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Forefoot MCQs

Practice Set 1 of 17

This practice set contains high-yield board review questions covering key concepts in Forefoot. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 1

Topic: Forefoot

The normal value for the hallux valgus angle is:

. 0° to 5°
. 10° to 20°
. 5° to 10°
. 30° to 40°
. 20° to 30°

Correct Answer & Explanation

. 10° to 20°

Explanation

The angle between the first metatarsal and its proximal phalanx is normally one of mild (10° to 20°) valgus. It is not normal for it to be too straight. An increase in this angle beyond this value is often noted by the patient as a bunion.

Question 2

Topic: Forefoot

In comparing the clinical efficacy of intra-articular sodium hyaluronate injections vs triamcinolone injections for the treatment of hallux rigidus, which factor showed significantly better improvement in the sodium hyaluronate group:

. Gait pain
. Pain at rest
. Pain with passive mobilization
. Use of analgesics
. Pain with palpation

Correct Answer & Explanation

. Gait pain

Explanation

In a prospective randomized study comparing sodium hyaluronate vs cortisone injections for hallux rigidus, gait pain and AOFAS scores were significantly better in the sodium hyaluronate-treated group. There was no significant difference between the two treatment groups with regard to rest pain, pain with mobilization, pain with palpation, and use of analgesics.

Question 3

Topic: Forefoot

The nonunion rate for the Lapidus procedure (first tarsometatarsal arthrodesis) for the treatment of moderate to severe hallux valgus is:

. 2%
. 7%
. 15%
. 20%
. 25%

Correct Answer & Explanation

. 7%

Explanation

In a prospective cohort study following 105 Lapidus bunionectomies for 3.7 years, the nonunion rate was found to be 6.7%. The American Orthopaedic Foot & Ankle Society scores improved significantly, and loss of correction over 3.7 years was less than 1° for intermetatarsal and hallux valgus angles.

Question 4

Topic: Forefoot
A tailor's bunion is an abnormal prominence of the lateral aspect of the 5th metatarsal head. Similar to hallux valgus deformities, tailor's bunions can be due to a widened intermetatarsal angle between the 4th and 5th metatarsal shafts. The normal 4-5 intermetatarsal angle is:
. Less than 8°-9°
. Less than 12°
. Less than 15°
. Less than 20°
. Less than 25°

Correct Answer & Explanation

. Less than 8°-9°

Explanation

4-5 intermetatarsal angle in normal feet averages 6.2 degrees. Different authors believe an abnormally wide 4-5 intermetatarsal angle to be anything greater than 8°-9°.

Question 5

Topic: Forefoot

When planning surgical correction for hallux valgus, a patient presents with a hallux valgus angle (HVA) of 38 degrees and an intermetatarsal angle (IMA) of 18 degrees. Which of the following procedures is most appropriate to predictably correct this deformity?

. Distal metatarsal chevron osteotomy
. Modified McBride bunionectomy alone
. Proximal metatarsal crescentic osteotomy or Lapidus procedure
. Keller resection arthroplasty
. Akin osteotomy alone

Correct Answer & Explanation

. Proximal metatarsal crescentic osteotomy or Lapidus procedure

Explanation

An intermetatarsal angle (IMA) greater than 13-15 degrees constitutes a severe deformity requiring a proximal metatarsal osteotomy (e.g., crescentic or Ludloff) or a first tarsometatarsal fusion (Lapidus procedure). Distal osteotomies are generally insufficient for an IMA of 18 degrees.

Question 6

Topic: Forefoot

A patient underwent an arthrodesis of the hallux metatarsophalangeal joint for correction of painful arthritis (Slide 1 and Slide 2). She remains symptomatic and cannot walk without pain. The most likely cause for her pain is:

. Fusion of the hallux in too much plantarflexion
. Fusion of the hallux in too much dorsiflexion
. Fusion of the hallux in too much varus
. Removal of too much bone in the metatarsophalangeal joint during fusion, leading to claw hallux
. Removal of too much bone in the metatarsophalangeal joint during fusion, leading to lesser toe metatarsalgia

Correct Answer & Explanation

. Fusion of the hallux in too much varus

Explanation

The ideal position for arthrodesis of the hallux metatarsophalangeal joint is in 5° of valgus, 10° of dorsiflexion relative to the ground, and neutral rotation. Although the hallux is short and may be associated with painful metatarsalgia, the most likely cause of pain is abutment of the hallux against the shoe because it was fused in varus.

Question 7

Topic: Forefoot

A patient presents with a claw toe deformity (Slide). What is the strongest flexor of the metatarsophalangeal joint, which in this patient is not functioning adequately:

. Flexor digitorum longus
. Flexor digitorum brevis
. Lumbrical
. Volar plate
. Interosseous

Correct Answer & Explanation

. Interosseous

Explanation

Although the long and short flexor tendons have some effect albeit indirect on the flexion of the metatarsophalangeal joint, the flexor that acts directly on the joint is the interosseous muscle. Intrinsic atrophy will lead to claw toe deformity.

Question 8

Topic: Forefoot

A 40-year-old female presents with painful bunions. Weight-bearing radiographs demonstrate a hallux valgus angle of 35 degrees and an intermetatarsal angle of 15 degrees. Clinical exam reveals gross hypermobility of the first tarsometatarsal (TMT) joint. Which of the following surgical procedures is most indicated?

. Distal chevron osteotomy
. Proximal crescentic osteotomy
. Lapidus procedure (first TMT arthrodesis)
. Keller resection arthroplasty
. First metatarsophalangeal joint arthrodesis

Correct Answer & Explanation

. Lapidus procedure (first TMT arthrodesis)

Explanation

The Lapidus procedure (arthrodesis of the first tarsometatarsal joint) is specifically indicated for moderate to severe hallux valgus associated with first ray hypermobility. It definitively stabilizes the medial column and reliably corrects the intermetatarsal angle.

Question 9

Topic: Forefoot

A 43-year-old patient presents with pain in the hallux metatarsophalangeal (MP) joint. Motion is limited in dorsiflexion and to some extent in plantarflexion, and mild arthritis is radiographically evident. If a cheilectomy is performed on this patient, what is the primary goal of the procedure in the management of hallux rigidus:

. To increase the range of motion of the MP joint
. To remove the osteophytes from the medial and lateral surface of the metatarsal head
. To decrease the impingement on the terminal branch of the deep peroneal nerve
. To decrease pain
. To decrease the likelihood of a subsequent arthrodesis of the MP joint

Correct Answer & Explanation

. To decrease pain

Explanation

The goal of cheilectomy is to decrease pain. Although motion may increase, this must not be the goal of surgery because the motion may only be minimally increased. Some patients improve motion markedly after cheilectomy, but this should not be the focus of treatment or promised to the patient.

Question 10

Topic: Forefoot

The patient shown in Slide 1 and Slide 2 underwent surgical correction of painful hallux rigidus. The purpose of the procedure on the hallux was:

. To increase the range of motion of the hallux metatarsophalangeal (MP) joint
. To elevate the hallux off the ground
. To depress the hallux and improve push off strength
. To decrease the jamming of the hallux MP joint on push off
. To change the kinematics of the hallux MP joint, thereby decreasing the likelihood of recurrent deformity

Correct Answer & Explanation

. To elevate the hallux off the ground

Explanation

The osteotomy of the proximal phalanx of the hallux (the Moberg osteotomy) is designed to elevate the hallux off the ground. The procedure does not improve the range of motion of the MP joint, but it increases the available motion of the hallux in toe off.

Question 11

Topic: Forefoot

A 61-year-old man has been treated for type I diabetes for 6 years and presents for evaluation and treatment of an ulcer on the plantar aspect of the forefoot. The ulcer has been present for 4 weeks. The ulcer does not appear infected, claw toe deformities are present, and a posterior tibial pulse is palpable. An important screening test for this patient is:

. Doppler ultrasound
. 128-MHz tuning fork examination
. C ombined technetium-indium scan
. Semmes-Weinstein monofilament testing
. Transcutaneous oxygen measurements

Correct Answer & Explanation

. Semmes-Weinstein monofilament testing

Explanation

Although vascular evaluation of all patients with diabetes is important, this patient has a neuropathic plantar ulcer and it is important to assess the extent of neuropathy. The Semmes-Weinstein monofilament is a first-rate screening tool.

Question 12

Topic: Forefoot

The most common complication of arthrodesis of the proximal interphalangeal (PIP) joint is:

. Claw toe deformity
. Mallet toe deformity
. Hammer toe deformity
. Curly toe deformity
. Instability of metatarsophalangeal (MP) joint

Correct Answer & Explanation

. Mallet toe deformity

Explanation

With arthrodesis of the proximal interphalangeal joint (PIP), the long flexor tendon that remains intact flexes the toe at the metatarsophalangeal (MP) joint and also at the distal interphalangeal (DIP) joint, thus the development of a mallet toe deformity.

Question 13

Topic: Forefoot

The structure on the side of the metatarsophalangeal joint of the second toe which is marked by the pointer is the:

. Lumbrical tendon
. Volar plate ligament
. C ollateral ligament
. Interosseous tendon
. Lateral joint capsule

Correct Answer & Explanation

. Volar plate ligament

Explanation

The structure is the volar plate ligament. This ligament may assume a pathologic role in claw toe deformity and instability of the metatarsophalangeal joint.

Question 14

Topic: Forefoot

Resection of the tibial sesamoid may result in which deformity of the hallux:

. Hallux extensus
. Hallux valgus
. Hallux varus
. C ock-up deformity
. Supination deformity

Correct Answer & Explanation

. Hallux varus

Explanation

The abductor hallucis muscle attaches to the tibial sesamoid and resection without repair of the abductor and medial capsule may lead to hallux valgus. Hallux varus may occur after resection of the fibular sesamoid, and a cock- up extension hallux deformity occurs after resection of both sesamoids or with a rupture of the volar plate.

Question 15

Topic: Forefoot

A 50-year-old male requires open reduction and internal fixation of a complex, intra-articular distal humerus fracture (AO/OTA 13C3). The surgeon decides to perform an olecranon osteotomy for adequate joint visualization. Which of the following describes the most mechanically stable orientation for the osteotomy?

. Transverse osteotomy perpendicular to the ulnar shaft
. Chevron osteotomy with the apex pointing distally
. Chevron osteotomy with the apex pointing proximally
. Oblique osteotomy from proximal-medial to distal-lateral
. Step-cut osteotomy exiting through the coronoid

Correct Answer & Explanation

. Chevron osteotomy with the apex pointing distally

Explanation

A chevron osteotomy with the apex pointing distally provides superior inherent mechanical stability against torsional and translational forces compared to transverse or apex-proximal osteotomies.

Question 16

Topic: Forefoot

A 55-year-old female presents with a long-standing, painful hallux valgus deformity that has failed conservative management including wider shoes and orthotics. Clinical examination reveals a severe deformity with a hallux valgus angle of 40 degrees and an intermetatarsal angle of 18 degrees. Radiographs confirm these measurements. Which of the following surgical procedures is most appropriate to address this deformity?

. Simple bunionectomy (exostectomy)
. Chevron osteotomy (distal metatarsal osteotomy)
. Lapidus procedure (proximal metatarsal fusion)
. Keller arthroplasty
. Arthrodesis of the first metatarsophalangeal joint

Correct Answer & Explanation

. Lapidus procedure (proximal metatarsal fusion)

Explanation

Correct Answer: CThe patient presents with a severe hallux valgus deformity (HVA 40 degrees, IMA 18 degrees). For severe deformities, especially with a large intermetatarsal angle, a proximal metatarsal osteotomy or a fusion procedure is typically required to achieve adequate correction and stability. The Lapidus procedure, which involves fusion of the first metatarsocuneiform joint, is highly effective for correcting severe hallux valgus and reducing the intermetatarsal angle. Simple bunionectomy (A) is an exostectomy and does not correct the underlying bony deformity. A Chevron osteotomy (B) is a distal metatarsal osteotomy, suitable for mild to moderate deformities. Keller arthroplasty (D) is a resection arthroplasty, typically reserved for older, low-demand patients with severe arthritis, as it can lead to instability and transfer metatarsalgia. Arthrodesis of the first MTP joint (E) is a salvage procedure for severe arthritis or failed previous surgeries, not typically for primary hallux valgus correction in an active patient.

Question 17

Topic: Forefoot

A 45-year-old female presents with a painful bunion deformity. Weight-bearing radiographs reveal a hallux valgus angle (HVA) of 28 degrees and an intermetatarsal angle (IMA) of 12 degrees. There is no hypermobility of the first tarsometatarsal joint. Which of the following is the most appropriate surgical indication for a distal chevron osteotomy?

. IMA > 20 degrees
. Hypermobile first tarsometatarsal joint
. Mild to moderate hallux valgus with IMA < 13 degrees
. Severe hallux valgus with severe first MTP osteoarthritis
. Previous failed Lapidus procedure

Correct Answer & Explanation

. Mild to moderate hallux valgus with IMA < 13 degrees

Explanation

A distal chevron osteotomy is indicated for mild to moderate hallux valgus deformities, typically with an intermetatarsal angle (IMA) of less than 13 degrees. Severe deformities or hypermobility require proximal osteotomies or a Lapidus procedure.

Question 18

Topic: Forefoot

A 62-year-old female presents with severe pain and stiffness at the base of her great toe. Radiographs demonstrate end-stage hallux rigidus (Coughlin Grade 4). She elects to undergo a first metatarsophalangeal (MTP) joint arthrodesis. What is the optimal position for fusing the first MTP joint?

. 0 degrees of extension, 0 degrees of valgus
. 5 degrees of dorsiflexion, 5 degrees of varus
. 10-15 degrees of dorsiflexion, 10-15 degrees of valgus
. 25 degrees of dorsiflexion, 5 degrees of valgus
. 10 degrees of plantarflexion, 10 degrees of valgus

Correct Answer & Explanation

. 10-15 degrees of dorsiflexion, 10-15 degrees of valgus

Explanation

The optimal position for first MTP arthrodesis is 10-15 degrees of valgus, 10-15 degrees of dorsiflexion (relative to the floor), and neutral rotation. This allows for normal push-off during the gait cycle and accommodates most shoewear.

Question 19

Topic: Forefoot

A 35-year-old active runner presents with early-stage hallux rigidus, characterized by intermittent pain and mild dorsal osteophytes on radiographs, consistent with Coughlin and Shurnas Grade 1. He has failed a 3-month trial of NSAIDs and activity modification. During surgical planning for a cheilectomy, the surgeon emphasizes meticulous dissection in the dorsomedial aspect of the first MTP joint. Which neurovascular structure is at highest risk of iatrogenic injury during a standard dorsomedial approach to the first MTP joint?

. A. Medial plantar nerve.
. B. Deep fibular nerve.
. C. Dorsalis pedis artery.
. D. Medial dorsal cutaneous nerve.
. E. Flexor hallucis longus tendon.

Correct Answer & Explanation

. D. Medial dorsal cutaneous nerve.

Explanation

Correct Answer: DThe case explicitly states under 'Neurovascular Structures' within the 'First MTP Joint Anatomy' section that 'The medial dorsal cutaneous nerve (a branch of the superficial fibular nerve) typically courses dorsomedially, posing a risk during dorsal incisions.' Furthermore, in the 'Dorsomedial Approach' section, it reiterates, 'Meticulous dissection is required to identify and protect the branches of the medial dorsal cutaneous nerve, which typically courses dorsomedially over the first MTP joint. Retraction of these nerve branches... is critical to prevent iatrogenic injury, which can lead to post-operative numbness or painful neuroma formation.'A. The medial plantar nerve provides sensation to the plantar aspect of the great toe and is not typically in the field of a dorsal incision.B. The deep fibular nerve (deep peroneal nerve) typically innervates the intrinsic muscles of the dorsum of the foot and the first web space, but the medial dorsal cutaneous nerve is the more superficial and directly vulnerable structure in a dorsomedial incision for the first MTP joint.C. The dorsalis pedis artery and its branches supply the dorsal aspect but are generally deeper and less superficially vulnerable than the medial dorsal cutaneous nerve during the initial skin and subcutaneous dissection for a dorsomedial approach.E. The flexor hallucis longus (FHL) tendon runs plantarly between the sesamoids and is not at risk during a dorsal approach.

Question 20

Topic: Forefoot

A 62-year-old sedentary patient presents with severe, constant pain in her left great toe, significantly limiting her ability to walk even short distances. She has tried various conservative treatments, including orthotics, NSAIDs, and multiple corticosteroid injections over the past year, with only transient relief. Weight-bearing radiographs reveal severe joint space effacement, extensive dorsal and plantar osteophytes, subchondral sclerosis, and cyst formation at the first MTP joint. Based on the Coughlin and Shurnas classification system and the provided case, what is the most appropriate surgical recommendation for this patient?

. A. Cheilectomy with a Moberg osteotomy to improve dorsiflexion.
. B. Interposition arthroplasty using an autograft to preserve motion.
. C. First MTP joint arthrodesis for reliable pain relief and stability.
. D. Microfracture of the articular cartilage to stimulate fibrocartilage formation.
. E. Hemiarthroplasty of the proximal phalanx to replace the damaged articular surface.

Correct Answer & Explanation

. C. First MTP joint arthrodesis for reliable pain relief and stability.

Explanation

Correct Answer: CThe patient's presentation of severe, constant pain, failure of extensive conservative management, and radiographic findings of 'severe joint space effacement, extensive dorsal and plantar osteophytes, subchondral sclerosis, and cyst formation' are classic indicators of end-stage hallux rigidus, corresponding to Coughlin and Shurnas Grade 4. The case explicitly states under 'Operative Indications' and 'Summary of Key Literature and Guidelines' that 'Arthrodesis (fusion) of the first MTP joint is often considered the gold standard for end-stage hallux rigidus due to its reliable pain relief and high success rates' and 'provides the most reliable and durable pain relief.' Given the patient's sedentary lifestyle, the loss of motion associated with fusion is less of a concern compared to achieving predictable pain relief.A. Cheilectomy with a Moberg osteotomy is indicated for Grade 1-3 hallux rigidus, primarily for motion preservation in less severe cases, and would be ineffective for end-stage disease.B. Interposition arthroplasty is indicated for Grade 3-4 HR in older, lower-demand patients who wish to preserve some motion, but the case notes 'results are variable, with concerns regarding graft incorporation, spacer migration, and long-term durability.' Arthrodesis offers more reliable pain relief for end-stage disease.D. Microfracture is indicated for 'focal cartilage defects... where the surrounding cartilage is relatively healthy' in younger patients, not for diffuse, end-stage arthritis.E. Hemiarthroplasty is also indicated for Grade 3-4 HR in older, less active individuals seeking motion preservation, but similar to interposition arthroplasty, concerns exist regarding implant loosening, wear of the contralateral cartilage, and less predictable long-term outcomes compared to arthrodesis for severe cases.

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