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Midfoot & Hindfoot MCQs

Practice Set 32 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 621

Topic: Midfoot & Hindfoot

A 60-year-old diabetic patient presents with a warm, swollen, erythematous left foot. Radiographs reveal fragmentation and periarticular debris around the midfoot, with subluxation of the tarsometatarsal joints. Skin is intact. Inflammatory markers are mildly elevated. What is the appropriate initial management?

. Total contact casting and non-weight bearing
. Immediate surgical arthrodesis of the midfoot
. Intravenous antibiotics for 6 weeks
. Below-knee amputation
. Incision and drainage

Correct Answer & Explanation

. Total contact casting and non-weight bearing

Explanation

The patient is in the acute fragmentation phase (Eichenholtz stage I) of Charcot arthropathy. The hallmark of initial treatment for acute Charcot is offloading and immobilization, most effectively achieved with a total contact cast. Surgery in the acute inflammatory phase is generally contraindicated due to poor bone quality and high failure rates, unless there is severe impending ulceration or instability that cannot be managed conservatively.

Question 622

Topic: Midfoot & Hindfoot

A 55-year-old female presents with medial ankle pain and a progressively flattening arch. She has pain with single-limb heel rise but is able to perform it weakly. Passively, her hindfoot corrects to neutral. What is the most appropriate surgical intervention if conservative management fails?

. Gastrocnemius recession, flexor digitorum longus (FDL) transfer to the navicular, and medial displacement calcaneal osteotomy
. Triple arthrodesis
. Talonavicular arthrodesis
. Isolated flexor digitorum longus (FDL) transfer to the navicular
. Subtalar arthrodesis

Correct Answer & Explanation

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

Explanation

This presentation is consistent with Stage II posterior tibial tendon dysfunction (flexible deformity). Standard surgical treatment includes a soft tissue reconstruction (FDL transfer) combined with an extra-articular bony procedure (medial displacement calcaneal osteotomy) and often a gastroc recession.

Question 623

Topic: Midfoot & Hindfoot

A 55-year-old female presents with Stage IIB adult-acquired flatfoot deformity. Clinical exam demonstrates a flexible hindfoot valgus and significant forefoot abduction (too many toes sign). Radiographs show greater than 30% uncovering of the talonavicular joint. Which of the following procedures is essential to correct her deformity in addition to a flexor digitorum longus transfer and medial displacement calcaneal osteotomy?

. Spring ligament reconstruction
. Lateral column lengthening
. First tarsometatarsal arthrodesis
. Subtalar arthrodesis
. Triple arthrodesis

Correct Answer & Explanation

. Spring ligament reconstruction

Explanation

Stage IIB flatfoot is characterized by substantial forefoot abduction due to talonavicular uncoverage (>30%). A lateral column lengthening (e.g., Evans osteotomy) is necessary to restore the lateral column length and correct the abduction deformity.

Question 624

Topic: Midfoot & Hindfoot

A 60-year-old male with poorly controlled diabetes presents with a red, hot, swollen right foot. There are no open ulcers or portals of entry. Radiographs show fragmentation and debris at the tarsometatarsal joints. What is the most appropriate initial management?

. Intravenous antibiotics and MRI
. Surgical debridement and acute midfoot fusion
. Total contact casting (TCC) and strict non-weight bearing
. Exostectomy of the prominent midfoot bone
. Charcot restraint orthotic walker (CROW)

Correct Answer & Explanation

. Intravenous antibiotics and MRI

Explanation

The patient has acute (Eichenholtz Stage I) Charcot arthropathy, which presents similarly to an infection but lacks an ulcer. The gold standard initial treatment is offloading with total contact casting (TCC) to halt progression during the acute inflammatory phase.

Question 625

Topic: Midfoot & Hindfoot
A 28-year-old snowboarder sustains a Hawkins Type III fracture of the talar neck. Which of the following best describes the fracture pattern and the associated risk of avascular necrosis (AVN) of the talar body?
. Undisplaced fracture, AVN risk < 10%
. Fracture with subtalar subluxation/dislocation, AVN risk 20-50%
. Fracture with subtalar and tibiotalar dislocation, AVN risk near 100%
. Fracture with subtalar, tibiotalar, and talonavicular dislocation, AVN risk 100%
. Fracture with isolated talonavicular dislocation, AVN risk 50%

Correct Answer & Explanation

. Fracture with subtalar and tibiotalar dislocation, AVN risk near 100%

Explanation

The Hawkins classification for talar neck fractures is predictive of the risk of AVN. Type I: nondisplaced (AVN risk 0-15%). Type II: displaced with subtalar subluxation or dislocation (AVN risk 20-50%). Type III: displaced with both subtalar and tibiotalar (ankle) dislocation (AVN risk > 90% or near 100% historically). Type IV: Type III + talonavicular subluxation/dislocation. Therefore, Type III involves dislocation of both the subtalar and ankle joints.

Question 626

Topic: Midfoot & Hindfoot
A 32-year-old male sustains a displaced talar neck fracture with subluxation of the subtalar joint, but the tibiotalar and talonavicular joints remain congruent. What is the Hawkins classification and the estimated risk of avascular necrosis (AVN)?
. Hawkins I; < 10% risk of AVN
. Hawkins II; 20-50% risk of AVN
. Hawkins III; 80-100% risk of AVN
. Hawkins IV; 100% risk of AVN
. Hawkins II; 80-100% risk of AVN

Correct Answer & Explanation

. Hawkins II; 20-50% risk of AVN

Explanation

A Hawkins II talar neck fracture involves subtalar subluxation or dislocation while the ankle and talonavicular joints remain aligned. The associated risk of avascular necrosis (AVN) is historically cited as 20-50%.

Question 627

Topic: Midfoot & Hindfoot

A 25-year-old athlete sustains a purely ligamentous Lisfranc injury. Nonoperative management is unsuccessful, and surgical intervention is planned. Based on high-quality prospective literature comparing open reduction internal fixation (ORIF) to primary arthrodesis for purely ligamentous Lisfranc injuries, which of the following is true regarding primary arthrodesis?

. It yields clinically inferior functional outcome scores compared to ORIF.
. It results in a higher rate of hardware-related complications requiring removal.
. It is associated with a significantly lower rate of secondary surgical procedures.
. It preserves greater midfoot sagittal plane motion than ORIF.
. It is contraindicated in young, highly active patients.

Correct Answer & Explanation

. It yields clinically inferior functional outcome scores compared to ORIF.

Explanation

Prospective randomized trials (such as Ly and Coetzee, JBJS 2006) comparing ORIF to primary arthrodesis for primarily ligamentous Lisfranc injuries have shown that primary arthrodesis results in better or comparable short- and long-term functional outcomes and significantly lowers the rate of secondary surgeries (such as hardware removal or salvage fusion for post-traumatic arthritis).

Question 628

Topic: Midfoot & Hindfoot
A 55-year-old poorly controlled diabetic patient presents with a swollen, warm, and erythematous left foot. Peripheral pulses are bounding. Radiographs show periarticular debris, subluxation of the tarsometatarsal joints, and active fragmentation of the bone without signs of coalescence. According to the Eichenholtz classification, what is the current stage of this patient's Charcot arthropathy and what is the primary treatment?
. Stage 0; Surgical arthrodesis
. Stage I; Total contact casting and strict non-weight bearing
. Stage II; Total contact casting and weight bearing as tolerated
. Stage III; Custom accommodative orthotic footwear
. Stage I; Intravenous antibiotics and surgical debridement

Correct Answer & Explanation

. Stage I; Total contact casting and strict non-weight bearing

Explanation

This patient is in Eichenholtz Stage I (Developmental/Fragmentation) of Charcot arthropathy, characterized clinically by the 'hot, swollen' foot and radiographically by bony fragmentation, joint dislocation, and debris. The standard of care during this active phase is strict offloading and immobilization, most effectively achieved with a total contact cast (TCC) to prevent further deformity until the active inflammatory process subsides.

Question 629

Topic: Midfoot & Hindfoot

The spring ligament complex is a critical static stabilizer of the medial longitudinal arch of the foot. Which of its distinct anatomic fascicles is the strongest and provides the most significant structural support to the talar head?

. Plantar calcaneocuboid ligament
. Inferoplantar calcaneonavicular ligament
. Superomedial calcaneonavicular ligament
. Medioplantar calcaneonavicular ligament
. Dorsal talonavicular ligament

Correct Answer & Explanation

. Plantar calcaneocuboid ligament

Explanation

The spring ligament (plantar calcaneonavicular ligament) complex has three main distinct components: superomedial, inferoplantar, and medioplantar. The superomedial calcaneonavicular ligament is the thickest, widest, and most important fascicle. It provides the primary hammock-like support beneath the talar head and is commonly attenuated or ruptured in adult acquired flatfoot deformity (posterior tibial tendon dysfunction).

Question 630

Topic: Midfoot & Hindfoot
A 25-year-old male sustains a Hawkins type III talar neck fracture following an aviation accident. Which of the following accurately describes the displacement and the associated risk of avascular necrosis (AVN) for this specific injury pattern?
. Undisplaced fracture; 0-10% AVN risk
. Subtalar subluxation/dislocation; 20-50% AVN risk
. Subtalar dislocation; 70-90% AVN risk
. Subtalar, tibiotalar, and talonavicular dislocation; close to 100% AVN risk
. Subtalar and tibiotalar dislocation; close to 100% AVN risk

Correct Answer & Explanation

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

Explanation

Hawkins classification for talar neck fractures determines the risk of AVN. Type I: Undisplaced (0-15% AVN risk). Type II: Associated with subtalar subluxation/dislocation (20-50% AVN risk). Type III: Subtalar and tibiotalar dislocation (approaching 90-100% AVN risk). Type IV (Canale addition): Subtalar, tibiotalar, and talonavicular dislocation (~100% AVN risk).

Question 631

Topic: Midfoot & Hindfoot
A 28-year-old male sustains a displaced talar neck fracture with subluxation of the subtalar joint, while the tibiotalar and talonavicular joints remain congruous. According to the Hawkins classification, what is the type and approximate historical risk of avascular necrosis (AVN)?
. Hawkins I, 0-10%
. Hawkins II, 80-100%
. Hawkins III, 80-100%
. Hawkins IV, 100%
. Hawkins II, 20-50%

Correct Answer & Explanation

. Hawkins II, 20-50%

Explanation

Hawkins type II is defined as a talar neck fracture with subluxation or dislocation of the subtalar joint, while the tibiotalar and talonavicular joints remain intact. The risk of AVN is historically reported as 20-50%. Hawkins I: undisplaced (0-10%). Hawkins III: subtalar and tibiotalar dislocation (approaching 100%).

Question 632

Topic: Midfoot & Hindfoot
A 28-year-old male is involved in a high-speed MVA and sustains a closed fracture of the talar neck. Imaging shows a displaced fracture of the talar neck with subluxation of the subtalar joint, while the tibiotalar and talonavicular joints remain congruent. What is the Hawkins classification for this injury?
. Type I
. Type II
. Type III
. Type IV
. Type V

Correct Answer & Explanation

. Type II

Explanation

The Hawkins classification is used for talar neck fractures. Type I: Non-displaced. Type II: Displaced with subtalar subluxation or dislocation. Type III: Displaced with subtalar and tibiotalar dislocation. Type IV: Displaced with subtalar, tibiotalar, and talonavicular dislocation. The scenario describes a Type II fracture, which carries an avascular necrosis risk of approximately 20-50%.

Question 633

Topic: Midfoot & Hindfoot
A 29-year-old male falls from a height and sustains a talar neck fracture with subluxation of the subtalar joint but a congruous tibiotalar and talonavicular joint. According to the Hawkins classification, what is the risk of avascular necrosis (AVN)?
. 0-10%
. 20-50%
. 70-100%
. 100%
. AVN does not occur in this pattern

Correct Answer & Explanation

. 20-50%

Explanation

This is a Hawkins Type II fracture (talar neck fracture with subtalar dislocation). The risk of AVN for Type I is 0-10%, Type II is 20-50%, Type III (subtalar and tibiotalar dislocation) is 50-100%, and Type IV (Type III plus talonavicular dislocation) is near 100%.

Question 634

Topic: Midfoot & Hindfoot
A 60-year-old female presents with a progressive, flexible flatfoot deformity and inability to perform a single-leg heel raise. Examination shows severe hindfoot valgus and >40% uncovering of the talonavicular joint. She reports lateral ankle impingement pain. According to the Johnson and Strom classification modified by Myerson, what is the most appropriate surgical management if conservative treatment fails?
. FDL transfer and medial displacement calcaneal osteotomy alone
. FDL transfer, medial displacement calcaneal osteotomy, and lateral column lengthening
. Subtalar arthrodesis only
. Isolated triple arthrodesis
. Tibiotalocalcaneal arthrodesis

Correct Answer & Explanation

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

Explanation

This patient has a flexible Stage IIb Adult Acquired Flatfoot Deformity (Posterior Tibial Tendon Dysfunction). Stage IIb is characterized by significant forefoot abduction (>30-40% talonavicular uncovering). Appropriate treatment includes correcting the deformity with a lateral column lengthening (e.g., Evans osteotomy) in addition to an FDL transfer and medial displacement calcaneal osteotomy (MDCO) to address both the valgus and the abduction.

Question 635

Topic: Midfoot & Hindfoot

A 55-year-old patient with poorly controlled diabetes mellitus presents with a red, hot, and swollen left foot. Radiographs show periarticular osteopenia, fragmentation of bone, and early subluxation at the midtarsal joints. Infection has been definitively ruled out. According to the Eichenholtz classification, what stage is this, and what is the standard initial management?

. Stage 0; custom orthotics
. Stage 1; total contact casting and strict non-weight bearing
. Stage 2; total contact casting and strict non-weight bearing
. Stage 3; open reduction and internal fixation
. Stage 1; immediate midfoot arthrodesis

Correct Answer & Explanation

. Stage 0; custom orthotics

Explanation

Eichenholtz Stage 1 (Development/Fragmentation) of Charcot arthropathy is characterized clinically by a red, hot, swollen foot and radiographically by bone fragmentation, joint subluxation, and debris. The gold standard initial treatment is immobilization in a total contact cast (TCC) and offloading to prevent further deformity until the acute inflammatory phase resolves (progressing to Stage 2 - Coalescence, and Stage 3 - Consolidation).

Question 636

Topic: Midfoot & Hindfoot

A 55-year-old female presents with a painful, progressive flatfoot deformity. Examination reveals an inability to perform a single-limb heel rise and significant flexible hindfoot valgus. Weight-bearing radiographs demonstrate a talonavicular coverage angle of 45 degrees and uncovering of the talar head. Which of the following surgical strategies is most appropriate for this stage of deformity?

. Flexor digitorum longus (FDL) transfer to the navicular and medial displacement calcaneal osteotomy (MDCO) alone
. FDL transfer to the navicular, MDCO, and lateral column lengthening
. Isolated subtalar arthrodesis
. Triple arthrodesis
. Gastrocnemius recession and conservative shoe wear modification

Correct Answer & Explanation

. Flexor digitorum longus (FDL) transfer to the navicular and medial displacement calcaneal osteotomy (MDCO) alone

Explanation

This patient has Stage IIb adult-acquired flatfoot deformity, characterized by a flexible deformity with significant forefoot abduction (>40% talonavicular uncovering). Management requires a soft tissue reconstruction (FDL transfer), hindfoot correction (MDCO), and a lateral column lengthening (e.g., Evans osteotomy) to correct the forefoot abduction.

Question 637

Topic: Midfoot & Hindfoot

A 50-year-old runner undergoes a complete surgical release of the plantar fascia for recalcitrant plantar fasciitis. Post-operatively, she reports relief of her heel pain but develops new-onset, severe pain along the lateral border of her midfoot. What is the most likely biomechanical cause of this new symptom?

. Iatrogenic injury to the medial calcaneal nerve
. Sural nerve neuroma at the operative site
. Lateral column overload secondary to loss of the windlass mechanism and arch collapse
. Avascular necrosis of the cuboid
. Avulsion of the peroneus brevis tendon

Correct Answer & Explanation

. Iatrogenic injury to the medial calcaneal nerve

Explanation

A complete release of the plantar fascia destroys the windlass mechanism, leading to arch depression, increased strain on the midfoot ligaments, and subsequent lateral column overload. This complication causes severe, recalcitrant lateral midfoot pain.

Question 638

Topic: Midfoot & Hindfoot

A 55-year-old female presents with a progressive flatfoot deformity. Examination reveals a flexible hindfoot valgus and inability to perform a single-leg heel raise. Weight-bearing radiographs show more than 30% uncovering of the talonavicular joint on the AP view. Which of the following surgical interventions is most appropriate for this Stage IIb posterior tibial tendon dysfunction?

. 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
. Talonavicular arthrodesis
. Triple arthrodesis

Correct Answer & Explanation

. Isolated posterior tibial tendon debridement

Explanation

Stage IIb adult acquired flatfoot deformity is characterized by a flexible deformity with significant forefoot abduction (>30% talonavicular uncovering). Adding a lateral column lengthening to an FDL transfer and MDCO is required to correct the severe forefoot abduction.

Question 639

Topic: Midfoot & Hindfoot

A 52-year-old female presents with a progressive, painful flatfoot deformity. Clinical examination reveals an inability to perform a single-leg heel rise. Weight-bearing radiographs show a flexible hindfoot valgus and greater than 30% uncovering of the talonavicular joint with forefoot abduction. What is the most appropriate surgical management for this Stage IIb posterior tibial tendon dysfunction?

. Non-operative management with an articulated AFO
. Isolated flexor digitorum longus (FDL) transfer to the navicular
. FDL transfer combined with a medializing calcaneal osteotomy
. FDL transfer, medializing calcaneal osteotomy, and lateral column lengthening
. Triple arthrodesis

Correct Answer & Explanation

. Non-operative management with an articulated AFO

Explanation

Stage IIb adult-acquired flatfoot deformity involves a flexible hindfoot with significant forefoot abduction (>30% talonavicular uncovering). Surgical correction requires a medializing calcaneal osteotomy to correct hindfoot valgus, an FDL transfer to replace the dysfunctional PTT, and a lateral column lengthening to correct the forefoot abduction.

Question 640

Topic: Midfoot & Hindfoot

A 55-year-old diabetic patient presents with a swollen, warm, and erythematous foot without any open ulcers. Radiographs reveal joint subluxation, debris, and fragmentation. According to the Eichenholtz classification, what is the most appropriate initial management for this patient?

. Total contact casting and non-weight bearing
. Immediate surgical arthrodesis
. Amputation of the affected limb
. Oral antibiotics and weight-bearing as tolerated
. Custom accommodative footwear

Correct Answer & Explanation

. Total contact casting and non-weight bearing

Explanation

The patient is in Eichenholtz Stage I (Developmental/Fragmentation stage of Charcot arthropathy), characterized by erythema, warmth, joint laxity, subluxation, and bony fragmentation. The gold standard of initial management is immobilization with a total contact cast and strict non-weight bearing until the acute phase resolves (transition to Stage II).

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