Ankle Sprains and Instability — MCQs
Deltoid ligament is attached to all, except which structure?
A ballet dancer presents with chronic anterolateral ankle pain. Most likely diagnosis?
A patient prescribed crutches for residual paralysis in poliomyelitis is a type of -
Sudden dorsiflexion of the foot may lead to which of the following injuries?
A 36-year-old man presents with an ankle injury sustained during a soccer match. What urgent intervention is required?
Patient had an injury to thumb causing thumb abduction. Which of the following can happen?
Which of the following ligaments is injured in an ankle inversion injury?
Which activity will be difficult to perform for a patient with an anterior cruciate deficient knee joint?
Which one of the following tests will you adopt while examining a knee joint where you suspect an old tear of anterior cruciate ligament?
Pivot shift test is positive with
Ankle Sprains and Instability Indian Medical PG Practice Questions and MCQs
Question 1: Deltoid ligament is attached to all, except which structure?
- A. Sustentaculum tali
- B. Medial cuneiform (Correct Answer)
- C. Navicular bone
- D. Medial malleolus
Explanation: ***Medial cuneiform*** - The **deltoid ligament** is located on the **medial side of the ankle** and primarily connects the **tibia** to several tarsal bones. It does not attach to the medial cuneiform. - The **medial cuneiform** is a midfoot bone primarily involved in the **tarsometatarsal joint** and is not a direct attachment site for the deltoid ligament. *Medial malleolus* - The **medial malleolus**, the distal end of the **tibia**, serves as the **proximal attachment point** for all four parts of the deltoid ligament. - This strong connection is crucial for **stabilizing the ankle joint** medially. *Navicular bone* - The **tibionavicular part** of the deltoid ligament attaches to the **tuberosity of the navicular bone**. - This attachment helps **limit excessive abduction** and **eversion** of the foot. *Sustentaculum tali* - The **tibiocalcaneal part** of the deltoid ligament attaches to the **sustentaculum tali** on the calcaneus. - This attachment provides significant stability to the **subtalar joint**.
Question 2: A ballet dancer presents with chronic anterolateral ankle pain. Most likely diagnosis?
- A. Lateral Ankle Sprain (Correct Answer)
- B. Calcaneal Stress Fracture
- C. Tibialis Posterior Tendinitis
- D. Anterior Ankle Impingement Syndrome
Explanation: **Lateral Ankle Sprain** - **Chronic anterolateral ankle pain** in a ballet dancer is highly suggestive of a **lateral ankle sprain**, often due to repetitive strain and instability. - Sprains commonly involve the **anterior talofibular ligament (ATFL)** and **calcaneofibular ligament (CFL)**, leading to persistent discomfort and potential functional deficits. *Calcaneal Stress Fracture* - A **calcaneal stress fracture** typically presents with **heel pain** that is worse with weight-bearing activities, rather than primarily anterolateral pain. - While common in athletes, the pain location is less consistent with the description in the question. *Tibialis Posterior Tendinitis* - **Tibialis posterior tendinitis** causes pain and tenderness along the **medial arch** and posterior aspect of the ankle, often associated with a **flatfoot deformity**. - The pain location described (anterolateral) does not align with the typical presentation of this condition. *Anterior Ankle Impingement Syndrome* - **Anterior ankle impingement syndrome** results from compression of soft tissues or bony spurs at the **anterior ankle joint**, typically causing pain with **dorsiflexion**. - While possible in a dancer, the presentation as chronic anterolateral pain without specific mention of dorsiflexion-related pain makes a lateral ankle sprain a more probable initial diagnosis.
Question 3: A patient prescribed crutches for residual paralysis in poliomyelitis is a type of -
- A. Disability limitation
- B. Primordial prevention
- C. Primary prevention
- D. Rehabilitation (Correct Answer)
Explanation: ***Rehabilitation*** - Rehabilitation is a component of **tertiary prevention** that aims to restore maximum functional ability after permanent damage has occurred from disease. - Providing crutches to a polio patient with **residual (established) paralysis** helps restore mobility and independence, allowing the patient to adapt to their permanent disability. - This intervention occurs **after the disease has run its course** and permanent sequelae have developed, which is the hallmark of rehabilitation. *Disability limitation* - Disability limitation is another component of **tertiary prevention** but focuses on **preventing progression or complications** of an already established disease. - It applies during the **disease active phase** to minimize further damage (e.g., physiotherapy during acute polio to prevent contractures, or strict glycemic control in diabetes to prevent complications). - In this case, the paralysis is **residual (fixed)**, not active, so we are beyond the disability limitation phase. *Primordial prevention* - Primordial prevention targets the underlying environmental and social determinants to prevent the emergence of risk factors at the population level. - This occurs **before any risk factors** for disease have developed (e.g., policies to prevent emergence of sedentary lifestyles). - Not applicable to a patient with established disease. *Primary prevention* - Primary prevention aims to prevent disease occurrence by reducing risk factors or increasing resistance (e.g., polio vaccination, health education). - This intervention is applied **before the disease occurs**, which is not the case for a patient with established paralysis from poliomyelitis.
Question 4: Sudden dorsiflexion of the foot may lead to which of the following injuries?
- A. Anterior talofibular ligament injury
- B. Tendo Achilles avulsion injury (Correct Answer)
- C. Rupture of deltoid ligament
- D. Tarsal tunnel syndrome
Explanation: ***Tendo Achilles avulsion injury*** - **Sudden dorsiflexion** of the foot, especially if forced or excessive, can cause extreme stretch on the **Achilles tendon**, potentially leading to its avulsion or rupture. - This mechanism often occurs during activities requiring a forceful push-off or landing with the foot in dorsiflexion, placing significant tensile stress on the tendon. *Anterior talofibular ligament injury* - This injury typically results from an **inversion sprain** of the ankle, where the foot is forcefully turned inward, causing damage to the lateral ankle ligaments. - **Dorsiflexion** alone is not the primary mechanism for injury to the **anterior talofibular ligament**. *Rupture of deltoid ligament* - The **deltoid ligament** is located on the medial side of the ankle and is most commonly injured with an **eversion sprain**, where the foot rolls outward. - While extreme dorsiflexion can put some strain on anterior fibers, it is not the primary mechanism, and a concomitant eversion force would likely be required for rupture. *Tarsal tunnel syndrome* - This condition involves **compression of the tibial nerve** as it passes through the tarsal tunnel, typically causing pain, numbness, and tingling in the sole of the foot. - It is often caused by chronic factors such as swelling, repetitive stress, or structural abnormalities, rather than an acute traumatic event like sudden dorsiflexion.
Question 5: A 36-year-old man presents with an ankle injury sustained during a soccer match. What urgent intervention is required?
- A. Performing a CT scan to assess the injury
- B. Manipulation to restore alignment
- C. Immediate reduction of the dislocation
- D. Applying a splint to stabilize the injury (Correct Answer)
Explanation: ***Applying a splint to stabilize the injury*** - **Splinting** is a crucial urgent intervention for an ankle injury to **immobilize** the affected joint, reducing pain and preventing further damage to soft tissues or bone fragments. - It provides temporary stability until a definitive diagnosis and treatment plan can be established. *Performing a CT scan to assess the injury* - A **CT scan** is a diagnostic tool used to visualize complex fractures or soft tissue injuries in detail, but it is not an urgent intervention for initial management. - While important for diagnosis, it should typically follow initial stabilization and clinical assessment. *Immediate reduction of the dislocation* - **Reduction** is an urgent intervention for **dislocations**, but the question describes an "ankle injury," which could be a sprain, fracture, or dislocation. **Reduction** is only appropriate if a **dislocation** is confirmed. - Attempting to reduce a potential fracture without imaging can cause further trauma or pain. *Manipulation to restore alignment* - **Manipulation to restore alignment** is typically reserved for **dislocations** or certain types of **fractures** after proper imaging has been performed to understand the extent and type of injury. - Similar to reduction, it is not the universal first urgent intervention for an undiagnosed ankle injury.
Question 6: Patient had an injury to thumb causing thumb abduction. Which of the following can happen?
- A. Kaplan lesion
- B. Game keepers thumb (Correct Answer)
- C. Mallet finger
- D. Bennett fracture
Explanation: ***Gamekeeper's thumb*** - A **Gamekeeper's thumb**, or **skier's thumb**, is an injury to the **ulnar collateral ligament (UCL)** of the thumb's metacarpophalangeal (MCP) joint. - This injury commonly occurs due to a **forceful abduction** and hyperextension of the thumb. *Kaplan lesion* - A **Kaplan lesion** refers to an avulsion fracture of the radial styloid process, usually associated with scaphoid fractures. - This lesion is typically related to wrist injuries, not primarily thumb abduction. *Bennett fracture* - A **Bennett fracture** is an intra-articular fracture at the base of the first metacarpal bone. - It usually results from an axial load applied to a partially flexed thumb, rather than pure abduction. *Mallet finger* - A **mallet finger** is an injury to the **extensor tendon** of the finger, causing the fingertip to remain in a flexed position. - This injury typically affects the distal interphalangeal (DIP) joint of any finger and is not directly related to thumb abduction.
Question 7: Which of the following ligaments is injured in an ankle inversion injury?
- A. Calcaneofibular ligament
- B. Posterior talofibular ligament
- C. Deltoid ligament
- D. Anterior talofibular ligament (Correct Answer)
Explanation: ***Anterior talofibular ligament*** - The **anterior talofibular ligament (ATFL)** is the most commonly injured ligament in an **ankle inversion sprain** due to its position and weaker structure. - It connects the **fibula** to the **talus** anteriorly, and when the foot inverts, this ligament is stretched and often torn first. *Calcaneofibular ligament* - The **calcaneofibular ligament (CFL)** is also an important lateral ankle ligament that can be injured in **severe inversion sprains**. - It is often damaged in conjunction with the ATFL, but typically only after the ATFL has already been compromised through an ankle inversion injury. *Posterior talofibular ligament* - The **posterior talofibular ligament (PTFL)** is the strongest of the **lateral collateral ligaments** and is rarely injured in isolation. - Injury to the PTFL usually occurs in cases of **severe, high-grade ankle dislocations** or very forceful inversion injuries, often involving other ligaments. *Deltoid ligament* - The **deltoid ligament** is a strong, fan-shaped ligament located on the **medial side of the ankle**. - It resists **eversion** of the ankle, meaning it is more commonly injured in **eversion sprains**, not inversion sprains.
Question 8: Which activity will be difficult to perform for a patient with an anterior cruciate deficient knee joint?
- A. Getting up from a sitting position
- B. Walk downhill (Correct Answer)
- C. Walk uphill
- D. Sitting cross-legged
Explanation: ***Walk downhill*** - An **anterior cruciate ligament (ACL) deficient knee** experiences anterior tibial translation, especially when the muscles can't compensate, leading to instability. - Walking downhill places higher **anterior shear forces** on the knee joint and often involves knee extension or hyperextension, which dramatically increases the risk of the tibia translating anteriorly relative to the femur. *Getting up from a sitting position* - This activity primarily involves **quadriceps muscle contraction** and a concentric movement of the knee, which stabilizes the joint. - It does not typically place significant **anterior shear stress** on the ACL, even in a deficient knee. *Walk uphill* - Walking uphill often involves knee flexion and places the knee in a more protected position against **anterior tibial translation**. - The quadriceps and hamstrings work synergistically to **stabilize the joint** during this motion, reducing stress on the ACL. *Sitting cross-legged* - This position primarily involves **hip and knee flexion and external rotation**, but it is generally a static and non-weight-bearing position. - It does not impose significant **dynamic loads** or shear forces that would cause instability in an ACL-deficient knee.
Question 9: Which one of the following tests will you adopt while examining a knee joint where you suspect an old tear of anterior cruciate ligament?
- A. Mc Murray test
- B. Lachman test (Correct Answer)
- C. Pivot shift test
- D. Posterior drawer test
Explanation: ***Lachman test*** - The **Lachman test** is considered the most sensitive and reliable test for detecting an **anterior cruciate ligament (ACL) tear**, especially in the acute setting or for an old tear. - It assesses the **anterior translation of the tibia** on the femur at 20-30 degrees of flexion, minimizing hamstring guarding and improving diagnostic accuracy for subtle instabilities. *Mc Murray test* - The **McMurray test** is primarily used to detect **meniscal tears**, not ACL tears. - It involves internally and externally rotating the tibia while extending the knee to elicit a click or pain due to a torn meniscus. *Pivot shift test* - The **pivot shift test** is highly specific for an **ACL tear** but is often difficult to perform and requires a fully relaxed patient, sometimes necessitating anesthesia. - It detects rotatory instability and gives a clinical indication of the degree of **anterolateral rotatory instability** caused by an ACL tear. *Posterior drawer test* - The **posterior drawer test** is used to assess the integrity of the **posterior cruciate ligament (PCL)**. - It involves pushing the tibia posteriorly on the femur at 90 degrees of knee flexion to check for excessive posterior translation.
Question 10: Pivot shift test is positive with
- A. Posterior cruciate ligament tear
- B. Anterior cruciate ligament tear (Correct Answer)
- C. Medial meniscus injury
- D. Lateral meniscus injury
Explanation: **Anterior cruciate ligament tear** - The **pivot shift test** is a specific clinical examination maneuver used to detect **rotary knee instability** caused by an **ACL tear**. - It demonstrates the feeling of the tibia subluxing anteriorly on the femur during knee extension and then reducing with flexion, indicative of ACL insufficiency. *Posterior cruciate ligament tear* - PCL tears are primarily assessed using the **posterior drawer test** or **posterior sag sign**. - The pivot shift test is not designed to evaluate the stability provided by the PCL. *Medial meniscus injury* - Meniscal injuries are typically assessed with tests like **McMurray's test** or **Apley's compression test**, which elicit pain or clicking. - While meniscal tears can contribute to knee instability, the pivot shift test specifically targets rotatory instability associated with ACL deficiency. *Lateral meniscus injury* - Similar to medial meniscus injuries, lateral meniscal tears are identified through specific maneuvers like McMurray's test, focusing on pain and clicking during rotation and flexion/extension. - The pivot shift test is not a primary diagnostic tool for isolated meniscal pathology.
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