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Midfoot & Hindfoot MCQs

Practice Set 28 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 541

Topic: Midfoot & Hindfoot

A 55-year-old woman presents with medial ankle pain and a progressively flattening arch. She has a flexible flatfoot, cannot perform a single-leg heel rise, and has tenderness over the posterior tibial tendon. Nonoperative management has failed. What is the most appropriate surgical procedure?

. Triple arthrodesis
. Flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy
. Gastrocnemius recession and isolated FDL transfer
. Subtalar arthrodesis
. Talonavicular arthrodesis

Correct Answer & Explanation

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

Explanation

This patient has Stage II (flexible) adult-acquired flatfoot deformity. The standard joint-sparing surgical treatment utilizes an FDL transfer and a medial displacement calcaneal osteotomy (MDCO) to restore the arch.

Question 542

Topic: Midfoot & Hindfoot

A 45-year-old runner presents with chronic, aching heel pain that is worse at the end of the day. Examination reveals maximal tenderness over the medial calcaneal tuberosity and an inability to abduct the fifth toe. Compression of which of the following nerves is the most likely cause?

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

Correct Answer & Explanation

. First branch of the lateral plantar nerve

Explanation

Baxter's nerve is the first branch of the lateral plantar nerve and provides motor innervation to the abductor digiti minimi. Entrapment commonly causes chronic heel pain and weakness in abducting the fifth toe, mimicking plantar fasciitis.

Question 543

Topic: Midfoot & Hindfoot
A 55-year-old woman presents with severe flexible flatfoot deformity. Examination shows inability to perform a single-leg heel rise. Radiographs demonstrate >40% uncoverage of the talonavicular joint and severe forefoot abduction. What surgical reconstruction is most appropriate for this Stage IIb posterior tibial tendon dysfunction?
. Isolated flexor digitorum longus (FDL) transfer to the navicular
. Medial displacement calcaneal osteotomy and FDL transfer
. Medial displacement calcaneal osteotomy, lateral column lengthening, and FDL transfer
. Talonavicular arthrodesis alone
. Triple arthrodesis

Correct Answer & Explanation

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

Explanation

Stage IIb adult-acquired flatfoot involves significant forefoot abduction (>30% talonavicular uncoverage). A lateral column lengthening (Evans osteotomy) is necessary to correct the abduction, combined with an FDL transfer and medializing calcaneal osteotomy.

Question 544

Topic: Midfoot & Hindfoot

A 55-year-old female presents with medial ankle pain and a progressively flattening arch. Examination reveals a flexible hindfoot valgus and inability to perform a single-leg heel raise. Nonoperative management has failed. Which of the following is the most appropriate surgical intervention?

. Subtalar arthrodesis
. Triple arthrodesis
. Flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy
. Talonavicular arthrodesis
. Kidner procedure

Correct Answer & Explanation

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

Explanation

This patient has Stage II adult-acquired flatfoot deformity (posterior tibial tendon dysfunction) characterized by a flexible deformity. Joint-sparing procedures such as an FDL transfer combined with a medial displacement calcaneal osteotomy are indicated.

Question 545

Topic: Midfoot & Hindfoot

A 24-year-old football player sustains a high-energy midfoot injury. Radiographs reveal a "fleck sign" in the first intermetatarsal space. Ligamentous Lisfranc injuries are most reliably treated with which of the following methods to minimize the risk of hardware failure and long-term midfoot arthritis?

. Closed reduction and cast immobilization
. Percutaneous Kirschner wire fixation
. Primary arthrodesis of the first, second, and third tarsometatarsal joints
. Open reduction and internal fixation with rigid transarticular screws
. Suture button suspensionplasty alone

Correct Answer & Explanation

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

Explanation

For purely ligamentous Lisfranc injuries, primary arthrodesis of the medial columns (1st-3rd TMT joints) has been shown to have superior long-term outcomes and fewer reoperations compared to ORIF.

Question 546

Topic: Midfoot & Hindfoot

A 22-year-old collegiate football player sustains a purely ligamentous Lisfranc injury.

MRI demonstrates a complete rupture of the Lisfranc ligament. He elects for operative management. Compared to open reduction and internal fixation (ORIF), primary arthrodesis of the first, second, and third tarsometatarsal joints in this patient is associated with:

. Higher rate of hardware removal
. Similar functional outcomes but decreased need for subsequent operations
. Increased risk of midfoot compartment syndrome
. Lower rates of return to sport
. Faster time to full weight-bearing

Correct Answer & Explanation

. Similar functional outcomes but decreased need for subsequent operations

Explanation

Studies comparing primary arthrodesis to ORIF for purely ligamentous Lisfranc injuries show similar or superior functional outcomes for arthrodesis. Arthrodesis also significantly lowers the rate of planned or unplanned secondary surgeries, such as hardware removal.

Question 547

Topic: Midfoot & Hindfoot

A 35-year-old man sustains a purely ligamentous Lisfranc injury. He undergoes open reduction and primary arthrodesis of the first, second, and third tarsometatarsal joints. Compared to open reduction and internal fixation (ORIF), primary arthrodesis for purely ligamentous Lisfranc injuries is most strongly associated with:

. Lower rates of hardware removal and subsequent midfoot arthritis
. Higher rates of complex regional pain syndrome
. Decreased return to pre-injury activity levels
. Increased risk of nonunion at the fourth and fifth TMT joints
. Higher rates of deep vein thrombosis

Correct Answer & Explanation

. Lower rates of hardware removal and subsequent midfoot arthritis

Explanation

Primary arthrodesis for purely ligamentous Lisfranc injuries demonstrates similar or superior functional outcomes to ORIF. It significantly reduces the need for subsequent hardware removal and secondary salvage arthrodesis.

Question 548

Topic: Midfoot & Hindfoot

A 58-year-old man with poorly controlled diabetes mellitus presents with a red, hot, swollen right foot. He has no open wounds or systemic signs of infection. Radiographs reveal fragmentation and subluxation of the midfoot. What is the most appropriate initial management?

. Intravenous antibiotics
. Urgent irrigation and debridement
. Total contact casting and strict non-weight-bearing
. Open reduction and internal fixation of the midfoot
. Midfoot arthrodesis

Correct Answer & Explanation

. Total contact casting and strict non-weight-bearing

Explanation

This presentation is classic for acute Eichenholtz stage 1 (fragmentation) Charcot arthropathy. Initial treatment demands strict immobilization and offloading with a total contact cast until the acute inflammatory phase resolves.

Question 549

Topic: Midfoot & Hindfoot
A 55-year-old woman presents with medial ankle pain and a progressive flatfoot deformity. Examination shows a flexible hindfoot valgus and inability to perform a single-leg heel raise. Radiographs demonstrate >40% talonavicular uncoverage. Which surgical intervention is most appropriate if conservative management fails?
. Isolated flexor digitorum longus (FDL) transfer to the navicular
. FDL transfer and medial displacement calcaneal osteotomy (MDCO)
. FDL transfer, MDCO, and lateral column lengthening
. Subtalar arthrodesis alone
. Triple arthrodesis

Correct Answer & Explanation

. FDL transfer, MDCO, and lateral column lengthening

Explanation

This patient has Stage IIb adult-acquired flatfoot deformity, characterized by a flexible deformity with forefoot abduction (>30-40% talonavicular uncoverage). Treatment requires an FDL transfer, medial displacement calcaneal osteotomy, and a lateral column lengthening (Evans osteotomy) to correct the forefoot abduction.

Question 550

Topic: Midfoot & Hindfoot

A 60-year-old patient with poorly controlled diabetes presents with a unilaterally swollen, red, and warm foot for 3 weeks. Radiographs show periarticular debris, fragmentation, and subluxation at the tarsometatarsal joints. What is the most appropriate immediate management?

. Intravenous antibiotics and emergent surgical debridement
. Total contact casting and strict non-weight-bearing
. Primary arthrodesis of the tarsometatarsal joints
. Open reduction and internal fixation of the midfoot
. Custom orthotic shoe wear and weight-bearing as tolerated

Correct Answer & Explanation

. Total contact casting and strict non-weight-bearing

Explanation

This patient presents with Eichenholtz Stage I (developmental/fragmentation) Charcot arthropathy. The mainstay of initial treatment for acute Charcot is immobilization and offloading, most effectively achieved with a total contact cast to prevent further deformity.

Question 551

Topic: Midfoot & Hindfoot

A 25-year-old professional football player sustains a purely ligamentous Lisfranc injury involving the first, second, and third tarsometatarsal joints. Nonoperative management is deemed inappropriate due to the severity of the instability. According to recent high-level prospective studies, which of the following surgical interventions is associated with the best functional outcome and lowest rate of hardware removal in purely ligamentous injuries?

. Open reduction and internal fixation with transarticular screws
. Open reduction and internal fixation with dorsal spanning plates
. Primary arthrodesis of the first, second, and third tarsometatarsal joints
. Closed reduction and percutaneous pinning
. Suture button suspensionplasty of the medial column

Correct Answer & Explanation

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

Explanation

For purely ligamentous Lisfranc injuries, primary arthrodesis of the involved medial rays (1st-3rd TMT joints) has been shown to yield superior functional outcomes and lower reoperation rates compared to ORIF. ORIF is generally preferred when there is significant bony involvement rather than purely ligamentous disruption.

Question 552

Topic: Midfoot & Hindfoot
A 58-year-old woman is diagnosed with stage IIb adult acquired flatfoot deformity secondary to posterior tibial tendon insufficiency. Clinical and radiographic evaluation reveals a flexible hindfoot valgus and significant forefoot abduction (uncoverage of the talonavicular joint >40%). In addition to a flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy, which procedure is essential to correct her specific deformity?
. Lateral column lengthening
. First tarsometatarsal arthrodesis
. Subtalar arthrodesis
. Triple arthrodesis
. Spring ligament excision

Correct Answer & Explanation

. Lateral column lengthening

Explanation

Stage IIb adult acquired flatfoot deformity is characterized by significant forefoot abduction (talonavicular uncoverage). A lateral column lengthening (e.g., Evans osteotomy) is required to correct the forefoot abduction in addition to the standard medial-sided soft tissue and bony procedures.

Question 553

Topic: Midfoot & Hindfoot

A 45-year-old runner presents with chronic medial heel pain that radiates into the plantar aspect of the foot, which has failed conservative management for plantar fasciitis. MRI reveals isolated atrophy of the abductor digiti minimi muscle. Entrapment of the first branch of the lateral plantar nerve (Baxter's nerve) is suspected. Between which two structures is this nerve most commonly compressed?

. Flexor retinaculum and the medial malleolus
. Flexor digitorum longus and tibialis posterior tendons
. Deep fascia of the abductor hallucis and the medial margin of the quadratus plantae
. Plantar aponeurosis and the flexor digitorum brevis
. Peroneus longus and brevis tendons

Correct Answer & Explanation

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

Explanation

Baxter's nerve (first branch of the lateral plantar nerve) is most frequently entrapped as it passes between the deep fascia of the abductor hallucis muscle and the medial margin of the quadratus plantae muscle. Chronic compression leads to denervation atrophy of the abductor digiti minimi.

Question 554

Topic: Midfoot & Hindfoot

A 55-year-old patient with poorly controlled diabetes presents with a swollen, erythematous, and warm foot. Radiographs show fragmentation, periarticular debris, and subluxation at the midfoot. What is the most appropriate initial management?

. Intravenous antibiotics and surgical debridement
. Open reduction and internal fixation of the midfoot
. Total contact casting and strict non-weight-bearing
. Midfoot arthrodesis with a rigid plate construct
. Below-knee amputation

Correct Answer & Explanation

. Total contact casting and strict non-weight-bearing

Explanation

This patient is presenting with acute Eichenholtz Stage I (fragmentation) Charcot arthropathy. The mainstay of initial treatment during the active phase is immobilization and offloading, typically utilizing a total contact cast until erythema and edema resolve.

Question 555

Topic: Midfoot & Hindfoot
A 55-year-old woman 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. Radiographs demonstrate >40% talonavicular uncoverage. What is the most appropriate surgical management?
. Isolated posterior tibial tendon debridement
. Posterior tibial tendon debridement with tenosynovectomy
. Flexor digitorum longus (FDL) transfer to the navicular and medial displacement calcaneal osteotomy (MDCO)
. FDL transfer, MDCO, and lateral column lengthening
. Triple arthrodesis

Correct Answer & Explanation

. FDL transfer, MDCO, and lateral column lengthening

Explanation

This patient has Stage IIb adult acquired flatfoot deformity (flexible, >40% talonavicular uncoverage indicating severe forefoot abduction). Treatment requires FDL transfer, MDCO, and a lateral column lengthening (e.g., Evans osteotomy) to correct the forefoot abduction.

Question 556

Topic: Midfoot & Hindfoot

A 55-year-old diabetic male presents with a swollen, erythematous, warm, and painless left foot. Radiographs reveal fragmentation of the navicular and cuneiforms with joint subluxation. What is the most appropriate initial management?

. Urgent surgical debridement and internal fixation
. Non-weight bearing in a total contact cast
. Intravenous antibiotics and MRI
. Midfoot arthrodesis
. Calcaneal osteotomy

Correct Answer & Explanation

. Non-weight bearing in a total contact cast

Explanation

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

Question 557

Topic: Midfoot & Hindfoot

A 50-year-old female presents with a painful, progressive flatfoot. She can perform a single leg heel rise but it is painful and incomplete. Examination shows a flexible hindfoot valgus. What is the most appropriate surgical intervention if conservative measures fail?

. Flexor digitorum longus (FDL) transfer and medializing calcaneal osteotomy
. Triple arthrodesis
. Isolated subtalar arthrodesis
. Tibialis anterior transfer
. First TMT arthrodesis

Correct Answer & Explanation

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

Explanation

The patient has Stage II adult-acquired flatfoot deformity (flexible hindfoot, PTT insufficiency). Joint-sparing surgery with FDL transfer and a medializing calcaneal osteotomy corrects the deformity and restores tendon function.

Question 558

Topic: Midfoot & Hindfoot
A 35-year-old man falls from a height and sustains a Hawkins type III fracture of the talar neck. What is the approximate reported rate of avascular necrosis (AVN) of the talar body associated with this specific injury pattern?
. 0-10%
. 15-30%
. 40-50%
. 80-100%
. Approximately 5%

Correct Answer & Explanation

. 80-100%

Explanation

A Hawkins type III talar neck fracture involves subluxation or dislocation of both the subtalar and tibiotalar joints. This severe displacement disrupts the major blood supply to the talar body, leading to an AVN rate of 80% to 100%.

Question 559

Topic: Midfoot & Hindfoot

A 55-year-old woman presents with a flexible flatfoot deformity, lateral hindfoot pain, and an inability to perform a single-leg heel rise. Radiographs show uncovering of the talonavicular joint. What is the most widely accepted initial surgical management for stage IIb posterior tibial tendon dysfunction?

. UCBL orthosis
. Flexor digitorum longus (FDL) transfer, medial displacement calcaneal osteotomy, and lateral column lengthening
. Triple arthrodesis
. Subtalar arthrodesis alone
. Gastrocnemius recession alone

Correct Answer & Explanation

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

Explanation

Stage IIb PTTD denotes a flexible flatfoot with forefoot abduction. Surgical reconstruction typically involves an FDL tendon transfer to substitute for the PTT, combined with a medializing calcaneal osteotomy and lateral column lengthening to correct the forefoot abduction.

Question 560

Topic: Midfoot & Hindfoot

A 55-year-old woman presents with a painful, flexible acquired flatfoot deformity. She is unable to perform a single-leg heel rise. Radiographs demonstrate uncovering of the talonavicular joint of 45% and significant forefoot abduction. Which of the following surgical interventions is most appropriate if conservative management fails?

. Flexor digitorum longus (FDL) transfer to the navicular alone
. FDL transfer with a medial displacement calcaneal osteotomy
. FDL transfer with a lateral column lengthening (Evans osteotomy)
. Triple arthrodesis
. Isolated talonavicular arthrodesis

Correct Answer & Explanation

. FDL transfer with a lateral column lengthening (Evans osteotomy)

Explanation

This represents a Stage IIb posterior tibial tendon dysfunction (PTTD), characterized by >30% talonavicular uncovering and forefoot abduction. Appropriate treatment requires FDL transfer combined with lateral column lengthening to correct the abduction deformity.

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