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Midfoot & Hindfoot MCQs

Practice Set 36 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 701

Topic: Midfoot & Hindfoot

A 55-year-old female presents with a flexible acquired flatfoot deformity. Standing radiographs reveal 45% talonavicular uncoverage. She is diagnosed with Stage IIB posterior tibial tendon dysfunction. Which of the following surgical strategies is most appropriate?

. Medial displacement calcaneal osteotomy (MDCO) and FDL transfer alone
. FDL transfer, MDCO, and lateral column lengthening
. Triple arthrodesis
. Isolated talonavicular arthrodesis
. Isolated gastrocnemius recession

Correct Answer & Explanation

. FDL transfer, MDCO, and lateral column lengthening

Explanation

Stage IIB posterior tibial tendon dysfunction is characterized by a flexible deformity with significant forefoot abduction (typically >40% talonavicular uncoverage on AP radiograph). Treatment requires addressing both the valgus hindfoot and the forefoot abduction. Therefore, a lateral column lengthening (e.g., Evans osteotomy) is required in addition to an MDCO and FDL transfer to adequately correct the severe abduction deformity.

Question 702

Topic: Midfoot & Hindfoot

The calcaneonavicular (spring) ligament complex is a critical static stabilizer of the longitudinal arch and is often attenuated in adult acquired flatfoot deformity. Which of the following describes its most robust and clinically critical fascicle for supporting the talonavicular joint?

. Superomedial calcaneonavicular ligament
. Inferior calcaneonavicular ligament
. Bifurcate ligament
. Long plantar ligament
. Plantar aponeurosis

Correct Answer & Explanation

. Superomedial calcaneonavicular ligament

Explanation

The spring ligament complex consists of three main fascicles. The superomedial calcaneonavicular ligament is the most robust, widest, and most clinically important fascicle. It acts as a sling under the talar head, and its failure is a hallmark of progressive adult acquired flatfoot deformity associated with posterior tibial tendon dysfunction.

Question 703

Topic: Midfoot & Hindfoot
A 55-year-old female presents with medial ankle pain and an inability to perform a single-leg heel rise. Clinical examination reveals a flexible hindfoot valgus, with no significant forefoot abduction (too-many-toes sign is negative). Radiographs show a preserved subtalar joint without arthritis. Which of the following is the most appropriate surgical management for this patient?
. Isolated flexor digitorum longus (FDL) transfer to the navicular
. Flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy (MDCO)
. Triple arthrodesis
. FDL transfer, MDCO, and lateral column lengthening
. Subtalar arthrodesis

Correct Answer & Explanation

. Flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy (MDCO)

Explanation

This patient presents with Stage IIA Adult Acquired Flatfoot Deformity (Posterior Tibial Tendon Dysfunction). Stage II denotes a flexible deformity. Stage IIA involves hindfoot valgus without significant forefoot abduction. The gold standard surgical management for Stage IIA is a Flexor Digitorum Longus (FDL) tendon transfer to the navicular combined with a Medial Displacement Calcaneal Osteotomy (MDCO) to correct the hindfoot valgus axis. Lateral column lengthening (Evans osteotomy) is typically added for Stage IIB, where clinically significant forefoot abduction is present. Triple arthrodesis is reserved for Stage III (rigid deformity).

Question 704

Topic: Midfoot & Hindfoot

A 45-year-old avid distance runner presents with chronic, intractable medial plantar heel pain that radiates laterally. The pain has failed to improve after 6 months of physical therapy, orthotics, and corticosteroid injections. MRI of the hindfoot demonstrates isolated fatty atrophy of the abductor digiti minimi muscle. Entrapment of which of the following nerves is the most likely cause of this patient's symptoms?

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

Correct Answer & Explanation

. First branch of the lateral plantar nerve

Explanation

The first branch of the lateral plantar nerve, also known as Baxter's nerve, provides sensory innervation to the calcaneal periosteum and motor innervation to the abductor digiti minimi (ADM) muscle. Entrapment commonly occurs between the deep fascia of the abductor hallucis and the medial margin of the quadratus plantae. Chronic compression leads to denervation and subsequent fatty atrophy of the ADM on MRI, a pathognomonic finding for Baxter's nerve entrapment.

Question 705

Topic: Midfoot & Hindfoot
A 55-year-old female presents with Stage IIb Adult Acquired Flatfoot Deformity (posterior tibial tendon dysfunction). Clinical examination reveals a flexible hindfoot valgus and significant forefoot abduction (>30%). Which surgical reconstruction is most appropriate?
. FDL transfer to the navicular and medial displacement calcaneal osteotomy alone
. Triple arthrodesis
. FDL transfer, medial displacement calcaneal osteotomy, and lateral column lengthening
. Isolated subtalar arthrodesis
. Gastrocnemius recession and spring ligament repair alone

Correct Answer & Explanation

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

Explanation

Stage IIb features forefoot abduction (uncovering of the talonavicular joint). It requires an FDL transfer, medial displacement calcaneal osteotomy, and a lateral column lengthening (e.g., Evans osteotomy) to correct the abduction.

Question 706

Topic: Midfoot & Hindfoot

A 30-year-old construction worker falls from a ladder and sustains an injury to his midfoot. Radiographs show a purely ligamentous Lisfranc injury with widening of the first intermetatarsal space. According to recent literature, what is the preferred surgical treatment to maximize long-term functional outcome?

. Closed reduction and percutaneous pinning (CRPP)
. Open reduction and internal fixation (ORIF) with transarticular screws
. Primary partial midfoot arthrodesis (TMT joints 1-3)
. Dorsal bridge plating spanning the entire midfoot
. Flexible fixation with suture buttons only across all TMT joints

Correct Answer & Explanation

. Primary partial midfoot arthrodesis (TMT joints 1-3)

Explanation

Recent studies, including classic prospective trials, demonstrate that purely ligamentous Lisfranc injuries treated with primary arthrodesis of the first three TMT joints have better functional outcomes and lower reoperation rates compared to ORIF.

Question 707

Topic: Midfoot & Hindfoot

A 55-year-old overweight female presents with acquired flatfoot deformity. Examination shows a flexible hindfoot, but radiographs reveal greater than 40% talonavicular uncoverage indicating significant forefoot abduction. What is the most appropriate surgical management for this Stage IIb posterior tibial tendon dysfunction?

. Flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy alone
. Triple arthrodesis
. FDL transfer, medial displacement calcaneal osteotomy, and lateral column lengthening
. Talonavicular arthrodesis
. Isolated spring ligament repair

Correct Answer & Explanation

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

Explanation

Stage IIb PTTD is characterized by a flexible hindfoot with significant forefoot abduction (talonavicular uncoverage >40%). Optimal treatment includes an FDL transfer, medial displacement calcaneal osteotomy, and a lateral column lengthening (e.g., Evans osteotomy) to correct the abduction.

Question 708

Topic: Midfoot & Hindfoot

A 58-year-old male with poorly controlled diabetes mellitus and severe peripheral neuropathy presents with a red, hot, swollen foot without skin ulceration. Radiographs show periarticular debris, fragmentation, and subluxation at the tarsometatarsal joints. What is the most appropriate initial management?

. Immediate open reduction and internal fixation
. Total contact casting (TCC) and non-weight-bearing
. Intravenous antibiotics for 6 weeks
. Midfoot arthrodesis with autograft
. Below-knee amputation

Correct Answer & Explanation

. Total contact casting (TCC) and non-weight-bearing

Explanation

The patient is in Eichenholtz Stage I (fragmentation/development) of Charcot arthropathy. The gold standard initial treatment to prevent further deformity is strict offloading, typically achieved with total contact casting (TCC).

Question 709

Topic: Midfoot & Hindfoot

Which of the following theories best explains the neurovascular pathophysiology underlying the active phase of Charcot arthropathy in patients with diabetes mellitus?

. Decreased blood flow leading to avascular necrosis
. Repetitive microtrauma due to sensory loss alone
. Autonomic neuropathy causing arteriovenous shunting and bone resorption
. Chronic deep space infection spreading to the joint
. Reduced osteoclast activity leading to brittle, non-compliant bone

Correct Answer & Explanation

. Autonomic neuropathy causing arteriovenous shunting and bone resorption

Explanation

The neurovascular theory of Charcot arthropathy postulates that autonomic neuropathy leads to a loss of sympathetic vascular tone, causing continuous arteriovenous shunting and hyperemia. This hyperemia increases osteoclastic bone resorption. The weakened, osteopenic bone, combined with loss of protective sensation (neurotraumatic theory), leads to repetitive microtrauma, fracture, and severe joint destruction.

Question 710

Topic: Midfoot & Hindfoot

A 55-year-old diabetic patient presents with a red, hot, swollen right foot. He is afebrile and his WBC count is normal. Radiographs reveal fragmentation of the tarsometatarsal joints, subchondral debris, and subluxation. Based on the Eichenholtz classification of Charcot arthropathy, which stage is this patient in, and what is the gold standard initial treatment?

. Stage 0; Intravenous antibiotics and I&D
. Stage 1; Total contact casting (TCC)
. Stage 2; Custom orthotic footwear
. Stage 3; Arthrodesis of the midfoot
. Stage 1; Immediate midfoot reconstructive arthrodesis

Correct Answer & Explanation

. Stage 1; Total contact casting (TCC)

Explanation

The patient is in Eichenholtz Stage 1 (Developmental/Fragmentation stage) of Charcot arthropathy, characterized clinically by a red, hot, swollen foot and radiographically by bone fragmentation, joint dislocation, and debris. The gold standard for initial management during this active phase is immobilization and offloading using a Total Contact Cast (TCC) to prevent further deformity until the active inflammatory phase subsides (transitioning to Stage 2 - Coalescence).

Question 711

Topic: Midfoot & Hindfoot

Compared to baseline ambulation in an able-bodied individual, which of the following lower extremity amputations theoretically requires the greatest increase in energy expenditure during ambulation?

. Unilateral transtibial
. Bilateral transtibial
. Unilateral transfemoral
. Syme amputation
. Chopart amputation

Correct Answer & Explanation

. Unilateral transfemoral

Explanation

Energy expenditure increases significantly as the level of lower extremity amputation moves proximally, largely due to the loss of the knee joint. A unilateral transtibial amputation increases energy cost by roughly 25%, and bilateral transtibial by roughly 40%. A unilateral transfemoral amputation increases energy cost by 60-70%, making it more energetically demanding than a bilateral transtibial amputation.

Question 712

Topic: Midfoot & Hindfoot
A 52-year-old patient with poorly controlled diabetes presents with a swollen, warm, and erythematous right foot. Radiographs reveal fragmentation, periarticular debris, and joint subluxation at the tarsometatarsal joints. According to the Eichenholtz classification for Charcot neuroarthropathy, what stage does this represent?
. Stage 0
. Stage I
. Stage II
. Stage III
. Stage IV

Correct Answer & Explanation

. Stage I

Explanation

The Eichenholtz classification divides Charcot arthropathy into stages: Stage 0 (prodromal, normal x-rays), Stage I (development/fragmentation, characterized by debris, subluxation, and fragmentation), Stage II (coalescence, absorption of fine debris, early fusion), and Stage III (reconstruction, consolidation, remodeling).

Question 713

Topic: Midfoot & Hindfoot
A 30-year-old male sustains a displaced Hawkins type III talar neck fracture. Which of the following best describes the anatomical disruption associated with this specific classification?
. Undisplaced talar neck fracture
. Talar neck fracture with subtalar subluxation
. Talar neck fracture with subtalar and tibiotalar dislocations
. Talar neck fracture with subtalar, tibiotalar, and talonavicular dislocations
. Talar head fracture with talonavicular dislocation

Correct Answer & Explanation

. Talar neck fracture with subtalar and tibiotalar dislocations

Explanation

A Hawkins type III fracture is a displaced talar neck fracture accompanied by dislocation of both the subtalar and tibiotalar joints. This pattern carries an exceptionally high risk of avascular necrosis of the talar body.

Question 714

Topic: Midfoot & Hindfoot

A 55-year-old poorly controlled diabetic male presents with a swollen, erythematous, warm, and painless right foot. Radiographs show early subluxation of the midfoot joints but no open ulcers. What is the most appropriate initial management?

. Urgent irrigation and debridement
. Total contact casting
. Intravenous antibiotics
. Primary arthrodesis of the midfoot
. Below-knee amputation

Correct Answer & Explanation

. Total contact casting

Explanation

The patient is presenting with acute Eichenholtz Stage I Charcot arthropathy. In the absence of ulceration or systemic infection, the gold standard initial treatment is offloading and immobilization with a total contact cast.

Question 715

Topic: Midfoot & Hindfoot

The Eichenholtz classification is used to stage Charcot arthropathy. Which of the following clinical and radiographic findings is characteristic of the Stage 1 phase?

. Clinical erythema, osteopenia, subluxation, and periarticular debris
. Absorption of debris, sclerosis, and coalescence of fracture fragments
. Remodeling of bone ends, decreased sclerosis, and stable ankylosis
. Resolution of erythema and swelling with firm fibrous union
. Progressive varus deformity with complete loss of protective sensation

Correct Answer & Explanation

. Clinical erythema, osteopenia, subluxation, and periarticular debris

Explanation

Eichenholtz Stage 1 (Development/Fragmentation) is characterized by a red, hot, swollen extremity. Radiographs show osteopenia, periarticular debris, fragmentation, and subluxation. Stage 2 (Coalescence) shows absorption of debris and sclerosis. Stage 3 (Reconstruction/Consolidation) shows remodeling and decreased sclerosis.

Question 716

Topic: Midfoot & Hindfoot
A 55-year-old poorly controlled diabetic patient presents with a swollen, warm, erythematous foot. Radiographs show periarticular fragmentation, subluxation, and bony debris in the midfoot. According to the Eichenholtz classification, this presentation best represents which stage of Charcot arthropathy?
. Stage 0 (Prodromal)
. Stage I (Fragmentation)
. Stage II (Coalescence)
. Stage III (Consolidation)
. Stage IV (Ulceration)

Correct Answer & Explanation

. Stage I (Fragmentation)

Explanation

Eichenholtz Stage I is the developmental or fragmentation phase, characterized by joint effusion, bone fragmentation, subluxation, and joint debris. Clinically, the foot is warm, red, and swollen. Stage II is coalescence (absorption of debris), and Stage III is consolidation (remodeling with mature bony architecture).

Question 717

Topic: Midfoot & Hindfoot

A 55-year-old male with poorly controlled type II diabetes presents with a unilaterally swollen, warm, and erythematous foot without ulceration. Radiographs show periarticular fragmentation, bony debris, and early subluxation of the midfoot joints, but no significant sclerosis or consolidation. According to the Eichenholtz classification, what is the stage and the most appropriate initial management?

. Stage 0 / Intravenous antibiotics for presumed osteomyelitis
. Stage 1 / Total contact casting and non-weight bearing
. Stage 2 / Immediate midfoot arthrodesis
. Stage 3 / Custom accommodative orthotic footwear
. Stage 1 / Open reduction and internal fixation

Correct Answer & Explanation

. Stage 1 / Total contact casting and non-weight bearing

Explanation

The patient is presenting with acute Charcot arthropathy. The clinical and radiographic findings of fragmentation, debris, and subluxation characterize Eichenholtz Stage 1 (Developmental/Fragmentation stage). Stage 0 (prodromal) has clinical swelling but normal radiographs. Stage 2 (Coalescence) shows early healing and sclerosis. Stage 3 (Reconstruction) shows consolidation and remodeling. The gold standard initial treatment for acute Stage 1 Charcot is immobilization with a total contact cast (TCC) to prevent further deformity until the acute inflammatory phase resolves.

Question 718

Topic: Midfoot & Hindfoot

A 55-year-old diabetic male presents with a swollen, erythematous, but painless foot. Radiographs show acute fragmentation and subluxation of the tarsometatarsal joints. What is the most appropriate initial management?

. Intravenous antibiotics for presumed osteomyelitis
. Total contact casting and strictly non-weight-bearing
. Open reduction and internal fixation of the midfoot
. Below-knee amputation
. Intra-articular corticosteroid injection

Correct Answer & Explanation

. Total contact casting and strictly non-weight-bearing

Explanation

The patient is in the acute, inflammatory phase (Eichenholtz Stage I) of Charcot arthropathy. The standard initial treatment is rigorous offloading and immobilization, most commonly achieved with a total contact cast, until the acute phase resolves.

Question 719

Topic: Midfoot & Hindfoot
A 55-year-old diabetic male presents with a swollen, erythematous, and warm foot without skin ulceration. Radiographs show osteopenia, prominent periarticular fragmentation, subluxation of the tarsometatarsal joints, and bony debris. According to the Eichenholtz classification of Charcot arthropathy, which stage does this represent?
. Stage 0 (Prodromal)
. Stage I (Developmental/Fragmentation)
. Stage II (Coalescence)
. Stage III (Reconstruction/Consolidation)
. Stage IV (Ulceration)

Correct Answer & Explanation

. Stage I (Developmental/Fragmentation)

Explanation

Eichenholtz Stage I (Developmental or Fragmentation stage) is characterized clinically by an acute inflammatory response (erythema, swelling, warmth mimicking infection) and radiographically by osteopenia, bony fragmentation, joint subluxation/dislocation, and intra-articular debris. Stage II (Coalescence) shows absorption of fine debris and early fusion. Stage III (Reconstruction) shows mature bony remodeling.

Question 720

Topic: Midfoot & Hindfoot

A 55-year-old female presents with medial foot pain and a progressive flatfoot deformity. Examination reveals a flexible hindfoot valgus, a 'too-many-toes' sign, and inability to perform a single-limb heel rise. Weight-bearing radiographs show 40% talonavicular uncovering. According to the Johnson and Strom classification modified by Myerson, which of the following surgical interventions is most appropriate for this stage IIb deformity?

. Medial displacement calcaneal osteotomy (MDCO) and flexor digitorum longus (FDL) transfer alone
. Lateral column lengthening (Evans osteotomy), MDCO, and FDL transfer
. Triple arthrodesis
. Talonavicular arthrodesis alone
. Gastrocnemius recession alone

Correct Answer & Explanation

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

Explanation

The patient has a Stage IIb posterior tibial tendon dysfunction (PTTD), characterized by a flexible deformity with significant forefoot abduction (>30% talonavicular uncovering). Stage IIa is treated with FDL transfer and MDCO. Stage IIb requires the addition of a lateral column lengthening (such as an Evans osteotomy) to correct the severe forefoot abduction.

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