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Midfoot & Hindfoot MCQs

Practice Set 23 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 441

Topic: Midfoot & Hindfoot

A 24-year-old female sustains a purely ligamentous Lisfranc injury with dynamic instability. What is the most appropriate definitive surgical management based on prospective randomized trials?

. Closed reduction and percutaneous pinning
. Primary arthrodesis of the medial tarsometatarsal joints
. Open reduction and internal fixation (ORIF) with transarticular screws
. Nonoperative management in a non-weight-bearing cast
. Dorsal bridge plating without joint debridement

Correct Answer & Explanation

. Closed reduction and percutaneous pinning

Explanation

Prospective randomized studies demonstrate that primary arthrodesis for purely ligamentous Lisfranc injuries results in superior functional outcomes and lower reoperation rates compared to ORIF. ORIF is generally preferred when treating bony Lisfranc fracture-dislocations.

Question 442

Topic: Midfoot & Hindfoot

A 29-year-old snowboarder is diagnosed with a Hawkins type III fracture of the talar neck. What specific pattern of displacement defines a Hawkins type III injury?

. A nondisplaced talar neck fracture
. A talar neck fracture with subtalar subluxation or dislocation
. A talar neck fracture with simultaneous subtalar and tibiotalar dislocation
. A talar neck fracture with subtalar, tibiotalar, and talonavicular dislocation
. A fracture of the talar head with articular surface depression

Correct Answer & Explanation

. A nondisplaced talar neck fracture

Explanation

In the Hawkins classification for talar neck fractures, Type III is defined as a displaced talar neck fracture with dislocation of both the subtalar and tibiotalar joints. This injury carries a very high risk of avascular necrosis (AVN) of the talar body.

Question 443

Topic: Midfoot & Hindfoot

A 32-year-old male sustains a Hawkins Type III talar neck fracture following a motor vehicle collision. What is the approximate rate of avascular necrosis (AVN) of the talar body expected in this injury pattern?

. 0 to 10 percent
. 20 to 30 percent
. 40 to 50 percent
. 70 to 100 percent
. Always 100 percent

Correct Answer & Explanation

. 0 to 10 percent

Explanation

Hawkins Type III talar neck fractures involve displacement of the talar neck with subluxation or dislocation of both the subtalar and tibiotalar joints. This severe injury disrupts all three major blood supplies to the talar body, leading to an AVN rate approaching 70 to 100 percent.

Question 444

Topic: Midfoot & Hindfoot

A 28-year-old man sustains a Hawkins type III fracture of the talar neck. Which joints are subluxated or dislocated in this injury pattern?

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

Correct Answer & Explanation

. Subtalar joint only

Explanation

A Hawkins type III talar neck fracture involves displacement of the talar neck with dislocation of both the subtalar and tibiotalar (ankle) joints. This pattern carries nearly a 100% risk of avascular necrosis of the talar body.

Question 445

Topic: Midfoot & Hindfoot

A 29-year-old snowboarder sustains a Hawkins type III talar neck fracture. Which of the following joint dislocations is characteristic of this specific injury pattern?

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

Correct Answer & Explanation

. Subtalar joint only

Explanation

A Hawkins type III fracture is defined as a talar neck fracture with dislocation of the subtalar, tibiotalar (ankle), and talonavicular joints. This pattern carries an extremely high rate of avascular necrosis due to the disruption of all three major blood supplies to the talar body.

Question 446

Topic: Midfoot & Hindfoot
A 55-year-old woman presents with medial ankle pain and a progressive flatfoot deformity. She is able to perform a single heel rise, though it is painful and weak. On examination, she has a positive too-many-toes sign and flexible hindfoot valgus. Forefoot abduction is present and uncovers >40% of the talar head. What is the most appropriate surgical management?
. FDL transfer to the navicular and medial displacement calcaneal osteotomy
. FDL transfer to the navicular, medial displacement calcaneal osteotomy, and lateral column lengthening
. Subtalar arthrodesis
. Triple arthrodesis
. Spring ligament repair alone

Correct Answer & Explanation

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

Explanation

Stage IIb posterior tibial tendon dysfunction (PTTD) is characterized by a flexible deformity with significant forefoot abduction (>40% talonavicular uncoverage). This requires a lateral column lengthening in addition to FDL transfer and medial displacement calcaneal osteotomy.

Question 447

Topic: Midfoot & Hindfoot

A 24-year-old collegiate football player sustains a purely ligamentous Lisfranc injury with 3 mm of diastasis between the medial and middle cuneiforms.

What is the most appropriate surgical management?

. Closed reduction and percutaneous pinning
. Open reduction and internal fixation with screws
. Primary arthrodesis of the first, second, and third tarsometatarsal joints
. Primary arthrodesis of all five tarsometatarsal joints
. Dorsal bridge plating without joint preparation

Correct Answer & Explanation

. Closed reduction and percutaneous pinning

Explanation

Purely ligamentous Lisfranc injuries have a high rate of hardware failure and loss of reduction with ORIF. Primary arthrodesis of the medial column (1st, 2nd, and 3rd TMT joints) is preferred for athletes to ensure a more reliable return to play and prevent post-traumatic arthritis.

Question 448

Topic: Midfoot & Hindfoot

A 58-year-old man with poorly controlled type 2 diabetes presents with an acutely swollen, erythematous, and warm left foot. He denies trauma. Radiographs reveal no fractures or subluxations. Serum inflammatory markers are mildly elevated, but he is afebrile. What is the most appropriate initial management?

. Urgent surgical debridement and intravenous antibiotics
. Total contact casting and strict non-weight-bearing
. Primary subtalar and talonavicular arthrodesis
. Aspirin 81 mg and supportive care for deep vein thrombosis
. Custom accommodative footwear and full weight-bearing

Correct Answer & Explanation

. Urgent surgical debridement and intravenous antibiotics

Explanation

This patient presents with Eichenholtz stage 0 acute Charcot neuroarthropathy. The gold standard treatment to prevent progressive deformity and joint destruction is immediate immobilization with a total contact cast and offloading.

Question 449

Topic: Midfoot & Hindfoot

A 48-year-old woman reports medial ankle pain and the inability to perform a single-leg heel rise. Examination reveals a flexible flatfoot with a positive "too many toes" sign. Nonoperative management has failed. What is the most appropriate surgical intervention?

. Flexor digitorum longus (FDL) transfer and medializing calcaneal osteotomy
. Triple arthrodesis
. Subtalar arthrodesis
. Tibiotalocalcaneal arthrodesis
. Spring ligament repair alone

Correct Answer & Explanation

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

Explanation

This patient has a Stage II (flexible) adult acquired flatfoot deformity secondary to posterior tibial tendon dysfunction. The standard joint-sparing surgical treatment is an FDL transfer to the navicular combined with a medializing calcaneal osteotomy.

Question 450

Topic: Midfoot & Hindfoot

A 56-year-old diabetic patient presents with a red, hot, swollen foot without systemic signs of infection. Radiographs show fragmentation of the navicular and cuneiforms with subluxation of the midfoot. Which Eichenholtz stage does this represent, and what is the best initial management?

. Stage 0; Total contact cast
. Stage 1; Total contact cast
. Stage 2; Surgical arthrodesis
. Stage 3; Custom orthotic shoe
. Stage 1; Surgical arthrodesis

Correct Answer & Explanation

. Stage 0; Total contact cast

Explanation

Eichenholtz Stage 1 (development/fragmentation) is characterized by acute inflammation, osteopenia, fragmentation, and subluxation. The gold standard initial treatment for acute Charcot arthropathy is offloading with a total contact cast.

Question 451

Topic: Midfoot & Hindfoot

A 62-year-old woman complains of progressive medial foot pain and flattening of her arch. On examination, she has a "too many toes" sign and cannot perform a single-limb heel rise. Radiographs demonstrate a flexible pes planus deformity without degenerative changes in the subtalar or talonavicular joints. What is the most appropriate surgical treatment?

. Flexor digitorum longus transfer and medial displacement calcaneal osteotomy
. Subtalar arthrodesis
. Triple arthrodesis
. Talonavicular arthrodesis
. Gastrocnemius recession alone

Correct Answer & Explanation

. Flexor digitorum longus transfer and medial displacement calcaneal osteotomy

Explanation

Stage II adult-acquired flatfoot deformity involves a flexible hindfoot without arthritis. Appropriate surgical management includes a flexor digitorum longus (FDL) transfer to replace the diseased posterior tibial tendon, combined with a medial displacement calcaneal osteotomy to correct the valgus.

Question 452

Topic: Midfoot & Hindfoot

A 24-year-old football player suffers a purely ligamentous Lisfranc injury. He undergoes surgery. Which of the following has been shown to provide superior functional outcomes for purely ligamentous Lisfranc injuries compared to internal fixation?

. Primary arthrodesis
. Non-weight bearing cast for 8 weeks
. Closed reduction and percutaneous pinning
. Spanning external fixation
. Bridge plating

Correct Answer & Explanation

. Primary arthrodesis

Explanation

Primary arthrodesis of the first, second, and third tarsometatarsal joints provides superior functional outcomes and lower revision rates compared to ORIF for purely ligamentous Lisfranc injuries.

Question 453

Topic: Midfoot & Hindfoot

A 60-year-old female presents with medial ankle pain and a progressive flatfoot. She is unable to perform a single heel raise. Examination shows a flexible hindfoot valgus and forefoot abduction. What is the most appropriate surgical treatment?

. FDL transfer alone
. FDL transfer and medial displacement calcaneal osteotomy
. Triple arthrodesis
. Subtalar arthrodesis
. Spring ligament repair alone

Correct Answer & Explanation

. FDL transfer alone

Explanation

For Stage II posterior tibial tendon dysfunction (flexible deformity, inability to perform heel raise), a flexor digitorum longus (FDL) transfer combined with a medial displacement calcaneal osteotomy (MDCO) is the standard treatment.

Question 454

Topic: Midfoot & Hindfoot

A 20-year-old track athlete presents with chronic midfoot pain. A CT scan reveals a non-displaced stress fracture of the central third of the navicular. What anatomical factor contributes most to the high risk of nonunion in this specific area?

. High tensile forces from the posterior tibial tendon insertion
. An avascular watershed zone in the central third of the navicular
. Continuous compressive forces from the talonavicular joint
. Lack of periosteum on the dorsal surface
. Insertional forces from the anterior tibial tendon

Correct Answer & Explanation

. High tensile forces from the posterior tibial tendon insertion

Explanation

The central third of the navicular is a relative vascular watershed zone between the branches of the dorsalis pedis and medial plantar arteries, strongly predisposing this region to delayed union or nonunion.

Question 455

Topic: Midfoot & Hindfoot

A 55-year-old female presents with progressive medial ankle pain and a new-onset flatfoot deformity. Examination shows weakness with single-leg heel rise but a flexible hindfoot that corrects to neutral. What is the most appropriate surgical intervention?

. Subtalar arthrodesis
. Triple arthrodesis
. FDL transfer combined with a medializing calcaneal osteotomy
. Gastrocnemius recession alone
. First tarsometatarsal arthrodesis

Correct Answer & Explanation

. Subtalar arthrodesis

Explanation

For Stage II (flexible) adult-acquired flatfoot deformity secondary to posterior tibial tendon dysfunction, a joint-sparing reconstruction using an FDL transfer and a medializing calcaneal osteotomy is the standard of care.

Question 456

Topic: Midfoot & Hindfoot

A 60-year-old diabetic male presents with a swollen, erythematous, and warm unilateral foot without an open ulcer or signs of systemic infection. Radiographs show osseous fragmentation and joint subluxation at the midfoot. What is the most appropriate initial management?

. Intravenous antibiotics
. Immediate midfoot arthrodesis
. Total contact casting and strict non-weight-bearing
. Below-knee amputation
. Excisional debridement of bone debris

Correct Answer & Explanation

. Intravenous antibiotics

Explanation

This patient presents with acute Eichenholtz stage I (fragmentation) Charcot arthropathy. The gold standard for initial management is immediate immobilization and offloading, typically via a total contact cast, until the acute inflammatory phase resolves.

Question 457

Topic: Midfoot & Hindfoot

A 55-year-old female presents with medial foot pain and progressive flattening of her arch. She is unable to perform a single-leg heel rise. Examination reveals flexible hindfoot valgus and midfoot abduction. Which surgical intervention is most appropriate for this stage of Adult Acquired Flatfoot Deformity (Stage II)?

. Isolated debridement of the posterior tibial tendon
. Triple arthrodesis
. Flexor digitorum longus (FDL) transfer with a medializing calcaneal osteotomy
. Talonavicular arthrodesis
. Subtalar arthrodesis

Correct Answer & Explanation

. Isolated debridement of the posterior tibial tendon

Explanation

Stage II posterior tibial tendon dysfunction (PTTD) is characterized by a flexible deformity. It is optimally treated with joint-sparing procedures such as an FDL transfer to the navicular combined with a medializing calcaneal osteotomy to correct the hindfoot valgus.

Question 458

Topic: Midfoot & Hindfoot

A 35-year-old female sustains a purely ligamentous Lisfranc injury involving the first, second, and third tarsometatarsal joints. Which of the following surgical interventions provides superior functional outcomes and lower revision rates for purely ligamentous injuries?

. Open reduction and internal fixation with transarticular screws
. Primary arthrodesis of the medial column (1st, 2nd, and 3rd TMT joints)
. Closed reduction and percutaneous pinning
. Dorsal bridge plating without joint decortication
. Spanning external fixation

Correct Answer & Explanation

. Open reduction and internal fixation with transarticular screws

Explanation

Prospective randomized trials demonstrate that primary arthrodesis of the medial rays in purely ligamentous Lisfranc injuries yields better functional outcomes. It also significantly lowers hardware removal and revision rates compared to ORIF.

Question 459

Topic: Midfoot & Hindfoot

A 50-year-old woman presents with medial ankle pain and an acquired flatfoot deformity. Examination reveals a flexible hindfoot valgus. Weight-bearing radiographs show greater than 30% uncoverage of the talar head on the AP view, indicating significant forefoot abduction. She has failed conservative management. Which surgical reconstruction is most appropriate for this Stage IIb posterior tibial tendon dysfunction?

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

Correct Answer & Explanation

. Medial displacement calcaneal osteotomy (MDCO) alone

Explanation

Stage IIb posterior tibial tendon dysfunction is characterized by a flexible flatfoot with severe forefoot abduction (>30% talonavicular uncoverage). It is best addressed with FDL transfer, medializing calcaneal osteotomy, and a lateral column lengthening to correct the abduction.

Question 460

Topic: Midfoot & Hindfoot

A 45-year-old man presents with chronic heel pain that worsens at the end of the day. He has focal tenderness over the medial calcaneal tuberosity, and compression reproduces radiating pain. EMG reveals denervation of the abductor digiti minimi muscle. Which nerve is most likely entrapped?

. Medial plantar nerve
. First branch of the lateral plantar nerve
. Sural nerve
. Deep peroneal nerve
. Saphenous nerve

Correct Answer & Explanation

. Medial plantar nerve

Explanation

Baxter's nerve is the first branch of the lateral plantar nerve. Entrapment of this nerve typically causes chronic heel pain mimicking severe plantar fasciitis and leads to selective denervation of the abductor digiti minimi.

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