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Forefoot MCQs

Practice Set 15 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 281

Topic: Forefoot

A 28-year-old active female presents with Stage 1 hallux rigidus. She has tried conservative measures, including orthotics and NSAIDs, but continues to have activity-related pain. She is keen to avoid surgery if possible. What would be the most appropriate next step in her non-operative management plan?

. Immediately proceed to dorsal cheilectomy
. Recommend a first MTP joint arthrodesis
. Consider a corticosteroid injection into the first MTP joint
. Prescribe a short course of oral corticosteroids
. Advise complete immobilization for 6 weeks

Correct Answer & Explanation

. Consider a corticosteroid injection into the first MTP joint

Explanation

For Stage 1 hallux rigidus, where conservative management has been partially effective but pain persists, a corticosteroid injection into the first MTP joint can be a valuable adjunctive treatment. It can help reduce inflammation and pain, potentially offering a period of relief and delaying surgical intervention. While it is not a cure, it can be a useful diagnostic and therapeutic tool. Surgical intervention like cheilectomy is typically reserved for those who fail multiple conservative measures. Arthrodesis is for advanced stages. Oral corticosteroids are generally not used for chronic localized joint pain, and complete immobilization is rarely indicated and can lead to stiffness.

Question 282

Topic: Forefoot

Which of the following describes a key differentiating feature between hallux rigidus and gout affecting the first MTP joint?

. Presence of hyperuricemia
. Pain and stiffness worsened with activity
. Acute onset of severe pain, redness, and swelling
. Radiographic evidence of joint space narrowing
. Response to NSAIDs

Correct Answer & Explanation

. Acute onset of severe pain, redness, and swelling

Explanation

While both hallux rigidus and gout can affect the first MTP joint and respond to NSAIDs, the presentation differs significantly. Gout typically presents with an acute, often sudden, onset of excruciating pain, redness, and swelling (podagra), commonly waking the patient from sleep. Hallux rigidus, in contrast, usually has an insidious onset with chronic pain and stiffness that worsens with activity. Hyperuricemia is a risk factor for gout, not hallux rigidus. Both can eventually show joint space narrowing on radiographs in later stages.

Question 283

Topic: Forefoot

A patient undergoing first MTP joint arthrodesis for severe hallux rigidus requires internal fixation. Which of the following is generally considered the most biomechanically stable fixation construct?

. A single K-wire crossing the joint
. A dorsal compression plate with an interfragmentary screw
. Two divergent cancellous screws
. An external fixator alone
. Intramedullary K-wires

Correct Answer & Explanation

. A dorsal compression plate with an interfragmentary screw

Explanation

For first MTP joint arthrodesis, a dorsal compression plate with an interfragmentary screw is generally considered the most biomechanically stable and preferred fixation construct. The plate provides robust dorsal tension band fixation, while the interfragmentary screw provides compression across the fusion site, promoting primary bone healing. Two divergent cancellous screws are also a common and effective method, but a plate-and-screw construct often offers superior rigidity. A single K-wire is insufficient for stable fusion. External fixators are typically reserved for complex cases or infected fusions. Intramedullary K-wires are not commonly used for MTP fusions due to lack of compression and rotational instability.

Question 284

Topic: Forefoot

Following a successful cheilectomy for hallux rigidus, what is the expected timeline for return to full activity, including sports, assuming an uncomplicated recovery?

. Immediately, with no restrictions
. 2-4 weeks
. 6-8 weeks
. 3-4 months
. 6-12 months

Correct Answer & Explanation

. 3-4 months

Explanation

After an uncomplicated dorsal cheilectomy, patients typically progress to full weight-bearing in a rigid-soled shoe or post-op shoe fairly quickly (within a few days to 2 weeks). However, return to full, unrestricted activity, including sports, usually takes around 3-4 months. This allows for soft tissue healing, resolution of swelling, and regaining full range of motion and strength. Earlier return risks exacerbating symptoms or impeding recovery. Immediately or 2-4 weeks is too aggressive for full activity, while 6-12 months is generally too long unless complications arise.

Question 285

Topic: Forefoot

What is the typical age range for onset of symptoms in primary hallux rigidus?

. Adolescence (10-18 years)
. Young adults (18-30 years)
. Middle age (30-60 years)
. Elderly (>70 years)
. Congenital at birth

Correct Answer & Explanation

. Middle age (30-60 years)

Explanation

Primary hallux rigidus, which is degenerative in nature, typically presents with the onset of symptoms in middle age, generally between 30 and 60 years. While some individuals may experience earlier onset (juvenile hallux rigidus, often associated with specific anatomical factors like metatarsus primus elevatus), the vast majority of cases present in the middle-aged population, progressing with time. It is not congenital.

Question 286

Topic: Forefoot

In a patient presenting with hallux rigidus, why is the term 'hallux limitus' sometimes used, and what does it typically refer to?

. It refers to an earlier stage of the disease where motion is merely limited, not completely rigid.
. It describes a variant where the great toe is fused at birth.
. It is an old term for hallux valgus with limited motion.
. It indicates stiffness of the interphalangeal joint of the great toe.
. It is a misnomer, and the term 'hallux rigidus' should always be used.

Correct Answer & Explanation

. It refers to an earlier stage of the disease where motion is merely limited, not completely rigid.

Explanation

'Hallux limitus' is often used interchangeably with or to describe an earlier stage of hallux rigidus. It refers to a condition where there is a significant limitation of motion (particularly dorsiflexion) at the first MTP joint, but the joint is not yet 'rigid' or completely fused/ankylosed. It represents a continuum where the degenerative process has started, leading to restricted motion, but full-blown osteoarthritis with severe rigidity may not yet be present. Essentially, hallux limitus progresses to hallux rigidus.

Question 287

Topic: Forefoot

A patient presents with pain and stiffness in the first MTP joint, but physical exam reveals a painful and restricted MTP joint that is fixed in 10 degrees of plantarflexion. Radiographs confirm joint space narrowing and osteophytes. This specific fixed deformity is known as:

. Hallux valgus
. Hallux varus
. Hallux saltans
. Hallux extensus
. Hallux flexus

Correct Answer & Explanation

. Hallux flexus

Explanation

Hallux flexus refers to a painful and rigid deformity of the great toe MTP joint where it is fixed in plantarflexion. This is a less common presentation of hallux rigidus, as the typical restriction is in dorsiflexion, but it can occur and cause similar pain and functional limitations. Hallux valgus and varus refer to transverse plane deformities. Hallux saltans refers to a snapping toe. Hallux extensus would imply fixed dorsiflexion, which is not the case here.

Question 288

Topic: Forefoot

After a cheilectomy, a patient reports continued pain localized to the dorsal medial aspect of the great toe, particularly with light touch or shoe wear. What is the most likely iatrogenic complication?

. Infection
. Neuroma of the medial dorsal cutaneous nerve
. Recurrent osteophyte formation
. Plantar plate tear
. Deep vein thrombosis

Correct Answer & Explanation

. Neuroma of the medial dorsal cutaneous nerve

Explanation

Pain with light touch (allodynia) or direct pressure over a nerve distribution, particularly following surgery in that area, is highly suggestive of a neuroma. The medial dorsal cutaneous nerve, a branch of the superficial fibular nerve, courses dorsally over the first MTP joint and is at risk of injury or entrapment during approaches for cheilectomy, leading to neuroma formation. Recurrent osteophyte formation would typically present with mechanical impingement symptoms rather than neuropathic pain. Infection would have signs of inflammation, and DVT and plantar plate tears are unrelated to this specific presentation.

Question 289

Topic: Forefoot

In which stage of Coughlin and Shurnas classification for hallux rigidus is a cheilectomy alone typically considered insufficient, often requiring a concomitant osteotomy or moving towards arthroplasty/arthrodesis?

. Stage 0
. Stage 1
. Stage 2
. Stage 3
. Stage 4

Correct Answer & Explanation

. Stage 3

Explanation

In Stage 3 hallux rigidus, there is significant osteophyte formation, moderate-to-severe joint space narrowing, and subchondral sclerosis affecting greater than 50% of the articular surface. At this stage, a cheilectomy alone is often insufficient to restore adequate motion and provide lasting pain relief due to the extensive articular damage. It is frequently combined with a Moberg osteotomy (proximal phalangeal plantarflexion osteotomy) to enhance dorsiflexion, or considered for salvage procedures like arthroplasty or arthrodesis if symptoms are severe and cartilage loss is extensive. Stage 0, 1, and 2 are more amenable to isolated cheilectomy.

Question 290

Topic: Forefoot

A patient with Stage 4 hallux rigidus presents with severe pain and a desire to remain active, including hiking. Considering their desire for activity, which surgical procedure is most likely to provide a durable, pain-free outcome?

. Keller arthroplasty
. Silicone MTP joint implant
. First MTP joint arthrodesis
. Interpositional arthroplasty with soft tissue
. Dorsal cheilectomy with Moberg osteotomy

Correct Answer & Explanation

. First MTP joint arthrodesis

Explanation

For Stage 4 hallux rigidus in an active patient, first MTP joint arthrodesis (fusion) is the most reliable option for providing a durable, pain-free, and stable platform. While it eliminates motion, the stability it provides is excellent for high-demand activities. Keller arthroplasty and silicone implants are associated with high failure rates, instability, and transfer metatarsalgia in active individuals. Interpositional arthroplasty is less predictable for stability in high-demand settings. Cheilectomy with Moberg osteotomy is reserved for earlier stages with more preserved joint cartilage.

Question 291

Topic: Forefoot

Which non-operative treatment for hallux rigidus specifically targets inflammation within the joint capsule?

. Rocker-bottom shoes
. Carbon fiber plate inserts
. First MTP joint corticosteroid injection
. Activity modification to avoid aggravating activities
. Use of toe spacers

Correct Answer & Explanation

. First MTP joint corticosteroid injection

Explanation

A first MTP joint corticosteroid injection directly delivers an anti-inflammatory agent into the joint space, targeting the synovitis and inflammation within the joint capsule that contributes to pain in hallux rigidus. Rocker-bottom shoes, carbon fiber plates, and activity modification are mechanical solutions that limit motion. Toe spacers address interdigital pressure or alignment, not joint inflammation directly.

Question 292

Topic: Forefoot

A patient with hallux rigidus undergoes a cheilectomy and Moberg osteotomy. Six weeks post-operatively, they complain of persistent stiffness and pain with dorsiflexion. On examination, the MTP joint is still restricted. What is the most likely reason for this persistent stiffness?

. Early arthrodesis of the joint
. Transfer metatarsalgia to the lesser toes
. Inadequate bone resection during cheilectomy or insufficient Moberg correction
. Fracture of the proximal phalanx
. Complex Regional Pain Syndrome (CRPS)

Correct Answer & Explanation

. Inadequate bone resection during cheilectomy or insufficient Moberg correction

Explanation

Persistent stiffness and pain with dorsiflexion after a cheilectomy and Moberg osteotomy strongly suggest inadequate bone resection or insufficient correction. If the osteophytes were not fully removed or the Moberg osteotomy did not provide enough relative plantarflexion of the phalanx, impingement will persist. Early arthrodesis implies complete fusion, which is not the goal. Transfer metatarsalgia is pain in lesser toes. Fracture would cause acute pain and instability. CRPS would present with a constellation of neurovascular symptoms, not just mechanical stiffness.

Question 293

Topic: Forefoot

When advising on footwear for a patient with early-stage hallux rigidus, which feature is most important?

. High heels for aesthetic purposes
. Flexible sole to allow maximal toe motion
. Tight-fitting toe box to immobilize the joint
. Rigid sole, often with a rocker-bottom design, and a wide, deep toe box
. Open-toed sandals exclusively

Correct Answer & Explanation

. Rigid sole, often with a rocker-bottom design, and a wide, deep toe box

Explanation

For early-stage hallux rigidus, the most important footwear features are a rigid sole (often with a rocker-bottom or rigid shank) to minimize motion at the first MTP joint during gait, and a wide, deep toe box to prevent compression and irritation of the dorsal osteophytes. Flexible soles exacerbate pain by allowing painful dorsiflexion. High heels and tight toe boxes increase pressure and pain. Open-toed sandals may be comfortable for some but don't offer the necessary rigidity.

Question 294

Topic: Forefoot

Which clinical test specifically assesses the functional range of dorsiflexion at the first MTP joint in a weight-bearing scenario, which is often limited in hallux rigidus?

. Lachman test
. Thomson test
. Hubscher's maneuver (Jack's Test)
. Anterior drawer test
. Tinel's sign

Correct Answer & Explanation

. Hubscher's maneuver (Jack's Test)

Explanation

Hubscher's maneuver, also known as Jack's Test, is a clinical test performed in a weight-bearing patient. The examiner dorsiflexes the great toe, which should lead to elevation of the medial longitudinal arch if the windlass mechanism is intact. In hallux rigidus, due to limited MTP dorsiflexion, this maneuver will be painful, restricted, and the arch may not elevate, indicating impaired functional dorsiflexion and a compromised windlass mechanism. The other tests are for different anatomical regions or pathologies.

Question 295

Topic: Forefoot

Which of the following describes the purpose of a dorsiflexion-plantarflexion stress radiograph of the first MTP joint in the evaluation of hallux rigidus?

. To measure the intermetatarsal angle.
. To assess the integrity of the collateral ligaments.
. To quantify the true range of motion and identify the point of impingement.
. To determine the extent of sesamoidopathy.
. To evaluate midfoot collapse.

Correct Answer & Explanation

. To quantify the true range of motion and identify the point of impingement.

Explanation

Dorsiflexion-plantarflexion stress radiographs (often a lateral view) are used to dynamically assess the first MTP joint's range of motion and pinpoint the exact position and degree of bony impingement. This helps in surgical planning, especially for cheilectomy, to determine the amount of bone resection required to achieve adequate motion. It provides more functional information than static radiographs. It is not for intermetatarsal angle, collateral ligaments, sesamoidopathy, or midfoot collapse.

Question 296

Topic: Forefoot

When comparing cheilectomy to MTP joint arthrodesis for hallux rigidus, which statement is TRUE?

. Arthrodesis provides greater motion but less pain relief than cheilectomy.
. Cheilectomy is preferred for Stage 4 disease, while arthrodesis is for Stage 2.
. Arthrodesis generally offers more predictable and complete pain relief for severe stages, sacrificing motion.
. Cheilectomy has a higher rate of transfer metatarsalgia.
. Arthrodesis has a faster return to full activity.

Correct Answer & Explanation

. Arthrodesis generally offers more predictable and complete pain relief for severe stages, sacrificing motion.

Explanation

Arthrodesis (fusion) of the first MTP joint is generally recognized as providing the most predictable and complete pain relief for severe (Stage 3-4) hallux rigidus, albeit at the cost of sacrificing all motion at that joint. Cheilectomy is a joint-preserving procedure for earlier stages (Stage 1-2) aiming to improve motion. Cheilectomy does not have a higher rate of transfer metatarsalgia than arthrodesis. Arthrodesis typically has a longer recovery and return to full activity due to the need for bone healing.

Question 297

Topic: Forefoot

What type of imaging is most sensitive for detecting early articular cartilage damage in hallux rigidus, not typically visible on plain radiographs?

. Computed Tomography (CT) scan
. Bone scintigraphy
. Magnetic Resonance Imaging (MRI)
. Ultrasound
. Weight-bearing plain radiographs

Correct Answer & Explanation

. Magnetic Resonance Imaging (MRI)

Explanation

Magnetic Resonance Imaging (MRI) is the most sensitive imaging modality for detecting early articular cartilage damage, subchondral bone marrow edema, and subtle soft tissue changes (e.g., synovitis) associated with hallux rigidus that are not typically visible on plain radiographs. CT scans are excellent for bony detail but less so for cartilage. Bone scintigraphy shows metabolic activity but is non-specific. Ultrasound can assess superficial soft tissues but not deep articular cartilage well. Plain radiographs show advanced bony changes but miss early cartilage loss.

Question 298

Topic: Forefoot

After a first MTP joint arthrodesis, a patient complains of a stiff, painful interphalangeal (IP) joint of the great toe. What is the most likely cause?

. Infection of the IP joint
. Developing hallux valgus deformity
. Pre-existing, undiagnosed IP joint arthritis exacerbated by increased demands post-fusion
. Transfer metatarsalgia to the IP joint
. Neuroma formation at the IP joint

Correct Answer & Explanation

. Pre-existing, undiagnosed IP joint arthritis exacerbated by increased demands post-fusion

Explanation

A stiff, painful IP joint after first MTP arthrodesis strongly suggests pre-existing, undiagnosed (or underestimated) arthritis in the IP joint. Once the MTP joint is fused, the IP joint becomes the primary mobile joint for the great toe, experiencing increased stress and compensatory motion. If it already has degenerative changes, these will likely become symptomatic. This highlights the importance of thorough IP joint assessment pre-operatively. Infection, hallux valgus, transfer metatarsalgia (which typically refers to lesser MTP joints), and neuroma are less likely to directly cause diffuse stiffness and pain within the IP joint itself.

Question 299

Topic: Forefoot

Which of the following is a potential complication specific to a proximal phalangeal osteotomy (Moberg type) for hallux rigidus?

. Recurrence of dorsal osteophytes
. Nonunion or delayed union of the osteotomy site
. Transfer metatarsalgia
. Flail toe deformity
. Deep vein thrombosis

Correct Answer & Explanation

. Nonunion or delayed union of the osteotomy site

Explanation

Nonunion or delayed union of the osteotomy site is a specific complication to any osteotomy, including the Moberg osteotomy. While rare, failure of the osteotomy to heal properly can lead to persistent pain and require revision. Recurrence of dorsal osteophytes is typically a complication of cheilectomy alone. Transfer metatarsalgia and flail toe are more associated with resection arthroplasties (like Keller). DVT is a general surgical complication.

Question 300

Topic: Forefoot

Which of the following is NOT typically considered a primary etiologic factor for the development of hallux rigidus?

. Trauma (e.g., turf toe injury)
. Metatarsus primus elevatus
. Hyperpronation of the foot
. Rheumatoid arthritis
. Genetics

Correct Answer & Explanation

. Rheumatoid arthritis

Explanation

Rheumatoid arthritis is an inflammatory arthritis that can affect the first MTP joint, but it is distinct from primary hallux rigidus, which is a degenerative osteoarthritic process. While rheumatoid arthritis can lead to MTP joint destruction, it is considered a secondary cause rather than a primary etiologic factor for the typical hallux rigidus presentation. Trauma, metatarsus primus elevatus, hyperpronation (altering biomechanics), and genetics are all considered primary or contributing etiologic factors for hallux rigidus.

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