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Midfoot & Hindfoot MCQs

Practice Set 34 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 661

Topic: Midfoot & Hindfoot

A 52-year-old obese female presents with a progressive, painful flatfoot. She is unable to perform a single-leg heel raise. Upon examination, her hindfoot valgus deformity is fully flexible. Weight-bearing radiographs demonstrate an AP talonavicular coverage angle of 45 degrees, consistent with greater than 30% uncovering of the talar head. Which of the following surgical interventions is most appropriate for this specific stage of Posterior Tibial Tendon Dysfunction (PTTD)?

. Isolated primary end-to-end repair of the posterior tibial tendon
. Flexor digitorum longus (FDL) transfer to the navicular and medial displacement calcaneal osteotomy alone
. FDL transfer, medial displacement calcaneal osteotomy, and a lateral column lengthening
. Triple arthrodesis
. Isolated talonavicular arthrodesis

Correct Answer & Explanation

. Isolated primary end-to-end repair of the posterior tibial tendon

Explanation

This is a Stage IIb PTTD (Johnson and Strom/Myerson classification), characterized by a flexible deformity with severe forefoot abduction (>30% talonavicular uncovering). Management requires FDL transfer and a medial displacement calcaneal osteotomy (MDCO) to address the tendon insufficiency and hindfoot valgus, PLUS a lateral column lengthening (e.g., Evans osteotomy) to adequately correct the severe forefoot abduction component.

Question 662

Topic: Midfoot & Hindfoot

A 40-year-old long-distance runner experiences refractory heel pain despite 6 months of conservative treatment, including stretching, custom orthotics, and night splints. He describes a radiating, burning pain over the medial heel that worsens considerably following a long run. Examination reveals maximal tenderness at the medial aspect of the heel, just distal to the medial malleolus, without pinpoint tenderness at the medial calcaneal tubercle. Entrapment of which specific nerve is the most likely cause?

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

Correct Answer & Explanation

. Medial calcaneal nerve

Explanation

The first branch of the lateral plantar nerve (Baxter's nerve) can become entrapped between the deep fascia of the abductor hallucis and the medial margin of the quadratus plantae. It often mimics severe plantar fasciitis but typically presents with radiating, burning neurological pain. Tenderness is slightly more proximal and medial along the nerve's course, rather than directly at the plantar medial calcaneal tubercle.

Question 663

Topic: Midfoot & Hindfoot

A 45-year-old woman presents with a painful, flexible flatfoot. Clinical exam reveals weakness in single-leg heel rise but a passively correctable hindfoot valgus deformity. Which of the following is the most appropriate surgical intervention if conservative measures fail?

. Triple arthrodesis
. Isolated subtalar arthrodesis
. Flexor digitorum longus (FDL) transfer to the navicular and medial displacement calcaneal osteotomy
. Spring ligament repair alone
. Gastrocnemius recession alone

Correct Answer & Explanation

. Triple arthrodesis

Explanation

Stage II adult-acquired flatfoot deformity involves a flexible deformity with posterior tibial tendon insufficiency. Joint-sparing procedures like an FDL transfer combined with a medializing calcaneal osteotomy are the standard surgical treatment.

Question 664

Topic: Midfoot & Hindfoot

A 55-year-old diabetic male presents with an acutely swollen, erythematous, and warm foot with a bounding dorsalis pedis pulse. Radiographs show fragmentation and periarticular debris around the midfoot. What is the most appropriate initial management?

. Urgent irrigation and debridement
. Intravenous antibiotics for 6 weeks
. Total contact casting and non-weight-bearing
. Midfoot arthrodesis with rigid fixation
. Amputation at the Chopart level

Correct Answer & Explanation

. Urgent irrigation and debridement

Explanation

The patient is presenting in the acute, fragmentation phase (Eichenholtz stage I) of Charcot arthropathy. The gold standard of initial treatment is offloading with a total contact cast to prevent further deformity until the active phase resolves.

Question 665

Topic: Midfoot & Hindfoot

A 42-year-old runner complains of chronic, recalcitrant heel pain that radiates into the medial plantar arch. MRI reveals isolated atrophy of the abductor digiti minimi muscle. Entrapment of which of the following nerves is the most likely cause?

. Medial calcaneal nerve
. First branch of the lateral plantar nerve
. Medial plantar nerve
. Sural nerve
. Saphenous nerve

Correct Answer & Explanation

. Medial calcaneal nerve

Explanation

The first branch of the lateral plantar nerve (Baxter's nerve) innervates the abductor digiti minimi. Entrapment of this nerve causes chronic heel pain and isolated muscle atrophy visible on MRI.

Question 666

Topic: Midfoot & Hindfoot

In the operative management of a purely ligamentous Lisfranc injury, current literature suggests which of the following regarding primary arthrodesis compared to open reduction and internal fixation (ORIF)?

. ORIF has a significantly lower rate of reoperation
. Primary arthrodesis yields better functional outcomes and fewer reoperations for hardware removal
. There is no difference in outcomes or reoperation rates
. Primary arthrodesis leads to an unacceptably high rate of adjacent segment disease within 2 years
. ORIF is preferred due to preserved midfoot motion and better athletic performance

Correct Answer & Explanation

. ORIF has a significantly lower rate of reoperation

Explanation

Studies have shown that primary arthrodesis for purely ligamentous Lisfranc injuries provides comparable or superior functional outcomes and a significantly lower reoperation rate compared to ORIF, which often requires routine hardware removal and may fail.

Question 667

Topic: Midfoot & Hindfoot

A 58-year-old male with long-standing, poorly controlled type 2 diabetes presents with a unilaterally swollen, red, and warm foot. Radiographs demonstrate fragmentation of the midfoot with subluxation, but no skin ulceration. Inflammatory markers are mildly elevated. What is the most appropriate initial management?

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

Correct Answer & Explanation

. Total contact casting and non-weight-bearing

Explanation

The patient is in Eichenholtz Stage I (developmental/acute) of Charcot arthropathy, characterized by fragmentation and joint subluxation. The mainstay of acute treatment to prevent further deformity is strict immobilization with a total contact cast and offloading.

Question 668

Topic: Midfoot & Hindfoot

A 45-year-old runner presents with chronic, severe heel pain refractory to conservative management, including corticosteroid injections. Pain is maximal at the medial aspect of the heel and radiates distally. Examination reveals tenderness over the first branch of the lateral plantar nerve. This nerve provides motor innervation to which of the following muscles?

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

Correct Answer & Explanation

. Abductor hallucis

Explanation

The first branch of the lateral plantar nerve (Baxter's nerve) courses between the abductor hallucis and quadratus plantae, providing motor innervation to the abductor digiti minimi. Entrapment can mimic or coexist with plantar fasciitis.

Question 669

Topic: Midfoot & Hindfoot

A 40-year-old laborer sustains a purely ligamentous, unstable Lisfranc injury. Based on high-level evidence, which of the following surgical treatments yields the best long-term clinical outcomes and functional scores for purely ligamentous midfoot injuries?

. Closed reduction and percutaneous K-wire fixation
. Open reduction and flexible suture-button fixation
. Open reduction and internal fixation with transarticular screws
. Dorsal bridge plating across the tarsometatarsal joints
. Primary arthrodesis of the first, second, and third tarsometatarsal joints

Correct Answer & Explanation

. Closed reduction and percutaneous K-wire fixation

Explanation

Current evidence demonstrates that primary arthrodesis of the medial columns (1st, 2nd, and 3rd TMT joints) leads to better functional outcomes and lower reoperation rates than ORIF for purely ligamentous Lisfranc injuries.

Question 670

Topic: Midfoot & Hindfoot
A 55-year-old male with poorly controlled diabetes mellitus presents with a massively swollen, erythematous, and warm left foot without ulceration. He is afebrile with normal inflammatory markers. Radiographs demonstrate fragmentation, periarticular debris, and subluxation of the tarsometatarsal joints. According to the Eichenholtz classification, what stage does this represent and what is the most appropriate initial management?
. Stage 0; Intravenous antibiotics and wound care
. Stage I; Total contact casting and non-weight bearing
. Stage II; Custom orthotic shoe wear and weight bearing as tolerated
. Stage III; Arthrodesis of the midfoot
. Stage I; Immediate surgical debridement and external fixation

Correct Answer & Explanation

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

Explanation

The clinical picture describes acute Charcot arthropathy in the fragmentation phase, which is Eichenholtz Stage I. Key radiographic features include fragmentation, osteopenia, subluxation, and debris. The gold standard initial treatment for active Stage I Charcot is immobilization with a total contact cast (TCC) and strict non-weight bearing to prevent further deformity.

Question 671

Topic: Midfoot & Hindfoot
A 55-year-old diabetic patient presents with a swollen, warm, and erythematous foot. Radiographs show periarticular fragmentation, debris, and subluxation of the tarsometatarsal joints, with no signs of sclerosis or fusion. According to the Eichenholtz classification, what stage of Charcot arthropathy is this?
. Stage 0
. Stage I
. Stage II
. Stage III
. Stage IV

Correct Answer & Explanation

. Stage I

Explanation

Eichenholtz Stage I (Development/Fragmentation) is characterized by acute clinical inflammation, bony debris, fragmentation, and joint subluxation/dislocation. Stage II is Coalescence (absorption of debris, early fusion), and Stage III is Reconstruction (consolidation and remodeling).

Question 672

Topic: Midfoot & Hindfoot

A 55-year-old male with long-standing, poorly controlled type 2 diabetes presents with a unilaterally swollen, red, warm, and painless foot. Radiographs demonstrate periarticular debris, fragmentation of the tarsometatarsal joints, and subluxation, without evidence of osteomyelitis. According to the Eichenholtz classification of Charcot arthropathy, what stage does this represent?

. Stage 0 (Prodromal/Inflammatory)
. Stage 1 (Developmental/Fragmentation)
. Stage 2 (Coalescence)
. Stage 3 (Consolidation/Reconstruction)
. Stage 4 (Ulceration)

Correct Answer & Explanation

. Stage 1 (Developmental/Fragmentation)

Explanation

The Eichenholtz classification stages Charcot neuroarthropathy. Stage 0 features erythema, edema, and heat with normal radiographs. Stage 1 (Fragmentation) is characterized clinically by a hot, swollen foot and radiographically by periarticular debris, bone fragmentation, and subluxation/dislocation. Stage 2 (Coalescence) shows absorption of fine debris and early fusion. Stage 3 (Consolidation) shows remodeling and stable ankylosis.

Question 673

Topic: Midfoot & Hindfoot
A 28-year-old male sustains a high-energy motor vehicle collision resulting in a Hawkins Type III talar neck fracture. What is the defining anatomical feature of a Hawkins Type III fracture, and what is the approximate risk of avascular necrosis (AVN)?
. Talar neck fracture with subtalar dislocation; 20-50% risk of AVN
. Talar neck fracture with subtalar and tibiotalar dislocation; nearly 100% risk of AVN
. Talar neck fracture with subtalar, tibiotalar, and talonavicular dislocation; 100% risk of AVN
. Non-displaced talar neck fracture; <10% risk of AVN
. Talar body fracture with extrusion; 50% risk of AVN

Correct Answer & Explanation

. Talar neck fracture with subtalar and tibiotalar dislocation; nearly 100% risk of AVN

Explanation

A Hawkins Type III fracture is a displaced talar neck fracture with dislocation of both the subtalar and tibiotalar joints. The risk of AVN is historically reported as nearly 100% due to the disruption of all three major blood supplies to the talar body (artery of the tarsal canal, deltoid branches, and anterior tibial/dorsalis pedis branches). Type IV involves the talonavicular joint as well.

Question 674

Topic: Midfoot & Hindfoot
A 50-year-old female presents with progressive medial ankle pain, swelling, and a 'flattening' of her arch. On examination, she is unable to perform a single-leg heel raise on the affected side. Weight-bearing radiographs reveal >40% uncovering of the talar head on the AP view (forefoot abduction). What is the appropriate classification and most comprehensive surgical reconstruction for this patient?
. Stage IIa Posterior Tibial Tendon Dysfunction; FDL transfer and Medial Displacement Calcaneal Osteotomy (MDCO)
. Stage IIb Posterior Tibial Tendon Dysfunction; FDL transfer, MDCO, and Lateral Column Lengthening (Evans osteotomy)
. Stage III Posterior Tibial Tendon Dysfunction; Triple arthrodesis
. Stage IV Posterior Tibial Tendon Dysfunction; Tibiotalocalcaneal (TTC) arthrodesis
. Stage I Posterior Tibial Tendon Dysfunction; Tenosynovectomy and orthotics

Correct Answer & Explanation

. Stage IIb Posterior Tibial Tendon Dysfunction; FDL transfer, MDCO, and Lateral Column Lengthening (Evans osteotomy)

Explanation

This patient has a flexible flatfoot deformity with significant forefoot abduction (>30-40% talonavicular uncoverage), consistent with Stage IIb PTTD. To correct the multiplanar deformity, the standard surgical reconstruction includes a tendon transfer (usually FDL to navicular), a medial displacement calcaneal osteotomy (MDCO) to correct hindfoot valgus, and a lateral column lengthening (e.g., Evans osteotomy) to correct the forefoot abduction.

Question 675

Topic: Midfoot & Hindfoot
A 55-year-old woman presents with progressive flattening of her left medial longitudinal arch, medial ankle pain, and an inability to perform a single-leg heel raise. The deformity remains flexible on examination. Which of the following surgical combinations is the most appropriate initial joint-sparing approach?
. Flexor digitorum longus (FDL) transfer to the navicular alone
. Flexor digitorum longus (FDL) transfer combined with a medial displacement calcaneal osteotomy (MDCO)
. Triple arthrodesis
. Subtalar arthrodesis alone
. Tibialis anterior tendon transfer to the navicular

Correct Answer & Explanation

. Flexor digitorum longus (FDL) transfer combined with a medial displacement calcaneal osteotomy (MDCO)

Explanation

The patient has Stage II Adult Acquired Flatfoot Deformity (Posterior Tibial Tendon Insufficiency). Stage II is characterized by a flexible deformity. Joint-sparing procedures are indicated. The standard of care includes addressing both the soft tissue deficit and the bony malalignment. This is typically achieved with an FDL tendon transfer (to replace the deficient posterior tibial tendon) and a medial displacement calcaneal osteotomy (to correct the valgus hindfoot vector and protect the tendon transfer). Arthrodesis is reserved for rigid deformities (Stage III) or advanced arthritis.

Question 676

Topic: Midfoot & Hindfoot
A 30-year-old driver is involved in a high-speed motor vehicle collision. Radiographs demonstrate a displaced talar neck fracture with subluxation of the subtalar joint, but the tibiotalar and talonavicular joints remain congruent. According to the Hawkins classification, what is the type of fracture and its associated risk of avascular necrosis (AVN)?
. Type I; AVN risk is 0-10%
. Type II; AVN risk is 20-50%
. Type III; AVN risk is 80-100%
. Type IV; AVN risk is 100%
. Type II; AVN risk is greater than 80%

Correct Answer & Explanation

. Type II; AVN risk is 20-50%

Explanation

Hawkins Type II talar neck fractures involve displacement with subtalar subluxation or dislocation while the tibiotalar and talonavicular joints remain intact. The risk of AVN for Type II fractures is historically quoted as 20% to 50%. Type I is nondisplaced (0-15% AVN risk). Type III involves both subtalar and tibiotalar dislocation (~80-100% AVN risk). Type IV includes subtalar, tibiotalar, and talonavicular dislocation (near 100% AVN risk).

Question 677

Topic: Midfoot & Hindfoot

A 45-year-old runner presents with chronic, severe heel pain that has failed 6 months of conservative management including stretching, orthotics, and corticosteroid injections. He reports a burning sensation radiating to the lateral aspect of the heel. Examination reveals maximal tenderness at the medial aspect of the heel, slightly distal to the calcaneal tuberosity. The clinician suspects entrapment of the first branch of the lateral plantar nerve (Baxter's nerve). Between which two structures does this nerve most commonly become entrapped?

. Deep fascia of the abductor hallucis and the medial margin of the quadratus plantae
. Flexor digitorum brevis and the plantar aponeurosis
. Flexor hallucis longus and the medial malleolus
. Adductor hallucis and the deep transverse metatarsal ligament
. Posterior tibial tendon and the flexor digitorum longus

Correct Answer & Explanation

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

Explanation

Baxter's nerve, the first branch of the lateral plantar nerve, provides motor innervation to the abductor digiti minimi and sensory innervation to the anterior aspect of the calcaneal tuberosity. Entrapment of this nerve is a cause of recalcitrant heel pain (accounting for up to 20% of cases of chronic heel pain). The nerve is most commonly compressed between the deep muscular fascia of the abductor hallucis muscle and the medial plantar margin of the quadratus plantae muscle.

Question 678

Topic: Midfoot & Hindfoot

Diabetic Charcot neuroarthropathy can present insidiously or as an acute, hot, swollen foot that mimics infection. According to the Brodsky anatomical classification of Charcot arthropathy, which joint complex represents the most frequent site of involvement (Type 1)?

. Subtalar joint
. Ankle (tibiotalar) joint
. Calcaneal tuberosity
. Tarsometatarsal (Lisfranc) and Naviculocuneiform joints
. Metatarsophalangeal joints

Correct Answer & Explanation

. Tarsometatarsal (Lisfranc) and Naviculocuneiform joints

Explanation

The Brodsky classification categorizes Charcot neuroarthropathy based on anatomical location. Type 1 involves the midfoot (tarsometatarsal/Lisfranc and naviculocuneiform joints) and is by far the most common, accounting for approximately 60% of cases. It classically leads to midfoot collapse and a "rocker-bottom" deformity. Type 2 involves the hindfoot (subtalar, talonavicular, calcaneocuboid). Type 3A involves the ankle joint. Type 3B involves the calcaneal tuberosity.

Question 679

Topic: Midfoot & Hindfoot

A 35-year-old male sustains a purely ligamentous Lisfranc injury. After a thorough discussion, he is randomized in a clinical trial comparing Open Reduction Internal Fixation (ORIF) with transarticular screws versus Primary Arthrodesis. Based on the landmark prospective randomized study by Ly and Coetzee, what outcome is most likely to be expected if the patient undergoes Primary Arthrodesis rather than ORIF?

. A significantly higher rate of late post-traumatic arthritis in the adjacent naviculocuneiform joints
. No statistical difference in clinical outcomes or reoperation rates between the two procedures
. A higher rate of nonunion and hardware failure in the Primary Arthrodesis group
. Superior short- and long-term functional outcome scores and a lower rate of reoperation in the Primary Arthrodesis group
. Faster return to competitive high-impact sports but inferior overall AOFAS scores in the Primary Arthrodesis group

Correct Answer & Explanation

. Superior short- and long-term functional outcome scores and a lower rate of reoperation in the Primary Arthrodesis group

Explanation

The treatment of Lisfranc injuries remains debated, but high-level evidence exists for specific subsets. The landmark prospective randomized trial by Ly and Coetzee (JBJS 2006) specifically evaluated primary arthrodesis versus ORIF for primarilyligamentousLisfranc injuries. They found that primary arthrodesis of the first, second, and third tarsometatarsal joints yielded superior functional outcomes (AOFAS scores) and had a significantly lower reoperation rate (fewer planned hardware removals and fewer conversions to fusion for late arthritis) compared to ORIF. While bony Lisfranc fracture-dislocations may still be treated with ORIF, purely ligamentous injuries are increasingly treated with primary fusion due to this evidence.

Question 680

Topic: Midfoot & Hindfoot

A 45-year-old runner with chronic heel pain is diagnosed with recalcitrant plantar fasciitis. MRI reveals edema not only at the plantar fascia origin but also within the abductor digiti minimi muscle, suggesting entrapment of Baxter's nerve. Baxter's nerve is a branch of which of the following?

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

Correct Answer & Explanation

. Lateral plantar nerve

Explanation

Baxter's nerve is the first branch of the lateral plantar nerve. It courses between the abductor hallucis and the quadratus plantae, then turns laterally to innervate the abductor digiti minimi. Entrapment can mimic or occur concomitantly with chronic plantar fasciitis.

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