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 301
Topic: Forefoot
When evaluating a patient with hallux rigidus, a positive 'grind test' at the first MTP joint indicates:
Correct Answer & Explanation
. Cartilage degeneration and bone-on-bone articulation
Explanation
A positive 'grind test' (axial compression and rotation of the MTP joint) that elicits pain and often crepitus is indicative of significant articular cartilage degeneration and bone-on-bone articulation within the joint. This test directly stresses the joint surfaces, making it a reliable indicator of the extent of arthritic changes in hallux rigidus. It is not primarily for plantar plate integrity, sesamoid inflammation (though they may be involved), neuroma, or subluxation (though subluxation can be part of advanced degeneration).
Question 302
Topic: Forefoot
A 65-year-old female presents with a painful bunion deformity (hallux valgus). She has failed conservative management. Clinical examination shows a painful hallux valgus angle of 35 degrees and an intermetatarsal angle of 18 degrees. What is the most appropriate surgical procedure for this deformity?
Correct Answer & Explanation
. Proximal metatarsal osteotomy (e.g., Ludloff or scarf) combined with soft tissue release
Explanation
For moderate to severe hallux valgus deformities (typically Hallux Valgus Angle >30 degrees and Intermetatarsal Angle >15 degrees, as seen here with HVA 35 and IMA 18), a proximal first metatarsal osteotomy (such as a Ludloff, Scarf, or crescentic osteotomy) combined with a distal soft tissue release (McBride-type) is generally indicated. This combination allows for significant correction of both the intermetatarsal angle and the hallux valgus angle. A Chevron osteotomy (distal metatarsal osteotomy) is usually reserved for mild-to-moderate deformities (IMA <15 degrees). Akin osteotomy is a phalangeal osteotomy used for residual hallux valgus and is often combined with metatarsal osteotomies. Cheilectomy is for hallux rigidus.
Question 303
Topic: Forefoot
Which of the following is the primary indication for surgical intervention in patients with hallux valgus deformity?
Correct Answer & Explanation
. Presence of a painful bunion
Explanation
The primary indication for surgical correction of hallux valgus (bunion deformity) is symptomatic pain that significantly interferes with daily activities or shoe wear, and has failed conservative management. While radiographic angles (HVA, IMA) and shoe-fitting difficulties are important considerations, pain is the overarching factor that drives the decision for surgery. Cosmetic improvement alone is generally not considered a primary indication for elective orthopedic surgery due to potential complications. Hammertoe is an associated deformity but not the primary indication for bunion surgery.
Question 304
Topic: Forefoot
A 40-year-old female presents with a painful bunion. Weight-bearing radiographs reveal a Hallux Valgus Angle (HVA) of 42 degrees and an Intermetatarsal Angle (IMA) of 18 degrees. Which of the following is the most appropriate surgical option?
Correct Answer & Explanation
. Proximal metatarsal osteotomy or Lapidus procedure
Explanation
An IMA of >15 degrees and HVA >40 degrees defines a severe hallux valgus deformity. Proximal osteotomies or a first tarsometatarsal fusion (Lapidus) provide the necessary corrective power, whereas distal osteotomies are insufficient for this degree of deformity.
Question 305
Topic: Forefoot
A 45-year-old female presents with symptomatic hallux valgus. Radiographs demonstrate a hallux valgus angle (HVA) of 45 degrees, an intermetatarsal angle (IMA) of 16 degrees, and hypermobility of the first tarsometatarsal (TMT) joint. Which surgical procedure is most appropriate?
Correct Answer & Explanation
. First tarsometatarsal arthrodesis (Lapidus procedure)
Explanation
The patient has a severe hallux valgus deformity combined with first TMT joint hypermobility. A modified Lapidus procedure (first TMT arthrodesis) is the most appropriate operation to correct the deformity and stabilize the medial column.
Question 306
Topic: Forefoot
A 55-year-old female presents with severe bunion pain. Radiographs reveal a hallux valgus angle (HVA) of 45 degrees, an intermetatarsal angle (IMA) of 19 degrees, and clinical hypermobility of the first ray in the sagittal plane. Which procedure is most appropriate?
Correct Answer & Explanation
. First tarsometatarsal joint arthrodesis (Lapidus procedure)
Explanation
The Lapidus procedure (first TMT arthrodesis) is indicated for moderate to severe hallux valgus (IMA >15 degrees) associated with first ray hypermobility. It definitively corrects the deformity at the apex (TMT joint) and stabilizes the medial column.
Question 307
Topic: Forefoot
A 60-year-old male presents with severe pain and stiffness in the first metatarsophalangeal (MTP) joint. Examination reveals pain throughout the entire arc of motion and less than 10 degrees of dorsiflexion. Radiographs show complete loss of the joint space, subchondral cysts, and large dorsal osteophytes (Grade 3 hallux rigidus). What is the gold standard surgical treatment?
Correct Answer & Explanation
. First metatarsophalangeal joint arthrodesis
Explanation
First MTP joint arthrodesis is the gold standard for advanced (Grade 3 or 4) hallux rigidus characterized by significant joint space narrowing and mid-arc pain. Cheilectomy is generally reserved for Grade 1 or 2 disease with pain only at the extremes of dorsiflexion.
Question 308
Topic: Forefoot
A professional football player sustains a forced hyperextension injury to his great toe. MRI reveals a complete rupture of the plantar plate and joint capsule with proximal retraction of the sesamoids (Grade 3 Turf Toe). What is the recommended management?
Correct Answer & Explanation
. Operative repair of the plantar plate and capsule
Explanation
Grade 3 turf toe injuries (complete disruption of the plantar plate complex) in elite athletes usually require operative repair to restore the push-off mechanism and prevent chronic instability, progressive hallux valgus, or hallux rigidus.
Question 309
Topic: Forefoot
A 55-year-old female presents with pain at the plantar aspect of the second metatarsophalangeal (MTP) joint and a new onset of the second toe crossing over the hallux. A positive dorsal drawer test of the second MTP joint is elicited. What is the most likely diagnosis?
Correct Answer & Explanation
. Plantar plate tear
Explanation
A positive dorsal drawer test at the MTP joint, localized plantar pain, and crossover toe deformity are hallmark clinical signs of a plantar plate attenuation or tear. Morton's neuroma usually presents with web space pain and a positive Mulder's click, without joint instability.
Question 310
Topic: Forefoot
A 28-year-old female presents with a painful bunion deformity. Examination reveals a hallux valgus angle of 45 degrees, an intermetatarsal angle of 18 degrees, and clinical hypermobility of the 1st tarsometatarsal (TMT) joint. What is the most appropriate surgical procedure?
Correct Answer & Explanation
. First TMT arthrodesis (Lapidus procedure)
Explanation
The Lapidus procedure (first TMT arthrodesis) is indicated for severe hallux valgus deformities (IMA > 15 degrees) associated with 1st ray hypermobility. It provides powerful correction and addresses the apex of the deformity at the TMT joint.
Question 311
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 of the first tarsometatarsal (TMT) joint. Which of the following surgical options is most appropriate?
Correct Answer & Explanation
. First TMT joint arthrodesis (Lapidus procedure)
Explanation
A Lapidus procedure (first TMT arthrodesis) is indicated for severe hallux valgus (HVA >40, IMA >15) associated with first TMT joint hypermobility. It corrects the deformity at the apex and stabilizes the medial column.
Question 312
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. Which of the following procedures is most appropriate?
Correct Answer & Explanation
. First TMT joint arthrodesis (Lapidus procedure)
Explanation
A Lapidus procedure (first TMT arthrodesis) is indicated for moderate-to-severe hallux valgus associated with first ray hypermobility. It corrects the intermetatarsal angle and stabilizes the medial column, preventing recurrence.
Question 313
Topic: Forefoot
A 45-year-old female presents with a painful bunion. Radiographs reveal a hallux valgus angle (HVA) of 42 degrees, an intermetatarsal angle (IMA) of 18 degrees, and clinical examination demonstrates significant hypermobility of the first tarsometatarsal (TMT) joint. What is the most appropriate surgical intervention?
Correct Answer & Explanation
. First TMT arthrodesis (Lapidus procedure)
Explanation
A first TMT arthrodesis (Lapidus procedure) is indicated for patients with moderate to severe hallux valgus (IMA > 15 degrees) accompanied by hypermobility of the first TMT joint. Distal osteotomies do not correct large IMA angles or address TMT hypermobility, leading to high recurrence rates in these specific patients.
Question 314
Topic: Forefoot
A 62-year-old male complains of worsening pain and stiffness in his right great toe, particularly during the toe-off phase of gait. Radiographs demonstrate severe joint space narrowing (>50%), extensive dorsal osteophytosis, and subchondral sclerosis at the first metatarsophalangeal (MTP) joint. On examination, dorsiflexion is limited to 10 degrees and elicits significant pain. According to the Coughlin and Shurnas classification, what is the most definitive and reliable surgical treatment for this condition?
Correct Answer & Explanation
. First MTP joint arthrodesis
Explanation
The patient has Grade 3 hallux rigidus (Coughlin and Shurnas classification), characterized by significant pain at the extremes of motion, >50% joint space narrowing, and extensive osteophytes. While a dorsal cheilectomy is highly successful for Grade 1 and 2 hallux rigidus, Grade 3 and 4 disease is best treated with a first MTP joint arthrodesis, which is the gold standard and provides the most reliable long-term pain relief and functional restoration.
Question 315
Topic: Forefoot
A 60-year-old male presents with dorsal foot pain and restricted toe dorsiflexion. Radiographs show severe joint space narrowing, large dorsal osteophytes, and subchondral sclerosis at the first metatarsophalangeal joint (Coughlin and Shurnas Grade 3). What is the gold standard surgical treatment?
Correct Answer & Explanation
. First MTP joint arthrodesis
Explanation
For advanced hallux rigidus (Grade 3 or 4) with diffuse joint space loss and significant pain, first MTP joint arthrodesis is the gold standard procedure. It provides reliable pain relief and functional improvement.
Question 316
Topic: Forefoot
A 65-year-old male with severe hallux rigidus (Coughlin and Shurnas Grade 3) complains of persistent pain and inability to wear normal shoes despite conservative management. He desires a definitive surgical procedure with the lowest risk of recurrence. What is the gold standard treatment?
Correct Answer & Explanation
. First metatarsophalangeal (MTP) joint arthrodesis
Explanation
First MTP joint arthrodesis is the gold standard for advanced (Grade 3 or 4) hallux rigidus, providing reliable pain relief, durable functional outcomes, and the lowest recurrence rate.
Question 317
Topic: Forefoot
A 45-year-old female presents with a painful bunion. Weight-bearing radiographs reveal a Hallux Valgus Angle (HVA) of 42 degrees and an Intermetatarsal Angle (IMA) of 18 degrees. Clinical examination reveals no hypermobility at the first tarsometatarsal (TMT) joint. What is the most appropriate surgical intervention for this deformity?
Correct Answer & Explanation
. Proximal metatarsal osteotomy with a distal soft tissue reconstruction
Explanation
This patient has a severe hallux valgus deformity, defined by an HVA > 40 degrees and an IMA > 15 degrees. Distal osteotomies (like the Chevron) cannot achieve enough translation to correct an IMA > 15 degrees. For severe deformities without TMT hypermobility or degenerative arthritis, a proximal metatarsal osteotomy (e.g., Ludloff, proximal crescentic) combined with a distal soft tissue release (modified McBride) is the most appropriate procedure. A Lapidus is favored if there is documented TMT hypermobility or arthritis.
Question 318
Topic: Forefoot
A 45-year-old female presents with a painful bunion. Weight-bearing radiographs demonstrate a Hallux Valgus Angle (HVA) of 36 degrees and an Intermetatarsal Angle (IMA) of 17 degrees. The 1st MTP joint shows no arthritic changes. Which of the following surgical procedures is most appropriate to achieve correction?
Correct Answer & Explanation
. Proximal metatarsal osteotomy
Explanation
An intermetatarsal angle (IMA) greater than 15 degrees and a hallux valgus angle (HVA) greater than 30 degrees classify as severe hallux valgus. Distal osteotomies (like a distal Chevron) cannot adequately translate the metatarsal head to correct an IMA >15 degrees. A proximal metatarsal osteotomy (e.g., Ludloff, Crescentic) or a Lapidus procedure (1st TMT fusion) is required to correct this magnitude of deformity.
Question 319
Topic: Forefoot
A 45-year-old female presents with a painful bunion. Weight-bearing radiographs reveal a hallux valgus angle (HVA) of 38 degrees and an intermetatarsal angle (IMA) of 18 degrees. Clinical examination reveals hypermobility of the first tarsometatarsal (TMT) joint. What is the most appropriate surgical management?
Correct Answer & Explanation
. First tarsometatarsal (TMT) arthrodesis (Lapidus procedure)
Explanation
The Lapidus procedure (arthrodesis of the 1st TMT joint) is indicated for moderate to severe hallux valgus (IMA > 15 degrees) associated with first ray hypermobility. A distal chevron is inadequate for an IMA of 18 degrees. While a proximal osteotomy can correct a large IMA, it does not address the TMT hypermobility, leading to a high recurrence rate. First MTP arthrodesis is typically reserved for severe deformity with osteoarthritis or rheumatoid arthritis.
Question 320
Topic: Forefoot
A 72-year-old woman presents with severe first metatarsophalangeal (MTP) joint pain and a recurrent, rigid hallux valgus deformity 15 years after previous bunion surgery. Radiographs demonstrate severe osteoarthritis of the first MTP joint with a prominent retained screw. The decision is made to perform hardware removal and a first MTP arthrodesis. What is the optimal position for fusion of the first MTP joint?
Correct Answer & Explanation
. 10-15 degrees of valgus, 10-15 degrees of dorsiflexion relative to the floor, and neutral rotation
Explanation
Correct Answer: 10-15 degrees of valgus, 10-15 degrees of dorsiflexion relative to the floor, and neutral rotationFirst MTP joint arthrodesis is a reliable salvage procedure for failed bunion surgery with severe arthritis. The optimal position for fusion is critical for a good functional outcome and to prevent transfer metatarsalgia or interphalangeal joint arthritis. The recommended position is 10-15 degrees of valgus, 10-15 degrees of dorsiflexion relative to the floor (which equates to about 25-30 degrees of dorsiflexion relative to the first metatarsal shaft), and neutral rotation. This allows for normal toe-off during the gait cycle and accommodates most standard footwear.
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