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Midfoot & Hindfoot MCQs

Practice Set 26 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 501

Topic: Midfoot & Hindfoot
A 55-year-old female presents with medial foot pain and a progressive flatfoot deformity. Examination shows a flexible hindfoot valgus and inability to perform a single-leg heel raise. Weight-bearing radiographs demonstrate >40% uncovering of the talonavicular joint. If conservative management fails, which of the following surgical interventions is most appropriate?
. Flexor digitorum longus (FDL) transfer to the navicular alone
. FDL transfer, medial displacement calcaneal osteotomy (MDCO), and lateral column lengthening
. Primary triple arthrodesis
. Isolated subtalar arthrodesis
. Gastrocnemius recession alone

Correct Answer & Explanation

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

Explanation

The patient has Stage IIb adult acquired flatfoot deformity (posterior tibial tendon dysfunction), characterized by a flexible hindfoot valgus and forefoot abduction (>40% talonavicular uncoverage). Surgical correction requires addressing both the medial column weakness and the biomechanical deformity. An FDL transfer addresses the tendon deficiency, an MDCO corrects the hindfoot valgus, and a lateral column lengthening corrects the severe forefoot abduction.

Question 502

Topic: Midfoot & Hindfoot

A 58-year-old male with poorly controlled type II diabetes presents with a swollen, erythematous, and warm right foot. He denies any trauma. Radiographs reveal periarticular fragmentation, subluxation of the tarsometatarsal joints, and osseous debris. According to the Eichenholtz classification, what stage does this represent, and what is the standard initial treatment?

. Stage 0; immediate open reduction and internal fixation
. Stage 1 (Developmental); total contact casting and non-weight bearing
. Stage 2 (Coalescence); custom orthoses and weight bearing as tolerated
. Stage 3 (Reconstruction); primary arthrodesis
. Stage 1 (Developmental); intravenous antibiotics and irrigation and debridement

Correct Answer & Explanation

. Stage 1 (Developmental); total contact casting and non-weight bearing

Explanation

This clinical and radiographic picture characterizes Eichenholtz Stage 1 (Developmental/Fragmentation) Charcot arthropathy. It is marked by joint edema, warmth, periarticular fragmentation, debris, and subluxation/dislocation. The standard of care in the acute active phase is immobilization (Total Contact Cast) and strict non-weight bearing to prevent further deformity until the active phase transitions to coalescence (Stage 2).

Question 503

Topic: Midfoot & Hindfoot

A 55-year-old female presents with progressive, painful flatfoot deformity. Examination reveals a flexible hindfoot valgus and an inability to perform a single-limb heel rise. When viewing the foot from behind, 'too many toes' are visible. Radiographs demonstrate an uncoverage of the talar head of 45%. Which of the following surgical strategies is most appropriate for addressing this specific stage of adult acquired flatfoot deformity?

. Flexor digitorum longus (FDL) transfer to the navicular and spring ligament repair alone
. Medial displacement calcaneal osteotomy and FDL transfer
. Lateral column lengthening, medial displacement calcaneal osteotomy, and FDL transfer
. Isolated subtalar arthrodesis
. Triple arthrodesis

Correct Answer & Explanation

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

Explanation

This patient has Stage IIb adult-acquired flatfoot deformity (posterior tibial tendon dysfunction). Stage IIb is differentiated from Stage IIa by the presence of significant forefoot abduction (typically >30% talonavicular uncoverage). While Stage IIa can be treated with a medial displacement calcaneal osteotomy (MDCO) and FDL transfer, Stage IIb requires the addition of a lateral column lengthening (e.g., Evans osteotomy) to adequately correct the transverse plane deformity (forefoot abduction).

Question 504

Topic: Midfoot & Hindfoot

A 55-year-old poorly controlled diabetic male presents with a red, hot, swollen right foot. Radiographs reveal fragmentation of the navicular and cuneiforms with a collapse of the medial longitudinal arch. Laboratory markers show a normal white blood cell count and a mildly elevated ESR. He is diagnosed with acute Eichenholtz stage I Charcot arthropathy. What is the most appropriate initial management?

. Urgent surgical debridement and external fixation
. Intravenous antibiotics and bone biopsy
. Total contact casting and non-weight-bearing
. Midfoot arthrodesis with robust internal fixation
. Corticosteroid injection into the midfoot joints

Correct Answer & Explanation

. Total contact casting and non-weight-bearing

Explanation

Acute (Eichenholtz stage I) Charcot arthropathy presents with erythema, edema, and warmth, often mimicking an infection. Treatment in the acute phase is strict immobilization with total contact casting and non-weight-bearing to prevent further deformity until the active inflammatory phase resolves. Surgery is generally contraindicated in the acute phase due to severe osteopenia and the high risk of hardware failure, unless there is severe instability threatening the soft tissue envelope or an associated deep infection.

Question 505

Topic: Midfoot & Hindfoot
A 32-year-old male sustains a severe hyperdorsiflexion injury to his right ankle in a motor vehicle collision. Radiographs reveal a displaced talar neck fracture with subluxation of the subtalar joint, but the ankle mortise and talonavicular joints remain congruent. According to the Hawkins classification, what is the approximate risk of developing avascular necrosis (AVN) of the talar body?
. 0 - 15%
. 20 - 50%
. 70 - 100%
. 100%

Correct Answer & Explanation

. 20 - 50%

Explanation

The patient has a Hawkins Type II fracture, defined as a talar neck fracture with subtalar subluxation or dislocation. The risk of AVN for Type I (nondisplaced) is 0-15%. For Type II, it increases to 20-50%. For Type III (subtalar and tibiotalar dislocation), it is 70-100%. Type IV (addition of talonavicular dislocation) also carries a near 100% risk of AVN.

Question 506

Topic: Midfoot & Hindfoot
A 35-year-old male is involved in a high-speed motor vehicle collision and sustains a displaced talar neck fracture. Radiographs show a fracture of the talar neck with subluxation of the subtalar joint, while the tibiotalar and talonavicular joints remain concentrically reduced. According to the Hawkins classification, what is the grade of this injury and the approximate historically reported risk of developing avascular necrosis (AVN) of the talar body?
. Hawkins I; 0-10%
. Hawkins II; 20-50%
. Hawkins III; 80-100%
. Hawkins IV; 100%
. Hawkins II; 80-100%

Correct Answer & Explanation

. Hawkins II; 20-50%

Explanation

The Hawkins classification is used for talar neck fractures. Type I is non-displaced (0-10% AVN risk). Type II involves subtalar subluxation or dislocation with a reduced ankle joint (historically 20-50% AVN risk). Type III involves dislocation of both the subtalar and tibiotalar joints (historically >80% AVN risk). Type IV (added by Canale and Kelly) involves subtalar, tibiotalar, and talonavicular dislocation (nearly 100% AVN risk). The scenario describes a Type II fracture.

Question 507

Topic: Midfoot & Hindfoot
A 55-year-old female presents with progressive flattening of her left foot, medial arch pain, and an inability to perform a single-leg heel raise. Examination reveals a flexible flatfoot deformity with notable forefoot abduction. Weight-bearing radiographs reveal greater than 40% uncovering of the talonavicular joint on the AP view. Non-operative management has failed. Which of the following surgical strategies is most appropriate?
. Isolated posterior tibial tendon debridement
. Flexor digitorum longus (FDL) transfer to the navicular and medial displacement calcaneal osteotomy (MDCO)
. FDL transfer, MDCO, and lateral column lengthening
. Isolated triple arthrodesis
. Isolated talonavicular arthrodesis

Correct Answer & Explanation

. FDL transfer, MDCO, and lateral column lengthening

Explanation

The patient has Stage IIb adult acquired flatfoot deformity (AAFD) / posterior tibial tendon dysfunction. Stage II indicates a flexible deformity. Stage IIb is distinguished from IIa by the presence of significant forefoot abduction (typically >30-40% talonavicular uncoverage on AP radiograph). Surgical management for Stage IIb requires addressing the transverse plane deformity (forefoot abduction) through a lateral column lengthening (e.g., Evans osteotomy) in addition to an FDL transfer and MDCO. Triple arthrodesis is reserved for Stage III (rigid) deformity.

Question 508

Topic: Midfoot & Hindfoot
A 55-year-old female presents with progressive medial foot pain and a flatfoot deformity. Clinical examination reveals a flexible pes planovalgus deformity, an inability to perform a single heel rise, and tenderness directly along the course of the posterior tibial tendon. Radiographs show a talonavicular uncoverage angle of 20 degrees. Following a failed 6-month trial of conservative management with customized orthotics and physical therapy, which of the following is the most appropriate surgical intervention?
. Flexor digitorum longus (FDL) transfer to the navicular, medial displacement calcaneal osteotomy, and gastrocnemius recession
. Subtalar arthrodesis with isolated posterior tibial tendon debridement
. Triple arthrodesis (subtalar, talonavicular, and calcaneocuboid)
. Isolated naviculocuneiform arthrodesis
. Tenodesis of the posterior tibial tendon to the flexor hallucis longus (FHL) tendon

Correct Answer & Explanation

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

Explanation

This patient presents with Stage II posterior tibial tendon dysfunction (PTTD), characterized by a flexible flatfoot deformity and the inability to perform a single heel rise. When conservative management fails, joint-sparing flatfoot reconstruction is indicated. The standard of care includes soft tissue reconstruction (FDL transfer to the navicular to replace the incompetent PTT) combined with bony procedures to correct the deformity (medial displacement calcaneal osteotomy) and addressing equinus contracture (gastrocnemius recession or Achilles tendon lengthening). Triple arthrodesis is reserved for rigid deformities (Stage III) or significant arthritic changes.

Question 509

Topic: Midfoot & Hindfoot
A 30-year-old male is brought to the trauma bay following a high-speed motorcycle collision. Plain radiographs reveal a displaced fracture of the talar neck with complete dislocation of both the subtalar and tibiotalar joints. According to the Hawkins classification, what is the grade of this injury and its historically associated risk of avascular necrosis (AVN) of the talar body?
. Hawkins Type I; 0-10% risk of AVN
. Hawkins Type II; 20-50% risk of AVN
. Hawkins Type III; near 100% risk of AVN
. Hawkins Type IV; 20-50% risk of AVN
. Hawkins Type I; near 100% risk of AVN

Correct Answer & Explanation

. Hawkins Type III; near 100% risk of AVN

Explanation

The Hawkins classification is used for talar neck fractures and predicts the risk of avascular necrosis (AVN). Type I is non-displaced (0-10% AVN). Type II involves subtalar subluxation or dislocation (20-50% AVN). Type III involves dislocation of both the subtalar and tibiotalar joints, historically carrying an AVN rate approaching 100%, though modern fixation techniques have slightly reduced this. Type IV (added by Canale and Kelly) includes subtalar, tibiotalar, and talonavicular dislocation.

Question 510

Topic: Midfoot & Hindfoot
A 55-year-old female presents with progressive flattening of her left foot, medial-sided pain, and an inability to perform a single-leg heel raise. Clinical examination demonstrates a flexible hindfoot valgus and forefoot abduction. Which of the following is the most appropriate surgical treatment?
. Posterior tibial tendon debridement and tenosynovectomy
. Flexor digitorum longus (FDL) transfer with a medial displacement calcaneal osteotomy
. Subtalar arthrodesis
. Triple arthrodesis
. Tibiotalocalcaneal fusion

Correct Answer & Explanation

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

Explanation

This patient has Stage II posterior tibial tendon dysfunction, characterized by a flexible deformity and an inability to perform a single-leg heel raise. The gold standard surgical management for Stage II is a soft tissue transfer (FDL to navicular or medial cuneiform) combined with a bony procedure to correct the deformity, most commonly a medial displacement calcaneal osteotomy (MDCO). Stage I is treated with conservative care or tenosynovectomy. Stage III involves a rigid deformity requiring triple or isolated hindfoot arthrodesis.

Question 511

Topic: Midfoot & Hindfoot

A 60-year-old male with poorly controlled type 2 diabetes presents with a red, hot, swollen right foot of 3 weeks' duration. He denies ulceration, fevers, or chills. Laboratory studies show normal WBC and CRP. Radiographs demonstrate early fragmentation and periarticular debris at the tarsometatarsal joints. What is the initial treatment of choice?

. Intravenous antibiotics and surgical debridement
. Total contact casting and strict non-weight-bearing
. Midfoot arthrodesis with rigid internal fixation
. Custom orthotic shoe wear
. Below-knee amputation

Correct Answer & Explanation

. Total contact casting and strict non-weight-bearing

Explanation

The presentation is classic for acute (Eichenholtz Stage I) Charcot neuroarthropathy. The absence of an ulcer and normal inflammatory markers make osteomyelitis unlikely. The initial treatment of choice for acute Charcot arthropathy is strict immobilization and offloading, best achieved with a total contact cast (TCC). This prevents further architectural collapse while allowing the acute inflammatory process to consolidate. Surgery is generally contraindicated in the acute inflammatory phase.

Question 512

Topic: Midfoot & Hindfoot

A 30-year-old male sustains a purely ligamentous Lisfranc injury after a fall from a horse. The first and second tarsometatarsal joints are widely displaced. What is the most appropriate definitive management for this specific injury pattern?

. Closed reduction and casting for 6 weeks
. Open reduction and internal fixation (ORIF) with transarticular screws
. Primary arthrodesis of the first, second, and third tarsometatarsal joints
. Dorsal bridge plating of the midfoot
. Primary arthrodesis of the fourth and fifth tarsometatarsal joints

Correct Answer & Explanation

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

Explanation

In purely ligamentous Lisfranc injuries, the interosseous and plantar ligaments are disrupted without substantial bony avulsions, rendering the healing potential poor with simple stabilization. High-level evidence has demonstrated that primary arthrodesis of the medial and middle columns (1st, 2nd, and 3rd tarsometatarsal joints) yields superior functional outcomes, a higher rate of return to pre-injury activity levels, and significantly lower rates of reoperation or hardware failure compared to ORIF. The 4th and 5th TMT joints should be left mobile.

Question 513

Topic: Midfoot & Hindfoot

A 55-year-old female presents with progressive flattening of her left foot, pain along the medial ankle, and inability to perform a single-leg heel raise. Examination reveals a flexible hindfoot valgus and forefoot abduction. Radiographs show uncovering of the talonavicular joint but no arthritic changes. What is the best surgical management if prolonged conservative care fails?

. Posterior tibial tendon debridement and tenosynovectomy
. Flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy (MDCO)
. Lateral column lengthening (Evans osteotomy) in isolation
. Triple arthrodesis
. Isolated subtalar arthrodesis

Correct Answer & Explanation

. Flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy (MDCO)

Explanation

The patient presents with Stage IIA adult-acquired flatfoot deformity (posterior tibial tendon dysfunction), characterized by a flexible deformity without significant arthritic changes in the hindfoot. The standard of care for a symptomatic flexible deformity that fails conservative management is a joint-sparing flatfoot reconstruction. This typically consists of transferring the FDL to substitute for the deficient posterior tibial tendon, combined with an MDCO to correct the mechanical axis of the hindfoot.

Question 514

Topic: Midfoot & Hindfoot

A 58-year-old male with poorly controlled type 2 diabetes presents with a swollen, erythematous, and warm left foot. He denies trauma. X-rays show extensive fragmentation, debris, and subluxation of the midfoot joints. There are no skin ulcers. What is the most appropriate initial management?

. Intravenous antibiotics and emergent surgical debridement
. Total contact casting and strict non-weight-bearing
. Open reduction and internal fixation of the midfoot
. Primary midfoot arthrodesis
. Custom orthotics and supportive shoe wear

Correct Answer & Explanation

. Total contact casting and strict non-weight-bearing

Explanation

The patient's clinical and radiographic presentation is classic for Eichenholtz Stage I (acute fragmentation stage) Charcot arthropathy. The gold standard of treatment at this stage is immediate offloading and immobilization to prevent further mechanical destruction of the midfoot while the severe inflammatory process resolves. This is most effectively achieved with a total contact cast (TCC) and strict non-weight-bearing. Surgery during the acute inflammatory phase is highly discouraged due to the extreme risk of hardware failure.

Question 515

Topic: Midfoot & Hindfoot
A 50-year-old woman presents with progressive medial ankle pain and a severe flatfoot deformity. She is unable to perform a single-limb heel rise on the affected side. Examination reveals a flexible hindfoot with significant forefoot abduction. Weight-bearing radiographs show greater than 40% uncoverage of the talonavicular joint on the AP view. What is the most appropriate operative treatment?
. Flexor digitorum longus (FDL) transfer to the navicular alone
. Medial displacement calcaneal osteotomy (MDCO) + FDL transfer
. FDL transfer + MDCO + lateral column lengthening
. Triple arthrodesis
. Isolated subtalar arthrodesis

Correct Answer & Explanation

. FDL transfer + MDCO + 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, whereas Stage III is rigid. Stage IIB is distinguished from IIA by the presence of significant forefoot abduction (clinically seen as 'too many toes' and radiographically as >30-40% talonavicular uncoverage). To adequately address the forefoot abduction in Stage IIB, a lateral column lengthening (such as an Evans calcaneal osteotomy) is required in addition to a medial displacement calcaneal osteotomy and FDL transfer.

Question 516

Topic: Midfoot & Hindfoot

A 58-year-old man with poorly controlled type 2 diabetes and profound peripheral neuropathy presents with a red, hot, swollen unilateral foot. He denies any prior trauma or fevers. Pulses are palpable and laboratory markers (WBC, CRP) are within normal limits. Radiographs demonstrate periarticular debris, fragmentation of the tarsometatarsal joints, and early subluxation.

What is the most appropriate initial management?

. Urgent irrigation and debridement of the midfoot
. Total contact casting and strict non-weight-bearing
. Open reduction and internal fixation of the midfoot
. Prescription of a Charcot Restraint Orthotic Walker (CROW) and full weight-bearing
. Intravenous antibiotics and observation

Correct Answer & Explanation

. Total contact casting and strict non-weight-bearing

Explanation

The clinical and radiographic picture is pathognomonic for acute Charcot arthropathy (Eichenholtz Stage I - Developmental/Fragmentation phase). There is no clinical or laboratory evidence of acute infection to warrant antibiotics or debridement. The gold standard for initial management of acute active Charcot arthropathy is strict immobilization and offloading, typically achieved with a total contact cast (TCC) to halt the progression of deformity and allow progression to the coalescent and reconstructive phases. CROW boots are utilized in the later, quiescent phases.

Question 517

Topic: Midfoot & Hindfoot
A 55-year-old woman presents with medial ankle pain and progressive flattening of her left foot over the past year. On examination, she has a flexible flatfoot deformity, is unable to perform a single-leg heel raise on the left, and has >40% of the talar head uncovered on the AP weight-bearing radiograph. There is notable forefoot abduction. What is the most appropriate surgical management for this Stage IIb flatfoot deformity after failure of non-operative treatment?
. Gastrocnemius recession, FDL transfer to the navicular, and medial displacement calcaneal osteotomy
. Subtalar arthrodesis
. Gastrocnemius recession, FDL transfer to the navicular, medial displacement calcaneal osteotomy, and lateral column lengthening
. Triple arthrodesis
. Spring ligament repair only

Correct Answer & Explanation

. Gastrocnemius recession, 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 (typically >40% talonavicular uncoverage). Surgical management for Stage IIb typically involves a combination of soft tissue and bony procedures: gastrocnemius recession (if equinus is present), flexor digitorum longus (FDL) transfer to the navicular, medial displacement calcaneal osteotomy (MDCO) to correct hindfoot valgus, and a lateral column lengthening (e.g., Evans osteotomy) to correct the forefoot abduction. A procedure without lateral column lengthening is generally indicated for Stage IIa (minimal to no forefoot abduction). Subtalar and triple arthrodesis are reserved for rigid deformities (Stage III) or when degenerative joint disease is present.

Question 518

Topic: Midfoot & Hindfoot
A 28-year-old man is involved in a high-speed motor vehicle collision and sustains a Hawkins type III talar neck fracture. Which of the following best describes this injury and its associated risk of avascular necrosis (AVN) of the talar body?
. Nondisplaced talar neck fracture; AVN risk is 0-10%
. Subtalar subluxation or dislocation; AVN risk is 20-50%
. Subtalar and talonavicular dislocation; AVN risk is 50-75%
. Subtalar, tibiotalar, and talonavicular dislocation; AVN risk is nearly 100%
. Subtalar and tibiotalar dislocation; AVN risk is historically approaching 90-100%

Correct Answer & Explanation

. Subtalar, tibiotalar, and talonavicular dislocation; AVN risk is nearly 100%

Explanation

The Hawkins classification is used for talar neck fractures. Type I is a nondisplaced fracture (AVN risk 0-10%). Type II involves subtalar subluxation or dislocation (AVN risk 20-50%). Type III involves both subtalar and tibiotalar dislocation, meaning the talar body is extruded from the ankle mortise. The AVN risk for Type III is historically quoted as nearly 100%, though modern series show it may be slightly lower. Type IV (added by Canale and Kelly) involves subtalar, tibiotalar, and talonavicular dislocation.

Question 519

Topic: Midfoot & Hindfoot

A 45-year-old female marathon runner with recalcitrant heel pain that is worst with the first steps in the morning has failed 9 months of conservative management. Tenderness is distinctly maximal at the medial aspect of the calcaneal tuberosity, and she describes radiating burning pain. A release of the first branch of the lateral plantar nerve (Baxter's nerve) is planned. Between which two muscular structures does this nerve typically become entrapped?

. Abductor hallucis and flexor digitorum brevis
. Quadratus plantae and flexor digitorum brevis
. Abductor digiti minimi and quadratus plantae
. Deep fascia of the abductor hallucis and the medial aspect of the quadratus plantae
. Tibialis posterior and flexor digitorum longus

Correct Answer & Explanation

. Deep fascia of the abductor hallucis and the medial aspect of the quadratus plantae

Explanation

The first branch of the lateral plantar nerve, also known as Baxter's nerve, provides motor innervation to the abductor digiti minimi. It most commonly becomes entrapped as it travels vertically between the deep fascia of the abductor hallucis and the medial margin of the quadratus plantae muscle. Release of this fascial band is the basis of surgical decompression.

Question 520

Topic: Midfoot & Hindfoot

A 14-year-old male presents with rigid, painful flatfeet and a history of recurrent ankle sprains. Examination shows significantly restricted subtalar motion and peroneal spasticity. A CT scan confirms a middle facet talocalcaneal coalition involving 60% of the posterior facet area, accompanied by early degenerative changes in the talonavicular joint. What is the most appropriate definitive surgical intervention?

. Resection of the coalition with interposition of the extensor digitorum brevis
. Resection of the coalition with fat graft interposition
. Isolated subtalar arthrodesis
. Triple arthrodesis
. Calcaneal lengthening osteotomy (Evans procedure)

Correct Answer & Explanation

. Triple arthrodesis

Explanation

Resection of a talocalcaneal coalition is generally contraindicated if the coalition involves > 50% of the posterior facet or if there is evidence of advanced degenerative arthritis in adjacent joints. Because this patient has extensive facet involvement (>50%) and concomitant talonavicular arthritis, resection alone is destined to fail. A triple arthrodesis (fusion of the talocalcaneal, talonavicular, and calcaneocuboid joints) is the treatment of choice to address both the rigid deformity and the arthritic changes.

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