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Forefoot MCQs

Practice Set 4 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 61

Topic: Forefoot

A 45-year-old female presents with a painful bunion. Clinical examination reveals hypermobility of the first tarsometatarsal (TMT) joint. Weight-bearing radiographs demonstrate an Intermetatarsal Angle (IMA) of 18 degrees and a Hallux Valgus Angle (HVA) of 42 degrees. Which of the following procedures is most appropriate to address this deformity?

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

Correct Answer & Explanation

. Lapidus procedure

Explanation

The Lapidus procedure (1st TMT arthrodesis) is indicated for moderate-to-severe hallux valgus (IMA > 15, HVA > 40) in the setting of first ray hypermobility. It provides powerful correction and stabilizes the medial column.

Question 62

Topic: Forefoot

A 28-year-old female presents with medial great toe pain. Radiographs reveal a congruent 1st MTP joint, an IMA of 8 degrees, an HVA of 14 degrees, and a Hallux Valgus Interphalangeus (HVI) angle of 22 degrees. What is the most appropriate surgical intervention?

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

Correct Answer & Explanation

. Akin osteotomy alone

Explanation

The patient has isolated hallux valgus interphalangeus (HVI), defined by an abnormal angle between the proximal and distal phalanges with normal IMA and HVA. An Akin osteotomy (medial closing wedge of the proximal phalanx) alone is the appropriate procedure.

Question 63

Topic: Forefoot

A 45-year-old female presents with hallux rigidus. She complains of dorsal impingement pain at the first metatarsophalangeal (MTP) joint, specifically with forced dorsiflexion. Clinical exam shows she has 40 degrees of dorsiflexion. Radiographs reveal dorsal osteophytes, but the joint space is generally preserved and there are no large cystic changes. According to the Coughlin and Shurnas classification, what is her grade and most appropriate surgical treatment if conservative measures fail?

. Grade 1; First MTP arthrodesis
. Grade 2; Dorsal cheilectomy
. Grade 3; Silastic joint replacement
. Grade 3; First MTP arthrodesis
. Grade 4; Keller resection arthroplasty

Correct Answer & Explanation

. Grade 2; Dorsal cheilectomy

Explanation

The patient has Coughlin and Shurnas Grade 2 hallux rigidus (mild-to-moderate joint space narrowing, dorsal osteophytes, dorsiflexion >30 degrees but pain at the end of range). The treatment of choice for symptomatic Grade 1 and 2 hallux rigidus that fails conservative management is a dorsal cheilectomy (excision of the dorsal osteophytes and the dorsal one-third of the metatarsal head).

Question 64

Topic: Forefoot

A 65-year-old female presents with severe pain and stiffness in her first metatarsophalangeal (MTP) joint. Examination reveals less than 10 degrees of total dorsiflexion and severe pain in the mid-arc of motion. Radiographs demonstrate diffuse joint space narrowing, large dorsal osteophytes, and subchondral sclerosis. What is the most reliable, gold-standard surgical treatment for this condition?

. Extracorporeal shockwave therapy
. Dorsal cheilectomy with Moberg osteotomy
. First MTP arthrodesis
. Silicone implant arthroplasty
. Keller resection arthroplasty

Correct Answer & Explanation

. First MTP arthrodesis

Explanation

This patient has Grade 3/4 hallux rigidus (diffuse arthritis, severe restriction of motion, pain in mid-arc). The gold standard treatment providing the most reliable pain relief and functional improvement is a first MTP arthrodesis.

Question 65

Topic: Forefoot
A 48-year-old man has had pain and swelling of the hallux metatarsophalangeal joint for the past 9 months. A rocker bottom stiff-soled shoe has failed to provide relief; however, two cortisone injections have temporarily alleviated his symptoms. The radiographs shown in Figures 20a and 20b reveal diffuse arthritis of the entire hallux metatarsophalangeal joint. What is the most definitive surgical treatment?
. Dorsal cheilectomy
. Keller resection arthroplasty
. Silastic joint replacement
. Hallux metatarsophalangeal arthrodesis
. Hallux valgus correction

Correct Answer & Explanation

. Hallux metatarsophalangeal arthrodesis

Explanation

DISCUSSION: Because the radiographs demonstrate severe arthritis, hallux metatarsophalangeal arthrodesis is the treatment of choice. Cheilectomy alone will not relieve pain because the entire joint is degenerative. Joint replacement has not been shown to be a long-term solution. Keller resection arthroplasty is not indicated in younger active patients. Hallux valgus correction will not address arthritis of the joint and could stiffen the joint further. REFERENCES: Smith RW, Joanis TL, Maxwell PD: Great toe metatarsophalangeal joint arthrodesis: A user-friendly technique. Foot Ankle 1992;13:367-377. Mann RA: Hallux rigidus. Instr Course Lect 1990;39:15-21.

Question 66

Topic: Forefoot
Examination of a 28-year-old woman reveals a moderate hallux valgus deformity and a prominence of the medial eminence. She reports that she can participate in all activities, wear 3-inch heels with minimal discomfort, and walk in a 1-inch heel with no pain. However, she is concerned that the deformity will get worse and requests recommendations regarding surgical correction. What is the best course of action?
. Hallux valgus correction
. Custom orthosis to prevent further deformity
. Observation only
. Steroid injection to decrease inflammation
. Extra-depth shoes

Correct Answer & Explanation

. Observation only

Explanation

DISCUSSION: Because the patient is essentially asymptomatic, the most appropriate course of action is observation. Prophylactic hallux valgus surgery is not medically indicated. Steroid injection would only risk infection, as well as joint and capsule damage. There are no data to support the use of a custom orthosis to delay the progression of a hallux valgus deformity. Special shoe wear or an extra-depth shoe is not necessary and is unlikely to be accepted by the patient. REFERENCES: Donley BG, Tisdel CL, Sferra JJ, Hall JO: Diagnosing and treating hallux valgus: A conservative approach for a common problem. Cleve Clin J Med 1997;64:469-474. Teitz CC, Hu SS, Arendt EA: The female athlete: Evaluation and treatment of sports-related problems. J Am Acad Orthop Surg 1997;5:87-96.

Question 67

Topic: Forefoot
  • A 40-year old man has limited, painful motion in dorsiflexion at the metatarsophalangeal (MTP) joint of the right great toe, despite nonsurgical treatment. Radiographs show dorsal and medial osteophytes and minimal narrowing of the articular space. Treatment should consist of
. Arthrodesis of the MTP joint
. A Silastic implant of the MTP joint
. Resection arthroplasty of the MTP joint
. Cheilctomy of the MTP joint
. Osteotomy of the base of the proximal phalanx

Correct Answer & Explanation

. Arthrodesis of the MTP joint

Explanation

Cheilectomy, the excision of an irregular osseous rim that interferes with motion of a joint was performed on the distal part of the metatarsal of patients who had hallux rigidus. In this study by Mann, published in JBJS 1988, they were able to conclude that cheilectomy is a better method of treatment for hallux rigidus than arthrodesis, resection arthroplasty, or arthroplasty with the use of a flexible implant. In older adults who present late, with more severe X-Ray changes, Keller procedure is indicated.

Question 68

Topic: Forefoot

A 55-year-old active male presents with advanced hallux rigidus (Coughlin and Shurnas Grade 3) and severe pain. He wishes to maintain maximum walking activity levels without pain. Which surgical procedure offers the most reliable, long-term functional outcome?

. Cheilectomy
. Proximal phalanx (Moberg) osteotomy
. Metatarsophalangeal (MTP) joint arthrodesis
. Silicone interposition arthroplasty
. Hemiarthroplasty of the proximal phalanx

Correct Answer & Explanation

. Cheilectomy

Explanation

First MTP joint arthrodesis is the gold standard for advanced (Grade 3 and 4) hallux rigidus. It provides the most reliable long-term pain relief and restores excellent functional push-off for active patients.

Question 69

Topic: Forefoot

A 45-year-old female presents with severe bunion pain. 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 procedures is most appropriate?

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

Correct Answer & Explanation

. Distal chevron osteotomy

Explanation

The Lapidus procedure (1st TMT arthrodesis) is indicated for severe hallux valgus (IMA > 15 degrees) combined with first ray hypermobility. Distal or proximal osteotomies alone fail to address the apex of deformity at the unstable TMT joint in this specific presentation.

Question 70

Topic: Forefoot

A 40-year-old female presents with a severe hallux valgus deformity (Intermetatarsal Angle = 18 degrees, Hallux Valgus Angle = 45 degrees). Clinical examination reveals profound multiplanar hypermobility of the first tarsometatarsal (TMT) joint. Which of the following surgical procedures is most strongly indicated?

. Distal chevron osteotomy
. Proximal crescentic osteotomy
. Lapidus procedure (first TMT arthrodesis)
. Akin osteotomy alone
. Keller resection arthroplasty

Correct Answer & Explanation

. Distal chevron osteotomy

Explanation

The Lapidus procedure involves an arthrodesis of the first tarsometatarsal joint. It is the gold standard for correcting moderate-to-severe hallux valgus deformities when concurrent first ray hypermobility is present, as it provides definitive stabilization and powerful triplanar correction.

Question 71

Topic: Forefoot

A 55-year-old female presents with severe hallux valgus (HVA 45 degrees, IMA 19 degrees) and demonstrable clinical hypermobility of the first tarsometatarsal (TMT) joint. Which surgical procedure is most appropriate to address her deformity and prevent long-term recurrence?

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

Correct Answer & Explanation

. Distal chevron osteotomy

Explanation

The Lapidus procedure (1st TMT arthrodesis) is specifically indicated for patients with moderate to severe hallux valgus coupled with first ray hypermobility. It uniquely restores medial column stability and provides robust correction of the intermetatarsal angle.

Question 72

Topic: Forefoot

What is the preferred treatment of a symptomatic curly toe deformity in a 6-year-old child?

. Observation
. Tape the toe to the adjacent toes for 8 weeks
. Tenotomy of the flexor tendons
. Transfer of the flexor tendons to the extensor mechanism
. Arthrodesis of the proximal interphalangeal joint

Correct Answer & Explanation

. Tenotomy of the flexor tendons

Explanation

DISCUSSION: While some curly toe deformities spontaneously improve in younger children, the deformity is likely to persist in a 6-year-old child.  Taping techniques result in no change or only a temporary decrease in deformity.  Studies have shown that simple flexor tenotomy is as effective as flexor tendon transfer.  Arthrodesis is rarely indicated.REFERENCES: Hamer A, Stanley D, Smith TW: Surgery for curly toe deformity: Adouble-blind, randomized, prospective trial.  J Bone Joint Surg Br 1993;75:662-663.Ross ER, Menelaus MB: Open flexor tenotomy for hammer toes and curly toes in childhood.J Bone Joint Surg Br 1984;66:770-771.

Question 73

Topic: Forefoot

A 12-year-old girl has the painful foot deformity seen in Figure 79. You advise her that she has juvenile bunions. How do they differ from adult bunions?

. Metatarsus primus varus
. Large exostosis
. Rigidity of the metatarsal phalangeal joint
. Greater hallux valgus angle than in adult bunions
. Prominent bursal thickening over the medial eminence

Correct Answer & Explanation

. Metatarsus primus varus

Explanation

The hallmark of the juvenile bunion is metatarsus primus varus. Increased flexibility of the first metatarsal phalangeal joint leads to increased deformity. The hallux valgusangle is less than the adult bunion. Bursal thickenings and prominence of the medial eminence are less in a juvenile bunion.

Question 74

Topic: Forefoot
A 42-year-old woman who observes traditional Muslim practices is seen in your office accompanied by her physician husband to discuss possible elective bunion correction. In considering the treatment of this patient, what is one of the most important considerations?
. The role her husband will play in the decision to proceed with surgery
. Her role as primary caregiver in the household
. Dietary concerns during her hospitalization
. Daily cleansing rituals that may affect wound care
. The importance of maintaining modesty precautions during examination, surgery, and postoperative appointments

Correct Answer & Explanation

. The importance of maintaining modesty precautions during examination, surgery, and postoperative appointments

Explanation

DISCUSSION: In considering faith-based issues regarding treatment of this patient, the presence of her husband for the office visit would imply an agreement with her decision to have surgery. It also may facilitate her examination. Her role as caregiver, dietary concerns, and cleansing rituals are less important considerations with an outpatient-based procedure. Privacy concerns remain paramount to Muslim women, which include limited exposure during examination, during surgery, and in subsequent follow-up visits.

Question 75

Topic: Forefoot
A 13-year-old girl with hallux valgus reports pain after playing basketball. Radiographs show a hallux valgus angle of 20 degrees, an intermetatarsal angle of 11 degrees, a distal metatarsal articular angle of 10 degrees, and a congruent joint. Management should consist of
. shoe wear modification.
. proximal crescentic osteotomy with distal soft-tissue realignment.
. Mitchell osteotomy.
. chevron osteotomy.
. Keller procedure.

Correct Answer & Explanation

. shoe wear modification.

Explanation

DISCUSSION: Shoe wear modification is the most appropriate management based on the patient’s age, high activity level, and relatively minor symptoms. She also has a mild hallux valgus. Normal radiographic measurements are an intermetatarsal angle of less than 9 degrees, a hallux valgus angle of less than 15 degrees, and a distal metatarsal articular angle of less than 9 degrees. Surgical procedures should be reserved for patients with more severe or progressive deformities. REFERENCES: Stephens HM: Bunions, in Fitzgerald RH, Kaufer H, Malkani AL (eds): Orthopaedics. St Louis, MO, Mosby, 2002, pp 1510-1519. Donley BG, Richardson GE: Disorders of the first ray, in Fitzgerald RH, Kaufer H, Malkani AL (eds): Orthopaedics. St Louis, MO, Mosby, 2002, pp 1718-1731.

Question 76

Topic: Forefoot
  • Analysis of which of the following proteins is used to establish the diagnosis of Becker muscular dystrophy?
. Myosin
. Troponin
. Tropomyosin
. Fibrillin
. Dystrophin

Correct Answer & Explanation

. Myosin

Explanation

Becker muscular dystrophy is an X-linked inherited disorder present in approximately 1 in 30,000 live male births. The responsible gene is located on the xp21 region of the X chromosome including sixty-five exons that encode for the protein dystrophin. Duchenne muscular dystrophy is also related to a mutation of the dystrophin gene. Muscle biopsies for dystrophin have been extremely successful for identifying these dystrophies and distinguishing them from other clinically similar autosomal recessive myopathies. (Ref: Shapiro, Hoffman)Question 18 -A 25-year-old woman with spastic diplegia has a painful progressive bunion deformity that has failed to respond to nonsurgical treatment. Examination reveals tenderness and erythema over the bunion prominence; however, the hallux metatarsophalangeal joint has full range of motion. A standing AP radiograph shows a hallux valgus angle of 30 degrees and a 1-2 intermetatarsal angle of 13 degrees. Treatment should now consist ofarthrodesis of the hallux metatarsophalangeal joint.arthrodesis of the first tarsometatarsal joint.excision of the medial eminence and medial capsular reefing of the metatarsophalangeal joint.osteotomy of the distal first metatarsal.proximal metatarsal osteotomy with distal soft-tissue realignment.Treatment of hallux valgus in a patient with cerebral palsy is largely dependent on the degree of spasticity and the pattern of gait. The only way to adequately eliminate spastic deforming forces is with an arthrodesis of the MTP joint. Any other procedure will most likely lead to a high incidence of either hallux varus or recurrent hallux valgus.The optimal arthrodesis angle is 25-30 degrees, and the metatarsal inclination angle should be 25-30 degrees also. Sagittal plane position should be checked intraoperatively and the proximal phalanx should clear the table by 5-10mm with simulated WB

Question 77

Topic: Forefoot

A 50-year-old woman complains of a painful bunion. Radiographs reveal a hallux valgus angle (HVA) of 35 degrees, an intermetatarsal angle (IMA) of 16 degrees, and a distal metatarsal articular angle (DMAA) of 20 degrees. Clinical examination demonstrates hypermobility of the first tarsometatarsal (TMT) joint. Which of the following procedures is most appropriate to provide lasting correction?

. Distal chevron osteotomy
. Proximal crescentic osteotomy
. Lapidus procedure (First TMT arthrodesis)
. Akin osteotomy alone
. Keller resection arthroplasty

Correct Answer & Explanation

. Distal chevron osteotomy

Explanation

The patient has a moderate-to-severe hallux valgus deformity (IMA > 13 degrees, HVA > 30 degrees) with clinical first TMT hypermobility. The Lapidus procedure (arthrodesis of the first TMT joint) directly addresses the hypermobility and provides powerful correction of the high IMA, minimizing the risk of recurrence.

Question 78

Topic: Forefoot

A 45-year-old woman is being evaluated for hallux valgus surgery. Her weight-bearing AP foot radiograph reveals a Hallux Valgus Angle (HVA) of 35 degrees and an Intermetatarsal Angle (IMA) of 16 degrees. The metatarsophalangeal joint is subluxated but reducible. Which of the following surgical procedures is most appropriate?

. Distal chevron osteotomy
. Proximal metatarsal osteotomy with a distal soft tissue procedure
. Akin osteotomy alone
. First MTP joint arthrodesis
. Lapidus procedure

Correct Answer & Explanation

. Distal chevron osteotomy

Explanation

An HVA of 35° and IMA of 16° indicates a moderate to severe hallux valgus deformity. A distal osteotomy (like a chevron) is generally indicated for mild deformities (IMA < 13°). For an IMA > 13° to 15°, a proximal osteotomy (e.g., crescentic or Ludloff) or a diaphyseal osteotomy (Scarf) combined with a distal soft tissue release (modified McBride) is indicated. A Lapidus procedure is preferred if there is first ray hypermobility or arthritis.

Question 79

Topic: Forefoot

A 50-year-old female complains of a painful bunion. Weight-bearing radiographs show a hallux valgus angle (HVA) of 38 degrees and an intermetatarsal angle (IMA) of 16 degrees. Clinical examination reveals no hypermobility of the first tarsometatarsal (TMT) joint and no evidence of degenerative joint disease. What is the most appropriate surgical intervention?

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

Correct Answer & Explanation

. Distal chevron osteotomy

Explanation

The patient has a moderate-to-severe hallux valgus deformity (IMA >13-15 degrees, HVA >30-40 degrees). A distal chevron osteotomy is generally reserved for mild deformities (IMA <13 deg) because it provides limited correction. For an IMA of 16 degrees, a proximal osteotomy (e.g., crescentic, Ludloff, or SCARF) combined with a distal soft tissue release is indicated to achieve adequate correction. A Lapidus procedure is preferred if there is first TMT hypermobility or arthritis. First MTP arthrodesis is used for severe deformity with concomitant arthritis.

Question 80

Topic: Forefoot

A 48-year-old female presents with a painful bunion. Weight-bearing radiographs reveal a hallux valgus angle (HVA) of 45 degrees, an intermetatarsal angle (IMA) of 18 degrees, and evidence of hypermobility at the first tarsometatarsal (TMT) joint.

Which surgical intervention is most appropriate?

. Distal chevron osteotomy
. Proximal closing wedge osteotomy
. First TMT joint arthrodesis (Lapidus)
. First metatarsophalangeal joint arthrodesis
. Akin osteotomy alone

Correct Answer & Explanation

. First TMT joint arthrodesis (Lapidus)

Explanation

A first TMT joint arthrodesis (Lapidus procedure) is indicated for moderate to severe hallux valgus (IMA > 15 degrees) associated with first ray hypermobility. It permanently corrects the IMA and stabilizes the medial column.

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