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Midfoot & Hindfoot MCQs

Practice Set 5 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 81

Topic: Midfoot & Hindfoot

A different patient presents with a severe midfoot deformity after a high-energy twisting injury. Radiographs show complete disarticulation at the talonavicular and calcaneocuboid joints, but the subtalar joint remains intact. Based on the provided differential diagnosis table, what is the most likely injury?

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

Correct Answer & Explanation

. Chopart Joint Dislocation

Explanation

Correct Answer: DThe differential diagnosis table explicitly defines 'Chopart Joint Dislocation' as having 'Disarticulation at talonavicular and calcaneocuboid joints, subtalar joint intact.' This perfectly matches the clinical scenario described in the question. Medial and Lateral Subtalar Dislocations involve disarticulation of the talonavicular and talocalcaneal joints. Talar Neck Fractures involve a fracture line through the talar neck. Pantalar Dislocation involves dislocation of the tibiotalar, subtalar, and talonavicular joints simultaneously. Therefore, Chopart Joint Dislocation is the correct answer.

Question 82

Topic: Midfoot & Hindfoot

A patient undergoes a standard triple arthrodesis for a severe rigid pes planovalgus deformity with generalized hindfoot osteoarthritis. Postoperatively, the patient develops a symptomatic non-union. Which joint involved in a triple arthrodesis has the highest reported rate of non-union?

. Calcaneocuboid joint
. Subtalar joint
. Talonavicular joint
. Naviculocuneiform joint
. Tibiotalar joint

Correct Answer & Explanation

. Talonavicular joint

Explanation

The talonavicular joint historically has the highest rate of non-union during a triple arthrodesis, with rates cited between 5% to 10%. It is critical to adequately prepare this joint and ensure robust compression during fixation.

Question 83

Topic: Midfoot & Hindfoot

A 55-year-old female requires isolated fusion of the talonavicular joint due to advanced osteoarthritis. If this joint is successfully fused, what percentage of native subtalar joint motion will approximately remain?

. 80-90%
. 50-60%
. 25-35%
. Less than 10%
. 0%

Correct Answer & Explanation

. Less than 10%

Explanation

The talonavicular joint is the "key" to the acetabulum pedis. Biomechanical studies (like those by Astion et al.) demonstrate that isolated talonavicular fusion restricts subtalar motion to roughly 2 degrees, leaving less than 10% of native subtalar motion.

Question 84

Topic: Midfoot & Hindfoot

When performing a triple arthrodesis for a severe rigid flatfoot deformity, meticulous joint preparation is required. Which of the following joints has the highest reported rate of nonunion following this procedure?

. Subtalar joint
. Talonavicular joint
. Calcaneocuboid joint
. Naviculocuneiform joint
. Tarsometatarsal joint

Correct Answer & Explanation

. Talonavicular joint

Explanation

The talonavicular joint consistently demonstrates the highest nonunion rate following triple arthrodesis, with reports ranging from 5% to 37% in the literature. This is largely due to its spherical anatomy, limited vascularity, and high biomechanical demands, requiring meticulous preparation and rigid fixation.

Question 85

Topic: Midfoot & Hindfoot

A 45-year-old patient undergoes an isolated tibiotalar arthrodesis for post-traumatic arthritis.

Based on the altered biomechanics shown postoperatively, which adjacent joint is at the highest risk of developing progressive symptomatic osteoarthritic changes over the next 10 years?

. Patellofemoral joint
. Subtalar joint
. Naviculocuneiform joint
. Metatarsophalangeal joints
. Calcaneocuboid joint

Correct Answer & Explanation

. Subtalar joint

Explanation

The subtalar joint is highly susceptible to adjacent segment arthritis following isolated ankle arthrodesis due to increased stress transfer and altered hindfoot kinematics. The talonavicular joint is also at significant risk, as the hindfoot complex functions interdependently.

Question 86

Topic: Midfoot & Hindfoot

An orthopaedic surgeon performs an isolated talonavicular arthrodesis for severe isolated degenerative joint disease. Based on standard in vivo kinematic studies, what effect will this isolated fusion have on the motion of the subtalar joint?

. It will increase subtalar motion by 10% to compensate.
. It will preserve approximately 90% of native subtalar motion.
. It will virtually eliminate subtalar motion, restricting it to approximately 2 degrees.
. It will limit subtalar motion to exactly 50% of its normal arc.
. It has no measurable biomechanical effect on subtalar motion.

Correct Answer & Explanation

. It will virtually eliminate subtalar motion, restricting it to approximately 2 degrees.

Explanation

An isolated talonavicular arthrodesis virtually eliminates subtalar joint motion, reducing it to approximately 2 degrees. The talonavicular, subtalar, and calcaneocuboid joints function as a tightly coupled, interdependent complex; therefore, locking the TN joint severely restricts motion in the entire hindfoot.

Question 87

Topic: Midfoot & Hindfoot

Ten years following a successful isolated tibiotalar arthrodesis, a 55-year-old male develops new, progressive hindfoot pain exacerbated by walking on uneven ground. Radiographs are obtained. Degenerative changes in which of the following joints are the most common cause of this new presentation?

. Subtalar joint
. Talonavicular joint
. Calcaneocuboid joint
. Naviculocuneiform joint
. Tarsometatarsal joints

Correct Answer & Explanation

. Subtalar joint

Explanation

Following an ankle arthrodesis, the subtalar joint is subjected to significantly increased biomechanical stress to compensate for the loss of tibiotalar motion. This leads to a high incidence of adjacent segment osteoarthritis over time, most prominently in the subtalar joint.

Question 88

Topic: Midfoot & Hindfoot

A 55-year-old diabetic patient presents with an acutely swollen, erythematous, and warm foot but no systemic signs of infection. Radiographs show periarticular debris, fragmentation of the tarsometatarsal joints, and subluxation. According to the Eichenholtz classification, what stage does this represent, and what is the preferred initial management?

. Stage 0; Immediate open reduction internal fixation
. Stage 1; Total contact casting and non-weight-bearing
. Stage 2; Custom orthosis and weight-bearing as tolerated
. Stage 3; Arthrodesis of the midfoot
. Stage 1; Intravenous antibiotics and surgical debridement

Correct Answer & Explanation

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

Explanation

This presentation describes Eichenholtz Stage 1 (development/fragmentation) of Charcot arthropathy. The gold standard initial management is offloading via total contact casting to prevent further deformity while the acute inflammatory phase resolves.

Question 89

Topic: Midfoot & Hindfoot

The candidate discusses the management options for the navicular fracture, stating that operative intervention is favored. However, they also mention a specific scenario where primary fusion of the talonavicular joint might be considered. What is this specific indication for primary fusion, as outlined in the case?

. A. Patient refusal for internal fixation.
. B. Significant soft tissue compromise precluding open reduction.
. C. Severe comminution of the articular surface making anatomical reduction impossible.
. D. Associated Lisfranc injury requiring concurrent fusion.
. E. Presence of pre-existing talonavicular arthritis.

Correct Answer & Explanation

. C. Severe comminution of the articular surface making anatomical reduction impossible.

Explanation

Correct Answer: CExplanation:The case states, 'The principles of management are to restore the articular surface, stabilize and hold the fracture to allow early mobilization. The aim of the treatment is to have a mobile, pain-free and functional joint. However, sometimes that is not possible due to severe comminution of the articular surface, in which case I may consider primary fusion of the talonavicular joint.' This directly indicates that severe comminution of the articular surface, rendering anatomical reduction and restoration of joint congruity unachievable, is the primary indication for considering primary talonavicular fusion.A. Patient refusal for internal fixation:While patient preference is always a factor in consent, it is not aclinicalindication for primary fusion in the context of fracture severity.B. Significant soft tissue compromise precluding open reduction:Soft tissue compromise might delay surgery or influence the approach, but it doesn't directly lead to a decision for primary fusion of the joint unless the soft tissue damage is so severe that it prevents any form of reconstruction or fixation. The case focuses on articular comminution as the reason for fusion.D. Associated Lisfranc injury requiring concurrent fusion:The case describes an 'isolated closed injury of the foot' and does not mention a Lisfranc injury. While a Lisfranc injury might require fusion, it's not the reason for primary talonavicular fusion in this specific navicular fracture scenario.E. Presence of pre-existing talonavicular arthritis:Pre-existing arthritis would certainly make fusion a more attractive option, but the case does not mention this. The indication given in the case is specifically related to the acute fracture's severity.

Question 90

Topic: Midfoot & Hindfoot

Following initial radiographs, the emergency department physician is still uncertain about the diagnosis of a Lisfranc injury. The patient continues to experience severe pain and swelling. According to the case discussion, what would be the MOST appropriate next step in imaging to confirm or rule out a Lisfranc injury?

. Immediate MRI of the foot.
. Repeat AP and oblique radiographs with increased exposure.
. Obtain lateral view, stress views, and a CT scan.
. Order a bone scan to assess for occult fractures.
. Discharge the patient with a walking boot and follow-up in 1 week.

Correct Answer & Explanation

. Obtain lateral view, stress views, and a CT scan.

Explanation

Correct Answer: CExplanation:The case explicitly states the candidate's response to inconclusive radiographs: "I would consider further radiographic imaging, oblique and lateral view, stress views and a CT scan or may opt for an MRI scan." This indicates a clear progression of imaging modalities to definitively diagnose a Lisfranc injury when initial views are insufficient.Option A (Immediate MRI of the foot):While MRI is excellent for soft tissue and ligamentous injuries, it is often reserved for cases where CT is inconclusive or for assessing ligamentous integrity more precisely. The immediate next step typically involves further plain radiographs and CT.Option B (Repeat AP and oblique radiographs with increased exposure):Simply repeating the same views with different exposure is unlikely to provide new diagnostic information if the initial views were inconclusive for a structural injury like a Lisfranc dislocation. Additional views and advanced imaging are needed.Option C (Obtain lateral view, stress views, and a CT scan):This aligns perfectly with the candidate's recommended approach. A lateral view is crucial for assessing dorsal/plantar displacement, stress views can reveal instability not apparent on static films, and a CT scan provides detailed bony anatomy, crucial for identifying subtle fractures, displacement, and comminution within the complex tarsometatarsal joint.Option D (Order a bone scan):A bone scan is highly sensitive but non-specific for fractures and can take hours to days for results, making it unsuitable for acute diagnosis in the emergency setting for a potentially unstable injury.Option E (Discharge with a walking boot):Discharging a patient with a suspected Lisfranc injury, especially if radiographs are inconclusive, is inappropriate and carries a high risk of missed diagnosis and poor outcome, as up to 20% of these injuries are initially missed.

Question 91

Topic: Midfoot & Hindfoot

A 49-year-old female sustains a Lisfranc injury. The candidate in the case mentions the importance of the 'fleck sign'. What does the 'fleck sign' specifically represent in the context of a Lisfranc injury?

. A small avulsion fracture from the insertion of the Lisfranc ligament into the base of the second metatarsal.
. A small intra-articular fracture within the talonavicular joint.
. A displaced fracture of the cuboid bone.
. A comminuted fracture of the medial cuneiform.
. A small osteochondral defect on the talar dome.

Correct Answer & Explanation

. A small avulsion fracture from the insertion of the Lisfranc ligament into the base of the second metatarsal.

Explanation

Correct Answer: AExplanation:The case explicitly defines the 'fleck sign': "There is a small avulsed fragment of bone in that interval. This avulsion fracture could be from the insertion of the Lisfranc ligament into the base of the second metatarsal, called a โ€˜fleck signโ€™." This is a classic radiographic indicator of a Lisfranc ligament injury.Option A (A small avulsion fracture from the insertion of the Lisfranc ligament into the base of the second metatarsal):This is the correct definition of the 'fleck sign' as described in the case and in orthopedic literature. It signifies disruption of the Lisfranc ligament complex.Option B (A small intra-articular fracture within the talonavicular joint):This describes an injury to the Chopart joint, not the Lisfranc joint.Option C (A displaced fracture of the cuboid bone):While cuboid fractures can occur, they are not referred to as a 'fleck sign' in the context of Lisfranc injuries.Option D (A comminuted fracture of the medial cuneiform):Fractures of the cuneiforms can be part of a Lisfranc injury, but the 'fleck sign' specifically refers to the avulsion from the second metatarsal base.Option E (A small osteochondral defect on the talar dome):This is an ankle injury, unrelated to the Lisfranc joint.

Question 92

Topic: Midfoot & Hindfoot

A 58-year-old female presents with a progressive, flexible flatfoot deformity and inability to perform a single-leg heel rise. Examination reveals a 'too many toes' sign and tenderness over the medial ankle. Which of the following surgical interventions is most appropriate for a Stage IIb posterior tibial tendon dysfunction?

. Isolated posterior tibial tendon debridement
. Flexor digitorum longus (FDL) transfer to the navicular and medial displacement calcaneal osteotomy
. FDL transfer, medial displacement calcaneal osteotomy, and lateral column lengthening
. Triple arthrodesis
. Subtalar arthrodesis

Correct Answer & Explanation

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

Explanation

Stage IIb posterior tibial tendon dysfunction denotes a flexible flatfoot with significant forefoot abduction (>40% talonavicular uncoverage). Appropriate treatment includes FDL transfer, medial displacement calcaneal osteotomy, and lateral column lengthening to correct the abduction.

Question 93

Topic: Midfoot & Hindfoot

A 40-year-old laborer sustains a purely ligamentous Lisfranc injury with 3 mm of diastasis between the medial and middle cuneiforms. Based on current high-level evidence, what is the primary advantage of primary arthrodesis over open reduction and internal fixation (ORIF) for this specific injury pattern?

. Lower rate of hardware removal and higher functional scores
. Decreased risk of deep vein thrombosis
. Shorter time to full weight-bearing
. Higher rate of return to heavy labor within 3 months
. Preserved physiologic motion of the medial column

Correct Answer & Explanation

. Lower rate of hardware removal and higher functional scores

Explanation

Purely ligamentous Lisfranc injuries have a significantly higher rate of failure with ORIF compared to primary arthrodesis. Primary arthrodesis of the medial columns (1st-3rd TMT joints) typically yields higher long-term functional scores and avoids the morbidity of planned hardware removal.

Question 94

Topic: Midfoot & Hindfoot

A 55-year-old diabetic patient presents with a swollen, erythematous, but painless foot. Radiographs show extensive bone fragmentation, joint subluxation, and debris. According to the Eichenholtz classification for Charcot arthropathy, which stage does this represent?

. Stage 0
. Stage 1
. Stage 2
. Stage 3
. Stage 4

Correct Answer & Explanation

. Stage 1

Explanation

Eichenholtz Stage 1 (Developmental/Fragmentation) of Charcot arthropathy is characterized clinically by a hot, swollen foot and radiographically by bone fragmentation, joint subluxation, and debris. Stage 2 is coalescence, and Stage 3 is consolidation.

Question 95

Topic: Midfoot & Hindfoot

Which of the following physical examination maneuvers is BEST for assessing the flexibility of a pes planovalgus deformity in a patient with rheumatoid arthritis?

. Checking the 'too many toes' sign while weightbearing
. Performing the Tarsal Tunnel compression test
. Observing the arch height while standing on toes (Jack's test equivalent)
. Palpating for tenderness over the posterior tibial tendon insertion
. Assessing subtalar joint range of motion in non-weightbearing

Correct Answer & Explanation

. Observing the arch height while standing on toes (Jack's test equivalent)

Explanation

Correct Answer: CObserving the arch height while standing on toes (a modification of the Jack's test or heel-rise test) is the most effective way to assess the flexibility of a pes planovalgus deformity. If the arch reconstitutes or significantly improves with a single heel-rise, the deformity is largely flexible. If the arch remains collapsed, it indicates a rigid deformity, which has significant implications for treatment planning. The 'too many toes' sign indicates hindfoot valgus but not flexibility. Tarsal Tunnel test is for nerve compression. Palpation of the posterior tibial tendon assesses tendon integrity but not overall arch flexibility.

Question 96

Topic: Midfoot & Hindfoot
A 55-year-old diabetic male with peripheral neuropathy presents with a deformed, painless, swollen foot. Radiographs display absorption of fine intra-articular debris, early fusion of large fracture fragments, and significant subchondral sclerosis. These findings correspond to which stage of the Eichenholtz classification for Charcot arthropathy?
. Stage I (Development)
. Stage II (Coalescence)
. Stage III (Reconstruction)
. Stage IV (Resolution)
. Stage 0 (High risk)

Correct Answer & Explanation

. Stage II (Coalescence)

Explanation

Eichenholtz Stage II (Coalescence) is characterized radiographically by absorption of fine debris, early fusion of adjacent large fragments, and sclerosis. Stage I features acute fragmentation and dislocation, while Stage III shows remodeling and rounded bone ends.

Question 97

Topic: Midfoot & Hindfoot

A 28-year-old runner sustains a purely ligamentous Lisfranc injury with 3 mm of widening between the medial and middle cuneiforms. What is the current recommended operative management?

. Closed reduction and cast application for 6 weeks
. Primary arthrodesis of the first, second, and third tarsometatarsal joints
. Open reduction and internal fixation (ORIF) with transarticular screws
. Flexible fixation with a suture button device only
. Midfoot amputation

Correct Answer & Explanation

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

Explanation

Recent literature supports primary arthrodesis for purely ligamentous Lisfranc injuries. It yields better functional outcomes and fewer reoperations compared to traditional ORIF.

Question 98

Topic: Midfoot & Hindfoot
A 40-year-old construction worker undergoes ORIF for a Sanders Type III calcaneal fracture. Post-operatively, he develops persistent pain, stiffness, and limited subtalar motion, despite appropriate rehabilitation. Radiographs show some residual articular incongruity. Based on the case, what is the most common long-term complication following calcaneal fracture fixation, even with anatomical reduction, that this patient is likely experiencing?
. A. Nonunion
. B. Peroneal tendon impingement
. C. Post-traumatic subtalar arthritis
. D. Tarsal tunnel syndrome
. E. Complex Regional Pain Syndrome (CRPS)

Correct Answer & Explanation

. C. Post-traumatic subtalar arthritis

Explanation

Post-traumatic subtalar arthritis is the most common long-term sequela following calcaneal fracture, even with anatomical reduction, with an incidence of 30-70%. The patient's symptoms of persistent pain, stiffness, and limited subtalar motion, along with residual articular incongruity, are classic signs of developing subtalar arthritis.

Question 99

Topic: Midfoot & Hindfoot

A 60-year-old diabetic patient presents with a closed, displaced tongue-type calcaneal fracture with significant tension and blanching of the posterior heel skin. What is the most appropriate next step in management?

. Elevation, ice, and reassessment in 10-14 days for a positive wrinkle sign
. Urgent application of a well-padded splint in extreme dorsiflexion
. Urgent percutaneous reduction and screw fixation
. Extensile lateral approach and plate fixation within 24 hours
. Primary subtalar arthrodesis

Correct Answer & Explanation

. Urgent percutaneous reduction and screw fixation

Explanation

Tongue-type calcaneal fractures with posterior skin blanching represent an orthopedic emergency due to the risk of posterior skin necrosis. Urgent reduction and fixation (often percutaneous) are required to relieve tension on the skin.

Question 100

Topic: Midfoot & Hindfoot

A 50-year-old patient with a history of trauma presents with a complex distal tibial deformity. Preoperative planning involves identifying the Center of Rotation of Angulation (CORA). Why is identifying the CORA considered the single most important step in preoperative templating and planning for angular deformity correction?

. Option A: It determines the optimal length of the external fixator pins.
. Option B: It dictates the ideal location for the axis of correction (the 'hinge' of the osteotomy).
. Option C: It helps in assessing the patient's bone quality for hardware selection.
. Option D: It predicts the exact amount of bone graft needed for the osteotomy gap.
. Option E: It identifies the presence of a fixed subtalar contracture.

Correct Answer & Explanation

. Option B: It dictates the ideal location for the axis of correction (the 'hinge' of the osteotomy).

Explanation

Correct Answer: BThe case states: 'Identifying the CORA is the single most important step in preoperative templating and planning. The location of the CORA dictates the ideal location for the axis of correction (the 'hinge' of your osteotomy).' This is fundamental to applying Paley's osteotomy rules correctly and achieving the desired correction without creating secondary deformities.Option A is incorrectbecause while external fixator pin placement is related to the osteotomy, the CORA's primary role is not to determine pin length but the hinge location.Option C is incorrectbecause bone quality assessment is a separate consideration, typically done through imaging and clinical evaluation, not directly determined by the CORA.Option D is incorrectbecause the CORA helps plan the angular correction and translation, which in turn might influence the osteotomy gap, but it doesn't directly predict the amount of bone graft needed. The gap size is a consequence of the correction, not the primary purpose of CORA identification.Option E is incorrectbecause identifying a fixed subtalar contracture is done through clinical examination and stress radiographs, not by identifying the CORA of the tibial deformity.

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