Flatfoot Deformities — MCQs
Deltoid ligament is attached to all, except which structure?
Which of the following conditions is least likely to be associated with rigid flat foot?
A child presented to an orthopaedic clinic with a limp. The surgeon suspected him to have a fixed flexion deformity of the hip. Which test should the surgeon perform to confirm his finding?
A 65-year-old alcoholic suffering from diabetes has a flexion deformity of the right little finger over the metacarpophalangeal joint of around 15 degrees. The ideal management would be:
Foot eversion is caused by
Combination of appearance in CTEV
A 41-year-old man is admitted to the emergency department with a swollen and painful foot. Radiographic examination reveals that the head of the talus has become displaced inferiorly, thereby causing the medial longitudinal arch of the foot to fall. What is the most likely cause in this case?
Watson Jones operation is indicated for which condition?
Triple arthrodesis does not involve which of the following joints?
Hallux valgus is associated with all of the following except:
Flatfoot Deformities Indian Medical PG Practice Questions and MCQs
Question 1: Deltoid ligament is attached to all, except which structure?
- A. Sustentaculum tali
- B. Medial cuneiform (Correct Answer)
- C. Navicular bone
- D. Medial malleolus
Explanation: ***Medial cuneiform*** - The **deltoid ligament** is located on the **medial side of the ankle** and primarily connects the **tibia** to several tarsal bones. It does not attach to the medial cuneiform. - The **medial cuneiform** is a midfoot bone primarily involved in the **tarsometatarsal joint** and is not a direct attachment site for the deltoid ligament. *Medial malleolus* - The **medial malleolus**, the distal end of the **tibia**, serves as the **proximal attachment point** for all four parts of the deltoid ligament. - This strong connection is crucial for **stabilizing the ankle joint** medially. *Navicular bone* - The **tibionavicular part** of the deltoid ligament attaches to the **tuberosity of the navicular bone**. - This attachment helps **limit excessive abduction** and **eversion** of the foot. *Sustentaculum tali* - The **tibiocalcaneal part** of the deltoid ligament attaches to the **sustentaculum tali** on the calcaneus. - This attachment provides significant stability to the **subtalar joint**.
Question 2: Which of the following conditions is least likely to be associated with rigid flat foot?
- A. Rheumatoid arthritis
- B. Athlete's foot (Correct Answer)
- C. Peroneal spasm
- D. Congenital tarsal coalition.
Explanation: ***Athlete's foot*** - **Athlete's foot** (tinea pedis) is a **fungal infection** of the skin of the foot, which typically causes itching, scaling, and redness. - It does not directly affect the bony or ligamentous structures of the foot to cause **rigid flat foot** deformation. *Rheumatoid arthritis* - **Rheumatoid arthritis** can cause **inflammatory arthropathy** affecting the joints of the foot, leading to joint destruction and subsequent collapse of the **medial longitudinal arch**, resulting in **rigid flat foot**. - Chronic inflammation and synovitis can alter pedal biomechanics and lead to a painful, **fixed deformity** of the foot. *Peroneal spasm* - **Peroneal spasm** is often associated with conditions like **tarsal coalition** or other painful foot pathologies. - The spasm of the peroneal muscles can pull the foot into **eversion** and **abduction**, contributing to a **rigid flat foot deformity** as the foot becomes fixed in this position. *Congenital tarsal coalition* - **Tarsal coalition** is an **abnormal connection** between two or more bones in the hindfoot or midfoot, which restricts normal motion and leads to a **rigid flat foot**. - It is a common cause of **peroneal spasm** as the body tries to immobilize the painful, rigid hindfoot motion.
Question 3: A child presented to an orthopaedic clinic with a limp. The surgeon suspected him to have a fixed flexion deformity of the hip. Which test should the surgeon perform to confirm his finding?
- A. Thomas test (Correct Answer)
- B. Trendelenburgs test
- C. Telescoping test
- D. Nelaton's test
Explanation: ***Thomas test*** - The **Thomas test** is specifically designed to detect a **fixed flexion deformity of the hip**, where the hip cannot fully extend. - During the test, the patient's hip is flexed to flatten the lumbar spine, and if the contralateral leg then rises off the table, it indicates a fixed flexion deformity. *Trendelenburg's test* - The **Trendelenburg's test** assesses the strength and function of the **hip abductor muscles**, primarily the gluteus medius. - A positive result indicates weakness of the abductors on the standing leg, causing the pelvis to drop on the unsupported side, which is unrelated to fixed flexion deformity. *Nelaton's test* - **Nelaton's test** is used to determine the relative position of the **greater trochanter** in relation to the **ischial tuberosity** and **anterior superior iliac spine (ASIS)**, primarily in cases of hip dislocation or fracture. - It would not specifically identify a fixed flexion deformity of the hip joint itself. *Telescoping test* - The **telescoping test** is used to evaluate for hip instability, particularly in infants with **developmental dysplasia of the hip (DDH)**. - It involves applying axial pressure to the femur while moving the hip, assessing for abnormal movement of the femoral head within the acetabulum, and does not directly detect fixed flexion deformity.
Question 4: A 65-year-old alcoholic suffering from diabetes has a flexion deformity of the right little finger over the metacarpophalangeal joint of around 15 degrees. The ideal management would be:
- A. Complete fasciectomy
- B. Partial (selective) fasciectomy
- C. Percutaneous fasciotomy
- D. Observation (Correct Answer)
Explanation: ***Observation*** - A 15-degree flexion deformity of the **metacarpophalangeal (MCP) joint** is considered mild and does not significantly impair hand function, making observation the appropriate initial management. - The goal of intervention in **Dupuytren's contracture** is to improve hand function, and surgical or medical treatment is typically reserved for deformities of **30 degrees or more** at the MCP joint or any **proximal interphalangeal (PIP) joint contracture**. *Complete fasciectomy* - This procedure involves the **excision of all diseased palmar fascia**, including tissue not directly involved in the contracture. - Due to its **aggressiveness** and higher rates of complications and recurrence, complete fasciectomy is generally **not recommended** for Dupuytren's contracture. *Partial (selective) fasciectomy* - This involves the **excision of only the diseased and contracted fascia**, aiming to release the finger contracture. - While an effective treatment for advanced Dupuytren's contracture, it is **overtreatment** for a mild, 15-degree MCP joint deformity, which typically does not require surgical intervention. *Percutaneous fasciotomy* - This minimally invasive procedure involves **dividing the contracted cords** using a needle, typically performed in an outpatient setting. - It's mainly suitable for **isolated cord contractures** at the MCP joint without extensive fascial involvement and for patients who prefer less invasive options, but similar to fasciectomy, it is reserved for more significant contractures to improve function.
Question 5: Foot eversion is caused by
- A. Tibialis anterior
- B. Tibialis posterior
- C. Peroneus longus (Correct Answer)
- D. Extensor digitorum
Explanation: ***Peroneus longus*** - The **peroneus longus** muscle (fibularis longus) is a primary evertor of the foot. - It originates from the head and upper lateral surface of the fibula, inserts into the medial cuneiform and first metatarsal, and its contraction pulls the foot outwards and downwards. *Tibialis anterior* - The **tibialis anterior** is the primary dorsiflexor and invertor of the foot. - It pulls the foot upwards and inwards, which is the opposite action of eversion. *Tibialis posterior* - The **tibialis posterior** is a strong invertor and plantar flexor of the foot. - It contributes to maintaining the arch of the foot and does not cause eversion. *Extensor digitorum* - The **extensor digitorum longus** primarily extends the toes and assists in dorsiflexion of the ankle. - While it may have a slight eversion component, it is not the primary muscle responsible for foot eversion.
Question 6: Combination of appearance in CTEV
- A. Equinus, eversion, forefoot adduction, cavus
- B. Equinus, inversion, forefoot adduction, planus
- C. Equinus, inversion, forefoot adduction, cavus (Correct Answer)
- D. Equinus, eversion, forefoot abduction, cavus
Explanation: ***Equinus, inversion, forefoot adduction, cavus*** - The classic presentation of **clubfoot** (CTEV) involves a characteristic combination of deformities: **equinus** (fixed plantarflexion of the ankle), **inversion** (tilting of the heel inward), **forefoot adduction** (inward turning of the front of the foot), and **cavus** (an abnormally high arch). - These four components are essential for the diagnosis and classification of CTEV. *Equinus, eversion, forefoot adduction, cavus* - This option incorrectly lists **eversion** instead of inversion. Eversion involves the outward tilting of the heel and is not a feature of CTEV. - While equinus, forefoot adduction, and cavus are typical, the presence of eversion rules out classic CTEV. *Equinus, inversion, forefoot adduction, planus* - This option incorrectly lists **planus** (pes planus or flatfoot) instead of cavus. Cavus (high arch) is a defining characteristic of CTEV, not a flatfoot. - While equinus, inversion, and forefoot adduction are correct, the presence of planus makes this option incorrect. *Equinus, eversion, forefoot abduction, cavus* - This option incorrectly lists both **eversion** and **forefoot abduction**. Eversion is the outward tilting of the heel, and forefoot abduction is the outward turning of the front of the foot. - Both eversion and forefoot abduction are opposite to the deformities seen in classical CTEV.
Question 7: A 41-year-old man is admitted to the emergency department with a swollen and painful foot. Radiographic examination reveals that the head of the talus has become displaced inferiorly, thereby causing the medial longitudinal arch of the foot to fall. What is the most likely cause in this case?
- A. Tearing of the plantar calcaneonavicular (spring) ligament (Correct Answer)
- B. Fracture of the navicular bone
- C. Tearing of the deltoid ligament
- D. Sprain of the calcaneocuboid ligament
Explanation: ***Tearing of the plantar calcaneonavicular (spring) ligament*** - The **plantar calcaneonavicular ligament**, also known as the **spring ligament**, is crucial for supporting the head of the talus and maintaining the **medial longitudinal arch** of the foot. - Tearing of this ligament leads to the **inferior displacement of the talar head** and subsequent collapse of the arch, consistent with the symptoms described. *Fracture of the navicular bone* - A fracture of the **navicular bone** would typically cause localized pain and tenderness over the navicular, and while it could contribute to arch instability, it wouldn't primarily cause the **talar head** to *inferiorly displace* in this specific manner. - While a navicular fracture might lead to secondary arch collapse, the primary issue described is the displacement of the **talar head**, which is more directly related to spring ligament integrity. *Tearing of the deltoid ligament* - The **deltoid ligament** is located on the medial side of the ankle and primarily stabilizes the **talocrural joint**, preventing excessive eversion of the foot. - Its rupture would lead to ankle instability and pain, but it doesn't directly support the **medial longitudinal arch** in the same way the spring ligament does, nor would its tearing directly cause the talar head to displace inferiorly as described. *Sprain of the calcaneocuboid ligament* - The **calcaneocuboid ligament** is a component of the **lateral longitudinal arch** of the foot and connects the calcaneus to the cuboid bone. - A sprain of this ligament would primarily affect the *lateral* foot stability and lead to pain in that region, not the described collapse of the **medial longitudinal arch** or inferior displacement of the talar head.
Question 8: Watson Jones operation is indicated for which condition?
- A. Poliomyelitis
- B. Muscle paralysis
- C. Neglected clubfoot
- D. Chronic ankle instability (Correct Answer)
Explanation: **Explanation:** The **Watson-Jones operation** is a reconstructive surgical procedure used to treat **chronic lateral ankle instability**, typically resulting from recurrent sprains that have led to insufficiency of the **Anterior Talofibular Ligament (ATFL)** and the **Calcaneofibular Ligament (CFL)**. The procedure is a type of **non-anatomic tenodesis stabilization**. It involves using the **Peroneus Brevis tendon**, which is rerouted through tunnels drilled in the distal fibula and the neck of the talus to functionally replace the damaged lateral ligaments. While it provides significant stability, it is often associated with a decrease in subtalar joint motion. **Analysis of Options:** * **Poliomyelitis & Muscle Paralysis:** These conditions often require tendon transfers (like the Jones procedure for great toe clawing) or arthrodesis (like Triple Arthrodesis) to restore balance, but not the Watson-Jones ligament reconstruction. * **Neglected Clubfoot:** This requires extensive soft tissue releases (Turco’s procedure) or bony procedures (Ilizarov, Triple Arthrodesis, or Dwyer’s osteotomy) depending on the age of the patient. **High-Yield Clinical Pearls for NEET-PG:** * **Other Tenodesis Procedures:** Apart from Watson-Jones, the **Evans procedure** and **Chrisman-Snook procedure** also use the Peroneus Brevis for ankle stability. * **Gold Standard:** The **Broström procedure** (anatomic repair/imbrication of the original ligaments) is now preferred over Watson-Jones as it preserves more normal joint kinematics. * **Confusing Names:** Do not confuse the **Watson-Jones operation** (ankle) with the **Watson-Jones approach** (anterolateral approach to the hip).
Question 9: Triple arthrodesis does not involve which of the following joints?
- A. Calcaneocuboid Joint
- B. Talanovicular Joint
- C. Talocalcaneal Joint
- D. Tibiotalar Joint (Correct Answer)
Explanation: ### Explanation **Triple arthrodesis** is a surgical procedure aimed at stabilizing the hindfoot, correcting deformities, and relieving pain caused by arthritis or neuromuscular conditions. The term "triple" refers to the fusion of **three specific joints** of the hindfoot. #### Why Tibiotalar Joint is the Correct Answer: The **Tibiotalar joint (Ankle joint)** is responsible for plantarflexion and dorsiflexion. It is **not** part of a triple arthrodesis. Fusing the ankle joint along with the hindfoot joints is termed a "pantalar arthrodesis." In a standard triple arthrodesis, the goal is to preserve ankle motion while stabilizing the joints responsible for inversion and eversion. #### Analysis of Incorrect Options: The three joints involved in a triple arthrodesis are: 1. **Talocalcaneal (Subtalar) Joint:** Fusion here stabilizes the primary site of hindfoot inversion and eversion. 2. **Talonavicular Joint:** This is considered the "key" joint of the triple arthrodesis; its fusion significantly limits the motion of the other two joints. 3. **Calcaneocuboid Joint:** Fusion of the lateral column completes the stabilization of the midtarsal (Chopart) joint complex. --- ### High-Yield Clinical Pearls for NEET-PG: * **Indications:** Most commonly performed for **Rigid Flatfoot**, Talipes Equinovarus (TEV), and neuromuscular imbalances (e.g., Polio, Charcot-Marie-Tooth). * **Order of Fixation:** The standard sequence for surgical fixation is usually **Talonavicular → Subtalar → Calcaneocuboid**. * **Impact on Motion:** While it provides excellent stability, it results in the loss of almost all inversion and eversion, placing increased stress on the ankle joint (Tibiotalar joint) over time. * **Chopart’s Joint:** This consists of the Talonavicular and Calcaneocuboid joints. Triple arthrodesis essentially fuses the Subtalar joint + Chopart’s joint.
Question 10: Hallux valgus is associated with all of the following except:
- A. An exostosis on the medial side of the head of the first metatarsal (Correct Answer)
- B. A bunion
- C. Osteoarthritis of the metatarsophalangeal joint
- D. Overriding or under-riding of the second toe by the third
Explanation: **Explanation:** The correct answer is **A** because the bony prominence seen in Hallux Valgus is **not a true exostosis** (new bone growth). Instead, it is a **pseudo-exostosis** formed by the medial prominence of the first metatarsal head as it deviates medially (metatarsus primus varus), combined with overlying soft tissue thickening. **Analysis of Options:** * **Option A (Correct):** As stated, the "bump" is the displaced metatarsal head itself, not a pathological outgrowth of bone (exostosis). This is a common distractor in orthopedic exams. * **Option B:** A **bunion** is a classic feature of Hallux Valgus. It consists of the pseudo-exostosis, an inflamed adventitial bursa, and thickened skin on the medial aspect of the first MTP joint. * **Option C:** Chronic malalignment and lateral subluxation of the great toe lead to abnormal loading and articular cartilage wear, eventually resulting in **secondary osteoarthritis** of the first MTP joint. * **Option D:** As the hallux deviates laterally, it crowds the lesser toes. This often leads to the **second toe** being displaced (usually overriding the hallux) and subsequent deformities of the **third toe** due to space constraints. **NEET-PG High-Yield Pearls:** * **Hallux Valgus Angle (HVA):** Normal is <15°. * **Intermetatarsal Angle (IMA):** Normal is <9°. * **Associated Deformity:** Often associated with *Pes Planus* (flat foot) and contracture of the Achilles tendon. * **Surgery:** Common procedures include **Chevron osteotomy** (for mild cases) and **Lapidus procedure** (for severe cases with hypermobility).
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