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Midfoot & Hindfoot MCQs

Practice Set 11 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 201

Topic: Midfoot & Hindfoot
A 60-year-old woman presents with a painful, severe flatfoot deformity. Physical examination reveals an inability to perform a single-leg heel rise, and the hindfoot valgus deformity cannot be passively corrected to neutral. What is the most appropriate surgical management for this stage of disease?
. Flexor digitorum longus (FDL) transfer to the navicular
. FDL transfer combined with a medial displacement calcaneal osteotomy
. FDL transfer, calcaneal osteotomy, and lateral column lengthening
. Triple arthrodesis
. Isolated subtalar arthrodesis

Correct Answer & Explanation

. Triple arthrodesis

Explanation

The patient has a rigid, non-correctable hindfoot valgus, diagnostic of Stage III adult acquired flatfoot deformity. A triple arthrodesis (fusion of the subtalar, talonavicular, and calcaneocuboid joints) is required to correct rigid multi-planar deformities.

Question 202

Topic: Midfoot & Hindfoot

In a lateral subtalar dislocation, the injury is often irreducible by closed means. Which of the following structures most commonly blocks the closed reduction of a lateral subtalar dislocation?

. Extensor digitorum brevis
. Posterior tibial tendon
. Flexor hallucis longus
. Anterior tibial tendon
. Peroneus brevis tendon

Correct Answer & Explanation

. Posterior tibial tendon

Explanation

Lateral subtalar dislocations are commonly irreducible due to the interposition of the posterior tibial tendon around the talar neck. In contrast, medial subtalar dislocations are typically blocked by the extensor digitorum brevis, extensor retinaculum, or the talonavicular joint capsule.

Question 203

Topic: Midfoot & Hindfoot

A 55-year-old female presents with Stage IIb posterior tibial tendon dysfunction. Clinical exam shows a flexible hindfoot valgus and significant forefoot abduction with greater than 30% uncoverage of the talonavicular joint. In addition to a flexor digitorum longus transfer and a medial displacement calcaneal osteotomy, which additional procedure is most appropriate?

. Subtalar arthrodesis
. Talonavicular arthrodesis
. Lateral column lengthening
. First tarsometatarsal arthrodesis
. Medial cuneiform opening wedge osteotomy

Correct Answer & Explanation

. Lateral column lengthening

Explanation

Stage IIb posterior tibial tendon dysfunction is characterized by significant forefoot abduction (>30% talonavicular uncoverage). A lateral column lengthening (such as an Evans osteotomy) is required to restore the lateral column length and correct the forefoot abduction.

Question 204

Topic: Midfoot & Hindfoot

A 40-year-old marathon runner with chronic heel pain continues to have symptoms despite 6 months of stretching and orthotics. The pain is maximal over the medial heel and is associated with weakness in active abduction of the fifth toe. Entrapment of which of the following nerves is the most likely diagnosis?

. Medial plantar nerve
. Sural nerve
. First branch of the lateral plantar nerve
. Saphenous nerve
. Deep peroneal nerve

Correct Answer & Explanation

. First branch of the lateral plantar nerve

Explanation

Baxter's nerve is the first branch of the lateral plantar nerve. Entrapment mimics plantar fasciitis but often presents with chronic medial heel pain and motor weakness of the abductor digiti minimi.

Question 205

Topic: Midfoot & Hindfoot

A 55-year-old patient with long-standing diabetes presents with a swollen, warm, and erythematous foot. Radiographs reveal fragmentation, periarticular debris, and subluxation at the tarsometatarsal joints. According to the Eichenholtz classification of Charcot arthropathy, what stage does this represent?

. Stage 0 (Prodromal)
. Stage 1 (Development/Fragmentation)
. Stage 2 (Coalescence)
. Stage 3 (Reconstruction/Consolidation)
. Stage 4 (Ulceration)

Correct Answer & Explanation

. Stage 1 (Development/Fragmentation)

Explanation

Eichenholtz Stage 1 (Fragmentation) is characterized clinically by a warm, swollen, erythematous foot and radiographically by joint subluxation, bony fragmentation, and debris. Stage 2 shows coalescence with absorption of debris, and Stage 3 shows bony remodeling.

Question 206

Topic: Midfoot & Hindfoot
A 22-year-old snowboarder sustains a forced dorsiflexion injury of the ankle, resulting in a Hawkins type III talar neck fracture. According to the Hawkins classification, this fracture pattern involves subluxation or dislocation of which specific joints?
. Subtalar joint only
. Subtalar and tibiotalar joints
. Subtalar, tibiotalar, and talonavicular joints
. Tibiotalar and talonavicular joints
. Subtalar and talonavicular joints only

Correct Answer & Explanation

. Subtalar, tibiotalar, and talonavicular joints

Explanation

In the Hawkins classification for talar neck fractures, Type I is nondisplaced, Type II involves subtalar subluxation/dislocation, Type III involves subtalar and tibiotalar subluxation/dislocation, and Type IV (Canale modification) involves subtalar, tibiotalar, and talonavicular disruption.

Question 207

Topic: Midfoot & Hindfoot
A 58-year-old male with poorly controlled type 2 diabetes presents with a swollen, erythematous right foot. Radiographs reveal fragmentation of the midfoot joints, periarticular debris, and joint subluxation. According to the Eichenholtz classification, the patient is currently in Stage I (Fragmentation). What is the hallmark radiographic finding of the subsequent stage (Stage II)?
. Normal radiographs with mild soft tissue swelling
. Progressive bony destruction and active osteomyelitis
. Coalescence, absorption of fine debris, and early sclerosis
. Complete bony consolidation and joint remodeling
. Osteolysis and profound periosteal elevation

Correct Answer & Explanation

. Coalescence, absorption of fine debris, and early sclerosis

Explanation

The Eichenholtz classification of Charcot arthropathy consists of three stages. Stage I (Developmental/Fragmentation) involves joint edema, fragmentation, and debris. Stage II (Coalescence) is marked by the absorption of fine debris, fusion of larger fragments, and early sclerosis as the inflammatory phase resolves. Stage III (Reconstruction) involves bony consolidation, remodeling, and rounding of bone ends.

Question 208

Topic: Midfoot & Hindfoot

A 30-year-old male sustains a strictly ligamentous Lisfranc injury. Based on randomized controlled trials comparing primary arthrodesis versus open reduction and internal fixation (ORIF) for purely ligamentous Lisfranc injuries, primary arthrodesis is associated with which of the following outcomes?

. Higher functional scores and a lower rate of secondary surgeries
. A higher rate of post-traumatic osteoarthritis in the adjacent joints
. Lower functional scores but a faster return to competitive sports
. No difference in functional scores but a significantly higher risk of deep infection
. Decreased preservation of the medial longitudinal arch

Correct Answer & Explanation

. Higher functional scores and a lower rate of secondary surgeries

Explanation

Level I evidence (e.g., Ly and Coetzee, Henning et al.) has demonstrated that for purely ligamentous Lisfranc injuries, primary arthrodesis results in superior functional outcomes and significantly lower rates of secondary surgeries (such as hardware removal or salvage arthrodesis for post-traumatic arthritis) compared to ORIF.

Question 209

Topic: Midfoot & Hindfoot

A 55-year-old male with long-standing poorly controlled diabetes presents with a warm, swollen, erythematous right foot. He denies trauma or fever. Radiographs show early fragmentation of the navicular and cuneiforms. Blood work reveals a normal erythrocyte sedimentation rate (ESR). What is the most appropriate initial management?

. Intravenous antibiotics and emergent surgical debridement
. Total contact casting and non-weight bearing
. Primary midfoot arthrodesis to prevent collapse
. Incisional biopsy and culture of the midfoot
. Below-knee amputation

Correct Answer & Explanation

. Total contact casting and non-weight bearing

Explanation

This is a classic presentation of acute Charcot neuroarthropathy (Eichenholtz Stage I - Fragmentation phase). The normal ESR helps differentiate this from acute osteomyelitis. The gold standard initial management for acute Charcot arthropathy is immobilization in a total contact cast (TCC) and protected weight bearing to arrest the inflammatory process and prevent further bone destruction and deformity. Surgery is generally contraindicated in the acute phase.

Question 210

Topic: Midfoot & Hindfoot
A 45-year-old obese female presents with progressive medial foot pain and an inability to perform a single-leg heel rise. Examination reveals a flexible pes planovalgus deformity. She has failed 6 months of orthotics and physical therapy. What is the most appropriate surgical management for this stage of her condition?
. Gastrocnemius recession and subtalar arthrodesis
. Triple arthrodesis
. Flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy
. Tibialis anterior tendon transfer and lateral column lengthening
. Spring ligament reconstruction alone

Correct Answer & Explanation

. Flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy

Explanation

The patient has Stage II adult-acquired flatfoot deformity (posterior tibial tendon dysfunction), characterized by medial pain, a flexible deformity, and inability to perform a single heel rise. The standard surgical treatment for Stage II disease after failed conservative management involves a flexor digitorum longus (FDL) tendon transfer to replace the diseased posterior tibial tendon, combined with a medial displacement calcaneal osteotomy (MDCO) to correct the valgus malalignment. Triple arthrodesis is reserved for Stage III (rigid) deformity.

Question 211

Topic: Midfoot & Hindfoot

A 55-year-old diabetic patient with peripheral neuropathy presents with a red, hot, swollen foot without open ulcers. Radiographs reveal fragmentation of the tarsometatarsal joints, periarticular debris, and subluxation. There is no systemic fever or leukocytosis. According to the Eichenholtz classification of Charcot arthropathy, which stage does this represent?

. Stage 0 (Inflammation)
. Stage 1 (Development/Fragmentation)
. Stage 2 (Coalescence)
. Stage 3 (Remodeling/Consolidation)
. Stage 4 (Ulceration)

Correct Answer & Explanation

. Stage 1 (Development/Fragmentation)

Explanation

The Eichenholtz classification of Charcot neuroarthropathy includes: Stage 0 (clinically red, hot, swollen, but normal radiographs); Stage 1 (Development/Fragmentation: joint dislocation, subchondral fragmentation, debris formation); Stage 2 (Coalescence: absorption of debris, early fusion of fragments); and Stage 3 (Consolidation/Remodeling: remodeling of bone ends, solid fusion). This patient has radiographic evidence of fragmentation, consistent with Stage 1.

Question 212

Topic: Midfoot & Hindfoot

Which of the following is the primary advantage of primary arthrodesis compared to open reduction and internal fixation (ORIF) for the treatment of a purely ligamentous Lisfranc injury?

. Higher rate of successful anatomic reduction
. Decreased rate of hardware removal and subsequent reoperation
. Preservation of physiological midfoot motion
. Significantly shorter required non-weight-bearing duration
. Lower risk of postoperative deep venous thrombosis

Correct Answer & Explanation

. Decreased rate of hardware removal and subsequent reoperation

Explanation

Multiple studies (such as the landmark RCT by Ly and Coetzee) have demonstrated that primary arthrodesis of the first, second, and third tarsometatarsal joints for purely ligamentous Lisfranc injuries results in superior functional outcomes and a significantly decreased rate of hardware removal and reoperation compared to ORIF. ORIF of ligamentous injuries often fails due to hardware breakage or loss of reduction once weight-bearing begins, often necessitating a secondary fusion.

Question 213

Topic: Midfoot & Hindfoot

A 22-year-old collegiate football player sustains a purely ligamentous Lisfranc injury. Weight-bearing radiographs demonstrate 3 mm of diastasis between the medial and middle cuneiforms with no associated fractures. Based on Level 1 evidence (e.g., Ly and Coetzee), what is the most appropriate surgical management?

. Closed reduction and percutaneous pinning (CRPP)
. Open reduction and internal fixation (ORIF) with transarticular screws
. Primary arthrodesis of the 1st, 2nd, and 3rd tarsometatarsal joints
. Dorsal bridge plating without joint violation
. Primary ligament repair with suture tape augmentation

Correct Answer & Explanation

. Primary arthrodesis of the 1st, 2nd, and 3rd tarsometatarsal joints

Explanation

The landmark prospective randomized study by Ly and Coetzee demonstrated that for strictly ligamentous Lisfranc injuries, primary arthrodesis of the medial 2 or 3 rays yields superior functional outcomes and a lower rate of planned/unplanned reoperations compared to traditional ORIF with transarticular screws. Ligamentous injuries heal poorly, and ORIF often leads to late collapse and post-traumatic arthritis requiring salvage arthrodesis.

Question 214

Topic: Midfoot & Hindfoot
A 50-year-old female presents with a progressive, painful flatfoot deformity. Examination reveals a flexible hindfoot valgus, but she is unable to perform a single-leg heel rise. Weight-bearing radiographs demonstrate a talonavicular coverage angle indicating >50% lateral subluxation of the navicular on the talus. Based on this Stage IIb posterior tibial tendon dysfunction (PTTD), what is the most appropriate surgical treatment algorithm?
. Isolated gastrocnemius recession
. Medial displacement calcaneal osteotomy and FDL transfer
. Lateral column lengthening, medial displacement calcaneal osteotomy, and FDL transfer
. Triple arthrodesis
. Tibiotalocalcaneal arthrodesis

Correct Answer & Explanation

. Lateral column lengthening, medial displacement calcaneal osteotomy, and FDL transfer

Explanation

Stage II PTTD is a flexible deformity. Stage IIa has minimal forefoot abduction (<30-40% talonavicular uncoverage) and is typically treated with a medial displacement calcaneal osteotomy (MDCO) and FDL transfer. Stage IIb has significant forefoot abduction (>40-50% TN uncoverage). To adequately correct the forefoot abduction, a lateral column lengthening (Evans osteotomy) is required in addition to MDCO and FDL transfer. Rigid deformities (Stage III) require triple arthrodesis.

Question 215

Topic: Midfoot & Hindfoot

In a patient presenting with Stage II acquired adult flatfoot deformity (posterior tibial tendon dysfunction), physical examination and MRI often reveal attenuation of a key static stabilizing ligament that supports the talonavicular joint. Which of the following ligaments is most commonly affected in this scenario?

. Long plantar ligament
. Short plantar ligament
. Plantar calcaneonavicular ligament
. Bifurcate ligament
. Plantar aponeurosis

Correct Answer & Explanation

. Plantar calcaneonavicular ligament

Explanation

The plantar calcaneonavicular ligament, commonly known as the spring ligament, is the primary static stabilizer of the longitudinal arch and the talonavicular joint. It is frequently attenuated or torn in conjunction with posterior tibial tendon dysfunction (PTTD), contributing to the characteristic talonavicular sag and abducted midfoot.

Question 216

Topic: Midfoot & Hindfoot
A 55-year-old female presents with stage IIb posterior tibial tendon dysfunction. She has a flexible flatfoot deformity but experiences significant lateral foot pain during stance phase due to subfibular impingement. There is more than 40% uncoverage of the talar head. Which of the following surgical strategies is most appropriate?
. FDL transfer with isolated medial displacement calcaneal osteotomy (MDCO)
. FDL transfer, MDCO, and lateral column lengthening
. Triple arthrodesis
. Isolated talonavicular arthrodesis
. Spring ligament reconstruction alone

Correct Answer & Explanation

. FDL transfer, MDCO, and lateral column lengthening

Explanation

Stage IIb adult acquired flatfoot deformity is characterized by a flexible deformity with significant forefoot abduction (typically >40% talonavicular uncoverage). This degree of abduction requires a lateral column lengthening (e.g., Evans osteotomy) to correct, in addition to an FDL transfer and often a medial displacement calcaneal osteotomy (MDCO) for valgus correction. Triple arthrodesis is reserved for rigid deformities (Stage III).

Question 217

Topic: Midfoot & Hindfoot

A 55-year-old diabetic patient presents with an acute, warm, swollen, and erythematous midfoot. Radiographs show fragmentation and early collapse of the midfoot with no open ulcers. Infection is ruled out. According to the Eichenholtz classification, what is the most appropriate initial management for this Stage I Charcot arthropathy?

. Immediate open reduction and rigid internal fixation with beaming screws
. Intravenous antibiotics and surgical debridement
. Total contact casting and non-weight bearing
. Midfoot exostectomy
. Amputation

Correct Answer & Explanation

. Total contact casting and non-weight bearing

Explanation

Acute (Eichenholtz Stage I - developmental/fragmentation) Charcot neuroarthropathy is characterized by profound active inflammation, bone fragmentation, and joint subluxation. The gold standard initial management is strict immobilization using a total contact cast and non-weight bearing to arrest the inflammatory process and prevent further collapse. Surgical reconstruction during this acute phase has an unacceptably high rate of failure and hardware pullout.

Question 218

Topic: Midfoot & Hindfoot

A 55-year-old poorly controlled diabetic patient presents with a painless, swollen, erythematous right foot. Radiographs reveal extensive subchondral fragmentation, subluxation of the midfoot joints, and intra-articular debris without evidence of bony consolidation. According to the Eichenholtz classification, what stage of Charcot arthropathy does this represent?

. Stage 0
. Stage 1
. Stage 2
. Stage 3
. Stage 4

Correct Answer & Explanation

. Stage 1

Explanation

Eichenholtz Stage 1 (Development/Fragmentation) is characterized by joint edema, erythema, bony fragmentation, subluxation, and intra-articular debris. Stage 2 is coalescence (absorption of debris), and Stage 3 is reconstruction (remodeling and consolidation).

Question 219

Topic: Midfoot & Hindfoot

A 42-year-old man has a symptomatic flatfoot deformity and walks with a slight limp after falling off a scaffold 9 months ago. He also reports that he has had difficulty returning to work. Orthotics have failed to provide relief. Current radiographs are shown in Figures 19a and 19b. To relieve his pain and return the patient to work, treatment should consist of

. lateral column lengthening.
. open reduction and internal fixation.
. double arthrodesis (talonavicular and calcaneocuboid joints).
. tarsometatarsal arthrodesis.
. medial displacement calcaneal osteotomy and tendon transfer.

Correct Answer & Explanation

. tarsometatarsal arthrodesis.

Explanation

Because the patient has sustained a tarsometatarsal injury with midfoot sag, the treatment of choice is a tarsometatarsal arthrodesis. The cause of his flatfoot deformity is secondary to the tarsometatarsal injury and not from posterior tibialis tendon deficiency. Lateral column lengthening, double arthrodesis, and calcaneal osteotomy are not indicated. Although open reduction and internal fixation may be performed late when arthritis is present, these procedures are less likely to succeed. Komenda GA, Myerson MS, Biddinger KR: Results of arthrodesis of the tarsometatarsal joints after traumatic injury. J Bone Joint Surg Am 1996;78:1665-1676.

Question 220

Topic: Midfoot & Hindfoot

A 35-year-old woman states that she stepped on a piece of glass 6 months ago and reports numbness and shooting pain along the plantar lateral forefoot. She had previously received steroid injections in the 3 to 4 webspace. Examination reveals mild tenderness along the plantar fascia; no Tinel's sign is noted plantar medially and no Mulder's click is noted distally. An MRI scan is shown in Figure 7. What is the most likely cause of the numbness?

Foot & Ankle 2009 Practice Questions: Set 1 (Solved) - Figure 24

. Residual foreign body
. Lateral plantar nerve laceration
. Impingement of Baxter's nerve
. Interdigital neuroma
. Digital nerve laceration

Correct Answer & Explanation

. Lateral plantar nerve laceration

Explanation

The MRI scan reveals a laceration through the abductor hallucis musculature and lateral plantar nerve, producing numbness along its distribution. There is no evidence of a foreign body on the MRI scan. Baxter's nerve, or nerve to the abductor digiti quinti muscle, is the first branch off the lateral plantar nerve and impingement of this nerve typically produces a Tinel's sign along the nerve branch deep to the abductor hallucis muscle. Interdigital neuroma would be suggested by the presence of a Mulder's click. A digital nerve laceration would exhibit isolated numbness more distally. Baxter DE, Pfeffer GB: Treatment of chronic heel pain by surgical release of the first branch of the lateral plantar nerve. Clin Orthop Relat Res 1992;279:229-236.

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