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Midfoot & Hindfoot MCQs

Practice Set 14 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 261

Topic: Midfoot & Hindfoot
A 32-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 anatomical disruptions defining a Hawkins III fracture?
. Nondisplaced fracture of the talar neck
. Displaced fracture of the talar neck with subluxation of the subtalar joint
. Displaced fracture of the talar neck with dislocation of both the subtalar and tibiotalar joints
. Displaced fracture of the talar neck with dislocation of the subtalar, tibiotalar, and talonavicular joints
. Comminuted fracture of the talar body with extrusion

Correct Answer & Explanation

. Displaced fracture of the talar neck with 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/dislocation; Type III involves dislocation of the subtalar and tibiotalar joints. Type IV (added by Canale and Kelly) includes talonavicular dislocation. Type III injuries have a very high rate of avascular necrosis.

Question 262

Topic: Midfoot & Hindfoot
A 55-year-old obese woman presents with medial ankle pain and a progressive flatfoot deformity. Examination reveals an inability to perform a single-leg heel raise, flexible hindfoot valgus, and forefoot abduction. According to the Johnson and Strom classification (modified by Myerson), 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 II

Explanation

Johnson and Strom Stage I PTTD presents with pain and tenosynovitis but no deformity and intact heel raise. Stage II is characterized by a flexible flatfoot deformity (hindfoot valgus, forefoot abduction) and inability to perform a single-leg heel raise. Stage III is a rigid deformity. Stage IV involves deltoid incompetence and ankle valgus tilt.

Question 263

Topic: Midfoot & Hindfoot
A 52-year-old obese woman presents with a flexible, painful flatfoot deformity. Examination shows she is unable to perform a single-leg heel rise on the affected side. Weight-bearing radiographs reveal more than 40% uncovering of the talonavicular joint and significant forefoot abduction. According to the Johnson and Strom classification modified by Myerson, what is the most appropriate surgical management for this Stage IIb Posterior Tibial Tendon Dysfunction (PTTD)?
. Medial displacement calcaneal osteotomy and Flexor Digitorum Longus (FDL) transfer alone
. Lateral column lengthening, FDL transfer, and medial displacement calcaneal osteotomy
. Triple arthrodesis
. Isolated subtalar arthrodesis
. Talonavicular arthrodesis alone

Correct Answer & Explanation

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

Explanation

Stage IIb PTTD is characterized by a flexible flatfoot with significant forefoot abduction (typically >40% talonavicular uncovering). Surgical correction requires addressing both the valgus hindfoot and the abducted forefoot. This is best achieved with a lateral column lengthening (e.g., Evans osteotomy) to correct the abduction, combined with FDL transfer and often a medial displacement calcaneal osteotomy. Arthrodesis is reserved for Stage III (rigid deformity).

Question 264

Topic: Midfoot & Hindfoot

A 55-year-old poorly controlled diabetic patient presents with a massively swollen, erythematous, and warm left foot. Radiographs reveal periarticular fragmentation, bony debris, and subluxation at the tarsometatarsal joints. Which Eichenholtz stage does this represent, and what is the standard of care?

. Stage 0; MRI and immediate open reduction internal fixation
. Stage 1; Total contact casting and strict non-weight bearing
. Stage 2; Custom orthosis and weight bearing as tolerated
. Stage 3; Midfoot arthrodesis
. Stage 1; Intravenous antibiotics and surgical debridement

Correct Answer & Explanation

. Stage 1; Total contact casting and strict non-weight bearing

Explanation

This patient presents with acute Charcot arthropathy. The Eichenholtz classification describes Stage 1 (Development/Fragmentation) as characterized by joint edema, erythema, and radiographs showing fragmentation, debris, and subluxation. The treatment of choice is immobilization with total contact casting (TCC) to protect the foot and prevent progressive deformity while the acute inflammatory phase resolves.

Question 265

Topic: Midfoot & Hindfoot
A 32-year-old male sustains a Hawkins Type III talar neck fracture. This injury involves subluxation or dislocation of which of the following articulations?
. Subtalar joint only
. Subtalar and tibiotalar joints
. Subtalar, tibiotalar, and talonavicular joints
. Tibiotalar and talonavicular joints
. Subtalar and talonavicular joints

Correct Answer & Explanation

. Subtalar, tibiotalar, and talonavicular joints

Explanation

The Hawkins classification for talar neck fractures: Type I is nondisplaced; Type II is displaced with subtalar subluxation/dislocation; Type III is displaced with both subtalar and tibiotalar dislocation; Type IV (added by Canale and Kelly) involves subtalar, tibiotalar, and talonavicular dislocation.

Question 266

Topic: Midfoot & Hindfoot

A 55-year-old diabetic male presents with a unilaterally swollen, erythematous, and warm midfoot for the past 3 weeks. Radiographs show fragmentation of the navicular and cuneiforms with periarticular debris and subluxation. There is no open ulcer. According to the modified Eichenholtz classification, what stage is this, and what is the preferred initial management?

. Stage 0; Intravenous antibiotics and I&D
. Stage 1; Total contact casting and non-weight-bearing
. Stage 2; Custom orthosis and weight-bearing as tolerated
. Stage 3; Arthrodesis of the midfoot
. Stage 1; Immediate open reduction and internal fixation

Correct Answer & Explanation

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

Explanation

The patient is in Eichenholtz Stage 1 (Development/Fragmentation stage), characterized by erythema, swelling, joint subluxation, bony fragmentation, and periarticular debris. The cornerstone of acute management for Charcot arthropathy without deep infection is strict immobilization and offloading, typically using a total contact cast (TCC). Surgery is generally contraindicated during the acute inflammatory stage.

Question 267

Topic: Midfoot & Hindfoot

In adult acquired flatfoot deformity (posterior tibial tendon dysfunction), what is the primary static stabilizing ligament of the medial longitudinal arch that classically attenuates and fails?

. Deltoid ligament
. Bifurcate ligament
. Long plantar ligament
. Plantar calcaneonavicular (spring) ligament
. Plantar aponeurosis

Correct Answer & Explanation

. Plantar calcaneonavicular (spring) ligament

Explanation

While the posterior tibial tendon provides dynamic support to the medial longitudinal arch, the primary static stabilizer is the plantar calcaneonavicular ligament, commonly known as the spring ligament. In adult acquired flatfoot deformity, the posterior tibial tendon fails, leading to increased stress on the static stabilizers. Attenuation and ultimate failure of the spring ligament leads to severe talonavicular subluxation (peritalar subluxation) characteristic of Stage 2b/3 disease.

Question 268

Topic: Midfoot & Hindfoot

A 55-year-old diabetic patient presents with a swollen, warm, and erythematous right foot. Radiographs show periarticular debris, fragmentation of the navicular, and early subluxation of the talonavicular joint. According to the Eichenholtz classification of Charcot arthropathy, what stage does this represent?

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

Correct Answer & Explanation

. Stage 1 (Fragmentation)

Explanation

The Eichenholtz classification describes the natural history of Charcot arthropathy. Stage 0 is inflammation with normal radiographs. Stage 1 is the Developmental/Fragmentation stage characterized by periarticular debris, fragmentation, and subluxation. Stage 2 is Coalescence (absorption of debris, early fusion). Stage 3 is Consolidation (remodeling and rounded bone edges).

Question 269

Topic: Midfoot & Hindfoot
A 45-year-old female presents with painful, progressive flattening of her left foot. Clinical examination reveals a 'too many toes' sign and inability to perform a single-leg heel raise. Radiographs demonstrate significant talonavicular uncoverage (>40%) without evidence of osteoarthritis. According to the Johnson and Strom classification, what is the stage and the most appropriate surgical treatment?
. Stage I; Tenosynovectomy of the tibialis posterior
. Stage IIA; Medial displacement calcaneal osteotomy and FDL transfer
. Stage IIB; Lateral column lengthening, FDL transfer, and medial displacement calcaneal osteotomy
. Stage III; Subtalar arthrodesis
. Stage IV; Tibiotalocalcaneal arthrodesis

Correct Answer & Explanation

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

Explanation

The inability to perform a single-leg heel raise with flexible deformity indicates Stage II adult acquired flatfoot deformity. The presence of significant forefoot abduction (talonavicular uncoverage >30-40%) sub-classifies it as Stage IIB, which necessitates a lateral column lengthening (Evans osteotomy) in addition to soft tissue transfers and medial displacement calcaneal osteotomy.

Question 270

Topic: Midfoot & Hindfoot

A 58-year-old male with poorly controlled diabetes mellitus presents with a swollen, warm, and erythematous left foot. X-rays show pronounced osteopenia, extensive periarticular bony fragmentation, subluxation of the tarsometatarsal joints, and debris. 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

The Eichenholtz classification stages Charcot arthropathy: Stage 0 (Inflammation without radiographic changes), Stage 1 (Development/Fragmentation: osteopenia, bony fragmentation, joint subluxation/dislocation, debris), Stage 2 (Coalescence: absorption of debris, early sclerosis, fusion of fragments), and Stage 3 (Reconstruction: rounding of bone ends, decreased sclerosis, permanent deformity). This patient's fragmentation and debris indicate Stage 1.

Question 271

Topic: Midfoot & Hindfoot

A 62-year-old male with poorly controlled type 2 diabetes presents with a swollen, warm, and erythematous foot without ulceration. Radiographs show extensive periarticular fragmentation, debris, and subluxation of the tarsometatarsal joints. According to the Eichenholtz classification of Charcot arthropathy, what stage does this represent, and what is the primary initial treatment?

. Stage 0; surgical arthrodesis
. Stage 1; total contact casting and strict non-weight bearing
. Stage 2; specialized orthotic depth-inlay shoe wear
. Stage 3; rigid internal fixation and realignment
. Stage 1; immediate intravenous antibiotics and surgical debridement

Correct Answer & Explanation

. Stage 1; total contact casting and strict non-weight bearing

Explanation

The patient is presenting with Eichenholtz Stage 1 (Developmental/Fragmentation stage) Charcot arthropathy, characterized clinically by acute inflammation (erythema, warmth, swelling) and radiographically by osteopenia, bony fragmentation, and joint subluxation/dislocation. The gold standard initial treatment is strict immobilization and offloading using a total contact cast (TCC) to prevent further deformity until the acute inflammatory phase resolves and bone consolidation begins.

Question 272

Topic: Midfoot & Hindfoot

A 52-year-old male with long-standing, poorly controlled type 2 diabetes presents with a diffusely swollen, erythematous, and warm right foot. There is no history of trauma and no open ulcers. Radiographs reveal prominent periarticular debris, fragmentation of the tarsometatarsal joints, and subluxation. Based on the Eichenholtz classification, what is the current stage of this patient's disease and the most appropriate initial management?

. Stage 0; observation and return to regular shoe wear
. Stage 1 (Development); immediate non-weight bearing in a total contact cast
. Stage 2 (Coalescence); arthrodesis of the midfoot
. Stage 3 (Reconstruction); Charcot restraint orthotic walker (CROW) boot
. Stage 4; primary below-knee amputation

Correct Answer & Explanation

. Stage 1 (Development); immediate non-weight bearing in a total contact cast

Explanation

The patient is presenting with acute Charcot arthropathy. Eichenholtz Stage 1 (Development) is characterized by clinical warmth, erythema, and swelling, with radiographic findings of bony fragmentation, subluxation, and periarticular debris. The mainstay of treatment in the acute phase (Stage 1) is strict immobilization and offloading, typically utilizing a total contact cast until the acute inflammation subsides and the bones begin to coalesce (transition to Stage 2). Surgery is generally avoided in the acute fragmentation phase.

Question 273

Topic: Midfoot & Hindfoot
A 60-year-old female presents with medial ankle pain and a flatfoot deformity. She has a flexible hindfoot valgus and is unable to perform a single-leg heel rise. Clinical examination also reveals > 40% uncoverage of the talonavicular joint on the AP radiograph. This presentation is most consistent with which stage of Posterior Tibial Tendon Dysfunction (PTTD)?
. Stage I
. Stage IIa
. Stage IIb
. Stage III
. Stage IV

Correct Answer & Explanation

. Stage IIb

Explanation

Stage II indicates a flexible flatfoot deformity. Stage IIa has minimal forefoot abduction, while Stage IIb is characterized by significant forefoot abduction ('too many toes' sign) and > 30-40% talonavicular uncoverage on AP radiograph. Stage III is a rigid deformity.

Question 274

Topic: Midfoot & Hindfoot
A 54-year-old diabetic patient presents with a swollen, warm, erythematous right foot. Radiographs show extensive bone fragmentation, periarticular debris, and joint subluxation at the tarsometatarsal joints. According to the Eichenholtz classification, what stage of Charcot arthropathy is this?
. Stage 0
. Stage I (Development/Fragmentation)
. Stage II (Coalescence)
. Stage III (Consolidation/Reconstruction)
. Stage IV

Correct Answer & Explanation

. Stage I (Development/Fragmentation)

Explanation

Eichenholtz Stage I is the Development/Fragmentation stage, characterized radiographically by bone debris, fragmentation, joint subluxation, and fractures. Stage II (Coalescence) shows absorption of debris and early fusion. Stage III (Consolidation) shows remodeling and a stable but deformed foot.

Question 275

Topic: Midfoot & Hindfoot

A 55-year-old male with poorly controlled diabetes mellitus presents with a deformed, non-tender midfoot. Radiographs reveal coalescing bone fragments, absorption of fine bone debris, and early fusion of large fragments. According to the Eichenholtz classification of Charcot arthropathy, what stage is currently demonstrated?

. Stage 0 (High risk/Inflammation)
. Stage 1 (Developmental/Fragmentation)
. Stage 2 (Coalescence)
. Stage 3 (Reconstruction/Consolidation)
. Stage 4 (Remodeling)

Correct Answer & Explanation

. Stage 2 (Coalescence)

Explanation

Eichenholtz Stage 1 involves active fragmentation, joint dislocation, and fine debris. Stage 2 (Coalescence) is marked by the absorption of fine debris, early fusion, and sclerosis of large fragments. Stage 3 (Consolidation) shows remodeling and rounding of bone ends.

Question 276

Topic: Midfoot & Hindfoot
A 28-year-old male sustains a severe hyperdorsiflexion injury to the ankle. Radiographs reveal a displaced talar neck fracture with subluxation of the subtalar joint. The tibiotalar and talonavicular joints remain congruent. According to the Hawkins classification, what is the stage of this injury and its approximate associated risk of avascular necrosis (AVN)?
. Hawkins I, 0-10% AVN
. Hawkins II, 20-50% AVN
. Hawkins III, 80-100% AVN
. Hawkins IV, 100% AVN
. Hawkins II, 90-100% AVN

Correct Answer & Explanation

. Hawkins III, 80-100% AVN

Explanation

Hawkins classification for talar neck fractures: Type I = non-displaced (0-10% AVN). Type II = displaced with subtalar subluxation/dislocation (20-50% AVN). Type III = displaced with subtalar and tibiotalar dislocation (~80-100% AVN). Type IV = displaced with subtalar, tibiotalar, and talonavicular dislocation (~100% AVN).

Question 277

Topic: Midfoot & Hindfoot

A 24-year-old professional athlete sustains a purely ligamentous Lisfranc injury. Based on prospective randomized trials comparing open reduction internal fixation (ORIF) to primary arthrodesis for purely ligamentous Lisfranc injuries, primary arthrodesis is associated with:

. Higher rates of hardware failure and implant breakage
. Decreased ability to return to the previous level of sports
. Better short- and medium-term functional outcomes and lower rates of secondary surgeries
. Increased risk of complex regional pain syndrome (CRPS)
. A higher rate of nonunion requiring massive bone grafting

Correct Answer & Explanation

. Better short- and medium-term functional outcomes and lower rates of secondary surgeries

Explanation

Studies (such as Ly and Coetzee, JBJS 2006) demonstrate that for purely ligamentous Lisfranc injuries, primary arthrodesis of the medial 2 or 3 rays yields better functional outcomes and avoids the frequent need for secondary fusion due to post-traumatic arthritis or hardware removal associated with ORIF.

Question 278

Topic: Midfoot & Hindfoot
A 55-year-old overweight female presents with progressive flattening of her left foot, medial pain, and inability to perform a single-leg heel rise. Examination shows a flexible hindfoot with significant forefoot abduction (>40% uncoverage of the talonavicular joint). What is the most appropriate surgical management for this Stage IIb adult-acquired flatfoot?
. Gastrocnemius recession and flexor digitorum longus (FDL) transfer alone
. FDL transfer, medial displacement calcaneal osteotomy (MDCO), and lateral column lengthening
. Subtalar arthrodesis and FDL transfer
. Triple arthrodesis
. Talonavicular arthrodesis alone

Correct Answer & Explanation

. FDL transfer, medial displacement calcaneal osteotomy (MDCO), and lateral column lengthening

Explanation

Stage IIb posterior tibial tendon dysfunction (adult-acquired flatfoot) is characterized by a flexible deformity with profound forefoot abduction. Surgical correction requires addressing both columns: a medializing calcaneal osteotomy (for hindfoot valgus), lateral column lengthening (e.g., Evans osteotomy for forefoot abduction), and soft tissue reconstruction (FDL transfer).

Question 279

Topic: Midfoot & Hindfoot
A 30-year-old man falls from a height and sustains a Hawkins Type III fracture of the talar neck. Which of the following best describes the anatomical disruption associated with a Hawkins Type III fracture?
. Undisplaced fracture of the talar neck
. Fracture of the talar neck with subluxation of the subtalar joint only
. Fracture of the talar neck with dislocation of both the subtalar and tibiotalar joints
. Fracture of the talar neck with dislocation of the subtalar, tibiotalar, and talonavicular joints
. Comminuted fracture of the talar body with extrusion

Correct Answer & Explanation

. Fracture of the talar neck with dislocation of the subtalar, tibiotalar, and talonavicular joints

Explanation

The Hawkins classification describes talar neck fractures: Type I is non-displaced. Type II involves subluxation or dislocation of the subtalar joint. Type III involves dislocation of both the subtalar and tibiotalar (ankle) joints. Type IV involves dislocation of the subtalar, tibiotalar, and talonavicular joints.

Question 280

Topic: Midfoot & Hindfoot

A 20-year-old collegiate football player sustains a severe midfoot injury. Radiographs and MRI confirm a purely ligamentous Lisfranc injury with lateral displacement of the second through fifth metatarsals. Based on high-level prospective evidence comparing primary arthrodesis versus open reduction and internal fixation (ORIF) for purely ligamentous Lisfranc injuries, primary arthrodesis of which specific joints is recommended to yield superior long-term clinical outcomes?

. 1st, 2nd, and 3rd tarsometatarsal (TMT) joints
. 4th and 5th tarsometatarsal (TMT) joints
. Naviculocuneiform joints
. Talonavicular joint
. Calcaneocuboid joint

Correct Answer & Explanation

. 1st, 2nd, and 3rd tarsometatarsal (TMT) joints

Explanation

In purely ligamentous Lisfranc injuries, prospective randomized studies (such as those by Ly and Coetzee) have demonstrated that primary arthrodesis of the medial column (1st, 2nd, and 3rd TMT joints) leads to significantly better functional outcomes, less need for hardware removal, and a lower rate of subsequent procedures compared to ORIF. The 4th and 5th TMT joints are highly mobile and are generally pinned with K-wires rather than fused, to preserve their necessary sagittal motion.

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