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Midfoot & Hindfoot MCQs

Practice Set 33 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 641

Topic: Midfoot & Hindfoot

A 55-year-old patient with poorly controlled diabetes presents with a red, hot, swollen foot without skin ulceration. Radiographs show fragmentation of the navicular and cuneiforms with subluxation of the tarsometatarsal joints. According to the Eichenholtz classification, what is the most appropriate initial management?

. Intravenous antibiotics and immediate surgical debridement
. Total contact casting and strict non-weight-bearing
. Primary arthrodesis of the midfoot
. Prescription of custom orthotic rocker-bottom shoes
. Below-knee amputation

Correct Answer & Explanation

. Intravenous antibiotics and immediate surgical debridement

Explanation

The patient is in Eichenholtz Stage I (Developmental/Fragmentation stage) of Charcot arthropathy, characterized by acute inflammation and bony destruction. The gold standard of initial treatment is immobilization and offloading with a total contact cast to prevent progressive, irreversible deformity.

Question 642

Topic: Midfoot & Hindfoot

A 13-year-old male presents with recurrent ankle sprains and chronic vague midfoot pain. Physical examination demonstrates a rigid flatfoot with absent subtalar motion. Radiographs reveal a 'C-sign' on the lateral view. A CT scan confirms a talocalcaneal coalition. Which of the following specific anatomical sites is most commonly involved in this type of coalition?

. Anterior facet of the subtalar joint
. Middle facet of the subtalar joint
. Posterior facet of the subtalar joint
. Calcaneocuboid joint
. Talonavicular joint

Correct Answer & Explanation

. Anterior facet of the subtalar joint

Explanation

Talocalcaneal coalitions most commonly involve the middle facet of the subtalar joint. Radiographically, the 'C-sign' (formed by the medial outline of the talar dome and the inferior outline of the sustentaculum tali) is highly indicative of a middle facet talocalcaneal coalition. Resection of the coalition is typically considered if the coalition involves less than 50% of the posterior facet surface area and there are no significant degenerative changes; otherwise, subtalar fusion may be required.

Question 643

Topic: Midfoot & Hindfoot
A 40-year-old male with poorly controlled type 2 diabetes presents with a warm, swollen, and erythematous right foot. Radiographs reveal joint subluxation, osteopenia, and early bone fragmentation in the midfoot, but no frank osteomyelitis. According to the Eichenholtz classification for Charcot arthropathy, what stage does this represent?
. Stage 0 (High risk)
. Stage I (Developmental/Fragmentation)
. Stage II (Coalescence)
. Stage III (Reconstruction/Consolidation)
. Stage IV (Late deformity)

Correct Answer & Explanation

. Stage I (Developmental/Fragmentation)

Explanation

Eichenholtz Stage I (Developmental phase) is characterized clinically by a red, hot, swollen foot and radiographically by bone debris, fragmentation, and joint subluxation/dislocation. Treatment primarily involves strict immobilization and offloading.

Question 644

Topic: Midfoot & Hindfoot

A 55-year-old diabetic male presents with a swollen, erythematous, and warm foot. Radiographs reveal fragmentation of the navicular and subluxation of the talonavicular joint, consistent with Eichenholtz stage I Charcot arthropathy. What is the most appropriate initial management?

. Intravenous antibiotics and surgical debridement
. Urgent arthrodesis of the midfoot
. Total contact casting and non-weight bearing
. Customized accommodative footwear
. Open reduction and internal fixation

Correct Answer & Explanation

. Intravenous antibiotics and surgical debridement

Explanation

The initial treatment for acute Eichenholtz stage I (fragmentation stage) Charcot arthropathy is strict immobilization and offloading. This is most effectively achieved using a total contact cast (TCC).

Question 645

Topic: Midfoot & Hindfoot
A 35-year-old male falls from a height and sustains a Hawkins Type III talar neck fracture (fracture with subtalar and tibiotalar dislocation). What is the approximate risk of developing avascular necrosis (AVN) of the talar body in this injury pattern?
. 0 - 10%
. 15 - 30%
. 40 - 50%
. 75 - 100%
. It only occurs if fixation is delayed > 24 hours

Correct Answer & Explanation

. 75 - 100%

Explanation

The Hawkins classification for talar neck fractures directly correlates with the risk of AVN. Type I: 0-10%; Type II (subtalar dislocation): 20-50%; Type III (subtalar and tibiotalar dislocation): near 100% (often cited as 75-100%); Type IV (Type III plus talonavicular dislocation): near 100%.

Question 646

Topic: Midfoot & Hindfoot

A 55-year-old patient with long-standing, poorly controlled diabetes presents with a unilaterally swollen, red, and warm foot. He denies pain or recent trauma. Radiographs reveal bone fragmentation, periarticular osteopenia, intra-articular debris, and subluxation at the midfoot. According to the Eichenholtz classification of Charcot arthropathy, which stage does this represent?

. Stage 0 (Pre-fragmentation)
. Stage 1 (Development/Fragmentation)
. Stage 2 (Coalescence)
. Stage 3 (Reconstruction/Consolidation)
. Stage 4 (Ankylosis)

Correct Answer & Explanation

. Stage 0 (Pre-fragmentation)

Explanation

The Eichenholtz classification describes the natural history of Charcot neuroarthropathy. Stage 0 is the clinical "red, hot, swollen" foot with normal x-rays. Stage 1 (Development/Fragmentation) is characterized by clinical inflammation and radiographic findings of bone fragmentation, debris, joint subluxation, and dislocation. Stage 2 (Coalescence) shows absorption of fine debris, early fusion of larger fragments, and decreased clinical swelling. Stage 3 (Reconstruction) features remodeling of bone ends, rounding of fragments, and decreased osteopenia without inflammation.

Question 647

Topic: Midfoot & Hindfoot



A 55-year-old male with poorly controlled diabetes presents with a swollen, erythematous, and warm foot. He denies trauma and reports minimal pain. Radiographs demonstrate acute periarticular fragmentation and subluxation at the tarsometatarsal joint. According to the Eichenholtz classification, what is the standard of care for this acute phase?

. Total contact casting and non-weight-bearing
. Immediate open reduction and internal fixation
. Midfoot arthrodesis with a rigid plating system
. Intravenous antibiotics for 6 weeks
. Surgical debridement and application of an external fixator

Correct Answer & Explanation

. Total contact casting and non-weight-bearing

Explanation

The clinical picture represents the acute fragmentation phase (Eichenholtz stage I) of Charcot arthropathy. The standard initial management is strict immobilization and offloading, typically with a total contact cast, to prevent further deformity while the acute inflammatory process subsides.

Question 648

Topic: Midfoot & Hindfoot

A 60-year-old diabetic patient presents with a severely swollen, erythematous, but painless foot. Radiographs demonstrate marked osteopenia, bony fragmentation, and periarticular debris at the tarsometatarsal joints. According to the Eichenholtz classification, what stage is this?

. Stage 0 (Inflammatory)
. Stage 1 (Developmental/Fragmentation)
. Stage 2 (Coalescence)
. Stage 3 (Reconstruction)
. Stage 4 (Ankylosis)

Correct Answer & Explanation

. Stage 0 (Inflammatory)

Explanation

Eichenholtz Stage 1 (Developmental/Fragmentation) of Charcot arthropathy is characterized clinically by acute inflammation and radiographically by bone fragmentation, joint dislocation, and debris formation. Stage 2 involves early healing and absorption of fine debris.

Question 649

Topic: Midfoot & Hindfoot

A 55-year-old diabetic male presents with a painless, red, hot, and swollen right foot. He is afebrile with normal inflammatory markers. Radiographs demonstrate periarticular fragmentation, subluxation, and bony debris at the midfoot. According to the Eichenholtz classification, what is the most appropriate initial management?

. Urgent surgical debridement and washout
. Immobilization in a total contact cast
. Intravenous broad-spectrum antibiotics
. Primary arthrodesis of the midfoot
. Below-knee amputation

Correct Answer & Explanation

. Urgent surgical debridement and washout

Explanation

The patient is presenting with acute Charcot arthropathy (Eichenholtz Stage 1: Development/Fragmentation), characterized by a red, hot, swollen foot with radiographic evidence of osteopenia, fragmentation, and joint subluxation. The mainstay of treatment in the acute phase is strict offloading and immobilization, most effectively achieved with a total contact cast, until the joint transitions to the coalescence phase.

Question 650

Topic: Midfoot & Hindfoot
A 55-year-old diabetic male with peripheral neuropathy presents with a markedly swollen, warm, and erythematous left foot. Pulses are bounding. Radiographs demonstrate acute periarticular fragmentation, bony debris, and early subluxation at the tarsometatarsal joints. According to the Eichenholtz classification of Charcot neuroarthropathy, which stage does this represent?
. Stage 0
. Stage I
. Stage II
. Stage III
. Stage IV

Correct Answer & Explanation

. Stage I

Explanation

The Eichenholtz classification of Charcot arthropathy includes three main stages (plus a more recently recognized Stage 0). Stage I is the Development/Fragmentation phase, characterized clinically by a red, hot, swollen foot and radiographically by bony debris, fragmentation, and joint subluxation/dislocation. Stage II is Coalescence (absorption of fine debris, early fusion), and Stage III is Consolidation (remodeling and stable deformity).

Question 651

Topic: Midfoot & Hindfoot
A 55-year-old female presents with stage IIb adult-acquired flatfoot deformity (posterior tibial tendon insufficiency), characterized by flexible flatfoot and more than 40% uncovering of the talonavicular joint. Which of the following surgical procedures is most appropriate?
. Medial displacement calcaneal osteotomy (MDCO) and FDL transfer alone
. FDL transfer to the navicular alone
. Lateral column lengthening (Evans), MDCO, and FDL transfer
. Triple arthrodesis
. Subtalar arthrodesis alone

Correct Answer & Explanation

. Lateral column lengthening (Evans), MDCO, and FDL transfer

Explanation

Adult-acquired flatfoot Stage II is a flexible deformity. Stage IIa has minimal forefoot abduction, typically managed with a medial displacement calcaneal osteotomy (MDCO) and FDL transfer. Stage IIb features significant forefoot abduction (> 40% talonavicular uncovering), which necessitates an additional lateral column lengthening (e.g., Evans osteotomy) to correct the forefoot abduction, along with MDCO and FDL transfer. Stage III (rigid) requires arthrodesis (e.g., triple).

Question 652

Topic: Midfoot & Hindfoot

A 55-year-old patient with long-standing, poorly controlled diabetes presents with a warm, swollen, erythematous left foot. Radiographs show fragmentation and periarticular debris at the tarsometatarsal joints. Laboratory markers (WBC, ESR, CRP) are minimally elevated. What is the most appropriate initial management?

. Intravenous antibiotics and surgical debridement
. Total contact casting and non-weight-bearing
. Arthrodesis of the midfoot
. Corticosteroid injection into the affected joints
. Below-knee amputation

Correct Answer & Explanation

. Intravenous antibiotics and surgical debridement

Explanation

The clinical presentation is classic for acute Eichenholtz Stage I Charcot arthropathy (fragmentation). The initial treatment of choice is strict immobilization and offloading, most effectively achieved with total contact casting and non-weight-bearing. Surgery is contraindicated during the acute inflammatory phase unless there is severe impending ulceration or instability that cannot be braced.

Question 653

Topic: Midfoot & Hindfoot

A 55-year-old woman presents with medial ankle pain and a progressive flatfoot deformity. She is unable to perform a single-leg heel raise on the affected side. Radiographs show uncovering of the talonavicular joint. This condition is primarily due to dysfunction of which tendon?

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

Correct Answer & Explanation

. Anterior tibial tendon

Explanation

Adult acquired flatfoot deformity is most commonly caused by posterior tibial tendon dysfunction (PTTD). The posterior tibial tendon acts as the primary dynamic stabilizer of the medial longitudinal arch, and its failure results in the inability to perform a single-leg heel raise, leading to hindfoot valgus and forefoot abduction.

Question 654

Topic: Midfoot & Hindfoot
A 28-year-old patient sustains a Hawkins type III talar neck fracture. Which of the following best describes the displacement pattern and the approximate associated risk of avascular necrosis (AVN)?
. Subtalar subluxation with a 20% AVN risk
. Subtalar and tibiotalar dislocation with an AVN risk approaching 90-100%
. Nondisplaced fracture with a 10% AVN risk
. Talonavicular dislocation only with a 50% AVN risk
. Subtalar and talonavicular dislocation with an 80% AVN risk

Correct Answer & Explanation

. Subtalar and tibiotalar dislocation with an AVN risk approaching 90-100%

Explanation

A Hawkins type III fracture involves dislocation of both the subtalar and tibiotalar joints. Because of the severe disruption to the retrograde blood supply, the risk of AVN is extremely high.

Question 655

Topic: Midfoot & Hindfoot
A 60-year-old male with long-standing diabetes presents with a swollen, erythematous, and warm foot but no systemic signs of infection. Radiographs reveal joint fragmentation, periarticular debris, and subluxation of the midfoot joints. According to the Eichenholtz classification of Charcot arthropathy, what is the current stage of this disease process?
. Stage 0 (Prodromal)
. Stage I (Developmental/Fragmentation)
. Stage II (Coalescence)
. Stage III (Reconstruction/Consolidation)
. Stage IV (Degenerative)

Correct Answer & Explanation

. Stage I (Developmental/Fragmentation)

Explanation

Eichenholtz Stage I is the developmental or fragmentation stage, characterized clinically by an acute, swollen, erythematous foot. Radiographically, it shows joint effusion, subchondral osteopenia, fragmentation, joint subluxation/dislocation, and bony debris. Stage II (Coalescence) shows absorption of debris and early fusion. Stage III (Consolidation) shows remodeling and stable deformity.

Question 656

Topic: Midfoot & Hindfoot

A 45-year-old distance runner presents with chronic heel pain. It is maximal on the plantar-medial aspect of the heel and radiates distally along the lateral border of the foot. The pain is not worse with the first step in the morning but worsens after prolonged activity. Entrapment of Baxter's nerve is suspected. Baxter's nerve is the first branch of which nerve?

. Medial plantar nerve
. Lateral plantar nerve
. Sural nerve
. Medial calcaneal nerve
. Deep peroneal nerve

Correct Answer & Explanation

. Medial plantar nerve

Explanation

Baxter's nerve is the first branch of the lateral plantar nerve. It courses deep to the abductor hallucis muscle and supplies motor innervation to the abductor digiti minimi. Entrapment of Baxter's nerve can cause chronic heel pain that mimics, or coexists with, plantar fasciitis but often includes radiating pain and possible hypotrophy of the abductor digiti minimi on MRI.

Question 657

Topic: Midfoot & Hindfoot
A 65-year-old woman presents with a painful, severe flatfoot deformity. Examination reveals a rigid deformity that is not passively correctable to neutral, and she cannot perform a single-limb heel rise. Radiographs demonstrate advanced degenerative changes in the subtalar and talonavicular joints. What is the most appropriate definitive surgical management?
. FDL transfer and medial displacement calcaneal osteotomy
. Lateral column lengthening and medial cuneiform osteotomy
. Subtalar arthrodesis alone
. Triple arthrodesis
. Tibiotalocalcaneal arthrodesis

Correct Answer & Explanation

. Triple arthrodesis

Explanation

The patient has Stage III Adult Acquired Flatfoot Ddeformity (Posterior Tibial Tendon Dysfunction), characterized by a rigid deformity and hindfoot arthrosis. Joint-sparing osteotomies and tendon transfers (Stages I and II) are no longer appropriate. A triple arthrodesis (subtalar, talonavicular, and calcaneocuboid) is the gold standard for restoring a plantigrade foot and eliminating arthritic pain.

Question 658

Topic: Midfoot & Hindfoot

A 45-year-old marathon runner presents with chronic, recalcitrant heel pain. Clinical examination reveals maximal tenderness at the medial aspect of the calcaneal tuberosity. MRI demonstrates fatty atrophy of the abductor digiti minimi muscle. Entrapment of which of the following nerves is the most likely cause of these findings?

. Medial plantar nerve
. Lateral plantar nerve
. First branch of the lateral plantar nerve
. First branch of the medial plantar nerve
. Medial calcaneal nerve

Correct Answer & Explanation

. Medial plantar nerve

Explanation

Baxter's nerve is the first branch of the lateral plantar nerve. It supplies motor innervation to the abductor digiti minimi. Entrapment typically occurs between the deep fascia of the abductor hallucis and the medial margin of the quadratus plantae, leading to chronic heel pain and isolated fatty atrophy of the abductor digiti minimi on MRI.

Question 659

Topic: Midfoot & Hindfoot

A 55-year-old poorly controlled diabetic male presents with a markedly swollen, erythematous, and warm foot. Radiographs demonstrate periarticular bone fragmentation, subluxation, and soft tissue swelling at the tarsometatarsal joints. Based on the Eichenholtz classification, what is the appropriate stage and recommended initial management?

. Stage 0; Total contact casting
. Stage 1; Total contact casting
. Stage 2; Surgical arthrodesis
. Stage 3; Surgical arthrodesis
. Stage 1; Immediate surgical debridement and external fixation

Correct Answer & Explanation

. Stage 0; Total contact casting

Explanation

The patient is in Eichenholtz Stage 1 (Development/Fragmentation) of Charcot arthropathy, characterized by clinical inflammation and radiographic evidence of osteopenia, fragmentation, and joint subluxation/dislocation. The standard of care during the acute phase (Stage 1) is offloading and immobilization, most commonly via total contact casting. Surgery is generally contraindicated during the acute inflammatory phase.

Question 660

Topic: Midfoot & Hindfoot

A 22-year-old collegiate athlete sustains a purely ligamentous Lisfranc injury with 3 mm of diastasis between the medial and middle cuneiforms. Based on comparative literature regarding purely ligamentous Lisfranc injuries in adults, which procedure provides the most predictable long-term functional outcome and lowest rate of revision surgery?

. Closed reduction and percutaneous pinning
. Open reduction and internal fixation (ORIF) with rigid transarticular screws
. Primary arthrodesis of the first, second, and third tarsometatarsal joints
. Non-weight bearing cast immobilization for 8 weeks
. Excision of the Lisfranc ligament and extensor digitorum brevis transfer

Correct Answer & Explanation

. Closed reduction and percutaneous pinning

Explanation

Several pivotal studies, notably by Coetzee and Ly, have demonstrated that for purely ligamentous Lisfranc injuries, primary arthrodesis of the medial columns (1st, 2nd, and 3rd TMT joints) yields significantly better functional outcomes and lower revision rates compared to ORIF, which often leads to hardware failure, loss of reduction, or progressive post-traumatic arthritis requiring salvage arthrodesis.

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