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Midfoot & Hindfoot MCQs

Practice Set 20 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 381

Topic: Midfoot & Hindfoot
A 62-year-old female presents with severe, rigid planovalgus deformity and lateral hindfoot pain secondary to subfibular impingement. Radiographs show significant subtalar and talonavicular arthritis. What is the most appropriate definitive treatment?
. Lateral column lengthening
. FDL transfer and calcaneal osteotomy
. Triple arthrodesis
. Ankle arthrodesis
. Gastrocnemius recession alone

Correct Answer & Explanation

. Triple arthrodesis

Explanation

Stage III adult acquired flatfoot deformity is characterized by a rigid deformity with associated hindfoot arthritis. Triple arthrodesis (subtalar, talonavicular, and calcaneocuboid) provides deformity correction, stability, and definitive pain relief.

Question 382

Topic: Midfoot & Hindfoot

A 55-year-old woman presents with a flexible flatfoot deformity, unable to perform a single-leg heel raise. She has pain along the medial hindfoot. Imaging shows uncovering of the talonavicular joint but no arthritis. Conservative management has failed. Which of the following surgical procedures is most appropriate?

. Triple arthrodesis
. Isolated talonavicular fusion
. Flexor digitorum longus (FDL) transfer to the navicular and medializing calcaneal osteotomy
. Tibialis anterior tendon transfer

Correct Answer & Explanation

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

Explanation

Stage II posterior tibial tendon dysfunction (PTTD) presents as a flexible deformity without arthritis. It is typically treated with joint-sparing procedures such as an FDL transfer combined with a medializing calcaneal osteotomy to correct the mechanical axis.

Question 383

Topic: Midfoot & Hindfoot
A 55-year-old female presents with Stage IIB posterior tibial tendon dysfunction (flexible pes planovalgus with >30% uncoverage of the talar head). She has failed conservative management. Surgical reconstruction is planned, including a flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy (MDCO). What additional procedure is most critical to correct the forefoot abduction deformity?
. Subtalar arthrodesis
. Lateral column lengthening
. First tarsometatarsal arthrodesis
. Spring ligament reconstruction
. Evans osteotomy of the cuboid

Correct Answer & Explanation

. Lateral column lengthening

Explanation

In Stage IIB PTTD with significant forefoot abduction (indicated by talar head uncoverage), a medial displacement calcaneal osteotomy alone is insufficient. A lateral column lengthening (e.g., Evans osteotomy of the calcaneus) is required to restore talonavicular joint alignment and correct the abduction.

Question 384

Topic: Midfoot & Hindfoot

A 22-year-old collegiate football player sustains a purely ligamentous Lisfranc injury with 3 mm of diastasis between the medial and middle cuneiforms. He undergoes operative intervention. According to recent literature, which of the following outcomes is associated with primary arthrodesis compared to open reduction and internal fixation (ORIF) for this specific injury pattern?

. Higher rate of hardware failure
. Lower rate of return to sport
. Decreased incidence of secondary procedures
. Increased incidence of midfoot arthritis
. Inferior midfoot clinical outcome scores at 2 years

Correct Answer & Explanation

. Decreased incidence of secondary procedures

Explanation

For purely ligamentous Lisfranc injuries, primary arthrodesis has been shown to result in a decreased incidence of secondary procedures (such as hardware removal or salvage fusion) compared to ORIF. Short- and mid-term functional scores are generally similar or slightly favor primary arthrodesis in purely ligamentous patterns.

Question 385

Topic: Midfoot & Hindfoot

A 55-year-old woman presents with progressive flattening of her left arch and medial ankle pain. Examination reveals a flexible hindfoot valgus, inability to perform a single-leg heel raise, and forefoot abduction of 30 degrees (positive 'too many toes' sign). Radiographs confirm Stage IIb posterior tibial tendon dysfunction. Which surgical intervention is most appropriate?

. Primary talonavicular arthrodesis
. FDL transfer to the navicular and medial displacement calcaneal osteotomy alone
. FDL transfer, medial displacement calcaneal osteotomy, and lateral column lengthening
. Triple arthrodesis
. Gastrocnemius recession alone

Correct Answer & Explanation

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

Explanation

Stage IIb adult acquired flatfoot deformity involves a flexible hindfoot with significant forefoot abduction (often >30-40% uncoverage of the talar head). Management typically requires FDL transfer, medial displacement calcaneal osteotomy, and a lateral column lengthening (Evans osteotomy or calcaneocuboid distraction arthrodesis) to correct the abduction.

Question 386

Topic: Midfoot & Hindfoot

A 55-year-old female presents with progressive medial ankle pain and a severe flatfoot deformity. Examination reveals a flexible hindfoot and forefoot abduction with greater than 30 percent talonavicular uncoverage on weight-bearing radiographs. She cannot perform a single-leg heel rise. What is the most appropriate surgical management for this Stage IIb adult acquired flatfoot deformity?

. Medial displacement calcaneal osteotomy and flexor digitorum longus transfer
. Lateral column lengthening, medial displacement calcaneal osteotomy, and flexor digitorum longus transfer
. Isolated triple arthrodesis
. Isolated subtalar arthrodesis
. Gastrocnemius recession and spring ligament repair alone

Correct Answer & Explanation

. Lateral column lengthening, medial displacement calcaneal osteotomy, and flexor digitorum longus transfer

Explanation

Stage IIb posterior tibial tendon dysfunction is characterized by a flexible hindfoot with significant forefoot abduction (greater than 30% talonavicular uncoverage). Lateral column lengthening is necessary to correct the severe forefoot abduction and restore talonavicular joint alignment, combined with a medial displacement calcaneal osteotomy and FDL transfer.

Question 387

Topic: Midfoot & Hindfoot
A 35-year-old male presents after a high-speed motor vehicle collision with a displaced talar neck fracture. Radiographs confirm a Hawkins Type III injury. By definition, this classification indicates dislocation or subluxation of which of the following joints?
. Subtalar joint only
. Tibiotalar joint only
. Subtalar and tibiotalar joints
. Subtalar, tibiotalar, and talonavicular joints
. Calcaneocuboid and talonavicular joints

Correct Answer & Explanation

. Subtalar and tibiotalar joints

Explanation

The Hawkins classification for talar neck fractures is based on displacement. Type I is nondisplaced; Type II involves subtalar subluxation/dislocation; Type III involves both subtalar and tibiotalar dislocation; Type IV adds talonavicular dislocation.

Question 388

Topic: Midfoot & Hindfoot

A 55-year-old woman is diagnosed with acquired adult flatfoot deformity secondary to posterior tibial tendon dysfunction. Examination and weight-bearing radiographs reveal flexible hindfoot valgus and greater than 40% uncoverage of the talonavicular joint. What is the most appropriate surgical reconstruction?

. FDL transfer and isolated medial displacement calcaneal osteotomy
. Subtalar arthrodesis
. Triple arthrodesis
. FDL transfer and lateral column lengthening
. Spring ligament repair alone

Correct Answer & Explanation

. FDL transfer and lateral column lengthening

Explanation

This patient has Stage IIb flatfoot deformity characterized by significant forefoot abduction (talonavicular uncoverage > 40%). Lateral column lengthening combined with an FDL transfer is required to adequately correct the severe abduction deformity.

Question 389

Topic: Midfoot & Hindfoot

A 22-year-old competitive rugby player sustains a purely ligamentous Lisfranc injury with dynamic instability demonstrated on weight-bearing radiographs. To minimize the risk of articular cartilage damage and hardware breakage while allowing early return to sport, what is the current recommended surgical treatment?

. Closed reduction and casting
. Temporary K-wire fixation
. Primary partial midfoot arthrodesis
. Open reduction and transarticular screw fixation
. Open reduction and dorsal spanning plate fixation

Correct Answer & Explanation

. Open reduction and dorsal spanning plate fixation

Explanation

Dorsal spanning plates have become the preferred treatment for purely ligamentous Lisfranc injuries. They provide rigid fixation without violating the articular cartilage, avoiding the joint damage associated with transarticular screws.

Question 390

Topic: Midfoot & Hindfoot

A 35-year-old sustains a lateral subtalar dislocation that is irreducible by closed means in the emergency department. Which anatomic structure is most commonly interpositioned, blocking reduction?

. Tibialis posterior tendon
. Extensor digitorum brevis
. Peroneus brevis tendon
. Flexor hallucis longus tendon
. Sural nerve

Correct Answer & Explanation

. Tibialis posterior tendon

Explanation

In lateral subtalar dislocations, the tibialis posterior tendon is the most frequent structure to block closed reduction. In medial dislocations, the extensor digitorum brevis or talonavicular capsule typically blocks reduction.

Question 391

Topic: Midfoot & Hindfoot

In a 45-year-old patient with a purely ligamentous Lisfranc injury, primary arthrodesis of the 1st, 2nd, and 3rd tarsometatarsal joints compared to open reduction and internal fixation (ORIF) offers which of the following advantages?

. Lower rate of planned reoperation
. Decreased operative time
. Higher rate of return to pre-injury sports
. Better preservation of midfoot motion
. Decreased risk of deep infection

Correct Answer & Explanation

. Lower rate of planned reoperation

Explanation

Primary arthrodesis for purely ligamentous Lisfranc injuries leads to comparable functional outcomes but significantly lowers the rate of planned hardware removal and secondary salvage arthrodesis compared to ORIF.

Question 392

Topic: Midfoot & Hindfoot

According to Level I evidence, which of the following is a primary advantage of primary arthrodesis over open reduction internal fixation (ORIF) for purely ligamentous Lisfranc injuries?

. Decreased rate of secondary surgeries
. Faster return to pre-injury sports
. Lower rate of wound complications
. Improved range of motion of the midfoot
. Decreased incidence of deep vein thrombosis

Correct Answer & Explanation

. Decreased rate of secondary surgeries

Explanation

Primary arthrodesis of the first, second, and third tarsometatarsal joints for purely ligamentous Lisfranc injuries has similar functional outcomes to ORIF but significantly decreases the need for planned hardware removal and secondary salvage arthrodesis.

Question 393

Topic: Midfoot & Hindfoot

A 25-year-old male sustains a closed lateral subtalar dislocation. Closed reduction in the emergency department is unsuccessful. Which of the following anatomic structures is most likely blocking the reduction?

. Extensor digitorum brevis
. Tibialis posterior tendon
. Extensor retinaculum
. Flexor hallucis longus tendon
. Peroneus brevis tendon

Correct Answer & Explanation

. Tibialis posterior tendon

Explanation

Lateral subtalar dislocations represent about 15% of subtalar dislocations and occur when the talar head is forced medially. An irreducible lateral subtalar dislocation is most commonly blocked by the interposition of the tibialis posterior tendon.

Question 394

Topic: Midfoot & Hindfoot

In young, active patients with purely ligamentous Lisfranc injuries, which surgical intervention has been shown to yield the best long-term functional outcomes and lowest reoperation rates?

. Closed reduction and percutaneous pinning
. Dorsal bridge plating across the midfoot
. Primary arthrodesis of the first, second, and third tarsometatarsal joints
. Open reduction and internal fixation with transarticular screws
. Flexible fixation utilizing suture button constructs exclusively

Correct Answer & Explanation

. Primary arthrodesis of the first, second, and third tarsometatarsal joints

Explanation

Recent studies demonstrate that primary arthrodesis of the 1st, 2nd, and 3rd TMT joints yields better functional outcomes and lower reoperation rates than ORIF for purely ligamentous Lisfranc injuries.

Question 395

Topic: Midfoot & Hindfoot

A 25-year-old sustains a lateral subtalar dislocation after a fall from a height. A closed reduction in the emergency department is unsuccessful due to a soft tissue block. What is the most likely anatomic structure preventing reduction?

. Peroneus brevis tendon
. Flexor hallucis longus tendon
. Extensor digitorum brevis muscle
. Posterior tibial tendon
. Anterior tibial tendon

Correct Answer & Explanation

. Posterior tibial tendon

Explanation

In a lateral subtalar dislocation, the talar head is displaced medially and can become buttonholed through the posterior tibial tendon, blocking closed reduction. Medial dislocations are typically blocked by the EDB or extensor retinaculum.

Question 396

Topic: Midfoot & Hindfoot
A 50-year-old overweight female presents with progressive flattening of her left medial longitudinal arch. Examination reveals an inability to perform a single-leg heel raise and forefoot abduction with >30% talonavicular uncoverage on radiographs, but the hindfoot remains manually correctable. What is the appropriate surgical classification and treatment?
. Stage I PTTD; synovectomy and orthotics
. Stage IIA PTTD; FDL transfer and medializing calcaneal osteotomy
. Stage IIB PTTD; FDL transfer, medializing calcaneal osteotomy, and lateral column lengthening
. Stage III PTTD; Triple arthrodesis
. Stage IV PTTD; Tibiotalocalcaneal arthrodesis

Correct Answer & Explanation

. Stage IIB PTTD; FDL transfer, medializing calcaneal osteotomy, and lateral column lengthening

Explanation

Stage IIB adult acquired flatfoot deformity (flexible, but with severe forefoot abduction / >30% TN uncoverage) typically requires a lateral column lengthening (e.g., Evans osteotomy) in addition to FDL transfer and medial displacement calcaneal osteotomy.

Question 397

Topic: Midfoot & Hindfoot

A 45-year-old runner with recalcitrant plantar fasciitis undergoes a complete surgical release of the plantar fascia. Post-operatively, she complains of new-onset, severe lateral midfoot pain and a visibly flatter arch. This complication is most directly related to which of the following pathomechanical changes?

. Medial column overload
. Lateral column overload and cuboid syndrome
. Avascular necrosis of the navicular
. Rupture of the tibialis anterior tendon
. Entrapment of the medial plantar nerve

Correct Answer & Explanation

. Lateral column overload and cuboid syndrome

Explanation

Complete release of the plantar fascia destroys the 'windlass mechanism' supporting the arch. This leads to arch collapse and subsequent lateral column overload, which often presents as severe lateral midfoot or cuboid pain.

Question 398

Topic: Midfoot & Hindfoot

A 35-year-old male sustains a purely ligamentous Lisfranc injury. Current evidence suggests that when compared to open reduction and internal fixation (ORIF), primary arthrodesis of the first, second, and third tarsometatarsal joints for this specific injury pattern results in:

. Decreased rate of hardware removal and higher functional scores
. Increased rate of hardware removal
. Lower union rates
. Increased risk of deep infection
. Similar outcomes with higher reoperation rates

Correct Answer & Explanation

. Decreased rate of hardware removal and higher functional scores

Explanation

For purely ligamentous Lisfranc injuries, primary arthrodesis has been shown to yield better functional outcomes and a lower rate of planned hardware removal and secondary procedures compared to ORIF.

Question 399

Topic: Midfoot & Hindfoot

A 50-year-old woman presents with medial ankle pain and a progressively flattening arch. She is able to perform a single-leg heel rise but it is weak and painful. She has a flexible flatfoot deformity. Nonoperative management with a custom orthosis has failed. What is the most appropriate surgical intervention?

. Gastrocnemius recession alone
. Flexor digitorum longus (FDL) transfer to the navicular and a medializing calcaneal osteotomy
. Subtalar arthrodesis
. Triple arthrodesis
. Tibiotalocalcaneal arthrodesis

Correct Answer & Explanation

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

Explanation

The patient has Stage II posterior tibial tendon dysfunction characterized by a flexible deformity and weak single-leg heel rise. Standard surgical treatment includes an FDL transfer combined with a medializing calcaneal osteotomy.

Question 400

Topic: Midfoot & Hindfoot
A 30-year-old male is involved in a motor vehicle collision and sustains a Hawkins type III fracture of the talar neck. Which of the following best describes the joint dislocations associated with this specific injury pattern?
. Subtalar joint only
. Tibiotalar joint only
. Subtalar and tibiotalar joints
. Subtalar, tibiotalar, and talonavicular joints
. Talonavicular and calcaneocuboid joints

Correct Answer & Explanation

. Subtalar and tibiotalar joints

Explanation

A Hawkins type III talar neck fracture involves displacement with dislocation of both the subtalar and tibiotalar joints. This injury carries a very high risk (approaching 100% in some series) of avascular necrosis of the talar body.

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