Foot and Ankle Surgery Practice Questions

Q: An MRI of the ankle shows a whitish, irregular abnormality in the Achilles tendon. What is the most likely finding and its corresponding management?

Thompson test positive. ***Thompson test positive*** - An MRI finding of a whitish, irregular signal intensity in the Achilles tendon is characteristic of an **Achilles tendon rupture**, which represents a complete discontinuity of the tendon fibers. - A **positive Thompson test** (absence of plantar flexion upon squeezing the calf muscle) confirms the diagnosis of an Achilles tendon rupture by demonstrating the lack of continuity between the triceps surae and the calcaneus. *Steroid injection* - **Corticosteroid injections** into the Achilles tendon are generally contraindicated due to the high risk of accelerating tendon degeneration and predisposing the patient to **iatrogenic rupture**. - This management is inappropriate for an acute, complete rupture because steroids do not address the mechanical discontinuity and may impede natural healing. *Plaster cast* - While **conservative management** with a cast or functional bracing is a treatment option, it is not the *finding itself*, but rather a therapeutic method. - The question asks for the

Q: Frieberg's disease involves which of the following?

2nd metatarsal. **Explanation:** **Freiberg’s disease** is an **osteochondrosis** (avascular necrosis) affecting the head of the metatarsal. It most commonly involves the **2nd metatarsal head (Option C)** because it is the longest and most rigid metatarsal, making it susceptible to repetitive microtrauma and excessive loading during the toe-off phase of gait. It is typically seen in adolescent girls and presents with pain, swelling, and limited range of motion at the metatarsophalangeal joint. **Analysis of Incorrect Options:** * **Option A (Tibial tuberosity):** This is the site for **Osgood-Schlatter disease**, a traction apophysitis caused by repetitive strain from the patellar tendon. * **Option B (Calcaneal tuberosity):** This is the site for **Sever’s disease**, an apophysitis of the calcaneus common in active children. * **Option D (5th metatarsal):** The base of the 5th metatarsal is the site for **Iselin’s disease** (apophysitis). While the 5th metatarsal is also prone to Jones fractures, it is not the classic site for Freiberg’s. **High-Yield Clinical Pearls for NEET-PG:** * **Demographics:** Most common in adolescent females (ratio ~3:1). * **Radiology:** Early stages show flattening and sclerosis of the metatarsal head; late stages show joint space narrowing and secondary osteoarthritis. * **Hierarchy of Involvement:** 2nd Metatarsal (most common) > 3rd Metatarsal > 4th Metatarsal. * **Management:** Conservative (activity modification, orthotics) is first-line; surgery (debridement or osteotomy) is reserved for refractory cases.

Q: A 22-year-old football player presents with pain and swelling at the lateral aspect of the ankle, diagnosed as an inversion sprain. Which of the following ligaments is most likely affected?

Calcaneofibular ligament. **Explanation:** **1. Why the Correct Answer is Right:** Inversion sprains are the most common type of ankle injury, occurring when the foot is forcibly turned inward. The lateral collateral ligament complex of the ankle consists of three ligaments: the **Anterior Talofibular Ligament (ATFL)**, the **Calcaneofibular Ligament (CFL)**, and the **Posterior Talofibular Ligament (PTFL)**. * The **ATFL** is the weakest and most commonly injured ligament in plantarflexion-inversion. * The **CFL** is the second most commonly injured and is typically stressed when the ankle is in a neutral or dorsiflexed position during inversion. In clinical scenarios involving significant lateral ankle trauma, the CFL is a primary structure affected. **2. Why the Incorrect Options are Wrong:** * **A. Calcaneonavicular ligament (Spring ligament):** This is a medial structure that supports the head of the talus and maintains the medial longitudinal arch. It is not involved in lateral inversion sprains. * **C & D. Long and Short plantar ligaments:** These are located on the plantar (sole) aspect of the foot. They support the lateral longitudinal arch and are involved in conditions like pes planus or plantar fasciitis, rather than acute ankle sprains. **3. Clinical Pearls for NEET-PG:** * **Sequence of Injury:** In lateral sprains, the order of tearing is usually **ATFL > CFL > PTFL**. * **Anterior Drawer Test:** Used to assess the integrity of the ATFL. * **Talar Tilt Test:** Used to assess the integrity of the CFL. * **Deltoid Ligament:** The strong medial ligament of the ankle; it is rarely torn but can be involved in eversion injuries (Pott’s fracture).

Q: In which type of fracture, the tuber-joint angle is reduced to about half?

Crush fracture of calcaneum. Explanation: The **Tuber-joint angle**, also known as **Bohler’s Angle**, is a critical radiological parameter used to assess the severity of calcaneal fractures [1]. It is formed by the intersection of two lines: one from the highest point of the anterior process to the highest point of the posterior facet, and another from the posterior facet to the highest point of the posterior tuberosity. 1. **Why Option A is correct:** In a **Crush (depressed) fracture of the calcaneum**, the posterior facet is driven downward into the body of the bone. This collapse flattens the calcaneal arch, leading to a significant reduction or even reversal of Bohler’s angle [1]. The normal range is **20° to 40°**; in crush fractures, this is typically reduced to half or less (often <10°). 2. **Why other options are wrong:** * **Fracture neck of humerus & Dislocation of shoulder:** These involve the upper limb and have no anatomical relationship with the tuber-joint angle. * **Split fracture of calcaneum:** While this involves the same bone, a simple split (extra-articular or non-depressed) does not necessarily cause the vertical collapse of the articular surface required to significantly alter Bohler’s angle. **High-Yield Clinical Pearls for NEET-PG:** * **Bohler’s Angle:** Normal = 20°–40°. A decrease indicates a calcaneal burst/crush fracture. * **Gissane’s Angle (Critical Angle):** Another important calcaneal angle; normal is **120°–145°**. It increases in intra-articular fractures. * **Mondor’s Sign:** Ecchymosis extending to the sole of the foot, pathognomonic for calcaneal fractures [1]. * **Associated Injuries:** Always rule out **compression fractures of the lumbar spine (L1)** and bilateral calcaneal fractures in patients who fall from a height (Don Juan Syndrome).

Q: In a child with a cavovarus foot deformity, the standing lateral block test assesses the flexibility of which structure?

Hindfoot. **Explanation:** The **Coleman Block Test** (standing lateral block test) is a clinical maneuver used to evaluate the flexibility of the **hindfoot (subtalar joint)** in patients with a cavovarus deformity. **1. Why Hindfoot is Correct:** In many cases of cavovarus foot (often seen in Charcot-Marie-Tooth disease), the primary deformity is a **plantar-flexed first ray (forefoot valgus)**. When the patient stands, this rigid forefoot forces the hindfoot into a compensatory varus position to maintain balance. By placing a block under the lateral aspect of the foot (unweighting the first ray), the clinician observes if the heel (hindfoot) corrects to a neutral or valgus position. * If the heel corrects: The hindfoot is **flexible**, and surgery should focus on the forefoot. * If the heel remains in varus: The hindfoot is **fixed/rigid**, and bony procedures (like a calcaneal osteotomy) are required. **2. Why Other Options are Incorrect:** * **Forefoot:** The test *uses* the forefoot's position to influence the hindfoot, but it specifically *assesses* the mobility of the subtalar joint (hindfoot). * **Ankle:** The ankle joint primarily allows dorsiflexion and plantarflexion; varus/valgus alignment is a function of the subtalar joint. * **Ankle and Hindfoot:** While the ankle is part of the foot complex, the block test is specific to the subtalar joint's ability to compensate for forefoot driven deformity. **Clinical Pearls for NEET-PG:** * **Primary Deformity:** In cavovarus, the "driver" is often the **Plantar-flexed 1st ray** (due to Peroneus Longus overactivity). * **Components of Cavovarus:** **C**avus (midfoot), **A**dduction (forefoot), **V**arus (hindfoot). * **Associated Condition:** Always screen for **Spinal Dysraphism** or **Charcot-Marie-Tooth (CMT)** in bilateral cases.

Q: Lisfranc fracture dislocation involves which joint complex?

Tarso-metatarsal. **Explanation:** The **Lisfranc joint complex** refers to the **tarso-metatarsal (TMT) joints**, which represent the articulation between the midfoot (cuneiforms and cuboid) and the forefoot (bases of the five metatarsals). The hallmark of this injury is the disruption of the **Lisfranc ligament**, a strong oblique band connecting the lateral aspect of the medial cuneiform to the base of the second metatarsal. Because there is no transverse ligament between the first and second metatarsal bases, this ligament is the primary stabilizer of the midfoot arch. Injury typically occurs due to high-energy trauma (RTA) or indirect axial loading on a plantar-flexed foot. **Analysis of Options:** * **Option C (Correct):** Lisfranc injuries specifically involve the tarso-metatarsal joints. Radiographically, this is often seen as a widening of the space between the 1st and 2nd metatarsal bases (the "fleck sign"). * **Options A, B, and D (Incorrect):** The **Lunate, Scaphoid, and Capitate** are carpal bones located in the **wrist**. Injuries involving these bones include Scaphoid fractures (most common carpal fracture) or Perilunate dislocations, but they have no anatomical relation to the Lisfranc complex in the foot. **High-Yield Clinical Pearls for NEET-PG:** * **Fleck Sign:** An avulsion fracture of the 2nd metatarsal base; pathognomonic for Lisfranc injury. * **Chopart’s Joint:** The mid-tarsal joint (calcaneocuboid and talonavicular joints). Do not confuse this with Lisfranc. * **Clinical Sign:** Plantar ecchymosis (bruising on the sole of the midfoot) is highly suggestive of a Lisfranc injury. * **Management:** Stable injuries are treated with non-weight-bearing casts; unstable injuries require ORIF (Open Reduction Internal Fixation).

Q: What is March fracture?

Fracture of the 2nd metatarsal. **Explanation:** **March fracture** is a type of **stress fracture** (fatigue fracture) that occurs due to repetitive submaximal loading on a bone that has not had time to adapt to the stress. It classically occurs in the **neck or shaft of the 2nd metatarsal** (and occasionally the 3rd). 1. **Why Option A is correct:** The 2nd metatarsal is the longest and most rigid of the metatarsals. During walking or running, it acts as a fixed lever arm. When an individual (traditionally a military recruit or long-distance hiker) undergoes sudden, prolonged physical activity, the repetitive stress leads to microfractures. Because the 2nd metatarsal is less mobile than the others, it bears the brunt of the force, leading to a fracture. 2. **Why other options are incorrect:** * **Option B:** While the 3rd metatarsal can be involved, the 2nd is the most common site. The 4th and 5th metatarsals are more mobile and less prone to this specific stress mechanism. * **Option C:** Cuboid fractures are rare and usually result from direct trauma or "nutcracker" compression injuries, not repetitive stress. * **Option D:** Stress fractures of the tibia are common in athletes (often called "dreaded black line" on X-ray), but they are not termed "March fractures." **Clinical Pearls for NEET-PG:** * **Radiology:** Initial X-rays are often **negative** for the first 2–3 weeks. Diagnosis is confirmed later by the appearance of **periosteal callus** formation or early on via **MRI** (most sensitive) or Bone Scan. * **Management:** Most are treated conservatively with rest, activity modification, and stiff-soled shoes. * **Jones Fracture vs. March Fracture:** Do not confuse these. A Jones fracture occurs at the base of the **5th metatarsal** (Zone 2), typically due to acute inversion injury, not repetitive stress.

Q: Watson Jones operation is done for:

Chronic ankle instability. **Explanation:** **Watson-Jones Operation** is a classic reconstructive surgical procedure used for **Chronic Ankle Instability**, specifically to address lateral ligament laxity (the Anterior Talofibular Ligament - ATFL and Calcaneofibular Ligament - CFL). The underlying medical concept involves **tenodesis**. In this procedure, the **Peroneus Brevis tendon** is harvested (either partially or fully), passed through bone tunnels in the distal fibula and the neck of the talus, and then sutured back onto itself. This creates a "new" ligamentous structure that mechanically stabilizes the ankle joint and prevents recurrent inversion injuries. **Analysis of Incorrect Options:** * **Polio & Muscle Paralysis:** While various tendon transfers (like the Jones procedure for great toe deformity) are used in Polio or paralytic conditions to restore balance, the Watson-Jones operation specifically targets mechanical ligamentous stability rather than motor power restoration. * **Neglected Clubfoot:** This condition requires extensive soft tissue releases (e.g., Turco’s procedure) or bony corrections (e.g., Triple Arthrodesis or Ilizarov) rather than lateral ligament reconstruction. **High-Yield Clinical Pearls for NEET-PG:** * **Modified Broström Procedure:** Currently the "Gold Standard" for chronic ankle instability; it involves direct repair of the ligaments rather than using a tendon graft (unlike Watson-Jones). * **Evans and Chrisman-Snook:** Other historical tenodesis procedures for ankle instability using the Peroneus Brevis. * **Distinction:** Do not confuse the **Watson-Jones Operation** (Ankle) with the **Watson-Jones Approach** (Anterolateral approach to the Hip).

Q: What is the most common site for ligamentous injuries?

Ankle joint. The **Ankle joint** is the most common site for ligamentous injuries in the human body. This is primarily due to the joint's anatomy and the biomechanical stresses it endures during weight-bearing activities. ### Why the Ankle Joint is Correct The ankle is a hinge joint that frequently experiences high-velocity inversion or eversion forces on uneven terrain. The **Lateral Ligament Complex** is the most frequently injured, specifically the **Anterior Talofibular Ligament (ATFL)**, which is the weakest and first to tear during an inversion injury (the most common mechanism). ### Analysis of Incorrect Options * **Shoulder Joint:** While the shoulder is the most common site for **dislocations** (due to the shallow glenoid cavity), ligamentous sprains are less frequent than ankle sprains. * **Knee Joint:** The knee is a major site for ligamentous injuries (ACL, MCL, PCL), especially in athletes. However, statistically, the incidence of ankle sprains in the general population and across all sports significantly exceeds that of knee injuries. * **Elbow:** Ligamentous injuries here (like the Ulnar Collateral Ligament) are usually specific to overhead throwing athletes or associated with fractures/dislocations, making them less common than ankle injuries. ### NEET-PG High-Yield Pearls * **Most common ligament injured in the body:** Anterior Talofibular Ligament (ATFL). * **Mechanism of injury:** Inversion + Plantarflexion. * **Order of lateral ligament injury:** ATFL > Calcaneofibular ligament (CFL) > Posterior Talofibular ligament (PTFL). * **Ottawa Ankle Rules:** Used clinically to determine the need for X-rays to rule out fractures following an ankle sprain. * **Treatment:** The standard initial management is the **RICE** protocol (Rest, Ice, Compression, Elevation).

Question 1

An MRI of the ankle shows a whitish, irregular
abnormality in the Achilles tendon. What is the most
likely finding and its corresponding management?

Accepted Answer

Thompson test positive

Answer

Steroid injection

Answer

Plaster cast

Answer

Surgical repair

Question 2

Frieberg's disease involves which of the following?

Accepted Answer

2nd metatarsal

Answer

Tibial tuberosity

Answer

Calcaneal tuberosity

Answer

5th metatarsal

Question 3

A 22-year-old football player presents with pain and swelling at the lateral aspect of the ankle, diagnosed as an inversion sprain. Which of the following ligaments is most likely affected?

Accepted Answer

Calcaneofibular ligament

Answer

Calcaneonavicular ligament

Answer

Long plantar ligament

Answer

Short plantar ligament

Question 4

A 56-year-old Type II diabetic presents with complaints of swelling in the left ankle with effusion but only minimal pain. X-rays show severe osteopenia with bone destruction, extensive osteophytosis, and loose bodies. Which of the following is NOT a component of the management of this patient?

Accepted Answer

Total ankle replacement

Answer

Resting and splinting

Answer

Aspiration and compression bandage

Answer

Ankle arthrodesis

Question 5

In which type of fracture, the tuber-joint angle is reduced to about half?

Accepted Answer

Crush fracture of calcaneum

Answer

Fracture neck of humerus

Answer

Dislocation of shoulder

Answer

Spilt fracture of calcaneum

Question 6

In a child with a cavovarus foot deformity, the standing lateral block test assesses the flexibility of which structure?

Accepted Answer

Hindfoot

Answer

Ankle

Answer

Forefoot

Answer

Ankle and hindfoot

Question 7

Lisfranc fracture dislocation involves which joint complex?

Accepted Answer

Tarso-metatarsal

Answer

Lunate

Answer

Scaphoid

Answer

Capitate

Question 8

What is March fracture?

Accepted Answer

Fracture of the 2nd metatarsal

Answer

Fracture of the 4th metatarsal

Answer

Fracture of the cuboid

Answer

Fracture of the tibia

Question 9

Watson Jones operation is done for:

Accepted Answer

Chronic ankle instability

Answer

Polio

Answer

Muscle paralysis

Answer

Neglected clubfoot

Question 10

What is the most common site for ligamentous injuries?

Accepted Answer

Ankle joint

Answer

Shoulder joint

Answer

Elbow

Answer

Knee joint

Foot and Ankle Surgery — MCQs

Foot and Ankle Surgery — MCQs

On this page

Practice by Chapter

Want unlimited practice?