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Forefoot MCQs

Practice Set 13 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 241

Topic: Forefoot

A 62-year-old man presents with painful, restricted dorsiflexion of the great toe. Radiographs show severe joint space narrowing, large dorsal osteophytes, and subchondral sclerosis at the first metatarsophalangeal (MTP) joint. He has pain throughout the entire arc of motion. What is the most reliable surgical option for long-term pain relief?

. Cheilectomy
. First MTP joint arthrodesis
. Moberg osteotomy
. First TMT joint arthrodesis
. Silicone implant arthroplasty

Correct Answer & Explanation

. First MTP joint arthrodesis

Explanation

This patient has Grade 3/4 hallux rigidus with pain throughout the arc of motion and severe radiographic changes. First MTP joint arthrodesis is the gold standard for end-stage hallux rigidus, providing the most reliable long-term pain relief.

Question 242

Topic: Forefoot

A 62-year-old woman presents with end-stage hallux rigidus (Coughlin and Shurnas Grade 3) and severe pain with ambulation. Conservative measures have failed, and she elects to undergo first metatarsophalangeal (MTP) joint arthrodesis. To ensure an optimal functional outcome, in what position should the first MTP joint be fused?

. 10 degrees of plantarflexion and 5 degrees of varus
. Neutral dorsiflexion and neutral rotation
. 30 degrees of dorsiflexion and 20 degrees of valgus
. 10 to 15 degrees of valgus and 15 degrees of dorsiflexion relative to the floor
. 5 degrees of valgus and 40 degrees of dorsiflexion relative to the floor

Correct Answer & Explanation

. 10 to 15 degrees of valgus and 15 degrees of dorsiflexion relative to the floor

Explanation

The ideal position for a first MTP joint arthrodesis is approximately 10-15 degrees of valgus and 15 degrees of dorsiflexion relative to the floor. This position allows for normal toe-off during the gait cycle and accommodates standard shoe wear.

Question 243

Topic: Forefoot

A 45-year-old woman presents with pain and difficulty wearing shoes 2 years after undergoing a distal chevron osteotomy and lateral soft-tissue release for hallux valgus. Examination reveals a flexible first metatarsophalangeal (MTP) joint with a 15-degree hallux varus deformity. Radiographs show no degenerative changes in the MTP joint. Which of the following is the most appropriate surgical treatment?

. First MTP joint arthrodesis
. Extensor hallucis longus (EHL) tendon transfer to the base of the proximal phalanx
. Medial capsulorrhaphy alone
. Abductor hallucis release and split extensor hallucis brevis (EHB) tendon transfer
. First metatarsal closing wedge osteotomy

Correct Answer & Explanation

. Abductor hallucis release and split extensor hallucis brevis (EHB) tendon transfer

Explanation

In a flexible hallux varus deformity without MTP arthritis following bunion surgery, an abductor hallucis release and a split extensor hallucis brevis (EHB) or extensor hallucis longus (EHL) tendon transfer is indicated. First MTP arthrodesis is reserved for rigid deformities or those with concurrent arthritis.

Question 244

Topic: Forefoot

A 55-year-old female presents with severe hallux valgus, an intermetatarsal angle of 22 degrees, and clinical hypermobility of the first tarsometatarsal (TMT) joint. Which of the following surgical procedures is most appropriate to provide a durable correction?

. Chevron osteotomy
. Scarf osteotomy
. First TMT arthrodesis (Lapidus)
. First MTP joint arthrodesis
. Akin osteotomy

Correct Answer & Explanation

. First TMT arthrodesis (Lapidus)

Explanation

A Lapidus procedure (first TMT arthrodesis) is indicated for severe hallux valgus (IMA > 20 degrees) and when there is clinical hypermobility at the first TMT joint. It provides powerful correction and stabilization of the medial column.

Question 245

Topic: Forefoot

A 45-year-old female presents with a painful bunion. Weight-bearing radiographs show a hallux valgus angle (HVA) of 42 degrees, an intermetatarsal angle (IMA) of 18 degrees, and hypermobility of the first tarsometatarsal (TMT) joint. Which of the following surgical options is most appropriate?

. Distal chevron osteotomy
. Proximal crescentic osteotomy with distal soft tissue realignment
. First TMT joint arthrodesis (Lapidus procedure)
. Keller resection arthroplasty
. First metatarsophalangeal joint arthrodesis

Correct Answer & Explanation

. First TMT joint arthrodesis (Lapidus procedure)

Explanation

A Lapidus procedure (first TMT arthrodesis) is indicated for severe hallux valgus deformities (IMA > 15 degrees, HVA > 40 degrees) associated with first ray hypermobility. It provides powerful deformity correction and long-term stabilization of the medial column.

Question 246

Topic: Forefoot

A 55-year-old man presents with dorsal midfoot pain and limited, painful dorsiflexion of the right great toe. Radiographs show dorsal osteophytes and mild joint space narrowing at the first metatarsophalangeal joint, consistent with Grade 2 hallux rigidus. He has failed shoe modifications and NSAIDs. What is the most appropriate surgical management?

. Keller resection arthroplasty
. Dorsal cheilectomy
. First metatarsophalangeal joint arthrodesis
. Silicone implant arthroplasty
. Proximal phalanx dorsiflexion osteotomy (Moberg)

Correct Answer & Explanation

. Dorsal cheilectomy

Explanation

For moderate (Grade 1 or 2) hallux rigidus with preserved plantar joint space and pain primarily upon dorsiflexion, a dorsal cheilectomy is the standard bone-preserving procedure. Arthrodesis is typically reserved for severe, end-stage (Grade 3 or 4) disease.

Question 247

Topic: Forefoot

A 45-year-old woman complains of a painful bunion. Weight-bearing radiographs show a hallux valgus angle of 45 degrees and an intermetatarsal angle (IMA) of 16 degrees. The first tarsometatarsal joint is hypermobile. What is the most appropriate surgical procedure?

. Distal chevron osteotomy
. Akin osteotomy
. Proximal phalangeal exostectomy
. Lapidus procedure (first TMT arthrodesis)
. First metatarsophalangeal joint arthrodesis

Correct Answer & Explanation

. Lapidus procedure (first TMT arthrodesis)

Explanation

A Lapidus procedure (first tarsometatarsal arthrodesis) is indicated for severe hallux valgus (IMA >15 degrees, HVA >40 degrees), particularly in the presence of first TMT joint hypermobility. Distal osteotomies are insufficient for large intermetatarsal angles.

Question 248

Topic: Forefoot

A 45-year-old female presents with a painful bunion. Clinical exam reveals a hypermobile first tarsometatarsal (TMT) joint. Radiographs show a hallux valgus angle of 35 degrees and an intermetatarsal angle of 16 degrees. What is the most appropriate surgical treatment?

. Proximal crescentic osteotomy
. Distal chevron osteotomy
. First TMT arthrodesis (Lapidus)
. MTP arthrodesis
. Keller resection arthroplasty

Correct Answer & Explanation

. First TMT arthrodesis (Lapidus)

Explanation

First TMT arthrodesis (Lapidus procedure) is indicated for moderate to severe hallux valgus with 1st ray hypermobility to correct the intermetatarsal angle and stabilize the medial column.

Question 249

Topic: Forefoot

A 48-year-old woman has a severe hallux valgus deformity with a hallux valgus angle of 45 degrees and an intermetatarsal angle of 18 degrees. Clinical examination reveals gross hypermobility of the first tarsometatarsal (TMT) joint. Which of the following procedures is most indicated?

. Distal chevron osteotomy
. Proximal crescentic osteotomy
. Lapidus procedure
. Akin osteotomy
. Keller resection arthroplasty

Correct Answer & Explanation

. Lapidus procedure

Explanation

The Lapidus procedure (first TMT joint arthrodesis) is the procedure of choice for severe hallux valgus associated with first ray hypermobility. Distal osteotomies are insufficient for high intermetatarsal angles combined with TMT instability.

Question 250

Topic: Forefoot

A 45-year-old female presents with a painful bunion. Clinical examination reveals hypermobility of the first tarsometatarsal (TMT) joint with primarily sagittal plane instability. Radiographs show a hallux valgus angle of 38 degrees and an intermetatarsal angle of 18 degrees. Which of the following surgical procedures is most appropriate?

. Distal chevron osteotomy
. Proximal crescentic osteotomy
. First TMT joint arthrodesis (Lapidus procedure)
. First metatarsophalangeal joint arthrodesis
. Akin osteotomy alone

Correct Answer & Explanation

. First TMT joint arthrodesis (Lapidus procedure)

Explanation

A Lapidus procedure (first TMT arthrodesis) is indicated for patients with moderate-to-severe hallux valgus associated with first ray hypermobility. It stabilizes the medial column and corrects the intermetatarsal angle at its apex.

Question 251

Topic: Forefoot

A 45-year-old woman presents with painful hallux valgus. Examination and weight-bearing radiographs reveal an intermetatarsal angle (IMA) of 12 degrees and a hallux valgus angle (HVA) of 28 degrees. The first tarsometatarsal joint is stable without hypermobility. What is the most appropriate surgical intervention?

. Lapidus procedure
. Proximal crescentic osteotomy
. Distal chevron osteotomy
. Keller resection arthroplasty
. First metatarsophalangeal joint arthrodesis

Correct Answer & Explanation

. Distal chevron osteotomy

Explanation

A distal chevron osteotomy is indicated for mild to moderate hallux valgus deformities (IMA < 13 degrees, HVA < 30 degrees) without hypermobility. The Lapidus procedure is reserved for more severe deformities or when first TMT hypermobility is present.

Question 252

Topic: Forefoot

A 60-year-old female presents with progressively worsening pain in her first metatarsophalangeal (MTP) joint, stiffness, and a painful 'bump' dorsally. Radiographs show joint space narrowing, dorsal osteophytes, and subchondral sclerosis. What is the most appropriate initial management?

. Cheilectomy
. MTP joint arthrodesis
. Corticosteroid injection
. Stiff-soled shoes with a rocker bottom modification
. Excisional arthroplasty (Keller procedure)

Correct Answer & Explanation

. Stiff-soled shoes with a rocker bottom modification

Explanation

The patient's symptoms and radiographic findings are consistent with hallux rigidus (osteoarthritis of the first MTP joint). Initial non-operative management includes stiff-soled shoes with a rocker bottom modification, which limits motion at the MTP joint and reduces stress. Activity modification, NSAIDs, and stretching can also be beneficial. Cheilectomy is a surgical procedure for earlier stages, while arthrodesis or excisional arthroplasty are for advanced stages or failed cheilectomy.

Question 253

Topic: Forefoot

What is the primary goal of surgical treatment for hallux valgus (bunion deformity)?

. Cosmetic correction of toe deformity
. Achieve a pain-free, functional foot
. Increase hallux range of motion
. Prevent recurrence of the deformity
. Reduce the intermetatarsal angle to zero

Correct Answer & Explanation

. Achieve a pain-free, functional foot

Explanation

The primary goal of surgical treatment for hallux valgus is to achieve a pain-free, functional foot with good alignment. While cosmetic correction and prevention of recurrence are important secondary goals, the overarching aim is to alleviate pain, improve shoe wear, and restore normal foot mechanics. Simply reducing the intermetatarsal angle to zero is not the goal, as a slightly divergent angle is normal. Increasing range of motion is desired but secondary to pain relief and function.

Question 254

Topic: Forefoot
A 60-year-old female presents with severe pain and functional limitations due to advanced hallux rigidus (osteoarthritis of the first metatarsophalangeal joint). She desires a definitive surgical solution. Which of the following is the most appropriate surgical option for her condition?
. Bunionectomy (chevron osteotomy).
. Arthrodesis (fusion) of the first MTP joint.
. Keller arthroplasty (resection of proximal phalanx base).
. Distal metatarsal osteotomy.
. Cheilectomy (dorsal osteophyte resection).

Correct Answer & Explanation

. Arthrodesis (fusion) of the first MTP joint.

Explanation

For advanced hallux rigidus (Grade III/IV), especially in an older patient with severe pain and functional limitation, arthrodesis (fusion) of the first metatarsophalangeal (MTP) joint is considered the gold standard. It provides excellent pain relief, stable weight-bearing, and predictable long-term results by eliminating motion at the painful joint. Cheilectomy is for earlier stages (Grade I/II). Bunionectomy and distal metatarsal osteotomy are for hallux valgus (bunion deformity). Keller arthroplasty is a salvage procedure with higher rates of metatarsalgia and instability.

Question 255

Topic: Forefoot

What is the primary goal of surgical treatment for hallux valgus (bunion deformity)?

. Cosmetic improvement of foot appearance.
. Complete elimination of pain and restoration of normal foot mechanics.
. Correction of the intermetatarsal angle and hallux valgus angle.
. Fusion of the first metatarsophalangeal (MTP) joint.
. Amputation of the hallux.

Correct Answer & Explanation

. Correction of the intermetatarsal angle and hallux valgus angle.

Explanation

The primary goal of surgical treatment for hallux valgus is to correct the underlying bony deformity, specifically the increased intermetatarsal angle (IMA) between the first and second metatarsals, and the increased hallux valgus angle (HVA). This bony realignment aims to relieve pain, improve foot mechanics, and prevent recurrence. While pain relief is a significant outcome, restoring 'normal' mechanics can be challenging. Fusion is reserved for severe arthritis or failed previous surgeries. Cosmetic improvement is a secondary benefit, not the primary goal. Amputation is not a standard treatment.

Question 256

Topic: Forefoot

A 45-year-old female presents with a painful bunion. Radiographs demonstrate a hallux valgus angle (HVA) of 35 degrees and an intermetatarsal angle (IMA) of 16 degrees. Clinical examination reveals profound hypermobility at the first tarsometatarsal (TMT) joint. What is the most appropriate surgical treatment?

. Distal chevron osteotomy
. Proximal crescentic osteotomy
. First TMT joint arthrodesis (Lapidus procedure)
. First MTP joint arthrodesis
. Scarf osteotomy

Correct Answer & Explanation

. Distal chevron osteotomy

Explanation

The Lapidus procedure (first TMT joint arthrodesis) is indicated for moderate to severe hallux valgus associated with first TMT joint hypermobility. It stabilizes the medial column and corrects the IMA effectively.

Question 257

Topic: Forefoot

A 60-year-old male complains of severe pain and stiffness in his right big toe. Examination reveals significantly limited dorsiflexion and pain at the extremes of motion. Radiographs demonstrate large dorsal osteophytes and near-complete joint space narrowing of the first MTP joint, consistent with Grade 3 hallux rigidus. Which of the following is considered the gold standard surgical treatment?

. Cheilectomy
. Moberg osteotomy
. First MTP joint arthrodesis
. Keller arthroplasty
. First MTP joint silicone arthroplasty

Correct Answer & Explanation

. Cheilectomy

Explanation

First MTP joint arthrodesis is the gold standard for severe (Grade 3 or 4) hallux rigidus. It provides excellent, reliable pain relief and maintains functional outcomes for daily activities and moderate exercise.

Question 258

Topic: Forefoot

A 45-year-old female presents with a painful bunion. Weight-bearing radiographs show a hallux valgus angle (HVA) of 45 degrees, an intermetatarsal angle (IMA) of 18 degrees, and hypermobility at the first tarsometatarsal (TMT) joint. What is the most appropriate surgical intervention?

. Distal chevron osteotomy
. Proximal crescentic osteotomy with distal soft tissue procedure
. First TMT joint arthrodesis (Lapidus procedure)
. First MTP joint arthrodesis
. Keller resection arthroplasty

Correct Answer & Explanation

. Distal chevron osteotomy

Explanation

The patient has a severe hallux valgus deformity (HVA >40, IMA >13) combined with hypermobility of the first TMT joint. The Lapidus procedure (first TMT arthrodesis) is specifically indicated for hallux valgus associated with first ray hypermobility or first TMT arthritis. It stabilizes the medial column while effectively allowing for correction of large intermetatarsal angles.

Question 259

Topic: Forefoot
A 24-year-old professional football player hyperextends his great toe on artificial turf. He has severe pain, ecchymosis, and inability to bear weight. MRI shows a complete tear of the plantar plate with proximal retraction of the sesamoids. What is the most appropriate management?
. Taping and rigid carbon fiber orthosis
. First MTP arthrodesis
. Surgical repair of the plantar plate
. Excision of both sesamoids
. Corticosteroid injection

Correct Answer & Explanation

. Surgical repair of the plantar plate

Explanation

The patient has a Grade III turf toe injury (complete tear of the plantar plate/capsule complex) with proximal retraction of the sesamoids. Surgical repair is indicated for Grade III injuries with significant instability, sesamoid retraction, or intra-articular loose bodies. This is particularly true in professional athletes to restore push-off strength and prevent hallux rigidus or clawing.

Question 260

Topic: Forefoot

A 45-year-old female presents with severe bunion pain. Weight-bearing radiographs demonstrate a hallux valgus angle (HVA) of 42 degrees, an intermetatarsal angle (IMA) of 18 degrees, and clinical hypermobility of the first tarsometatarsal (TMT) joint. Which of the following procedures is most appropriate to effectively correct the deformity and minimize recurrence?

. Distal chevron osteotomy
. Proximal crescentic osteotomy without TMT fusion
. First TMT joint arthrodesis (Lapidus procedure)
. First MTP joint arthrodesis
. Akin osteotomy alone

Correct Answer & Explanation

. Distal chevron osteotomy

Explanation

A Lapidus procedure (first TMT arthrodesis) is indicated for severe hallux valgus deformities (IMA > 15-20 degrees, HVA > 40 degrees), particularly when there is hypermobility or instability at the first TMT joint. It corrects the intermetatarsal angle at the apex of the deformity and stabilizes the medial column.

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