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Forefoot MCQs

Practice Set 6 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 101

Topic: Forefoot

A 66-year-old male presents with severe pain in his great toe with walking. Examination reveals only 5 degrees of dorsiflexion and pain at all ranges of motion. Radiographs show a complete loss of the first MTP joint space, severe flattening of the metatarsal head, and large dorsal and lateral osteophytes (Coughlin and Shurnas Grade 4 Hallux Rigidus). Which of the following is the most definitive and reliable surgical option?

. Dorsal cheilectomy
. First MTP joint arthrodesis
. Moberg osteotomy
. Extensor hallucis longus lengthening
. Resection of the sesamoids

Correct Answer & Explanation

. First MTP joint arthrodesis

Explanation

For advanced (Grade 3 or 4) hallux rigidus where there is near complete loss of the joint space and pain throughout the entire range of motion (Grade 4), a dorsal cheilectomy will fail because the articular cartilage is already destroyed. First MTP joint arthrodesis is the gold standard and most reliable surgical option for pain relief and functional improvement in severe hallux rigidus.

Question 102

Topic: Forefoot

A professional football lineman sustains a severe hyperextension injury to his first metatarsophalangeal (MTP) joint ('turf toe'). Which of the following physical or radiographic findings is considered a definitive indication for surgical intervention?

. A Grade 1 sprain with localized plantar swelling
. A Grade 2 sprain with pain elicited upon maximal passive extension
. A Grade 3 sprain with significant proximal retraction of the sesamoids on radiography
. Presence of a bipartite tibial sesamoid on contralateral comparison views
. Dorsal osteophyte formation indicative of early hallux rigidus

Correct Answer & Explanation

. A Grade 3 sprain with significant proximal retraction of the sesamoids on radiography

Explanation

Operative indications for a turf toe injury (plantar plate rupture) include a Grade 3 injury characterized by gross instability, complete tear of the plantar plate with significant proximal retraction of the sesamoids, large intra-articular loose bodies, or persistent pain and instability preventing push-off in an elite athlete after conservative care.

Question 103

Topic: Forefoot

A 55-year-old female presents with painful hallux valgus that has failed shoe modification. Standing radiographs reveal a hallux valgus angle (HVA) of 45 degrees and an intermetatarsal angle (IMA) of 18 degrees. To achieve adequate correction and minimize the risk of recurrence, which surgical approach is most biomechanically appropriate?

. A distal chevron osteotomy of the first metatarsal
. A proximal first metatarsal osteotomy or first tarsometatarsal (Lapidus) arthrodesis
. An isolated Akin osteotomy of the proximal phalanx
. A Keller resection arthroplasty
. A simple bunionectomy (Silver procedure) with medial capsulorrhaphy

Correct Answer & Explanation

. A proximal first metatarsal osteotomy or first tarsometatarsal (Lapidus) arthrodesis

Explanation

Severe hallux valgus is defined by a hallux valgus angle (HVA) > 40 degrees and an intermetatarsal angle (IMA) > 15 to 20 degrees. Distal osteotomies (like the Chevron) do not provide sufficient medial translation to correct a large IMA. Therefore, severe deformities necessitate proximal procedures, such as a proximal metatarsal osteotomy (Ludloff, crescentic) or a first TMT joint arthrodesis (Lapidus procedure).

Question 104

Topic: Forefoot

In evaluating an athlete with a hyperextension injury of the first metatarsophalangeal (MTP) joint (turf toe), which of the following is considered an absolute indication for surgical intervention?

. Grade 2 sprain with partial plantar plate tear
. Painful range of motion
. Proximal migration of the sesamoids >3 mm
. Minimal ecchymosis over the plantar MTP joint
. 10 degrees loss of maximum dorsiflexion

Correct Answer & Explanation

. Proximal migration of the sesamoids >3 mm

Explanation

Turf toe represents a sprain or tear of the first MTP plantar plate complex. Absolute indications for operative intervention include a large intra-articular fracture, proximal migration of the sesamoids >3 mm (indicating complete disruption of the plantar plate/sesamoid complex), and a traumatic hallux valgus deformity.

Question 105

Topic: Forefoot

A 40-year-old female undergoes evaluation for hallux valgus. Her radiographs show a hallux valgus angle (HVA) of 30 degrees, an intermetatarsal angle (IMA) of 14 degrees, and a Distal Metatarsal Articular Angle (DMAA) of 20 degrees with a congruent MTP joint. Which of the following procedures is necessary to correct the abnormal DMAA?

. Standard Chevron osteotomy
. Lapidus procedure
. Proximal opening wedge osteotomy
. Reverdin (distal closing wedge) osteotomy
. Akin osteotomy

Correct Answer & Explanation

. Reverdin (distal closing wedge) osteotomy

Explanation

A Distal Metatarsal Articular Angle (DMAA) >15 degrees indicates an abnormal lateral slope of the distal metatarsal articular surface. In the presence of a congruent joint and an abnormal DMAA, an extra-articular correction such as a Reverdin (distal medial closing wedge) osteotomy or a biplanar chevron is required to reorient the articular surface while maintaining joint congruency.

Question 106

Topic: Forefoot

A 45-year-old female presents for surgical correction of symptomatic hallux valgus. Radiographs demonstrate a Hallux Valgus Angle (HVA) of 32 degrees, an Intermetatarsal Angle (IMA) of 13 degrees, and a Distal Metatarsal Articular Angle (DMAA) of 20 degrees. The first MTP joint is congruous. Which of the following procedures is best suited to address this specific combination of radiographic findings?

. Standard Chevron osteotomy
. Proximal crescentic osteotomy with distal soft tissue release
. Ludloff osteotomy
. Lapidus procedure
. Biplanar (Reverdin) or distal medial closing wedge osteotomy

Correct Answer & Explanation

. Biplanar (Reverdin) or distal medial closing wedge osteotomy

Explanation

The patient has an abnormally high DMAA (>10-15 degrees is considered abnormal). If the DMAA is high and the joint is congruous, a standard proximal or diaphyseal osteotomy alone will tilt the articular surface further into valgus, leading to incongruity and rapid recurrence. A distal biplanar osteotomy (like a Reverdin) or a modified chevron that includes a medial closing wedge is required to correct the articular orientation (DMAA).

Question 107

Topic: Forefoot
A 55-year-old female presents with symptomatic hallux valgus. Radiographs reveal a hallux valgus angle (HVA) of 35 degrees, an intermetatarsal angle (IMA) of 13 degrees, and a distal metatarsal articular angle (DMAA) of 22 degrees (normal < 10 degrees). The MTP joint is congruous. Which of the following procedures is most appropriate to correct her deformity while minimizing the risk of recurrence?
. Distal chevron osteotomy
. Proximal crescentic osteotomy
. Lapidus procedure
. Biplanar chevron osteotomy (e.g., Reverdin-Green)
. Akin osteotomy alone

Correct Answer & Explanation

. Biplanar chevron osteotomy (e.g., Reverdin-Green)

Explanation

This patient has moderate hallux valgus with a significantly elevated DMAA and a congruous MTP joint. Correcting the IMA alone without addressing the abnormal DMAA will create an incongruous joint and inevitably lead to early recurrence. A distal biplanar osteotomy (such as a Reverdin-Green or modified biplanar Chevron) is required to translate the metatarsal head laterally while simultaneously rotating the articular surface to correct the DMAA.

Question 108

Topic: Forefoot

A 40-year-old woman presents with a painful bunion. Weight-bearing radiographs reveal a hallux valgus angle of 45 degrees and an intermetatarsal angle (IMA) of 18 degrees. Clinical examination demonstrates notable hypermobility at the first tarsometatarsal (TMT) joint. Which of the following procedures is most strongly indicated?

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

Correct Answer & Explanation

. First TMT arthrodesis (Lapidus procedure) with distal soft tissue release

Explanation

The Lapidus procedure (first TMT arthrodesis) is ideal for correcting a large intermetatarsal angle, especially in the presence of first ray hypermobility. It definitively addresses the apex of the deformity while stabilizing the medial column.

Question 109

Topic: Forefoot

A 60-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 clinical hypermobility of the first tarsometatarsal (TMT) joint. Which of the following surgical procedures is most appropriate?

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

Correct Answer & Explanation

. First TMT joint arthrodesis (Lapidus procedure)

Explanation

For severe hallux valgus (IMA > 15 degrees, HVA > 40 degrees) accompanied by first TMT hypermobility, a Lapidus procedure (first TMT arthrodesis) provides powerful, stable correction and addresses the underlying hypermobility.

Question 110

Topic: Forefoot

A 55-year-old male with hallux rigidus complains of severe pain throughout the entire range of motion of the first metatarsophalangeal (MTP) joint, including pain in the mid-range. Radiographs show severe joint space narrowing, large dorsal osteophytes, and subchondral cysts. Based on the Coughlin and Shurnas classification, which grade does this represent and what is the definitive surgical option?

. Grade 2; Cheilectomy
. Grade 3; Cheilectomy
. Grade 4; 1st MTP Arthrodesis
. Grade 3; 1st MTP Arthrodesis
. Grade 4; Synthetic cartilage implant

Correct Answer & Explanation

. Grade 3; 1st MTP Arthrodesis

Explanation

The Coughlin and Shurnas classification for hallux rigidus defines Grade 4 by the presence of pain in the mid-range of motion (unlike Grade 3, where pain is only at the extremes of motion), severe joint space loss, and large osteophytes. While cheilectomy is acceptable for Grades 1-3, Grade 4 implies global joint destruction and mid-ROM pain, making 1st MTP arthrodesis the gold standard surgical treatment.

Question 111

Topic: Forefoot

A 50-year-old woman presents with severe, symptomatic hallux valgus. Weight-bearing radiographs reveal a Hallux Valgus Angle (HVA) of 45 degrees, an Intermetatarsal Angle (IMA) of 20 degrees, and clinical examination demonstrates gross hypermobility of the first tarsometatarsal (TMT) joint. Which surgical procedure is most indicated to correct the deformity and minimize the risk of recurrence?

. Distal chevron osteotomy with lateral soft tissue release
. Akin osteotomy alone
. Modified McBride procedure
. Lapidus procedure (first TMT fusion)
. Keller resection arthroplasty

Correct Answer & Explanation

. Lapidus procedure (first TMT fusion)

Explanation

The patient has a severe bunion deformity (IMA > 15-20 degrees, HVA > 40 degrees) coupled with first ray hypermobility. The Lapidus procedure (arthrodesis of the first tarsometatarsal joint) is the treatment of choice in this scenario, as it powerfully corrects large IMA deformities and stabilizes the hypermobile medial column, significantly reducing the recurrence rate compared to distal osteotomies.

Question 112

Topic: Forefoot

A 62-year-old male presents with big toe pain. Examination reveals less than 10 degrees of dorsiflexion at the first MTP joint with pain at the mid-range of motion. Radiographs show significant joint space narrowing, dorsal osteophytes, and a flattened metatarsal head. Which treatment is considered the gold standard for this advanced (Grade 3/4) hallux rigidus?

. Cheilectomy
. First MTP joint arthrodesis
. Synthetic cartilage implant (hemiarthroplasty)
. Moberg osteotomy
. First TMT joint arthrodesis (Lapidus)

Correct Answer & Explanation

. First MTP joint arthrodesis

Explanation

Advanced hallux rigidus (Coughlin and Shurnas Grade 3 or 4) presents with severe motion restriction, significant joint space loss, and pain even in the mid-range of motion. The gold standard surgical treatment is a first MTP joint arthrodesis, which provides predictable and long-lasting pain relief. Cheilectomy is indicated for Grade 1 and 2 where mid-arc motion is painless.

Question 113

Topic: Forefoot

A 45-year-old female presents with severe pain over the medial eminence of her great toe. Radiographs demonstrate a Hallux Valgus Angle (HVA) of 45 degrees, an Intermetatarsal Angle (IMA) of 18 degrees, and clinical examination reveals marked hypermobility of the first tarsometatarsal (TMT) joint. Which of the following surgical procedures is most appropriate to provide durable correction?

. Distal chevron osteotomy
. Akin osteotomy
. Lapidus procedure (First TMT arthrodesis)
. Keller resection arthroplasty
. Modified McBride soft tissue procedure

Correct Answer & Explanation

. Lapidus procedure (First TMT arthrodesis)

Explanation

A severely elevated IMA (>15 degrees) combined with clinical hypermobility of the first tarsometatarsal joint is the classic indication for a Lapidus procedure (arthrodesis of the 1st TMT joint). Distal osteotomies are insufficient for high IMA angles and do not address the hypermobility.

Question 114

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

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. Stephens HM: Bunions, in Fitzgerald RH, Kaufer H, Malkani AL (eds): Orthopaedics. St Louis, MO, Mosby, 2002, pp 1510-1519.

Question 115

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

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. 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.

Question 116

Topic: Forefoot

A 52-year-old woman who underwent cheilectomy 1 year ago for hallux rigidus now reports continued pain in the first metatarsophalangeal joint. She did not have any incision healing problems, and has not had any fevers, erythema, or drainage. Which of the following procedures will provide the best combination of pain relief and function?

Foot & Ankle Board Review 2009: High-Yield MCQs (Set 2) - Figure 25

. First metatarsophalangeal arthrodesis
. Soft-tissue interposition arthroplasty
. First metatarsophalangeal total joint arthroplasty
. First metatarsophalangeal resurfacing hemiarthroplasty
. Proximal phalanx dorsiflexion osteotomy (Moberg)

Correct Answer & Explanation

. First metatarsophalangeal arthrodesis

Explanation

All but the Moberg osteotomy are capable of providing pain relief; however, arthrodesis offers the best long-term results and restores weight bearing and propulsion function to the first ray. Machacek F Jr, Easley ME, Gruber F, et al: Salvage of a failed Keller resection arthroplasty. J Bone Joint Surg Am 2004;86:1131-1138.

Question 117

Topic: Forefoot

A 28-year-old woman has a moderate hallux valgus deformity and a prominence of the medial eminence. She can participate in all activities and reports that she could wear 3-inch heels in the past, but she now notes medial eminence pain even while wearing a soft leather flat shoe with a cushioned sole. She requests recommendations regarding surgical correction. Examination reveals a 1-2 intermetatarsal angle of 10 degrees. A clinical photograph and radiograph are shown in Figures 13a and 13b. What is the best course of action?

. Chevron osteotomy to correct hallux valgus
. Custom orthosis to prevent further deformity
. Observation only
. Steroid injection to decrease inflammation
. Extra-depth shoes

Correct Answer & Explanation

. Chevron osteotomy to correct hallux valgus

Explanation

Based on her symptoms and prior shoe wear modifications, the treatment of choice is surgical correction of the hallux valgus with a chevron osteotomy. There are no data to support the use of a custom orthosis to delay the progression of a hallux valgus deformity. Steroid injection would only risk infection, as well as joint and capsule damage. Extra-depth shoes are an option; however, the patient is interested in surgical options. Chou LB, Mann RA, Casillas MM: Biplanar chevron osteotomy. Foot Ankle Int 1998;19:579-584. Coughlin MJ: Roger A. Mann Award: Juvenile hallux valgus. Etiology and treatment. Foot Ankle Int 1995;16:682-697.

Question 118

Topic: Forefoot

A 45-year-old female presents with severe pain over the medial eminence of her first metatarsophalangeal (MTP) joint. Weight-bearing radiographs reveal a Hallux Valgus Angle (HVA) of 38 degrees and an Intermetatarsal Angle (IMA) of 16 degrees. Clinical examination reveals hypermobility at the first tarsometatarsal (TMT) joint. The distal metatarsal articular angle (DMAA) is normal. Which of the following surgical procedures is the most mechanically appropriate to permanently correct this deformity?

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

Correct Answer & Explanation

. Lapidus procedure (First TMT arthrodesis)

Explanation

This patient has a severe hallux valgus deformity (IMA > 15 degrees) combined with first ray hypermobility. A distal osteotomy (like a Chevron) cannot achieve sufficient translation to correct an IMA of 16 degrees. A Lapidus procedure (arthrodesis of the first TMT joint) provides powerful multiplanar correction of a large IMA and definitively addresses the underlying first ray hypermobility, preventing recurrence.

Question 119

Topic: Forefoot

A 55-year-old woman presents with a symptomatic hallux valgus deformity. Weight-bearing radiographs demonstrate a hallux valgus angle (HVA) of 42 degrees, an intermetatarsal angle (IMA) of 16 degrees, and clinical hypermobility of the first tarsometatarsal (TMT) joint. What is the most appropriate surgical intervention?

. Distal chevron osteotomy
. Proximal crescentic osteotomy
. First TMT joint arthrodesis (Lapidus procedure)
. Metatarsophalangeal (MTP) joint arthrodesis
. Akin osteotomy alone

Correct Answer & Explanation

. First TMT joint arthrodesis (Lapidus procedure)

Explanation

A first tarsometatarsal (TMT) joint arthrodesis, also known as a Lapidus procedure, is indicated for moderate to severe hallux valgus deformities (IMA > 15 degrees) that are accompanied by hypermobility of the first ray. It corrects the deformity at the apex (the TMT joint) and provides stability. A distal chevron is for mild deformities without hypermobility.

Question 120

Topic: Forefoot

A 45-year-old female presents with a painful bunion and clinically evident hypermobility of the first tarsometatarsal (TMT) joint. Weight-bearing radiographs demonstrate a hallux valgus angle of 40 degrees and an intermetatarsal angle (IMA) of 18 degrees.

Which surgical procedure is most appropriate to comprehensively address her pathology?

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

Correct Answer & Explanation

. First tarsometatarsal arthrodesis (Lapidus procedure)

Explanation

The patient has a severe hallux valgus deformity (IMA > 15 degrees) combined with first TMT joint hypermobility. The Lapidus procedure (arthrodesis of the first tarsometatarsal joint) addresses both the severe metatarsus primus varus and the hypermobility of the first ray at its apex, making it the most appropriate and biomechanically sound choice for this specific clinical scenario.

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