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Midfoot & Hindfoot MCQs

Practice Set 13 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 241

Topic: Midfoot & Hindfoot
A 55-year-old patient with poorly controlled type 2 diabetes mellitus presents with a severely swollen, red, and warm right foot. There are no open ulcers or breaks in the skin. Radiographs demonstrate joint fragmentation, subluxation of the tarsometatarsal joints, and periarticular bone debris. According to the Eichenholtz classification of Charcot arthropathy, what stage does this represent?
. Stage 0 (Inflammatory)
. Stage I (Developmental/Fragmentation)
. Stage II (Coalescence)
. Stage III (Reconstruction/Consolidation)
. Stage IV (Ulceration)

Correct Answer & Explanation

. Stage I (Developmental/Fragmentation)

Explanation

The Eichenholtz classification describes the natural history of Charcot arthropathy. Stage I (Fragmentation) is characterized clinically by acute inflammation (erythema, swelling, warmth) and radiographically by joint subluxation, osteocartilaginous fragmentation, and debris formation. Stage II (Coalescence) shows absorption of fine debris and early fusion. Stage III (Consolidation) shows remodeling and stable deformity. Stage 0 was added later by Shibata and represents clinical inflammation with completely normal radiographs.

Question 242

Topic: Midfoot & Hindfoot

A 55-year-old diabetic patient presents with a swollen, erythematous, and warm foot. Radiographs demonstrate periarticular osteopenia, osseous debris, and fragmentation of the midfoot. According to the Eichenholtz classification of Charcot arthropathy, what is the most appropriate initial treatment?

. Arthrodesis with rigid internal fixation
. Total contact casting and non-weight bearing
. Accommodative shoe wear and orthotics
. Exostectomy of the medial column
. Intravenous antibiotics for 6 weeks

Correct Answer & Explanation

. Total contact casting and non-weight bearing

Explanation

The patient is in Eichenholtz Stage I (Developmental/Fragmentation), characterized by erythema, swelling, debris, and fragmentation. The standard of care is immediate immobilization and offloading using total contact casting (TCC) until the acute inflammatory phase resolves and coalescence (Stage II) begins.

Question 243

Topic: Midfoot & Hindfoot
A 60-year-old female presents with medial ankle pain and a progressive flatfoot deformity. Examination reveals flexible hindfoot valgus and an inability to perform a single-leg heel rise. Radiographs demonstrate no arthritic changes in the subtalar or talonavicular joints. According to the Johnson and Strom classification, what stage of posterior tibial tendon dysfunction does this represent?
. Stage I
. Stage II
. Stage III
. Stage IV
. Stage V

Correct Answer & Explanation

. Stage II

Explanation

Stage II posterior tibial tendon dysfunction (PTTD) is characterized by a flexible flatfoot deformity, an inability to perform a single-leg heel rise, and the absence of degenerative joint changes. Stage I has normal alignment and preserved heel rise. Stage III is a rigid deformity with hindfoot arthritis. Stage IV involves lateral ankle instability and deltoid ligament compromise.

Question 244

Topic: Midfoot & Hindfoot

A 55-year-old male with long-standing, poorly controlled diabetes presents with a swollen, erythematous, and warm left foot without open wounds or signs of systemic sepsis.

Radiographs demonstrate significant soft tissue edema, osteopenia, and early periarticular fragmentation at the midfoot. According to the Eichenholtz classification, what is the most appropriate initial treatment for this stage of his condition?

. Total contact casting and strict non-weight-bearing
. Immediate midfoot arthrodesis with robust internal fixation
. Intravenous antibiotics and surgical debridement
. Prescription of custom accommodative orthotic footwear
. Excision of the fragmented bone (exostectomy)

Correct Answer & Explanation

. Total contact casting and strict non-weight-bearing

Explanation

The patient is presenting with acute Eichenholtz Stage I (developmental/fragmentation stage) Charcot arthropathy, characterized by a red, hot, swollen foot, osteopenia, subluxation, and bony fragmentation. The standard of care for acute Stage I Charcot is immediate offloading and immobilization using a total contact cast (TCC). Surgery is generally contraindicated in the acute inflammatory phase due to poor bone stock and high failure rates.

Question 245

Topic: Midfoot & Hindfoot



A 55-year-old male with poorly controlled diabetes mellitus and severe peripheral neuropathy presents with a globally swollen, erythematous, and warm left foot. He denies any inciting trauma. Radiographs show periarticular debris and subtle fragmentation at the tarsometatarsal joints. Which of the following is the most appropriate initial management?

. Immediate open reduction and internal fixation to restore arch alignment
. Total contact casting and strict non-weight-bearing precautions
. Admission for intravenous antibiotics and surgical debridement of the joints
. Corticosteroid injection into the affected tarsometatarsal joints to reduce inflammation
. Guillotine amputation at the transmalleolar level to prevent sepsis

Correct Answer & Explanation

. Total contact casting and strict non-weight-bearing precautions

Explanation

The patient is presenting with acute Charcot arthropathy (Eichenholtz stage 0 or 1). The clinical picture mimics infection, but the lack of an ulcer or systemic signs points to Charcot. The mainstay of initial treatment during the acute inflammatory phase is immobilization (usually via total contact casting) and non-weight-bearing to arrest the destructive process and prevent further deformity.

Question 246

Topic: Midfoot & Hindfoot
A 58-year-old man with long-standing diabetic peripheral neuropathy presents with a swollen, erythematous, and warm right foot without ulcerations. He reports minimal pain but his midfoot arch has collapsed over the past month. Radiographs demonstrate fragmentation, periarticular debris, and subluxation at the tarsometatarsal joints. Which of the following is the most appropriate initial management for the acute phase of this condition?
. Immediate open reduction and midfoot arthrodesis
. Intravenous antibiotics for 6 weeks followed by bracing
. Total contact casting with strict non-weight-bearing
. Custom orthotic inserts and modified deep-toe box shoes
. Below-knee amputation

Correct Answer & Explanation

. Total contact casting with strict non-weight-bearing

Explanation

This patient is presenting with acute Eichenholtz Stage I Charcot arthropathy (fragmentation stage). The hallmark of treatment for acute Charcot neuroarthropathy is strict offloading and immobilization to prevent further deformity until the active inflammatory process resolves (Stage III - consolidation). Total contact casting is the gold standard for achieving this.

Question 247

Topic: Midfoot & Hindfoot

A 55-year-old poorly controlled diabetic patient presents with a warm, swollen, and erythematous foot. Initial radiographs reveal fragmentation of the midfoot bones, periarticular debris, and early joint subluxation, but no signs of consolidation. According to the Eichenholtz classification of Charcot arthropathy, which stage does this represent?

. Stage 0 (Inflammation)
. Stage 1 (Fragmentation)
. Stage 2 (Coalescence)
. Stage 3 (Reconstruction)
. Stage 4 (Consolidation)

Correct Answer & Explanation

. Stage 1 (Fragmentation)

Explanation

The Eichenholtz classification outlines the natural history of Charcot arthropathy. Stage 0 is the inflammatory phase (normal x-rays, localized erythema/swelling). Stage 1 is the Fragmentation/Development phase, characterized by joint debris, subluxation, dislocation, and osteochondral fragmentation. Stage 2 is Coalescence, involving absorption of debris and early fusion of fragments. Stage 3 is Reconstruction, characterized by rounding of bone ends, remodeling, and decreased sclerosis.

Question 248

Topic: Midfoot & Hindfoot

A 55-year-old male with poorly controlled type 2 diabetes presents with a unilaterally swollen, red, and warm right foot. He denies any ulceration or systemic signs of infection. Radiographs demonstrate fragmentation of the midfoot bones, subchondral debris, and joint subluxation. According to the Eichenholtz classification, the patient is currently in Stage I (Developmental). What is the gold standard initial management?

. Total contact casting
. Immediate midfoot arthrodesis
. Intravenous antibiotics
. Below-knee amputation
. Calcaneal sliding osteotomy

Correct Answer & Explanation

. Total contact casting

Explanation

The clinical presentation is highly consistent with acute Charcot arthropathy (Eichenholtz Stage I: Developmental/Fragmentation). The primary goal during the acute phase is to prevent further deformity and allow the inflammatory process to subside. The gold standard treatment is immediate offloading and immobilization using a total contact cast (TCC). Surgery is generally contraindicated during the acute, hyperemic phase due to poor bone quality and high failure rates.

Question 249

Topic: Midfoot & Hindfoot

A 55-year-old diabetic male presents with a swollen, erythematous, and warm left foot. Radiographs demonstrate periarticular debris, fragmentation, and joint subluxation at the tarsometatarsal joints. According to the Eichenholtz classification of Charcot arthropathy, what stage 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 clinical erythema, swelling, and warmth, with radiographic features of bone fragmentation, debris, joint subluxation, and fracture. Stage 2 (Coalescence) shows absorption of debris and early fusion. Stage 3 (Reconstruction) shows consolidation and remodeling. Stage 0 is the clinical high-risk foot with no radiographic changes.

Question 250

Topic: Midfoot & Hindfoot
A 32-year-old female falls from a height and sustains a talar neck fracture with subtalar and tibiotalar joint dislocation, but the talonavicular joint remains intact. What is the Hawkins classification of this fracture and the approximate associated risk of avascular necrosis (AVN)?
. Hawkins Type II, 20-50% AVN risk
. Hawkins Type III, 50-100% AVN risk
. Hawkins Type IV, 50-100% AVN risk
. Hawkins Type II, 0-10% AVN risk
. Hawkins Type III, 20-50% AVN risk

Correct Answer & Explanation

. Hawkins Type III, 50-100% AVN risk

Explanation

Hawkins Type I: Nondisplaced (0-10% AVN). Type II: Subtalar dislocation/subluxation (20-50% AVN). Type III: Subtalar and tibiotalar dislocation (50-100% AVN). Type IV: Subtalar, tibiotalar, and talonavicular dislocation (50-100% AVN). The scenario describes a Type III fracture.

Question 251

Topic: Midfoot & Hindfoot

A 55-year-old poorly controlled diabetic male presents with a massively swollen, warm, and erythematous right foot. He denies any recent trauma or open wounds. Laboratory studies reveal a normal white blood cell count and normal inflammatory markers. Radiographs demonstrate fragmentation and subluxation at the tarsometatarsal joints. What is the most appropriate initial management for this condition?

. Intravenous broad-spectrum antibiotics
. Total contact casting and non-weight bearing
. Urgent arthrodesis of the midfoot
. Below-knee amputation
. Magnetic resonance imaging to definitively rule out osteomyelitis

Correct Answer & Explanation

. Total contact casting and non-weight bearing

Explanation

This patient is presenting with acute Charcot arthropathy (Eichenholtz stage 0 or 1), characterized by a swollen, warm, erythematous foot with radiographic evidence of joint fragmentation, in the setting of normal inflammatory markers. The mainstay of initial treatment for acute Charcot arthropathy is strict immobilization and off-loading, typically achieved with a total contact cast (TCC). This prevents progressive deformity while the acute inflammatory phase resolves. Surgery is contraindicated during the acute inflammatory phase due to the high risk of hardware failure and worsening bone destruction.

Question 252

Topic: Midfoot & Hindfoot
A 32-year-old male falls from a ladder and sustains a Hawkins Type III fracture of the talar neck. By definition, a Hawkins Type III injury involves a talar neck fracture accompanied by which of the following patterns of dislocation?
. Subluxation of the subtalar joint only
. Dislocation of the tibiotalar joint only
. Dislocation of both the subtalar and tibiotalar joints
. Dislocation of the subtalar, tibiotalar, and talonavicular joints
. Extrusion of the talar body with an intact talonavicular joint

Correct Answer & Explanation

. Dislocation of both the subtalar and tibiotalar joints

Explanation

The Hawkins classification describes talar neck fractures: Type I is nondisplaced; Type II involves subtalar subluxation or dislocation; Type III involves dislocation of both the subtalar and tibiotalar (ankle) joints (the talar body extrudes posteromedially); Type IV (added by Canale) involves dislocation of the subtalar, tibiotalar, and talonavicular joints. The risk of avascular necrosis (AVN) increases substantially with each grade, approaching 100% in Type III/IV if not reduced urgently.

Question 253

Topic: Midfoot & Hindfoot

A 55-year-old female presents with severe, progressive right foot pain and deformity for 2 years. She has a history of systemic lupus erythematosus (SLE) and chronic steroid use. Clinical examination reveals a fixed, planovalgus foot deformity with a prominence medially. Radiographs demonstrate collapse of the midfoot arch, marked talonavicular subluxation, and degenerative changes, consistent with a severe pes planovalgus deformity with secondary arthritis. What is the MOST appropriate surgical treatment for this rigid, symptomatic deformity in a patient with SLE and chronic steroid use?

. Isolated subtalar arthrodesis.
. Medializing calcaneal osteotomy and flexor digitorum longus (FDL) transfer.
. Triple arthrodesis.
. Lateral column lengthening with a calcaneocuboid fusion.
. Custom orthotics and shoe modifications.

Correct Answer & Explanation

. Triple arthrodesis.

Explanation

The patient presents with severe, rigid, symptomatic pes planovalgus deformity with secondary arthritis, complicated by a history of SLE and chronic steroid use (which can affect bone healing and soft tissue integrity). This is a complex, acquired flatfoot deformity.Conservative measures (orthotics) are typically ineffective for rigid deformities with established arthritis. Isolated subtalar arthrodesis or medializing calcaneal osteotomy with FDL transfer are reconstructive procedures often used for flexible flatfoot or early stages of rigid flatfoot, but they are unlikely to be sufficient for a severe, rigid deformity with talonavicular subluxation and arthritis.For severe, rigid pes planovalgus deformity with significant talonavicular subluxation and secondary arthritis, a triple arthrodesis (fusion of the subtalar, talonavicular, and calcaneocuboid joints) is often the most appropriate and reliable surgical option. It corrects the deformity, provides a stable, pain-free plantigrade foot, and addresses the multi-joint arthritis. The history of SLE and steroid use means attention to wound healing and bone fusion potential is critical, but triple arthrodesis is a proven salvage.Rationale for options:A. Isolated subtalar arthrodesis is for flexible flatfoot or less severe rigid flatfoot primarily affecting the subtalar joint. It would not correct the severe midfoot collapse and talonavicular subluxation.B. Medializing calcaneal osteotomy and FDL transfer are common procedures for flexible flatfoot reconstruction (adult acquired flatfoot deformity) and are insufficient for a rigid deformity with advanced arthritis.C. Triple arthrodesis (fusion of subtalar, talonavicular, and calcaneocuboid joints) is the definitive treatment for severe, rigid pes planovalgus deformity with secondary arthritis. It provides correction, stability, and pain relief. This is the correct answer.D. Lateral column lengthening with a calcaneocuboid fusion is a component of some flatfoot reconstructions but is not a comprehensive solution for a severe, rigid, multi-joint arthritic deformity.E. Custom orthotics and shoe modifications are conservative measures, which have already failed given the chronic and worsening nature of the rigid deformity.

Question 254

Topic: Midfoot & Hindfoot

A 54-year-old male with poorly controlled diabetes presents with a swollen, erythematous, and warm right foot. He denies fever or open wounds. Radiographs show periarticular fragmentation, subluxation of the tarsometatarsal joints, and debris. According to the Eichenholtz classification, what stage does this represent, and what is the standard initial treatment?

. Stage 0; Intravenous antibiotics
. Stage 1 (Developmental); Total contact casting and non-weight bearing
. Stage 2 (Coalescence); Surgical arthrodesis
. Stage 3 (Reconstruction); Custom orthotic wear
. Stage 1 (Developmental); Emergent surgical debridement

Correct Answer & Explanation

. Stage 1 (Developmental); Total contact casting and non-weight bearing

Explanation

This patient has an acute Charcot arthropathy in the developmental/fragmentation stage (Eichenholtz Stage 1). The gold standard initial treatment is immobilization in a total contact cast and strict non-weight bearing to prevent further deformity until the acute inflammatory phase resolves.

Question 255

Topic: Midfoot & Hindfoot

A 50-year-old male falls from a ladder, sustaining a calcaneal fracture. Radiographs show a severely comminuted intra-articular fracture with significant subtalar joint involvement (tongue-type). He has no other injuries. Which factor is most important in determining the functional outcome of this fracture?

. Patient's age.
. Presence of an open wound.
. Quality of the reduction of the subtalar joint.
. Duration of non-weight-bearing.
. Type of fixation used.

Correct Answer & Explanation

. Quality of the reduction of the subtalar joint.

Explanation

For intra-articular calcaneal fractures, the quality of the reduction of the subtalar joint articular surface is the most critical factor influencing long-term functional outcome and the development of post-traumatic subtalar arthritis. Anatomical reduction and stable fixation, when indicated, are paramount. While age and soft tissue status (open wound) are important, and the duration of non-weight-bearing and type of fixation play roles, none supersede the importance of restoring the joint congruity. A poor reduction significantly increases the risk of chronic pain, stiffness, and arthritis, irrespective of other factors.

Question 256

Topic: Midfoot & Hindfoot
A 28-year-old male falls from a ladder and sustains a Hawkins Type III fracture of the talar neck. Which of the following best describes the expected rate of avascular necrosis (AVN) of the talar body?
. 0-10%
. 20-50%
. 50-75%
. Nearly 100%
. AVN does not occur in Type III

Correct Answer & Explanation

. Nearly 100%

Explanation

Hawkins Type III fractures involve dislocation of the talar body from both the subtalar and tibiotalar joints. This disrupts all three major blood supplies to the talar body, leading to an AVN rate approaching 100%.

Question 257

Topic: Midfoot & Hindfoot

A 55-year-old diabetic patient presents with a swollen, erythematous, and warm foot. There are no systemic signs of infection and no skin ulcerations. Radiographs show periarticular debris, fragmentation, and subluxation at the tarsometatarsal joints. What is the most appropriate initial management?

. Intravenous antibiotics and surgical debridement
. Open reduction and internal fixation of the midfoot
. Total contact casting and non-weight bearing
. Primary arthrodesis of the affected joints
. Below-knee amputation

Correct Answer & Explanation

. Total contact casting and non-weight bearing

Explanation

The patient has acute Eichenholtz Stage 1 (developmental/fragmentation phase) Charcot arthropathy. The gold standard for initial treatment is immobilization and offloading using a total contact cast to halt progressive deformity.

Question 258

Topic: Midfoot & Hindfoot

A 55-year-old diabetic male presents with a swollen, warm, and erythematous left foot. Radiographs reveal fragmentation of the tarsometatarsal joints, subchondral cysts, and periarticular debris. He is diagnosed with acute Charcot arthropathy (Eichenholtz Stage 1). What is the gold standard initial treatment?

. Urgent surgical arthrodesis of the midfoot
. Total contact casting and non-weight bearing
. Intravenous antibiotics for presumed osteomyelitis
. Custom orthotic shoe wear
. Corticosteroid injection into the affected joints

Correct Answer & Explanation

. Total contact casting and non-weight bearing

Explanation

The gold standard initial management for acute phase (Eichenholtz Stage 1) Charcot arthropathy is strict immobilization and offloading using a total contact cast. Surgical intervention during the acute, inflammatory phase is associated with high failure and complication rates.

Question 259

Topic: Midfoot & Hindfoot
A 55-year-old poorly controlled diabetic patient presents with a swollen, warm, erythematous foot without an open ulcer or history of trauma. Radiographs show subluxation of the tarsometatarsal joints, osteopenia, and periarticular debris. According to the Eichenholtz classification, this stage of Charcot arthropathy is characterized primarily by which of the following?
. Coalescence with absorption of fine bone debris
. Consolidation with remodeling of bone ends
. Development of an infected neuropathic ulcer
. Active bone fragmentation, joint dislocation, and debris formation
. Complete osseous ankylosis of the midfoot

Correct Answer & Explanation

. Active bone fragmentation, joint dislocation, and debris formation

Explanation

The Eichenholtz classification of Charcot arthropathy has three main stages: Stage I (Development/Fragmentation) is marked by active bone fragmentation, subluxation/dislocation, joint effusion, and debris formation. Stage II (Coalescence) is marked by absorption of fine debris and early fusion. Stage III (Consolidation/Reconstruction) is marked by remodeling, rounding of bone ends, and stable fusion/ankylosis.

Question 260

Topic: Midfoot & Hindfoot
A 40-year-old male presents with a long-standing, rigid, and painful flatfoot deformity. Examination reveals an inability to perform a single-leg heel rise and rigid hindfoot valgus. Radiographs show advanced osteoarthritis of the subtalar, talonavicular, and calcaneocuboid joints. What is the gold standard surgical intervention?
. Medial displacement calcaneal osteotomy
. Flexor digitorum longus (FDL) tendon transfer to the navicular
. Isolated subtalar arthrodesis
. Triple arthrodesis
. Pantalar arthrodesis

Correct Answer & Explanation

. Triple arthrodesis

Explanation

The patient has a Stage III adult acquired flatfoot deformity (rigid flatfoot with degenerative changes). The gold standard treatment for a rigid deformity with arthritis involving the subtalar, talonavicular, and calcaneocuboid joints is a triple arthrodesis. Tendon transfers and osteotomies are reserved for flexible, earlier-stage deformities (Stage II).

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