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Midfoot & Hindfoot MCQs

Practice Set 25 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 481

Topic: Midfoot & Hindfoot
A 32-year-old snowboarder sustains a high-energy forced dorsiflexion injury to his right ankle. Radiographs and CT imaging reveal a Hawkins type III fracture of the talar neck. Based on the Hawkins classification, what does a type III fracture specifically indicate?
. Undisplaced fracture of the talar neck
. Displaced talar neck fracture with subtalar subluxation or dislocation
. Displaced talar neck fracture with subtalar and tibiotalar dislocations
. Displaced talar neck fracture with subtalar, tibiotalar, and talonavicular dislocations
. Osteochondral fracture of the talar dome

Correct Answer & Explanation

. Displaced talar neck fracture with subtalar and tibiotalar dislocations

Explanation

The Hawkins classification for talar neck fractures is: Type I (nondisplaced), Type II (displaced with subtalar joint subluxation/dislocation), Type III (displaced with both subtalar and tibiotalar joint dislocations), and Type IV (Type III plus talonavicular joint dislocation). Type III injuries carry a very high risk of avascular necrosis (AVN) of the talar body.

Question 482

Topic: Midfoot & Hindfoot
A 55-year-old female presents with progressive flatfoot deformity. Examination shows she is unable to perform a single-leg heel raise, has flexible hindfoot valgus, and forefoot abduction covering >40% of the talar head. What is the most appropriate surgical management?
. Spring ligament repair alone
. Flexor digitorum longus transfer and medial displacement calcaneal osteotomy
. Flexor digitorum longus transfer, medial displacement calcaneal osteotomy, and lateral column lengthening
. Triple arthrodesis
. Tibiotalocalcaneal arthrodesis

Correct Answer & Explanation

. Flexor digitorum longus transfer, medial displacement calcaneal osteotomy, and lateral column lengthening

Explanation

Stage IIb posterior tibial tendon dysfunction involves flexible pes planovalgus with significant forefoot abduction (>40% talonavicular uncoverage). Management requires a lateral column lengthening (e.g., Evans osteotomy) to correct abduction, along with FDL transfer and medial calcaneal displacement.

Question 483

Topic: Midfoot & Hindfoot

A 60-year-old patient with poorly controlled diabetes presents with a swollen, erythematous, and warm foot. Radiographs reveal fragmentation and periarticular debris at the tarsometatarsal joints without ulceration. What is the most appropriate initial management?

. Intravenous antibiotics and surgical debridement
. Total contact casting and non-weight-bearing
. Open reduction and internal fixation of the midfoot
. Arthrodesis of the midfoot with external fixation
. Charcot Restraint Orthotic Walker (CROW) boot and weight-bearing as tolerated

Correct Answer & Explanation

. Total contact casting and non-weight-bearing

Explanation

The patient is in the acute fragmentation phase (Eichenholtz Stage 1) of Charcot arthropathy. The gold standard initial treatment to prevent progressive deformity is immobilization with a total contact cast and strict non-weight-bearing until the acute phase resolves.

Question 484

Topic: Midfoot & Hindfoot

A 34-year-old female runner presents with chronic heel pain and tenderness at the medial calcaneal tuberosity. MRI confirms severe plantar fasciitis. If she develops compression of the first branch of the lateral plantar nerve, the function of which muscle is most directly compromised?

. Abductor hallucis
. Flexor digitorum brevis
. Abductor digiti minimi
. Quadratus plantae
. Adductor hallucis

Correct Answer & Explanation

. Abductor digiti minimi

Explanation

Baxter's nerve (first branch of the lateral plantar nerve) innervates the abductor digiti minimi. It can become entrapped between the deep fascia of the abductor hallucis and the medial head of the quadratus plantae in severe plantar fasciitis.

Question 485

Topic: Midfoot & Hindfoot
According to the Hawkins classification of talar neck fractures, a Type III fracture is defined by displacement of the talar neck with subluxation or dislocation of which specific joints?
. Subtalar joint only
. Subtalar and tibiotalar joints
. Subtalar, tibiotalar, and talonavicular joints
. Tibiotalar joint only
. Talonavicular joint only

Correct Answer & Explanation

. Subtalar and tibiotalar joints

Explanation

Hawkins Type III describes a talar neck fracture with dislocation of both the subtalar and tibiotalar joints. Type IV involves the additional dislocation of the talonavicular joint.

Question 486

Topic: Midfoot & Hindfoot
A 60-year-old diabetic patient presents with a red, swollen, and warm foot without skin ulceration. Radiographs show bone fragmentation, periarticular debris, and subluxation at the tarsometatarsal joints. According to the Eichenholtz classification, what stage of Charcot arthropathy does this represent?
. Stage 0 (High risk)
. Stage I (Development/Fragmentation)
. Stage II (Coalescence)
. Stage III (Reconstruction/Consolidation)
. Stage IV (Degenerative)

Correct Answer & Explanation

. Stage I (Development/Fragmentation)

Explanation

Eichenholtz Stage I is the active development phase characterized by a hot, swollen foot and radiographs demonstrating bone fragmentation, joint subluxation, and bony debris.

Question 487

Topic: Midfoot & Hindfoot

A 28-year-old female presents with medial midfoot pain and flatfoot deformity. Exam shows a prominent navicular tuberosity. Radiographs demonstrate a Type II accessory navicular. Which tendon inserts onto this accessory bone, potentially leading to its dysfunction?

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

Correct Answer & Explanation

. Posterior tibial tendon

Explanation

The posterior tibial tendon frequently inserts into a Type II accessory navicular. This abnormal insertion alters the tendon's mechanical advantage, predisposing it to tendinopathy and adult acquired flatfoot deformity.

Question 488

Topic: Midfoot & Hindfoot

What is the most common complication following an isolated talonavicular arthrodesis for midfoot arthritis?

. Avascular necrosis of the navicular
. Nonunion
. Sural nerve injury
. Dorsal midfoot impingement
. Subtalar arthritis

Correct Answer & Explanation

. Nonunion

Explanation

Isolated talonavicular arthrodesis has a historically high nonunion rate, often cited between 10-30%. This is due to complex biomechanical shear forces and the watershed blood supply of the navicular.

Question 489

Topic: Midfoot & Hindfoot

A 50-year-old woman presents with a flexible, adult-acquired flatfoot deformity (Stage II posterior tibial tendon dysfunction) that has not responded to custom orthotics. What is the gold standard surgical reconstruction?

. Isolated subtalar arthrodesis
. Triple arthrodesis
. Flexor digitorum longus (FDL) transfer combined with a medial displacement calcaneal osteotomy
. Tibialis anterior tendon transfer to the navicular
. Isolated talonavicular arthrodesis

Correct Answer & Explanation

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

Explanation

Stage II posterior tibial tendon dysfunction is characterized by a flexible deformity. The standard joint-sparing reconstruction consists of an FDL tendon transfer to substitute for the torn posterior tibial tendon, paired with a medial displacement calcaneal osteotomy to correct the mechanical axis.

Question 490

Topic: Midfoot & Hindfoot

A 45-year-old runner has severe inferior heel pain for 12 months, refractory to stretching, orthotics, and corticosteroid injections. If surgical intervention is pursued, which structure is typically released?

. The entire plantar fascia
. The medial one-third to one-half of the plantar fascia
. The lateral band of the plantar fascia
. The abductor digiti minimi fascia
. The flexor digitorum brevis origin

Correct Answer & Explanation

. The medial one-third to one-half of the plantar fascia

Explanation

Surgical treatment for recalcitrant plantar fasciitis involves a partial release of the medial one-third to one-half of the plantar fascia. Releasing the entire fascia risks severe arch destabilization and lateral column overload.

Question 491

Topic: Midfoot & Hindfoot

In a 45-year-old active male with a purely ligamentous Lisfranc injury involving the 1st, 2nd, and 3rd tarsometatarsal joints, which treatment has been shown to have lower rates of hardware removal and higher functional scores at medium-term follow-up compared to ORIF?

. Closed reduction and percutaneous pinning.
. Non-weight bearing cast for 8 weeks.
. Dorsal bridge plating.
. Suture-button fixation of the Lisfranc ligament.
. Primary arthrodesis of the medial three rays.

Correct Answer & Explanation

. Primary arthrodesis of the medial three rays.

Explanation

Primary arthrodesis for purely ligamentous Lisfranc injuries reduces the need for hardware removal and avoids the late midfoot arthrosis commonly associated with ORIF. Studies show comparable or superior functional outcomes in these patients.

Question 492

Topic: Midfoot & Hindfoot
A 50-year-old woman has flexible flatfoot, is unable to perform a single-leg heel raise, and has significant forefoot abduction (>40% talonavicular uncoverage). Which surgical combination is most appropriate for this Stage IIb posterior tibial tendon dysfunction?
. FDL transfer and medial displacement calcaneal osteotomy (MDCO).
. Triple arthrodesis.
. FDL transfer, MDCO, and lateral column lengthening.
. Isolated subtalar arthrodesis.
. Spring ligament repair alone.

Correct Answer & Explanation

. FDL transfer, MDCO, and lateral column lengthening.

Explanation

Stage IIb PTTD involves a flexible deformity with significant forefoot abduction. This is best addressed with FDL transfer, medial displacement calcaneal osteotomy, and lateral column lengthening (e.g., Evans osteotomy) to specifically correct the abduction.

Question 493

Topic: Midfoot & Hindfoot
A 55-year-old female presents with a progressive, painful flatfoot deformity of her right foot that has failed 6 months of conservative management with custom orthotics. Clinical examination demonstrates a flexible hindfoot valgus and an inability to perform a single-limb heel rise. Radiographs demonstrate advanced collapse of the medial longitudinal arch with 45% uncoverage of the talonavicular joint on the weight-bearing AP view. Which of the following surgical strategies is most appropriate?
. Flexor digitorum longus (FDL) transfer to the navicular and a medial displacement calcaneal osteotomy (MDCO) only
. Gastrocnemius recession and a lateral column lengthening only
. Flexor digitorum longus (FDL) transfer, medial displacement calcaneal osteotomy (MDCO), and lateral column lengthening
. Triple arthrodesis (subtalar, talonavicular, and calcaneocuboid)
. Talonavicular arthrodesis with a split anterior tibialis tendon transfer (SPLATT)

Correct Answer & Explanation

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

Explanation

This patient has Stage IIb Adult Acquired Flatfoot Deformity (posterior tibial tendon dysfunction). Stage II is characterized by a flexible deformity. Stage IIa has minimal forefoot abduction, typically managed with FDL transfer and MDCO. Stage IIb is defined by significant forefoot abduction (>30% talonavicular uncoverage). To adequately address the multiplanar deformity in Stage IIb, a lateral column lengthening (e.g., Evans osteotomy) must be added to the FDL transfer and MDCO to correct the transverse plane deformity (forefoot abduction). A triple arthrodesis is reserved for Stage III (rigid) deformities.

Question 494

Topic: Midfoot & Hindfoot

A 35-year-old male sustains a purely ligamentous Lisfranc injury. After nonoperative management fails to provide a stable arch, surgical intervention is discussed. Compared to primary open reduction and internal fixation (ORIF), recent literature suggests that primary arthrodesis for purely ligamentous Lisfranc injuries provides which of the following advantages?

. A significantly shorter period of non-weight bearing
. Decreased rates of subsequent and revision surgeries
. Superior restoration of the longitudinal arch height
. Lower risk of nonunion in the medial column
. Preservation of normal midfoot kinematics

Correct Answer & Explanation

. Decreased rates of subsequent and revision surgeries

Explanation

Multiple prospective, randomized studies (e.g., Ly and Coetzee) have demonstrated that primary arthrodesis for purely ligamentous Lisfranc injuries results in fewer subsequent surgeries. Patients undergoing ORIF frequently require a second procedure for hardware removal and have a higher rate of secondary surgeries for post-traumatic midfoot arthritis. Functional outcomes in the primary arthrodesis group are generally equivalent to or better than those in the ORIF group for purely ligamentous injuries.

Question 495

Topic: Midfoot & Hindfoot
A 52-year-old female presents with a progressive flatfoot deformity. Examination shows a flexible hindfoot valgus and inability to perform a single-leg heel raise. Additionally, there is uncovering of the talonavicular joint (more than 40%) on AP weight-bearing radiographs, indicative of severe forefoot abduction. She has failed prolonged brace management. What combination of procedures is most appropriate?
. Flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy (MDCO)
. FDL transfer, MDCO, and lateral column lengthening
. Subtalar arthrodesis
. Triple arthrodesis
. Tibialis anterior transfer and medial cuneiform osteotomy

Correct Answer & Explanation

. FDL transfer, MDCO, and lateral column lengthening

Explanation

This patient has Stage IIb posterior tibial tendon dysfunction (PTTD), characterized by a flexible deformity with severe forefoot abduction (talonavicular uncoverage > 30-40%). Management typically involves a soft tissue transfer (FDL to navicular) to replace the diseased posterior tibial tendon, a medial displacement calcaneal osteotomy (MDCO) to correct hindfoot valgus, and a lateral column lengthening (e.g., Evans osteotomy) to correct the severe forefoot abduction. Stage IIa (minimal abduction) can often be treated with FDL transfer and MDCO alone. Rigid deformities (Stage III) require arthrodesis.

Question 496

Topic: Midfoot & Hindfoot
A 60-year-old female presents with a progressive, painful flatfoot deformity. Clinical examination demonstrates a positive 'too many toes' sign, an inability to perform a single-limb heel rise, and a flexible hindfoot that corrects to neutral passively. Radiographs show significant collapse of the medial longitudinal arch and 45% lateral uncovering of the talonavicular joint on the AP view. What is the most appropriate surgical intervention for this specific stage of adult-acquired flatfoot deformity?
. Flexor digitorum longus (FDL) transfer to the navicular and gastrocnemius recession
. Medializing calcaneal osteotomy, lateral column lengthening, FDL transfer, and Achilles lengthening
. Triple arthrodesis
. Isolated talonavicular arthrodesis
. Subtalar arthrodesis and Spring ligament repair

Correct Answer & Explanation

. Medializing calcaneal osteotomy, lateral column lengthening, FDL transfer, and Achilles lengthening

Explanation

This patient presents with Stage IIb adult-acquired flatfoot deformity (posterior tibial tendon dysfunction). Stage II signifies a flexible hindfoot deformity. Stage II is further subdivided: IIa has minimal forefoot abduction, while IIb has significant forefoot abduction (typically >30-40% talonavicular uncovering on AP radiographs). For Stage IIa, an FDL transfer + medializing calcaneal osteotomy (MCO) is often sufficient. For Stage IIb, the significant forefoot abduction requires addressing the lateral column; therefore, a lateral column lengthening (e.g., Evans osteotomy) is indicated in addition to the MCO, FDL transfer, and heel cord lengthening. Triple arthrodesis (Option C) is reserved for Stage III (rigid deformity).

Question 497

Topic: Midfoot & Hindfoot

A 38-year-old warehouse worker sustains a crush injury to his foot. Radiographs and a subsequent CT scan demonstrate a highly comminuted, intra-articular fracture-dislocation involving the first, second, and third tarsometatarsal joints (Lisfranc injury). The articular surfaces of the medial and middle cuneiforms are extensively fragmented and impacted. What is the most appropriate definitive surgical management to minimize the need for future procedures?

. Closed reduction and percutaneous pinning with K-wires
. Open reduction and internal fixation (ORIF) with transarticular solid screws
. Open reduction and internal fixation (ORIF) using dorsal spanning plates
. Primary arthrodesis of the first, second, and third tarsometatarsal joints
. External fixation spanning the midfoot to allow secondary healing

Correct Answer & Explanation

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

Explanation

While Open Reduction and Internal Fixation (ORIF) has historically been the standard for bony Lisfranc injuries, primary arthrodesis is strongly indicated in specific scenarios to avoid post-traumatic osteoarthritis and subsequent revision surgery. The classic indications for primary arthrodesis of the medial columns (1st, 2nd, and 3rd TMT joints) in Lisfranc injuries include purely ligamentous injuries and injuries with severe, non-reconstructable intra-articular comminution. Given the extensive fragmentation and impaction of the articular surfaces in this patient, ORIF would almost certainly lead to early joint degeneration. Primary arthrodesis yields better mid- to long-term functional outcomes in this specific highly comminuted pattern.

Question 498

Topic: Midfoot & Hindfoot
A 55-year-old female presents with a painful, progressive flatfoot deformity. On examination, she is completely unable to perform a single-leg heel raise on the affected side. Her hindfoot rests in valgus but is manually correctable to neutral. Weight-bearing anteroposterior radiographs demonstrate >40% lateral subluxation (uncovering) of the talonavicular joint. In addition to a flexor digitorum longus (FDL) transfer to the navicular, which of the following osseous procedures is most appropriate?
. Triple arthrodesis
. Medial displacement calcaneal osteotomy combined with lateral column lengthening
. Isolated subtalar arthrodesis
. First tarsometatarsal arthrodesis (Lapidus)
. Isolated gastrocnemius recession

Correct Answer & Explanation

. Medial displacement calcaneal osteotomy combined with lateral column lengthening

Explanation

This patient has Stage IIb posterior tibial tendon dysfunction (PTTD), characterized by a flexible hindfoot valgus deformity and significant forefoot abduction (indicated by >40% talonavicular uncovering on the AP view). An isolated FDL transfer and medial displacement calcaneal osteotomy (MDCO) can address the hindfoot valgus but are insufficient to correct the severe forefoot abduction. Therefore, a lateral column lengthening (e.g., Evans osteotomy or calcaneocuboid distraction arthrodesis) must be added to swing the forefoot medially and restore talonavicular coverage. A triple arthrodesis is reserved for Stage III PTTD, where the deformity has become rigid.

Question 499

Topic: Midfoot & Hindfoot
A 55-year-old female presents with a painful, progressive flatfoot deformity. Examination shows a valgus hindfoot, prominent medial eminence, and 'too many toes' sign laterally. She has 45% uncovering of the talonavicular joint on weight-bearing AP radiographs. She is unable to perform a single-leg heel raise. The hindfoot remains flexible to manual reduction. Which of the following surgical procedures is most appropriate for this patient?
. FDL to navicular transfer and medial displacement calcaneal osteotomy alone
. Triple arthrodesis
. FDL transfer, medial displacement calcaneal osteotomy, and lateral column lengthening
. Isolated subtalar arthrodesis
. Gastrocnemius recession and orthotic management only

Correct Answer & Explanation

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

Explanation

This patient has Stage IIb adult acquired flatfoot deformity (posterior tibial tendon dysfunction). Stage IIb is characterized by a flexible hindfoot with significant forefoot abduction (>40% talonavicular uncovering). Appropriate operative management requires correcting both the hindfoot valgus and the forefoot abduction. This is reliably achieved with a flexor digitorum longus (FDL) transfer, a medializing calcaneal osteotomy, and a lateral column lengthening (e.g., Evans osteotomy). Triple arthrodesis is reserved for rigid (Stage III) deformities.

Question 500

Topic: Midfoot & Hindfoot
A 30-year-old male is involved in a high-speed motor vehicle collision and sustains a talar neck fracture with subluxation of the subtalar joint and complete dislocation of the tibiotalar joint. The talonavicular joint remains anatomically reduced. According to the Hawkins classification, what type of fracture is this, and what is the approximate risk of avascular necrosis (AVN) of the talar body?
. Type I; 0-10% risk of AVN
. Type II; 20-50% risk of AVN
. Type III; >75% risk of AVN
. Type IV; 100% risk of AVN
. Type II; >75% risk of AVN

Correct Answer & Explanation

. Type II; 20-50% risk of AVN

Explanation

The Hawkins classification describes talar neck fractures: Type I is non-displaced (0-10% AVN risk). Type II is a talar neck fracture with subtalar dislocation or subluxation (20-50% AVN risk). Type III involves subtalar and tibiotalar dislocation (>75% AVN risk, sometimes quoted as 75-90% in modern series). Type IV involves subtalar, tibiotalar, and talonavicular dislocation.

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