Multiple Choice Questions

Foot & Ankle

Test your knowledge , learn more and get ready for your orthopaedic exam

 61. A 59 year old man has a 3 year history of increased pain in his right foot with deformity. Examination reveals hindfoot fixed valgus of 15 degrees with midfoot abduction. He has tried nonsurgical treatment without relief. Which of the following would be the most appropriate surgical management?

A) Medial sliding os calcis osteotomy
B) Subtalar arthrodesis
C) Talonavicular arthrodesis
D) Subtalar arthrodesis with FDL transfer
E) Triple arthrodesis

Correct Answer : E

The most appropriate surgical treatment for stage III would triple arthrodesis.

Adult Acquired Flatfoot Deformity (AAFD) grading is by the Johnson and Strom classification system, which has classification grades of I to III. Myerson added a fourth grade in 1997. The classification system aids practitioners in identifying AAFD severity and also can guide treatment plans.

Stage I disease characteristically presents with posterior tibial tendon tenosynovitis with no arch collapse – Conservative with AFO +/- Tenosynovectomy
Stage II have flexible hindfoot, foot collapse and will be unable to perform a single-leg heel rise. This stage further subcategorizes into stage IIa and IIb. Stage IIa is foot collapse with valgus deformity of the hindfoot but no midfoot abduction, while in stage IIb midfoot abduction is present – Treatment with FDL transfer, calcaneal osteotomy, TAL, ± forefoot correction osteotomy ± spring ligament repair ± lateral column lengthening ± medial column arthrodesis ± PTT debridement
Stage III will have fixed deformity with hindfoot valgus and forefoot abduction.
Stage IV deformity will have ankle valgus secondary to deltoid ligament attenuation – triple arthrodesis and TAL + deltoid ligament reconstruction OR tibiotalocalcaneal arthrodesis (depending on flexibility of valgus ankle deformity)

Author : Firas Arnaout

 60. A 45-year-old manual worker presents with pain and resisted extension of the big toe. Plain radiograph shows a prominent dorsal osteophyte and early OA changes. Conservative management has failed.

What operative intervention would you suggest?

A) Cheilectomy
B) Chevron osteotomy
C) First MTPJ arthrodesis incorrect option
D) First MTPJ replacement
E) Lapidus

Correct Answer : A

Cheilectomy (first metatarsal osteotomy) for treatment of hallux rigidus will relieve dorsal impingement that is usually the source of pain in patients with this condition. Cheilectomy is recommended for mild to moderate deformity, that is, Grade1-2 and some 3s.

Arthrodesis is treatment of choice following failed cheilectomy or where advanced degenerative changes are present such as Grade 4 hallux rigidus and Grade 3 where <50% of the metatarsal head cartilage remains at the time of surgery.

Patients can also try non-operative options such as moulded shoe inserts or rocker bottom shoes.

Author : Firas Arnaout

 59. what is the mechanism of injury for ankle sprain:

A) plantarflexion and inversion
B) dorsiflexion and eversion
C) dorsiflexion
D) inversion
E) plantarflexion

Correct Answer : A

Lateral ligaments are commonly injured as compared to stronger deltoid ligament on medial side.

Author : Dr.Smita Patil

 58. Which of the following is FALSE regarding the following ankle injury, shown in the figure below:

A) This type of fracture is best treated by ORIF
B) This is usually caused by a Pronation-external rotation injury
C) This is a Spiral Fracture of the Lateral Malleolus and a transverse avulsion fracture of medial malleolus
D) The fracture shown is unstable
E) Migration of Talus bone is likely

Correct Answer : B

This is a supination-external rotation injury according to Hansen Classification. All other statements are true regarding this type of fracture. Lateral migration of Talus is likely

Author : Liam Borg

 57. A 27-year-old banker injures his foot and sustains a displaced divergent Lisfranc fracture-dislocation.
The optimal management would consist of:

A) Below knee plaster cast
B) Closed or open reduction and screw stabilization
C) Closed or open reduction and K-wire stabilization
D) A bridging external fixator
E) Closed or open reduction and combined screw and K-wire stabilization

Correct Answer : E

The tarsometatarsal joint is best thought of in three columns: a medial column (first tarsometatarsal joint), a middle column (second and third tarsometatarsal joints) and a lateral column (fourth and fifth tarsometatarsal joints).

Any dislocation or subluxation needs reduction. A cast or external fixator does not hold the reduction adequately.
Although there are many ways to stabilize the fracture-dislocation after reduction, it is generally accepted that the medial and middle columns should be treated with permanent fixation (for example screws) and the lateral column should have temporary fixation (for example K-wires removed after 6–12 weeks). This is due to the relatively greater mobility of the lateral column.
 

Author : Zihad Taher

 56. The Achilles tendon reflex (ankle reflex) is transmitted through which of the following nerve roots

A) L4
B) L5
C) S1
D) S2
E) S3

Correct Answer : C

The Achilles tendon reflex is based upon the triceps muscle group (medial and lateral gastrocnemius muscles and soleus muscle) and is transmitted through the S1 nerve root.
Note the reflexes and the associated nerve roots:
Patellar tendon reflex – L4
Posterior tibial reflex – L5
Achilles tendon reflex – S1

Author : Rajesh Bahadur Lakhey

 55. The extensor digitorum longus and brevis muscles are primarily innervated by which of the following nerve roots

A) L1
B) L2
C) L3
D) L4
E) L5

Correct Answer : E

The extensor digitorum and longus muscles are primarily innervated by the L5 nerve root.
Remember that the L5 nerve root innervates the following muscles:
– Extensor hallucis longus
Extensor digitorum longus and brevis
Gluteus medius

Author : Rajesh Bahadur Lakhey

 54. A magnetic resonance image (MRI) of the right foot of a 16-year-old female cross-country runner is presented. 

The patient complains of progressive pain in her right foot. 

Recommended initial management should include:

A) Excisional biopsy
B) A period of non-weight bearing with further workup including nutritional and endocrine evaluation
C) Resumption of activities as tolerated
D) Open reduction internal fixation
E) Incisional biopsy

Correct Answer: B

The MRI demonstrates a stress fracture of the second metatarsal. 

Appropriate initial management includes a period of non-weight bearing, as well as assessment of risk factors for additional stress fractures such as poor nutrition and amenorrhea.

Author: Rajesh Bahadur Lakhey

 

53. With regard to the level of athletics, which group of patients can be expected to have less satisfactory results after lateral ankle repair using a modified Brostrom technique:

A) Professional dancers
B) Recreational athletes
C) Non-athletes
D) Professional athletes
E) All groups can be expected to have similar success

Correct Answer: E

In a series of 28 ankles undergoing a modified Brostrom repair for lateral ankle instability, there were no significant differences in outcome whether the patients were professional dancers, athletes, or non-athletes.

Author: Rajesh Bahadur Lakhey

 

52. Isolated subtalar fusion:

A) Is not associated with development of ankle or transverse tarsal joint arthritis
B) Is associated only with development of transverse joint arthritis, but the ankle joint is spared
C) Is associated only with development of ankle arthritis, but the transverse tarsal joints are spared
D) Is associated with the development of both ankle and transverse tarsal joint arthritis
E) Is associated with knee joint degenerative arthritis

Correct Answer: D

In 48 subtalar fusions followed for 5 years, 36% of patients developed ankle arthritis and 41% of patients developed transverse tarsal joint arthritis.

Author: Rajesh Bahadur Lakhey

 

51. Take-down of ankle arthrodesis and conversion to total ankle replacement:

A) Is impossible if the fibula has been resected
B) Is a dependable procedure with a rate of complications similar to primary ankle replacement
C) Has a poor clinical success rate if there is no clear underlying cause of pain from the ankle fusion
D) Results in minimal gains in ankle range of motion
E) Requires custom made prosthetic implants 

Correct Answer: C

This article studied the success rates of revising previous ankle fusions to ankle replacement. The authors found that if the etiology of a patient’s pain was unclear, the patients did poorly. Patients with prior fibula resection could still be revised to ankle replacement with allograft bone to support the lateral side of the implant. Range of motion following revision to arthroplasty was comparable to primary replacement.

Author: Rajesh Bahadur Lakhey

 

50. Which of the following is the most reliable way to determine that a deltoid ligament injury is associated with a Weber B level lateral malleolus fracture:

A) The presence of medial tenderness on clinical examination 
B) The presence of medial ecchymosis on clinical examination 
C) The presence of significant medial swelling on clinical examination 
D) Evidence of medial clear space widening on stress radiographs
E) The presence of lateral malleolus tenderness 

Correct Answer: D 

Weber B supination, external rotation ankle fractures were evaluated to determine the reliability of medial tenderness, ecchymosis, and swelling in predicting deltoid incompetence. These clinical signs were poorly predictive, and stress radiographs were recommended for an accurate diagnosis of instability.

Author: Rajesh Bahadur Lakhey

 

49. The main blood supply to the talar body is from the:

A) Peroneal artery
B) Dorsalis pedis artery
C) Artery of the tarsal canal
D) Artery of the sinus tarsi
E) 1st dorsal metatarsal artery

Correct Answer: C

The main blood supply to the body of the talus is the artery of the tarsal canal, which is a branch off the posterior tibial artery. 

The dorsalis pedis and the artery of the sinus tarsi supply the talar head.