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Midfoot & Hindfoot MCQs

Practice Set 4 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 61

Topic: Midfoot & Hindfoot

A 14-year-old patient undergoes a medial approach for a talocalcaneal coalition resection. After incising the flexor retinaculum, the surgeon identifies and retracts the posterior tibial tendon superiorly and the flexor digitorum longus tendon inferiorly. Which critical structure lies posterior and inferior to the FDL and must be meticulously protected throughout the case?

. Sural nerve
. Intermediate dorsal cutaneous nerve
. Peroneal artery
. Neurovascular bundle (posterior tibial artery and tibial nerve)
. Flexor hallucis longus tendon

Correct Answer & Explanation

. Neurovascular bundle (posterior tibial artery and tibial nerve)

Explanation

Correct Answer: DThe case describes the detailed surgical approach for a talocalcaneal (TC) coalition, which requires a medial incision. During deep dissection, after identifying and retracting the posterior tibial tendon (PTT) superiorly and the flexor digitorum longus (FDL) tendon inferiorly, the text explicitly states: "The neurovascular bundle (posterior tibial artery and tibial nerve) lies posterior and inferior to the FDL and must be meticulously protected throughout the case." Options A and B (sural nerve, intermediate dorsal cutaneous nerve) are associated with the lateral approach for CN coalitions. Option C (peroneal artery) is not the primary neurovascular structure at risk in this specific medial approach. Option E (flexor hallucis longus tendon) runs directly beneath the sustentaculum tali and is identified, but the neurovascular bundle is the critical structure posterior and inferior to the FDL.

Question 62

Topic: Midfoot & Hindfoot

A 16-year-old patient, 18 months status post-talocalcaneal coalition resection, presents with persistent, debilitating hindfoot pain and progressive valgus deformity. A repeat CT scan shows an adequate initial resection but significant degenerative arthrosis of the posterior facet and early arthritic changes in the talonavicular joint. Non-operative measures have failed. What is the MOST appropriate salvage procedure for this patient?

. Revision resection of the coalition with a larger interposition graft.
. Lateral column lengthening osteotomy.
. Subtalar arthrodesis.
. Triple arthrodesis.
. Medializing calcaneal osteotomy.

Correct Answer & Explanation

. Triple arthrodesis.

Explanation

Correct Answer: DThe patient presents with persistent, debilitating pain and progressive valgus deformity after a talocalcaneal (TC) coalition resection. The CT scan reveals significant degenerative arthrosis of the posterior facet AND early arthritic changes in the talonavicular joint. The case's "Management of Persistent Pain" section states: "If the resection was adequate, the pain is likely secondary to advanced degenerative arthrosis of the posterior facet or the transverse tarsal joints. In these scenarios, the salvage procedure of choice is a subtalar arthrodesis. If the Chopart joint is also severely arthritic, a triple arthrodesis (subtalar, talonavicular, and calcaneocuboid) may be necessary to provide a stable, plantigrade, and pain-free foot." Since the talonavicular joint (part of the Chopart joint) is involved with early arthritic changes in addition to the posterior facet arthrosis, a triple arthrodesis is the most comprehensive and appropriate salvage procedure to address all affected joints and provide a stable, pain-free hindfoot. Subtalar arthrodesis (Option C) would only address the subtalar joint, leaving the talonavicular arthrosis untreated. Options A, B, and E are not indicated for advanced arthrosis.

Question 63

Topic: Midfoot & Hindfoot

In an adolescent patient with a confirmed talocalcaneal coalition, which of the following is considered an absolute contraindication to isolated surgical resection of the coalition?

. Patient age greater than 10 years
. Coalition involving less than 30% of the middle facet
. Degenerative arthritic changes in the posterior subtalar facet
. Presence of an asymptomatic calcaneonavicular coalition
. Failure of 6 weeks of short-leg cast immobilization

Correct Answer & Explanation

. Degenerative arthritic changes in the posterior subtalar facet

Explanation

Resection of a talocalcaneal coalition is contraindicated if there are significant degenerative changes in the posterior facet or if the coalition involves >50% of the joint surface. In these cases, arthrodesis is preferred.

Question 64

Topic: Midfoot & Hindfoot

A 15-year-old patient with a symptomatic talocalcaneal coalition has failed 6 months of non-operative management. CT scan reveals that the coalition involves 60% of the posterior facet. What is the most appropriate surgical management?

. Resection of the coalition with fat interposition
. Resection of the coalition with extensor digitorum brevis interposition
. Isolated talonavicular arthrodesis
. Subtalar arthrodesis
. Calcaneal lengthening osteotomy

Correct Answer & Explanation

. Subtalar arthrodesis

Explanation

For talocalcaneal coalitions involving greater than 50% of the posterior facet area, resection is associated with poor outcomes. Subtalar arthrodesis is the recommended surgical treatment in these extensive cases.

Question 65

Topic: Midfoot & Hindfoot

A 14-year-old girl presents with deep medial hindfoot pain and a rigid flatfoot. A CT scan confirms a tarsal coalition. Which of the following anatomic locations is most commonly involved in this specific type of coalition?

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

Correct Answer & Explanation

. Middle facet of the subtalar joint

Explanation

Talocalcaneal coalitions typically present later (ages 12-16) and most commonly involve the middle facet of the subtalar joint. They often cause deep medial hindfoot pain and a rigid flatfoot deformity.

Question 66

Topic: Midfoot & Hindfoot

A 13-year-old boy requires surgical intervention for a symptomatic talocalcaneal coalition after failing conservative treatment. Preoperative CT imaging is utilized to evaluate the joint. According to current literature, resection of the coalition is generally indicated if it involves less than what percentage of the posterior facet area?

. 25%
. 33%
. 50%
. 75%
. 90%

Correct Answer & Explanation

. 50%

Explanation

Resection of a talocalcaneal coalition is typically indicated if the coalition involves less than 50% of the posterior subtalar facet surface area and there is no significant adjacent joint arthrosis. If >50%, primary subtalar fusion is preferred.

Question 67

Topic: Midfoot & Hindfoot

In a 14-year-old patient with a symptomatic talocalcaneal coalition that has failed conservative management, which of the following is considered a relative contraindication to coalition resection and instead warrants primary subtalar arthrodesis?

. Coalition size measuring 30% of the posterior facet area
. Age greater than 12 years
. Hindfoot valgus of 5 degrees
. Degenerative changes in the posterior facet of the subtalar joint
. Failure of a 6-week course of casting

Correct Answer & Explanation

. Degenerative changes in the posterior facet of the subtalar joint

Explanation

Resection of a talocalcaneal coalition is generally contraindicated if there are significant degenerative changes in the posterior facet or if the coalition involves greater than 50% of the joint. In these scenarios, a subtalar or triple arthrodesis provides superior outcomes.

Question 68

Topic: Midfoot & Hindfoot

A 55-year-old diabetic male presents with a swollen, warm, and erythematous left foot. Radiographs show periarticular debris, fragmentation of the navicular, and subluxation of the talonavicular joint. According to the Eichenholtz classification, what is the most appropriate initial management?

. Immediate midfoot arthrodesis
. Total contact casting and non-weight-bearing
. Corticosteroid injection
. Antibiotic therapy for osteomyelitis
. Custom orthotic shoe wear

Correct Answer & Explanation

. Total contact casting and non-weight-bearing

Explanation

The patient is in the acute fragmentation phase (Stage 1) of Charcot arthropathy. The standard of care is immobilization with a total contact cast and strict non-weight-bearing until the inflammatory phase resolves.

Question 69

Topic: Midfoot & Hindfoot

A 55-year-old male with poorly controlled diabetes mellitus presents with a severely swollen, erythematous, and warm left foot. He denies any recent trauma, systemic fevers, or pain. Radiographs reveal fragmentation and early subluxation of the navicular and cuneiforms without open wounds. What is the most appropriate initial management?

. Midfoot arthrodesis
. Total contact casting
. Intravenous antibiotics and surgical debridement
. Excision of the fragmented bone
. Amputation

Correct Answer & Explanation

. Total contact casting

Explanation

This patient presents with acute Eichenholtz Stage I (fragmentation) Charcot arthropathy. The gold standard initial treatment to prevent further deformity is strict immobilization and offloading, most effectively achieved with total contact casting.

Question 70

Topic: Midfoot & Hindfoot

A 28-year-old athlete sustains a low-energy twisting injury to the foot while playing basketball. Initial radiographs are interpreted as normal. However, due to persistent midfoot pain and swelling, a follow-up MRI is performed, which reveals a subtle disruption of the Lisfranc ligament without significant bony displacement. Based on the case discussion, what is the MOST appropriate initial non-operative management for this stable Lisfranc sprain?

. A. Immediate weight-bearing as tolerated with a supportive shoe.
. B. Non-weightbearing cast for 6 weeks with regular clinical and radiological review.
. C. Partial weight-bearing in a walking boot for 2-3 weeks.
. D. Aggressive physical therapy focusing on strengthening and flexibility.
. E. Corticosteroid injection into the tarsometatarsal joint.

Correct Answer & Explanation

. B. Non-weightbearing cast for 6 weeks with regular clinical and radiological review.

Explanation

Correct Answer: BThe case states: 'There is a role for non-operative management of an undisplaced stable injury or sprain which includes a non-weightbearing cast for 6 weeks and regular clinical and radiological review.' Even a stable Lisfranc sprain involves disruption of critical ligaments and requires a period of strict non-weightbearing immobilization to allow for healing and prevent progression to instability. Regular review is essential to ensure stability is maintained.Option A (Immediate weight-bearing as tolerated with a supportive shoe)is incorrect. This would place undue stress on the healing ligaments and could lead to chronic instability and pain.Option C (Partial weight-bearing in a walking boot for 2-3 weeks)is incorrect. This duration and level of activity are insufficient for a Lisfranc sprain, which requires longer non-weightbearing to heal adequately.Option D (Aggressive physical therapy focusing on strengthening and flexibility)is incorrect. While physical therapy is crucial after immobilization, aggressive therapy too early would jeopardize ligament healing.Option E (Corticosteroid injection into the tarsometatarsal joint)is incorrect. Corticosteroid injections are generally not indicated for acute ligamentous injuries and could potentially weaken the healing tissue.

Question 71

Topic: Midfoot & Hindfoot

A 25-year-old professional athlete sustains a purely ligamentous Lisfranc injury. According to recent literature, what is the primary advantage of performing a primary arthrodesis of the first, second, and third tarsometatarsal joints rather than open reduction and internal fixation (ORIF)?

. Shorter initial non-weight-bearing duration
. Decreased rate of subsequent surgeries and hardware removal
. Superior restoration of the medial longitudinal arch height
. Reduced risk of adjacent segment disease at the midtarsal joints
. Lower incidence of superficial wound infections

Correct Answer & Explanation

. Decreased rate of subsequent surgeries and hardware removal

Explanation

Primary arthrodesis for purely ligamentous Lisfranc injuries has been shown to yield similar or slightly better functional outcomes compared to ORIF, primarily due to a significantly decreased need for subsequent surgeries such as hardware removal.

Question 72

Topic: Midfoot & Hindfoot

A 24-year-old athlete is diagnosed with a purely ligamentous Lisfranc injury involving the first, second, and third tarsometatarsal joints. Which of the following is the most appropriate definitive management for the medial columns?

. Non-weight-bearing cast immobilization for 8 weeks
. Closed reduction and percutaneous pinning
. Open reduction and internal fixation with transarticular screws
. Primary arthrodesis of the first, second, and third tarsometatarsal joints
. Open reduction and internal fixation with dorsal bridge plating

Correct Answer & Explanation

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

Explanation

Current evidence demonstrates that pure ligamentous Lisfranc injuries have better functional outcomes and lower reoperation rates when treated with primary arthrodesis of the medial three rays compared to open reduction and internal fixation.

Question 73

Topic: Midfoot & Hindfoot

Recent randomized controlled trials comparing open reduction internal fixation (ORIF) to primary arthrodesis for Lisfranc injuries have shown primary arthrodesis is most strongly indicated for which specific injury pattern?

. Purely ligamentous Lisfranc injuries
. Bony avulsion of the 2nd metatarsal base
. Open Lisfranc fracture-dislocations
. Injuries in high-level athletes
. Pediatric Lisfranc injuries

Correct Answer & Explanation

. Purely ligamentous Lisfranc injuries

Explanation

Multiple studies (such as those by Ly and Coetzee) have demonstrated that purely ligamentous Lisfranc injuries have better functional outcomes and lower reoperation rates with primary arthrodesis compared to ORIF.

Question 74

Topic: Midfoot & Hindfoot

A 26-year-old athlete with a missed Lisfranc injury from 8 months ago now presents with chronic, debilitating midfoot pain and a severe flatfoot deformity. Weight-bearing radiographs confirm chronic dorsal subluxation of the 2nd TMT joint. What is the most appropriate surgical treatment?

. Open reduction and internal fixation with screws
. Tarsometatarsal joint debridement and primary closure
. Medializing calcaneal osteotomy
. Midfoot corrective arthrodesis of the affected TMT joints
. Primary repair of the Lisfranc ligament

Correct Answer & Explanation

. Midfoot corrective arthrodesis of the affected TMT joints

Explanation

In chronic, missed Lisfranc injuries with fixed deformity and secondary arthritic changes, corrective arthrodesis of the medial column (TMT joints) is required to restore anatomy and eliminate pain.

Question 75

Topic: Midfoot & Hindfoot

In a 50-year-old patient with a purely ligamentous Lisfranc injury, what is the primary advantage of primary arthrodesis of the first, second, and third tarsometatarsal joints compared to open reduction and internal fixation (ORIF)?

. Better postoperative range of motion at the midfoot
. Decreased rate of hardware removal and secondary procedures
. Faster time to initial weight-bearing
. Complete preservation of normal midfoot kinematics
. Lower rate of postoperative wound infection

Correct Answer & Explanation

. Decreased rate of hardware removal and secondary procedures

Explanation

Prospective randomized trials have shown that primary arthrodesis for purely ligamentous Lisfranc injuries results in comparable or superior functional outcomes while significantly decreasing the need for hardware removal and secondary salvage procedures compared to ORIF.

Question 76

Topic: Midfoot & Hindfoot
A 30-year-old male sustains a displaced talar neck fracture with subluxation of the subtalar joint, while the ankle and talonavicular joints remain perfectly congruent. What is the Hawkins classification for this injury, and what is the approximate risk of avascular necrosis (AVN)?
. Type I; 0-10% risk
. Type II; 20-50% risk
. Type III; 80-100% risk
. Type IV; 100% risk
. Type II; >90% risk

Correct Answer & Explanation

. Type II; 20-50% risk

Explanation

A Hawkins Type II talar neck fracture involves displacement with subtalar subluxation or dislocation, while the tibiotalar and talonavicular joints remain reduced. The risk of AVN for Type II fractures is widely cited as 20% to 50%.

Question 77

Topic: Midfoot & Hindfoot

A 22-year-old athlete sustains a purely ligamentous Lisfranc injury with 3 mm of displacement between the medial and middle cuneiforms. Based on current literature comparing treatment modalities for purely ligamentous midfoot injuries, what is the best definitive surgical treatment?

. Closed reduction and percutaneous pinning (CRPP)
. Open reduction and internal fixation (ORIF) with transarticular screws
. Primary arthrodesis of the first, second, and third tarsometatarsal joints
. Dorsal bridge plating without joint violation
. Non-operative management in a short leg cast

Correct Answer & Explanation

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

Explanation

Studies (e.g., Ly and Coetzee) have demonstrated that purely ligamentous Lisfranc injuries treated with primary arthrodesis yield better functional outcomes and lower reoperation rates compared to ORIF. Bony fracture-dislocations, however, are typically treated with ORIF.

Question 78

Topic: Midfoot & Hindfoot

The patient's definitive reconstruction involves a dual incision strategy, including a posteromedial approach to address the posterior malleolar extension and the medial column. Which of the following describes the correct internervous plane for the deep dissection of this posteromedial approach and the neurovascular structures to protect?

. Between the Tibialis Anterior and the Extensor Hallucis Longus; protect the deep peroneal nerve and anterior tibial artery.
. Between the Peroneus Longus and the Peroneus Brevis; protect the superficial peroneal nerve.
. Between the Flexor Digitorum Longus and the Flexor Hallucis Longus; protect the sural nerve.
. Between the Posterior Tibial Tendon and the Flexor Digitorum Longus; protect the saphenous nerve and vein anteriorly.
. Between the Gastrocnemius and Soleus; protect the posterior tibial nerve and artery.

Correct Answer & Explanation

. Between the Posterior Tibial Tendon and the Flexor Digitorum Longus; protect the saphenous nerve and vein anteriorly.

Explanation

Correct Answer: DThe case explicitly states for the posteromedial approach: 'The saphenous nerve and vein are protected anteriorly. The deep dissection proceeds between the posterior tibial tendon and the flexor digitorum longus, allowing access to the posterior aspect of the medial malleolus and the Volkmann fragment.' This accurately describes the internervous plane and the key neurovascular structures to protect during this approach.Option A is incorrectas this describes an anterior approach.Option B is incorrectas this describes a lateral approach.Option C is incorrectbecause while the Flexor Digitorum Longus and Flexor Hallucis Longus are in the deep posterior compartment, the primary internervous plane for the posteromedial approach is between the Posterior Tibial Tendon and the Flexor Digitorum Longus. The sural nerve is lateral.Option E is incorrectbecause while the Gastrocnemius and Soleus are posterior, the approach for the distal tibia is typically deeper, and the posterior tibial nerve and artery are deep to the flexor tendons, not directly between the gastrocnemius and soleus for this specific approach to the medial malleolus/Volkmann fragment.

Question 79

Topic: Midfoot & Hindfoot

A 32-year-old male presents to the Emergency Department following a high-energy motor vehicle accident. He reports immediate pain and deformity in his left foot after an axial load through a plantarflexed foot with a severe inversion component. Clinical examination reveals an 'acquired clubfoot' deformity with significant varus angulation of the hindfoot, supination, plantarflexion, and a prominently palpable talar head dorsolaterally. The skin overlying the talar head is stretched and blanched. Based on this presentation, what is the most likely diagnosis?

. Lateral Subtalar Dislocation
. Talar Neck Fracture with Dislocation
. Medial Subtalar Dislocation
. Chopart Joint Dislocation
. Pantalar Dislocation

Correct Answer & Explanation

. Medial Subtalar Dislocation

Explanation

Correct Answer: CThe patient's presentation is classic for a medial subtalar dislocation. The mechanism of injury (axial load through a plantarflexed foot with severe inversion) directly correlates with the pathomechanics of this injury. Clinically, the 'acquired clubfoot' deformity, significant varus angulation of the hindfoot, supination, plantarflexion, and the prominent dorsolateral talar head are pathognomonic findings for a medial subtalar dislocation. The skin tension over the talar head is a critical sign of impending soft tissue compromise. Lateral subtalar dislocations present with the foot in valgus and pronation, and the talar head prominent medially. Talar neck fractures involve a fracture line through the talar neck, often with variable hindfoot deformity. Chopart joint dislocations involve disarticulation at the talonavicular and calcaneocuboid joints, with an intact subtalar joint. Pantalar dislocations involve simultaneous dislocation of the tibiotalar, subtalar, and talonavicular joints, which is a much more severe and unstable injury.

Question 80

Topic: Midfoot & Hindfoot

Despite two well-executed attempts at closed reduction under adequate sedation, the patient's medial subtalar dislocation remains irreducible. The decision is made to proceed with emergent open reduction. For an irreducible medial subtalar dislocation, which of the following soft tissue structures is most commonly implicated as an interpositional block to reduction?

. Posterior tibial tendon
. Flexor hallucis longus tendon
. Extensor digitorum brevis muscle belly
. Deltoid ligament
. Peroneus brevis tendon

Correct Answer & Explanation

. Extensor digitorum brevis muscle belly

Explanation

Correct Answer: CThe case explicitly details the indications for operative intervention: 'In medial dislocations, the most common blocks to closed reduction include the buttonholing of the talar head through the extensor digitorum brevis muscle belly, the extensor retinaculum, or the talonavicular joint capsule.' The other options (posterior tibial tendon, flexor hallucis longus tendon, deltoid ligament, peroneus brevis tendon) are less common or not typically involved in blocking reduction of a medial subtalar dislocation. The EDB muscle belly, located dorsolaterally, is directly in the path of the prominent talar head during a medial dislocation.

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