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Forefoot MCQs

Practice Set 5 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 81

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. There is no evidence of first tarsometatarsal hypermobility or midfoot arthritis. What is the most appropriate surgical intervention?

. Distal chevron osteotomy
. Akin osteotomy alone
. Proximal metatarsal osteotomy with distal soft tissue release
. First metatarsophalangeal (MTP) joint arthrodesis
. Keller resection arthroplasty

Correct Answer & Explanation

. Proximal metatarsal osteotomy with distal soft tissue release

Explanation

An IMA greater than 13 to 15 degrees is considered severe and typically requires a proximal metatarsal osteotomy (e.g., Ludloff, Scarf) or Lapidus procedure. A distal osteotomy alone is insufficient for this degree of intermetatarsal widening.

Question 82

Topic: Forefoot

A 45-year-old female presents with a painful bunion. Weight-bearing radiographs reveal a hallux valgus angle of 42 degrees, an intermetatarsal angle of 18 degrees, and clinical hypermobility of the first tarsometatarsal joint. Which of the following procedures is most appropriate?

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

Correct Answer & Explanation

. First tarsometatarsal arthrodesis (Lapidus procedure)

Explanation

A Lapidus procedure (first TMT arthrodesis) is indicated for severe hallux valgus (IMA > 15 degrees) combined with first ray hypermobility, as it addresses both the large deformity and the instability at the apex.

Question 83

Topic: Forefoot

When performing an olecranon osteotomy for the surgical management of an intra-articular distal humerus fracture (AO/OTA type 13C), what is the optimal shape of the osteotomy to maximize stability and surface area for healing?

. Transverse osteotomy at the bare area of the sigmoid notch
. Chevron osteotomy with the apex directed distally
. Chevron osteotomy with the apex directed proximally
. Oblique osteotomy from dorsal-proximal to volar-distal
. Step-cut osteotomy

Correct Answer & Explanation

. Chevron osteotomy with the apex directed proximally

Explanation

A chevron osteotomy with the apex directed proximally is preferred because it increases the surface area for healing and provides intrinsic rotational stability compared to a transverse osteotomy. It should be directed into the 'bare area' of the greater sigmoid notch, where there is naturally less articular cartilage.

Question 84

Topic: Forefoot

When performing an olecranon osteotomy for exposure of a complex distal humerus fracture, what type of osteotomy provides the best stability and surface area for subsequent repair?

. Transverse osteotomy at the bare area
. Chevron osteotomy with the apex pointing distally
. Chevron osteotomy with the apex pointing proximally
. Oblique osteotomy from dorsal to volar-proximal
. Step-cut osteotomy through the coronoid

Correct Answer & Explanation

. Chevron osteotomy with the apex pointing distally

Explanation

A chevron osteotomy with the apex pointing distally (into the ulnar shaft) provides superior rotational stability and a larger surface area for healing compared to a transverse osteotomy. It should be performed at the bare area of the greater sigmoid notch.

Question 85

Topic: Forefoot

A 30-year-old female presents with severe bunion pain. Weight-bearing radiographs reveal a hallux valgus angle of 45 degrees, an intermetatarsal angle of 18 degrees, and clinical hypermobility of the first ray. Which of the following surgical procedures is most appropriate to provide durable correction?

. Akin osteotomy
. Distal chevron osteotomy
. First metatarsophalangeal joint arthrodesis
. First tarsometatarsal joint arthrodesis (Lapidus procedure)
. Keller resection arthroplasty

Correct Answer & Explanation

. First tarsometatarsal joint arthrodesis (Lapidus procedure)

Explanation

The Lapidus procedure (arthrodesis of the first tarsometatarsal joint) is specifically indicated for severe hallux valgus (IMA >15 degrees) accompanied by first ray hypermobility. It stabilizes the medial column and prevents recurrence.

Question 86

Topic: Forefoot

A 60-year-old male with Coughlin Grade 3 hallux rigidus undergoes a first metatarsophalangeal (MTP) joint arthrodesis. What is the optimal position for the arthrodesis to maximize postoperative function and footwear compatibility?

. Neutral dorsiflexion and neutral valgus
. 10-15 degrees dorsiflexion and 10-15 degrees valgus
. 25-30 degrees dorsiflexion and neutral valgus
. 5 degrees plantarflexion and 15 degrees valgus
. Neutral dorsiflexion and 20 degrees varus

Correct Answer & Explanation

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

Explanation

The optimal position for a first MTP joint arthrodesis is 10-15 degrees of valgus and 10-15 degrees of dorsiflexion relative to the floor. This position restores normal push-off mechanics and accommodates standard footwear.

Question 87

Topic: Forefoot
A 22-year-old football running back suffers a hyperextension injury to his first metatarsophalangeal (MTP) joint. Examination reveals marked swelling, ecchymosis, and inability to bear weight. MRI shows a complete tear of the plantar plate with proximal retraction of the sesamoids. Which of the following is an absolute indication for operative repair?
. Grade I capsuloligamentous sprain
. Medial collateral ligament sprain
. Proximal migration of the sesamoids indicating instability
. 10 degrees of MTP joint extension loss
. Painful push-off without objective instability

Correct Answer & Explanation

. Proximal migration of the sesamoids indicating instability

Explanation

Indications for operative intervention in turf toe include large intra-articular loose bodies, sesamoid fracture with diastasis, traumatic bunion deformity, and proximal migration of the sesamoids. Proximal migration signifies a complete, unstable Grade III plantar plate disruption.

Question 88

Topic: Forefoot
The Keller proximal phalanx resection procedure is most useful for which of the following conditions?
. Mild bunion deformity in a 35-year-old woman
. Severe bunion deformity in a patient with rheumatoid arthritis
. Recurrent juvenile bunion deformity
. Plantar neuropathic ulcer of the great toe
. Bunion deformity associated with a hypermobile first tarsometatarsal joint

Correct Answer & Explanation

. Plantar neuropathic ulcer of the great toe

Explanation

Discussion: A Keller proximal phalanx resection procedure usually results in reduced weight bearing under the first ray because of shortening of the toe and disruption of intrinsic flexor function. This can be an effective method of offloading a neuropathic ulcer under the great toe at the interphalangeal or metatarsophalangeal joint area. However, these features are generally undesirable in young active patients. The procedure has a high rate of recurrent deformity in patients with rheumatoid arthritis. It would exacerbate transfer metatarsalgia in a patient with a hypermobile first ray.

Question 89

Topic: Forefoot

A 65-year-old woman presents with severe bunion pain. Radiographs show a hallux valgus angle of 45 degrees, an intermetatarsal angle of 18 degrees, and obvious plantar gapping at the first tarsometatarsal (TMT) joint on the lateral weight-bearing view indicating hypermobility. Which of the following procedures is most appropriate?

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

Correct Answer & Explanation

. Lapidus procedure (First TMT arthrodesis)

Explanation

The Lapidus procedure (first TMT fusion) is indicated for severe hallux valgus, especially in the presence of first ray hypermobility. It provides powerful correction of the intermetatarsal angle and stabilizes the medial column.

Question 90

Topic: Forefoot

Six months after undergoing a distal chevron osteotomy and modified McBride procedure for hallux valgus, a 45-year-old woman complains of pain and a deformity in the opposite direction. Examination reveals a flexible hallux varus deformity. Non-operative measures have failed. What is the most appropriate surgical treatment?

. First metatarsophalangeal joint arthrodesis
. Closing wedge osteotomy of the medial proximal phalanx
. Release of the medial capsule and abductor hallucis
. Extensor hallucis brevis (EHB) transfer and medial capsular release
. Flexor hallucis longus to extensor hallucis longus transfer

Correct Answer & Explanation

. Extensor hallucis brevis (EHB) transfer and medial capsular release

Explanation

For a flexible, iatrogenic hallux varus without degenerative joint changes, treatment involves medial soft tissue release and reconstruction of the lateral stabilizing structures, typically using an EHB tendon transfer.

Question 91

Topic: Forefoot

A 42-year-old male construction worker presents with severe pain and stiffness in his right great toe. Examination reveals palpable dorsal osteophytes and less than 10 degrees of dorsiflexion at the first MTP joint. Radiographs show joint space narrowing, subchondral sclerosis, and large dorsal osteophytes (Coughlin and Shurnas Grade 3 hallux rigidus). What is the most reliable surgical treatment for this patient?

. Dorsal cheilectomy
. First metatarsophalangeal joint arthrodesis
. First metatarsophalangeal joint hemiarthroplasty
. Moberg osteotomy
. Keller resection arthroplasty

Correct Answer & Explanation

. First metatarsophalangeal joint arthrodesis

Explanation

For young, active patients or heavy laborers with advanced (Grade 3 or 4) hallux rigidus, first MTP joint arthrodesis is the gold standard. It provides reliable pain relief and durability that arthroplasty or cheilectomy cannot match in this demographic.

Question 92

Topic: Forefoot

A 35-year-old woman presents with a painful bunion. Clinical examination reveals hypermobility of the first tarsometatarsal (TMT) joint. Radiographs show a hallux valgus angle of 45 degrees and an intermetatarsal angle of 18 degrees. Which of the following procedures is most appropriate?

. Distal chevron osteotomy
. Proximal crescentic osteotomy
. First TMT arthrodesis (Lapidus procedure)
. First MTP arthrodesis
. Keller arthroplasty

Correct Answer & Explanation

. First TMT arthrodesis (Lapidus procedure)

Explanation

The Lapidus procedure (first TMT arthrodesis) is indicated for moderate to severe hallux valgus associated with first ray hypermobility. It provides powerful correction of the intermetatarsal angle and stabilizes the medial column.

Question 93

Topic: Forefoot

A 62-year-old man presents with severe pain and stiffness in his right great toe. Examination shows less than 10 degrees of dorsiflexion and pain throughout the entire arc of motion. Radiographs reveal complete loss of joint space and large dorsal, medial, and lateral osteophytes at the first MTP joint. Which treatment offers the most reliable long-term pain relief?

. First MTP joint cheilectomy
. Moberg osteotomy
. First MTP joint arthrodesis
. Silicone implant arthroplasty
. Resection arthroplasty (Keller procedure)

Correct Answer & Explanation

. First MTP joint arthrodesis

Explanation

This patient has Grade 4 hallux rigidus (pain throughout ROM, complete joint space loss). Arthrodesis is the gold standard for end-stage hallux rigidus, providing the most reliable long-term pain relief and functional improvement.

Question 94

Topic: Forefoot

A 28-year-old female runner complains of pain and stiffness localized to the dorsal aspect of her right first metatarsophalangeal (MTP) joint. Radiographs show a dorsal osteophyte but normal joint space width and no central cartilage loss (Grade 1 hallux rigidus). Nonoperative management has failed. Which of the following is the most appropriate surgical option?

. Keller arthroplasty
. Silastic implant arthroplasty
. First MTP joint arthrodesis
. Dorsal cheilectomy
. Proximal phalanx extension osteotomy (Moberg) alone

Correct Answer & Explanation

. Dorsal cheilectomy

Explanation

Dorsal cheilectomy is the surgical treatment of choice for early-stage (Grades 1 and 2) hallux rigidus with preserved joint space and pain primarily with dorsiflexion. It reliably relieves pain and preserves joint motion.

Question 95

Topic: Forefoot

A 55-year-old woman presents with a painful bunion deformity. Weight-bearing radiographs reveal a hallux valgus angle (HVA) of 42 degrees, an intermetatarsal angle (IMA) of 18 degrees, and clinical hypermobility of the first tarsometatarsal (TMT) joint. Which of the following procedures is most appropriate to provide long-term correction?

. Distal chevron osteotomy
. Akin osteotomy
. Lapidus procedure (first TMT arthrodesis)
. Keller resection arthroplasty
. First MTP joint arthrodesis

Correct Answer & Explanation

. Lapidus procedure (first TMT arthrodesis)

Explanation

The Lapidus procedure (first TMT arthrodesis) is indicated for severe hallux valgus deformities (IMA > 15 degrees) and is especially preferred when there is concurrent first TMT joint hypermobility or arthritis.

Question 96

Topic: Forefoot

A 45-year-old female presents with a painful bunion. Weight-bearing radiographs demonstrate a Hallux Valgus Angle (HVA) of 45 degrees, an Intermetatarsal Angle (IMA) of 18 degrees, a congruent first MTP joint, and hypermobility of the first tarsometatarsal (TMT) joint. Which of the following procedures provides the most reliable long-term correction?

. Distal chevron osteotomy
. Scarf osteotomy
. Lapidus procedure (first TMT arthrodesis)
. Keller resection arthroplasty
. First MTP joint arthrodesis

Correct Answer & Explanation

. Lapidus procedure (first TMT arthrodesis)

Explanation

The Lapidus procedure (arthrodesis of the first tarsometatarsal joint) is highly indicated for patients with a severe hallux valgus deformity (IMA > 15-20 degrees) in the setting of first ray hypermobility. Distal osteotomies (like the Chevron) are inadequate for large IMA corrections. MTP arthrodesis is reserved for severe deformity combined with significant MTP degenerative joint disease.

Question 97

Topic: Forefoot

A 60-year-old female presents with dorsal midfoot pain and stiffness in her great toe. Radiographs show a preserved plantar joint space but significant dorsal osteophytes and joint space narrowing at the first MTP joint. She has pain at the extremes of motion but not in the mid-range. What is the most appropriate surgical management if conservative care fails?

. First MTP arthrodesis
. Keller arthroplasty
. Dorsal cheilectomy
. First MTP total joint arthroplasty
. Akin osteotomy

Correct Answer & Explanation

. Dorsal cheilectomy

Explanation

This patient has Grade 2 hallux rigidus according to the Coughlin and Shurnas classification (preserved plantar joint space, pain only at extremes of motion, prominent dorsal osteophytes). The standard surgical treatment for Grades 1 and 2, when conservative measures fail, is a dorsal cheilectomy. Arthrodesis is generally reserved for advanced disease (Grades 3 and 4) with diffuse pain throughout the range of motion and global joint space loss.

Question 98

Topic: Forefoot

A 28-year-old professional football player sustains an acute hyperextension injury to his first metatarsophalangeal (MTP) joint (Turf Toe). MRI demonstrates a complete rupture of the plantar plate. Which of the following is considered an absolute indication for operative repair rather than conservative management?

. Traumatic hallux valgus deformity
. Grade II sprain of the capsuloligamentous complex without frank instability
. Grade I injury with localized plantar tenderness
. Proximal sesamoid retraction of 2 mm compared to the contralateral side
. Pain resolving within 2 weeks of conservative management

Correct Answer & Explanation

. Traumatic hallux valgus deformity

Explanation

Operative indications for turf toe (plantar plate injury) include a large intra-articular bony avulsion, diastasis of a bipartite sesamoid, a sesamoid fracture with diastasis, traumatic hallux valgus, frank vertical instability, or failure of conservative treatment. Traumatic hallux valgus indicates complete failure of the medial stabilizing structures requiring surgical repair.

Question 99

Topic: Forefoot

A 28-year-old wide receiver sustains a hyperextension injury to his first metatarsophalangeal (MTP) joint, resulting in a severe turf toe. Which of the following is considered an absolute indication for surgical intervention?

. Grade 1 injury with localized plantar tenderness
. Grade 2 injury with a partial tear of the plantar plate
. Proximal retraction of the sesamoids by greater than 3 mm compared to the contralateral side
. A hallux valgus angle of 12 degrees
. Mild attenuation of the medial collateral ligament of the MTP joint

Correct Answer & Explanation

. Proximal retraction of the sesamoids by greater than 3 mm compared to the contralateral side

Explanation

Turf toe is a sprain of the first MTP joint plantar plate complex. Grade 3 injuries involve complete tears of the plantar plate. Indications for operative management of turf toe include: large intra-articular loose bodies/fractures, traumatic hallux valgus deformity, gross clinical instability, and proximal migration of the sesamoids > 3 mm (indicating a complete tear of the plantar plate and flexor hallucis brevis from the base of the proximal phalanx).

Question 100

Topic: Forefoot

A 40-year-old female presents with a painful bunion. Clinical examination reveals hypermobility of the first tarsometatarsal (TMT) joint. Weight-bearing radiographs demonstrate a hallux valgus angle of 45 degrees and an intermetatarsal angle of 18 degrees. Which of the following surgical procedures is most appropriate to address her deformity?

. Distal chevron osteotomy
. Akin osteotomy alone
. Lapidus procedure (first TMT arthrodesis)
. Keller resection arthroplasty
. First metatarsophalangeal (MTP) joint arthrodesis

Correct Answer & Explanation

. Lapidus procedure (first TMT arthrodesis)

Explanation

This patient has a severe hallux valgus deformity (IMA > 15 degrees, HVA > 40 degrees) associated with clinical hypermobility of the first TMT joint. The Lapidus procedure involves arthrodesis of the first TMT joint. It provides powerful correction for large intermetatarsal angles and inherently addresses the hypermobility of the first ray, making it the procedure of choice in this scenario.

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