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Midfoot & Hindfoot MCQs

Practice Set 10 of 39

This practice set contains high-yield board review questions covering key concepts in Midfoot & Hindfoot. Each clinical scenario is designed to test your diagnostic and management skills relevant to this subspecialty.

Question 181

Topic: Midfoot & Hindfoot
A 58-year-old diabetic female with peripheral neuropathy presents with a warm, swollen, and erythematous left foot. Radiographs demonstrate coalescing of previously seen fracture fragments, absorption of fine bone debris, and early sclerosis of the midfoot bones. According to the Eichenholtz classification of Charcot arthropathy, which stage does this represent?
. Stage 0
. Stage I
. Stage II
. Stage III
. Stage IV

Correct Answer & Explanation

. Stage II

Explanation

The Eichenholtz classification divides Charcot arthropathy into three main clinical/radiographic stages (plus Stage 0). Stage 0 represents clinical inflammation with normal radiographs. Stage I (Development/Fragmentation) is characterized by acute inflammation, osteopenia, joint subluxation, and bony fragmentation/debris. Stage II (Coalescence) is marked by decreased inflammation, absorption of fine debris, early sclerosis, and fusion of fragments. Stage III (Reconstruction/Remodeling) shows decreased sclerosis and remodeling of bone ends.

Question 182

Topic: Midfoot & Hindfoot
A 30-year-old male falls from a height and sustains a Hawkins Type III fracture of the talar neck. Which of the following best describes the pathomechanics and vascular risk associated with this specific injury pattern?
. Nondisplaced fracture with a 0-10% risk of avascular necrosis (AVN).
. Fracture with subtalar subluxation/dislocation only, and a 20-50% risk of AVN.
. Fracture with subtalar and tibiotalar dislocations, and a risk of AVN approaching 80-100%.
. Fracture with subtalar, tibiotalar, and talonavicular dislocations, with AVN risk of 10-20%.
. Fracture of the talar head with normal subtalar alignment and <5% risk of AVN.

Correct Answer & Explanation

. Fracture with subtalar and tibiotalar dislocations, and a risk of AVN approaching 80-100%.

Explanation

The Hawkins classification for talar neck fractures: Type I is nondisplaced (AVN 0-15%). Type II involves subtalar subluxation/dislocation (AVN 20-50%). Type III involves dislocation of both the subtalar and tibiotalar joints (extruded talar body), with an AVN risk near 100%. Type IV (added by Canale/Kelly) involves subtalar, tibiotalar, and talonavicular dislocation.

Question 183

Topic: Midfoot & Hindfoot
A 50-year-old obese female presents with a progressive flatfoot deformity. Clinically, she has pain along the medial ankle and is unable to perform a single-leg heel rise on the affected side. Weight-bearing radiographs show uncovering of the talonavicular joint, but clinical examination reveals the hindfoot deformity remains fully flexible and correctable. What stage of posterior tibial tendon dysfunction (PTTD) does this represent?
. Stage I
. Stage II
. Stage III
. Stage IV
. Stage V

Correct Answer & Explanation

. Stage III

Explanation

Johnson and Strom classification of PTTD: Stage I is tenosynovitis with pain and swelling, but normal alignment and a positive single-leg heel rise. Stage II involves tendinosis/rupture with a flexible flatfoot deformity and inability to perform a single-leg heel rise. Stage III is characterized by a rigid, fixed flatfoot deformity (fixed hindfoot valgus). Stage IV (added by Myerson) involves deltoid ligament compromise leading to rigid ankle valgus.

Question 184

Topic: Midfoot & Hindfoot
A 58-year-old poorly controlled diabetic patient presents with a swollen, erythematous, and warm left foot. Radiographs demonstrate joint effusion, soft tissue edema, osteopenia, and periarticular fragmentation with early subluxation. According to the Eichenholtz classification of Charcot arthropathy, which stage does this represent?
. Stage 0 (Prodromal)
. Stage I (Fragmentation)
. Stage II (Coalescence)
. Stage III (Consolidation)
. Stage IV (Remodeling)

Correct Answer & Explanation

. Stage I (Fragmentation)

Explanation

Eichenholtz Stage I is the Developmental or Fragmentation stage. It is characterized clinically by a red, hot, swollen foot and radiographically by joint effusion, bone fragmentation, debris formation, and subluxation/dislocation. Stage II (Coalescence) shows absorption of debris and early fusion, while Stage III (Consolidation) shows remodeling and stable deformity.

Question 185

Topic: Midfoot & Hindfoot
A 30-year-old male sustains a Hawkins Type III talar neck fracture. Which of the following best describes the articulations subluxated or dislocated in this injury pattern?
. Subtalar joint only
. Tibiotalar joint only
. Subtalar, tibiotalar, and talonavicular joints
. Subtalar and tibiotalar joints
. Talonavicular joint only

Correct Answer & Explanation

. Subtalar, tibiotalar, and talonavicular joints

Explanation

The Hawkins classification describes talar neck fractures. Type I is non-displaced. Type II involves subtalar subluxation/dislocation. Type III involves dislocation of the subtalar, tibiotalar, and talonavicular joints (extruded talar body). Type IV adds talonavicular subluxation/dislocation to a Type III, though a true Type III intrinsically often involves disruption of all three surrounding articulations of the body. Type III has an avascular necrosis (AVN) rate approaching 100%.

Question 186

Topic: Midfoot & Hindfoot

A 22-year-old gymnast sustains a hyperplantarflexion injury to her midfoot. Weight-bearing radiographs show 3 mm of widening between the medial and middle cuneiforms with no associated fractures. What is the most appropriate definitive management for this purely ligamentous injury?

. Closed reduction and non-weight-bearing cast for 6 weeks
. Primary arthrodesis of the first, second, and third tarsometatarsal joints
. Open reduction and internal fixation (ORIF) with transarticular screws
. Open reduction and temporary K-wire fixation
. Conservative management in a walking boot

Correct Answer & Explanation

. Primary arthrodesis of the first, second, and third tarsometatarsal joints

Explanation

Purely ligamentous Lisfranc injuries have a high rate of failure, hardware breakage, and post-traumatic arthritis with ORIF. Primary arthrodesis is the preferred treatment as it yields significantly better long-term functional outcomes in pure ligamentous variants.

Question 187

Topic: Midfoot & Hindfoot
A 25-year-old female sustains a Hawkins type III talar neck fracture following a motor vehicle collision. Which of the following best describes the specific pattern of dislocation and the associated risk of avascular necrosis (AVN)?
. Subtalar dislocation only with 50% AVN risk
. Subtalar and tibiotalar dislocations with up to 100% AVN risk
. Subtalar, tibiotalar, and talonavicular dislocations with 100% AVN risk
. Undisplaced fracture with 10% AVN risk
. Subtalar and talonavicular dislocations with 50% AVN risk

Correct Answer & Explanation

. Subtalar, tibiotalar, and talonavicular dislocations with 100% AVN risk

Explanation

A Hawkins Type III fracture involves a talar neck fracture with both subtalar and tibiotalar dislocations. This severe disruption of the blood supply leads to an avascular necrosis rate approaching 100% in some series.

Question 188

Topic: Midfoot & Hindfoot
A 32-year-old man falls from a height and sustains a Hawkins Type III talar neck fracture. What joint disruptions characterize this injury, and what is the approximate risk of developing avascular necrosis (AVN) of the talar body?
. Subtalar subluxation; 50% AVN risk
. Subtalar and tibiotalar dislocation; nearly 100% AVN risk
. Talonavicular subluxation; 20% AVN risk
. Subtalar, tibiotalar, and talonavicular dislocation; 100% AVN risk
. Undisplaced fracture; 10% AVN risk

Correct Answer & Explanation

. Subtalar, tibiotalar, and talonavicular dislocation; 100% AVN risk

Explanation

A Hawkins Type III fracture involves a fracture of the talar neck with dislocation of both the subtalar and tibiotalar joints. Because of the severe disruption of the retrograde blood supply to the talar body, the risk of AVN is exceedingly high, approaching 80-100%.

Question 189

Topic: Midfoot & Hindfoot

A 24-year-old professional football player sustains a purely ligamentous Lisfranc injury. Based on prospective randomized data (e.g., Ly and Coetzee), which of the following statements comparing primary arthrodesis to open reduction internal fixation (ORIF) is true?

. ORIF results in a significantly higher return to pre-injury level of sport compared to primary arthrodesis.
. Primary arthrodesis yields better mid-term functional outcomes and lower rates of secondary surgery.
. Primary arthrodesis is associated with a higher rate of deep infection.
. ORIF provides greater preservation of midfoot motion, leading to significantly higher AOFAS scores.
. There is no difference in outcomes, but ORIF requires a shorter period of immobilization.

Correct Answer & Explanation

. Primary arthrodesis yields better mid-term functional outcomes and lower rates of secondary surgery.

Explanation

For purely ligamentous Lisfranc injuries, primary arthrodesis of the first, second, and third tarsometatarsal joints has been shown to provide better functional outcomes and lower rates of hardware removal and secondary salvage procedures (due to post-traumatic arthritis) compared to ORIF. Ly and Coetzee's landmark prospective randomized study demonstrated superiority of primary arthrodesis over ORIF in purely ligamentous injuries.

Question 190

Topic: Midfoot & Hindfoot

A 55-year-old female presents with stage IIb posterior tibial tendon dysfunction (PTTD), characterized by a flexible flatfoot deformity and greater than 40% uncovering of the talonavicular joint on the AP radiograph. What is the standard of care surgical reconstruction for this specific stage?

. Isolated flexor digitorum longus (FDL) transfer to the navicular
. Triple arthrodesis
. FDL transfer, medial displacement calcaneal osteotomy, and a lateral column lengthening procedure
. Subtalar arthroereisis
. Talonavicular fusion alone

Correct Answer & Explanation

. FDL transfer, medial displacement calcaneal osteotomy, and a lateral column lengthening procedure

Explanation

Stage II PTTD is a flexible deformity. Stage IIa has minimal forefoot abduction, while Stage IIb has significant forefoot abduction (typically >30-40% talonavicular uncovering). To correct the severe forefoot abduction in Stage IIb, a lateral column lengthening (such as an Evans calcaneal osteotomy or calcaneocuboid distraction arthrodesis) is required in addition to an FDL transfer and often a medial displacement calcaneal osteotomy (MDCO) to correct the hindfoot valgus.

Question 191

Topic: Midfoot & Hindfoot
A 55-year-old patient with poorly controlled type 2 diabetes presents with a swollen, erythematous, and warm left foot. Radiographs demonstrate periarticular fragmentation, bony debris, and subluxation at the tarsometatarsal joints. According to the Eichenholtz classification, what is the current stage of this patient's Charcot arthropathy?
. Stage 0 (Prodromal)
. Stage I (Developmental)
. Stage II (Coalescence)
. Stage III (Reconstruction)
. Stage IV (Remodeling)

Correct Answer & Explanation

. Stage I (Developmental)

Explanation

Eichenholtz Stage I (Developmental/Fragmentation) is characterized clinically by a red, hot, swollen foot and radiographically by bony debris, fragmentation, subluxation/dislocation, and osteopenia. Stage II (Coalescence) shows absorption of debris and early fusion. Stage III (Reconstruction) shows consolidation, remodeling, and smoothing of bone edges.

Question 192

Topic: Midfoot & Hindfoot

A 35-year-old male is involved in a high-speed motor vehicle collision and sustains a purely ligamentous Chopart joint dislocation. Which two specific articulations comprise the Chopart joint line?

. Talonavicular and calcaneocuboid
. Naviculocuneiform and calcaneocuboid
. Tarsometatarsal and intercuneiform
. Talocalcaneal and talonavicular
. Cuneocuboid and cuboidometatarsal

Correct Answer & Explanation

. Talonavicular and calcaneocuboid

Explanation

The Chopart joint, or transverse tarsal joint, connects the hindfoot to the midfoot. It is composed of two articulations: the talonavicular joint medially and the calcaneocuboid joint laterally.

Question 193

Topic: Midfoot & Hindfoot

A 28-year-old man is involved in a motor vehicle collision and sustains a displaced fracture of the talar head. Which joint is most directly impacted and at risk for post-traumatic arthritis as a result of this injury?

. Tibiotalar joint
. Talocalcaneal (subtalar) joint
. Talonavicular joint
. Calcaneocuboid joint
. Naviculocuneiform joint

Correct Answer & Explanation

. Talonavicular joint

Explanation

Talar head fractures directly involve the talonavicular joint, a crucial component of the transverse tarsal (Chopart) joint complex. Displaced fractures require open reduction and internal fixation to restore the congruity of the talonavicular joint and prevent stiffness and early arthritis.

Question 194

Topic: Midfoot & Hindfoot

A 26-year-old male sustained a severe midfoot injury during a high-speed motorcycle crash. Radiographs demonstrate a pure dislocation through the transverse tarsal joint. The Chopart joint complex involves dislocations of which of the following specific articulations?

. The tarsometatarsal (Lisfranc) joints
. The talonavicular and calcaneocuboid joints
. The subtalar and tibiotalar joints
. The naviculocuneiform joints
. The medial, intermediate, and lateral cuneiform interosseous joints

Correct Answer & Explanation

. The talonavicular and calcaneocuboid joints

Explanation

The transverse tarsal joint, historically known as the Chopart joint, represents the anatomic boundary between the hindfoot and midfoot. It consists of two distinct articulations: the talonavicular joint medially and the calcaneocuboid joint laterally.

Question 195

Topic: Midfoot & Hindfoot

A 42-year-old marathon runner presents with chronic, severe plantar heel pain that has not improved with 6 months of stretching, orthotics, and cortisone injections. He notes the pain frequently radiates distally and laterally across the plantar aspect of his foot. On exam, there is maximal tenderness over the medial aspect of the heel, and a Tinel's sign is positive just inferior to the medial malleolus. The patient likely suffers from entrapment of which of the following nerves?

. Medial plantar nerve
. Sural nerve
. Deep peroneal nerve
. First branch of the lateral plantar nerve (Baxter's nerve)
. Saphenous nerve

Correct Answer & Explanation

. First branch of the lateral plantar nerve (Baxter's nerve)

Explanation

Entrapment of the first branch of the lateral plantar nerve (often called Baxter's nerve) is a well-recognized cause of chronic heel pain that mimics or coexists with recalcitrant plantar fasciitis. The nerve typically becomes compressed between the deep fascia of the abductor hallucis muscle and the medial head of the quadratus plantae. Symptoms may include radiating pain and sometimes atrophy of the abductor digiti minimi.

Question 196

Topic: Midfoot & Hindfoot
A 55-year-old woman presents with a flexible flatfoot deformity, marked weakness with manual muscle testing of inversion in plantarflexion, and inability to perform a single-limb heel rise test. The deformity is fully correctable passively. According to the Johnson and Strom classification, what stage of posterior tibial tendon dysfunction (PTTD) does this represent, and what is the standard surgical treatment if conservative measures fail?
. Stage I; Tenosynovectomy of the PTT
. Stage II; FDL transfer to the navicular combined with a medial displacement calcaneal osteotomy
. Stage III; Subtalar or Triple arthrodesis
. Stage IV; Tibiotalocalcaneal arthrodesis
. Stage II; Isolated primary repair of the PTT

Correct Answer & Explanation

. Stage II; FDL transfer to the navicular combined with a medial displacement calcaneal osteotomy

Explanation

Stage II PTTD is characterized by a flexible flatfoot deformity, inability to perform a single-limb heel rise, and PTT weakness/dysfunction. Treatment typically involves a soft tissue procedure (FDL transfer to reconstruct the PTT) combined with a bony procedure to correct the deformity and protect the transfer (e.g., medial displacement calcaneal osteotomy, lateral column lengthening). Stage I involves pain and tenosynovitis without deformity. Stage III is a rigid deformity requiring arthrodesis.

Question 197

Topic: Midfoot & Hindfoot
A 28-year-old male sustains a Hawkins Type III fracture of the talar neck. What does this fracture pattern involve, and what is the approximate historical rate of avascular necrosis (AVN) of the talar body associated with it?
. Fracture of the talar neck with subtalar subluxation; AVN rate is 20-50%
. Fracture of the talar neck with subtalar and tibiotalar dislocation; AVN rate is 80-100%
. Fracture of the talar neck with talonavicular dislocation; AVN rate is 10-15%
. Fracture of the talar head with talonavicular dislocation; AVN rate is 50%
. Fracture of the talar neck with extrusion of the talar body; AVN rate is 100%

Correct Answer & Explanation

. Fracture of the talar neck with subtalar and tibiotalar dislocation; AVN rate is 80-100%

Explanation

Hawkins Type III is a vertical fracture of the talar neck with dislocation of both the subtalar and tibiotalar (ankle) joints. Because the major blood supply to the talar body is severely disrupted, the rate of AVN is historically reported as nearly 80-100%.

Question 198

Topic: Midfoot & Hindfoot

A 45-year-old marathon runner complains of chronic, severe heel pain that has failed 6 months of conservative management for plantar fasciitis. Pain is maximal at the medial calcaneal tuberosity and radiates distally. At surgery, release of the first branch of the lateral plantar nerve (Baxter's nerve) is planned. Between which two muscles is this nerve typically entrapped?

. Abductor hallucis and quadratus plantae
. Flexor digitorum brevis and abductor digiti minimi
. Abductor hallucis and flexor digitorum brevis
. Quadratus plantae and flexor digitorum longus
. Tibialis posterior and flexor hallucis longus

Correct Answer & Explanation

. Flexor digitorum brevis and abductor digiti minimi

Explanation

Baxter's nerve (the first branch of the lateral plantar nerve) provides motor innervation to the abductor digiti minimi. It typically becomes entrapped as it passes under the deep fascia of the abductor hallucis and travels between the deep surface of the abductor hallucis muscle and the medial surface of the quadratus plantae muscle.

Question 199

Topic: Midfoot & Hindfoot

In Stage II adult acquired flatfoot deformity (posterior tibial tendon dysfunction), the spring ligament is frequently attenuated or torn. Which of the following is the most important static stabilizer of the talonavicular joint and the strongest component of the spring ligament complex?

. Superomedial calcaneonavicular ligament
. Inferior calcaneonavicular ligament
. Medioplantar oblique calcaneonavicular ligament
. Bifurcate ligament
. Dorsal talonavicular ligament

Correct Answer & Explanation

. Superomedial calcaneonavicular ligament

Explanation

The spring ligament complex consists of three main components. The superomedial calcaneonavicular ligament is the strongest and most critical static restraint to plantar and medial subluxation of the talar head in flatfoot deformity.

Question 200

Topic: Midfoot & Hindfoot

A 45-year-old construction worker falls from a height of 6 feet, sustaining an acute, purely ligamentous Lisfranc injury with lateral subluxation of the 1st through 3rd tarsometatarsal joints. Which of the following statements regarding primary arthrodesis compared to Open Reduction Internal Fixation (ORIF) for this specific injury pattern is supported by current Level I evidence?

. ORIF provides a statistically significant improvement in functional outcomes at 2 years.
. Primary arthrodesis results in fewer planned secondary surgeries.
. ORIF has a significantly lower rate of early hardware failure.
. Primary arthrodesis restores midfoot arch height significantly better than ORIF.
. There is no difference in the rate of postoperative degenerative joint disease requiring fusion.

Correct Answer & Explanation

. Primary arthrodesis results in fewer planned secondary surgeries.

Explanation

Multiple RCTs (e.g., Ly and Coetzee, 2006) demonstrate that for purely ligamentous Lisfranc injuries, primary arthrodesis results in similar or superior long-term functional outcomes but with a significantly lower rate of planned secondary surgeries. ORIF frequently requires hardware removal or late conversion to arthrodesis due to post-traumatic arthritis.

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