Foot and Ankle Arthritis — MCQs

10 questions

A patient presents with a history of arthritis involving the 1st CMC joint and other PIP & DIP joints, while sparing the wrist and ankle. What is the most likely diagnosis for this condition?

Tarsometatarsal amputation is also known as?

Earliest radiographic finding in rheumatoid arthritis

A 40 year old male who is being treated for UTI with Oflazacin presents to you with sudden onset of pain in the back of the ankle while running. It is still possible for him to walk but finds it difficult to stand on tiptoe. What is your diagnosis?

The operative procedure known as "microfracture" is done for the

A child presents with painful limp and restricted hip rotation. ESR and CRP are elevated. Initial plain radiograph is normal. What is the next best imaging study?

Which of the following conditions is least likely to be associated with rigid flat foot?

Osteoarthritis not seen in ?

The rephrased question is:What is the most common complication of a fractured talus?

Q10

A diabetic patient presents with sensory involvement, tingling, numbness, ankle swelling, and absence of pain. What is the most likely diagnosis?

Foot and Ankle Arthritis Indian Medical PG Practice Questions and MCQs

Question 1: A patient presents with a history of arthritis involving the 1st CMC joint and other PIP & DIP joints, while sparing the wrist and ankle. What is the most likely diagnosis for this condition?

A. Osteoarthritis (Correct Answer)
B. Rheumatoid arthritis
C. Psoriatic arthritis
D. Gout

Explanation: ***Osteoarthritis*** - This condition presents with **arthritis in the 1st carpometacarpal (CMC)**, **proximal interphalangeal (PIP)**, and **distal interphalangeal (DIP)** joints, which is highly characteristic of osteoarthritis [1]. - The sparing of the **wrist and ankle** joints further supports osteoarthritis, as these joints are more commonly affected in inflammatory arthropathies [1]. *Rheumatoid arthritis* - **Rheumatoid arthritis (RA)** typically affects the **small joints of the hands and feet**, but it characteristically spares the **DIP joints** and often involves the **wrists** symmetrically [1]. - It also usually presents with morning stiffness that lasts longer than 30 minutes, which is not mentioned here. *Psoriatic arthritis* - **Psoriatic arthritis** can affect the **DIP joints** and can present with an oligoarticular or polyarticular pattern, but it is typically associated with **psoriasis**, dactylitis, and enthesitis, none of which are described [1]. - The pattern of joint involvement, particularly the sparing of wrists and ankles, is less typical for psoriatic arthritis compared to osteoarthritis [1]. *Gout* - **Gout** typically presents as **acute, severe monoarthritis**, most commonly affecting the **first metatarsophalangeal (MTP) joint** (podagra). - While it can affect other joints, its episodic nature and sudden onset differentiate it from the chronic, progressive pattern often seen in osteoarthritis.

Question 2: Tarsometatarsal amputation is also known as?

A. Pirogoff amputation
B. Symes amputation
C. Chopart's amputation
D. Lisfranc amputation (Correct Answer)

Explanation: ***Lisfranc amputation*** - This amputation is performed through the **tarsometatarsal joints**, detaching the forefoot from the midfoot. - It is named after **Jacques Lisfranc de St. Martin**, a French surgeon who described the disarticulation. *Pirogoff amputation* - This is an ankle disarticulation with preservation of the posterior part of the **calcaneus**, which is then fused with the tibia. - Its goal is to create an end-weight-bearing stump by providing a longer lever arm. *Symes amputation* - This involves disarticulation at the **ankle joint**, removing the entire foot but preserving the heel fat pad to create an end-weight-bearing stump. - It is distinct from a tarso-metatarsal amputation as it is performed at a more proximal level. *Chopart's amputation* - This is a midtarsal disarticulation through the **talonavicular** and **calcaneocuboid joints**, preserving the talus and calcaneus. - It involves removing the forefoot and part of the midfoot, thus being more proximal than a Lisfranc amputation.

Question 3: Earliest radiographic finding in rheumatoid arthritis

A. Subluxation
B. Erosions
C. Periarticular osteopenia (Correct Answer)
D. Joint space narrowing

Explanation: ***Periarticular osteopenia*** - This is often the **earliest radiographic finding** in **rheumatoid arthritis**, reflecting bone demineralization around the inflamed joint. - It results from the inflammatory processes and increased vascularity in the synovium, leading to enhanced **osteoclast activity**. *Subluxation* - This is a **late consequence** of extensive joint destruction and ligamentous laxity in rheumatoid arthritis. - It indicates significant structural damage, which typically occurs **after** earlier signs like osteopenia and erosions. *Erosions* - While characteristic of rheumatoid arthritis, **bone erosions** are usually seen after periarticular osteopenia has developed. - They represent focal areas of bone destruction due to the inflamed synovium invading and damaging the adjacent bone. *Joint space narrowing* - This finding occurs due to the gradual **destruction of articular cartilage** and is commonly seen in later stages. - While a defining feature of chronic arthritis, it often appears **after** periarticular osteopenia and sometimes coincident with initial erosions.

Question 4: A 40 year old male who is being treated for UTI with Oflazacin presents to you with sudden onset of pain in the back of the ankle while running. It is still possible for him to walk but finds it difficult to stand on tiptoe. What is your diagnosis?

A. Deep vein thrombosis
B. Achilles tendon rupture (Correct Answer)
C. Fracture calcaneus
D. Plantar fasciitis

Explanation: ***Achilles tendon rupture*** - Sudden onset of **posterior ankle pain**, difficulty standing on **tiptoe**, and a history of **fluoroquinolone** (Oflazacin) use are classic signs of Achilles tendon rupture. - Fluoroquinolones are known to increase the risk of **tendinopathy** and tendon rupture, especially in older adults and those with pre-existing tendon issues. *Deep vein thrombosis* - While DVT can cause **calf pain** and swelling, it typically does not present with a sudden "pop" or immediate inability to stand on tiptoe, and is not directly associated with fluoroquinolone use in this manner. - There would usually be signs of **swelling** and **tenderness** to palpation along the calf veins, not specifically localized to the Achilles tendon. *Fracture calcaneus* - A calcaneal fracture would typically result from a **high-impact injury** (e.g., fall from height) and would cause severe pain, inability to bear weight, and significant swelling, which is not fully described here. - While an X-ray would be definitive, the mechanism and symptoms better fit a soft tissue injury like a tendon rupture. *Plantar fasciitis* - Plantar fasciitis causes **heel pain**, especially with the first steps in the morning or after rest, and typically does not present as an acute injury from running with sudden pain in the back of the ankle. - The pain is usually in the **sole of the foot**, not the posterior ankle, and does not commonly lead to difficulty standing on tiptoe due to an acute event.

Question 5: The operative procedure known as "microfracture" is done for the

A. Delayed union of femur
B. Osteochondral defect of femur (Correct Answer)
C. Non union of tibia
D. Loose bodies of ankle joint

Explanation: ***Osteochondral defect of femur*** - **Microfracture** is a surgical technique used to stimulate the growth of **fibrocartilage** in areas of damaged articular cartilage, such as an **osteochondral defect**. - It involves creating small holes in the **subchondral bone** to allow stem cells and growth factors from the bone marrow to form a new reparative tissue. *Delayed union of femur* - **Delayed union** typically involves an extended time for fracture healing, which is often managed through prolonged immobilization, **bone grafting**, or sometimes revision surgery. - Microfracture specifically targets cartilage repair, not the process of **bony union** after a fracture. *Non union of tibia* - **Non-union** refers to the failure of a fractured bone to heal within a reasonable timeframe, often requiring surgical intervention with **bone grafts** or **internal fixation**. - This condition involves bone healing problems, distinct from cartilage defects that microfracture addresses. *Loose bodies of ankle joint* - **Loose bodies** in a joint are typically removed surgically, often arthroscopically, to relieve pain and prevent joint damage. - This procedure does not involve the repair of cartilage defects, which is the primary goal of microfracture.

Question 6: A child presents with painful limp and restricted hip rotation. ESR and CRP are elevated. Initial plain radiograph is normal. What is the next best imaging study?

A. CT Scan
B. MRI with contrast (Correct Answer)
C. Bone Scan
D. Plain Radiograph

Explanation: ***MRI with contrast*** - An **MRI with contrast** is the most sensitive and specific imaging modality for detecting early changes in **osteomyelitis** or **septic arthritis**, which are serious conditions given the child's symptoms and elevated inflammatory markers. - It can visualize soft tissue and bone marrow edema, joint effusions, and abscesses, guiding immediate treatment. *CT Scan* - While useful for bony detail, a CT scan is **less sensitive than MRI** for detecting early bone marrow changes or soft tissue inflammation in the hip joint. - It also involves **radiation exposure**, which should be limited in children when other effective modalities are available. *Bone Scan* - A bone scan using **technetium-99m** is sensitive for detecting increased bone turnover, but it is **not specific for infection** and cannot differentiate between inflammatory processes, tumors, or fractures. - It provides less anatomical detail compared to MRI, making precise localization of an infection more challenging. *Plain Radiograph* - Plain radiographs are typically the **initial imaging study** for orthopedic complaints but are often **normal in early stages** of septic arthritis or osteomyelitis. - Significant radiographic changes, such as bone erosion or joint space widening, usually appear much later in the disease process.

Question 7: Which of the following conditions is least likely to be associated with rigid flat foot?

A. Rheumatoid arthritis
B. Athlete's foot (Correct Answer)
C. Peroneal spasm
D. Congenital tarsal coalition.

Explanation: ***Athlete's foot*** - **Athlete's foot** (tinea pedis) is a **fungal infection** of the skin of the foot, which typically causes itching, scaling, and redness. - It does not directly affect the bony or ligamentous structures of the foot to cause **rigid flat foot** deformation. *Rheumatoid arthritis* - **Rheumatoid arthritis** can cause **inflammatory arthropathy** affecting the joints of the foot, leading to joint destruction and subsequent collapse of the **medial longitudinal arch**, resulting in **rigid flat foot**. - Chronic inflammation and synovitis can alter pedal biomechanics and lead to a painful, **fixed deformity** of the foot. *Peroneal spasm* - **Peroneal spasm** is often associated with conditions like **tarsal coalition** or other painful foot pathologies. - The spasm of the peroneal muscles can pull the foot into **eversion** and **abduction**, contributing to a **rigid flat foot deformity** as the foot becomes fixed in this position. *Congenital tarsal coalition* - **Tarsal coalition** is an **abnormal connection** between two or more bones in the hindfoot or midfoot, which restricts normal motion and leads to a **rigid flat foot**. - It is a common cause of **peroneal spasm** as the body tries to immobilize the painful, rigid hindfoot motion.

Question 8: Osteoarthritis not seen in ?

A. Ankle joints (Correct Answer)
B. Knee joints
C. Hip joints
D. 1st metacarpophalangeal joint

Explanation: ***Ankle joints*** - While other joints are frequently affected by osteoarthritis, the **ankle joint** is *relatively spared* from primary osteoarthritis. - Osteoarthritis in the ankle is more commonly **secondary** to trauma, inflammation, or structural abnormalities rather than a primary degenerative process. *Knee joints* - The **knee joint** is one of the most frequently affected joints in osteoarthritis due to its weight-bearing function and complex biomechanics. - **Cartilage degeneration** in the knee leads to pain, stiffness, and reduced mobility. *Hip joints* - The **hip joint** is another common site for osteoarthritis, particularly in older adults, due to its significant weight-bearing role. - **Acetabular and femoral head cartilage erosion** causes deep groin pain and restricted range of motion. *1st metacarpophalangeal joint* - The **1st metacarpophalangeal (MCP) joint** of the thumb is a common site for osteoarthritis, especially in women. - This is due to the significant **stress and forces** placed on this joint during pinching and gripping activities.

Question 9: The rephrased question is:What is the most common complication of a fractured talus?

A. Avascular necrosis (AVN) (Correct Answer)
B. Osteoarthritis of the subtalar joint
C. Nonunion of the talus
D. Osteoarthritis of the ankle joint

Explanation: ***Avascular necrosis (AVN)*** - The talus has a **precarious blood supply**, with arterial branches entering at multiple points but often centrally, making it vulnerable to **ischemia** after fracture. - Fractures, especially neck fractures, can disrupt these delicate vessels, leading to **osteonecrosis** and collapse of the bone. *Nonunion of the talus* - While possible, talar nonunion is **less common** than AVN due to the talus's dense cortical bone and limited muscle attachments. - Nonunion is more frequently seen with fractures of other bones, such as the **scaphoid**. *Osteoarthritis of the subtalar joint* - **Subtalar osteoarthritis** can occur post-talar fracture, often as a **secondary complication** of disrupted articular surfaces or AVN. - However, the **initial and most common direct complication** stemming from the blood supply disruption is AVN. *Osteoarthritis of the ankle joint* - **Ankle osteoarthritis** can also develop after certain talar fractures, particularly those involving the talar dome or leading to incongruity of the ankle joint. - Similar to subtalar arthritis, it is often a **later or secondary sequela**, rather than the immediate and most frequent direct complication like AVN.

Question 10: A diabetic patient presents with sensory involvement, tingling, numbness, ankle swelling, and absence of pain. What is the most likely diagnosis?

A. Charcot's joint (Correct Answer)
B. Gout
C. Rheumatoid arthritis
D. Ankylosing spondylitis

Explanation: ***Charcot's joint*** - This condition is characterized by **neuropathic arthropathy**, resulting from nerve damage (often due to **diabetes**), leading to sensory involvement, **numbness**, and **absence of pain** [1]. - The loss of protective sensation and repeated microtrauma contribute to joint destruction, often manifesting as **swelling** and deformity, particularly in the feet and ankles [1]. *Gout* - Gout typically presents with sudden, severe episodes of **pain**, redness, and swelling in a single joint, most commonly the **big toe**. - It is caused by **uric acid crystal deposition** and is not primarily associated with sensory deficits or chronic painless swelling. *Rheumatoid arthritis* - This is a **chronic autoimmune** inflammatory disease primarily affecting the **small joints** of the hands and feet symmetrically, causing pain, stiffness, and swelling. - It does not typically present with sensory neuropathy or painless joint destruction in the way described. *Ankylosing spondylitis* - This is a **chronic inflammatory disease** primarily affecting the **spine and sacroiliac joints**, causing progressive stiffness and pain that improves with activity. - It is not associated with peripheral joint neuropathy, numbness, or painless ankle swelling [1].

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