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Midfoot & Hindfoot MCQs

Practice Set 31 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 601

Topic: Midfoot & Hindfoot

A 40-year-old male presents with worsening right foot pain, particularly around the medial longitudinal arch, radiating to the heel. He describes a 'too many toes' sign on clinical examination. On weight-bearing radiographs, there is a collapse of the medial longitudinal arch, talonavicular sag, and forefoot abduction. What is the most likely diagnosis?

. Plantar fasciitis.
. Achilles tendinitis.
. Haglund's deformity.
. Adult acquired flatfoot deformity (AAFD) due to posterior tibial tendon dysfunction (PTTD).
. Stress fracture of the navicular.

Correct Answer & Explanation

. Adult acquired flatfoot deformity (AAFD) due to posterior tibial tendon dysfunction (PTTD).

Explanation

The patient's symptoms (medial arch pain, radiating to heel), clinical sign ('too many toes' indicating forefoot abduction), and radiographic findings (arch collapse, talonavicular sag) are classic for adult acquired flatfoot deformity (AAFD), most commonly caused by progressive posterior tibial tendon dysfunction (PTTD). Plantar fasciitis is typically heel pain. Achilles tendinitis is posterior heel/calf pain. Haglund's deformity is posterior heel pain with retrocalcaneal bursitis. Navicular stress fractures cause localized navicular pain and often edema.

Question 602

Topic: Midfoot & Hindfoot

A 40-year-old male develops a significant malunion of a calcaneal fracture, resulting in hindfoot varus, subtalar stiffness, and impingement on the lateral malleolus. He experiences chronic pain and difficulty with ambulation. Which of the following surgical procedures is most appropriate to address his symptoms?

. Subtalar arthrodesis
. Triple arthrodesis
. Lateralizing calcaneal osteotomy with subtalar arthrodesis
. Exostectomy of the lateral malleolus
. Arthrodesis of the calcaneocuboid joint

Correct Answer & Explanation

. Lateralizing calcaneal osteotomy with subtalar arthrodesis

Explanation

A malunited calcaneal fracture with hindfoot varus and lateral impingement requires a complex correction. A lateralizing calcaneal osteotomy addresses the varus deformity and widens the calcaneal body to decompress the lateral structures. Combining this with a subtalar arthrodesis stabilizes the hindfoot, corrects the deformity, and addresses the painful subtalar stiffness. Isolated subtalar arthrodesis may not correct the varus and impingement adequately. Triple arthrodesis includes the talonavicular and calcaneocuboid joints, which may be excessive if pathology is confined to the subtalar joint and calcaneal body. Exostectomy alone is insufficient for the underlying deformity. Calcaneocuboid arthrodesis alone does not address the hindfoot varus or subtalar pathology.

Question 603

Topic: Midfoot & Hindfoot

What is the most common cause of painful pes planus in an adult, often leading to progressive flatfoot deformity?

. Spring ligament insufficiency
. Accessory navicular syndrome
. Tibialis anterior tendon rupture
. Posterior tibial tendon dysfunction (PTTD)
. Charcot arthropathy

Correct Answer & Explanation

. Posterior tibial tendon dysfunction (PTTD)

Explanation

Posterior tibial tendon dysfunction (PTTD) is the most common cause of adult-acquired flatfoot deformity, leading to progressive painful pes planus. The posterior tibial tendon is a primary supporter of the medial longitudinal arch. Its dysfunction leads to failure of the arch. While spring ligament insufficiency can contribute, it's often secondary to PTTD. Accessory navicular syndrome is a congenital anomaly that can cause pain, but not typically progressive flatfoot. Tibialis anterior tendon rupture results in a cavus-like deformity, and Charcot arthropathy is a neuropathic joint condition seen in diabetes, not the most common cause of painful acquired flatfoot.

Question 604

Topic: Midfoot & Hindfoot
A 30-year-old man falls from a height and sustains a Hawkins Type III fracture of the talar neck. Which of the following accurately describes the displacement pattern and the approximate associated risk of avascular necrosis (AVN) of the talar body?
. Displacement of the subtalar joint only; ~20% AVN risk
. Dislocation of the subtalar and tibiotalar joints; ~50% AVN risk
. Dislocation of the subtalar and tibiotalar joints; ~90-100% AVN risk
. Extrusion of the talar body; ~10% AVN risk
. Subluxation of the talonavicular joint only; ~0-10% AVN risk

Correct Answer & Explanation

. Dislocation of the subtalar and tibiotalar joints; ~90-100% AVN risk

Explanation

The Hawkins classification describes talar neck fractures. Type I is non-displaced (0-15% AVN risk). Type II involves subluxation or dislocation of the subtalar joint (20-50% AVN risk). Type III involves dislocation of both the subtalar and tibiotalar joints, and the risk of AVN is exceedingly high, approaching 90-100% due to the disruption of the major blood supply to the talar body (artery of the tarsal canal, deltoid artery, and superior capsular network). Type IV adds talonavicular dislocation.

Question 605

Topic: Midfoot & Hindfoot

A 33-year-old male sustains a lateral subtalar dislocation after a fall from scaffolding. Closed reduction in the emergency department is unsuccessful. Which anatomical structure is most commonly responsible for blocking the reduction in a lateral subtalar dislocation?

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

Correct Answer & Explanation

. Posterior tibial tendon

Explanation

Lateral subtalar dislocations account for about 15% of subtalar dislocations and are frequently irreducible by closed means. The posterior tibial tendon often becomes entrapped in the talonavicular joint, blocking reduction.

Question 606

Topic: Midfoot & Hindfoot

A 55-year-old diabetic male presents with a swollen, erythematous, and warm foot. Radiographs reveal prominent periarticular fragmentation, subluxation of the tarsometatarsal joints, and bony debris. According to the Eichenholtz classification of Charcot arthropathy, what stage does this represent, and what is the hallmark radiographic finding of the subsequent stage?

. Stage 0; subsequent stage shows joint subluxation
. Stage 1; subsequent stage shows coalescence and absorption of fine debris
. Stage 2; subsequent stage shows reconstitution and consolidation of bone
. Stage 3; subsequent stage shows progressive fragmentation
. Stage 1; subsequent stage shows complete joint dislocation with massive osteolysis

Correct Answer & Explanation

. Stage 1; subsequent stage shows coalescence and absorption of fine debris

Explanation

The patient is in Eichenholtz Stage 1 (Development/Fragmentation), characterized clinically by acute inflammation and radiographically by periarticular fragmentation, debris, and subluxation. The subsequent stage is Stage 2 (Coalescence), where the hallmark is the absorption of fine debris, early fusion of larger fragments, and sclerosis.

Question 607

Topic: Midfoot & Hindfoot
A 28-year-old male sustains a high-energy dorsiflexion injury. Radiographs show a displaced fracture of the talar neck with subluxation of the subtalar joint, but the tibiotalar and talonavicular joints remain concentrically reduced. According to the Hawkins classification, what is the approximate risk of developing avascular necrosis (AVN) of the talar body?
. Less than 10%
. 20% to 50%
. 70% to 100%
. 100% in all cases regardless of reduction
. 0% as the blood supply is entirely unaffected

Correct Answer & Explanation

. 20% to 50%

Explanation

This describes a Hawkins Type II fracture (talar neck fracture with subtalar subluxation/dislocation). The risk of AVN for Type II fractures is historically cited as 20% to 50%. Type I (nondisplaced) carries a 0-10% risk. Type III (subtalar and tibiotalar dislocation) and Type IV (Type III plus talonavicular dislocation) carry a very high risk of AVN, approaching 70-100%.

Question 608

Topic: Midfoot & Hindfoot

A 60-year-old patient with long-standing poorly controlled diabetes presents with a unilaterally red, hot, swollen foot without an open ulcer. Radiographs reveal prominent periarticular fragmentation, debris, and subluxation of the midfoot joints. This represents Eichenholtz Stage I Charcot arthropathy. What is the most appropriate initial management?

. Intravenous antibiotics and emergent surgical debridement
. Primary midfoot arthrodesis with rigid internal fixation
. Total contact casting and strict non-weight bearing
. Custom orthotic shoe wear and early range of motion exercises
. Prescription of bisphosphonates to reverse bone fragmentation

Correct Answer & Explanation

. Total contact casting and strict non-weight bearing

Explanation

The patient is in the acute fragmentation phase (Stage I) of Charcot arthropathy, mimicking an infection. The gold standard for initial management is immediate offloading and immobilization using a total contact cast to halt progressive deformity while waiting for the inflammatory phase to coalesce (Stage II).

Question 609

Topic: Midfoot & Hindfoot
A 60-year-old diabetic patient presents with a swollen, warm foot. Radiographs show marked periarticular fragmentation, subluxation of the tarsometatarsal joints, and considerable bony debris, without signs of consolidation. According to the Eichenholtz classification of Charcot arthropathy, which stage does this represent?
. Stage 0 (High Risk)
. Stage I (Development/Fragmentation)
. Stage II (Coalescence)
. Stage III (Reconstruction/Consolidation)
. Stage IV (Ulceration)

Correct Answer & Explanation

. Stage I (Development/Fragmentation)

Explanation

The Eichenholtz classification describes Charcot arthropathy stages. Stage I (Development/Fragmentation) is characterized by acute inflammation, osteopenia, periarticular fragmentation, subluxation, and bony debris. Stage II (Coalescence) involves absorption of debris and early fusion. Stage III (Consolidation) shows remodeling and stable deformity.

Question 610

Topic: Midfoot & Hindfoot
According to the Eichenholtz classification of Charcot arthropathy, which of the following radiographic findings characterizes the coalescence stage (Stage II)?
. Osseous fragmentation, joint dislocation, and extensive subchondral debris.
. Absorption of fine debris, fusion of larger fragments, and early sclerosis.
. Subchondral bone marrow edema on MRI with entirely normal plain radiographs.
. Remodeling of bone ends, decreased sclerosis, and reformation of the joint architecture.
. Acute osteopenia, periarticular fracture, and gas in the soft tissues.

Correct Answer & Explanation

. Absorption of fine debris, fusion of larger fragments, and early sclerosis.

Explanation

The Eichenholtz classification divides Charcot arthropathy into three stages. Stage I (Development/Fragmentation) involves debris, fragmentation, and dislocation. Stage II (Coalescence) involves absorption of fine debris, early fusion of fragments, and sclerosis. Stage III (Reconstruction) involves rounding of bone ends and decreased sclerosis.

Question 611

Topic: Midfoot & Hindfoot
A 28-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 dislocated in this injury pattern?
. Subtalar joint only
. Subtalar and tibiotalar joints
. Subtalar, tibiotalar, and talonavicular joints
. Talonavicular joint only
. Tibiotalar joint only

Correct Answer & Explanation

. Subtalar, tibiotalar, and talonavicular joints

Explanation

In the Hawkins classification of talar neck fractures, a Type III injury involves displacement of the fracture with dislocation of the subtalar, tibiotalar, and talonavicular joints. It carries a nearly 100% risk of avascular necrosis.

Question 612

Topic: Midfoot & Hindfoot

A 58-year-old patient with long-standing, poorly controlled diabetes mellitus presents with a swollen, erythematous, and warm foot but no open ulcers. Radiographs demonstrate periarticular fragmentation, subchondral cyst formation, and joint subluxation at the tarsometatarsal joints. According to the Eichenholtz classification, what is the most appropriate initial management?

. Immediate open reduction and internal fixation
. Intravenous antibiotics and urgent surgical debridement
. Total contact casting and non-weight-bearing
. Custom orthotic shoe wear and weight-bearing as tolerated
. Midfoot arthrodesis using a rigid plating system

Correct Answer & Explanation

. Total contact casting and non-weight-bearing

Explanation

This patient is in Eichenholtz Stage I (Development/Fragmentation) of Charcot arthropathy, characterized by acute inflammation, hyperemia, and bony fragmentation. The gold standard for initial management in this active phase is rigid immobilization and offloading, typically achieved with a total contact cast (TCC), to prevent progressive deformity until the process reaches the consolidation phase.

Question 613

Topic: Midfoot & Hindfoot

Which of the following lower extremity amputation levels is generally associated with the highest increase in metabolic energy expenditure during ambulation compared to a healthy, non-amputee baseline?

. Syme amputation
. Transtibial amputation
. Knee disarticulation
. Transfemoral amputation
. Chopart amputation

Correct Answer & Explanation

. Syme amputation

Explanation

The metabolic energy required for ambulation increases exponentially as the level of lower extremity amputation becomes more proximal. A transfemoral amputation requires a significantly higher metabolic energy increase (approximately 60-65%) than a transtibial amputation.

Question 614

Topic: Midfoot & Hindfoot
A 28-year-old male sustains a talar neck fracture following a fall from a height. Radiographs demonstrate a displaced fracture of the talar neck with subluxation of the subtalar joint, but the tibiotalar joint remains congruous. According to the Hawkins classification, what is the fracture type and the historically associated risk of avascular necrosis (AVN) of the talar body?
. Hawkins Type I, less than 10% risk of AVN
. Hawkins Type II, 20% to 50% risk of AVN
. Hawkins Type III, almost 100% risk of AVN
. Hawkins Type IV, 10% to 20% risk of AVN
. Hawkins Type II, greater than 90% risk of AVN

Correct Answer & Explanation

. Hawkins Type II, 20% to 50% risk of AVN

Explanation

This injury is a Hawkins Type II talar neck fracture, defined by displacement of the talar neck with subluxation or dislocation of the subtalar joint, while the ankle (tibiotalar) joint remains intact. The risk of avascular necrosis (AVN) for Hawkins Type II fractures is widely cited as 20% to 50%. Type I (nondisplaced) is <10%, Type III (subtalar and tibiotalar dislocation) is >90%, and Type IV (Type III plus talonavicular disruption) approaches 100%.

Question 615

Topic: Midfoot & Hindfoot
Which of the following patients who sustained a calcaneal fracture will most likely undergo an eventual subtalar fusion?
. Male worker's compensation patient who participates in heavy labor work with an initial Bรถhler angle less than 0 degrees
. Female worker's compensation patient who participates in heavy labor work with an initial Bรถhler angle >15 degrees
. Male non-worker's compensation patient who participates in heavy labor work with an initial Bรถhler angle less than 0 degrees
. Male worker's compensation patient who participates in heavy labor work with an initial Bรถhler angle >15 degrees
. Female non-worker's compensation patient who participates in heavy labor work with an initial Bรถhler less than 0 degrees

Correct Answer & Explanation

. Male worker's compensation patient who participates in heavy labor work with an initial Bรถhler angle less than 0 degrees

Explanation

The Level 2 study by Czisy et al is a review of a randomized trial database that analyzed the prospective clinical outcome of 45 patients who failed closed or open treatment of displaced intra-articular calcaneal fractures. The cohort underwent a subtalar fusion by distraction bone-block arthrodesis for subtalar arthritis. They found that male worker's compensation patients who participate in heavy labor work with a fracture pattern with a Bรถhler angle less than 0 degrees were the most likely to undergo a subtalar fusion. The meta-analysis by Randle et al reviewed 6 clinical studies comparing the results of operative vs. conservative management of calcaneal fracture studies. They found a trend for nonoperatively treated patients to have a higher risk of experiencing severe foot pain than did operatively treated patients, however they could not draw any definitive conclusions guiding treatment.

Question 616

Topic: Midfoot & Hindfoot
A 55-year-old female presents with a progressive flatfoot deformity. She is unable to perform a single-limb heel rise on the affected side. Radiographs demonstrate talonavicular uncoverage of 40% and a Meary's angle of 15 degrees apex plantar. The hindfoot deformity is correctable passively. Which stage of posterior tibial tendon dysfunction (PTTD) does this represent?
. Stage I
. Stage IIa
. Stage IIb
. Stage III
. Stage IV

Correct Answer & Explanation

. Stage IIb

Explanation

Stage IIb PTTD involves a flexible flatfoot with significant forefoot abduction (talonavicular uncoverage >30%). Stage IIa is flexible without significant forefoot abduction. Stage III indicates a rigid hindfoot deformity, and Stage IV involves ankle valgus tilt or arthritis.

Question 617

Topic: Midfoot & Hindfoot
A 60-year-old diabetic male presents with a warm, swollen, erythematous foot. His pedal pulses are bounding. Radiographs demonstrate periarticular fragmentation, subluxation, and bony debris at the tarsometatarsal joints. Which stage of the Eichenholtz classification does this clinical and radiographic picture represent?
. Stage 0
. Stage I (Developmental/Fragmentation)
. Stage II (Coalescence)
. Stage III (Reconstruction/Consolidation)
. Stage IV

Correct Answer & Explanation

. Stage I (Developmental/Fragmentation)

Explanation

Eichenholtz Stage I is the developmental or fragmentation stage of Charcot arthropathy. It is characterized clinically by a hot, swollen foot and radiographically by active bone resorption, fragmentation, joint subluxation, and debris formation.

Question 618

Topic: Midfoot & Hindfoot

In the context of Tarsal Tunnel Syndrome, compression of the tibial nerve occurs deep to the flexor retinaculum. The first branch of the lateral plantar nerve, which can become entrapped and cause symptoms mimicking severe chronic heel pain, is anatomically known as:

. Medial calcaneal nerve
. Sural nerve
. Baxter's nerve
. Deep peroneal nerve
. Saphenous nerve

Correct Answer & Explanation

. Medial calcaneal nerve

Explanation

The first branch of the lateral plantar nerve is commonly referred to as Baxter's nerve. It courses anterior to the medial calcaneal tuberosity and deep to the abductor hallucis. Entrapment here can cause chronic heel pain that mimics or coexists with plantar fasciitis.

Question 619

Topic: Midfoot & Hindfoot
A 60-year-old female presents with progressive flattening of her left foot. Examination reveals a flexible hindfoot valgus and inability to perform a single-limb heel rise. Radiographs show >40% talonavicular uncoverage on the AP view. What procedure is indicated in addition to flexor digitorum longus (FDL) transfer and medializing calcaneal osteotomy to address the specific deformity seen on the AP radiograph?
. Cotton osteotomy
. Lateral column lengthening (Evans osteotomy)
. Spring ligament reconstruction
. Subtalar arthrodesis
. Tarsometatarsal arthrodesis

Correct Answer & Explanation

. Lateral column lengthening (Evans osteotomy)

Explanation

The patient has Stage IIb adult-acquired flatfoot deformity, characterized by significant forefoot abduction, which corresponds to >30-40% talonavicular uncoverage on the AP radiograph. This requires a lateral column lengthening (e.g., Evans osteotomy) in addition to an FDL transfer and medializing calcaneal osteotomy to structurally correct the abduction. A Cotton osteotomy is used to correct residual forefoot supination.

Question 620

Topic: Midfoot & Hindfoot
A 30-year-old involved in a motor vehicle collision sustains a Hawkins Type III talar neck fracture. What does this classification imply regarding the displacement and the blood supply to the talar body?
. Non-displaced fracture; minimal risk of avascular necrosis (AVN)
. Subtalar subluxation; ~50% risk of AVN
. Subtalar and tibiotalar dislocation; close to 100% risk of AVN
. Subtalar, tibiotalar, and talonavicular dislocation; ~20% risk of AVN
. Talar head fracture; high risk of nonunion

Correct Answer & Explanation

. Subtalar and tibiotalar dislocation; close to 100% risk of AVN

Explanation

The Hawkins classification evaluates talar neck fractures and predicts the risk of avascular necrosis (AVN). Type I: non-displaced (0-10% AVN risk). Type II: subtalar dislocation or subluxation (20-50% AVN risk). Type III: subtalar and tibiotalar dislocation (nearly 100% AVN risk). Type IV (added by Canale): subtalar, tibiotalar, and talonavicular dislocation (also near 100% AVN risk).

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