Menu

Midfoot & Hindfoot MCQs

Practice Set 8 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 141

Topic: Midfoot & Hindfoot
A 60-year-old female presents with a progressive, painful flatfoot deformity. She is unable to perform a single-leg heel raise on the affected side. Examination reveals a flexible pes planovalgus deformity. Radiographs demonstrate 40% talonavicular uncoverage but no significant degenerative joint disease. After failing 6 months of orthotics and bracing, which surgical procedure is most appropriate?
. Isolated gastrocnemius recession
. Flexor digitorum longus (FDL) transfer to the navicular combined with a medial displacement calcaneal osteotomy (MDCO)
. Triple arthrodesis
. Subtalar arthrodesis
. Ankle arthrodesis

Correct Answer & Explanation

. Flexor digitorum longus (FDL) transfer to the navicular combined with a medial displacement calcaneal osteotomy (MDCO)

Explanation

The patient has Stage II posterior tibial tendon dysfunction (PTTD), defined by a painful, flexible flatfoot with an inability to perform a single-leg heel raise. Because the deformity is flexible and there is no arthritis, joint-sparing surgery is indicated. The gold standard is replacing the dysfunctional posterior tibial tendon with an FDL transfer, combined with a medial displacement calcaneal osteotomy (MDCO) to restore the biomechanical axis of the hindfoot and protect the transfer. Stage III (rigid flatfoot or arthritis) requires arthrodesis.

Question 142

Topic: Midfoot & Hindfoot

A 56-year-old male with uncontrolled type II diabetes presents with an acute, warm, swollen right foot. Radiographs reveal fragmentation, osteopenia, and subluxation exclusively involving the talonavicular and calcaneocuboid joints. The tarsometatarsal joints are entirely spared. According to the Brodsky anatomic classification of Charcot neuroarthropathy, what type of injury is this?

. Type 1
. Type 2
. Type 3a
. Type 3b
. Type 4

Correct Answer & Explanation

. Type 1

Explanation

In the Brodsky classification for Charcot arthropathy: Type 1 involves the tarsometatarsal (Lisfranc) joints (most common). Type 2 involves the hindfoot (Chopart) joints: talonavicular, calcaneocuboid, and subtalar joints. Type 3a involves the tibiotalar joint. Type 3b is a pathologic fracture of the calcaneal tuberosity.

Question 143

Topic: Midfoot & Hindfoot

A 55-year-old female presents with Stage IIb adult acquired flatfoot deformity, demonstrating a flexible hindfoot valgus and greater than 40% talonavicular uncoverage on AP weight-bearing radiographs. In addition to a flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy, which procedure is specifically indicated to address her profound forefoot abduction?

. First tarsometatarsal (Lapidus) arthrodesis
. Dorsiflexion osteotomy of the medial cuneiform
. Lateral column lengthening (Evans osteotomy)
. Subtalar arthrodesis
. Kidner procedure

Correct Answer & Explanation

. First tarsometatarsal (Lapidus) arthrodesis

Explanation

Stage IIb posterior tibial tendon dysfunction (PTTD) is characterized by severe forefoot abduction (>40% TN uncoverage). A lateral column lengthening (such as an Evans calcaneal osteotomy) is required to restore the lateral column length and swing the forefoot out of abduction.

Question 144

Topic: Midfoot & Hindfoot
A 55-year-old woman presents with a progressive flatfoot deformity. Examination reveals a flexible pes planovalgus, an inability to perform a single-leg heel rise, and > 40% uncovering of the talonavicular joint on weight-bearing AP radiographs. What is the most appropriate surgical management for this Stage IIb adult-acquired flatfoot?
. Flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy (MDCO) alone
. FDL transfer, MDCO, and lateral column lengthening (e.g., Evans osteotomy)
. Isolated talonavicular arthrodesis
. Triple arthrodesis
. Medial cuneiform plantarflexion osteotomy (Cotton) alone

Correct Answer & Explanation

. FDL transfer, MDCO, and lateral column lengthening (e.g., Evans osteotomy)

Explanation

Stage IIb adult-acquired flatfoot (posterior tibial tendon dysfunction) is characterized by a flexible deformity with significant forefoot abduction (typically >40% talonavicular uncoverage). An FDL transfer and MDCO are standard for Stage IIa, but the significant forefoot abduction in Stage IIb requires the addition of a lateral column lengthening procedure (such as an Evans calcaneal osteotomy) to adequately restore the medial column arch and foot alignment.

Question 145

Topic: Midfoot & Hindfoot
A 58-year-old patient with long-standing poorly controlled diabetes presents with a swollen, erythematous, and warm foot. Radiographs demonstrate periarticular fragmentation, subluxation of the tarsometatarsal joints, and bony debris, but no signs of consolidation, fusion, or sclerosis. According to the Eichenholtz classification, what stage of Charcot arthropathy is this, and what is the current standard of care?
. Stage 0; rigid internal fixation
. Stage I; total contact casting and non-weight-bearing
. Stage II; customized accommodative orthoses
. Stage III; corrective midfoot arthrodesis
. Stage I; immediate open reduction and internal fixation

Correct Answer & Explanation

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

Explanation

This presentation describes acute Stage I (Developmental/Fragmentation phase) Charcot arthropathy, characterized by clinical signs of inflammation (erythema, warmth, swelling) and radiographic evidence of fragmentation, joint subluxation/dislocation, and debris without consolidation. The standard of care during this acute, hyperemic phase is strict immobilization and offloading, almost universally utilizing a total contact cast (TCC), to prevent further mechanical destruction until the foot reaches Stage II (Coalescence).

Question 146

Topic: Midfoot & Hindfoot
A 30-year-old male falls from a height and sustains a Hawkins Type III talar neck fracture. What best describes the displacement pattern and the approximate risk of avascular necrosis (AVN) of the talar body?
. Undisplaced fracture; <10% AVN risk
. Displacement of the subtalar joint only; 20-50% AVN risk
. Displacement of both the subtalar and tibiotalar joints; nearly 100% AVN risk
. Displacement of the subtalar, tibiotalar, and talonavicular joints; 50% AVN risk
. Extrusion of the talar body; 10-20% AVN risk

Correct Answer & Explanation

. Displacement of both the subtalar and tibiotalar joints; nearly 100% AVN risk

Explanation

A Hawkins Type III fracture is a talar neck fracture with subluxation or dislocation of both the subtalar and tibiotalar joints. Because all three major blood supplies to the talar body are disrupted, the risk of AVN is nearly 100%.

Question 147

Topic: Midfoot & Hindfoot

A 25-year-old football player sustains a purely ligamentous Lisfranc injury.

Recent prospective randomized trials comparing open reduction internal fixation (ORIF) with primary arthrodesis for this specific injury pattern show which of the following advantages for primary arthrodesis?

. Lower rate of nonunion
. Better preservation of midfoot motion
. Decreased rate of hardware removal and fewer reoperations
. Shorter operative time and less blood loss
. Decreased risk of deep vein thrombosis

Correct Answer & Explanation

. Decreased rate of hardware removal and fewer reoperations

Explanation

For purely ligamentous Lisfranc injuries, level I evidence (e.g., Ly and Coetzee) has demonstrated that primary arthrodesis of the medial column (1st, 2nd, and 3rd TMT joints) results in superior functional outcomes, less need for hardware removal, and fewer reoperations compared to ORIF.

Question 148

Topic: Midfoot & Hindfoot

In the pathogenesis of adult-acquired flatfoot deformity (posterior tibial tendon dysfunction), failure of static stabilizers occurs sequentially. Which ligamentous structure is considered the primary static stabilizer of the talonavicular joint and is typically the first to fail?

. Plantar fascia
. Long plantar ligament
. Bifurcate ligament
. Superomedial band of the spring ligament
. Inferior extensor retinaculum

Correct Answer & Explanation

. Superomedial band of the spring ligament

Explanation

The spring ligament (plantar calcaneonavicular ligament) complex, specifically the superomedial band, is the primary static stabilizer of the talonavicular joint. Its attenuation or rupture is a critical step in the progression of adult-acquired flatfoot deformity.

Question 149

Topic: Midfoot & Hindfoot

A 30-year-old male sustains a purely ligamentous Lisfranc injury after falling from a horse. The first, second, and third tarsometatarsal (TMT) joints are diastased. Which of the following surgical treatments yields the best long-term functional outcome for this specific injury pattern?

. Primary arthrodesis of the medial three TMT joints
. Open reduction and internal fixation with transarticular screws
. Closed reduction and percutaneous pinning
. Dorsal bridge plating of the midfoot
. Non-weight-bearing cast immobilization for 8 weeks

Correct Answer & Explanation

. Primary arthrodesis of the medial three TMT joints

Explanation

For purely ligamentous Lisfranc injuries, primary arthrodesis of the first, second, and third TMT joints has been shown to have superior functional outcomes and a lower reoperation rate compared to open reduction and internal fixation (ORIF).

Question 150

Topic: Midfoot & Hindfoot

A 58-year-old male with poorly controlled type 2 diabetes mellitus presents with a swollen, erythematous, and warm right foot without any open ulcers. Plain radiographs are normal. MRI shows diffuse marrow edema in the midfoot. What is the most appropriate initial management?

. Intravenous broad-spectrum antibiotics
. Total contact casting and strict non-weight-bearing
. Midfoot exostectomy
. Primary midfoot arthrodesis
. Surgical debridement and bone biopsy

Correct Answer & Explanation

. Total contact casting and strict non-weight-bearing

Explanation

This patient presents with Eichenholtz stage 0 (pre-fragmentation) Charcot arthropathy, characterized by clinical signs of inflammation and MRI edema but normal X-rays. The standard of care is immediate offloading with a total contact cast to prevent deformity.

Question 151

Topic: Midfoot & Hindfoot
A 32-year-old male sustains a high-energy axial load injury to his foot resulting in a Hawkins Type III fracture of the talar neck. Based on the Hawkins classification system, which specific joints are disrupted in this injury pattern?
. Subtalar joint only
. Tibiotalar joint only
. Subtalar and tibiotalar joints
. Subtalar, tibiotalar, and talonavicular joints
. Talonavicular joint only

Correct Answer & Explanation

. Subtalar and tibiotalar joints

Explanation

The Hawkins classification of talar neck fractures predicts the risk of avascular necrosis based on the degree of dislocation. Type I is a nondisplaced fracture. Type II is a displaced fracture with subluxation or dislocation of the subtalar joint (the tibiotalar and talonavicular joints remain congruent). Type III is a displaced fracture with dislocation of both the subtalar and tibiotalar joints (the talar body extrudes, often posteriorly). Type IV (added by Canale and Kelly) involves dislocation of the subtalar, tibiotalar, and talonavicular joints.

Question 152

Topic: Midfoot & Hindfoot
A 25-year-old male sustains a severe inversion injury resulting in a Hawkins Type III talar neck fracture. What does this classification imply regarding the fracture displacement and the blood supply to the talar body?
. Displacement of the subtalar joint only; moderate risk of AVN
. Displacement of the subtalar and tibiotalar joints; very high risk of AVN
. Displacement of the talonavicular joint only; low risk of AVN
. Displacement of the subtalar, tibiotalar, and talonavicular joints; near 100% risk of AVN
. Nondisplaced fracture; negligible risk of AVN

Correct Answer & Explanation

. Displacement of the subtalar and tibiotalar joints; very high risk of AVN

Explanation

A Hawkins Type III fracture involves a talar neck fracture with dislocation of both the subtalar and tibiotalar joints. It carries a very high risk of avascular necrosis (frequently >80%) due to massive disruption of the talar body blood supply.

Question 153

Topic: Midfoot & Hindfoot

A 28-year-old athlete sustains a purely ligamentous Lisfranc injury involving the first, second, and third tarsometatarsal joints. High-quality randomized controlled trials comparing primary arthrodesis of the medial three rays to open reduction and internal fixation (ORIF) for this specific injury pattern show primary arthrodesis is associated with which of the following?

. Higher rate of hardware removal
. Decreased rate of return to pre-injury level of sport
. Lower rate of secondary surgeries
. Increased risk of adjacent segment arthritis at 1 year
. Inferior functional scores at 2 years follow-up

Correct Answer & Explanation

. Lower rate of secondary surgeries

Explanation

For purely ligamentous Lisfranc injuries, primary arthrodesis of the medial three rays (first, second, and third TMT joints) has been shown to yield equivalent or better functional outcomes compared to ORIF, while significantly decreasing the rate of secondary surgeries (due to hardware removal or subsequent salvage arthrodesis for post-traumatic arthritis).

Question 154

Topic: Midfoot & Hindfoot
A 30-year-old male sustains a high-energy motor vehicle collision resulting in a Hawkins Type III talar neck fracture. By definition, which of the following joints are dislocated in this injury pattern, and what is the classic historical rate of avascular necrosis (AVN) of the talar body?
. Subtalar joint only; 20-30% AVN risk
. Subtalar and tibiotalar joints; 40-50% AVN risk
. Subtalar and tibiotalar joints; nearly 100% AVN risk
. Subtalar, tibiotalar, and talonavicular joints; nearly 100% AVN risk
. Subtalar, tibiotalar, and talonavicular joints; 40-50% AVN risk

Correct Answer & Explanation

. Subtalar and tibiotalar joints; nearly 100% AVN risk

Explanation

The Hawkins classification for talar neck fractures: Type I is nondisplaced (0-15% AVN). Type II involves subluxation or dislocation of the subtalar joint (20-50% AVN). Type III involves dislocation of both the subtalar and tibiotalar joints (historically associated with a nearly 100% risk of AVN, though modern series report 70-100%). Type IV adds talonavicular joint dislocation.

Question 155

Topic: Midfoot & Hindfoot

A 52-year-old female is diagnosed with Stage IIB posterior tibial tendon dysfunction (PTTD), demonstrating a flexible flatfoot with severe forefoot abduction and greater than 30% talonavicular uncoverage on radiographs. In addition to a flexor digitorum longus (FDL) transfer and medial displacement calcaneal osteotomy (MDCO), what additional procedure is biomechanically required to correct her specific deformity?

. Evans lateral column lengthening
. First metatarsophalangeal arthrodesis
. Talonavicular arthrodesis
. Gastrocnemius recession alone
. Subtalar arthrodesis

Correct Answer & Explanation

. Evans lateral column lengthening

Explanation

Stage IIB PTTD involves a flexible flatfoot with significant forefoot abduction (talonavicular uncoverage >30%). An Evans lateral column lengthening is required in addition to MDCO and FDL transfer to effectively correct the severe forefoot abduction.

Question 156

Topic: Midfoot & Hindfoot

A 25-year-old competitive athlete sustains a purely ligamentous Lisfranc injury. He undergoes operative stabilization. Compared to open reduction and internal fixation (ORIF) with screws, what is the primary advantage of performing a primary arthrodesis for this specific injury pattern?

. Decreased risk of adjacent segment arthritis
. Lower rate of subsequent hardware removal and revision surgery
. Superior postoperative athletic sprint speed
. Faster time to initial weight-bearing
. Reduced risk of deep vein thrombosis

Correct Answer & Explanation

. Lower rate of subsequent hardware removal and revision surgery

Explanation

Primary arthrodesis for purely ligamentous Lisfranc injuries demonstrates similar functional outcomes to ORIF but significantly reduces the need for hardware removal and revision surgeries.

Question 157

Topic: Midfoot & Hindfoot

A 50-year-old female presents with Stage IIb adult acquired flatfoot deformity, characterized by a flexible hindfoot and greater than 40% talonavicular uncoverage on radiographs. Which combination of procedures is the most appropriate surgical management?

. Isolated talonavicular arthrodesis
. Flexor digitorum longus (FDL) transfer with medial displacement calcaneal osteotomy alone
. FDL transfer with medial displacement calcaneal osteotomy and lateral column lengthening
. Triple arthrodesis
. Subtalar arthrodesis with spring ligament repair

Correct Answer & Explanation

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

Explanation

Stage IIb adult acquired flatfoot deformity involves a flexible hindfoot with significant forefoot abduction. Management typically requires an FDL transfer, a medializing calcaneal osteotomy, and a lateral column lengthening to correct the forefoot abduction.

Question 158

Topic: Midfoot & Hindfoot

In the surgical treatment of Stage IIb adult-acquired flatfoot deformity, an Evans lateral column lengthening osteotomy is performed. What is the primary biomechanical consequence of this procedure on the adjacent midfoot joints?

. Decreases talonavicular joint contact pressures
. Increases medial column instability
. Increases calcaneocuboid joint contact pressures
. Decreases stress on the spring ligament complex
. Increases tibiotalar joint dorsal impingement

Correct Answer & Explanation

. Increases calcaneocuboid joint contact pressures

Explanation

The Evans lateral column lengthening osteotomy effectively corrects forefoot abduction but significantly increases contact pressures across the calcaneocuboid joint. This can predispose the patient to early calcaneocuboid arthritis.

Question 159

Topic: Midfoot & Hindfoot

A 24-year-old athlete sustains a pure ligamentous Lisfranc injury with instability of the first, second, and third tarsometatarsal joints. Based on prospective randomized data, which of the following provides the most reliable long-term functional outcome?

. Primary arthrodesis of the involved tarsometatarsal joints
. Open reduction and rigid screw fixation with planned removal at 4 months
. Open reduction and flexible Kirschner wire fixation
. Closed reduction and casting for 8 weeks
. Dorsal bridge plating spanning the midfoot

Correct Answer & Explanation

. Primary arthrodesis of the involved tarsometatarsal joints

Explanation

For primarily ligamentous Lisfranc injuries, prospective randomized studies (e.g., Ly and Coetzee) have demonstrated that primary arthrodesis of the medial columns (TMT 1-3) yields superior functional outcomes and lower reoperation rates compared to ORIF.

Question 160

Topic: Midfoot & Hindfoot

A 45-year-old runner presents with chronic medial heel pain. Examination reveals maximal tenderness over the medial calcaneal tuberosity and radiating pain along the course of the first branch of the lateral plantar nerve. This nerve primarily provides motor innervation to which muscle?

. Flexor digitorum brevis
. Quadratus plantae
. Adductor hallucis
. Abductor digiti minimi
. Flexor hallucis brevis

Correct Answer & Explanation

. Abductor digiti minimi

Explanation

The first branch of the lateral plantar nerve, also known as Baxter's nerve, courses between the abductor hallucis and quadratus plantae. It provides motor innervation primarily to the abductor digiti minimi, and its entrapment is a classic cause of chronic heel pain.

Test Yourself

Switch to an interactive, timed exam simulation to truly master this topic.

On this Page