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Midfoot & Hindfoot MCQs

Practice Set 2 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 21

Topic: Midfoot & Hindfoot

A 55-year-old diabetic patient presents with a warm, swollen, erythematous left foot. Radiographs show no fractures or joint subluxation. MRI demonstrates diffuse marrow edema. If this represents the earliest stage of Charcot arthropathy, it is classified in the Eichenholtz system as:

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

Correct Answer & Explanation

. Stage 0

Explanation

Eichenholtz Stage 0 represents the pre-radiographic stage of Charcot arthropathy, characterized by clinical signs of inflammation and MRI changes, but normal plain radiographs. Stage 1 is fragmentation, Stage 2 is coalescence, and Stage 3 is consolidation.

Question 22

Topic: Midfoot & Hindfoot

A 55-year-old patient with long-standing, poorly controlled diabetes mellitus presents with a severely swollen, erythematous, and warm but painless left foot. Skin integrity is completely intact. Radiographs show early fragmentation and debris at the midtarsal joints. What is the most appropriate initial management?

. Intravenous antibiotics
. Urgent surgical debridement
. Total contact casting
. Arthrodesis of the midfoot
. Below-knee amputation

Correct Answer & Explanation

. Total contact casting

Explanation

This patient presents with an acute (Eichenholtz Stage 0 or 1) Charcot arthropathy. The gold standard for initial management is strict offloading utilizing a total contact cast to prevent further deformity and allow the acute inflammatory phase to subside.

Question 23

Topic: Midfoot & Hindfoot

A 55-year-old poorly controlled diabetic man presents with a swollen, erythematous, but painless foot. Radiographs show dissolution of the tarsometatarsal joints with early fragmentation and debris. What is the most critical initial management?

. Intravenous antibiotics
. Total contact casting
. Arthrodesis of the midfoot
. Transtibial amputation
. Incision, drainage, and washout

Correct Answer & Explanation

. Total contact casting

Explanation

The patient has acute Charcot arthropathy (Eichenholtz stage I). The most critical initial non-operative management is strict immobilization and offloading, typically achieved with a total contact cast, to halt progressive bone destruction and deformity.

Question 24

Topic: Midfoot & Hindfoot

In the Eichenholtz classification of Charcot neuroarthropathy, which of the following radiographic findings is most characteristic of Stage 2 (Coalescence)?

. Joint subluxation, debris formation, and fragmentation
. Normal radiographs with mild soft tissue swelling
. Absorption of fine bone debris, fusion of fragments, and early sclerosis
. Massive osteolysis with 'pencil-in-cup' deformity
. Complete bone remodeling and rounded bone ends

Correct Answer & Explanation

. Absorption of fine bone debris, fusion of fragments, and early sclerosis

Explanation

Eichenholtz Stage 2 (Coalescence) is marked by the absorption of fine intra-articular debris, early fusion of larger bone fragments, and subchondral sclerosis. Stage 1 is fragmentation, and Stage 3 is remodeling.

Question 25

Topic: Midfoot & Hindfoot

Isolated subtalar arthrodesis:

. Increases transverse tarsal joint over time
. Decreases talonavicular motion less than calcaneocuboid motion
. Decreased talonavicular joint motion but increases calcaneocuboid joint motion
. Decreases talonavicular motion more than calcaneocuboid motion
. Increases subtalar motion

Correct Answer & Explanation

. Decreases talonavicular motion more than calcaneocuboid motion

Explanation

Subtalar fusion decreased talonavicular motion more so than calcaneocuboid motion in this cadaver study. Isolated talonavicular fusion is the most influential of the hindfoot joints, locking hindfoot motion.

Question 26

Topic: Midfoot & Hindfoot

Which injury is likely to have a worse clinical outcome:

. A purely ligamentous Lisfranc injury
. A Lisfranc fracture-dislocation Purely ligamentous Lisfranc injuries have a worse clinical outcome than injuries associated with bony fractures.

Correct Answer & Explanation

. A purely ligamentous Lisfranc injury

Explanation

Question 27

Topic: Midfoot & Hindfoot

Isolated talonavicular fusion:

. Decreases subtalar motion by 25%
. Decreases subtalar motion by 50%
. Locks subtalar motion
. Has no effect on subtalar motion
. Decreases subtalar motion by 10%

Correct Answer & Explanation

. Locks subtalar motion

Explanation

This cadaver study examined the motion that remained in the hindfoot joints following sequential immobilization of the talonavicular, subtalar, and calcaneo-cuboid joints. Fixing the talo-navicular joint virtually locked all subtalar motion.

Question 28

Topic: Midfoot & Hindfoot

Following anatomic open reduction and internal fixation of a Lisfranc fracture-dislocation:

. Development of tarsometatarsal arthritis will not occur.
. Tarsometatarsal arthritis may still arise in approximately 25% of patients.
. If tarsometatarsal arthritis develops, then subsequent arthrodesis is required.
. The screws should be routinely removed at 12 weeks.
. The screws should be routinely removed at 6 weeks.

Correct Answer & Explanation

. Tarsometatarsal arthritis may still arise in approximately 25% of patients.

Explanation

In a series of patients who underwent open reduction internal fixation of Lisfranc fracture dislocations, 25% of patients developed midfoot arthritis at final follow-up, but only half of these patients required eventual midfoot arthrodesis.

Question 29

Topic: Midfoot & Hindfoot

A 55-year-old female presents with a painful, flexible flatfoot deformity. She is unable to perform a single-leg heel rise. MRI confirms a complete rupture of the posterior tibial tendon. What is the most appropriate surgical intervention?

. Isolated posterior tibial tendon repair
. Flexor digitorum longus (FDL) transfer with a medial displacement calcaneal osteotomy
. Subtalar arthrodesis only
. Triple arthrodesis
. Gastrocnemius recession and orthotics

Correct Answer & Explanation

. Flexor digitorum longus (FDL) transfer with a medial displacement calcaneal osteotomy

Explanation

For a Stage II (flexible) adult-acquired flatfoot deformity due to posterior tibial tendon insufficiency, joint-sparing surgery is indicated. FDL transfer combined with a medial displacement calcaneal osteotomy addresses both the tendon pathology and the mechanical malalignment.

Question 30

Topic: Midfoot & Hindfoot
A 55-year-old female presents with progressive flattening of her left foot and medial arch pain. On examination, she has a flexible flatfoot deformity and cannot perform a single-limb heel rise. Radiographs show no degenerative changes in the subtalar or talonavicular joints. What is the correct stage of her posterior tibial tendon dysfunction (PTTD) and the most appropriate surgical management if conservative treatment fails?
. Stage I; tenosynovectomy
. Stage II; flexor digitorum longus transfer and medial displacement calcaneal osteotomy
. Stage III; triple arthrodesis
. Stage IV; tibiotalocalcaneal arthrodesis
. Stage II; isolated subtalar arthrodesis

Correct Answer & Explanation

. Stage II; flexor digitorum longus transfer and medial displacement calcaneal osteotomy

Explanation

Stage II PTTD is characterized by a flexible planovalgus deformity, inability to perform a single heel rise, and absent degenerative joint changes. Surgical management typically involves joint-sparing procedures such as an FDL tendon transfer coupled with a medial displacement calcaneal osteotomy.

Question 31

Topic: Midfoot & Hindfoot

Which injury is likely to have a worse clinical outcome:

. A purely ligamentous Lisfranc injury
. A Lisfranc fracture-dislocation Purely ligamentous Lisfranc injuries have a worse clinical outcome than injuries associated with bony fractures.C orrect Answer: A purely ligamentous Lisfranc injury

Correct Answer & Explanation

. A purely ligamentous Lisfranc injury

Explanation

Question 32

Topic: Midfoot & Hindfoot

The joint contact area of the second tarsometatarsal joint after Lisfranc dislocation diminishes the greatest with:

. Dorsolateral subluxation
. Dorsal subluxation
. Lateral subluxation
. Medial subluxation
. Plantar subluxation

Correct Answer & Explanation

. Dorsolateral subluxation

Explanation

Minor degrees of displacement not apparent on plain radiographs lead to significant decrease in the contact area of the second tarsometatarsal joint. Dorsolateral subluxation of the second tarsometatarsal joint suffers a loss of contact area more severely than pure dorsal or lateral subluxation. Just 3 mm of dorsolateral subluxation causes a 38% loss of contact area.

Question 33

Topic: Midfoot & Hindfoot

Which of the following tendons is the main inverter of the hind foot:

. Peroneus longus tendon
. Peroneus brevis tendon
. Flexor hallucis longus tendon
. Flexor digitorum longus tendon
. Posterior tibial tendon

Correct Answer & Explanation

. Posterior tibial tendon

Explanation

p class="subHeader"> Discussion The posterior tibial tendon is the main inverter of the hindfoot. To conduct a sensitive test for posterior tibial tendon function, ask a patient to perform a single leg rise and observe if the hindfoot inverts. Patients with no posterior tibial tendon function are unable to invert the hindfoot on single leg rise.

Question 34

Topic: Midfoot & Hindfoot

Which of the following statements describes the results of extracorporeal shock wave therapy for chronic plantar fasciitis:

. No improvement in pain scores occurred at 4 or 12 weeks.
. No improvement in pain scores occurred at 4 weeks, but significant improvement occurred at 12 weeks.
. Pain scores significantly improved at 4 and 12 weeks.
. Pain scores improved, but function did not improve.
. Although pain scores improved, less than 50% of the patients were satisfied.

Correct Answer & Explanation

. Pain scores significantly improved at 4 and 12 weeks.

Explanation

Discussion In a recent study in Orthopaedics, Furia showed that a significant improvement in pain and function scores occurred in patients who had plantar fasciitis treated with extracorporeal shock wave therapy. Approximately 80% of the patients were satisfied with the treatment and would have the shock wave treatment again. Results Pain Visual Analog Scale (VAS) Pre-treatment VAS 9.2 standard deviation (SD) 0.7 Post-treatment VAS (4 weeks) 3.4 SD 1.9 (P<.05) Post-treatment VAS (12 weeks) 2.4 SD dev 1.8 (P<.05) RAND Score Physical functioning Pre-treatment 40.4 SD 1.3 Post-treatment (4 weeks) 91.5 SD 11.5 (P<.05) Post-treatment (12 weeks) 91.5 SD 10.6 (P<.05) RAND Score Pain Pre-treatment 3.3 SD dev 1.1 Post-treatment (4 weeks) 88.6 SD 16 (P<.05) Post-treatment (12 weeks) 90.0 SD 11.6 (P<.05) Patient satisfaction At 4 and 12 weeks post treatment, 49 (82%) patients were satisfied, and all patients would undergo the procedure again.

Question 35

Topic: Midfoot & Hindfoot

A 30-year-old male sustains a Hawkins Type II fracture of the talar neck following a motor vehicle collision. Which of the following accurately describes the joint dislocation and the associated risk of avascular necrosis (AVN)?

. Tibiotalar joint dislocation; 0-10% AVN risk
. Subtalar joint dislocation; 20-50% AVN risk
. Subtalar joint dislocation; 90-100% AVN risk
. Talonavicular joint dislocation; 0-10% AVN risk
. Tibiotalar and subtalar joint dislocations; 90-100% AVN risk

Correct Answer & Explanation

. Subtalar joint dislocation; 20-50% AVN risk

Explanation

A Hawkins Type II fracture involves a talar neck fracture with subluxation or dislocation of the subtalar joint. The risk of AVN in Type II fractures is classically reported as 20% to 50%.

Question 36

Topic: Midfoot & Hindfoot
According to the Hawkins classification of talar neck fractures, a Type III fracture is characterized by which of the following dislocation patterns?
. Nondisplaced fracture with no dislocations
. Subtalar joint dislocation only
. Subtalar and tibiotalar joint dislocations
. Subtalar, tibiotalar, and talonavicular joint dislocations
. Isolated talonavicular joint dislocation

Correct Answer & Explanation

. Subtalar and tibiotalar joint dislocations

Explanation

A Hawkins Type III talar neck fracture involves a displaced fracture of the talar neck with subluxation or dislocation of both the subtalar and tibiotalar (ankle) joints. This pattern carries a very high risk of avascular necrosis.

Question 37

Topic: Midfoot & Hindfoot

A 55-year-old diabetic patient presents with a red, warm, and severely swollen foot. Radiographs reveal extensive periarticular bone fragmentation, joint subluxation, and intra-articular 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 (Ankylosis)

Correct Answer & Explanation

. Stage 1 (Developmental/Fragmentation)

Explanation

Eichenholtz Stage 1 (Developmental) is characterized clinically by an erythematous, edematous foot and radiographically by bone fragmentation, joint subluxation, and periarticular debris. Stage 2 involves coalescence with absorption of fine debris, while Stage 3 shows remodeling.

Question 38

Topic: Midfoot & Hindfoot

A 55-year-old female presents with medial ankle pain and a progressive flatfoot deformity. Examination reveals an inability to perform a single-leg heel rise, but the hindfoot remains flexible and correctable. Which of the following surgical interventions is most appropriate for this stage of disease?

. Medial displacement calcaneal osteotomy and flexor digitorum longus (FDL) transfer
. Triple arthrodesis
. Subtalar arthrodesis
. Gastrocnemius recession alone
. Ankle arthrodesis

Correct Answer & Explanation

. Medial displacement calcaneal osteotomy and flexor digitorum longus (FDL) transfer

Explanation

This patient has Stage II posterior tibial tendon dysfunction (PTTD), characterized by a flexible hindfoot and inability to perform a single-leg heel rise. Treatment involves a joint-sparing procedure such as an FDL transfer combined with a medial displacement calcaneal osteotomy.

Question 39

Topic: Midfoot & Hindfoot

A 66-year-old woman has experienced the gradual onset of a flatfoot deformity over the past 10 years. She notes that the condition is bilateral, although worse on one side. Presented are clinical and radiographic images of her condition. This is associated with pain upon ambulation and difficulty with shoe wear. The most likely cause of this flatfoot deformity is:

. Posterior tibial tendon tear
. Spring ligament tear
. Neuropathy
. Subtalar arthritis
. Tarsometatarsal arthritis

Correct Answer & Explanation

. Tarsometatarsal arthritis

Explanation

Although posterior tibial tendon insufficiency is a more common cause of adult acquired flatfoot, in this patient the associated clinical and radiographic deformity makes the diagnosis of tarsometatarsal arthritis more likely.

Question 40

Topic: Midfoot & Hindfoot

The nerve commonly associated with painful heel syndrome is the:

. Medial plantar nerve
. Lateral plantar nerve
. First branch of the lateral plantar nerve
. C alcaneal nerve
. Deep peroneal nerve

Correct Answer & Explanation

. First branch of the lateral plantar nerve

Explanation

The first branch of the lateral plantar nerve (occasionally referred to as the nerve to the abductor digiti quinti) is occasionally involved in pathologic painful heel syndrome and plantar fasciitis.

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