Foot and Ankle Surgery Practice Questions

Q: What is the recommended treatment for a complete rupture of the tendo calcaneum?

Surgical repair. **Explanation:** **Tendo Calcaneum (Achilles tendon) rupture** is a common injury, typically occurring 2–6 cm proximal to its insertion on the calcaneus (the watershed area). For a **complete rupture**, surgical repair is the preferred treatment, especially in young, active individuals and athletes. **1. Why Surgical Repair is Correct:** Surgical repair (primary end-to-end anastomosis) is the gold standard because it restores the optimal length-tension relationship of the gastrocnemius-soleus complex. Compared to conservative management, surgery significantly **reduces the rate of re-rupture** (approx. 2–5% vs. 10–15% in conservative) and provides superior plantar flexion strength, allowing a faster return to sports. **2. Why Other Options are Incorrect:** * **Observation (A):** A complete rupture will not heal spontaneously with functional strength; it leads to permanent disability and a "calcaneus gait." * **Physiotherapy alone (B):** While rehab is vital *after* surgery or casting, it cannot bridge a complete gap in the tendon. Conservative management requires immobilization in an equinus cast, not just physiotherapy. * **Arthrodesis (C):** This is joint fusion (e.g., ankle or subtalar). It is not indicated for a soft tissue tendon injury unless there is associated end-stage arthritis. **Clinical Pearls for NEET-PG:** * **Simmonds/Thompson Test:** The most reliable clinical test. Squeezing the calf fails to produce plantar flexion of the foot. * **Matles Test:** With the patient prone and knees flexed to 90°, the affected foot is more dorsiflexed than the normal side. * **Drug Association:** Fluoroquinolones (e.g., Ciprofloxacin) and systemic steroids increase the risk of rupture. * **Radiology:** Ultrasound is the initial investigation, but **MRI** is the gold standard for differentiating partial from complete tears.

Q: A patient presents with a hindfoot deformity requiring triple arthrodesis. Which of the following bones are fused in a triple arthrodesis?

Subtalar, Calcaneocuboid, Talonavicular. ### Explanation **Triple arthrodesis** is a surgical procedure designed to stabilize the hindfoot, correct deformities, and relieve pain by fusing three specific joints. Despite the name "triple," it involves the fusion of **four bones** across **three joint complexes**. #### 1. Why Option A is Correct The procedure targets the joints responsible for inversion and eversion of the foot. The three joints fused are: * **Subtalar joint** (between the Talus and Calcaneus) * **Talonavicular joint** (between the Talus and Navicular) * **Calcaneocuboid joint** (between the Calcaneus and Cuboid) By fusing these joints, the hindfoot is locked into a neutral position, providing a stable base for weight-bearing, though at the cost of losing side-to-side (inversion/eversion) motion. #### 2. Why Other Options are Incorrect * **Options B & C:** Both include the **Tibiofibular joint** (specifically the distal syndesmosis or the ankle joint/Tibiotalar joint). Fusing the ankle joint is termed an *Ankle Arthrodesis*, not a triple arthrodesis. Triple arthrodesis specifically preserves the ankle joint to maintain dorsiflexion and plantarflexion. #### 3. Clinical Pearls for NEET-PG * **Indications:** Rigid flatfoot (Pes Planus), Charcot-Marie-Tooth disease, severe rheumatoid arthritis, or neglected clubfoot. * **Sequence of Fusion:** In surgery, the joints are usually prepared in the order: Subtalar → Calcaneocuboid → Talonavicular. However, they are **fixed** in the reverse order (Talonavicular first) to ensure proper alignment. * **Position of Fusion:** The foot should be fused in **5° of valgus**, neutral dorsiflexion, and 10° of external rotation. * **High-Yield Fact:** The Talonavicular joint is considered the "key" to the triple arthrodesis; if this joint is not correctly aligned, the entire foot remains deformed.

Q: A 22-year-old athlete sustained a twisting injury to his right ankle, resulting in significant swelling around the medial malleolus. An X-ray revealed no fracture. Which structure is most likely injured?

Deltoid ligament. ### Explanation **Correct Option: D. Deltoid Ligament** The **Deltoid ligament** is a strong, fan-shaped ligament located on the **medial side** of the ankle joint. It consists of superficial and deep fibers that resist eversion (outward turning) of the foot. In this clinical scenario, the patient presents with swelling specifically around the **medial malleolus** following a twisting injury. Since the X-ray ruled out a fracture (such as a medial malleolus avulsion), the most likely diagnosis is a medial ankle sprain involving the Deltoid ligament. **Analysis of Incorrect Options:** * **A. Tendo Achilles:** This is the thickest tendon in the body, located **posteriorly**. Injury typically presents with pain at the heel, a palpable gap, and a positive Thompson (Simmonds) test, rather than medial swelling. * **B. Spring Ligament (Plantar Calcaneonavicular):** While located medially, it supports the medial longitudinal arch. Chronic injury leads to flatfoot deformity (pes planus). It is less commonly the primary site of acute swelling compared to the deltoid ligament in eversion injuries. * **C. Anterior Talofibular Ligament (ATFL):** This is the **most commonly injured ligament** in the ankle, but it is located on the **lateral side**. It is injured during inversion (supination) injuries, causing swelling near the lateral malleolus. **High-Yield Clinical Pearls for NEET-PG:** * **Mechanism of Injury:** Inversion injuries (most common) affect lateral ligaments (ATFL > CFL); Eversion injuries affect the Deltoid ligament. * **Ottawa Ankle Rules:** Used to determine if an X-ray is required (tenderness at the posterior edge of malleoli or inability to bear weight). * **Pott’s Fracture:** Often involves a Deltoid ligament tear associated with a fibular fracture. * **Stability:** The Deltoid ligament is so strong that eversion forces often result in a medial malleolus avulsion fracture rather than a pure ligamentous tear.

Q: Radiographic examination of a woman with foot pain reveals a neuroma. What is the most typical location of this neuroma?

Between the third and fourth metatarsophalangeal joints. **Explanation:** The clinical scenario describes **Morton’s Neuroma**, which is not a true neoplasm but rather a perineural fibrosis and degeneration of the common digital nerve. **1. Why Option A is Correct:** The most common location for Morton’s Neuroma is the **third intermetatarsal space** (between the 3rd and 4th metatarsal heads). This predilection occurs due to two anatomical factors: * **Nerve Thickness:** The third digital nerve is often thicker because it receives communicating branches from both the medial and lateral plantar nerves. * **Mechanical Stress:** The third space is more mobile compared to the relatively fixed second space, leading to chronic compression of the nerve against the deep transverse metatarsal ligament during the toe-off phase of walking. **2. Analysis of Incorrect Options:** * **Option B (2nd & 3rd space):** This is the second most common site. While it occurs frequently, it is statistically less common than the third space. * **Options C & D (1st/2nd and 4th/5th spaces):** These are extremely rare locations for a neuroma. Pain in the first space is more likely related to hallux valgus or sesamoiditis, while fifth-space pain often suggests a tailor’s bunion. **3. NEET-PG High-Yield Pearls:** * **Demographics:** Most common in middle-aged women, often exacerbated by narrow, high-heeled shoes. * **Clinical Sign:** **Mulder’s Click** – A palpable click or "pop" felt when squeezing the metatarsal heads together while applying pressure to the interspace. * **Diagnosis:** Primarily clinical; however, Ultrasound or MRI can be used for confirmation. * **Treatment:** Initial management includes wide-toe-box shoes and metatarsal pads. Refractory cases require surgical excision of the nerve.

Q: Which of the following best describes a toe deformity where there is hyperextension at the metatarsophalangeal joint, flexion at the proximal interphalangeal joint, and flexion at the distal interphalangeal joint?

Claw toe. To master toe deformities for NEET-PG, it is essential to focus on the specific position of the three joints: the Metatarsophalangeal (MTP), Proximal Interphalangeal (PIP), and Distal Interphalangeal (DIP) joints. ### **Explanation of the Correct Answer** **A. Claw Toe:** This deformity is characterized by **MTP hyperextension**, **PIP flexion**, and **DIP flexion**. It typically involves all the lesser toes and is often associated with neuromuscular disorders (like Charcot-Marie-Tooth disease) or inflammatory conditions (like Rheumatoid Arthritis). The underlying pathology involves an imbalance between the extrinsic and intrinsic muscles of the foot. ### **Analysis of Incorrect Options** * **B. Hammer Toe:** This involves **MTP hyperextension**, **PIP flexion**, but the **DIP joint is neutral or hyperextended**. It most commonly affects the second toe and is often associated with a long second metatarsal or hallux valgus. * **C. Mallet Toe:** This is an isolated flexion deformity of the **DIP joint** only. The MTP and PIP joints remain in a neutral position. It is often caused by pressure from ill-fitting shoes. * **D. Curly Toe:** A congenital condition, usually affecting the 3rd, 4th, or 5th toes, characterized by flexion and medial rotation of the PIP and DIP joints. ### **High-Yield Clinical Pearls for NEET-PG** * **Mnemonic for Claw vs. Hammer:** In **Claw** toe, the tip of the toe digs into the sole (DIP flexion), whereas in **Hammer** toe, the tip usually points straight or up (DIP neutral/extension). * **Friedreich’s Ataxia:** Frequently presents with bilateral claw toes and high-arched feet (Pes Cavus). * **Girdlestone-Taylor Procedure:** A high-yield surgical fix for flexible claw/hammer toes involving the transfer of the Flexor Digitorum Longus (FDL) tendon to the extensor expansion.

Q: What does equinus deformity refer to?

Plantar flexion at the ankle. **Explanation:** **Equinus deformity** refers to a condition where the foot is held in a position of **plantar flexion** at the ankle joint. The term is derived from the Latin word *equus* (horse), as the patient walks on their toes with the heel unable to touch the ground, mimicking the gait of a horse. This is typically caused by tightness or contracture of the **Tendo-Achilles** or the gastrocnemius-soleus complex. **Analysis of Options:** * **Option C (Correct):** Plantar flexion is the downward movement of the foot. In equinus, the ankle cannot be dorsiflexed to a neutral position (90°), resulting in a fixed plantar-flexed posture. * **Option A & B:** Inversion (turning inward) and Eversion (turning outward) are movements that primarily occur at the **subtalar and midtarsal joints**, not the ankle joint proper. * **Option D:** Dorsiflexion is the upward movement of the foot. A fixed dorsiflexion deformity is known as **Calcaneus deformity** (often seen in paralytic conditions like Polio). **High-Yield Clinical Pearls for NEET-PG:** 1. **CTEV (Clubfoot):** Equinus is one of the four primary components of Congenital Talipes Equinovarus, represented by the mnemonic **CAVE** (Cavus, Adduction, Varus, **Equinus**). Equinus is the last component to be corrected in the Ponseti technique. 2. **Silfverskiöld Test:** Used to differentiate between isolated gastrocnemius contracture and global Achilles tendon tightness. If equinus improves with knee flexion, only the gastrocnemius is tight. 3. **Gait:** Equinus deformity leads to a "Toe-walking" gait and can cause secondary compensatory changes like genu recurvatum (knee hyperextension).

Q: The angle of Gissane is associated with which bone?

Calcaneus. The **Angle of Gissane** (also known as the "Crucial Angle") is a vital radiographic landmark used in the evaluation of **calcaneal fractures**. ### 1. Why Calcaneus is Correct The Angle of Gissane is formed by the downward slope of the calcaneal thalami (the floor of the sinus tarsi) and the upward slope of the posterior facet of the calcaneus. On a lateral X-ray, it normally measures between **120° and 145°**. In intra-articular calcaneal fractures, this angle typically increases as the posterior facet is depressed or crushed, signaling a disruption of the subtalar joint. ### 2. Why Other Options are Incorrect * **Talus:** While the talus sits directly above the calcaneus to form the subtalar joint, the specific anatomical landmarks defining the Angle of Gissane are intrinsic to the calcaneus. (Note: The *Angle of Hawkins* is associated with the talus). * **Navicular & Cuboid:** These are midfoot bones. While they are part of the Chopart joint complex along with the calcaneus and talus, they do not contribute to the measurement of Gissane’s angle. ### 3. Clinical Pearls for NEET-PG * **Bohler’s Angle:** Another critical calcaneal measurement (Normal: **20°–40°**). In fractures, Bohler’s angle **decreases**, whereas Gissane’s angle **increases**. * **Mondor’s Sign:** Ecchymosis extending to the sole of the foot, highly suggestive of a calcaneal fracture. * **Associated Injuries:** Always look for "Don Juan Syndrome"—calcaneal fractures are frequently associated with compression fractures of the **lumbar spine (L1)** due to axial loading (e.g., falling from a height). * **Imaging Gold Standard:** While X-rays are initial, **CT scan** is the gold standard for classification (Sanders Classification).

Q: A 45-year-old man presents with intense pain in his left calf and ankle after playing tennis. He reports hearing a "snap" during a forward lunge, followed by falling to the ground in severe pain and inability to walk. Examination reveals a tender and indurated left calf with an irregular mass in the posterior mid-calf area. What type of excessive abnormal ankle movement would be present?

Dorsiflexion. ### Explanation **Diagnosis: Acute Achilles Tendon Rupture** The clinical presentation of a middle-aged man hearing a "snap" or "pop" during a sudden acceleration (lunge), followed by a palpable gap or mass in the calf and inability to plantarflex, is classic for an **Achilles tendon rupture**. **1. Why Dorsiflexion is the Correct Answer:** The Achilles tendon (formed by the gastrocnemius and soleus muscles) is the primary **plantarflexor** of the ankle and acts as the "posterior restraint" to ankle movement. When this tendon is ruptured, the counter-traction against the anterior leg muscles is lost. Consequently, the ankle can be passively or actively moved into **excessive dorsiflexion** because there is no intact posterior structure to limit the upward movement of the foot. **2. Why the Other Options are Incorrect:** * **Plantar flexion:** This movement is severely **weakened or lost**, not excessive. The patient will be unable to "push off" or stand on their toes. * **Inversion and Eversion:** These movements occur primarily at the subtalar joint and are controlled by the Tibialis posterior and Peroneal muscles, respectively. While they may be painful, their range of motion is not characteristically increased by an Achilles rupture. **3. NEET-PG High-Yield Pearls:** * **Simmonds/Thompson Test:** The most reliable clinical test. With the patient prone, squeezing the calf fails to produce passive plantarflexion of the foot (Positive test). * **Matles Test:** Increased passive dorsiflexion when the patient lies prone with knees flexed to 90°. * **Demographics:** Most common in "weekend warriors" (middle-aged athletes) and associated with **Fluoroquinolone** (e.g., Ciprofloxacin) use or local steroid injections. * **Management:** Usually involves surgical repair in young athletes or functional bracing in sedentary individuals.

Q: Inversion injury at the ankle can cause all of the following injuries except?

Sprain of the Extensor Digitorum Brevis. **Explanation:** Inversion injuries of the ankle occur when the foot rolls inward, placing sudden tension on the lateral structures and compression on the medial structures. **Why Option C is the correct answer:** The **Extensor Digitorum Brevis (EDB)** is a muscle located on the dorsum of the foot. While an inversion injury can cause an avulsion fracture at the EDB's origin on the calcaneus (often mistaken for an ankle sprain), the term "sprain" specifically refers to the stretching or tearing of **ligaments**, not muscles or tendons. Muscles undergo "strains." Therefore, "sprain of the EDB" is terminology-wise incorrect and clinically not a standard consequence of inversion compared to the other bony and ligamentous injuries listed. **Analysis of Incorrect Options:** * **A. Fracture of the tip of the lateral malleolus:** This is a classic result of inversion. The tension on the calcaneofibular or anterior talofibular ligaments leads to an **avulsion fracture** of the fibular tip. * **B. Fracture of the base of the 5th metatarsal:** Often called a **"Pseudo-Jones" fracture**, this occurs when the **Peroneus Brevis** tendon or the lateral band of the plantar fascia avulses the styloid process of the 5th metatarsal during sudden inversion. * **D. Fracture of the sustentaculum tali:** During severe inversion, the talus can rotate and exert significant compressive force against the medial side of the calcaneus, specifically the sustentaculum tali, leading to a fracture. **High-Yield Clinical Pearls for NEET-PG:** * **Most common ligament injured in inversion:** Anterior Talofibular Ligament (ATFL). * **Ottawa Ankle Rules:** Used to determine if an X-ray is required (tenderness at the posterior edge of malleoli, base of 5th metatarsal, or navicular). * **Snowboarder’s Fracture:** Fracture of the lateral process of the talus (often mimics a lateral ankle sprain).

Q: Which of the following is true about acute rupture of the tendo calcaneus (Achilles tendon)?

It usually occurs in middle-aged persons.. ### Explanation **1. Why Option D is Correct:** Acute rupture of the Achilles tendon (Tendo Calcaneus) typically occurs in **middle-aged individuals (30–50 years)**, often referred to as "weekend warriors." These are individuals who lead sedentary lifestyles but engage in sudden, strenuous physical activity. The rupture usually occurs 2–6 cm proximal to the calcaneal insertion (the "watershed area"), where the blood supply is poorest and age-related degenerative changes (tendinosis) are most prevalent. **2. Why Other Options are Incorrect:** * **Option A:** Rupture most commonly occurs due to **indirect injury**, such as sudden forced plantarflexion of the foot or unexpected dorsiflexion while the calf muscle is contracted. Direct trauma is a rare cause. * **Option B:** The diagnosis is primarily **clinical**. While ultrasound or MRI can be used for confirmation in ambiguous cases, a plain radiograph is generally unremarkable (except for the loss of Kager’s fat pad shadow) and cannot "confirm" a soft tissue rupture. * **Option C:** This describes a **negative Thompson Test**. In a complete rupture, compression of the calf muscles **fails** to produce plantarflexion. If plantarflexion occurs, the tendon is likely intact. **3. High-Yield Clinical Pearls for NEET-PG:** * **Simmonds/Thompson Test:** The gold standard clinical test. Squeezing the calf with the patient prone fails to produce plantarflexion. * **Matles Test:** With the patient prone and knees flexed to 90°, the affected foot will lie in more dorsiflexion compared to the normal side. * **Clinical Presentation:** Patients often report a sensation of being "kicked or shot in the heel" followed by a palpable gap (the "hatchet strike" defect). * **Management:** Non-operative (functional bracing) or operative repair depending on the patient's activity level and age.

Question 1

What is the recommended treatment for a complete rupture of the tendo calcaneum?

Accepted Answer

Surgical repair

Answer

Observation and no intervention

Answer

Physiotherapy alone

Answer

Arthrodesis

Question 2

A patient presents with a hindfoot deformity requiring triple arthrodesis. Which of the following bones are fused in a triple arthrodesis?

Accepted Answer

Subtalar, Calcaneocuboid, Talonavicular

Answer

Subtalar, Tibiofibular, Calcaneocuboid

Answer

Tibiofibular, Talonavicular, Subtalar

Answer

None of the above

Question 3

A 22-year-old athlete sustained a twisting injury to his right ankle, resulting in significant swelling around the medial malleolus. An X-ray revealed no fracture. Which structure is most likely injured?

Accepted Answer

Deltoid ligament

Answer

Tendo Achilles

Answer

Spring ligament

Answer

Anterior talofibular ligament

Question 4

Radiographic examination of a woman with foot pain reveals a neuroma. What is the most typical location of this neuroma?

Accepted Answer

Between the third and fourth metatarsophalangeal joints

Answer

Between the second and third metatarsophalangeal joints

Answer

Between the first and second metatarsophalangeal joints

Answer

Between the fourth and fifth metatarsophalangeal joints

Question 5

Which of the following best describes a toe deformity where there is hyperextension at the metatarsophalangeal joint, flexion at the proximal interphalangeal joint, and flexion at the distal interphalangeal joint?

Accepted Answer

Claw toe

Answer

Hammer toe

Answer

Mallet toe

Answer

Curly toe

Question 6

What does equinus deformity refer to?

Accepted Answer

Plantar flexion at the ankle

Answer

Inversion of the foot

Answer

Eversion of the foot

Answer

Dorsiflexion at the ankle

Question 7

The angle of Gissane is associated with which bone?

Accepted Answer

Calcaneus

Answer

Talus

Answer

Navicular

Answer

Cuboid

Question 8

A 45-year-old man presents with intense pain in his left calf and ankle after playing tennis. He reports hearing a "snap" during a forward lunge, followed by falling to the ground in severe pain and inability to walk. Examination reveals a tender and indurated left calf with an irregular mass in the posterior mid-calf area. What type of excessive abnormal ankle movement would be present?

Accepted Answer

Dorsiflexion

Answer

Plantar flexion

Answer

Inversion

Answer

Eversion

Question 9

Inversion injury at the ankle can cause all of the following injuries except?

Accepted Answer

Sprain of the Extensor Digitorum Brevis

Answer

Fracture of the tip of the lateral malleolus

Answer

Fracture of the base of the 5th metatarsal

Answer

Fracture of the sustentaculum tali

Question 10

Which of the following is true about acute rupture of the tendo calcaneus (Achilles tendon)?

Accepted Answer

It usually occurs in middle-aged persons.

Answer

It occurs due to direct injury.

Answer

Radiograph will confirm the diagnosis.

Answer

Compression of calf muscles produces plantarflexion of the ankle.

Foot and Ankle Surgery — MCQs

Foot and Ankle Surgery — MCQs

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