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Midfoot & Hindfoot MCQs

Practice Set 17 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 321

Topic: Midfoot & Hindfoot

A 55-year-old male with poorly controlled diabetes mellitus presents with a massively swollen, erythematous, and warm foot. Radiographs demonstrate marked osteopenia, periarticular fragmentation of the tarsometatarsal joints, and early joint subluxation. According to the Eichenholtz classification, what stage does this represent and what is the primary management?

. Stage 0; immediate open reduction and internal fixation
. Stage 1; total contact casting and non-weight bearing
. Stage 2; custom-molded Charcot Restraint Orthotic Walker (CROW) boot
. Stage 3; corrective midfoot osteotomy
. Stage 4; below knee amputation

Correct Answer & Explanation

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

Explanation

The clinical and radiographic presentation is classic for Eichenholtz Stage 1 (Developmental/Fragmentation stage) Charcot arthropathy, characterized by acute inflammation, osteopenia, fragmentation, and joint subluxation/dislocation. The gold standard treatment in this acute stage is offloading and immobilization using a total contact cast (TCC) to prevent further deformity until the active inflammatory process resolves.

Question 322

Topic: Midfoot & Hindfoot
A 60-year-old patient with long-standing poorly controlled diabetes presents with a unilaterally red, hot, and swollen foot. There is no history of trauma or skin ulceration. Radiographs reveal extensive periarticular debris, bony fragmentation, and joint subluxation at the midfoot. According to the Eichenholtz classification, what stage of Charcot arthropathy does this represent?
. Stage 0 (Pre-radiographic)
. Stage I (Developmental)
. Stage II (Coalescence)
. Stage III (Reconstruction/Consolidation)
. Stage IV (Ulceration)

Correct Answer & Explanation

. Stage I (Developmental)

Explanation

The Eichenholtz classification defines the stages of Charcot arthropathy based on clinical and radiographic findings. Stage I (Developmental/Fragmentation) is characterized by a red, hot, swollen foot with radiographs showing bone fragmentation, joint subluxation/dislocation, and debris. Stage II (Coalescence) shows absorption of debris and early fusion. Stage III (Consolidation) shows remodeling and stable ankylosis.

Question 323

Topic: Midfoot & Hindfoot

A 50-year-old overweight woman complains of medial foot pain and an inability to perform a single-leg heel rise. Examination shows a flexible flatfoot with forefoot abduction. Radiographs reveal unroofing of the talonavicular joint without arthritic changes. Which of the following surgical procedures is most commonly indicated for this Stage IIB adult-acquired flatfoot deformity?

. Talonavicular arthrodesis
. Subtalar arthrodesis
. Triple arthrodesis
. Flexor digitorum longus (FDL) transfer with lateral column lengthening and medial displacement calcaneal osteotomy
. Gastrocnemius recession alone

Correct Answer & Explanation

. Flexor digitorum longus (FDL) transfer with lateral column lengthening and medial displacement calcaneal osteotomy

Explanation

Stage IIB adult-acquired flatfoot deformity (posterior tibial tendon dysfunction) is a flexible deformity with forefoot abduction (>40% unroofing of the talonavicular joint). Optimal treatment involves FDL transfer (replacing PTT function) combined with bony corrections: a medializing calcaneal osteotomy (corrects hindfoot valgus) and a lateral column lengthening (corrects forefoot abduction).

Question 324

Topic: Midfoot & Hindfoot

A 55-year-old male with long-standing poorly controlled diabetes presents with a swollen, erythematous, and warm left foot. He denies trauma. Radiographs of the foot show osteopenia and soft tissue swelling but no evidence of fracture, subluxation, or debris. MRI demonstrates bone marrow edema in the midfoot. What is the Eichenholtz stage of this patient's Charcot arthropathy?

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

Correct Answer & Explanation

. Stage 0

Explanation

Eichenholtz Stage 0 (prodromal or inflammatory stage) presents with erythema, warmth, and swelling. Plain radiographs are normal or show only osteopenia, while MRI shows bone marrow edema. Stage 1 (developmental) shows fragmentation and subluxation. Stage 2 (coalescence) shows early healing and absorption of fine debris. Stage 3 (consolidation) shows remodeling and stable deformity.

Question 325

Topic: Midfoot & Hindfoot

A 52-year-old diabetic patient presents with a swollen, erythematous, and warm foot. Radiographs demonstrate fragmentation of the tarsometatarsal joints, periarticular debris, and joint subluxation. There are no skin ulcerations. What is the most appropriate initial management?

. Arthrodesis of the midfoot
. Total contact casting and non-weight-bearing
. Intravenous antibiotics
. Exostectomy of prominent bone
. Open reduction and internal fixation

Correct Answer & Explanation

. Total contact casting and non-weight-bearing

Explanation

The patient is in Eichenholtz Stage I (Developmental/Fragmentation) of Charcot arthropathy. The mainstay of initial treatment for acute, active Charcot arthropathy is strict immobilization and offloading, most effectively achieved with a total contact cast (TCC), until the extremity progresses to the coalescence phase.

Question 326

Topic: Midfoot & Hindfoot
A 28-year-old man sustains a talar neck fracture following a fall from a height. Radiographs reveal a displaced fracture of the talar neck with subluxation of the subtalar joint, but the tibiotalar and talonavicular joints remain perfectly congruent. According to the Hawkins classification, what is the approximate historical risk of developing avascular necrosis (AVN) of the talar body?
. 0-10%
. 20-50%
. 75-90%
. 100%
. AVN does not occur in this specific pattern

Correct Answer & Explanation

. 20-50%

Explanation

The patient has a Hawkins Type II talar neck fracture (subtalar subluxation/dislocation with intact ankle and talonavicular joints). The historical risk of AVN for a Hawkins II fracture is approximately 20-50% (commonly cited as 42%). Hawkins I (nondisplaced) is 0-10%; Hawkins III (subtalar + tibiotalar dislocation) is 50-100% (often ~90%); Hawkins IV (all 3 joints dislocated) is near 100%.

Question 327

Topic: Midfoot & Hindfoot
A 60-year-old man presents with a painful, severe, and rigid flatfoot deformity. Examination reveals an inability to perform a single-leg heel raise, and the heel remains in fixed valgus on double-leg heel raise. Weight-bearing radiographs demonstrate profound osteoarthritis of the subtalar, talonavicular, and calcaneocuboid joints. What is the most appropriate definitive surgical intervention?
. Medial displacement calcaneal osteotomy and flexor digitorum longus transfer
. Lateral column lengthening (Evans osteotomy)
. Isolated subtalar arthrodesis
. Triple arthrodesis
. Talonavicular arthrodesis with spring ligament repair

Correct Answer & Explanation

. Triple arthrodesis

Explanation

This patient has a Stage III posterior tibial tendon dysfunction (PTTD), which is characterized by a fixed, rigid flatfoot deformity and degenerative joint disease (osteoarthritis) of the hindfoot complex. The gold standard surgical treatment for Stage III PTTD with advanced degenerative changes in the subtalar, talonavicular, and calcaneocuboid joints is a triple arthrodesis.

Question 328

Topic: Midfoot & Hindfoot

A 55-year-old female presents with a progressive painful flatfoot deformity. Examination shows she is unable to perform a single-leg heel rise. Radiographs demonstrate collapse of the medial longitudinal arch, talonavicular unroofing of 40%, and significant forefoot abduction. What is the most appropriate surgical intervention?

. Gastrocnemius recession and medial displacement calcaneal osteotomy
. Flexor digitorum longus (FDL) transfer to the navicular alone
. FDL transfer, medial displacement calcaneal osteotomy, and lateral column lengthening
. Subtalar arthrodesis alone
. Triple arthrodesis

Correct Answer & Explanation

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

Explanation

The patient has Stage IIb adult-acquired flatfoot deformity (posterior tibial tendon dysfunction), characterized by flexible flatfoot with significant forefoot abduction (>30% talonavicular unroofing). Stage IIb requires addressing the medial column (FDL transfer) as well as correcting both the hindfoot valgus (medial displacement calcaneal osteotomy) and forefoot abduction (lateral column lengthening).

Question 329

Topic: Midfoot & Hindfoot

A 55-year-old woman presents with progressive, painful flatfoot deformity. She has inability to perform a single-limb heel rise, and the deformity is passively correctable. MRI shows a complete rupture of the posterior tibial tendon. Which of the following surgical interventions is most appropriate?

. Flexor digitorum longus (FDL) transfer to the navicular and medial displacement calcaneal osteotomy
. Triple arthrodesis
. Talonavicular arthrodesis
. Anterior tibial tendon transfer
. Gastrocnemius recession alone

Correct Answer & Explanation

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

Explanation

This patient has a Stage II adult acquired flatfoot deformity (passively correctable, unable to perform single heel rise). Standard treatment involves reconstruction, typically with an FDL tendon transfer to substitute for the PTT, combined with a medializing calcaneal osteotomy to correct the valgus hindfoot and protect the transfer.

Question 330

Topic: Midfoot & Hindfoot
A 60-year-old obese female presents with a painful, progressive flatfoot deformity. Examination reveals she is unable to perform a single-leg heel rise on the affected side. The deformity is flexible and passively correctable to neutral. What is the most appropriate surgical intervention for this stage of posterior tibial tendon dysfunction (PTTD)?
. Isolated primary repair of the posterior tibial tendon
. Flexor digitorum longus (FDL) transfer to the navicular and a medial displacement calcaneal osteotomy
. Subtalar arthrodesis with Achilles tendon lengthening
. Triple arthrodesis (subtalar, talonavicular, and calcaneocuboid)
. Talonavicular arthrodesis alone

Correct Answer & Explanation

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

Explanation

This patient has Stage II PTTD (flexible flatfoot, inability to perform a single-leg heel rise). Stage I is tenosynovitis without deformity; Stage III is a rigid/fixed deformity; Stage IV involves ankle joint arthritis/tilt. The gold standard surgical treatment for Stage II PTTD is an extra-articular bony correction (Medial Displacement Calcaneal Osteotomy) combined with a soft tissue reconstruction (FDL tendon transfer to substitute for the incompetent PTT). Triple arthrodesis is reserved for Stage III (rigid) deformity.

Question 331

Topic: Midfoot & Hindfoot
A 28-year-old male sustains a high-energy motor vehicle collision resulting in a Hawkins type III fracture of the talar neck. Which of the following accurately describes the fracture pattern and the associated risk of avascular necrosis (AVN)?
. Nondisplaced fracture; 0-10% risk of AVN
. Displaced fracture with subtalar subluxation; 20-50% risk of AVN
. Displaced fracture with subtalar and tibiotalar dislocation; nearly 100% risk of AVN
. Displaced fracture with subtalar, tibiotalar, and talonavicular dislocation; 100% risk of AVN
. Talar body fracture with extrusion; 50% risk of AVN

Correct Answer & Explanation

. Displaced fracture with subtalar and tibiotalar dislocation; nearly 100% risk of AVN

Explanation

The Hawkins classification is used for talar neck fractures. Type I is a nondisplaced fracture (AVN risk ~0-10%). Type II is displaced with subtalar subluxation or dislocation (AVN risk ~20-50%). Type III is displaced with both subtalar and tibiotalar dislocations, and the AVN risk approaches 100%. Type IV involves displacement of the subtalar, tibiotalar, and talonavicular joints. Therefore, Type III corresponds to subtalar and tibiotalar dislocation with a near 100% risk of AVN.

Question 332

Topic: Midfoot & Hindfoot

A 55-year-old patient with poorly controlled type 2 diabetes and peripheral neuropathy presents with a warm, swollen, and erythematous right foot. Radiographs demonstrate periarticular bony fragmentation, debris, and midfoot subluxation. According to the Eichenholtz classification of Charcot arthropathy, which stage does this represent?

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

Correct Answer & Explanation

. Stage 1 (Developmental/Fragmentation)

Explanation

The patient is in Eichenholtz Stage 1 (Developmental/Fragmentation phase). This stage is characterized clinically by a red, hot, swollen foot and radiographically by osteopenia, periarticular fragmentation, subluxation/dislocation, and bony debris. Stage 0 is the inflammatory phase with a normal radiograph (except possible osteopenia) but positive MRI findings. Stage 2 (Coalescence) involves the absorption of fine debris and early fusion. Stage 3 (Consolidation) shows remodeling and rounding of bone ends.

Question 333

Topic: Midfoot & Hindfoot

A 22-year-old collegiate athlete sustains a hyperplantarflexion injury to his midfoot. Weight-bearing radiographs demonstrate widening of the first and second intermetatarsal space with no evidence of fracture on CT.

Based on prospective randomized data, what is the recommended surgical management for this purely ligamentous injury?

. Closed reduction and percutaneous K-wire fixation
. Open reduction and internal fixation with temporary transarticular screws
. Primary arthrodesis of the involved medial column joints
. Application of a non-weight bearing cast for 8 weeks without surgery
. Suture-button suspensionplasty of the Lisfranc complex

Correct Answer & Explanation

. Primary arthrodesis of the involved medial column joints

Explanation

For purely ligamentous Lisfranc injuries, prospective randomized studies (most notably Ly and Coetzee, JBJS 2006) have demonstrated that primary arthrodesis yields better functional outcomes, a higher rate of return to pre-injury activity levels, and fewer reoperations compared to open reduction and internal fixation (ORIF). ORIF remains the standard of care for primarily bony Lisfranc fracture-dislocations.

Question 334

Topic: Midfoot & Hindfoot
A 28-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 displacement associated with this injury?
. Nondisplaced talar neck fracture
. Displaced talar neck fracture with subluxation of the subtalar joint only
. Fracture of the talar head with talonavicular dislocation
. Displaced talar neck fracture with dislocation of both the subtalar and tibiotalar joints
. Displaced talar neck fracture with dislocation of the subtalar, tibiotalar, and talonavicular joints

Correct Answer & Explanation

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

Explanation

According to the Hawkins classification for talar neck fractures: Type I is nondisplaced; Type II involves subluxation or dislocation of the subtalar joint; Type III involves dislocation of both the subtalar and tibiotalar (ankle) joints; and Type IV (Canale and Kelly modification) adds talonavicular joint dislocation. Type III fractures are associated with a very high rate of avascular necrosis of the talar body.

Question 335

Topic: Midfoot & Hindfoot

A 25-year-old male sustains a purely ligamentous Lisfranc injury after a twisting mechanism while playing football. Which of the following fixation constructs has been shown to provide the best long-term clinical outcomes for this specific injury pattern?

. Primary arthrodesis of the medial tarsometatarsal joints
. Open reduction and internal fixation with transarticular screws
. Open reduction and internal fixation with dorsal spanning plates
. Closed reduction and percutaneous pinning
. Cast immobilization and non-weight bearing for 8 weeks

Correct Answer & Explanation

. Primary arthrodesis of the medial tarsometatarsal joints

Explanation

Purely ligamentous Lisfranc injuries have historically demonstrated poor outcomes with ORIF due to the lack of bone-to-bone healing and reliance on ligamentous scar tissue. Prospective randomized controlled trials (such as Ly and Coetzee, JBJS 2006) have shown that primary arthrodesis of the medial two or three rays results in better functional outcomes and a lower rate of planned secondary surgeries compared to ORIF.

Question 336

Topic: Midfoot & Hindfoot
A 28-year-old roofer falls 15 feet, landing on his feet, and sustains a Hawkins Type III fracture of the talar neck. According to the Hawkins classification, what anatomic disruptions define a Type III fracture, and what is the approximate risk of avascular necrosis (AVN) of the talar body?
. Nondisplaced fracture; 0-10% AVN risk
. Displaced fracture with subtalar joint subluxation; 20-50% AVN risk
. Displaced fracture with dislocation of both the subtalar and tibiotalar joints; near 100% AVN risk
. Displaced fracture with dislocation of the subtalar, tibiotalar, and talonavicular joints; 100% AVN risk
. Comminuted fracture of the talar body; 50% AVN risk

Correct Answer & Explanation

. Displaced fracture with dislocation of both the subtalar and tibiotalar joints; near 100% AVN risk

Explanation

The Hawkins classification describes talar neck fractures. Type I is nondisplaced (0-10% AVN risk). Type II involves subluxation or dislocation of the subtalar joint (20-50% AVN risk). Type III involves dislocation of both the subtalar and tibiotalar (ankle) joints, with the talar body typically extruded posteromedially (near 100% AVN risk). Type IV adds talonavicular dislocation.

Question 337

Topic: Midfoot & Hindfoot
A 28-year-old man sustains a talar neck fracture following a high-energy motor vehicle collision. Radiographs demonstrate displacement of the talar neck with subluxation of the subtalar joint, but the tibiotalar and talonavicular joints remain congruent. According to the Hawkins classification, what is the approximate risk of developing avascular necrosis (AVN) of the talar body?
. 0-10%
. 20-50%
. 70-90%
. 90-100%
. 100%

Correct Answer & Explanation

. 20-50%

Explanation

The clinical scenario describes a Hawkins Type II talar neck fracture, which is characterized by a displaced talar neck fracture with subluxation or dislocation of the subtalar joint, while the tibiotalar and talonavicular joints remain normal. The blood supply to the talar body is tenuous, relying heavily on the artery of the tarsal canal. The risk of avascular necrosis (AVN) of the talar body correlates with the Hawkins classification: Type I (nondisplaced) is 0-10%; Type II is approximately 20-50%; Type III (subtalar and tibiotalar dislocation) is 70-90%; and Type IV (Type III plus talonavicular dislocation) approaches 100%.

Question 338

Topic: Midfoot & Hindfoot

A 52-year-old woman presents with severe pes planovarus deformity. She has inability to perform a single-leg heel raise, marked forefoot abduction, and talonavicular uncoverage of 45% on standing AP foot radiographs. The deformity is fully flexible on examination. Which of the following is the most appropriate surgical management?

. Flexor digitorum longus (FDL) transfer to the navicular and medial displacement calcaneal osteotomy (MDCO) only
. FDL transfer, MDCO, and lateral column lengthening
. Spring ligament repair and isolated subtalar arthrodesis
. Triple arthrodesis
. Gastrocnemius recession and isolated talonavicular arthrodesis

Correct Answer & Explanation

. FDL transfer, MDCO, and lateral column lengthening

Explanation

This patient has stage IIb adult-acquired flatfoot deformity (flexible, with significant forefoot abduction/>30% talonavicular uncoverage). Optimal treatment includes an FDL transfer, medial displacement calcaneal osteotomy, and a lateral column lengthening to correct the forefoot abduction.

Question 339

Topic: Midfoot & Hindfoot

A 58-year-old man with uncontrolled type 2 diabetes presents with a red, hot, swollen right foot. He recalls no trauma. Radiographs show periarticular fragmentation, subluxation of the tarsometatarsal joints, and bounding pedal pulses. What is the most appropriate initial treatment?

. Urgent irrigation and debridement of the midfoot
. Total contact casting and strict non-weight-bearing
. Intravenous antibiotics and observation
. Primary midfoot arthrodesis
. Below-knee amputation

Correct Answer & Explanation

. Total contact casting and strict non-weight-bearing

Explanation

This is a classic presentation of acute (Eichenholtz stage I) Charcot arthropathy. The mainstay of initial treatment to prevent progressive deformity and collapse is offloading with a total contact cast and strict non-weight-bearing.

Question 340

Topic: Midfoot & Hindfoot

A 55-year-old overweight woman complains of medial ankle pain and a collapsing arch. She is unable to perform a single-leg heel raise. Examination shows a flexible flatfoot deformity. Which surgical treatment is most appropriate after failure of conservative care?

. Triple arthrodesis
. Talonavicular arthrodesis
. Medial displacement calcaneal osteotomy with FDL transfer
. Subtalar arthrodesis
. Isolated FDL transfer to the navicular

Correct Answer & Explanation

. Medial displacement calcaneal osteotomy with FDL transfer

Explanation

Stage II adult acquired flatfoot deformity is characterized by a flexible deformity and posterior tibial tendon dysfunction. Joint-sparing procedures like medial displacement calcaneal osteotomy and FDL transfer are indicated.

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