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Forefoot MCQs

Practice Set 14 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 261

Topic: Forefoot



A 58-year-old male presents with dorsal first MTP joint pain. Radiographs demonstrate advanced joint space narrowing, large dorsal osteophytes, and subchondral sclerosis. Clinically, he has severe pain at the extremes of motion AND during the mid-arc of motion (Coughlin and Shurnas Grade 4 hallux rigidus). Which surgical procedure is considered the most reliable gold standard for this patient?

. Cheilectomy
. Moberg osteotomy
. Silicone arthroplasty
. First MTP joint arthrodesis
. Keller resection arthroplasty

Correct Answer & Explanation

. Cheilectomy

Explanation

For advanced hallux rigidus (Coughlin and Shurnas Grade 3 and 4), particularly Grade 4 where pain is present in the mid-arc of motion, cheilectomy alone is insufficient because the joint cartilage is destroyed globally. First MTP joint arthrodesis is the gold standard, providing reliable pain relief and functional improvement.

Question 262

Topic: Forefoot

A 52-year-old avid runner presents with worsening great toe pain. Examination reveals less than 10 degrees of dorsiflexion and significant pain through the mid-arc of motion. Radiographs demonstrate severe joint space narrowing, subchondral sclerosis, and large circumferential osteophytes at the first metatarsophalangeal (MTP) joint. What is the most definitive and reliable surgical treatment?

. Cheilectomy and Moberg osteotomy
. Silicone implant arthroplasty
. First MTP joint arthrodesis
. Keller resection arthroplasty
. First MTP joint hemiarthroplasty

Correct Answer & Explanation

. Cheilectomy and Moberg osteotomy

Explanation

The patient has Coughlin/Shurnas Grade 4 hallux rigidus (pain in mid-arc of motion, severe radiographic changes). First MTP arthrodesis is the most reliable and durable procedure for advanced hallux rigidus, particularly in young, active patients.

Question 263

Topic: Forefoot

A 45-year-old female with severe hallux valgus has a Hallux Valgus Angle (HVA) of 48 degrees, an Intermetatarsal Angle (IMA) of 20 degrees, and significant hypermobility of the first tarsometatarsal (TMT) joint. Which surgical procedure is most indicated to correct her deformity?

. Distal chevron osteotomy
. Akin osteotomy
. Scarf osteotomy
. Lapidus procedure
. Keller resection arthroplasty

Correct Answer & Explanation

. Distal chevron osteotomy

Explanation

The Lapidus procedure consists of a fusion of the first tarsometatarsal (TMT) joint. It is highly indicated for severe hallux valgus (IMA > 15-20 degrees) combined with clinical hypermobility of the first ray. Distal osteotomies (like the Chevron) cannot adequately correct an IMA of 20 degrees. The Scarf is a diaphyseal osteotomy but does not specifically address TMT hypermobility as reliably as a Lapidus fusion.

Question 264

Topic: Forefoot
Operative intervention for an acute turf toe injury is most clearly indicated in which of the following scenarios?
. Grade I sprain with localized pain
. Grade II sprain with partial tearing of the plantar plate
. Grade III complete plantar plate tear with proximal migration of the sesamoids
. Medial capsular sprain without clinical instability
. Failure of 2 weeks of conservative management in a Grade I sprain

Correct Answer & Explanation

. Grade III complete plantar plate tear with proximal migration of the sesamoids

Explanation

Turf toe is a sprain of the first metatarsophalangeal (MTP) joint plantar plate. Grade III injuries involve a complete tear of the plantar plate. Indications for surgery include a Grade III tear with proximal migration of the sesamoids, large intra-articular bony avulsion, traumatic bunion deformity, or progressive instability. Grades I and II are treated nonoperatively.

Question 265

Topic: Forefoot

A 62-year-old male presents with severe hallux rigidus (Coughlin and Shurnas Grade 3) and pain with daily activities. He does not engage in running or high-impact sports. Radiographs demonstrate severe joint space narrowing and large dorsal osteophytes. What is the gold standard surgical intervention for this patient?

. Cheilectomy with dorsal capsulectomy
. Silicone total joint arthroplasty
. First metatarsophalangeal (MTP) joint arthrodesis
. Keller resection arthroplasty
. Moberg osteotomy

Correct Answer & Explanation

. Cheilectomy with dorsal capsulectomy

Explanation

For advanced (Grade 3 or 4) hallux rigidus with diffuse joint degeneration, the gold standard treatment is first MTP joint arthrodesis. It provides reliable pain relief and durability. Cheilectomy is indicated for Grade 1 or 2 hallux rigidus where arthritis is confined to the dorsal aspect of the joint. Keller arthroplasty and silicone implants carry higher risks of failure and transfer metatarsalgia.

Question 266

Topic: Forefoot

A 58-year-old male presents with severe pain and stiffness in his right great toe, notably worsening at both extremes of dorsiflexion and plantarflexion. Radiographs reveal advanced dorsal osteophyte formation, near complete obliteration of the MTP joint space, and multiple subchondral cysts (Coughlin and Shurnas Grade 3). He has failed extensive conservative management. What is the gold standard surgical treatment?

. Extensive dorsal cheilectomy
. First MTP joint arthrodesis
. First MTP joint hemiarthroplasty
. Keller resection arthroplasty
. Proximal phalanx closing wedge osteotomy (Moberg)

Correct Answer & Explanation

. Extensive dorsal cheilectomy

Explanation

For advanced hallux rigidus (Coughlin and Shurnas Grade 3 or 4), where the joint space is obliterated and pain occurs throughout the entire range of motion, the gold standard surgical treatment providing the most reliable pain relief and predictable functional improvement is first MTP joint arthrodesis. Cheilectomy is indicated for early-stage disease (Grades 1 and 2) with preserved joint space and pain primarily at terminal dorsiflexion.

Question 267

Topic: Forefoot

A 50-year-old female presents with symptomatic hallux valgus. Radiographs show a hallux valgus angle (HVA) of 35 degrees, an intermetatarsal angle (IMA) of 16 degrees, and clinical examination reveals a hypermobile first tarsometatarsal joint. Which surgical procedure is most appropriate?

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

Correct Answer & Explanation

. Distal chevron osteotomy

Explanation

The Lapidus procedure (first tarsometatarsal arthrodesis) is indicated for moderate to severe hallux valgus associated with first ray hypermobility. Distal osteotomies are insufficient for an IMA greater than 13 degrees combined with significant instability.

Question 268

Topic: Forefoot

A 50-year-old male presents with painful, limited dorsiflexion of the right hallux. Radiographs reveal advanced narrowing of the 1st MTP joint, large dorsal osteophytes, and less than 50% of the joint space remaining (Coughlin and Shurnas Grade 3). What is the most reliable surgical option for long-term pain relief?

. Dorsal cheilectomy
. Moberg osteotomy
. Keller arthroplasty
. First MTP joint arthrodesis
. Silicone implant arthroplasty

Correct Answer & Explanation

. Dorsal cheilectomy

Explanation

First MTP joint arthrodesis is the gold standard for advanced hallux rigidus (Grade 3 and 4), providing the most reliable long-term pain relief and functional improvement. Cheilectomy is generally reserved for Grade 1 or 2 disease with preserved joint space.

Question 269

Topic: Forefoot

A 38-year-old female presents with symptomatic hallux valgus. Radiographs show a hallux valgus angle (HVA) of 35 degrees, an intermetatarsal angle (IMA) of 16 degrees, and significant hypermobility at the first tarsometatarsal (TMT) joint. Which of the following procedures is most appropriate?

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

Correct Answer & Explanation

. Distal chevron osteotomy

Explanation

The Lapidus procedure (first TMT arthrodesis) is indicated for moderate to severe hallux valgus, particularly when accompanied by first ray hypermobility. It provides powerful correction of the IMA and stabilizes the medial column.

Question 270

Topic: Forefoot
A 60-year-old female presents with severe pain and stiffness in her great toe. Radiographs demonstrate complete loss of joint space at the first MTP joint, extensive dorsal osteophytes, and subchondral cysts. She wishes to maintain an active lifestyle involving hiking. What is the gold standard surgical treatment?
. Dorsal cheilectomy
. Keller resection arthroplasty
. Silicone implant arthroplasty
. First metatarsophalangeal joint arthrodesis
. Moberg osteotomy

Correct Answer & Explanation

. First metatarsophalangeal joint arthrodesis

Explanation

This patient has Grade III/IV hallux rigidus. The gold standard surgical procedure for advanced, symptomatic hallux rigidus, especially in active patients, is a first MTP joint arthrodesis, providing reliable pain relief and durability.

Question 271

Topic: Forefoot

A 42-year-old female presents with severe bunion pain. Weight-bearing radiographs reveal a Hallux Valgus Angle (HVA) of 48 degrees and an Intermetatarsal Angle (IMA) of 22 degrees. On physical exam, there is demonstrable hypermobility at the first tarsometatarsal (TMT) joint. Which of the following surgical procedures is most appropriate to correct this deformity?

. Distal chevron osteotomy
. Proximal crescentic osteotomy with distal soft tissue release
. First tarsometatarsal arthrodesis (Lapidus procedure)
. First metatarsophalangeal arthrodesis
. Akin osteotomy

Correct Answer & Explanation

. First tarsometatarsal arthrodesis (Lapidus procedure)

Explanation

A first TMT arthrodesis (Lapidus procedure) is indicated for severe hallux valgus (IMA > 20 degrees, HVA > 40 degrees), particularly in the presence of first TMT hypermobility or arthritis. A distal chevron osteotomy is for mild deformity. A proximal osteotomy could address a high IMA but does not address TMT hypermobility, leading to a high recurrence rate.

Question 272

Topic: Forefoot

A 65-year-old male presents with severe pain in his first metatarsophalangeal (MTP) joint, constant pain throughout the entire arc of motion, and large dorsal osteophytes. Radiographs confirm end-stage Hallux Rigidus (Coughlin and Shurnas Grade 4). He elects to undergo a first MTP arthrodesis. What is the optimal position for this fusion?

. Neutral dorsiflexion and neutral valgus
. 10 to 15 degrees of valgus, and 10 to 15 degrees of dorsiflexion relative to the floor
. 30 degrees of dorsiflexion relative to the floor and 5 degrees of varus
. 5 degrees of plantarflexion and 15 degrees of valgus
. 15 degrees of dorsiflexion relative to the floor and neutral coronal alignment

Correct Answer & Explanation

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

Explanation

The optimal position for a first MTP joint arthrodesis is approximately 10-15 degrees of valgus (to mimic the normal hallux valgus angle and clear the second toe) and 10-15 degrees of dorsiflexion relative to the floor (which translates to about 20-25 degrees of dorsiflexion relative to the first metatarsal shaft). This allows for proper roll-off during the terminal stance phase of the gait cycle.

Question 273

Topic: Forefoot

A professional American football player sustains a hyperextension injury to his first metatarsophalangeal (MTP) joint, diagnosed as a severe "Turf Toe" (Grade 3). Which of the following combinations of clinical and radiographic findings serves as an absolute indication for acute surgical repair of the plantar plate in this athlete?

. Grade 3 sprain with inability to bear weight and localized swelling
. Grade 3 sprain with MRI evidence of isolated medial collateral ligament sprain
. Grade 3 sprain with active 15 degrees of dorsiflexion and localized pain
. Grade 3 sprain with >3 mm proximal retraction of the sesamoids compared to the contralateral side and traumatic hallux valgus
. Grade 3 sprain with an asymptomatic bipartite tibial sesamoid

Correct Answer & Explanation

. Grade 3 sprain with >3 mm proximal retraction of the sesamoids compared to the contralateral side and traumatic hallux valgus

Explanation

A Grade 3 Turf Toe injury represents a complete tear of the plantar plate-sesamoid complex from the base of the proximal phalanx. While many can be managed conservatively in a boot or cast, surgical intervention is indicated for high-level athletes if there is frank instability. Absolute indications for surgery include: large intra-articular fracture of a sesamoid, proximal retraction of the sesamoids > 3 mm (indicating complete gross rupture of the complex), traumatic hallux valgus (indicating tearing of the medial restraints allowing lateral subluxation), or vertical instability of the joint.

Question 274

Topic: Forefoot

A 25-year-old professional football player sustains an acute hyperdorsiflexion injury to his first metatarsophalangeal (MTP) joint, resulting in a 'turf toe'. Magnetic resonance imaging confirms a complete tear of the plantar plate with 4 mm of proximal sesamoid retraction. What is the most appropriate management?

. Immediate full weight-bearing in a stiff-soled shoe
. Short leg cast in plantarflexion for 6 weeks
. Surgical repair of the plantar plate and capsuloligamentous complex
. Closed reduction and percutaneous pinning of the MTP joint
. Excision of the sesamoid bones

Correct Answer & Explanation

. Surgical repair of the plantar plate and capsuloligamentous complex

Explanation

A complete tear of the plantar plate (Grade 3 turf toe injury) with significant sesamoid retraction (typically >3 mm), vertical instability, intra-articular fracture, or traumatic hallux valgus are indications for surgical repair in high-level athletes to restore the push-off strength and joint stability.

Question 275

Topic: Forefoot

A patient undergoes an isolated surgical excision of the fibular (lateral) sesamoid due to a chronic, non-healing fracture. Which of the following deformities is the most recognized complication of this specific procedure?

. Hallux valgus
. Hallux varus
. Claw toe deformity of the first ray
. Dorsal subluxation of the first MTP joint
. Hammer toe deformity of the first ray

Correct Answer & Explanation

. Hallux varus

Explanation

Excision of the fibular (lateral) sesamoid compromises the insertion of the adductor hallucis and the lateral head of the flexor hallucis brevis. This creates an imbalance of dynamic forces at the MTP joint, with unopposed pull from the abductor hallucis leading to a hallux varus deformity. Conversely, medial sesamoid excision risks hallux valgus.

Question 276

Topic: Forefoot

A 62-year-old man presents with severe pain and stiffness in his right great toe. On exam, he has pain throughout the entire range of motion of the 1st metatarsophalangeal (MTP) joint, including the mid-arc. Radiographs reveal near-complete joint space loss, prominent dorsal osteophytes, and subchondral sclerosis. Based on the Coughlin and Shurnas classification, what is the gold standard surgical treatment?

. Dorsal cheilectomy
. Moberg osteotomy
. First MTP joint arthrodesis
. Silicone implant arthroplasty
. Keller resection arthroplasty

Correct Answer & Explanation

. First MTP joint arthrodesis

Explanation

This patient has Grade 4 hallux rigidus, defined by pain throughout the range of motion including the mid-arc. First MTP joint arthrodesis is the gold standard for end-stage hallux rigidus, providing reliable pain relief and functional improvement.

Question 277

Topic: Forefoot

A 22-year-old football lineman presents with severe pain at the 1st MTP joint after another player fell on the back of his heel while his foot was planted and dorsiflexed. MRI reveals a complete rupture of the plantar plate with proximal retraction of the sesamoids by 10 mm. What is the most appropriate management for this Grade 3 Turf Toe injury?

. Stiff-soled shoe with a Morton's extension for 8 weeks
. Taping the toe in plantarflexion and immediate return to play
. Primary surgical repair of the plantar plate and capsuloligamentous complex
. First MTP joint arthrodesis
. Cheilectomy and sesamoidectomy

Correct Answer & Explanation

. Primary surgical repair of the plantar plate and capsuloligamentous complex

Explanation

Grade 3 turf toe injuries involve a complete tear of the plantar plate complex with sesamoid retraction. Surgical repair is indicated in high-level athletes to restore push-off strength and prevent progressive hallux valgus or rigidus deformities.

Question 278

Topic: Forefoot

A patient with long-standing rheumatoid arthritis presents with a severe hallux valgus deformity and significant MTP joint pain. When assessing the range of motion of the first MTP joint, you observe a significant restriction in dorsiflexion. This finding is MOST indicative of:

. Flexible hallux valgus
. Early stage synovitis
. Hallux rigidus (degenerative arthritis of the first MTP joint)
. Neuroma formation in the first web space
. Peroneal nerve entrapment

Correct Answer & Explanation

. Hallux rigidus (degenerative arthritis of the first MTP joint)

Explanation

Significant restriction in dorsiflexion of the first MTP joint, especially when associated with pain, is a hallmark feature of hallux rigidus (degenerative arthritis of the first MTP joint). In rheumatoid arthritis, the chronic inflammation and joint destruction can lead to severe arthritic changes, resulting in pain and stiffness, particularly with dorsiflexion required for normal gait push-off. While synovitis can cause pain, markedrestrictionsuggests structural arthritic changes.

Question 279

Topic: Forefoot

When assessing the lesser toe deformities in a rheumatoid foot, a key distinction between a hammer toe and a claw toe is:

. A hammer toe involves MTP joint hyperextension, while a claw toe involves MTP joint flexion.
. A hammer toe involves PIP joint flexion with DUP extension, while a claw toe involves MTP hyperextension, PIP flexion, and DIP flexion.
. A hammer toe is always flexible, whereas a claw toe is always rigid.
. A hammer toe affects only the second toe, while a claw toe affects all lesser toes.
. Claw toes are never associated with MTP joint subluxation, unlike hammer toes.

Correct Answer & Explanation

. A hammer toe involves PIP joint flexion with DUP extension, while a claw toe involves MTP hyperextension, PIP flexion, and DIP flexion.

Explanation

A claw toe is characterized by MTP joint hyperextension, PIP joint flexion, and DIP joint flexion. A hammer toe primarily involves PIP joint flexion with a neutral or hyperextended DIP joint. While both involve PIP flexion, the involvement of the MTP and DIP joints differentiates them. Claw toes are strongly associated with MTP joint subluxation or dislocation due to the imbalance of intrinsic and extrinsic muscles, common in RA. Flexibility varies for both deformities.

Question 280

Topic: Forefoot

In evaluating a severe hallux valgus deformity in a rheumatoid foot, what aspect of the deformity is MORE indicative of a poor prognosis for conservative management and higher likelihood for complex surgical intervention, compared to idiopathic hallux valgus?

. The degree of lateral deviation of the great toe
. The presence of a symptomatic bunion
. The extent of first MTP joint subluxation or dislocation and joint destruction
. The patient's age and activity level
. Associated lesser toe hammer deformities

Correct Answer & Explanation

. The extent of first MTP joint subluxation or dislocation and joint destruction

Explanation

In rheumatoid arthritis, the hallux valgus deformity is often characterized by significant MTP joint subluxation or complete dislocation, along with widespread joint destruction (erosions, cartilage loss). This severe joint pathology indicates advanced disease and mechanical instability, making conservative measures largely ineffective and often requiring complex reconstructive surgery (e.g., arthrodesis or arthroplasty) rather than simple bunionectomy. The other factors are important but less specific to therheumatoidnature and its surgical implications.

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