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Midfoot & Hindfoot MCQs

Practice Set 39 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 761

Topic: Midfoot & Hindfoot

Neuropathic arthropathy in the upper extremity associated with syringomyelia is primarily secondary to the destruction of which of the following spinal cord structures?

. Dorsal columns
. Corticospinal tract
. Lateral spinothalamic tract
. Anterior spinocerebellar tract
. Rubrospinal tract

Correct Answer & Explanation

. Lateral spinothalamic tract

Explanation

Syringomyelia causes cystic enlargement of the central canal, which first compresses the crossing fibers of the lateral spinothalamic tract. This leads to the characteristic loss of pain and temperature sensation, predisposing the joint to Charcot arthropathy.

Question 762

Topic: Midfoot & Hindfoot
A 5-year-old boy presents with a limp and midfoot pain. A radiograph is shown. What is the most appropriate management?
. Immediate surgical excision of the affected bone
. Talonavicular arthrodesis
. Short-leg walking cast for 4-6 weeks
. Extracorporeal shockwave therapy
. Corticosteroid injection

Correct Answer & Explanation

. Short-leg walking cast for 4-6 weeks

Explanation

The radiograph demonstrates Köhler's disease, an osteochondrosis of the navicular. It is self-limiting, and symptomatic relief with a short-leg walking cast for 4-6 weeks is the treatment of choice for significant pain.

Question 763

Topic: Midfoot & Hindfoot
A worried mother brings her 4-year-old son to the clinic after he began walking with a limp. Imaging confirms Köhler's disease. Which of the following statements is most accurate regarding long-term prognosis?
. He is at high risk for early-onset talonavicular osteoarthritis
. Surgical decompression is required to prevent navicular collapse
. The condition typically resolves completely with no long-term sequelae
. He will likely require a triple arthrodesis in early adulthood
. Lifelong custom orthotics are mandatory

Correct Answer & Explanation

. The condition typically resolves completely with no long-term sequelae

Explanation

Köhler's disease has an excellent prognosis. The condition typically resolves clinically and radiographically within 1-2 years with no residual deformity or long-term risk of osteoarthritis.

Question 764

Topic: Midfoot & Hindfoot
A 55-year-old female presents with a progressive painful flatfoot deformity. On examination, she is unable to perform a single-leg heel raise on the right side. A Coleman block test is performed, and the patient's hindfoot valgus fails to correct. Based on these findings, what is the most appropriate surgical intervention?
. Flexor digitorum longus transfer to the navicular
. Medial displacement calcaneal osteotomy with FDL transfer
. Spring ligament reconstruction and lateral column lengthening
. Subtalar or triple arthrodesis
. Gastrocnemius recession and orthotic fitting

Correct Answer & Explanation

. Subtalar or triple arthrodesis

Explanation

The inability to correct hindfoot valgus during a Coleman block test indicates a rigid hindfoot deformity, classifying this as Stage III posterior tibial tendon dysfunction. The standard surgical treatment for Stage III rigid deformity is a hindfoot fusion (e.g., subtalar or triple arthrodesis).

Question 765

Topic: Midfoot & Hindfoot
A 55-year-old female presents with progressive flattening of her left foot. Examination reveals a flexible flatfoot, inability to perform a single-leg heel raise, and >40% uncoverage of the talar head on AP radiographs. What is the most appropriate surgical management?
. Gastrocnemius recession, FDL transfer to the navicular, and medial displacement calcaneal osteotomy
. Gastrocnemius recession, FDL transfer to the navicular, and lateral column lengthening
. Subtalar arthrodesis with FHL transfer
. Triple arthrodesis
. Primary repair of the posterior tibial tendon

Correct Answer & Explanation

. Gastrocnemius recession, FDL transfer to the navicular, and lateral column lengthening

Explanation

Stage IIb posterior tibial tendon dysfunction is characterized by a flexible deformity with significant forefoot abduction (>40% talonavicular uncoverage). Lateral column lengthening is required to correct the forefoot abduction, alongside FDL transfer and calcaneal osteotomy.

Question 766

Topic: Midfoot & Hindfoot

A 60-year-old diabetic male presents with a swollen, erythematous, warm, and painless right foot. Radiographs show periarticular fragmentation and debris at the tarsometatarsal joints. Infection has been ruled out. What is the most appropriate initial management?

. Intravenous antibiotics and serial debridement
. Immediate open reduction and internal fixation
. Total contact casting and strict non-weight-bearing
. Primary midfoot arthrodesis
. Charcot restraint orthotic walker (CROW) with weight-bearing as tolerated

Correct Answer & Explanation

. Total contact casting and strict non-weight-bearing

Explanation

The patient is in the acute fragmentation phase (Eichenholtz stage I) of Charcot arthropathy. The gold standard initial treatment is immobilization with total contact casting and strict non-weight-bearing to prevent further deformity until the acute phase resolves.

Question 767

Topic: Midfoot & Hindfoot

A 16-year-old female presents with bilateral progressive cavovarus deformities and weakness in ankle dorsiflexion. A Coleman block test demonstrates that the hindfoot varus corrects to neutral when the first ray is allowed to drop off the block. What is the primary driving force behind this flexible hindfoot varus?

. Overpull of the tibialis anterior relative to the peroneus longus
. Plantarflexed first ray driven by an overactive peroneus longus relative to a weak tibialis anterior
. Spasticity of the gastrocnemius-soleus complex
. Contracture of the posterior talofibular ligament
. Bony coalition of the subtalar joint

Correct Answer & Explanation

. Plantarflexed first ray driven by an overactive peroneus longus relative to a weak tibialis anterior

Explanation

In Charcot-Marie-Tooth disease, weakness of the tibialis anterior allows the strong peroneus longus to severely plantarflex the first ray. This rigid plantarflexed first ray acts as a kickstand, forcing the hindfoot into a compensatory, initially flexible varus.

Question 768

Topic: Midfoot & Hindfoot

A 60-year-old patient with long-standing, poorly controlled diabetes mellitus presents with a swollen, red, and warm right foot. Which of the following clinical findings most reliably differentiates acute Charcot arthropathy (Eichenholtz stage 0 or I) from an acute localized infection?

. The presence of a bounding dorsalis pedis pulse
. Resolution of erythema following 10 minutes of limb elevation
. Elevated serum white blood cell count
. Presence of profound peripheral neuropathy on monofilament testing
. Absence of periosteal reaction on initial radiographs

Correct Answer & Explanation

. Resolution of erythema following 10 minutes of limb elevation

Explanation

Acute Charcot arthropathy presents with a red, hot, swollen foot that closely mimics infection. Erythema that completely resolves with limb elevation (dependent rubor) strongly points to acute Charcot, whereas erythema secondary to cellulitis or deep infection persists despite elevation.

Question 769

Topic: Midfoot & Hindfoot

A 55-year-old patient presents with a painful flatfoot deformity that has failed conservative management. Based on the provided radiographs, the primary site of degenerative collapse and deformity is located at which of the following articulations?

. Subtalar joint
. Talonavicular joint
. Calcaneocuboid joint
. Tarsometatarsal joints
. Metatarsophalangeal joints

Correct Answer & Explanation

. Tarsometatarsal joints

Explanation

Correct Answer: DThe radiographs demonstrate a degenerative collapse of the midfoot through the tarsometatarsal joints with significant forefoot abduction. Because the primary pathology and deformity are at the tarsometatarsal articulation, a midfoot arthrodesis is the required surgical intervention. Procedures targeting the hindfoot (like triple arthrodesis or lateral column lengthening) would not address the primary site of arthritis and deformity.

Question 770

Topic: Midfoot & Hindfoot

A 55-year-old female presents with progressive flattening of her medial longitudinal arch and pain posterior to the medial malleolus. Dysfunction of which of the following tendons is the most likely primary cause of her deformity?

. Flexor hallucis longus
. Tibialis anterior
. Peroneus longus
. Tibialis posterior
. Flexor digitorum longus

Correct Answer & Explanation

. Tibialis posterior

Explanation

Correct Answer: Tibialis posteriorThe posterior tibial tendon is the primary dynamic stabilizer of the medial longitudinal arch and the main invertor of the midfoot. Its dysfunction is the most common cause of adult-acquired flatfoot deformity, characterized by progressive arch collapse, hindfoot valgus, and forefoot abduction.

Question 771

Topic: Midfoot & Hindfoot

A 22-year-old athlete sustains a purely ligamentous Lisfranc injury with 3 mm of diastasis between the medial and middle cuneiforms. Based on recent prospective studies, which of the following is the most appropriate surgical management?

. Open reduction and internal fixation with screws across the involved joints
. Primary arthrodesis of the first, second, and third tarsometatarsal joints
. Closed reduction and percutaneous K-wire fixation
. Dorsal bridge plating spanning the tarsometatarsal joints
. Nonoperative management in a non-weight-bearing cast for 6 weeks

Correct Answer & Explanation

. Primary arthrodesis of the first, second, and third tarsometatarsal joints

Explanation

Primary arthrodesis is preferred for purely ligamentous Lisfranc injuries as it has been shown to reduce reoperation rates and hardware failure compared to ORIF.

Question 772

Topic: Midfoot & Hindfoot
A 58-year-old patient with poorly controlled diabetes presents with a warm, erythematous, and swollen foot. Radiographs demonstrate periarticular debris, fragmentation, and subluxation of the midfoot joints. Which stage of Charcot neuroarthropathy 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 (developmental/fragmentation phase) is characterized by clinical warmth, erythema, and radiographic findings of fragmentation, debris, and joint subluxation.

Question 773

Topic: Midfoot & Hindfoot

A 55-year-old female presents with a progressive flatfoot deformity. Examination reveals a flexible pes planovalgus and an inability to perform a single-limb heel rise. Which surgical intervention is the standard of care for this stage of adult acquired flatfoot deformity?

. Flexor digitorum longus (FDL) transfer to the navicular alone
. FDL transfer combined with a medializing calcaneal osteotomy
. Triple arthrodesis
. Isolated subtalar arthrodesis
. Gastrocnemius recession as an isolated procedure

Correct Answer & Explanation

. FDL transfer combined with a medializing calcaneal osteotomy

Explanation

Stage II posterior tibial tendon dysfunction involves a flexible flatfoot. It is treated with joint-sparing procedures, typically a medializing calcaneal osteotomy and FDL transfer to the navicular.

Question 774

Topic: Midfoot & Hindfoot
A 55-year-old woman presents with a flexible flatfoot deformity, inability to perform a single-leg heel raise, and >40% uncoverage of the talar head on AP standing radiographs. Which of the following surgical procedures is most appropriate to correct the transverse plane deformity?
. Medial displacement calcaneal osteotomy (MDCO)
. Lateral column lengthening (Evans osteotomy)
. Subtalar arthrodesis
. Triple arthrodesis
. Spring ligament repair alone

Correct Answer & Explanation

. Lateral column lengthening (Evans osteotomy)

Explanation

This patient has Stage IIb adult acquired flatfoot deformity characterized by significant forefoot abduction (transverse plane deformity). A lateral column lengthening (Evans osteotomy) is specifically indicated to address transverse plane uncoverage of the talar head.

Question 775

Topic: Midfoot & Hindfoot

A 55-year-old diabetic male presents with a red, hot, swollen foot without an ulcer. Radiographs show periarticular debris, fragmentation, and subluxation at the midfoot. Which of the following is the most appropriate initial management according to the Eichenholtz classification?

. Immediate open reduction and internal fixation
. Total contact casting and non-weight bearing
. Intravenous antibiotics and surgical debridement
. Midfoot arthrodesis with a superconstruct
. Custom orthotic shoe wear

Correct Answer & Explanation

. Total contact casting and non-weight bearing

Explanation

This presentation describes Eichenholtz Stage I (Developmental/Fragmentation stage) of Charcot arthropathy. The gold standard for acute Charcot neuroarthropathy is strict immobilization and offloading, typically utilizing a total contact cast to arrest the destructive phase.

Question 776

Topic: Midfoot & Hindfoot

A 55-year-old female presents with progressive flatfoot deformity. She has pain along the medial ankle and cannot perform a single-limb heel rise. Radiographs show a talonavicular uncoverage of 40%. The deformity is passively correctable. What is the most appropriate surgical management?

. Isolated subtalar fusion
. Flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy
. Triple arthrodesis
. Spring ligament repair alone
. Tibiotalocalcaneal arthrodesis

Correct Answer & Explanation

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

Explanation

This patient has Stage II posterior tibial tendon dysfunction, characterized by a flexible deformity and inability to perform a heel rise. The standard surgical treatment is a joint-sparing procedure such as an FDL transfer combined with a medial displacement calcaneal osteotomy.

Question 777

Topic: Midfoot & Hindfoot

A 60-year-old diabetic male presents with a swollen, erythematous, and warm left foot without systemic signs of infection. Radiographs show fragmentation of the midfoot, periarticular debris, and joint subluxation. Which Eichenholtz stage does this represent, and what is the optimal initial treatment?

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

Correct Answer & Explanation

. Stage 1; total contact casting and non-weight bearing

Explanation

This presentation describes Eichenholtz Stage 1 (development/fragmentation) Charcot arthropathy, marked by acute inflammation and osseous fragmentation. The gold standard initial treatment is total contact casting and offloading until the acute inflammatory phase resolves.

Question 778

Topic: Midfoot & Hindfoot

A 48-year-old runner complains of chronic medial heel pain radiating into the plantar aspect of the foot, worsening with prolonged activity. Examination reveals maximal tenderness over the medial heel and a positive Tinel's sign posterior to the medial malleolus radiating distally. Entrapment of which nerve is the most likely diagnosis?

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

Correct Answer & Explanation

. First branch of the lateral plantar 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 quadratus plantae. It typically presents with chronic heel pain mimicking plantar fasciitis but includes neurologic symptoms radiating laterally.

Question 779

Topic: Midfoot & Hindfoot

A 55-year-old diabetic patient presents with a swollen, red, and warm left foot. Radiographs show joint fragmentation, debris, and early subluxation at the midfoot, consistent with Eichenholtz Stage I Charcot arthropathy. There is no open ulcer. What is the most appropriate initial management?

. Intravenous antibiotics for 6 weeks
. Urgent surgical debridement and external fixation
. Total contact casting and strict non-weight-bearing
. Primary arthrodesis of the midfoot
. Below-knee amputation

Correct Answer & Explanation

. Total contact casting and strict non-weight-bearing

Explanation

Eichenholtz Stage I (fragmentation stage) is characterized by acute inflammation, osteopenia, and architectural breakdown. The gold standard initial management is immobilization with a total contact cast and strict non-weight-bearing to halt disease progression until it reaches the coalescence stage.

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