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Midfoot & Hindfoot MCQs

Practice Set 6 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 101

Topic: Midfoot & Hindfoot

A 55-year-old female presents with a longstanding, severe varus diaphyseal tibial malunion. Weight-bearing alignment radiographs reveal a compensatory deformity in the hindfoot. Which of the following compensatory mechanisms at the subtalar joint is most likely present to maintain a plantigrade foot?

. Fixed subtalar varus
. Fixed subtalar valgus (eversion)
. Forefoot supination
. Talonavicular dorsal subluxation
. Calcaneocuboid distraction

Correct Answer & Explanation

. Fixed subtalar valgus (eversion)

Explanation

In the setting of a severe, long-standing tibial varus deformity, the subtalar joint compensates by everting (valgus) to allow the plantar surface of the foot to remain flat on the ground. Over time, this compensatory eversion can become fixed.

Question 102

Topic: Midfoot & Hindfoot

A 45-year-old female presents with a severe valgus deformity of the knee. The Joint Line Convergence Angle (JLCA) is measured at 6 degrees opening medially. What does this abnormally increased JLCA most likely indicate in the context of lower extremity deformity?

. A purely extra-articular diaphyseal deformity
. Intra-articular deformity, cartilage wear, or medial ligamentous laxity
. A compensatory deformity in the subtalar joint
. An error in radiographic magnification
. A rotational deformity of the femur

Correct Answer & Explanation

. Intra-articular deformity, cartilage wear, or medial ligamentous laxity

Explanation

The normal JLCA is 0 to 2 degrees. An increased JLCA indicates that the joint space is asymmetric, which can be caused by cartilage loss, intra-articular deformity, or collateral ligament laxity.

Question 103

Topic: Midfoot & Hindfoot

A 55-year-old female presents with severe medial ankle pain and a progressively flattening arch. She cannot perform a single-leg heel rise. Radiographs demonstrate advanced flatfoot deformity with talonavicular uncoverage of 45%. The subtalar joint shows no degenerative changes. Based on this Stage IIb Adult Acquired Flatfoot Deformity, what is the most appropriate surgical reconstruction?

. Tenosynovectomy of the posterior tibial tendon
. FDL transfer and medial displacement calcaneal osteotomy (MDCO)
. FDL transfer, MDCO, and lateral column lengthening
. Subtalar arthrodesis
. Tibiotalocalcaneal arthrodesis

Correct Answer & Explanation

. FDL transfer, MDCO, and lateral column lengthening

Explanation

Stage IIb posterior tibial tendon dysfunction (PTTD) / adult acquired flatfoot deformity is characterized by flexible deformity but with significant forefoot abduction (typically defined as >30-40% talonavicular uncoverage). While an FDL transfer and MDCO address the medial and hindfoot components, the severe forefoot abduction requires a lateral column lengthening (e.g., Evans osteotomy or calcaneocuboid distraction arthrodesis) to adequately restore the foot's shape.

Question 104

Topic: Midfoot & Hindfoot

A 25-year-old male sustains a midfoot injury. Weight-bearing radiographs reveal 2mm of widening between the first and second metatarsal bases. MRI confirms a rupture of the dorsal Lisfranc ligament and a sprain of the plantar Lisfranc ligament. Which statement regarding the biomechanics of the Lisfranc ligament complex is most accurate in guiding treatment?

. The dorsal Lisfranc ligament provides the primary stability to the TMT joint
. Rupture of the interosseous Lisfranc ligament alone leads to multiplanar instability
. The plantar Lisfranc ligament is thicker and provides the majority of the biomechanical strength
. Operative fixation is only required if the 1st metatarsocuneiform joint is involved
. Non-operative management is indicated for any diastasis less than 4mm

Correct Answer & Explanation

. The plantar Lisfranc ligament is thicker and provides the majority of the biomechanical strength

Explanation

The Lisfranc ligament complex consists of dorsal, interosseous, and plantar components connecting the medial cuneiform to the second metatarsal base. The plantar Lisfranc ligament is the thickest and biomechanically strongest of the three. Disruption of the plantar ligament leads to significant instability requiring operative stabilization. Diastasis > 2mm on weight-bearing films is generally an indication for surgery.

Question 105

Topic: Midfoot & Hindfoot

A 55-year-old female presents with a progressive flatfoot deformity. Examination shows an inability to perform a single-limb heel rise, 'too many toes' sign, and severe forefoot abduction. Weight-bearing radiographs reveal greater than 40% uncoverage of the talonavicular joint and a talonavicular fault, but flexible hindfoot and midfoot joints. In addition to a flexor digitorum longus (FDL) transfer and medial calcaneal slide osteotomy, which of the following procedures is most strongly indicated to correct her specific multiplanar deformity?

. Spring ligament reconstruction only
. Medial column fusion (naviculocuneiform arthrodesis)
. Lateral column lengthening (Evans osteotomy)
. Subtalar arthrodesis
. Triple arthrodesis

Correct Answer & Explanation

. Lateral column lengthening (Evans osteotomy)

Explanation

This patient has Stage IIb posterior tibial tendon dysfunction (PTTD), differentiated from Stage IIa by significant forefoot abduction (typically >30-40% talonavicular uncoverage). To effectively correct the severe forefoot abduction and restore the arch in a flexible foot, a lateral column lengthening (Evans osteotomy) is indicated in conjunction with soft tissue reconstruction (FDL transfer) and hindfoot alignment (medializing calcaneal osteotomy).

Question 106

Topic: Midfoot & Hindfoot
A 52-year-old male with long-standing, poorly controlled type 2 diabetes presents with a red, hot, and severely swollen left foot. He is afebrile and has normal white blood cell counts. Radiographs show extensive bone fragmentation, subluxation of the tarsometatarsal joints, and osseous debris, with no distinct fracture lines. According to the Eichenholtz classification, what is the stage of this Charcot arthropathy and what is the most appropriate initial management?
. Stage 0; Intravenous antibiotics
. Stage I; Total contact casting and non-weight-bearing
. Stage II; Urgent open reduction and internal fixation
. Stage III; Custom accommodative footwear
. Stage I; Primary midfoot arthrodesis

Correct Answer & Explanation

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

Explanation

The patient is in Eichenholtz Stage I (Developmental/Fragmentation phase) of Charcot neuroarthropathy, characterized clinically by a red, hot, swollen foot and radiographically by bone fragmentation, joint subluxation/dislocation, and debris. The gold standard initial management to halt progression and prevent further deformity is immobilization with a total contact cast (TCC) and restricted weight-bearing until the acute inflammatory phase resolves and the bones begin to coalesce (Stage II).

Question 107

Topic: Midfoot & Hindfoot

A 55-year-old female with Stage IIb Adult Acquired Flatfoot Deformity (AAFD) is planned for reconstruction. The surgeon intends to perform a medializing calcaneal osteotomy and a flexor digitorum longus (FDL) transfer to the navicular. What specific radiographic finding is the primary indication to add a lateral column lengthening (Evans osteotomy) to this surgical construct?

. Talonavicular uncoverage of 20%
. Meary's angle of 5 degrees
. Hindfoot valgus of 10 degrees
. Talonavicular uncoverage greater than 40%
. Calcaneal pitch of 15 degrees

Correct Answer & Explanation

. Talonavicular uncoverage greater than 40%

Explanation

Stage IIb AAFD denotes a flexible flatfoot with significant forefoot abduction. Forefoot abduction is assessed radiographically on the AP view of the foot via talonavicular uncoverage. When talonavicular uncoverage exceeds 40%, a lateral column lengthening (Evans calcaneal osteotomy) is indicated to restore the length of the lateral column and swing the forefoot out of abduction, pivoting around the intact plantar medial calcaneonavicular (spring) ligament complex.

Question 108

Topic: Midfoot & Hindfoot
A 55-year-old female presents with progressive foot pain and flattening of her medial longitudinal arch. On examination, she is unable to perform a single-limb heel rise. Weight-bearing radiographs demonstrate >50% uncovering of the talonavicular joint. Examination confirms the hindfoot deformity remains flexible. What is the most appropriate surgical intervention?
. Gastrocnemius recession and medial displacement calcaneal osteotomy alone
. Subtalar arthrodesis and flexor digitorum longus (FDL) transfer
. Triple arthrodesis
. FDL transfer, medial displacement calcaneal osteotomy, and lateral column lengthening
. Spring ligament repair and isolated subtalar arthroereisis

Correct Answer & Explanation

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

Explanation

This patient has a Stage IIB adult-acquired flatfoot deformity (flexible, >50% TN uncovering/forefoot abduction). Treatment requires soft tissue reconstruction (FDL transfer) combined with both a medial displacement calcaneal osteotomy and lateral column lengthening to correct the severe forefoot abduction.

Question 109

Topic: Midfoot & Hindfoot
A 45-year-old female presents with a painful, progressive flatfoot deformity. Examination reveals an inability to perform a single-leg heel rise, flexible hindfoot valgus, and uncovering of the talar head of >40% on AP weight-bearing foot radiographs. Which of the following surgical interventions is most appropriate for this stage of deformity?
. Medial displacement calcaneal osteotomy and flexor digitorum longus (FDL) transfer
. Lateral column lengthening, medial displacement calcaneal osteotomy, and FDL transfer
. Isolated triple arthrodesis
. Subtalar arthrodesis combined with a Cobb procedure
. Isolated primary repair of the spring ligament

Correct Answer & Explanation

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

Explanation

The patient's clinical and radiographic presentation is consistent with Stage IIB adult-acquired flatfoot deformity (posterior tibial tendon dysfunction). Stage IIB is distinguished from IIA by significant forefoot abduction (uncovering of the talonavicular joint >30%). Therefore, in addition to an FDL transfer and a medial displacement calcaneal osteotomy (MDCO) to correct hindfoot valgus, a lateral column lengthening (e.g., Evans osteotomy) is required to correct the severe forefoot abduction.

Question 110

Topic: Midfoot & Hindfoot

A 55-year-old diabetic male presents with an acutely swollen, warm, erythematous foot without ulceration. Radiographs show periarticular fragmentation and dorsal subluxation of the midfoot. Which of the following is the most appropriate initial management?

. Immediate surgical arthrodesis of the midfoot
. Total contact casting and non-weight-bearing
. Intravenous antibiotics and bone biopsy
. Open reduction and internal fixation of the Lisfranc joint
. Amputation at the transmalleolar level

Correct Answer & Explanation

. Immediate surgical arthrodesis of the midfoot

Explanation

This patient is in Eichenholtz Stage I (developmental/fragmentation) of Charcot neuroarthropathy. The gold standard initial treatment is strict offloading and immobilization using a total contact cast to arrest the inflammatory cascade and prevent further collapse.

Question 111

Topic: Midfoot & Hindfoot
Figure 28 shows the radiograph of a 6-year-old girl who has a right thoracic scoliosis that measures 60°. Examination shows multiple cafe-au-lait spots, and family history reveals that the child’s mother has the same disorder. The gene responsible for this disorder codes for
. dystrophin.
. frataxin.
. neurofibromin.
. peripheral myelin protein.
. sulfate transport protein.

Correct Answer & Explanation

. neurofibromin.

Explanation

DISCUSSION: The patient has the dystrophic type of scoliosis seen in patients with neurofibromatosis type I (NF-1). The NF-1 gene is located on chromosome 17 and codes for neurofibromin, believed to be a tumor-suppressor gene. Abnormalities in the dystrophin gene are seen in Duchenne muscular dystrophy and Becker muscular dystrophy. A mutation in the frataxin gene is responsible for Friedreich ataxia. The most common type of hereditary motor and sensory neuropathy (Charcot-Marie-Tooth), HMSN type IA is caused by a complete duplication of the peripheral myelin protein gene. A defect in the cellular sulfate transport protein results in undersulfation of proteoglycans seen in diastrophic dysplasia.

Question 112

Topic: Midfoot & Hindfoot

-Which gene correlates with severity of disease in spinal muscular atrophy (SMA)?

. Peripheral myelin protein 22 (PMP22)
. Survival motor neuron I (SMN1)
. Survival motor neuron II (SMN2)
. Dystrophin

Correct Answer & Explanation

. Survival motor neuron I (SMN1)

Explanation

produce higher levels of SMN protein.The other choices are not associated with spinal muscular atrophy.Defects in PMP22 are the cause of 70% to 80% of cases of Charcot-Marie-Tooth disease. Mutations in the dystrophin gene cause Duchenne muscular dystrophy.

Question 113

Topic: Midfoot & Hindfoot

Which gene correlates with severity of disease in spinal muscular atrophy (SMA)? Review Topic

. Peripheral myelin protein 22 (PMP22)
. Survival motor neuron I (SMN1)
. Survival motor neuron II (SMN2)
. Dystrophin

Correct Answer & Explanation

. Survival motor neuron II (SMN2)

Explanation

SMA is caused by a deficiency in SMN protein. Deficiency of SMN protein leads to progressive loss of anterior horn cells and progressive muscle weakness. The severity of disease is directly related to the amount of reduction in circulating levels of SMN proteins, which are encoded by 2 alleles of the SMN1 gene and multiple copies of the SMN2 genes on chromosome 5. Affected patients with all types of SMA will have functional loss of both SMN1 genes, so this does not differentiate disease severity. Disease severity depends on the number of functional copies of SMN2 that remain. Patients with SMA1 have only 1 functioning SMN2 gene, whereas the milder forms, SMA types 2 and 3, have multiple copies that produce higher levels of SMN protein. The other choices are not associated with spinal muscular atrophy. Defects in PMP22 are the cause of 70% to 80% of cases of Charcot-Marie-Tooth disease. Mutations in the dystrophin gene cause Duchenne muscular dystrophy.

Question 114

Topic: Midfoot & Hindfoot

A 45-year-old previously healthy woman has experienced weakness and fatigability for 2 months. She states she feels best in the morning, but tires easily with exertion. If she sits and rests her strength improves, but she easily tires with each activity. When her fatigue is most severe, she has double vision. Physical examination is positive for ptosis with upward gaze after 20 seconds. When she holds her arms out straight she shows good initial strength, but rapidly decreasing strength with time. What is the pathologic cause of her muscle weakness? Review Topic

. Ig antibodies at the neuromuscular (NM) junction
. Decreased release of acetylcholine at the NM junction
. Decrease in myelin sheath of axonal nerves with loss of NM junction
. Absence of dystrophin with excess calcium at sarcolemma

Correct Answer & Explanation

. Ig antibodies at the neuromuscular (NM) junction

Explanation

The patient has myasthenia gravis, which has its onset in middle age and causes progressive weakness because of the loss of acetylcholine receptors secondary to autoimmune antibodies at the NM junction. Rest periods allow uptake of acetylcholine and initial strength, but easy fatigability. Treatment is aimed at immunomodulation; acetyl cholinesterase inhibitors often coupled with thymectomy can control symptoms. Decreased release of acetylcholine at the NM junction is the effect of a nondepolarizing drug or toxin botulinum. Patients with muscular dystrophy lack dystrophin that acts at the sarcolemma to regulate calcium channels, and onset of this condition occurs at a younger age. The decrease in myelin indicates Charcot-Marie-Tooth disease and is often seen with long axon degeneration, such as in the feet and lower legs.

Question 115

Topic: Midfoot & Hindfoot

-What is the most common impediment to successful closed reduction of the injury seen in Figures 9aand 9b?

. Extensor retinaculum
. Talonavicular joint capsule
. Posterior tibial tendon
. Peroneus teritus tendon
. Flexor hallucis longus tendon

Correct Answer & Explanation

. Extensor retinaculum

Explanation

Question 116

Topic: Midfoot & Hindfoot

A 28-year-old female runner presents with anterior knee pain, exacerbated by descending stairs. She is diagnosed with patellofemoral pain syndrome. Which of the following anatomical factors is most likely to increase the lateral force vector on the patella?

. Genu varum
. Internal tibial torsion
. Femoral anteversion
. Pes cavus
. Patella infera

Correct Answer & Explanation

. Femoral anteversion

Explanation

Increased femoral anteversion leads to internal rotation of the femur relative to the tibia. This, often combined with external tibial torsion and valgus knee alignment (the 'miserable malalignment syndrome'), increases the Q-angle. An increased Q-angle directly increases the lateral force vector on the patella, predisposing the patient to lateral patellar tracking and patellofemoral pain.

Question 117

Topic: Midfoot & Hindfoot

Which of the following is most commonly inherited as a X-linked recessive disorder? Review Topic

. Charcot-Marie-Tooth disease
. Marfan's syndrome
. Larsen's syndrome
. Duchenne's muscular dystrophy
. Turner's syndrome

Correct Answer & Explanation

. Charcot-Marie-Tooth disease

Explanation

Duchenne's muscular dystrophy is an X-linked recessive disorder.Duchenne's muscular dystrophy is caused by a mutation in the dystrophin gene. X-linked recessive inheritance is a mode of inheritance in which a mutation in a gene on the X chromosome causes the phenotype to be expressed (1) in males (who are necessarily hemizygous for the gene mutation because they have only one X chromosome) and (2) in females who are homozygous for the gene mutation (i.e., they have a copy of the gene mutation on each of their two X chromosomes).Zane reviewed paediatric neuromuscular disorders. Duchenne's muscular dystrophy patients will show markedly elevated CPK levels (10-200x normal). Muscle biopsy will show connective tissue infiltration, foci of necrosis and absent dystrophin with staining.Illustration A shows an illustration of Gowers sign. This indicates weakness of the proximal muscles. It is characteristic of patients with Duchenne's muscular dystrophy.Incorrect Answers:

Question 118

Topic: Midfoot & Hindfoot
Which of the following nerves is most likely responsible for symptoms associated with plantar fasciitis?
. Medial plantar
. Medial calcaneal
. First branch of lateral plantar
. Lateral plantar
. Lateral calcaneal

Correct Answer & Explanation

. First branch of lateral plantar

Explanation

The first branch of the lateral plantar nerve (Baxter's nerve) innervates the abductor digiti minimi. It is reported to be trapped at the interval between the abductor hallucis and the quadratus plantae muscles.

Question 119

Topic: Midfoot & Hindfoot
If heel varus corrects with a Coleman block test, then the hindfoot deformity is flexible. This test proves that the varus is due to a:
. dorsiflexed first ray.
. varus position of the forefoot.
. plantar flexed first ray.
. valgus hindfoot.
. rigid flatfoot.

Correct Answer & Explanation

. plantar flexed first ray.

Explanation

The Coleman block test is used to evaluate the effect of the forefoot on the rearfoot varus. If the deformity corrects with the block, then the hindfoot deformity is flexible and the varus position is secondary to the plantar flexed first ray or valgus position of the forefoot. A rearfoot orthotic will not correct the forefoot cause of the deformity. The patient still may need a lateralizing calcaneal osteotomy to realign the hindfoot.

Question 120

Topic: Midfoot & Hindfoot
A 20-year-old man sustains the injury shown in Figures 1a and 1b in a motorcycle accident. In addition to a prompt closed reduction, his outcome might be optimized by
. a subtalar arthrodesis.
. screw fixation of the talar neck.
. repair of the medial subtalar capsule.
. temporary transarticular pin fixation.
. evaluation for and excision or fixation of osteochondral fractures.

Correct Answer & Explanation

. evaluation for and excision or fixation of osteochondral fractures.

Explanation

DISCUSSION: Lateral subtalar dislocations, which are less common than medial subtalar dislocations, are high-energy injuries that are frequently associated with small osteochondral fractures. It is generally recommended that large fragments be internally fixed, and small fragments entrapped within the joint be excised. Although arthrosis frequently occurs after this injury and is the most common long-term complication, primary subtalar arthrodesis is not indicated. A talar neck fracture is not evident on the radiographs, and lateral subtalar dislocation usually does not lead to instability. REFERENCE: Saltzman C, Marsh JL: Hindfoot dislocations: When are they not benign? J Am Acad Orthop Surg 1997;5:192-198.

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