilization
B) High heel shoe with no heel counter
C) Debridement of the insertion of the Achilles tendon
D) Osteotomy of the calcaneus
E) Achilles stretching exercises and physical therapy modalities including corticosteroid application
28. A 22-year-old collegiate basketball player presents for treatment of a stress fracture of the base of the fifth metatarsal at the junction of the metaphysis and diaphysis. The fracture was treated operatively, and the patient returned to playing basketball. Three months later, it was apparent that a repeat fracture was present. The fracture was treated with screw removal and a repeat screw fixation. Four months later, after a successful basketball season, he sustained a repeat stress fracture of the metatarsal. On examination, he has a mild cavovarus foot configuration with normal ankle range of motion. Inversion is 15° and eversion is 5°. The base of the fifth metatarsal is prominent.
The most likely cause for the repeat fracture is
A) Abnormal ankle biomechanics
B) Chronic unrecognized ankle instability
C) A varus heel
D) Bone sclerosis of the fifth metatarsal base
E) Chronic avascularity of the fifth metatarsal base
27. A 23-year-old man sustains an injury to his foot when falling off a ladder. The foot is grossly twisted inward, and the talonavicular joint is dislocated with the talar head penetrating through the extensor brevis muscle. The dislocation is reduced.
The likelihood of this resulting in avascular necrosis of the talus is:
26. A 43-year-old construction worker sustained a work-related injury to his foot 7 months ago. He was initially treated with cast immobilization and limited weight bearing. He has lateral foot pain and inability to walk comfortably. He has limited walking endurance. Upon examination, pain is present laterally along the course of the peroneal tendons, and no motion of the subtalar joint is present.
The recommendation is:
A) Physical therapy followed by job modification
B) Shoe modification and orthotic support
C) Nonsteroidal medication, and ankle foot orthoses
D) Injection of the peroneal tendons with cortisone
E) Subtalar arthrodesis
25. You are commencing a repair of an acute rupture of the Achilles tendon that occurred 8 days previously in a 32- year-old recreational tennis player. Fibrillation of the tendon ends is noted.
The following is most important to maximize the ultimate outcome of the repair:
A) Resection of the frayed tendon end, and end-to-end apposition
B) Incorporation of the plantaris tendon in the repair
C) Repair of the tendon with the foot in slight equinus
D) Augmentation of the repair with a facial turn down flap
E) Repair with the tendon ends at normal resting tension
24. The nerve most likely to be at risk during surgical exposure when performing a triple arthrodesis is the:
B) Lateral cutaneous branch superficial peroneal
C) Intermediate cutaneous branch superficial peroneal
D) Lateral plantar
E) Dorsalis pedis
23. The radiograph of a 22-year-old woman with ankle pain and instability is presented. She has noted this problem for 10 years, and it appears to be worsening. The opposite ankle is not symptomatic. She has not had any previous treatment for foot or ankle problems.
The cause of this ankle deformity is most likely to be associated with which of the following conditions:
A) Recurrent ankle instability
B) Congenital bimalleolar dysplasia
C) Subtalar fusion
D) Talar growth arrest
E) Fibular hemimelic syndrome
22. A 14-year-old boy presents for treatment of a painful foot, which has been present for 2 years. He has limited his athletic activities. He has similar symptoms in the opposite foot, although not as severe. On clinical examination, the alignment and appearance of the foot are normal; motion of the foot and ankle is good; and some discomfort is present in the sinus tarsi. Standard radiographs, of which the lateral view is presented, include anteroposterior, lateral, and oblique views. Because the diagnosis is unclear, more imaging studies are required.
The next study to obtain is:
A) External oblique views of the foot
B) Axial views of the subtalar joint (Harris)
C) Oblique views of the subtalar joint (Broden)
D) Internal oblique views of the midfoot
E) Inclined views of the talonavicular joint (Canale)
21. A 52-year-old man presents for evaluation and treatment of a painful flatfoot deformity. While playing tennis 2 years ago, he felt a tearing sensation in his foot and ankle. Since that time, he notes that the arch of his foot has become progressively flatter. Upon examination, he has a flatfoot inability to perform a single heel rise and weak inversion strength. He desires to have this deformity corrected. At surgery, the posterior tibial tendon is grossly normal in appearance.
The most likely source of his deformity is:
A) Rupture of the Achilles tendon
B) Rupture of the peroneus longus tendon
C) Rupture of the plantar fascia
D) Rupture of the spring ligament
E) Rupture of the inferolateral long plantar ligament
20. The most common complication of arthrodesis of the proximal interphalangeal (PIP) joint is:
A) Claw toe deformity
B) Mallet toe deformity
C) Hammer toe deformity
D) Curly toe deformity
E) Instability of metatarsophalangeal (MP) joint
19. A 43-year-old woman has had a 2-year history of ankle pain. Her ankle pain is associated with swelling, decreased activities, and limited range of motion. Upon examination, diffuse warmth and swelling of the ankle are noted. Radiographs and a clinical picture are presented.
The most likely diagnosis is:
A) Rheumatoid arthritis
C) Septic arthritis
D) Synovial sarcoma
E) Pigmented villonodular synovitis (PVNS)
18. A patient presents for treatment in your emergency department following an injury that he sustained 4 hours earlier. His foot was run over by a piece of heavy industrial equipment. On examination, he has pain in the foot, a displaced fracture of the second metatarsal, a 3-cm area of severe contusion over the forefoot, and numbness of the dorsal surface of the foot.
The next examination that you recommend is:
A) Measurement of compartment pressures in the foot
B) Magnetic resonance imaging of the tarsometatarsal joint
C) Computerized axial tomography of the midfoot
D) Doppler evaluation of the foot pulses
E) Laser Doppler flowmetry
17. The nerve commonly associated with painful heel syndrome is the:
A) Medial plantar nerve
B) Lateral plantar nerve
C) First branch of the lateral plantar nerve
D) Calcaneal nerve
E) Deep peroneal nerve
16. A 23-year-old woman with juvenile rheumatoid arthritis presents for treatment of painful forefoot deformity. Painful hallux valgus is present and is associated with dislocation of the lesser metatarsophalangeal joints.
The recommended surgical treatment is:
A) Bunionectomy, first metatarsal osteotomy, and arthroplasty of the lesser metatarsophalangeal joints
B) Resection arthroplasty (Keller procedure) of the first metatarsophalangeal joint and arthroplasty of the lesser metatarsophalangeal joints
C) Arthrodesis hallux metatarsophalangeal joint and resection of the lesser metatarsal heads
D) Bunionectomy, first metatarsal osteotomy, and resection of the lesser metatarsal heads
E) Resection of all of the metatarsal heads
15. A 37-year-old construction worker presents for evaluation and treatment of a painful stiff foot. He has noticed the stiffness for approximately 12 years, and particularly feels the stiffness when he is working on uneven ground surfaces. Upon clinical and radiographic examination, he is noted to have a calcaneonavicular coalition without any peritalar arthritis.
Your recommended treatment is:
A) Triple arthrodesis
B) Subtalar arthrodesis
C) Resection of the coalition
D) Calcaneal osteotomy
E) Calcaneocuboid and talonavicular arthrodesis
14. A 13-year-old girl is seen in clinic for bunion. She is asymptomatic but has a hallux valgus angle of 29°, an intermetatarsal angle of 15°, and a medial prominence over the first metatarsal head. The family asks whether anything can be done to prevent future problems with the foot.
A) Osteotomy of the first metatarsal base
B) Hemiepiphyseodesis of the medial physis of the first metatarsal
C) Double osteotomy of the first metatarsal
D) Mitchell osteotomy
E) Shoe modifications if symptoms develop
13. Which of the following conditions is not associated with an increased risk of congenital vertical talus ?
A) Cerebral palsy
D) Nail patella syndrome
E) Larsen syndrome
12. Which of the following conditions is not associated with an increased risk of congenital vertical talus?
A) Sacral agenesis
B) Cerebral palsy
E) Nail patella syndrome
11. Prior to treatment, this pathologic finding characterizes clubfoot:
A) The talar head and neck are deviated medially.
B) The dome of the talus is flattened.
C) The navicular is positioned more laterally than normal.
D) The foot has a rocker deformity.
E) The tendoachilles inserts in a more lateral position than normal.
10. A 15-year-old basketball player has mild scoliosis, pes planus, pectus carinatum, and long slender fingers. In order to determine if he has Marfan syndrome and should be allowed to continue playing basketball.
It is most useful to order a:
A) Cardiac echo
B) Magnetic resonance image of the lumbosacral spine
C) Slit lamp examination
D) Chest radiograph
E) Dermal fibroblast assay
9. Which ancillary test is not helpful in the diagnosis of Charcot-Marie-Tooth disease (CMT):
A) Electromyography (EMG)
B) Nerve conduction velocity (NCV)
C) Nerve biopsy
D) Muscle biopsy
E) Muscle enzymes
8. A 7-year-old boy presents with bilateral high arches. His parents report that they are having difficulty finding shoes that comfortably fit him. The patient denies any foot pain. The father had similar problems with his feet and was diagnosed with a “mild” neurologic condition. On exam, the child has bilateral pes cavus with a supple hindfoot.
Treatment of the feet at this time should consist of:
A) Soft tissue procedures alone
B) Soft tissue procedures and calcaneal osteotomy
C) Triple arthrodesis
7. The most common cause of an indirect injury to the Lisfranc joint occurs through which mechanism:
C) Axial load of a plantarflexed foot
D) Supination and external rotation
E) Pronation and adduction
6. Initial management of a symptomatic Haglund’s deformity in a runner consists of:
A) Intratendinous steroid injection
B) Debridement of the tendon
C) Excision of the posterosuperior calcaneal prominence
D) Heel lift and soft shoe counter
E) A firm heel counter and medial heel wedge
5. The extensor hallucis longus muscle is innervated by which of the following nerve roots:
4. The skin on the medial aspect of the leg and great toe is innervated by which of the following nerve roots:
3. A 46y old man fell 20 feet and sustained the injury shown in the figure attached. The injury is closed; however, the soft tissues are swollen and ecchymotic with blisters.
The most appropriate initial management should consist of
A) long leg cast.
B) a short leg cast.
C) immediate open reduction and internal fi xation.
D) a temporizing spanning external fi xator.
E) primary ankle fusion.
2. 36y woman sustained a tarsometatarsal joint fracture-dislocation in a motor vehicle accident. The patient is treated with ORIF.
What is the most common complication?
A) Posttraumatic arthritis
C) Fixation failure
1. A 50-year-old patient presents with a 2 month history of midfoot pain after a twisting injury to their foot, which has now been diagnosed as a late Lisfranc injury.
Which of the following is TRUE about tarsometatarsal arthrodesis in this situation?
A) It is best performed across all tarso-metatarsal joints
B) It is a good option in late diagnosis of this injury
C) It will allow this patient to mobilise fully weight bearing from day one post-surgery
D) It is best performed through a lateral approach
E) It is part of the ‘Triple arthrodesis’ procedure