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Midfoot & Hindfoot MCQs

Practice Set 7 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 121

Topic: Midfoot & Hindfoot
Which of the following patients who sustained a calcaneal fracture will most likely undergo an eventual subtalar fusion?
. Male worker's compensation patient who participates in heavy labor work with an initial Böhler angle less than 0 degrees
. Female worker's compensation patient who participates in heavy labor work with an initial Böhler angle >15 degrees
. Male non-worker's compensation patient who participates in heavy labor work with an initial Böhler angle less than 0 degrees
. Male worker's compensation patient who participates in heavy labor work with an initial Böhler angle >15 degrees
. Female non-worker's compensation patient who participates in heavy labor work with an initial Böhler less than 0 degrees

Correct Answer & Explanation

. Male worker's compensation patient who participates in heavy labor work with an initial Böhler angle less than 0 degrees

Explanation

DISCUSSION: The Level 2 study by Czisy et al is a review of a randomized trial database that analyzed the prospective clinical outcome of 45 patients who failed closed or open treatment of a displaced intraarticular calcaneal fracture. The cohort underwent a subtalar fusion by distraction bone-block arthrodesis for subtalar arthritis. They found that male worker's compensation patients who participate in heavy labor work with a fracture pattern with Böhler angle less than 0 degrees were the most likely to undergo a subtalar fusion. The meta-analysis by Randle et al reviewed 6 clinical studies comparing the results of operative vs. conservative management of calcaneal fracture studies. They found a trend for nonoperatively treated patients to have a higher risk of experiencing severe foot pain than did operatively treated patients, however they could not draw any definitive conclusions guiding treatment.

Question 122

Topic: Midfoot & Hindfoot
A 34-year-old male is involved in a high-speed motor vehicle collision and sustains a Hawkins Type III talar neck fracture. According to the Hawkins classification, a Type III injury is characterized by a fracture of the talar neck with dislocation of which of the following joints?
. Subtalar joint only
. Subtalar and tibiotalar joints
. Subtalar, tibiotalar, and talonavicular joints
. Talonavicular and calcaneocuboid joints
. Tibiotalar joint only

Correct Answer & Explanation

. Subtalar and tibiotalar joints

Explanation

The Hawkins classification describes talar neck fractures: Type I is non-displaced; Type II involves subtalar subluxation/dislocation; Type III involves both subtalar and tibiotalar (ankle) dislocation; Type IV involves subtalar, tibiotalar, and talonavicular dislocation. Type III carries a nearly 100% risk of avascular necrosis if not rapidly reduced.

Question 123

Topic: Midfoot & Hindfoot
According to the Hawkins classification of talar neck fractures, a Type III fracture involves displacement of the talar neck with subluxation or dislocation of the talar body from which of the following articulations?
. Subtalar joint only
. Subtalar and tibiotalar joints
. Subtalar, tibiotalar, and talonavicular joints
. Tibiotalar joint only
. Talonavicular joint only

Correct Answer & Explanation

. Subtalar and tibiotalar joints

Explanation

The Hawkins classification for talar neck fractures is: Type I (nondisplaced), Type II (displaced with subtalar subluxation/dislocation), Type III (displaced with both subtalar and tibiotalar dislocation), and Type IV (displaced with subtalar, tibiotalar, and talonavicular dislocation). The risk of avascular necrosis increases progressively with the grade.

Question 124

Topic: Midfoot & Hindfoot

A 35-year-old male sustains a purely ligamentous Lisfranc injury. He undergoes primary arthrodesis of the first, second, and third tarsometatarsal joints. Compared to open reduction and internal fixation (ORIF), which of the following is true regarding primary arthrodesis in this scenario?

. Higher rate of hardware removal.
. Decreased rate of subsequent procedures.
. Lower functional outcome scores.
. Higher rate of nonunion.
. Faster return to sport.

Correct Answer & Explanation

. Higher rate of hardware removal.

Explanation

Primary arthrodesis for purely ligamentous Lisfranc injuries has been shown to result in decreased rates of subsequent procedures (e.g., hardware removal) and equivalent or superior functional outcomes compared to ORIF. ORIF is associated with a higher likelihood of hardware removal and potential progression to post-traumatic arthritis requiring salvage arthrodesis.

Question 125

Topic: Midfoot & Hindfoot

A 30-year-old male presents with an isolated medial subtalar dislocation. Closed reduction is attempted in the emergency department but is completely blocked. Which of the following structures is the most common block to closed reduction in a medial subtalar dislocation?

. Extensor digitorum brevis
. Tibialis posterior tendon
. Flexor hallucis longus tendon
. Peroneus brevis tendon
. Extensor hallucis longus tendon

Correct Answer & Explanation

. Extensor digitorum brevis

Explanation

In a medial subtalar dislocation (the most common type), the foot is displaced medially, and lateral structures can become entrapped. The extensor digitorum brevis (EDB) muscle, along with the talonavicular joint capsule, is the most common block to reduction. In a lateral subtalar dislocation, the most common block is the tibialis posterior tendon.

Question 126

Topic: Midfoot & Hindfoot

A 45-year-old male sustains a lateral subtalar dislocation after a high-energy motor vehicle collision. Closed reduction is attempted in the emergency department but is unsuccessful. What anatomic structure is most likely interposing and blocking the reduction?

. Tibialis posterior tendon
. Peroneus brevis tendon
. Extensor digitorum longus tendon
. Tibialis anterior tendon
. Extensor hallucis longus tendon

Correct Answer & Explanation

. Tibialis posterior tendon

Explanation

In a lateral subtalar dislocation, the talar head displaces medially. The most common block to closed reduction is the tibialis posterior tendon, which can 'buttonhole' around the talar neck. In contrast, medial subtalar dislocations are more common, and their reduction is typically blocked by the extensor retinaculum, extensor digitorum brevis, or the capsule of the talonavicular joint.

Question 127

Topic: Midfoot & Hindfoot
A 24-year-old snowboarder sustains a hyperdorsiflexion injury to his ankle. Radiographs show a talar neck fracture with subluxation of the subtalar joint, but the tibiotalar joint remains congruous. According to the Hawkins classification, what type is this fracture, and what is the approximate rate of avascular necrosis (AVN)?
. Type I, 0-10%
. Type II, 20-50%
. Type III, 80-100%
. Type IV, 100%
. Type II, 80-100%

Correct Answer & Explanation

. Type II, 20-50%

Explanation

According to the Hawkins classification of talar neck fractures: Type I is nondisplaced (AVN 0-10%). Type II has subtalar subluxation or dislocation with an intact tibiotalar joint (AVN ~20-50%). Type III has both subtalar and tibiotalar dislocation (AVN ~80-100%). Type IV (Canale modification) includes talonavicular subluxation/dislocation.

Question 128

Topic: Midfoot & Hindfoot
A 40-year-old man with amyloidosis injured his left knee while walking. Figure 17a shows an AP radiograph that was obtained 2 weeks after the injury. The radiograph shown in Figure 17b was obtained after the patient wore a hinged knee brace for 3 months. A clinical photograph is shown in Figure 17c. What is the most likely diagnosis?
. Pyarthrosis
. Pigmented villonodular synovitis
. Synovial osteochondromatosis
. Charcot arthropathy
. Spontaneous osteonecrosis

Correct Answer & Explanation

. Charcot arthropathy

Explanation

The patient has a Charcot arthropathy of the knee, which is associated with amyloidosis. The rapid joint destruction shown in the radiographs is most consistent with that diagnosis.

Question 129

Topic: Midfoot & Hindfoot
A 25-year-old male is involved in a high-speed motor vehicle collision and sustains a talar neck fracture. Radiographs and a subsequent CT scan confirm a completely displaced talar neck fracture with dislocation of both the subtalar and tibiotalar joints. The talonavicular joint remains reduced. According to the Hawkins classification, what type of fracture is this, and what is the approximate historical rate of avascular necrosis (AVN) associated with it?
. Hawkins Type I; AVN rate < 10%
. Hawkins Type II; AVN rate 20-50%
. Hawkins Type III; AVN rate 80-100%
. Hawkins Type IV; AVN rate 10-20%
. Hawkins Type III; AVN rate 20-50%

Correct Answer & Explanation

. Hawkins Type III; AVN rate 80-100%

Explanation

Hawkins classification for talar neck fractures: Type I is non-displaced (AVN < 10%). Type II is displaced with subtalar dislocation (AVN 20-50%). Type III is displaced with subtalar and tibiotalar dislocation (AVN 80-100% historically). Type IV includes talonavicular dislocation. Therefore, this is a Hawkins Type III with a historical AVN risk of nearly 100%.

Question 130

Topic: Midfoot & Hindfoot

A 45-year-old manual laborer sustains a purely ligamentous Lisfranc injury involving the 1st, 2nd, and 3rd tarsometatarsal joints. Which of the following statements regarding the definitive surgical management is most supported by current orthopedic literature?

. Primary open reduction and internal fixation (ORIF) offers superior functional outcomes compared to primary arthrodesis
. Primary arthrodesis of the 1st, 2nd, and 3rd TMT joints decreases the need for secondary surgeries compared to ORIF
. Bridge plating without articular cartilage debridement is contraindicated
. K-wire fixation should be maintained for a minimum of 12 weeks
. The fourth and fifth TMT joints must always be included in the primary arthrodesis construct

Correct Answer & Explanation

. Primary arthrodesis of the 1st, 2nd, and 3rd TMT joints decreases the need for secondary surgeries compared to ORIF

Explanation

Multiple randomized controlled trials have demonstrated that for purely ligamentous Lisfranc injuries, primary arthrodesis of the medial column (1st, 2nd, and 3rd TMT joints) results in comparable or superior functional outcomes and a significantly lower rate of secondary surgeries (due to hardware removal or subsequent post-traumatic arthritis) when compared to ORIF.

Question 131

Topic: Midfoot & Hindfoot

A 55-year-old overweight woman complains of medial ankle pain and flattening of her arch over the past year. She is unable to perform a single-limb heel rise on the affected side. Weight-bearing radiographs show a flexible flatfoot deformity with normal joint spaces and no subtalar arthritis. What is the most appropriate surgical intervention if conservative management fails?

. Gastrocnemius recession, flexor digitorum longus (FDL) transfer, and medial displacement calcaneal osteotomy
. Subtalar arthrodesis alone
. Triple arthrodesis
. Tibiotalocalcaneal arthrodesis
. Spring ligament repair only

Correct Answer & Explanation

. Gastrocnemius recession, flexor digitorum longus (FDL) transfer, and medial displacement calcaneal osteotomy

Explanation

The patient has a Stage II adult acquired flatfoot deformity (posterior tibial tendon dysfunction) characterized by a flexible deformity and an inability to perform a single-leg heel rise. Joint-sparing procedures are indicated. The classic reconstruction includes a soft tissue transfer (FDL to navicular), a bony procedure to restore the mechanical axis (medial displacement calcaneal osteotomy), and often a gastrocnemius recession for equinus contracture.

Question 132

Topic: Midfoot & Hindfoot
A 30-year-old male sustains a high-energy injury to his foot and is diagnosed with a Hawkins type III talar neck fracture. Which of the following best describes this injury and its associated risk of avascular necrosis (AVN)?
. Nondisplaced fracture; AVN risk is 0-10%
. Subtalar subluxation/dislocation; AVN risk is 20-50%
. Subtalar and tibiotalar dislocation; AVN risk is nearly 100%
. Subtalar, tibiotalar, and talonavicular dislocation; AVN risk is 100%
. Subtalar and tibiotalar dislocation; AVN risk is 50-70%

Correct Answer & Explanation

. Subtalar and tibiotalar dislocation; AVN risk is nearly 100%

Explanation

Hawkins classification for talar neck fractures: Type I: Nondisplaced (AVN 0-10%). Type II: Displaced with subtalar subluxation/dislocation (AVN 20-50%). Type III: Displaced with subtalar and tibiotalar dislocation (AVN near 100% in original series, modern series quote 70-100%). Type IV (added by Canale): Displaced with subtalar, tibiotalar, and talonavicular dislocation (AVN near 100%).

Question 133

Topic: Midfoot & Hindfoot

A 60-year-old patient with poorly controlled diabetes mellitus presents with a red, hot, swollen foot. Radiographs demonstrate periarticular fragmentation, subluxation, and bony debris around the midfoot. According to the Eichenholtz classification, what stage of Charcot arthropathy is this, and what is the most appropriate initial treatment?

. Stage 0; observation
. Stage 1; total contact casting and non-weight bearing
. Stage 2; custom orthosis
. Stage 3; midfoot arthrodesis
. Stage 1; immediate midfoot arthrodesis

Correct Answer & Explanation

. Stage 0; observation

Explanation

Eichenholtz classification of Charcot arthropathy: Stage 1 (Developmental/Fragmentation): characterized by erythema, edema, heat, and radiographs showing bony fragmentation, joint subluxation/dislocation, and debris. Treatment is immobilization and offloading, typically with a total contact cast (TCC). Stage 2 (Coalescence): decreased swelling, absorption of debris, and early fusion. Stage 3 (Reconstruction): no inflammation, stable deformity. Stage 0 is the prodromal phase with clinical signs but normal radiographs.

Question 134

Topic: Midfoot & Hindfoot
A 55-year-old female presents with a progressively collapsing arch and medial ankle pain. Examination reveals a positive 'too many toes' sign and the inability to perform a single-leg heel rise. Radiographs demonstrate a talonavicular uncoverage angle of 35 degrees and >40% uncovering of the talonavicular joint. What is the most appropriate surgical management for this stage of adult acquired flatfoot deformity?
. Flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy alone
. Flexor digitorum longus (FDL) transfer, medial displacement calcaneal osteotomy, and lateral column lengthening
. Gastrocnemius recession and spring ligament repair
. Isolated subtalar arthrodesis
. Tibialis anterior transfer to the midfoot

Correct Answer & Explanation

. Flexor digitorum longus (FDL) transfer, medial displacement calcaneal osteotomy, and lateral column lengthening

Explanation

This patient has Stage IIb posterior tibial tendon dysfunction (PTTD), indicated by >30% talonavicular uncoverage. The addition of a lateral column lengthening (e.g., Evans osteotomy) is required to correct the significant forefoot abduction.

Question 135

Topic: Midfoot & Hindfoot
A 52-year-old female presents with progressive medial ankle pain and a severe flatfoot deformity. Clinical examination demonstrates a positive single-leg heel rise test on the affected side but she can perform a double-leg heel rise. Weight-bearing radiographs reveal >30% uncovering of the talonavicular joint and a talonavicular angle of 25 degrees. The hindfoot deformity is flexible. Which of the following surgical strategies is most appropriate for this stage of deformity?
. Flexor digitorum longus (FDL) transfer to the navicular and medial displacement calcaneal osteotomy
. FDL transfer to the navicular, medial displacement calcaneal osteotomy, and lateral column lengthening
. Triple arthrodesis
. Subtalar arthrodesis
. Spring ligament repair alone

Correct Answer & Explanation

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

Explanation

This patient has a Stage IIB adult acquired flatfoot deformity, characterized by a flexible hindfoot with significant forefoot abduction (>30% talonavicular uncovering). Correcting the severe forefoot abduction requires a lateral column lengthening in addition to a medial displacement calcaneal osteotomy and FDL transfer.

Question 136

Topic: Midfoot & Hindfoot

A 14-year-old boy presents with recurrent ankle sprains and rigid flatfeet. A lateral weight-bearing radiograph demonstrates a prominent 'C-sign' and a talar beak.

Based on the most likely diagnosis, which specific anatomical structure is most commonly involved in this pathology?

. Anterior facet of the subtalar joint
. Middle facet of the subtalar joint
. Posterior facet of the subtalar joint
. Sustentaculum tali exclusively
. Naviculocuneiform joint

Correct Answer & Explanation

. Anterior facet of the subtalar joint

Explanation

The clinical presentation and 'C-sign' on a lateral radiograph are classic for a talocalcaneal coalition. The middle facet of the subtalar joint is the most commonly involved facet in talocalcaneal coalitions.

Question 137

Topic: Midfoot & Hindfoot

A 55-year-old diabetic patient presents with a swollen, erythematous, and warm unilateral foot without systemic signs of infection. Radiographs show periarticular fragmentation, subluxation, and bony debris around the midfoot. According to the Eichenholtz classification, what is the most appropriate initial management?

. Urgent surgical debridement and fusion
. Total contact casting and strict non-weight-bearing
. Intravenous antibiotics for 6 weeks
. Excisional arthroplasty
. Midfoot arthrodesis with robust internal fixation

Correct Answer & Explanation

. Urgent surgical debridement and fusion

Explanation

This patient is in Eichenholtz Stage I (developmental/fragmentation phase) of Charcot arthropathy. The gold standard of treatment during this acute inflammatory phase is immobilization and offloading, typically with a total contact cast.

Question 138

Topic: Midfoot & Hindfoot

A 62-year-old female presents with flatfoot deformity. Examination reveals a flexible hindfoot valgus, but she is unable to perform a single-leg heel raise. Radiographs demonstrate significant forefoot abduction with a talonavicular uncoverage angle of 40 degrees. Which surgical intervention is most appropriate?

. Isolated flexor digitorum longus (FDL) to navicular transfer
. FDL transfer with medial displacement calcaneal osteotomy and lateral column lengthening
. Isolated subtalar arthrodesis
. Triple arthrodesis
. Talonavicular arthrodesis

Correct Answer & Explanation

. Isolated flexor digitorum longus (FDL) to navicular transfer

Explanation

The patient has Stage IIb posterior tibial tendon dysfunction (flexible hindfoot valgus with greater than 30% talonavicular uncoverage). Treatment requires FDL transfer, medial displacement calcaneal osteotomy, and a lateral column lengthening to correct the severe forefoot abduction.

Question 139

Topic: Midfoot & Hindfoot

A 30-year-old male falls from a ladder and sustains an isolated lateral subtalar dislocation. Closed reduction in the emergency department under conscious sedation is unsuccessful. What anatomical structure is most likely blocking the reduction?

. Extensor digitorum brevis muscle
. Posterior tibial tendon
. Anterior tibial tendon
. Peroneus brevis tendon
. Flexor hallucis longus tendon

Correct Answer & Explanation

. Posterior tibial tendon

Explanation

Lateral subtalar dislocations are notorious for being irreducible by closed means. The posterior tibial tendon is the most common anatomic structure that incarcerates and blocks reduction in lateral dislocations.

Question 140

Topic: Midfoot & Hindfoot
A 55-year-old female presents with medial ankle pain and a progressive flatfoot deformity. She cannot perform a single-leg heel raise. Passive correction of the hindfoot valgus is possible. Radiographs demonstrate a talonavicular uncoverage of 20% without arthritic changes. Which of the following surgical procedures is most appropriate?
. Tibialis posterior tendon debridement alone
. Flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy
. Triple arthrodesis
. Subtalar arthrodesis
. Talonavicular arthrodesis

Correct Answer & Explanation

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

Explanation

This patient has a flexible Stage IIA adult-acquired flatfoot deformity (posterior tibial tendon dysfunction). Because the deformity is flexible and there is mild forefoot abduction (<30% talonavicular uncoverage), joint-sparing procedures are indicated. The standard of care is a flexor digitorum longus (FDL) transfer to the navicular combined with a medial displacement calcaneal osteotomy (MDCO) to correct the mechanical axis. If severe forefoot abduction was present (>30% uncoverage, Stage IIB), a lateral column lengthening would also be indicated. Arthrodesis is reserved for rigid deformities or arthritis (Stage III).

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