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Midfoot & Hindfoot MCQs

Practice Set 27 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 521

Topic: Midfoot & Hindfoot

A 12-year-old boy complains of recurrent ankle sprains and midfoot pain. Examination reveals a rigid flatfoot with absent subtalar motion. Oblique radiographs demonstrate a "calcaneonavicular" coalition. He has failed 6 months of conservative management with custom orthotics and a short leg cast. What is the most appropriate surgical treatment?

. Subtalar arthrodesis
. Triple arthrodesis
. Coalition resection with interposition of the extensor digitorum brevis
. Calcaneal lengthening osteotomy (Evans procedure)
. Talonavicular arthrodesis

Correct Answer & Explanation

. Coalition resection with interposition of the extensor digitorum brevis

Explanation

Symptomatic calcaneonavicular coalitions that fail extensive conservative management are best treated with surgical resection. Interposition of autologous fat or the extensor digitorum brevis muscle belly is performed to prevent recurrence of the coalition.

Question 522

Topic: Midfoot & Hindfoot

The superomedial calcaneonavicular (spring) ligament is a critical static stabilizer of the longitudinal arch. Which of the following tendons provides dynamic support by coursing directly plantar to this ligament?

. Flexor hallucis longus
. Flexor digitorum longus
. Tibialis posterior
. Peroneus longus
. Tibialis anterior

Correct Answer & Explanation

. Tibialis posterior

Explanation

The tibialis posterior tendon courses directly plantar and medial to the spring ligament, providing critical dynamic support to the talonavicular joint and medial longitudinal arch. Dysfunction of this tendon places excessive stress on the spring ligament, often precipitating acquired adult flatfoot deformity.

Question 523

Topic: Midfoot & Hindfoot

A marathon runner with chronic, severe medial heel pain is diagnosed with entrapment of the first branch of the lateral plantar nerve (Baxter's nerve). Which of the following muscles receives its motor innervation from this specific nerve?

. Abductor hallucis
. Flexor digitorum brevis
. Abductor digiti minimi
. Quadratus plantae
. First lumbrical

Correct Answer & Explanation

. Abductor digiti minimi

Explanation

Baxter's nerve is the first branch of the lateral plantar nerve. It provides sensory innervation to the calcaneal periosteum and motor innervation to the abductor digiti minimi muscle.

Question 524

Topic: Midfoot & Hindfoot

The calcaneonavicular (spring) ligament complex is a critical stabilizer of the longitudinal arch. Which portion of the spring ligament is the strongest and most frequently torn in adult-acquired flatfoot deformity?

. Superomedial calcaneonavicular ligament
. Inferior calcaneonavicular ligament
. Medioplantar calcaneonavicular ligament
. Dorsal talonavicular ligament
. Bifurcate ligament

Correct Answer & Explanation

. Superomedial calcaneonavicular ligament

Explanation

The superomedial calcaneonavicular ligament is the thickest and strongest component of the spring ligament complex. It provides primary support to the talar head and is commonly attenuated or torn in posterior tibial tendon dysfunction.

Question 525

Topic: Midfoot & Hindfoot

A patient presents with acquired adult flatfoot deformity resulting from posterior tibial tendon insufficiency. The secondary static stabilizer of the medial longitudinal arch is often attenuated. Which of the following bands of the calcaneonavicular (spring) ligament complex is the strongest and most critical for arch support?

. Superomedial
. Inferomedial
. Inferolateral
. Plantar
. Naviculocuneiform

Correct Answer & Explanation

. Superomedial

Explanation

The superomedial band of the spring ligament is the thickest and strongest component. It acts as the primary static sling supporting the talar head and is most frequently torn or attenuated in flatfoot deformity.

Question 526

Topic: Midfoot & Hindfoot

A 14-year-old boy presents with rigid flat feet and recurrent lateral ankle sprains. Examination reveals a lack of subtalar motion. Radiographs show a "C sign" on the lateral view. Which of the following represents the most likely anatomical location of the primary pathology?

. Calcaneonavicular joint
. Talonavicular joint
. Middle facet of the talocalcaneal joint
. Posterior facet of the talocalcaneal joint
. Cuboid-navicular joint

Correct Answer & Explanation

. Middle facet of the talocalcaneal joint

Explanation

The "C sign" on a lateral radiograph is highly indicative of a talocalcaneal coalition. This coalition most commonly involves the middle facet of the subtalar joint.

Question 527

Topic: Midfoot & Hindfoot

A 12-year-old boy presents with recurring ankle sprains and rigid flatfeet. CT scan confirms a large, symptomatic talocalcaneal coalition involving the middle facet, comprising 60% of the joint surface. Nonoperative management has failed. What is the most appropriate surgical treatment?

. Resection of the coalition with fat graft interposition
. Subtalar arthrodesis
. Triple arthrodesis
. Calcaneal lengthening osteotomy
. Talonavicular arthrodesis

Correct Answer & Explanation

. Subtalar arthrodesis

Explanation

For a talocalcaneal coalition involving greater than 50% of the posterior facet, isolated resection is associated with poor outcomes and recurrence. Subtalar arthrodesis is the most appropriate procedure to relieve pain and restore stability.

Question 528

Topic: Midfoot & Hindfoot

In a purely ligamentous Lisfranc injury with instability demonstrated on weight-bearing radiographs, what is the most appropriate surgical treatment to maximize long-term functional outcomes?

. Closed reduction and cast immobilization
. Percutaneous K-wire fixation
. Open reduction and screw fixation
. Primary arthrodesis of the first, second, and third tarsometatarsal joints
. Primary arthrodesis of the fourth and fifth tarsometatarsal joints

Correct Answer & Explanation

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

Explanation

For purely ligamentous Lisfranc injuries, primary arthrodesis of the medial column (1st, 2nd, and 3rd tarsometatarsal joints) has been shown to have better functional outcomes and lower reoperation rates compared to open reduction and internal fixation.

Question 529

Topic: Midfoot & Hindfoot

A 35-year-old male sustains a purely ligamentous Lisfranc injury with dynamic instability. Based on recent literature, which surgical intervention yields the best long-term functional outcomes and lowest revision rates?

. Closed reduction and percutaneous pinning
. Open reduction and internal fixation (ORIF) with transarticular screws
. Open reduction and internal fixation (ORIF) with dorsal spanning plates
. Primary arthrodesis of the first three tarsometatarsal joints
. Application of a bridging external fixator

Correct Answer & Explanation

. Primary arthrodesis of the first three tarsometatarsal joints

Explanation

Current evidence demonstrates that purely ligamentous Lisfranc injuries treated with primary arthrodesis of the first three TMT joints have superior functional outcomes and lower revision rates compared to ORIF.

Question 530

Topic: Midfoot & Hindfoot

A 34-year-old man presents with a purely ligamentous Lisfranc injury of the midfoot following a fall from a horse. The injury involves the 1st, 2nd, and 3rd tarsometatarsal joints. Comparing primary arthrodesis to open reduction and internal fixation (ORIF), primary arthrodesis in this specific injury pattern is associated with:

. Decreased rates of hardware removal
. Higher rates of deep postoperative infection
. Decreased rate of return to pre-injury activity levels
. Increased incidence of complex regional pain syndrome
. Inferior short-term functional outcome scores

Correct Answer & Explanation

. Decreased rates of hardware removal

Explanation

Studies comparing ORIF to primary arthrodesis for purely ligamentous Lisfranc injuries demonstrate that primary arthrodesis yields similar or slightly superior functional outcomes. Arthrodesis significantly lowers the rates of subsequent surgeries, specifically hardware removal and secondary salvage fusions.

Question 531

Topic: Midfoot & Hindfoot

A 35-year-old male sustains a purely ligamentous Lisfranc injury. There are no associated fractures, but weight-bearing radiographs show 3 mm of widening between the medial and middle cuneiforms. What is the recommended definitive treatment to optimize long-term functional outcomes?

. Cast immobilization and non-weight bearing for 6 weeks
. Open reduction and internal fixation with cortical screws
. Primary arthrodesis of the first, second, and third tarsometatarsal joints
. Closed reduction and percutaneous pinning
. Dorsal bridge plating

Correct Answer & Explanation

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

Explanation

Evidence demonstrates that primary arthrodesis yields superior functional outcomes and lower reoperation rates compared to open reduction and internal fixation for purely ligamentous Lisfranc injuries. ORIF is associated with higher rates of hardware failure and post-traumatic arthritis in purely ligamentous variants.

Question 532

Topic: Midfoot & Hindfoot
A 28-year-old male sustains a high-energy motor vehicle collision resulting in a closed, displaced talar neck fracture. Radiographs and CT scan demonstrate displacement of both the subtalar and tibiotalar joints, while the talonavicular joint remains congruent. Based on the Hawkins classification, what is the approximate rate of avascular necrosis (AVN) of the talar body associated with this specific injury pattern?
. 0 to 10 percent
. 15 to 30 percent
. 40 to 50 percent
. 70 to 100 percent
. Uniformly 100 percent regardless of treatment

Correct Answer & Explanation

. 70 to 100 percent

Explanation

This describes a Hawkins Type III talar neck fracture, which involves subluxation or dislocation of both the subtalar and tibiotalar joints. The risk of AVN for Hawkins Type III fractures is historically reported between 70% and 100% due to the disruption of multiple major blood supplies to the talar body.

Question 533

Topic: Midfoot & Hindfoot

A 55-year-old woman sustains a highly comminuted, purely ligamentous Lisfranc injury. Current evidence suggests that which of the following treatments provides the best long-term functional outcome for this specific injury pattern?

. Closed reduction and percutaneous pinning
. Open reduction and internal fixation with transarticular screws
. Primary partial midfoot arthrodesis
. Open reduction and internal fixation with dorsal bridge plating
. Nonoperative management in a short leg cast for 12 weeks

Correct Answer & Explanation

. Primary partial midfoot arthrodesis

Explanation

For purely ligamentous Lisfranc injuries, primary arthrodesis of the first, second, and third tarsometatarsal joints yields superior functional outcomes. It also demonstrates lower reoperation rates compared to traditional ORIF.

Question 534

Topic: Midfoot & Hindfoot
A 35-year-old female falls from a height and sustains a Hawkins Type III fracture of the talar neck. Which of the following best describes the articulations disrupted 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 and tibiotalar joints

Explanation

A Hawkins Type III talar neck fracture involves displacement of the talar body with subluxation or dislocation of both the subtalar and tibiotalar joints. The risk of avascular necrosis (AVN) in Type III injuries is extremely high, approaching 80-100%.

Question 535

Topic: Midfoot & Hindfoot
A 25-year-old female sustains a Hawkins Type III talar neck fracture. What is the estimated risk of developing avascular necrosis (AVN) of the talar body?
. 0-10%
. 15-20%
. 20-50%
. 70-100%
. 100% inevitable

Correct Answer & Explanation

. 70-100%

Explanation

A Hawkins Type III fracture involves displacement of the talar neck with subluxation or dislocation of both the subtalar and tibiotalar joints. This severely disrupts the delicate retrograde blood supply, carrying a 70-100% risk of AVN.

Question 536

Topic: Midfoot & Hindfoot

A 55-year-old woman presents with progressive medial ankle pain and the inability to perform a single-leg heel raise. Examination reveals a flexible hindfoot valgus and severe forefoot abduction. Radiographs show greater than 40% talonavicular uncoverage. What is the most appropriate surgical management for this stage IIb adult-acquired flatfoot deformity?

. Flexor digitorum longus (FDL) transfer to the navicular and medial displacement calcaneal osteotomy (MDCO)
. FDL transfer, MDCO, and lateral column lengthening
. Subtalar arthrodesis and FDL transfer
. Triple arthrodesis
. Gastrocnemius recession and FDL transfer

Correct Answer & Explanation

. FDL transfer, MDCO, and lateral column lengthening

Explanation

Stage IIb posterior tibial tendon dysfunction involves flexible hindfoot valgus with significant forefoot abduction (>40% talonavicular uncoverage). Surgical correction requires an FDL transfer, medial displacement calcaneal osteotomy, and a lateral column lengthening to correct the forefoot abduction.

Question 537

Topic: Midfoot & Hindfoot

A 55-year-old patient with poorly controlled diabetes presents with a red, hot, swollen foot. Radiographs show fragmentation, periarticular debris, and subluxation at the tarsometatarsal joints. There are no ulcers. What is the most appropriate initial management?

. Intravenous antibiotics and urgent debridement
. Total contact casting and non-weight-bearing
. Midfoot arthrodesis with robust hardware
. Calcaneal osteotomy
. Below-knee amputation

Correct Answer & Explanation

. Total contact casting and non-weight-bearing

Explanation

This patient is in the acute fragmentation phase (Eichenholtz stage I) of Charcot arthropathy. The mainstay of initial treatment is total contact casting and offloading to prevent further deformity.

Question 538

Topic: Midfoot & Hindfoot

A 48-year-old overweight man has classic plantar fasciitis symptoms for 12 months that have failed nonoperative management. He elects to proceed with surgery. Which specific structure must be protected during a plantar fascia release?

. Medial calcaneal nerve
. First branch of the lateral plantar nerve (nerve to the abductor digiti minimi)
. Deep peroneal nerve
. Sural nerve
. Saphenous nerve

Correct Answer & Explanation

. First branch of the lateral plantar nerve (nerve to the abductor digiti minimi)

Explanation

The first branch of the lateral plantar nerve (Baxter's nerve) courses deep to the abductor hallucis and is at risk during plantar fascial release. Entrapment of this nerve can also be a concurrent cause of heel pain.

Question 539

Topic: Midfoot & Hindfoot
A 55-year-old woman with a progressive flatfoot deformity complains of medial ankle pain and an inability to perform a single-limb heel rise. Weight-bearing radiographs show >30% uncovering of the talonavicular joint. What is the most appropriate surgical management?
. Medial displacement calcaneal osteotomy (MDCO) and FDL transfer
. Lateral column lengthening, MDCO, and FDL transfer
. Triple arthrodesis
. First TMT arthrodesis
. Isolated subtalar arthrodesis

Correct Answer & Explanation

. Lateral column lengthening, MDCO, and FDL transfer

Explanation

Stage IIb adult acquired flatfoot deformity is characterized by >30% forefoot abduction (talonavicular uncovering). Management requires a lateral column lengthening in addition to MDCO and FDL transfer to correct the abduction.

Question 540

Topic: Midfoot & Hindfoot

A 55-year-old male with poorly controlled diabetes presents with a red, hot, swollen right foot for 3 weeks. There is no history of ulceration or open wounds. Radiographs show periarticular debris, fragmentation, and subluxation at the tarsometatarsal joints. What is the most appropriate initial management?

. Intravenous antibiotics and urgent debridement
. Total contact casting and non-weight-bearing
. Open reduction and internal fixation of the midfoot
. Midfoot arthrodesis with autogenous bone graft
. Below-knee amputation

Correct Answer & Explanation

. Total contact casting and non-weight-bearing

Explanation

This patient has Eichenholtz stage I (fragmentation) Charcot arthropathy. The mainstay of initial treatment is offloading with total contact casting to prevent further deformity until the active inflammatory phase resolves.

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