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Forefoot MCQs

Practice Set 2 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 21

Topic: Forefoot

A 40-year-old female presents with a 6-month history of intermittent pain in her right great toe, exacerbated by high-heeled shoes and prolonged walking. Clinical examination reveals mild dorsal tenderness and a slight restriction in passive dorsiflexion (approximately 45 degrees). Radiographs show minimal dorsal osteophytes with preserved joint space. She is diagnosed with early-stage hallux rigidus (Coughlin and Shurnas Grade 1). According to the case, which of the following non-operative treatment modalities should be the initial recommendation?

. A. Intra-articular corticosteroid injections.
. B. Surgical cheilectomy to remove dorsal osteophytes.
. C. Footwear modification with a stiff sole and wide toe box.
. D. Aggressive physical therapy focusing on MTP joint mobilization.
. E. Prescription of strong opioid analgesics for pain management.

Correct Answer & Explanation

. C. Footwear modification with a stiff sole and wide toe box.

Explanation

Correct Answer: CThe case clearly states under 'Non-Operative Indications' that 'Non-operative management is typically the first-line treatment, especially for early stages of hallux rigidus (Coughlin and Shurnas Grade 0, 1, and often Grade 2).' Among the non-operative treatment modalities, 'Footwear Modification: Shoes with a stiff sole, rocker-bottom sole, or wide toe box can reduce motion at the MTP joint and alleviate dorsal impingement' is listed as a primary intervention. This directly addresses the patient's symptoms exacerbated by high-heeled shoes and aims to reduce stress on the affected joint.A. Corticosteroid injections are mentioned as providing 'temporary pain relief' but are 'not curative' and 'repeated injections are discouraged due to potential cartilage damage.' They are typically considered after initial, less invasive measures.B. Surgical cheilectomy is an operative indication, considered when conservative measures have failed, not as an initial treatment for early-stage disease.D. Physical therapy is a modality focused on 'improving range of motion,' but the initial step for early-stage HR often involves reducing aggravating factors through footwear modification before aggressive mobilization, especially if pain is activity-related.E. Opioid analgesics are not a first-line treatment for chronic musculoskeletal pain like hallux rigidus, especially in early stages, due to their side effect profile and risk of dependence. NSAIDs are mentioned as a more appropriate pharmacological option.

Question 22

Topic: Forefoot

A 42-year-old patient undergoes a cheilectomy and Moberg osteotomy for Coughlin and Shurnas Grade 2 hallux rigidus. Which of the following post-operative rehabilitation instructions is most consistent with the goals of this specific procedure, as outlined in the case?

. A. Strict non-weight-bearing in a short leg cast for 6 weeks to ensure bone healing.
. B. Immediate, gentle active and passive range of motion exercises for the first MTP joint.
. C. No active or passive ROM exercises for the first MTP joint for 12 weeks.
. D. Gradual progression to weight-bearing in a CAM boot only after radiographic confirmation of osteotomy union at 8 weeks.
. E. Avoidance of any MTP joint motion for 4 weeks, followed by passive stretching only.

Correct Answer & Explanation

. B. Immediate, gentle active and passive range of motion exercises for the first MTP joint.

Explanation

Correct Answer: BThe case, under 'Post-Operative Rehabilitation Protocols - Cheilectomy and Moberg Osteotomy,' states: 'These procedures aim to restore and maintain motion, so early mobilization is typically encouraged.' Specifically, for 'Immediately Post-operative (Day 0 - 2 weeks),' it instructs: 'Range of Motion (ROM): Crucial. Initiate immediate, gentle active and passive ROM exercises for the first MTP joint, focusing on dorsiflexion and plantarflexion. Patients are instructed to perform these exercises frequently throughout the day to prevent stiffness and scar tissue formation.'A. Strict non-weight-bearing in a cast for 6 weeks is typical for arthrodesis, not for cheilectomy/Moberg osteotomy, which allows for weight-bearing as tolerated in a surgical shoe.C. No active or passive ROM for 12 weeks is contrary to the goal of motion preservation and would lead to stiffness.D. Gradual progression to weight-bearing after radiographic confirmation of union at 8 weeks is characteristic of arthrodesis protocols, not cheilectomy/Moberg osteotomy, which allows earlier weight-bearing.E. Avoidance of MTP joint motion for 4 weeks is incorrect; early motion is emphasized to prevent stiffness.

Question 23

Topic: Forefoot

A 68-year-old patient with a history of rheumatoid arthritis and severe, painful hallux rigidus (Coughlin and Shurnas Grade 4) is considering surgical options. She expresses a strong desire to preserve some motion in her great toe, if possible, but her primary goal is reliable pain relief. Based on the provided case, which statement accurately reflects the current understanding of motion-preserving arthroplasty options versus arthrodesis for end-stage hallux rigidus?

. A. Metallic hemiarthroplasty offers superior long-term pain relief and durability compared to arthrodesis for end-stage disease.
. B. Interposition arthroplasty using autograft provides more predictable outcomes and motion preservation than arthrodesis.
. C. Arthrodesis is considered the gold standard for end-stage hallux rigidus, providing the most reliable and durable pain relief, despite sacrificing motion.
. D. Silicone implants are now the preferred choice for arthroplasty due to their excellent long-term results and low complication rates.
. E. Cartilage restoration techniques like microfracture are highly effective for diffuse, end-stage arthritis in older patients seeking motion preservation.

Correct Answer & Explanation

. C. Arthrodesis is considered the gold standard for end-stage hallux rigidus, providing the most reliable and durable pain relief, despite sacrificing motion.

Explanation

Correct Answer: CThe case, under 'Summary of Key Literature and Guidelines - Arthrodesis,' explicitly states: 'Fusion of the first MTP joint is widely considered the 'gold standard' for end-stage hallux rigidus (Coughlin and Shurnas Grade 4), providing the most reliable and durable pain relief. Fusion rates typically range from 90% to 98%, with high patient satisfaction despite the sacrifice of motion.' This directly addresses the patient's primary goal of reliable pain relief for end-stage disease.A. The case states regarding metallic hemiarthroplasty: 'Long-term comparative studies against arthrodesis often show superior pain relief and durability for fusion in severe cases.' This contradicts the option.B. Regarding interposition arthroplasty, the case notes: 'these procedures generally have less predictable outcomes than fusion, with variable rates of pain relief and maintenance of motion.' This contradicts the option.D. The case states: 'Silicone implants: Largely abandoned due to concerns regarding particulate synovitis and implant failure.' This contradicts the option.E. The case states regarding cartilage restoration: 'their application in diffuse, advanced hallux rigidus is limited, and long-term data specific to the first MTP joint is still evolving.' This contradicts the option, especially for an older patient with diffuse, end-stage arthritis.

Question 24

Topic: Forefoot

A 55-year-old male presents with dorsal pain and stiffness in his right great toe. Radiographs demonstrate dorsal osteophytes and mild joint space narrowing at the first metatarsophalangeal (MTP) joint consistent with Grade 2 hallux rigidus. Which of the following shoe modifications is most appropriate for initial conservative management?

. Flexible, thin-soled minimalist shoe
. Shoe with a flexible toe box and high heel
. Stiff-soled shoe with a Morton extension
. Shoe with a medial heel wedge
. UCBL orthosis

Correct Answer & Explanation

. Stiff-soled shoe with a Morton extension

Explanation

The mainstay of non-operative treatment for hallux rigidus is limiting dorsiflexion of the first MTP joint. A stiff-soled shoe with a Morton extension (a rigid plate under the first MTP) accomplishes this and effectively reduces pain.

Question 25

Topic: Forefoot

A 58-year-old male runner complains of chronic, progressive right great toe pain. On examination, he has significant pain throughout the mid-range of first metatarsophalangeal (MTP) joint motion. Radiographs reveal severe joint space narrowing, subchondral sclerosis, and large dorsal and lateral osteophytes, consistent with Grade 3 hallux rigidus. He has failed shoe modifications and NSAIDs. What is the gold standard surgical treatment for this patient?

. Dorsal cheilectomy
. First MTP joint arthrodesis
. Silicone implant arthroplasty
. Keller resection arthroplasty
. Proximal phalanx dorsal closing wedge osteotomy (Moberg)

Correct Answer & Explanation

. First MTP joint arthrodesis

Explanation

First MTP joint arthrodesis is the gold standard treatment for advanced (Grade 3 or 4) hallux rigidus, providing reliable pain relief while restoring weight-bearing capacity. Dorsal cheilectomy is typically reserved for early-stage disease (Grade 1 or 2) where pain occurs primarily at the extremes of dorsiflexion.

Question 26

Topic: Forefoot

A 45-year-old male is undergoing open reduction and internal fixation of a highly comminuted intra-articular distal humerus fracture (AO/OTA 13C3). The surgeon decides to use a transolecranon approach for optimal articular visualization. To maximize joint stability and facilitate anatomic reduction of the osteotomy site postoperatively, which of the following describes the optimal orientation of the olecranon osteotomy?

. Transverse osteotomy exactly at the deepest portion of the trochlear notch
. Apex-distal chevron osteotomy at the non-articular bare area
. Apex-proximal chevron osteotomy through the coronoid process
. Step-cut osteotomy through the olecranon tip
. Oblique osteotomy directed from proximal-dorsal to distal-volar

Correct Answer & Explanation

. Apex-distal chevron osteotomy at the non-articular bare area

Explanation

An apex-distal chevron osteotomy directed at the "bare area" of the greater sigmoid notch is preferred. This configuration maximizes surface area for healing and provides inherent rotational and translational stability.

Question 27

Topic: Forefoot

What is the primary biomechanical advantage of performing a Moberg osteotomy (dorsal closing wedge osteotomy of the proximal phalanx) in conjunction with a cheilectomy for hallux rigidus?

. To increase plantarflexion of the great toe MTP joint
. To offload the first metatarsal head
. To improve dorsiflexion of the great toe MTP joint by rotating the proximal phalanx dorsally
. To correct hallux valgus deformity
. To enhance intrinsic muscle function

Correct Answer & Explanation

. To improve dorsiflexion of the great toe MTP joint by rotating the proximal phalanx dorsally

Explanation

Correct Answer: CA Moberg osteotomy, a dorsal closing wedge osteotomy of the proximal phalanx, effectively plantarflexes the proximal phalanx relative to its articular surface. This maneuver indirectly increases functional dorsiflexion at the MTP joint by changing the resting position of the proximal phalanx, thereby reducing impingement and improving the toe-off phase of gait. It is typically performed in conjunction with a cheilectomy for Stage 2 or early Stage 3 hallux rigidus, or when isolated cheilectomy is insufficient to restore adequate dorsiflexion. It does not primarily offload the metatarsal head, correct hallux valgus (though some subtle correction might occur), or directly enhance intrinsic muscle function.

Question 28

Topic: Forefoot

A 60-year-old sedentary patient with Stage 4 hallux rigidus presents with severe, constant pain in the first MTP joint, significantly affecting daily activities. Radiographs show complete obliteration of the joint space and subchondral bone erosions. Considering the patient's age and activity level, which surgical option is generally considered the gold standard for pain relief and functional improvement in this scenario?

. Dorsal cheilectomy
. Proximal phalangeal osteotomy (Moberg)
. First MTP joint arthrodesis
. Interpositional arthroplasty
. Metatarsal shortening osteotomy

Correct Answer & Explanation

. First MTP joint arthrodesis

Explanation

Correct Answer: CFor Stage 4 hallux rigidus, characterized by severe degenerative changes or ankylosis, joint-preserving procedures like cheilectomy or Moberg osteotomy are inappropriate as they cannot address the diffuse damage. First MTP joint arthrodesis (fusion) is considered the gold standard for severe hallux rigidus, especially in active patients, or when other procedures have failed. It provides reliable pain relief and a stable, pain-free platform for push-off, though it sacrifices MTP joint motion. While interpositional arthroplasty or MTP joint implants might be considered for less active patients or those unwilling to sacrifice motion, arthrodesis typically offers the most predictable and durable pain relief for severe end-stage disease. A sedentary patient might be a candidate for arthroplasty, but for reliable pain relief and functional improvement, especially with complete obliteration, arthrodesis is still considered the gold standard for overall success.

Question 29

Topic: Forefoot

Which of the following is considered a relative contraindication to first MTP joint arthroplasty with an implant for hallux rigidus?

. Older, less active patient
. Rheumatoid arthritis
. Previous infection in the surgical field
. Failed cheilectomy
. Moderate hallux valgus deformity

Correct Answer & Explanation

. Previous infection in the surgical field

Explanation

Correct Answer: CPrevious infection in the surgical field is a strong contraindication for any joint replacement procedure, including MTP joint arthroplasty with an implant, due to the high risk of recurrent infection and subsequent implant failure. Older, less active patients are often considered good candidates for arthroplasty as motion preservation is prioritized over the robust stability of an arthrodesis. Rheumatoid arthritis can be an indication for arthroplasty, especially with polyarticular involvement. Failed cheilectomy is a common indication for salvage procedures like arthroplasty or arthrodesis. Moderate hallux valgus may need concomitant correction but isn't a direct contraindication to implant arthroplasty itself, though some implants may not be suitable.

Question 30

Topic: Forefoot

A 30-year-old professional athlete develops severe, painful hallux rigidus (Coughlin and Shurnas Stage 3-4). He requires a stable, pain-free foot for continued high-impact activities. Which surgical option would you most strongly recommend for this patient?

. Keller arthroplasty
. Silicone interpositional arthroplasty
. First MTP joint arthrodesis
. Dorsal cheilectomy with Moberg osteotomy
. Resection of the proximal phalanx base

Correct Answer & Explanation

. First MTP joint arthrodesis

Explanation

Correct Answer: CFor a young, active professional athlete with severe hallux rigidus (Stage 3-4), a first MTP joint arthrodesis is the most appropriate and recommended option. While it sacrifices motion, it provides a highly stable, pain-free, and durable platform capable of withstanding high-impact activities required by athletes. Cheilectomy with Moberg is generally for earlier stages (Stage 2-3). Keller arthroplasty (resection of proximal phalanx base) is largely abandoned due to high rates of complications like transfer metatarsalgia and instability. Silicone implants have a high failure rate in active patients and are prone to synovitis and osteolysis. Interpositional arthroplasty may be considered for less active patients but does not provide the same level of stability and predictable outcomes for high-demand individuals.

Question 31

Topic: Forefoot

A 65-year-old woman undergoes a first MTP arthrodesis for end-stage hallux rigidus. To optimize normal gait kinematics and prevent transfer metatarsalgia, what is the ideal position for fusion of the first MTP joint?

. Neutral dorsiflexion and neutral valgus
. 10-15 degrees of dorsiflexion and 10-15 degrees of valgus
. 25-30 degrees of dorsiflexion and neutral valgus
. 5-10 degrees of plantarflexion and 15 degrees of valgus
. 10-15 degrees of dorsiflexion and 25-30 degrees of valgus

Correct Answer & Explanation

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

Explanation

The ideal position for first MTP arthrodesis is 10 to 15 degrees of valgus and 10 to 15 degrees of dorsiflexion relative to the floor. This allows for normal toe-off during gait and accommodates most footwear.

Question 32

Topic: Forefoot

In the surgical management of hallux rigidus, a Moberg osteotomy (a dorsal closing wedge osteotomy of the proximal phalanx) is most appropriately utilized as an adjunct procedure to achieve which of the following goals?

. Increase true first MTP joint plantarflexion
. Increase total first MTP joint range of motion
. Correct metatarsus primus varus
. Improve apparent hallux dorsiflexion to facilitate toe-off during gait
. Decompress the sesamoid complex

Correct Answer & Explanation

. Improve apparent hallux dorsiflexion to facilitate toe-off during gait

Explanation

A Moberg osteotomy does not increase the true range of motion of the first MTP joint. Instead, it shifts the existing arc of motion into more dorsiflexion, improving apparent dorsiflexion and reducing impingement during the toe-off phase of gait.

Question 33

Topic: Forefoot

A 50-year-old male undergoes a dorsal cheilectomy for Grade 2 hallux rigidus. Postoperatively, he complains of persistent numbness along the dorsomedial aspect of the great toe. Which nerve was most likely injured during the surgical approach?

. Deep peroneal nerve
. Medial dorsal cutaneous nerve
. Sural nerve
. Lateral plantar nerve
. Saphenous nerve

Correct Answer & Explanation

. Medial dorsal cutaneous nerve

Explanation

The medial dorsal cutaneous nerve, a branch of the superficial peroneal nerve, supplies sensation to the dorsomedial aspect of the hallux. It is highly susceptible to injury during the standard dorsal or dorsomedial surgical approach to the first MTP joint.

Question 34

Topic: Forefoot

When performing a first metatarsophalangeal (MTP) joint arthrodesis for end-stage hallux rigidus, what is the optimal position for the fusion to ensure normal gait mechanics?

. Neutral valgus and neutral dorsiflexion
. 10-15 degrees of varus and 5-10 degrees of dorsiflexion
. 0-5 degrees of valgus and 20-25 degrees of dorsiflexion
. 10-15 degrees of valgus and 10-15 degrees of dorsiflexion relative to the floor
. 15-20 degrees of valgus and neutral dorsiflexion

Correct Answer & Explanation

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

Explanation

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

Question 35

Topic: Forefoot

What characteristic physical examination finding is most commonly associated with symptomatic hallux rigidus?

. Pain with passive plantarflexion of the MTP joint
. Pain exacerbated by active toe-off during the terminal stance phase of gait
. A hallux valgus angle greater than 15 degrees
. Pronation of the great toe during weight-bearing
. Increased passive MTP joint dorsiflexion compared to the contralateral side

Correct Answer & Explanation

. Pain exacerbated by active toe-off during the terminal stance phase of gait

Explanation

Hallux rigidus typically presents with dorsal joint pain and restricted dorsiflexion. This pain is most pronounced during the terminal stance (toe-off) phase of gait when maximum dorsiflexion is required.

Question 36

Topic: Forefoot

A 35-year-old female with Grade 1 hallux rigidus is scheduled for a cheilectomy. To further improve her functional dorsiflexion and shoe wear tolerance, an adjunctive procedure is planned. Which of the following osteotomies is most appropriate?

. Distal metatarsal articular angle (DMAA) correction
. Proximal phalanx dorsal closing wedge osteotomy (Moberg)
. Scarf osteotomy
. Weil osteotomy
. Lapidus procedure

Correct Answer & Explanation

. Proximal phalanx dorsal closing wedge osteotomy (Moberg)

Explanation

A Moberg osteotomy is a dorsal closing wedge osteotomy of the proximal phalanx. It effectively shifts the functional arc of motion towards dorsiflexion, making it a valuable adjunct to cheilectomy for improving toe clearance.

Question 37

Topic: Forefoot

A patient exhibits constant pain with ROM of the first MTP joint. Radiographs show significant dorsal osteophytes, subchondral sclerosis, and less than 50% joint space preservation. No loose bodies are visualized, and pain is absent in the midrange of motion. According to Coughlin and Shurnas, what is the grade of hallux rigidus?

. Grade 0
. Grade 1
. Grade 2
. Grade 3
. Grade 4

Correct Answer & Explanation

. Grade 4

Explanation

Coughlin and Shurnas Grade 3 is defined by severe radiographic changes (<50% joint space) and constant pain near the extremes of motion. Grade 4 shares the same radiographic findings but is distinguished by pain throughout the entire range of motion, including the midrange.

Question 38

Topic: Forefoot

During a dorsal cheilectomy for hallux rigidus, a surgeon uses a standard dorsomedial approach to the first MTP joint. Which superficial nerve is at the greatest risk of iatrogenic injury during this exposure?

. Deep peroneal nerve
. Dorsomedial cutaneous nerve
. Medial plantar nerve
. Sural nerve
. Saphenous nerve

Correct Answer & Explanation

. Dorsomedial cutaneous nerve

Explanation

The dorsomedial cutaneous nerve (a terminal branch of the superficial peroneal nerve) crosses over the extensor hallucis longus tendon and is highly vulnerable during the standard dorsomedial approach to the first MTP joint.

Question 39

Topic: Forefoot

A patient with hallux rigidus undergoes a first MTP arthrodesis. Six months postoperatively, the patient complains of pain at the plantar aspect of the interphalangeal (IP) joint of the great toe, particularly during the toe-off phase of gait. Radiographs show solid fusion of the MTP joint. What surgical technical error most likely caused this complication?

. Fusing the MTP joint in excessive dorsiflexion
. Fusing the MTP joint in excessive plantarflexion
. Fusing the MTP joint in excessive valgus
. Fusing the MTP joint with pronation of the hallux
. Over-shortening of the first ray during preparation

Correct Answer & Explanation

. Fusing the MTP joint in excessive plantarflexion

Explanation

Fusing the first MTP joint in excessive plantarflexion prevents the patient from rolling over the toe properly during gait. The patient compensates by forcefully hyperextending the IP joint, leading to rapid IP joint arthritis and plantar IP pain.

Question 40

Topic: Forefoot

The 65-year-old lady presents with a right foot deformity characterized by an intermetatarsal angle (IMA) of 15 degrees, a hallux valgus angle (HVA) of 35 degrees, and minimal passive correction of the hallux. Her first tarsometatarsal (TMT) joint is assessed as normal.

Based on these findings and the candidate's proposed management, which surgical approach would be MOST appropriate for her right foot?

. Chevron osteotomy with lateral release.
. Mitchell osteotomy with medial capsular plication.
. Scarf osteotomy with lateral release and possible Akin osteotomy.
. First MTP joint arthrodesis.
. Keller resection arthroplasty.

Correct Answer & Explanation

. Scarf osteotomy with lateral release and possible Akin osteotomy.

Explanation

Correct Answer: CThe examiner presents a specific scenario: 'If this lady had an intermetatarsal angle of 15 on the right with a hallux valgus angle of 35 and minimal passive correction of the hallux, what surgery would you plan?' The candidate responds: 'If the first tarsometatarsal joint is normal, I would plan a scarf osteotomy combined with a lateral release and an Akin osteotomy of the proximal phalanx if necessary.' This directly matches option C. Chevron and Mitchell osteotomies are typically for less severe deformities or have disadvantages like shortening, as discussed later in the case. Arthrodesis is usually reserved for severe arthrosis or recurrent cases, especially with missing toes, and Keller is a salvage procedure.

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