Foot and Ankle Surgery Practice Questions

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.

Q: Bohler angle measurement gives the reference for ?

Calcaneus. ***Calcaneus*** - The **Böhler angle** is a critical tool for assessing the integrity of the **calcaneus**, particularly after trauma. - A decreased Böhler angle is highly suggestive of a **calcaneal fracture**, especially involving the posterior facet of the calcaneus. *Navicular* - The navicular bone is located in the midfoot, and its alignment is typically assessed by other angles, such as the **Meary's angle**, which evaluates the relationship between the talus and the first metatarsal. - While fractures can occur in the navicular, the Böhler angle specifically pertains to the **calcaneal body**. *Talus* - The talus articulates with the tibia, fibula, and calcaneus, forming the ankle joint and subtalar joint, respectively. Its main angles are the **angle of Gissane** and **Meary's line**. - The **Böhler angle** focuses on the structural changes within the calcaneus itself rather than the position or alignment of the talus. *Cuboid* - The cuboid is a lateral midfoot bone that articulates with the calcaneus posteriorly and the fourth and fifth metatarsals anteriorly. - Its assessment typically involves looking for direct signs of fracture or dislocation, and not through the use of the **Böhler angle**.

Q: Motorcyclist's fracture is:

Fracture of lateral process of talus. ***Fracture of lateral process of talus*** - This is the classic **motorcyclist's fracture** due to the typical mechanism of injury during motorcycle accidents - Occurs when the rider's foot is **trapped between the motorcycle and the ground**, causing forced **dorsiflexion and eversion** of the ankle - The lateral process of the talus is vulnerable to this specific injury pattern in motorcyclists - Also known as **snowboarder's fracture** when it occurs during snowboarding due to similar dorsiflexion-inversion mechanism *Fracture of fifth metatarsal base* - While common in foot trauma, this is **not** specifically termed the "motorcyclist's fracture" - **Jones fracture** refers to a fracture at the metaphyseal-diaphyseal junction of the 5th metatarsal (1.5-3 cm from base) - **Avulsion fracture** of the 5th metatarsal base occurs from peroneus brevis pull during inversion injury - **Dancer's fracture** refers to spiral fracture of the distal 5th metatarsal shaft *Fracture of medial malleolus* - Common ankle injury typically occurring with **eversion or external rotation** forces - Part of ankle fracture patterns (Weber classification, Lauge-Hansen classification) - Not specifically associated with the "motorcyclist's fracture" terminology *Fracture of calcaneus* - Results from **high-energy axial loading** such as falls from height or motor vehicle accidents - While motorcyclists can sustain calcaneal fractures, this is not the specific "motorcyclist's fracture" - Characterized by loss of Böhler's angle and often bilateral

Q: The primary site of pathology in ankle arthritis is the:

Ankle. **Ankle** - Ankle arthritis specifically refers to the inflammation and degeneration of the joint surfaces within the **ankle joint**. - The pathology primarily involves the **talocrural joint**, which is formed by the distal tibia and fibula articulating with the talus. *Hip* - The hip joint is located where the **femur** meets the **pelvis**, and pathology there would be termed hip arthritis, not ankle arthritis. - Symptoms of hip arthritis typically involve the **groin**, buttock, or thigh, and gait disturbances different from ankle issues. *Wrist* - The wrist is located between the **forearm bones** (radius and ulna) and the **carpal bones** of the hand. - Pathology in this area would be called wrist arthritis and would present with pain and stiffness in the hand and forearm. *Knee* - The knee joint is the articulation between the **femur**, **tibia**, and **patella**. - Knee arthritis would present with symptoms localized to the knee, such as pain, swelling, and difficulty bending or straightening the leg.

Q: High stepping gait is due to

Foot drop. ***Foot drop*** - **Foot drop** causes the patient to lift the leg higher during walking to prevent the toes from dragging on the ground, resulting in a **high stepping gait**. - This condition is often due to weakness or paralysis of the **dorsiflexor muscles** of the foot, typically from **peroneal nerve injury** or **L4/L5 radiculopathy**. *Gluteus maximum paralysis* - **Gluteus maximus paralysis** causes difficulty with hip extension and is often compensated by a **backward lurch** of the trunk during gait. - It results in a **Trendelenburg gait** (if the gluteus medius is also affected) or instability during standing, but not typically a high stepping gait. *CDH* - **Congenital hip dysplasia (CDH)** involves abnormal development of the hip joint. - It usually leads to a **waddling gait** due to instability and pain, or limb length discrepancy, not a high stepping gait. *Quadriceps paralysis* - **Quadriceps paralysis** results in weakness or inability to extend the knee. - Patients typically compensate by hyperextending the knee or leaning forward over the affected leg during gait, which is not a high stepping gait.

Q: What is the most common fracture resulting from a fall onto the feet?

Jones fracture. ***Jones fracture*** - A **Jones fracture** is a fracture of the base of the **fifth metatarsal**, which is commonly associated with an inversion injury or a fall onto the foot. - This fracture type is specifically located in a **watershed area** of blood supply, making it prone to **nonunion** and requiring careful management. *Calcaneal fracture* - A **calcaneal fracture** typically results from a **high-energy axial load** to the heel, such as a fall from a significant height landing on the feet. - While possible, it is not the most common fracture for a general fall onto the feet, as it requires considerable force directly to the heel. *Lisfranc fracture* - A **Lisfranc fracture** involves the **tarsometatarsal joints** and occurs due to significant force, often from a **crushing injury** or a rotational force when the foot is plantarflexed. - This fracture pattern involves displacement of the metatarsals from the tarsus and is less common than a Jones fracture from a simple fall onto the feet. *Ankle fracture* - An **ankle fracture** involves the distal tibia and/or fibula and usually results from **twisting injuries** or direct trauma to the ankle joint. - While falling can cause an ankle fracture, it typically involves a rotational component or impact directly to the ankle, rather than a direct fall onto the plantar surface of the foot most commonly leading to a Jones fracture.

Q: Most common cause of insertional tendonitis of Achilles tendon is -

Overuse. ***Overuse*** - **Repetitive microtrauma** from activities like running or jumping is the most frequent cause of Achilles tendon insertional tendinopathy. - This leads to **degenerative changes** and inflammation at the tendon-bone interface. *Improper shoe wear* - While improper footwear can contribute to Achilles tendon issues, it is generally considered a **risk factor** that exacerbates overuse, rather than the primary cause itself. - Shoes that are too tight, too loose, or lack proper support can alter gait mechanics and increase stress on the tendon. *Runners and jumpers* - While "runners and jumpers" are indeed high-risk groups for Achilles tendinopathy, this option describes **the population at risk** rather than the direct cause of the condition. - The actual cause within this population is the repetitive stress and **overuse** associated with their activities. *Steroid injections* - **Corticosteroid injections** directly into or around the Achilles tendon are generally *contraindicated* due to the significant risk of **tendon rupture**. - They are not a cause of insertional tendinopathy but rather a potential complication of a misguided treatment.

Q: Tarsometatarsal amputation is also known as?

Lisfranc amputation. ***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.

Q: 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?

Achilles tendon rupture. ***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.

Q: A 24-year-old woman experiences pain in the heel when walking uphill, which decreases when walking downhill. X-ray shows a bone spur. What is the diagnosis?

Calcaneal exostosis. ***Calcaneal exostosis*** - This condition involves a **bone spur** on the calcaneus, specifically at the insertion of the **Achilles tendon**. - The pain when walking uphill and improvement when walking downhill are classic signs because uphill walking increases **dorsiflexion** and tension on the Achilles tendon, irritating the spur. *Achilles tendinitis* - While Achilles tendinitis also causes **heel pain**, the primary issue is inflammation of the tendon itself, not necessarily an improvement with downhill walking. - The presence of a distinct bone spur on X-ray, as described, more directly points to mechanical irritation from an **exostosis**. *Plantar fasciitis* - This typically presents as **heel pain** that is worst with the first steps in the morning or after prolonged rest, and not specifically exacerbated by walking uphill or down. - The pain is usually located on the **underside of the heel**, not primarily described as an issue with Achilles tendon mechanics. *Osteomyelitis of calcaneum* - This is an **infection of the bone**, which would present with signs of systemic infection like fever, malaise, and severe, persistent pain that is not typically relieved by changing walking angles. - A bone spur on its own is not indicative of an **infection** without other signs and symptoms.

Question 1

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

Question 2

Bohler angle measurement gives the reference for ?

Accepted Answer

Calcaneus

Answer

Navicular

Answer

Talus

Answer

Cuboid

Question 3

Motorcyclist's fracture is:

Accepted Answer

Fracture of lateral process of talus

Answer

Fracture of medial malleolus

Answer

Fracture of calcaneus

Answer

Fracture of fifth metatarsal base

Question 4

The primary site of pathology in ankle arthritis is the:

Accepted Answer

Ankle

Answer

Hip

Answer

Wrist

Answer

Knee

Question 5

High stepping gait is due to

Accepted Answer

Foot drop

Answer

Gluteus maximum paralysis

Answer

CDH

Answer

Quadriceps paralysis

Question 6

What is the most common fracture resulting from a fall onto the feet?

Accepted Answer

Jones fracture

Answer

Calcaneal fracture

Answer

Lisfranc fracture

Answer

Ankle fracture

Question 7

Most common cause of insertional tendonitis of Achilles tendon is -

Accepted Answer

Overuse

Answer

Improper shoe wear

Answer

Runners and jumpers

Answer

Steroid injections

Question 8

Tarsometatarsal amputation is also known as?

Accepted Answer

Lisfranc amputation

Answer

Pirogoff amputation

Answer

Symes amputation

Answer

Chopart's amputation

Question 9

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?

Accepted Answer

Achilles tendon rupture

Answer

Deep vein thrombosis

Answer

Fracture calcaneus

Answer

Plantar fasciitis

Question 10

A 24-year-old woman experiences pain in the heel when walking uphill, which decreases when walking downhill. X-ray shows a bone spur. What is the diagnosis?

Accepted Answer

Calcaneal exostosis

Answer

Achilles tendinitis

Answer

Plantar fasciitis

Answer

Osteomyelitis of calcaneum

Foot and Ankle Surgery — MCQs

Foot and Ankle Surgery — MCQs

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