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Midfoot & Hindfoot MCQs

Practice Set 15 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 281

Topic: Midfoot & Hindfoot

A 55-year-old male with poorly controlled diabetes mellitus presents with a swollen, erythematous, and warm right foot. Radiographs demonstrate periarticular osteopenia, prominent bony fragmentation, and multiple subluxations at the Lisfranc joint complex. According to the Eichenholtz classification of Charcot arthropathy, this presentation represents which stage?

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

Correct Answer & Explanation

. Stage 1 (Developmental/Fragmentation)

Explanation

Eichenholtz Stage 1 (Developmental/Fragmentation stage) is characterized clinically by the acute red, hot, swollen foot, and radiographically by periarticular fragmentation, debris formation, joint subluxation/dislocation, and osteopenia. Stage 2 (Coalescence) shows absorption of debris and early fusion, while Stage 3 (Reconstruction) shows rounding of bone ends and decreased sclerosis.

Question 282

Topic: Midfoot & Hindfoot

A 55-year-old patient with long-standing, poorly controlled diabetes presents with a swollen, warm, and erythematous right foot. There is no open ulceration. Radiographs reveal marked osteopenia, periarticular bony debris, fragmentation, and dorsal subluxation at the tarsometatarsal joints. According to the Eichenholtz classification of Charcot arthropathy, what stage does this represent?

. Stage 0 (Prodromal)
. Stage 1 (Developmental/Fragmentation)
. Stage 2 (Coalescence)
. Stage 3 (Consolidation/Remodeling)
. Stage 4 (Chronic)

Correct Answer & Explanation

. Stage 1 (Developmental/Fragmentation)

Explanation

Eichenholtz Stage 1 (Developmental) is characterized clinically by a red, hot, swollen foot and radiographically by active bone destruction, fragmentation, periarticular debris, and joint subluxation/dislocation. Stage 0 lacks radiographic changes. Stage 2 involves absorption of fine debris and early fusion. Stage 3 is characterized by remodeling and consolidation of the deformity.

Question 283

Topic: Midfoot & Hindfoot
A 28-year-old male presents with severe foot pain after a high-energy motor vehicle accident. Radiographs reveal a Hawkins Type III fracture of the talar neck. Which of the following precisely describes this injury pattern?
. Undisplaced talar neck fracture
. Talar neck fracture with subluxation or dislocation of the subtalar joint
. Talar neck fracture with dislocation of both the subtalar and tibiotalar joints
. Talar neck fracture with dislocation of the subtalar, tibiotalar, and talonavicular joints
. Talar head fracture with talonavicular joint dislocation

Correct Answer & Explanation

. Talar neck fracture with dislocation of both the subtalar and tibiotalar joints

Explanation

The Hawkins classification describes talar neck fractures: Type I is an undisplaced fracture; Type II involves subtalar subluxation or dislocation; Type III involves dislocation of both the subtalar and tibiotalar joints (the talar body is often extruded posteromedially); Type IV (added later by Canale and Kelly) includes subluxation or dislocation of the subtalar, tibiotalar, and talonavicular joints.

Question 284

Topic: Midfoot & Hindfoot
A 55-year-old male with poorly controlled diabetes presents with a swollen, warm, and erythematous left foot without any open ulcers. Radiographs demonstrate extensive subchondral fragmentation, joint subluxation, and intra-articular loose debris without significant osteosclerosis. According to the Eichenholtz classification of Charcot arthropathy, what stage does this clinical and radiographic picture 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

Eichenholtz Stage I is the developmental or fragmentation stage, characterized radiographically by osteochondral fragmentation, joint subluxation, and debris formation. Stage 0 is clinically warm and swollen but with normal radiographs. Stage II (coalescence) features absorption of fine debris and early sclerosis. Stage III (reconstruction) shows rounding of bone ends and solid consolidation.

Question 285

Topic: Midfoot & Hindfoot
A 50-year-old female presents with stage IIb adult-acquired flatfoot deformity, characterized by a flexible deformity with significant forefoot abduction (>40% uncovering of the talonavicular joint on AP weight-bearing radiographs). Which surgical combination is most appropriate to correct this multi-planar deformity?
. Gastrocnemius recession, FDL transfer to the navicular, and medial displacement calcaneal osteotomy (MDCO)
. FDL transfer to the navicular, MDCO, and lateral column lengthening
. Triple arthrodesis
. Talonavicular arthrodesis and FDL transfer
. Subtalar arthrodesis and medializing calcaneal osteotomy

Correct Answer & Explanation

. FDL transfer to the navicular, MDCO, and lateral column lengthening

Explanation

Stage IIb posterior tibial tendon dysfunction indicates a flexible flatfoot with significant forefoot abduction. While an FDL transfer and MDCO correct the valgus hindfoot, the forefoot abduction requires a lateral column lengthening (e.g., Evans osteotomy) to restore the talonavicular coverage and correct the transverse plane deformity. Stage III (rigid) requires a triple arthrodesis.

Question 286

Topic: Midfoot & Hindfoot
A 55-year-old patient with long-standing poorly controlled diabetes presents with a unilaterally swollen, erythematous, and warm foot without skin ulceration. Radiographs demonstrate extensive periarticular debris, bony fragmentation, and early subluxation of the tarsometatarsal joints. According to the Eichenholtz classification of Charcot arthropathy, this presentation corresponds to:
. Stage 0
. Stage I
. Stage II
. Stage III
. Stage IV

Correct Answer & Explanation

. Stage I

Explanation

The Eichenholtz classification of Charcot arthropathy includes: Stage 0 (high-risk foot, swelling, warmth, normal x-rays); Stage I (Developmental/Fragmentation: hyperemic, fragmentation, debris, subluxation); Stage II (Coalescence: decreased swelling/warmth, absorption of fine debris, early fusion); Stage III (Consolidation: remodeling, stable deformity). The clinical and radiographic findings match Stage I.

Question 287

Topic: Midfoot & Hindfoot

A 55-year-old patient with poorly controlled type 2 diabetes presents with a unilaterally swollen, erythematous, and warm foot without open ulcerations. Radiographs show periarticular fragmentation, subluxation, and bony debris at the tarsometatarsal joints. According to the Eichenholtz classification, what is the stage of this disease process and the standard initial management?

. Stage 0; rigid internal fixation
. Stage 1; total contact casting and non-weight bearing
. Stage 2; immediate midfoot arthrodesis
. Stage 3; custom accommodative shoe wear
. Stage 1; urgent surgical debridement and intravenous antibiotics

Correct Answer & Explanation

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

Explanation

The patient has Stage 1 (Developmental/Fragmentation stage) Charcot arthropathy, characterized by erythema, swelling, warmth, and radiographic evidence of fragmentation and subluxation. The standard of care for acute Stage 1 Charcot is immediate offloading, most effectively achieved with total contact casting (TCC) and non-weight bearing to prevent further collapse.

Question 288

Topic: Midfoot & Hindfoot

A 25-year-old athlete sustains a purely ligamentous Lisfranc injury. Current evidence comparing primary arthrodesis versus open reduction and internal fixation (ORIF) for purely ligamentous Lisfranc injuries suggests which of the following regarding primary arthrodesis?

. It results in a lower rate of return to competitive sports.
. It provides inferior midfoot functional scores at 2 years.
. It is associated with a lower rate of hardware removal and subsequent surgical procedures.
. It has a higher rate of nonunion than bony Lisfranc injuries.
. It requires a longer period of non-weight-bearing postoperatively compared to ORIF.

Correct Answer & Explanation

. It is associated with a lower rate of hardware removal and subsequent surgical procedures.

Explanation

Multiple prospective studies (e.g., Ly and Coetzee) have demonstrated that primary arthrodesis for purely ligamentous Lisfranc injuries provides comparable or superior functional outcomes and significantly lower rates of subsequent surgeries, such as hardware removal or conversion to salvage arthrodesis, compared to ORIF. ORIF in purely ligamentous injuries often leads to progressive arch collapse and post-traumatic arthritis.

Question 289

Topic: Midfoot & Hindfoot
A 55-year-old poorly controlled diabetic patient presents with a swollen, warm, and erythematous right foot. There is no open ulceration. Radiographs reveal focal osteopenia, joint subluxation, debris, and fragmentation around the tarsometatarsal joints. Which of the following corresponds to the correct Eichenholtz stage and the standard of care initial management?
. Stage 0; rigid internal fixation
. Stage I; total contact casting
. Stage II; total contact casting
. Stage III; custom orthotic footwear
. Stage I; immediate midfoot arthrodesis

Correct Answer & Explanation

. Stage II; total contact casting

Explanation

The clinical and radiographic presentation describes Eichenholtz Stage I (Development/Fragmentation stage) of Charcot arthropathy, characterized by swelling, warmth, joint debris, subluxation, and fragmentation. The gold standard initial management is immobilization and offloading with a total contact cast (TCC).

Question 290

Topic: Midfoot & Hindfoot
A 52-year-old female presents with medial ankle pain and a progressively flattening arch. Examination shows a flexible pes planovalgus, inability to perform a single-limb heel rise, and a positive "too many toes" sign. Radiographs show significant talonavicular uncoverage (>40%). Which of the following is the most appropriate surgical reconstruction for this specific stage of adult-acquired flatfoot deformity (Stage IIB)?
. Isolated flexor digitorum longus (FDL) transfer to the navicular
. FDL transfer, medial displacement calcaneal osteotomy, and lateral column lengthening
. Isolated subtalar arthrodesis
. Triple arthrodesis
. Gastrocnemius recession alone

Correct Answer & Explanation

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

Explanation

The patient has Stage IIB Posterior Tibial Tendon Dysfunction (flexible flatfoot with severe forefoot abduction, indicated by >40% talonavicular uncoverage). Stage IIB requires an FDL transfer to reconstruct the posterior tibial tendon, a medial displacement calcaneal osteotomy to correct the hindfoot valgus, and a lateral column lengthening (e.g., Evans osteotomy) to adequately correct the severe forefoot abduction.

Question 291

Topic: Midfoot & Hindfoot

A 55-year-old man with a 15-year history of poorly controlled type 2 diabetes mellitus presents with a swollen, warm, and erythematous left foot. He denies fevers, chills, or any open wounds. His inflammatory markers are normal. Radiographs demonstrate periarticular osteopenia, osseous debris, and fragmentation of the tarsometatarsal joints. According to the Eichenholtz classification of Charcot arthropathy, what is the most appropriate initial management for this patient?

. Urgent surgical debridement and intravenous antibiotics
. Open reduction and rigid internal fixation of the midfoot
. Total contact casting and strict non-weight-bearing
. Prescribing custom accommodative footwear and allowing full weight-bearing
. Intravenous bisphosphonates and immediate physical therapy

Correct Answer & Explanation

. Total contact casting and strict non-weight-bearing

Explanation

The patient's clinical presentation and radiographic findings (fragmentation, debris, periarticular osteopenia) correspond to Eichenholtz Stage 1 (Development/Fragmentation stage) of Charcot arthropathy. In this acute inflammatory stage, the primary treatment is strict immobilization and offloading to prevent further structural collapse. The gold standard is total contact casting (TCC) and non-weight-bearing. Surgery is generally contraindicated during the acute inflammatory phase due to poor bone quality and high risk of failure, unless there is an unstable deformity causing imminent skin breakdown.

Question 292

Topic: Midfoot & Hindfoot
A 50-year-old female presents with medial ankle pain, a progressively flattening arch, and an inability to perform a single-leg heel rise. Examination reveals a flexible pes planovalgus deformity. Radiographs show no degenerative changes in the subtalar or talonavicular joints. What is the standard surgical treatment if non-operative management fails?
. Isolated talonavicular fusion
. Subtalar fusion
. Flexor digitorum longus (FDL) transfer to the navicular and medial displacement calcaneal osteotomy
. Triple arthrodesis
. Ankle arthrodesis

Correct Answer & Explanation

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

Explanation

The patient has Stage II posterior tibial tendon dysfunction (PTTD), defined by a flexible flatfoot deformity and loss of PTT function. Standard joint-sparing surgical treatment consists of an FDL tendon transfer to replace the dysfunctional PTT, combined with a medializing calcaneal osteotomy to correct the valgus heel alignment and protect the transfer. Triple arthrodesis is indicated for Stage III, where the deformity becomes rigid with arthritic changes.

Question 293

Topic: Midfoot & Hindfoot

A 55-year-old female presents with stage IIB adult acquired flatfoot deformity (posterior tibial tendon dysfunction). Clinical and radiographic examination reveals a flexible flatfoot with significant forefoot abduction (talonavicular uncoverage of 45%). What surgical intervention is most appropriate to specifically address the excessive forefoot abduction?

. Subtalar arthrodesis
. Triple arthrodesis
. Flexor digitorum longus (FDL) transfer to navicular and medial displacement calcaneal osteotomy (MDCO) only
. FDL transfer, MDCO, and lateral column lengthening (e.g., Evans osteotomy)
. Isolated Spring ligament repair

Correct Answer & Explanation

. FDL transfer, MDCO, and lateral column lengthening (e.g., Evans osteotomy)

Explanation

Stage II posterior tibial tendon dysfunction indicates a flexible flatfoot deformity. Stage IIA has no significant forefoot abduction and is typically treated with an FDL transfer and MDCO. Stage IIB is defined by significant forefoot abduction (typically >30-40% talonavicular uncoverage). To correct this, a lateral column lengthening (such as an Evans calcaneal osteotomy) must be added to the FDL transfer and MDCO.

Question 294

Topic: Midfoot & Hindfoot

A 55-year-old male with poorly controlled type 2 diabetes presents with a swollen, warm, and erythematous right foot. There are no open ulcers, and his systemic inflammatory markers are normal. Radiographs reveal fragmentation and early subluxation of the talonavicular and calcaneocuboid joints. According to the Eichenholtz classification, what stage of Charcot arthropathy is this patient currently in, and what is the mainstay of treatment?

. Stage 0; immediate arthrodesis
. Stage 1; total contact casting and non-weight-bearing
. Stage 2; custom orthotics and modified shoe wear
. Stage 3; total contact casting and non-weight-bearing
. Stage 1; intravenous antibiotics and surgical debridement

Correct Answer & Explanation

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

Explanation

The patient is in Eichenholtz Stage 1 (Developmental/Fragmentation), characterized by erythema, warmth, swelling, and radiographic evidence of bone debris, fragmentation, and joint subluxation. The mainstay of treatment in the acute fragmentation phase is strict offloading, typically achieved with total contact casting (TCC) to prevent further deformity until the active inflammatory phase resolves.

Question 295

Topic: Midfoot & Hindfoot

A 55-year-old poorly controlled diabetic male presents with a swollen, erythematous, and warm left foot. Radiographs show periarticular debris, fragmentation of the tarsometatarsal joints, and early subluxation. According to the Eichenholtz classification of Charcot arthropathy, which stage does this represent and what is the key histological hallmark?

. Stage 1; presence of osseous debris and active bone resorption.
. Stage 2; absorption of fine debris and early fusion.
. Stage 3; remodeling of bone ends and decreased sclerosis.
. Stage 0; normal radiographs with diffuse marrow edema on MRI.
. Stage 4; fixed deformity with chronic plantar ulceration.

Correct Answer & Explanation

. Stage 1; presence of osseous debris and active bone resorption.

Explanation

The Eichenholtz classification divides Charcot arthropathy into three main radiographic stages (0 was added later). Stage 1 (Development/Fragmentation) is characterized by joint effusion, soft tissue swelling, osteopenia, periarticular fragmentation, debris formation, and subluxation. Stage 2 (Coalescence) shows absorption of fine debris, early sclerosis, and fusion. Stage 3 (Consolidation) shows remodeling and rounding of bone ends.

Question 296

Topic: Midfoot & Hindfoot

A 55-year-old diabetic patient presents with a swollen, warm, and erythematous foot without open ulceration. Radiographs reveal periarticular fragmentation, subluxation, and bony debris at the midfoot joints. According to the Eichenholtz classification of Charcot arthropathy, what is the most appropriate initial treatment?

. Immediate open reduction and internal fixation of the midfoot
. Total contact casting and non-weight bearing
. Below-knee amputation
. Intravenous antibiotics for 6 weeks followed by arthrodesis
. Custom orthotic shoe wear and unrestricted weight bearing

Correct Answer & Explanation

. Total contact casting and non-weight bearing

Explanation

The patient is in Eichenholtz Stage I (Developmental/Fragmentation stage), which is characterized clinically by a red, hot, swollen foot and radiographically by fragmentation, subluxation, and joint debris. The gold standard for treatment during this acute, active stage is rigid immobilization and offloading, typically via a total contact cast (TCC) and strict non-weight bearing until the disease progresses to the coalescent stage (Stage II).

Question 297

Topic: Midfoot & Hindfoot
A 55-year-old poorly controlled diabetic patient presents with a swollen, erythematous, and warm left foot. There are no open ulcers, and inflammatory markers are only mildly elevated. Radiographs reveal extensive periarticular fragmentation, bony debris, and subluxation at the tarsometatarsal joints. According to the Eichenholtz classification, what is the current stage of this Charcot neuroarthropathy and the most appropriate initial management?
. Stage 0; Immobilization in a total contact cast
. Stage I; Immobilization in a total contact cast and non-weight bearing
. Stage II; Transition to a custom orthotic shoe
. Stage III; Operative midfoot arthrodesis
. Stage I; Immediate surgical debridement and application of external fixation

Correct Answer & Explanation

. Stage I; Immobilization in a total contact cast and non-weight bearing

Explanation

The clinical and radiographic presentation is classic for Eichenholtz Stage I (Developmental/Fragmentation stage) Charcot arthropathy, characterized by acute inflammation, periarticular fragmentation, debris, and joint subluxation/dislocation. The mainstay of treatment in the acute fragmentation phase is strict immobilization (usually a total contact cast) and offloading to prevent further structural collapse. Surgery is generally avoided in the acute inflammatory stage unless severe deformity prevents casting or there is an associated deep infection.

Question 298

Topic: Midfoot & Hindfoot

A 58-year-old male with poorly controlled diabetes mellitus presents with a swollen, erythematous, and warm left foot. Radiographs reveal marked osteopenia, periarticular fragmentation, and joint subluxation at the midfoot. According to the Eichenholtz classification for Charcot arthropathy, which stage does this represent and what is the standard of care?

. Stage 0; Intravenous antibiotics and surgical debridement
. 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 4; Below knee amputation

Correct Answer & Explanation

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

Explanation

The patient's clinical and radiographic presentation is consistent with Stage 1 (Developmental/Fragmentation stage) of the Eichenholtz classification for Charcot arthropathy. Radiographically, this is characterized by osteopenia, bony fragmentation, joint subluxation/dislocation, and debris. Stage 2 is Coalescence (absorption of fine debris, early sclerosis). Stage 3 is Consolidation (remodeling, rounding of bone ends, solid fusion). The gold standard treatment for Stage 1 acute Charcot is offloading, most effectively achieved with a total contact cast (TCC).

Question 299

Topic: Midfoot & Hindfoot

A 55-year-old patient with poorly controlled diabetes mellitus presents with a warm, swollen, and erythematous right foot without an open ulcer. Radiographs demonstrate significant midfoot joint effusion, bone fragmentation, subluxation, and periarticular debris. According to the Eichenholtz classification of Charcot arthropathy, what stage does this represent, and what is the primary treatment?

. Stage 0; surgical arthrodesis
. Stage 1; total contact casting
. Stage 2; customized accommodating footwear
. Stage 3; surgical arthrodesis
. Stage 3; total contact casting

Correct Answer & Explanation

. Stage 1; total contact casting

Explanation

Eichenholtz Stage 1 (Fragmentation/Developmental phase) is characterized by acute inflammation, bone fragmentation, joint subluxation, and debris formation. The gold standard of treatment during this acute phase is strict immobilization and offloading, typically achieved via a total contact cast, until the inflammation resolves and the bone begins to consolidate (Stage 2).

Question 300

Topic: Midfoot & Hindfoot

A 55-year-old patient with poorly controlled type 2 diabetes presents with a unilaterally swollen, red, and warm left foot. He denies trauma or skin breaks. Radiographs reveal fragmentation of the tarsometatarsal joints, periarticular debris, and joint subluxation. Inflammatory markers are mildly elevated, but MRI shows no marrow enhancement characteristic of osteomyelitis. According to the Eichenholtz classification, what is the stage and most appropriate initial management?

. Stage 0; Intravenous antibiotics
. Stage 1; Total contact casting and strictly non-weight bearing
. Stage 2; Custom orthoses and progressive weight-bearing
. Stage 3; Arthrodesis of the midfoot
. Stage 1; Immediate surgical debridement and external fixation

Correct Answer & Explanation

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

Explanation

This patient presents with acute Charcot arthropathy of the midfoot. The Eichenholtz classification describes three stages. Stage 1 (Development/Fragmentation) is characterized by a red, hot, swollen foot with radiographs showing bone debris, fragmentation, and subluxation. Stage 2 (Coalescence) involves absorption of debris and early fusion. Stage 3 (Consolidation) shows mature remodeling. The gold standard for initial treatment of Stage 1 Charcot arthropathy is immobilization and offloading, typically using a total contact cast, until the active inflammatory phase subsides.

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