Exam Corner 

Foot & Ankle

Prepared by Mohamed Sukeik
SICOT Associate Member & SICOT Newsletter Associate Editor – London, United Kingdom

 

Questions

  1. Which of the following structures locks the transverse tarsal joints during toe-off phase of gait?

    1. Anterior tibialis tendon

    2. Posterior tibialis tendon

    3. Extensor hallucis longus

    4. Peroneus longus

    5. Peroneus brevis
       

  2. The Lisfranc ligament runs from: 

    1. ​Medial cuneiform to base of the first metatarsal

    2. Medial cuneiform to dorsum of the second metatarsal

    3. Medial cuneiform to base of the second metatarsal

    4. Middle cuneiform to dorsum of the second metatarsal

    5. Middle cuneiform to base of the second metatarsal
       

  3. Which of the following is more commonly involved in stress fractures?

    1. First metatarsal

    2. Second metatarsal

    3. Third metatarsal

    4. Fourth metatarsal

    5. Fifth metatarsal
       

  4. During the Heel-strike phase of gait which of the following is true?

    1. The anterior tibialis contracts concentrically

    2. The anterior tibialis contracts eccentrically

    3. Gastrocnemius-soleus complex contracts concentrically

    4. Gastrocnemius-soleus complex contracts eccentrically

    5. Hindfoot is locked/inverted for energy absorption
       

  5. During the Foot-flat phase of gait which of the following is true?

    1. The anterior tibialis contracts concentrically

    2. The anterior tibialis contracts eccentrically

    3. Gastrocnemius-soleus complex contracts concentrically

    4. Gastrocnemius-soleus complex contracts eccentrically

    5. Hindfoot is locked/inverted for ground accommodation
       

  6. During the Toe-off phase of gait which of the following is true?

    1. The anterior tibialis contracts concentrically

    2. The anterior tibialis contracts eccentrically

    3. Gastrocnemius-soleus complex contracts concentrically

    4. Gastrocnemius-soleus complex contracts eccentrically

    5. Hindfoot is unlocked/everted for ground accommodation
       

  7. Common deformities seen in a rheumatoid foot include all of the following except?

    1. Hammer toes

    2. Claw toes

    3. Hallux varus

    4. MTPJ dislocations

    5. Pes planovalgus
       

  8. The position for arthrodesis of the hindfoot is:

    1. 0-5 degrees hindfoot valgus, neutral abduction/adduction and plantigrade

    2. 0-5 degrees hindfoot valgus, 5 degrees abduction and 5 degrees plantar flexion

    3. 0-5 degrees hindfoot varus, neutral abduction/adduction and plantigrade

    4. 0-5 degrees hindfoot varus, 5 degrees abduction and plantigrade

    5. 0-5 degrees hindfoot valgus, 5 degrees adduction and 5 degrees dorsiflexion
       

  9. Baxter neuritis presents with plantar medial heel pain and is caused by compression of which of the following?

    1. Medial plantar nerve

    2. Lateral plantar nerve

    3. Tibial nerve

    4. Sural nerve

    5. Saphenous nerve
       

  10. Grade 3 according to Wagner Meggitt classification of foot ulcerations include?

    1. Superficial ulcer

    2. Ulcer with exposed bone/osteomyelitis or abscess

    3. Deep ulcer

    4. Local gangrene

    5. Whole foot gangrene
       

  11. Which of the following classification systems address osteoarthritis of the first metatarsophalangeal joint?

    1. Hattrup and Johnson

    2. Johnson and Myerson

    3. Berndt and Harty

    4. Hepple

    5. Eichenholtz
       

  12. In diabetic neuropathy, all of the following are true except:

    1. 90% of patients who cannot feel a 5.07 monofilament have lost protective sensation of their feet and are at risk of ulceration

    2. Small intrinsic musculature of the foot are affected resulting in claw toes and ulcers

    3. Minimum absolute toe pressures for healing is 40mmHg

    4. Transcutaneous oxygen pressure of the toes <40mmHg has been found to be predictive of healing

    5. In the coalescence phase, less inflammation, less swelling and less erythema are expected
       

  13. In talar fractures, all of the following are true except:

    1. Constitute less than 1% of all fractures and second among all tarsal fractures

    2. Blood supply is provided by the posterior tibial artery, the dorsalis pedis artery and the perforating peroneal artery

    3. The arteries of the tarsal sinus, tarsal canal and the deltoid are important branches of the main vessels

    4. The artery to the tarsal sinus carries the main supply to the talar body

    5. In type II Hawkin fracture, the only remaining blood supply comes from the deltoid branch of the posterior tibial artery
       

  14. In calcaneal fractures, all of the following are true except:

    1. Extraarticular fractures with significant displacement may endanger posterior skin 

    2. Lateral wall blow out causes subfibular impingement

    3. Disruption of the medial soft tissue does not increase the operative complication rate as opposed to lateral soft tissue trauma

    4. Delayed wound healing after operative fixation can occur in 25% of patients undergoing an extensile lateral approach. However, deep infection is much lower at 1-4%.

    5. EHL is at risk during placement of screws from lateral to medial at the level of the sustentaculum constant fragment
       

  15. In subtalar dislocations, all of the following are true except:

    1. Lateral dislocations are more common than medial dislocations

    2. In medial dislocations, obstacles to reduction include extensor digitorum brevis, the extensor retinaculum and peroneal tendons

    3. In lateral dislocations, obstacles to reduction include posterior tibial tendon and flexor hallucis longus tendon

    4. CT scan is recommended to rule out small intraarticular fragments

    5. Reduction can be accomplished under sedation or general anaesthesia
       

  16. In hallux valgus, all of the following are true except:

    1. The pathophysiology is likely multifactorial

    2. Dorsolateral migration of abductor hallucis causes the muscle to pronate the phalanx

    3. First metatarsal head moves medially off the sesamoids, increasing the intermetatarsal angle

    4. Secondary contractures of the lateral capsule, adductor hallucis, lateral metatarsal-sesamoid ligament and intermetatarsal ligament occurs

    5. The metatarsophalangeal joint may or may not remain congruent
       

  17. In Charcot-Marie-Tooth (CMT) disease, all of the following are true except:

    1. It is the most common inherited progressive neuropathy affecting 1 in 2500 people

    2. Type I is the most common presentation of CMT

    3. Tibialis posterior and peroneus brevis are weak

    4. First ray is plantar flexed due to relatively unopposed peroneus longus

    5. Intrinsic wasting leads to overpull of extrinsics causing claw-toe deformities
       

  18. In rheumatoid arthritis, all of the following are true except:

    1. It is a chronic, symmetric polyarthropathy that most commonly presents in the third and fourth decades

    2. More common in females

    3. Forefoot is less commonly involved than midfoot or hindfoot

    4. Toes sublux or dislocate dorsally, deviate laterally into valgus, and develop hammering

    5. Pes planovalgus may be midfoot or hindfoot driven
       

  19. In hallux rigidus, all of the following are true except:

    1. Osteoarthritis of the interphalangeal joint affects treatment options

    2. Position for fusion is 10-15 degrees of dorsiflexion and slight valgus

    3. Silicon arthroplasty is a well recognised and accepted treatment

    4. Cheilectomy is performed for early stages of the disease for dorsal osteophytes formation

    5. Patients present with pain, swelling and a positive grind test
       

  20. Regarding pes planus, all of the following are correct except:

    1. Most common cause of adult acquired pes planus is tibialis posterior tendon dysfunction

    2. The presence of gastrocnemius contracture should be assessed and corrected with a gastrocnemius recession if present

    3. A negative lateral talo-first metatarsal angle and talonavicular uncoverage are common radiological findings

    4. A cotton osteotomy is used to dorsiflex the first ray

    5. FDL or FHL tendon transfers are used for stage II disease

Answers

  1. b
    During toe-off, the transverse tarsal joints become divergent and lock, providing stiffness to the foot for forward propulsion. Failure of the posterior tibialis tendon to lock those joints is the biomechanical aetiology for lack of a heel-rise in patients with tibialis posterior tendon dysfunction.
    Reference: Review of Orthopaedics, Miller

  2. c
    The Lisfranc ligament runs from the medial cuneiform to base of the second metatarsal.
    Reference: Review of Orthopaedics, Miller

  3. b
    The first metatarsal is the widest and shortest and bears 50% of the weight during gait. The second metatarsal is usually the longest and experiences more stress than other lesser metatarsals.
    Reference: Review of Orthopaedics, Miller

  4. b
    During the Heel-strike phase of gait the anterior tibialis contracts eccentrically and the Hindfoot is unlocked/everted for energy absorption.
    Reference: Review of Orthopaedics, Miller

  5. d
    During the Foot-flat phase of gait the Gastrocnemius-soleus complex contracts eccentrically and the hindfoot is unlocked/everted for ground accommodation.
    Reference: Review of Orthopaedics, Miller

  6. c
    During the Toe-off phase of gait Gastrocnemius-soleus complex contracts concentrically and the hindfoot is locked/inverted to  provide a rigid lever arm for toe-off.
    Reference: Review of Orthopaedics, Miller

  7. c
    A Hallux valgus as opposed to a Hallux varus deformity is common in rheumatoid patients.
    Reference: Review of Orthopaedics, Miller

  8. a
    Hind foot fusion position is 0-5 degrees hindfoot valgus, neutral abduction/adduction and plantigrade. All other options are incorrect.
    Reference: Review of Orthopaedics, Miller

  9. b
    Baxter neuritis presents with plantar medial heel pain and is caused by compression of the first branch of the lateral plantar nerve.
    Reference: Review of Orthopaedics, Miller

  10. b
    0. Foot at risk; 1. Superficial ulcer; 2. Deep ulcer; 3. Ulcer with exposed bone/osteomyelitis or abscess; 4. Local gangrene; 5. Whole foot gangrene.
    Reference: Surgical Exposures in Orthopaedics, Hoppenfeld

  11. a
    Hattrup and Johnson: 1st MTPJ osteoarthritis; Johnson and Myerson: Pes planus; Berndt and Harty and Hepple: Osteochondral lesions of the ankle; Eichenholtz: Charcot arthropathy.
    Reference: Review of Orthopaedics, Miller

  12. d
    Transcutaneous oxygen pressure of the toes >40mmHg has been found to be predictive of healing.
    Reference: Review of Orthopaedics, Miller

  13. d
    The artery to the tarsal canal carries the main supply to the talar body.
    Reference: Review of Orthopaedics, Miller

  14. e
    FHL is at risk during placement of screws from lateral to medial at the level of the sustentaculum constant fragment.
    Reference: Review of Orthopaedics, Miller

  15. a
    Medial dislocations are more common than lateral dislocations.
    Reference: Review of Orthopaedics, Miller

  16. b
    Plantar-lateral migration of abductor hallucis causes the muscle to pronate the phalanx.
    Reference: Review of Orthopaedics, Miller

  17. c
    Tibialis anterior and peroneus brevis are weak.
    Reference: Review of Orthopaedics, Miller

  18. c
    Forefoot is more commonly involved than midfoot or hindfoot.
    Reference: Review of Orthopaedics, Miller

  19. c
    Silicone arthroplasty is not recommended due to silicone synovitis and associated osteolysis which result in pain, metatarsalgia and poor results of subsequent fusion.
    Reference: Review of Orthopaedics, Miller

  20. d
    A cotton osteotomy (dorsal open-wedge osteotomy of the cuneiform) is used to plantarflex the first ray if it remains elevated after correction of the hindfoot to neutral.
    Reference: Review of Orthopaedics, Miller