Foot and Ankle Surgery Practice Questions

Q: What is an Ator fracture?

Fracture of the neck of the talus. **Explanation:** **Aviator’s Fracture (Ator Fracture)** refers to a fracture of the **neck of the talus**. The term originated during World War I when pilots would crash-land; the sudden forceful dorsiflexion of the foot against the rudder pedal caused the neck of the talus to be driven against the anterior edge of the distal tibia, leading to a fracture. **Why the correct answer is right:** * **Option A:** The talus neck is the most common site for talar fractures. Because the talus has a retrograde blood supply (entering mainly through the neck and distal body), fractures here carry a high risk of **Avascular Necrosis (AVN)** of the talar body. **Why the incorrect options are wrong:** * **Option B (Scaphoid):** While also prone to AVN, scaphoid fractures are typically caused by a fall on an outstretched hand (FOOSH), not dorsiflexion of the foot. * **Option C (Calcaneum):** Known as "Lover’s Fracture" or "Don Juan Fracture," usually caused by a fall from a height onto the heels. * **Option D (5th Metatarsal):** Fractures here are classified as Jones fractures (base of the 5th metatarsal) or Dancer’s fractures (avulsion of the styloid process). **Clinical Pearls for NEET-PG:** 1. **Hawkins Classification:** Used to grade talar neck fractures and predict the risk of AVN (Type I to IV). 2. **Hawkins Sign:** A subcortical radiolucent line seen on X-ray 6–8 weeks post-injury, indicating intact vascularity (a good prognostic sign). 3. **Blood Supply:** The **Artery of the Tarsal Canal** (branch of the posterior tibial artery) is the most important vessel supplying the body of the talus.

Q: A Patients presents with ankle pain and swelling after a forceful eversion injury. Based on the mechanism of injury, which ligament is most likely to be damaged?

Deltoid ligament. ***Deltoid ligament***- This strong ligament complex is located on the medial side of the ankle and is the primary stabilizer resisting excessive **valgus** or **eversion forces**.- A forceful eversion mechanism subjects the medial side to tension, leading potentially to rupture of the Deltoid ligament or an associated avulsion fracture of the **medial malleolus**. *Anterior talofibular ligament*- This is the **most commonly injured** ligament in the ankle, typically resulting from an **inversion injury** combined with plantar flexion.- It connects the fibula to the talus and is the weakest of the lateral ligaments, making it the primary target of **lateral ankle sprains**. *Calcaneofibular ligament*- This ligament also acts as a restraint against **inversion** and is located laterally, deep to the peroneal tendons.- Injury to the CFL often occurs when the foot is **dorsiflexed** and inverted, usually damaged secondarily after the **ATFL** tears. *Posterior talofibular ligament*- Located on the posterior-lateral aspect, this ligament is the **strongest** of the lateral stabilizers.- It is rarely injured in isolated ligamentous sprains, typically requiring severe **dislocations** or extensive high-grade **inversion injuries**.

Q: Identify the deformity seen in the given picture:

Hallux valgus. ***Hallux valgus*** - The image clearly shows the great toe (hallux) angled away from the midline of the foot (laterally), which is characteristic of **hallux valgus**. - There is a noticeable **bunion** formation at the base of the great toe, indicating the medial deviation of the first metatarsal and lateral deviation of the proximal phalanx, which are hallmarks of this deformity. *Hallux varus* - This deformity involves the **great toe pointing towards the midline of the body** (medially), which is the opposite of what is seen in the image. - It is often a complication of **bunion surgery** or can be congenital, but the image does not show medial deviation of the great toe. *Cubitus valgus* - **Cubitus valgus** refers to an increased carrying angle of the **elbow**, where the forearm is angled away from the body when the arm is extended. - This is an deformity of the **upper limb** and is unrelated to the foot shown in the image. *Rheumatoid nodule* - A **rheumatoid nodule** is a subcutaneous lesion, typically firm and non-tender, found over pressure points in patients with rheumatoid arthritis. - While rheumatoid arthritis can affect the feet, the primary finding in the image is a **structural deformity of the great toe**, not an isolated nodule.

Q: The following test is done to evaluate for Achilles tendon rupture. The test is known as?

Thompson test. ***Thompson test*** - The **Thompson test** assesses for an **Achilles tendon rupture** by observing plantarflexion of the foot upon squeezing the calf muscle. - A **positive test** (absence of plantarflexion) indicates a complete rupture of the Achilles tendon. *Thomas test* - The **Thomas test** is used to evaluate for **hip flexor contracture** or tightness. - It involves assessing the ability of the thigh to remain flat on the examination table while the opposite hip is flexed. *Single leg heel raise test* - The **single leg heel raise test** evaluates the strength and endurance of the **calf muscles**, primarily the gastrocnemius and soleus. - Inability to perform this test can be due to weakness, pain, or an Achilles tendon rupture, but it's not a definitive diagnostic test on its own. *Gordon test* - The **Gordon test** is a neurological test used to elicit an abnormal plantar reflex, indicative of an **upper motor neuron lesion**. - It involves squeezing the calf muscles and observing for an extensor plantar response (dorsiflexion of the great toe and fanning of other toes).

Q: Comment on the diagnosis:

Jones fracture. ***Jones fracture*** - The image indicates a fracture located at the **proximal metaphyseal-diaphyseal junction of the fifth metatarsal**, which is characteristic of a **Jones fracture**. - This fracture involves the **base of the fifth metatarsal** and is often associated with a higher risk of nonunion due to limited blood supply. *March fracture* - A **March fracture** is a type of stress fracture, typically affecting the **shaft of the second, third, or fourth metatarsals**, often seen in military recruits or those who engage in prolonged walking or running. - It results from repetitive stress rather than an acute injury, and its location is distinct from the proximal fifth metatarsal. *Shepherd's fracture* - A **Shepherd's fracture** refers to an avulsion fracture of the **posterolateral tubercle of the talus**, also known as an os trigonum fracture. - This fracture is located in the ankle region, distinct from the metatarsals. *Cotton's fracture* - A **Cotton's fracture** is a trimalleolar fracture of the ankle, involving the **medial malleolus**, **lateral malleolus**, and the **posterior malleolus** of the tibia. - This is a complex ankle injury, entirely unrelated to fractures of the metatarsals.

Q: Comment on the diagnosis:

March fracture. ***March fracture*** - The image indicates a **stress fracture** of a metatarsal bone, which is characteristic of a **March fracture**. - This type of fracture commonly affects the **2nd or 3rd metatarsal** and is often seen in individuals who engage in strenuous physical activity. *June's fracture* - This is not a recognized eponym for a specific type of fracture in the foot. - The term "June's fracture" does not correspond to any known medical diagnosis related to metatarsal stress fractures. *Shepherd's fracture* - A Shepherd's fracture refers to a **fracture of the posterior process of the talus**. - It is distinct from a metatarsal stress fracture and typically results from forced plantarflexion. *Cotton's fracture* - A Cotton's fracture is a **trimalleolar ankle fracture**, involving the medial, lateral, and posterior malleoli of the ankle. - This is a complex ankle injury, unrelated to a metatarsal stress fracture.

Q: Which of the following statements regarding flat feet are true? 1. Nearly all children below 3 years have flat feet 2. 15% of adults have flat feet 3. Painless flexible flat feet need no treatment 4. Rigid flat feet result from tarsal coalition Select the correct answer using the code given below:

3 and 4 only. ***3 and 4 only*** - **Painless flexible flat feet** in both children and adults generally require **no treatment**, as they are often a physiological variant and do not cause functional limitations. - **Rigid flat feet** are almost always pathological and are commonly caused by a **tarsal coalition**, an abnormal connection between two or more bones in the foot. *1 and 2 only* - While nearly all children below 3 years have **physiological flat feet**, the statement that 15% of adults have flat feet is an underestimation; prevalence varies, but it is often reported to be higher, ranging from 20-30%. - This option incorrectly excludes the importance of not treating painless flexible flat feet and the established link between rigid flat feet and tarsal coalition. *1, 2, 3 and 4* - The statement that 15% of adults have flat feet is likely an **understatement** of the true prevalence, which is often cited as higher. - While statements 1, 3, and 4 are generally correct, the inaccuracy of statement 2 makes this option incorrect. *1, 2 and 3 only* - This option correctly identifies that nearly all children below 3 have flat feet and that painless flexible flat feet do not require treatment. - However, it incorrectly excludes the crucial fact that **rigid flat feet often result from tarsal coalition**, which is a significant pathological cause.

Q: A patient presents with a 5th metatarsal fracture. How many days would he/she need to wear a cast?

6-8 weeks. ***6-8 weeks*** - For most **5th metatarsal fractures**, especially **Jones fractures** or more significant avulsion fractures, **non-weight-bearing** immobilization in a cast, boot, or splint is typically required for **6 to 8 weeks** to allow for proper bone healing. - The **poor vascular supply** to the metaphyseal-diaphyseal junction of the 5th metatarsal (in Jones fractures) often necessitates a longer immobilization period. *2-3 weeks* - This duration is generally too short for the adequate healing of most 5th metatarsal fractures, especially those that are **displaced** or involve the **watershed zone**. - A shorter period might be considered for very minor, stable **avulsion fractures** with minimal pain, but even then, a slightly longer protection might be advised. *16-20 weeks* - This length of time is typically reserved for **severe, complex fractures**, open fractures with complications, or cases requiring **multiple surgical interventions** and prolonged rehabilitation, which is not the standard for an uncomplicated 5th metatarsal fracture. - Such an extended period of immobilization could also lead to **significant muscle atrophy** and joint stiffness. *3-5 weeks* - While sometimes considered for **stable avulsion fractures** of the 5th metatarsal base or mild stress fractures, this period is often insufficient for complete healing of the more common and problematic **Jones fracture**. - Rushing the return to weight-bearing can increase the risk of **non-union** or refracture.

Q: Surgery was performed as shown in the image below. What is the name of the procedure?

Chopart amputation. ***Chopart amputation*** - The image shows a disarticulation through the **talonavicular and calcaneocuboid joints**, which defines a **Chopart amputation**. - This procedure removes the distal foot while preserving the **calcaneus and talus**, forming a stump that allows for some ankle motion. *Below knee amputation* - A below-knee amputation involves transection of the tibia and fibula, preserving the knee joint, which is much more proximal than shown in the image. - This type of amputation removes a significant portion of the lower leg, with the foot entirely removed, unlike the partial foot amputation depicted. *Above knee amputation* - An above-knee amputation involves disarticulation or transection through the femur, completely removing the lower leg and knee joint. - This is a much more extensive amputation than what is illustrated, which is confined to the foot. *Lisfranc amputation* - A Lisfranc amputation is a disarticulation through the **tarsometatarsal joints**, removing the metatarsals and phalanges but preserving the tarsal bones. - The image clearly shows the incision more proximally, at the midtarsal level, specifically through the talonavicular and calcaneocuboid joints, not the tarsometatarsal joints.

Q: In a patient with a history of burning pain localized to the plantar aspect of the foot, the differential diagnosis must include -

Tarsal tunnel syndrome. ***Tarsal tunnel syndrome*** - This condition involves **compression of the posterior tibial nerve** or its branches as they pass through the tarsal tunnel, leading to **burning pain, numbness, and tingling** on the plantar aspect of the foot [2]. - Symptoms are often exacerbated by activity or prolonged standing and can be reproduced by tapping on the nerve (Tinel's sign). *Peripheral vascular disease* - While it can cause foot pain, it typically presents as **intermittent claudication** (pain with exertion that resolves with rest) or **ischemic rest pain**, often in the toes or forefoot [1]. - The pain is usually described as cramping or aching rather than burning and is associated with signs of **poor circulation** like diminished pulses and cool skin [1]. *Plantar fibromatosis* - This condition, also known as **Ledderhose disease**, involves the formation of benign fibrous nodules within the **plantar fascia**. - It usually presents as **palpable lumps** on the sole of the foot, which may or may not be painful, but burning pain is not a primary or characteristic symptom. *Tarsal coalition* - This is a congenital condition where two or more bones in the midfoot or hindfoot are **abnormally fused**, most commonly the calcaneus and navicular or talus and calcaneus. - It typically causes **pain, stiffness, and flatfoot deformity** that worsens with activity, but burning neuropathic pain is not its primary symptom.

Question 1

What is an Ator fracture?

Accepted Answer

Fracture of the neck of the talus

Answer

Fracture of the scaphoid

Answer

Fracture of the calcaneum

Answer

Fracture of the 5th metatarsal

Question 2

A Patients presents with ankle pain and swelling after a forceful eversion injury. Based on the mechanism of injury, which ligament is most likely to be damaged?

Accepted Answer

Deltoid ligament

Answer

Posterior talofibular ligament

Answer

Anterior talofibular ligament

Answer

Calcaneofibular ligament

Question 3

Identify the deformity seen in the given picture:

Accepted Answer

Hallux valgus

Answer

Hallux varus

Answer

Cubitus valgus

Answer

Rheumatoid nodule

Question 4

The following test is done to evaluate for Achilles tendon rupture. The test is known as?

Accepted Answer

Thompson test

Answer

Thomas test

Answer

Single leg heel raise test

Answer

Gordon test

Question 5

Comment on the diagnosis:

Accepted Answer

Jones fracture

Answer

March fracture

Answer

Shepherd's fracture

Answer

Cotton's fracture

Question 6

Comment on the diagnosis:

Accepted Answer

March fracture

Answer

June's fracture

Answer

Shepherd's fracture

Answer

Cotton's fracture

Question 7

Which of the following statements regarding flat feet are true?

1. Nearly all children below 3 years have flat feet
2. 15% of adults have flat feet
3. Painless flexible flat feet need no treatment
4. Rigid flat feet result from tarsal coalition

Select the correct answer using the code given below:

Accepted Answer

3 and 4 only

Answer

1 and 2 only

Answer

1, 2, 3 and 4

Answer

1, 2 and 3 only

Question 8

A patient presents with a 5th metatarsal fracture. How many days would he/she need to wear a cast?

Accepted Answer

6-8 weeks

Answer

2-3 weeks

Answer

16-20 weeks

Answer

3-5 weeks

Question 9

Surgery was performed as shown in the image below. What is the name of the procedure?

Accepted Answer

Chopart amputation

Answer

Below knee amputation

Answer

Above knee amputation

Answer

Lisfranc amputation

Question 10

In a patient with a history of burning pain localized to the plantar aspect of the foot, the differential diagnosis must include -

Accepted Answer

Tarsal tunnel syndrome

Answer

Peripheral vascular disease

Answer

Plantar fibromatosis

Answer

Tarsal coalition

Foot and Ankle Surgery — MCQs

Foot and Ankle Surgery — MCQs

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