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Midfoot & Hindfoot MCQs

Practice Set 35 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 681

Topic: Midfoot & Hindfoot

A 55-year-old female presents with a progressive flatfoot deformity, lateral hindfoot pain, and inability to perform a single-leg heel raise. Weight-bearing radiographs show talonavicular uncoverage of 45%. Clinical exam reveals severe forefoot abduction (too-many-toes sign) and a flexible hindfoot (Stage IIb Adult Acquired Flatfoot). Which of the following surgical combinations is most appropriate?

. Flexor digitorum longus (FDL) transfer to the navicular and medial displacement calcaneal osteotomy (MDCO) only
. FDL transfer, MDCO, and lateral column lengthening
. Isolated triple arthrodesis
. Talonavicular arthrodesis and Spring ligament repair
. Gastrocnemius recession and orthotic management

Correct Answer & Explanation

. FDL transfer, MDCO, and lateral column lengthening

Explanation

Stage IIb posterior tibial tendon dysfunction (PTTD) is characterized by significant forefoot abduction (>30-40% talonavicular uncoverage). This requires a lateral column lengthening (e.g., Evans osteotomy) in addition to FDL transfer and MDCO to correct the triplanar deformity.

Question 682

Topic: Midfoot & Hindfoot
A 32-year-old male falls from a roof and sustains a Hawkins Type III talar neck fracture. Which of the following describes the specific dislocations associated with this classification?
. Dislocation of the subtalar joint only
. Dislocation of the tibiotalar joint only
. Dislocation of both the subtalar and tibiotalar joints
. Dislocation of the talonavicular joint only
. Dislocation of the subtalar, tibiotalar, and talonavicular joints

Correct Answer & Explanation

. Dislocation of both the subtalar and tibiotalar joints

Explanation

A Hawkins Type III fracture is defined as a talar neck fracture accompanied by dislocation of both the subtalar and tibiotalar joints. This injury carries a very high risk of avascular necrosis of the talar body due to extensive disruption of its blood supply.

Question 683

Topic: Midfoot & Hindfoot
What is the primary goal of surgical management for an intra-articular calcaneal fracture?
. Achieve rigid non-weight-bearing fixation.
. Restore Bรถhler's and Gissane's angles.
. Achieve anatomical reduction of the posterior subtalar facet.
. Decompress the peroneal tendons.
. Prevent deep vein thrombosis.

Correct Answer & Explanation

. Achieve anatomical reduction of the posterior subtalar facet.

Explanation

The primary goal of surgical management for an intra-articular calcaneal fracture is to achieve anatomical reduction of the posterior subtalar facet. Restoration of this articular surface is critical to minimize the risk of post-traumatic subtalar arthritis, which is the most common long-term complication. While restoring Bรถhler's and Gissane's angles are important indicators of overall calcaneal morphology, they are secondary to the articular reduction. Rigid fixation is a means to achieve the goal, not the goal itself. Decompressing peroneal tendons might be an associated step but not the primary goal. Preventing DVT is a general post-operative concern.

Question 684

Topic: Midfoot & Hindfoot

A 7-year-old child undergoes limb salvage surgery for Ewing's Sarcoma of the distal femur. What is a primary long-term concern related to growth in this patient?

. Increased risk of deep vein thrombosis
. Development of significant limb length discrepancy
. Accelerated growth of the contralateral limb
. Premature fusion of all growth plates
. Development of Charcot arthropathy

Correct Answer & Explanation

. Development of significant limb length discrepancy

Explanation

In growing children undergoing limb salvage surgery, particularly around long bones like the distal femur, removing or irradiating a significant portion of the growth plate or replacing it with an endoprosthesis that does not grow can lead to substantial limb length discrepancy over time. This requires careful planning, sometimes using expandable prostheses, or subsequent lengthening procedures. DVT is an acute surgical complication, not a long-term growth issue. Accelerated growth of the contralateral limb is not a direct consequence. Premature fusion of all growth plates is too general. Charcot arthropathy is a neuropathic joint condition, unrelated to growth after Ewing's surgery.

Question 685

Topic: Midfoot & Hindfoot

A 40-year-old male presents with an isolated subtalar dislocation without associated fracture. After closed reduction, what is the most appropriate next step in management?

. Immediate weight-bearing in a walking boot
. Surgical exploration to repair torn ligaments
. CT scan to rule out occult fractures and assess reduction
. MRI to assess deltoid ligament integrity
. Long-term immobilization in a non-weight-bearing cast for 12 weeks

Correct Answer & Explanation

. CT scan to rule out occult fractures and assess reduction

Explanation

After successful closed reduction of a subtalar dislocation, a CT scan is essential. It is critical to rule out any occult osteochondral fragments, incarcerated soft tissue, or small fractures (e.g., talar or calcaneal) that may not be visible on plain radiographs and could impede congruity or stability. While ligamentous injury is expected, surgical repair is rarely indicated unless instability persists after reduction. Immobilization is necessary but typically for 4-6 weeks, not 12 weeks. Immediate weight-bearing is inappropriate.

Question 686

Topic: Midfoot & Hindfoot

Which of the following describes a key differentiating feature between a Lisfranc fracture-dislocation and a simple midfoot sprain on plain radiographs?

. Presence of a fleck sign
. Fracture of the cuboid
. Fracture of the navicular
. Talonavicular joint subluxation
. Widening of the tibiotalar joint

Correct Answer & Explanation

. Presence of a fleck sign

Explanation

A 'fleck sign' refers to an avulsion fracture off the base of the second metatarsal or the medial cuneiform, within the Lisfranc ligament complex. Its presence is highly indicative of a Lisfranc injury (fracture-dislocation) and suggests significant instability that requires surgical intervention. Cuboid or navicular fractures can occur in the midfoot but are not specific to Lisfranc injury. Talonavicular subluxation is a hindfoot/midfoot injury but not diagnostic of Lisfranc. Widening of the tibiotalar joint indicates ankle, not midfoot, pathology.

Question 687

Topic: Midfoot & Hindfoot

Which specific finding during the examination of the rheumatoid ankle and hindfoot suggests rupture or significant dysfunction of the posterior tibial tendon (PTT)?

. Pain with resisted eversion
. Inability to perform a single heel-rise and progressive pes planovalgus deformity
. Pain with palpation over the peroneus brevis tendon
. Positive Tinel's sign at the medial malleolus
. Restricted subtalar inversion but preserved eversion

Correct Answer & Explanation

. Inability to perform a single heel-rise and progressive pes planovalgus deformity

Explanation

Inability to perform a single heel-rise test and progressive pes planovalgus deformity are classic clinical signs of posterior tibial tendon dysfunction (PTTD), which can range from tendinopathy to complete rupture. The PTT is the primary dynamic stabilizer of the medial longitudinal arch, and its failure leads to progressive flatfoot. Pain with resisted eversion would suggest peroneal tendinopathy. Tinel's sign is for nerve compression. Restricted subtalar inversion/eversion assesses joint motion rather than tendon function directly.

Question 688

Topic: Midfoot & Hindfoot

Which of the following is an effective method to assess the flexibility of the forefoot adduction/abduction component in a cavus foot?

. Gait analysis on a treadmill.
. Passive inversion and eversion of the subtalar joint.
. Plantar pressure mapping.
. Talar head palpation test (Hubscher maneuver) while passively correcting the forefoot.
. Passive pronation and supination of the Chopart joint.

Correct Answer & Explanation

. Passive pronation and supination of the Chopart joint.

Explanation

To assess the flexibility of the forefoot relative to the hindfoot (which includes pronation/supination, abduction/adduction), passively manipulating the Chopart (midtarsal) joint is key. This joint allows the forefoot to be moved independently of the hindfoot. Assessing its range of motion and reducibility helps determine if forefoot abduction/adduction or pronation/supination components are flexible or rigid, which is crucial for surgical planning.

Question 689

Topic: Midfoot & Hindfoot

A 55-year-old female presents with a progressive, painful flatfoot deformity. Examination reveals inability to perform a single-leg heel rise and excessive forefoot abduction. Radiographs demonstrate greater than 40% talonavicular uncoverage but flexible hindfoot and forefoot joints. What is the most appropriate surgical intervention?

. Total contact casting
. Flexor digitorum longus (FDL) transfer, medial displacement calcaneal osteotomy, and lateral column lengthening
. Triple arthrodesis
. Isolated repair of the spring ligament
. Isolated subtalar arthrodesis

Correct Answer & Explanation

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

Explanation

This is a Stage IIb adult acquired flatfoot deformity (flexible, with significant forefoot abduction). Treatment requires addressing both the medial column (FDL transfer, medial osteotomy) and the lateral column lengthening to correct the forefoot abduction.

Question 690

Topic: Midfoot & Hindfoot

A 55-year-old diabetic patient presents with a red, hot, swollen foot without an ulcer. Radiographs show fragmentation and subluxation of the midfoot. What is the most appropriate initial management?

. Intravenous antibiotics and surgical debridement
. Total contact casting and non-weight-bearing
. Immediate midfoot arthrodesis
. Custom orthotics with arch support
. Aspiration of the midfoot joints

Correct Answer & Explanation

. Total contact casting and non-weight-bearing

Explanation

This patient is in Eichenholtz Stage I (fragmentation) of Charcot arthropathy. The gold standard for initial management is immobilization with a total contact cast to prevent further deformity while the acute inflammatory phase resolves.

Question 691

Topic: Midfoot & Hindfoot
A 45-year-old female presents with a flexible flatfoot deformity, unable to perform a single-leg heel rise, and >40% uncovering of the talonavicular joint on weight-bearing AP radiographs. What surgical procedure is specifically indicated to correct the forefoot abduction?
. Medial displacement calcaneal osteotomy
. Lateral column lengthening (Evans osteotomy)
. Spring ligament repair only
. Triple arthrodesis
. Isolated subtalar arthrodesis

Correct Answer & Explanation

. Lateral column lengthening (Evans osteotomy)

Explanation

This patient has Stage IIb posterior tibial tendon dysfunction, characterized by forefoot abduction (>30-40% talonavicular uncovering). A lateral column lengthening (Evans osteotomy) is indicated to specifically address and correct the forefoot abduction component.

Question 692

Topic: Midfoot & Hindfoot
A 35-year-old male sustains a Hawkins type III talar neck fracture. Which of the following describes the anatomical displacement and the associated rate of avascular necrosis (AVN)?
. Displacement of the subtalar joint only; 20-30% AVN
. Displacement of the subtalar and tibiotalar joints; 50% AVN
. Displacement of the subtalar, tibiotalar, and talonavicular joints; nearly 100% AVN
. Displacement of the subtalar and tibiotalar joints; nearly 100% AVN
. Displacement of the talonavicular joint only; 10% AVN

Correct Answer & Explanation

. Displacement of the subtalar and tibiotalar joints; nearly 100% AVN

Explanation

A Hawkins type III fracture involves displacement of both the subtalar and tibiotalar joints. The risk of avascular necrosis in these injuries is nearly 100% due to the disruption of the artery of the tarsal canal, deltoid branches, and dorsalis pedis branches.

Question 693

Topic: Midfoot & Hindfoot

A 60-year-old female presents with a flexible flatfoot deformity, unable to perform a single-leg heel raise. Radiographs show a talonavicular uncoverage of 40% but no arthritic changes in the subtalar, talonavicular, or calcaneocuboid joints. What is the most appropriate surgical intervention after failed conservative care?

. Flexor digitorum longus (FDL) transfer to the navicular and medializing calcaneal osteotomy
. Triple arthrodesis
. Subtalar arthrodesis
. Gastrocnemius recession alone
. Isolated talonavicular arthrodesis

Correct Answer & Explanation

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

Explanation

This patient has Stage II adult-acquired flatfoot deformity. Joint-sparing procedures, such as an FDL transfer combined with a medializing calcaneal osteotomy, are indicated since there is no fixed deformity or arthritis.

Question 694

Topic: Midfoot & Hindfoot
A 58-year-old female presents with adult-acquired flatfoot deformity. Examination shows a flexible hindfoot valgus, inability to perform a single-leg heel raise, and forefoot abduction with >40% talonavicular uncoverage on radiographs. What is the most appropriate surgical intervention?
. Isolated flexor digitorum longus (FDL) transfer to the navicular
. Triple arthrodesis
. Gastrocnemius recession and subtalar arthrodesis
. Medializing calcaneal osteotomy alone
. FDL transfer, medializing calcaneal osteotomy, and lateral column lengthening

Correct Answer & Explanation

. FDL transfer, medializing calcaneal osteotomy, and lateral column lengthening

Explanation

This is a Stage IIb posterior tibial tendon dysfunction (flexible deformity with significant forefoot abduction). The recommended treatment addresses all deformity planes: FDL transfer (tendon substitution), medializing calcaneal osteotomy (hindfoot valgus correction), and lateral column lengthening (forefoot abduction correction).

Question 695

Topic: Midfoot & Hindfoot

A 45-year-old female presents with progressive flattening of her left arch. She cannot perform a single-leg heel raise. Radiographs demonstrate an uncovered talar head of 45% and a talonavicular uncoverage angle of 25 degrees. She has pain over the lateral hindfoot but a passively correctable hindfoot valgus. What is the most appropriate surgical treatment?

. Medial calcaneal displacement osteotomy and FDL transfer
. Lateral column lengthening, FDL transfer, and medial calcaneal displacement osteotomy
. Subtalar arthrodesis
. Triple arthrodesis
. Tibiotalocalcaneal arthrodesis

Correct Answer & Explanation

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

Explanation

This describes Stage IIb posterior tibial tendon dysfunction (PTTD), characterized by a flexible deformity with >40% talonavicular uncoverage (forefoot abduction). Treatment requires lateral column lengthening to correct the forefoot abduction, in addition to FDL transfer and medial calcaneal slide.

Question 696

Topic: Midfoot & Hindfoot
A 40-year-old male sustains a Hawkins Type III talar neck fracture. Which of the following best describes this injury and its associated risk of avascular necrosis (AVN)?
. Undisplaced fracture; 0-10% AVN risk
. Displaced fracture with subtalar subluxation; 20-50% AVN risk
. Displaced fracture with subtalar and tibiotalar dislocation; nearly 100% AVN risk
. Displaced fracture with talonavicular dislocation; 10% AVN risk
. Comminuted fracture of the talar body; 50% AVN risk

Correct Answer & Explanation

. Displaced fracture with subtalar and tibiotalar dislocation; nearly 100% AVN risk

Explanation

A Hawkins Type III talar neck fracture involves displacement of the talar neck with dislocation of both the subtalar and tibiotalar joints. The risk of avascular necrosis (AVN) in Type III fractures is extremely high, approaching 90-100%.

Question 697

Topic: Midfoot & Hindfoot
A 55-year-old diabetic male presents with a swollen, erythematous, painless foot. Radiographs demonstrate severe osteochondral fragmentation, subluxation, and intra-articular bony debris. What stage of Charcot arthropathy does this represent?
. Eichenholtz Stage 0
. Eichenholtz Stage I
. Eichenholtz Stage II
. Eichenholtz Stage III
. Eichenholtz Stage IV

Correct Answer & Explanation

. Eichenholtz Stage I

Explanation

Eichenholtz Stage I (Fragmentation/Development) is characterized by acute inflammation, joint debris, subluxation, and fragmentation on radiographs. Stage II represents coalescence, and Stage III represents consolidation/reconstruction.

Question 698

Topic: Midfoot & Hindfoot
A 55-year-old patient with long-standing diabetes mellitus presents with a red, hot, swollen foot. Radiographs reveal periarticular fragmentation, subluxation, and bony debris at the midfoot without frank osteomyelitis. According to the Eichenholtz classification of Charcot arthropathy, what is the appropriate stage and most appropriate initial treatment?
. Stage 0; Intravenous antibiotics
. Stage I; Total contact casting and non-weight bearing
. Stage II; Custom orthotic shoe wear
. Stage III; Arthrodesis of the midfoot
. Stage I; Immediate surgical debridement and internal fixation

Correct Answer & Explanation

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

Explanation

The patient is in Eichenholtz Stage I (Development/Fragmentation stage), characterized by erythema, swelling, bony debris, fragmentation, and subluxation. The mainstay of initial treatment is strict immobilization and offloading, typically achieved with a total contact cast, until the acute inflammatory phase resolves and coalescence (Stage II) begins.

Question 699

Topic: Midfoot & Hindfoot
A 58-year-old poorly controlled diabetic patient presents with a red, hot, swollen foot without systemic signs of infection. Radiographs reveal prominent periarticular fragmentation, joint subluxation, and bony debris at the midfoot. According to the Eichenholtz classification of Charcot arthropathy, this patient is in which stage?
. Stage 0
. Stage I
. Stage II
. Stage III
. Stage IV

Correct Answer & Explanation

. Stage I

Explanation

Eichenholtz Stage I (Development/Fragmentation) is characterized clinically by a red, hot, swollen foot and radiographically by osteopenia, joint subluxation, bony fragmentation, and debris. Stage II (Coalescence) shows decreased swelling and radiographic absorption of debris. Stage III (Reconstruction) shows consolidated remodeling. Stage 0 features erythema/swelling but normal radiographs.

Question 700

Topic: Midfoot & Hindfoot
In the Eichenholtz classification of Charcot arthropathy, which stage is characterized clinically by a warm, swollen, erythematous foot, and radiographically by periarticular fragmentation, debris, and subluxation?
. Stage 0
. Stage I (Development/Fragmentation)
. Stage II (Coalescence)
. Stage III (Reconstruction)
. Stage IV (Ulceration)

Correct Answer & Explanation

. Stage I (Development/Fragmentation)

Explanation

Eichenholtz Stage I is the developmental or fragmentation phase, marked by acute inflammation and radiographic evidence of bone debris, fragmentation, and joint subluxation. Stage II involves coalescence, while Stage III represents reconstruction and consolidation.

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