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Midfoot & Hindfoot MCQs

Practice Set 16 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 301

Topic: Midfoot & Hindfoot

A 58-year-old patient with poorly controlled diabetes mellitus presents with a swollen, warm, and erythematous right foot. Radiographs demonstrate periarticular osteopenia, fragmentation of the navicular, and subluxation of the tarsometatarsal joints. According to the Eichenholtz classification of Charcot arthropathy, what stage does this represent and what is the hallmark of the subsequent stage?

. Stage 0; hallmark of next stage is fragmentation
. Stage 1; hallmark of next stage is coalescence and absorption of fine bone debris
. Stage 2; hallmark of next stage is reconstruction and remodeling
. Stage 1; hallmark of next stage is acute inflammation with normal radiographs
. Stage 3; hallmark of next stage is complete spontaneous fusion

Correct Answer & Explanation

. Stage 1; hallmark of next stage is coalescence and absorption of fine bone debris

Explanation

Eichenholtz Stage 1 (Development/Fragmentation stage) is characterized by acute inflammation, osteopenia, bone fragmentation, and joint subluxation/dislocation. The next stage, Stage 2 (Coalescence stage), is characterized by a decrease in inflammation, absorption of fine debris, and early bony consolidation/sclerosis.

Question 302

Topic: Midfoot & Hindfoot

A 30-year-old male sustains a purely ligamentous Lisfranc injury involving the first, second, and third tarsometatarsal joints. Based on prospective randomized trials, what is the major clinical advantage of primary arthrodesis compared to Open Reduction and Internal Fixation (ORIF) for this specific injury pattern?

. Decreased incidence of deep surgical site infection
. Faster return to competitive athletics
. Decreased rate of hardware removal and subsequent surgical procedures
. Superior post-operative range of motion of the midfoot
. Lower risk of adjacent joint arthrosis

Correct Answer & Explanation

. Decreased rate of hardware removal and subsequent surgical procedures

Explanation

Prospective randomized trials (e.g., Ly and Coetzee, JBJS 2006) have shown that for purely ligamentous Lisfranc injuries, primary arthrodesis leads to superior short- to medium-term outcomes and a significantly lower rate of secondary surgeries (such as hardware removal or salvage arthrodesis for post-traumatic arthritis) compared to ORIF.

Question 303

Topic: Midfoot & Hindfoot

A 52-year-old diabetic patient with peripheral neuropathy presents with a warm, swollen, erythematous foot. Radiographs demonstrate periarticular debris, fragmentation of the navicular and cuneiforms, and subluxation of the midfoot. According to the Eichenholtz classification, what stage of Charcot arthropathy is this patient currently in?

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

Correct Answer & Explanation

. Stage 1 (Development/Fragmentation)

Explanation

The Eichenholtz classification of Charcot arthropathy: Stage 0 (Inflammatory) shows clinical warmth/swelling with normal radiographs; Stage 1 (Development) shows bony fragmentation, periarticular debris, and joint subluxation/dislocation; Stage 2 (Coalescence) shows absorption of debris and early fusion/sclerosis; Stage 3 (Reconstruction) shows rounding of bone ends, consolidation, and decreased sclerosis.

Question 304

Topic: Midfoot & Hindfoot
According to the modified Hawkins classification, a Hawkins Type III fracture of the talar neck involves subluxation or dislocation of which of the following joints?
. Subtalar joint only
. Subtalar and tibiotalar joints
. Subtalar, tibiotalar, and talonavicular joints
. Tibiotalar joint only
. Talonavicular and calcaneocuboid joints

Correct Answer & Explanation

. Subtalar, tibiotalar, and talonavicular joints

Explanation

The Hawkins classification for talar neck fractures is: Type I: Nondisplaced. Type II: Displaced with subluxation/dislocation of the subtalar joint. Type III: Displaced with subluxation/dislocation of both the subtalar and tibiotalar joints. Type IV: Displaced with subluxation/dislocation of the subtalar, tibiotalar, and talonavicular joints.

Question 305

Topic: Midfoot & Hindfoot

Adult acquired flatfoot deformity is often initiated by posterior tibial tendon dysfunction, leading to attenuation of the spring ligament complex. Which component of the spring ligament is the thickest, most clinically significant, and provides the primary static support to the talar head?

. Inferomedial calcaneonavicular ligament
. Plantar calcaneocuboid ligament
. Superomedial calcaneonavicular ligament
. Bifurcate ligament
. Long plantar ligament

Correct Answer & Explanation

. Superomedial calcaneonavicular ligament

Explanation

The spring ligament complex consists of three main bands. The superomedial calcaneonavicular ligament is the thickest and most crucial component, providing primary static support to the talar head. Its attenuation allows plantar and medial migration of the talar head in adult acquired flatfoot deformity.

Question 306

Topic: Midfoot & Hindfoot

A 55-year-old poorly controlled diabetic presents with a swollen, erythematous, and warm foot with a rocker-bottom deformity. Radiographs demonstrate significant periarticular debris, fragmentation of the midfoot bones, and joint subluxation without evidence of consolidation. Pulses are palpable and skin is intact. According to the Eichenholtz classification, what is the most appropriate initial management?

. Immediate midfoot arthrodesis with robust internal fixation
. Total contact casting and strict non-weight-bearing
. Charcot Restraint Orthotic Walker (CROW) with weight-bearing as tolerated
. Surgical excision of the bony fragments to prevent ulceration
. Intravenous antibiotics for 6 weeks for presumed osteomyelitis

Correct Answer & Explanation

. Total contact casting and strict non-weight-bearing

Explanation

The patient is in Eichenholtz Stage I (Developmental/Fragmentation phase) of Charcot arthropathy, characterized by warmth, swelling, erythema, and radiographic fragmentation and debris. The standard of care in this acute, active phase is rigid immobilization, typically with a total contact cast (TCC), and non-weight-bearing to prevent further deformity. Surgical reconstruction is generally contraindicated in the acute phase due to high failure rates and soft tissue compromise. CROW boots are used later in the consolidation/coalescence phases.

Question 307

Topic: Midfoot & Hindfoot

A 55-year-old patient with poorly controlled diabetes mellitus presents with a swollen, erythematous, and warm right foot. Radiographs of the foot are completely normal. An MRI is obtained, demonstrating diffuse bone marrow edema across the midfoot without cortical disruption, subchondral cysts, or fragmentation. Which Eichenholtz stage of Charcot arthropathy does this represent?

. Stage 0 (Active inflammatory)
. Stage 1 (Developmental)
. Stage 2 (Coalescent)
. Stage 3 (Reconstructive)
. Stage 4 (Chronic non-active)

Correct Answer & Explanation

. Stage 0 (Active inflammatory)

Explanation

Eichenholtz Stage 0 (often added to the original 3-stage classification by Shibata et al.) represents the earliest, pre-radiographic phase of Charcot arthropathy. It is characterized by clinical inflammation (warmth, swelling, erythema) and normal radiographs. MRI will show early changes such as bone marrow edema and microfractures before gross structural collapse occurs.

Question 308

Topic: Midfoot & Hindfoot

The spring ligament complex is a critical static stabilizer of the medial longitudinal arch. Which of its components is most frequently degenerated or torn in adult acquired flatfoot deformity associated with posterior tibial tendon dysfunction?

. Superomedial calcaneonavicular ligament
. Inferior calcaneonavicular ligament
. Medioplantar oblique ligament
. Plantar fascia
. Cervical ligament

Correct Answer & Explanation

. Superomedial calcaneonavicular ligament

Explanation

The superomedial calcaneonavicular ligament is the most robust portion of the spring ligament complex and serves as a critical sling for the talar head. It is the most commonly torn or attenuated component in adult acquired flatfoot deformity associated with posterior tibial tendon dysfunction (PTTD).

Question 309

Topic: Midfoot & Hindfoot

A 55-year-old poorly controlled diabetic patient presents with a swollen, erythematous, and warm right foot. Radiographs show fragmentation, debris, and subluxation of the midfoot joints. Pulses are bounding. According to the Eichenholtz classification, this is Stage 1 Charcot arthropathy. What is the most appropriate initial management?

. Immediate primary arthrodesis of the midfoot
. Exostectomy of prominent bone
. Total contact casting and non-weight bearing
. Below-knee amputation
. Open reduction and internal fixation of acute fractures

Correct Answer & Explanation

. Total contact casting and non-weight bearing

Explanation

Eichenholtz Stage 1 (development/fragmentation) of Charcot neuroarthropathy presents with active inflammation (red, hot, swollen foot) and radiographic evidence of osteopenia, fragmentation, and joint subluxation. The gold standard of treatment during this acute, active phase is strict offloading and immobilization, typically achieved with a Total Contact Cast (TCC). Surgery in Stage 1 is generally avoided due to profound hyperemia, severe osteopenia, and high failure rates.

Question 310

Topic: Midfoot & Hindfoot

A 55-year-old patient with poorly controlled diabetes presents with a red, hot, swollen right foot. Radiographs reveal periarticular osteopenia, osseous fragmentation, and subluxation at the tarsometatarsal joints. According to the Eichenholtz classification of Charcot arthropathy, what stage is this, and what is the primary pathophysiologic process occurring?

. Stage 0; Inflammation and joint effusion
. Stage 1; Development and fragmentation
. Stage 2; Coalescence and absorption of fine debris
. Stage 3; Consolidation and remodeling
. Stage 4; Late deformity and ulceration

Correct Answer & Explanation

. Stage 1; Development and fragmentation

Explanation

Eichenholtz Stage 1 is the 'development' or 'fragmentation' stage, characterized clinically by a red, hot, swollen foot and radiographically by bony debris at articular margins, fragmentation, joint subluxation/dislocation, and loss of joint space. Stage 2 is coalescence, and Stage 3 is consolidation/remodeling.

Question 311

Topic: Midfoot & Hindfoot
A 55-year-old female presents with severe, progressive flattening of her left foot. Examination demonstrates a rigid hindfoot valgus deformity and a completely absent ability to perform a single-limb heel rise. Radiographs confirm subtalar and talonavicular osteoarthritis. What is the appropriate classification stage of her posterior tibial tendon dysfunction (PTTD) and the most definitive surgical treatment?
. Stage I; Tenosynovectomy and orthotics
. Stage II; Flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy
. Stage III; Triple or double hindfoot arthrodesis
. Stage IV; Tibiotalocalcaneal (TTC) arthrodesis
. Stage II; Subtalar arthrodesis

Correct Answer & Explanation

. Stage III; Triple or double hindfoot arthrodesis

Explanation

Posterior tibial tendon dysfunction (PTTD) is classified into four stages. Stage I: tendon pathology without deformity. Stage II: flexible flatfoot deformity. Stage III: fixed/rigid flatfoot deformity with degenerative joint changes in the hindfoot (subtalar/talonavicular). Stage IV: progression to involve the ankle joint (valgus talar tilt). Because this patient has a rigid hindfoot valgus with osteoarthritis, she is Stage III. The standard surgical treatment for Stage III is a corrective hindfoot arthrodesis (such as a triple or double arthrodesis).

Question 312

Topic: Midfoot & Hindfoot
A 50-year-old diabetic male presents with an erythematous, swollen, and warm foot with no open wounds. Radiographs show fragmentation of the navicular, periarticular osseous debris, and subluxation of the midfoot joints. According to the Eichenholtz classification of Charcot arthropathy, what is the current stage and best initial management?
. Stage 0; MRI evaluation and custom orthotics
. Stage I; Total contact casting and strict non-weight bearing
. Stage II; Rigid shoe wear and partial weight bearing
. Stage III; Midfoot arthrodesis
. Stage IV; Below-knee amputation

Correct Answer & Explanation

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

Explanation

Eichenholtz Stage I is the developmental (or fragmentation) stage, characterized clinically by a red, hot, swollen foot and radiographically by bone debris, fragmentation, and joint subluxation. The gold standard treatment during this active phase is offloading with a total contact cast (TCC) to prevent further deformity until the acute inflammatory process subsides (Stage II - coalescence).

Question 313

Topic: Midfoot & Hindfoot

A 55-year-old diabetic patient presents with a swollen, erythematous, and warm left foot. Radiographs reveal diffuse osteopenia, periarticular fragmentation, and early joint subluxation at the tarsometatarsal joints. According to the Eichenholtz classification, what stage of Charcot arthropathy does this represent, and what is the primary pathophysiological driver?

. Stage 0; autonomic neuropathy leading to vasospasm
. Stage 1; autonomic neuropathy leading to hyperemia and active bone resorption
. Stage 2; somatic neuropathy leading to repetitive microtrauma and coalescence
. Stage 3; motor neuropathy leading to muscle imbalance and remodeling
. Stage 4; advanced sensory neuropathy leading to ulceration

Correct Answer & Explanation

. Stage 1; autonomic neuropathy leading to hyperemia and active bone resorption

Explanation

The patient is in Eichenholtz Stage 1 (Development/Fragmentation stage), characterized clinically by a red, hot, swollen foot and radiographically by osteopenia, fragmentation, and joint subluxation/dislocation. The underlying pathophysiology involves autonomic neuropathy causing loss of sympathetic tone, arteriovenous shunting, hyperemia, and consequently increased osteoclastic bone resorption.

Question 314

Topic: Midfoot & Hindfoot

A 30-year-old construction worker sustains a purely ligamentous Lisfranc injury involving the first, second, and third tarsometatarsal joints. Based on prospective randomized trials comparing primary arthrodesis versus open reduction and internal fixation (ORIF) for purely ligamentous Lisfranc injuries, which of the following statements is most accurate regarding primary arthrodesis?

. It is associated with a significantly higher rate of hardware failure
. It results in decreased functional outcomes at 2-year follow-up
. It eliminates the need for hardware removal and reduces the rate of secondary procedures
. It relies solely on temporary K-wire fixation for 6 weeks
. It carries a higher risk of developing symptomatic adjacent joint arthritis

Correct Answer & Explanation

. It results in decreased functional outcomes at 2-year follow-up

Explanation

Level I randomized controlled trials (e.g., Ly and Coetzee, 2006) comparing ORIF to primary arthrodesis for purely ligamentous Lisfranc injuries have shown that primary arthrodesis yields better functional outcomes and a lower rate of secondary surgeries. ORIF of purely ligamentous injuries often results in progressive arch collapse or arthritis, and typically requires a planned secondary surgery for hardware removal, whereas primary arthrodesis provides a definitive, stable construct.

Question 315

Topic: Midfoot & Hindfoot

A 30-year-old male sustains a midfoot injury after falling from a height. Radiographs show a widening between the bases of the 1st and 2nd metatarsals. What is the primary stabilizing structure of the affected joint complex?

. Dorsal Lisfranc ligament
. Interosseous Lisfranc ligament
. Plantar Lisfranc ligament
. Spring ligament
. Long plantar ligament

Correct Answer & Explanation

. Interosseous Lisfranc ligament

Explanation

The patient has a Lisfranc injury. The Lisfranc ligament complex consists of dorsal, interosseous, and plantar ligaments. The interosseous Lisfranc ligament is the strongest and primary stabilizer of the Lisfranc complex, connecting the lateral aspect of the medial cuneiform to the medial aspect of the base of the second metatarsal. The plantar ligament is the second strongest, and the dorsal ligament is the weakest, which is why most dislocations occur dorsally.

Question 316

Topic: Midfoot & Hindfoot

A 55-year-old patient with poorly controlled diabetes presents with a warm, swollen, erythematous left foot. Radiographs show midfoot joint subluxation, osteopenia, and periarticular bony fragmentation/debris. 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 (Reconstruction/Consolidation)
. Stage 4 (Resolution)

Correct Answer & Explanation

. Stage 1 (Developmental/Fragmentation)

Explanation

Eichenholtz Stage 1 (Fragmentation) is the acute developmental phase characterized by clinical inflammation (erythema, warmth, swelling) and radiographic findings of osteopenia, joint subluxation/dislocation, bony fragmentation, and debris. Stage 2 (Coalescence) shows absorption of fine debris and early fusion/sclerosis. Stage 3 (Consolidation) shows remodeling and stable deformity. Stage 0 is the inflammatory prodrome with normal radiographs.

Question 317

Topic: Midfoot & Hindfoot
A 55-year-old diabetic patient presents with a swollen, erythematous, right foot. Radiographs reveal extensive periarticular fragmentation, bony debris, and subluxation at the tarsometatarsal joints. According to the Eichenholtz classification of Charcot arthropathy, this represents:
. 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 (Developmental/Fragmentation) is characterized clinically by a red, hot, swollen foot, and radiographically by bony fragmentation, debris formation, subluxation, and dislocation. Stage II (Coalescence) involves absorption of fine debris and early fusion. Stage III (Reconstruction) shows rounding of bone ends and decreased sclerosis.

Question 318

Topic: Midfoot & Hindfoot
According to the Hawkins classification of talar neck fractures, a fracture that is accompanied by subluxation or dislocation of the subtalar joint while the tibiotalar and talonavicular joints remain perfectly aligned is classified as:
. Hawkins Type I
. Hawkins Type II
. Hawkins Type III
. Hawkins Type IV
. Sneppen Type II

Correct Answer & Explanation

. Hawkins Type III

Explanation

The Hawkins classification determines the severity and risk of avascular necrosis (AVN) in talar neck fractures. Type I is a nondisplaced fracture (0-10% AVN risk). Type II involves subtalar subluxation/dislocation with an intact tibiotalar joint (20-50% AVN risk). Type III involves dislocation of both the subtalar and tibiotalar joints (50-100% AVN risk). Type IV (added by Canale) includes disruption of the subtalar, tibiotalar, and talonavicular joints.

Question 319

Topic: Midfoot & Hindfoot

A 55-year-old male with poorly controlled diabetes presents with a red, hot, swollen midfoot. There is no open ulcer. Radiographs show extensive bone fragmentation, periarticular debris, and subluxation at the tarsometatarsal joints. According to the Eichenholtz classification, what stage is this, and what is the standard treatment?

. Stage 0; Intravenous antibiotics
. Stage 1; Total contact casting and non-weight bearing
. Stage 2; Immediate midfoot arthrodesis
. Stage 3; Custom accommodative footwear
. Stage 4; Below-knee amputation

Correct Answer & Explanation

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

Explanation

Eichenholtz Stage 1 is the 'Developmental/Fragmentation' phase of Charcot arthropathy, characterized by redness, swelling, joint subluxation, debris, and fragmentation on X-ray. The primary treatment during this active, acute phase is immobilization and offloading, typically utilizing a total contact cast (TCC) to prevent further deformity until the limb transitions to the coalescence phase (Stage 2).

Question 320

Topic: Midfoot & Hindfoot
A 55-year-old female presents with an acquired flatfoot deformity. Examination shows a flexible hindfoot but an inability to perform a single-leg heel rise. Standing AP radiographs of the foot reveal that more than 40% of the talar head is uncovered by the navicular, indicating significant forefoot abduction. What is her posterior tibial tendon dysfunction (PTTD) stage and most appropriate surgical management?
. Stage IIA: FDL transfer and Medial Displacement Calcaneal Osteotomy (MDCO)
. Stage IIB: FDL transfer, MDCO, and Lateral Column Lengthening (Evans osteotomy)
. Stage III: Subtalar arthrodesis
. Stage III: Triple arthrodesis
. Stage IV: Tibiotalocalcaneal (TTC) arthrodesis

Correct Answer & Explanation

. Stage IIB: FDL transfer, MDCO, and Lateral Column Lengthening (Evans osteotomy)

Explanation

The patient has a flexible hindfoot, placing her in Stage II PTTD. Stage II is subdivided into IIA and IIB. Stage IIB is characterized by significant forefoot abduction (>40% talonavicular uncoverage on AP radiograph). A medial displacement calcaneal osteotomy (MDCO) alone does not sufficiently correct severe forefoot abduction. Therefore, Stage IIB requires a lateral column lengthening (e.g., Evans osteotomy) in addition to an FDL transfer and MDCO.

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