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Midfoot & Hindfoot MCQs

Practice Set 22 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 421

Topic: Midfoot & Hindfoot

Total contact casting (TCC) is considered the gold standard for offloading diabetic plantar foot ulcers. Which of the following is an absolute contraindication to the application of a TCC?

. Wagner Grade 1 forefoot ulcer
. Wagner Grade 2 midfoot ulcer
. Active deep space abscess or acute osteomyelitis
. Stable Charcot arthropathy (Eichenholtz Stage III)
. Loss of protective sensation (LOPS)

Correct Answer & Explanation

. Wagner Grade 1 forefoot ulcer

Explanation

Absolute contraindications to Total Contact Casting (TCC) include active deep infection (abscess, gangrene, acute osteomyelitis) and severe peripheral arterial disease, as enclosing an infected or profoundly ischemic limb can lead to rapid limb loss.

Question 422

Topic: Midfoot & Hindfoot

A 45-year-old construction worker sustains a purely ligamentous Lisfranc injury involving the 1st, 2nd, and 3rd tarsometatarsal (TMT) joints. What is the most appropriate definitive management?

. Cast immobilization for 8 weeks and non-weight bearing
. Open reduction and screw fixation of all involved joints
. Primary arthrodesis of the medial three TMT joints
. Closed reduction and percutaneous K-wire fixation
. Primary arthrodesis of all five TMT joints

Correct Answer & Explanation

. Cast immobilization for 8 weeks and non-weight bearing

Explanation

Purely ligamentous Lisfranc injuries have a higher rate of hardware failure and loss of reduction with ORIF compared to primary arthrodesis. Arthrodesis of the medial three TMT joints provides superior long-term functional outcomes in these specific injuries.

Question 423

Topic: Midfoot & Hindfoot

A 35-year-old male is 2 years out from an open reduction and internal fixation of a severe Lisfranc injury. He now complains of severe, localized midfoot pain with weight-bearing. Radiographs show advanced degenerative changes at the 2nd and 3rd TMT joints. Management should consist of:

. Intra-articular hyaluronic acid injections
. Midfoot arthrodesis of the affected TMT joints
. Total ankle arthroplasty
. Removal of hardware and anatomic ligament reconstruction
. Chopart amputation

Correct Answer & Explanation

. Intra-articular hyaluronic acid injections

Explanation

Post-traumatic arthritis is a frequent complication after severe or ORIF-treated Lisfranc injuries. When conservative measures fail, arthrodesis of the involved TMT joints is the standard of care and provides reliable pain relief.

Question 424

Topic: Midfoot & Hindfoot

Regarding lower extremity amputations in diabetic patients, which level of amputation requires the least increase in energy expenditure for ambulation compared to normal gait?

. Syme amputation
. Transmetatarsal amputation
. Below-knee amputation
. Above-knee amputation
. Chopart amputation

Correct Answer & Explanation

. Syme amputation

Explanation

The more distal the amputation, the lower the energy expenditure required for ambulation. A transmetatarsal amputation requires approximately a 10-15% increase in energy expenditure, which is less than a Syme (15-30%) or below-knee (40-50%) amputation.

Question 425

Topic: Midfoot & Hindfoot

A 30-year-old recreational athlete sustains a purely ligamentous Lisfranc injury involving the first, second, and third tarsometatarsal (TMT) joints. What surgical intervention has been shown in recent prospective literature to yield the most favorable functional outcomes and lowest reoperation rate for this specific injury pattern?

. Closed reduction and percutaneous pinning (CRPP)
. Open reduction and internal fixation (ORIF) with transarticular screws
. Open reduction and internal fixation (ORIF) with dorsal bridge plating
. Primary arthrodesis of the medial three TMT joints
. Ligamentous reconstruction with an allograft tendon

Correct Answer & Explanation

. Closed reduction and percutaneous pinning (CRPP)

Explanation

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

Question 426

Topic: Midfoot & Hindfoot

A patient with long-standing diabetes presents with a markedly swollen, warm, and erythematous foot. Radiographs demonstrate severe periarticular debris, joint dislocation, and fragmentation of the midfoot bones.

According to the Eichenholtz classification of Charcot neuroarthropathy, this represents which stage?

. Stage 0 (Pre-Charcot)
. Stage I (Fragmentation)
. Stage II (Coalescence)
. Stage III (Consolidation)
. Stage IV (Remodeling)

Correct Answer & Explanation

. Stage 0 (Pre-Charcot)

Explanation

Eichenholtz Stage I is the developmental (acute) phase of Charcot arthropathy. It is characterized clinically by a red, hot, swollen foot and radiographically by bone fragmentation, joint dislocation, and osseous debris.

Question 427

Topic: Midfoot & Hindfoot

A 30-year-old man falls from a height and sustains a Hawkins Type III talar neck fracture. This fracture pattern involves displacement of the talar neck with subluxation or dislocation of which joints?

. Subtalar joint only
. Subtalar and tibiotalar joints
. Subtalar, tibiotalar, and talonavicular joints
. Tibiotalar joint only
. Talonavicular joint only

Correct Answer & Explanation

. Subtalar joint only

Explanation

A Hawkins Type III talar neck fracture involves displacement of the talar body with dislocation of both the subtalar and tibiotalar joints. It carries a high risk of avascular necrosis.

Question 428

Topic: Midfoot & Hindfoot

A 58-year-old patient with poorly controlled type 2 diabetes presents with a red, hot, swollen right foot. There is no history of trauma or open wounds. Radiographs show periarticular debris, joint subluxation, and fragmentation of the midfoot. What is the most appropriate initial management?

. Intravenous antibiotics and urgent surgical debridement
. Total contact casting and non-weight bearing
. Primary arthrodesis of the midfoot
. Injection of intra-articular corticosteroids
. Custom orthotics and physical therapy

Correct Answer & Explanation

. Intravenous antibiotics and urgent surgical debridement

Explanation

The clinical presentation is classic for acute Charcot arthropathy (Eichenholtz stage I). The standard initial treatment is offloading with a total contact cast to prevent further deformity.

Question 429

Topic: Midfoot & Hindfoot

A 35-year-old man sustains a Hawkins type II fracture of the talar neck after a motor vehicle collision. By definition, a Hawkins type II talar neck fracture is characterized by displacement and subluxation or dislocation at which of the following articulations?

. Subtalar joint
. Tibiotalar joint
. Talonavicular joint
. Calcaneocuboid joint
. Naviculocuneiform joint

Correct Answer & Explanation

. Subtalar joint

Explanation

A Hawkins II talar neck fracture involves a fracture of the talar neck with subluxation or dislocation of the subtalar joint. The tibiotalar joint remains anatomically aligned.

Question 430

Topic: Midfoot & Hindfoot

A 55-year-old woman with stage IIb adult-acquired flatfoot deformity (posterior tibial tendon dysfunction) presents for surgical evaluation. She has a flexible flatfoot, inability to perform a single heel rise, and >40% uncovering of the talonavicular joint indicating substantial forefoot abduction. Which of the following is the most appropriate combination of surgical procedures?

. Flexor digitorum longus (FDL) transfer alone
. FDL transfer with a medial displacement calcaneal osteotomy (MDCO)
. FDL transfer, MDCO, and a lateral column lengthening
. Triple arthrodesis
. Isolated subtalar arthrodesis

Correct Answer & Explanation

. Flexor digitorum longus (FDL) transfer alone

Explanation

Stage IIb posterior tibial tendon dysfunction features significant forefoot abduction (talonavicular uncoverage). Optimal correction requires an FDL transfer, a medializing calcaneal osteotomy (for hindfoot valgus), and a lateral column lengthening to correct the forefoot abduction.

Question 431

Topic: Midfoot & Hindfoot

A 55-year-old woman presents with progressive medial ankle pain and a new-onset flatfoot deformity. She is unable to perform a single-limb heel rise on the affected side, but her hindfoot remains passively correctable to neutral. What is the most appropriate surgical treatment?

. Flexor digitorum longus (FDL) transfer to the navicular and medial displacement calcaneal osteotomy
. Triple arthrodesis
. Subtalar arthrodesis
. Gastrocnemius recession alone
. Tibialis anterior tendon transfer

Correct Answer & Explanation

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

Explanation

The patient has Stage II adult-acquired flatfoot deformity (flexible, unable to perform single-heel rise). The gold standard surgical treatment consists of an FDL tendon transfer to substitute for the incompetent posterior tibial tendon, combined with a medial displacement calcaneal osteotomy to correct hindfoot valgus.

Question 432

Topic: Midfoot & Hindfoot

A 55-year-old patient with poorly controlled type 2 diabetes presents with a unilaterally swollen, erythematous, and warm foot. There are no skin breaks or ulcers, and inflammatory markers are normal. Radiographs demonstrate fragmentation, periarticular debris, and subluxation at the tarsometatarsal joints. What is the most appropriate immediate management?

. Intravenous antibiotics and urgent surgical debridement
. Open reduction and internal fixation of the midfoot
. Primary midfoot arthrodesis with a rigid plate
. Immobilization in a total contact cast and non-weight-bearing
. Below-knee amputation

Correct Answer & Explanation

. Intravenous antibiotics and urgent surgical debridement

Explanation

The presentation is classic for acute Eichenholtz Stage I Charcot arthropathy (fragmentation stage). The mainstay of initial treatment to prevent progressive deformity is rigid immobilization, typically with a total contact cast, and strict non-weight-bearing.

Question 433

Topic: Midfoot & Hindfoot

A 55-year-old woman presents with a flexible flatfoot deformity, marked forefoot abduction, and an inability to perform a single-leg heel raise. Radiographs demonstrate more than 40% uncoverage of the talar head. What is the most appropriate surgical management for this Stage IIb posterior tibial tendon dysfunction?

. Medial displacement calcaneal osteotomy and FDL transfer
. Lateral column lengthening, medial displacement calcaneal osteotomy, and FDL transfer
. Talonavicular arthrodesis alone
. Triple arthrodesis
. Subtalar arthroereisis

Correct Answer & Explanation

. Medial displacement calcaneal osteotomy and FDL transfer

Explanation

Stage IIb PTTD is characterized by a flexible deformity with significant forefoot abduction. Treatment requires an FDL transfer, a medialuating calcaneal osteotomy for valgus, and a lateral column lengthening (Evans osteotomy) to correct the forefoot abduction.

Question 434

Topic: Midfoot & Hindfoot

A 55-year-old diabetic patient presents with a severely swollen, erythematous, and warm foot with no history of trauma. Radiographs reveal periarticular debris, joint subluxation, and fragmentation of the midfoot. Which of the following is the most appropriate initial management?

. Immediate surgical arthrodesis of the midfoot
. Intravenous antibiotics and surgical debridement
. Total contact casting and non-weight bearing
. Custom orthotic shoe insert
. Corticosteroid injection into the affected joints

Correct Answer & Explanation

. Immediate surgical arthrodesis of the midfoot

Explanation

This patient has acute Eichenholtz Stage I Charcot arthropathy. The gold standard initial treatment to prevent further deformity while the acute inflammatory phase resolves is total contact casting.

Question 435

Topic: Midfoot & Hindfoot

A 55-year-old woman presents with medial ankle pain and a progressive flatfoot deformity. Examination reveals a "too many toes" sign laterally, and she is unable to perform a single-leg heel rise. Her hindfoot valgus deformity is passively correctable. What is the most appropriate surgical treatment?

. Flexor digitorum longus transfer and medial displacement calcaneal osteotomy
. Triple arthrodesis
. Isolated subtalar arthrodesis
. Gastrocnemius recession and anterior tibial tendon transfer
. Primary repair of the posterior tibial tendon

Correct Answer & Explanation

. Flexor digitorum longus transfer and medial displacement calcaneal osteotomy

Explanation

The patient has a Stage II adult acquired flatfoot deformity (flexible). The gold standard surgical management includes a joint-sparing procedure such as flexor digitorum longus (FDL) transfer to the navicular combined with a medial displacement calcaneal osteotomy.

Question 436

Topic: Midfoot & Hindfoot

A 45-year-old woman is being evaluated for a custom orthosis to correct a flexible pes planovalgus deformity. Understanding normal hindfoot kinematics is essential. The axis of rotation of the subtalar joint is best described by which of the following orientations?

. 16 degrees superior to the horizontal plane and 42 degrees medial to the sagittal plane
. 42 degrees superior to the horizontal plane and 16 degrees medial to the sagittal plane
. Parallel to the transmalleolar axis
. 42 degrees inferior to the horizontal plane and 16 degrees lateral to the sagittal plane
. Perpendicular to the longitudinal axis of the tibia in all planes

Correct Answer & Explanation

. 16 degrees superior to the horizontal plane and 42 degrees medial to the sagittal plane

Explanation

The subtalar joint functions as a mitered hinge with a complex axis of rotation. This axis deviates approximately 42 degrees superiorly from the horizontal plane and 16 degrees medially from the sagittal plane, allowing coupled triplanar motion.

Question 437

Topic: Midfoot & Hindfoot

At the anatomically critical "Master Knot of Henry" in the plantar midfoot, which of the following relationships is correct?

. The flexor hallucis longus (FHL) tendon crosses dorsal (deep) to the flexor digitorum longus (FDL) tendon
. The FDL tendon crosses dorsal (deep) to the FHL tendon
. The posterior tibial tendon crosses plantar to the FHL tendon
. The medial plantar nerve crosses dorsal to the FHL tendon
. The FHL tendon crosses superficial (plantar) to the FDL tendon

Correct Answer & Explanation

. The flexor hallucis longus (FHL) tendon crosses dorsal (deep) to the flexor digitorum longus (FDL) tendon

Explanation

The Master Knot of Henry is located in the medial plantar midfoot. At this intersection, the FHL tendon courses medially from its lateral fibular origin, passing deep (dorsal) to the medially originating FDL tendon.

Question 438

Topic: Midfoot & Hindfoot

A 28-year-old male sustains a Hawkins type III fracture of the talar neck after falling from a height. Which of the following accurately describes the joint subluxations or dislocations seen in this specific classification?

. Nondisplaced talar neck fracture
. Dislocation of the subtalar joint only
. Dislocation of both the subtalar and tibiotalar joints
. Dislocation of the subtalar, tibiotalar, and talonavicular joints
. Isolated talonavicular joint dislocation

Correct Answer & Explanation

. Nondisplaced talar neck fracture

Explanation

Hawkins Type III talar neck fractures involve displacement of the fracture with dislocation of both the subtalar joint and the tibiotalar (ankle) joint. This pattern carries a very high risk (often near 100% without prompt reduction) of avascular necrosis.

Question 439

Topic: Midfoot & Hindfoot

A 24-year-old professional athlete sustains a purely ligamentous Lisfranc injury. What is the currently recommended treatment approach to minimize long-term arthrosis and maximize functional outcome?

. Cast immobilization for 8 weeks and non-weight bearing
. Open reduction and internal fixation with transarticular screws
. Dorsal bridge plating without joint violation
. Closed reduction and percutaneous K-wire pinning
. Primary arthrodesis of the first, second, and third tarsometatarsal joints

Correct Answer & Explanation

. Cast immobilization for 8 weeks and non-weight bearing

Explanation

Recent high-level literature supports primary arthrodesis over open reduction and internal fixation for purely ligamentous Lisfranc injuries. Arthrodesis has been associated with lower rates of hardware failure, fewer subsequent surgeries, and superior mid-term functional outcomes.

Question 440

Topic: Midfoot & Hindfoot

A 29-year-old male sustains a displaced fracture of the talar neck with subluxation of the subtalar joint and a dislocated tibiotalar joint. What is the expected historical rate of avascular necrosis (AVN) of the talar body for this Hawkins type III injury?

. Less than 10%
. 15% to 25%
. 30% to 40%
. 70% to 100%
. 100% in all cases despite prompt reduction

Correct Answer & Explanation

. Less than 10%

Explanation

A Hawkins type III talar neck fracture involves displacement of the talar neck with dislocation of both the subtalar and tibiotalar joints, severely disrupting the blood supply. The risk of avascular necrosis (AVN) is historically reported to be between 70% and 100%.

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