Krozer Manual

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TabLe of Contents

Introduction hy Dr. William Urbas. DPM.. Ph':2

Jntroduction "...... Pi:' 3

Chapter l-Antibiotics.................................................... PI:' L1

Chapter 2-Analomy , " . . . . .. . . . . .. . . . . .. . Pi:' J 9

Chapter 3-Medicine...................................................... PI' 25 Chapter -l-Clinical Podiatry... . . . . . .. . . . . . . . . ... .. . ... ... .. . . . . .. . ... .. . pg 36 Chapter S- Trauma........................................................ Pi:' 39 Chapter o-Labs and Patient Management.............................. pg 43

Chapter 7 -Surgery , . . .. .. .. . . . .. .. . . . .. pg 42

Chapter 8-Drug of Choice............... pg 57

Chapter 9-Gout. . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . pg 62

Chapter 1 O-Case Number 1............................... pg 64

Chapter l l-Case Number 2 '" pg 66

Chapter 12-NSAIDS.................. pg 68

Chapter l3-Classifications pg 71

Chapter 14-Name that Surgery '" . .. pg 100

Chapter IS-Normal Range of Motion " pg III

Chapter l S-Special Surgeries , pg 117

Achilles Tendon repair. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. pg 118

Ankle Arthroscopy pg 120

Ankle Fusion.................. pg 122

Brostrom-Gould pg 124

Delayed Repair of the Achilles Tendon pg 125

Ilizarov's Method , pg 127

Murphy's Procedure pg 128

ORIF Calcaneus , pg 129

ORIF Talus pg 131

Osteochondral Lesions pg 133

Subtalar Arthrodesis pg 133

STATT/TATT pg 135

Tibialis Posterior Tendon Transfer. '" pg 136

Triple Arthrodesis '" pg 13 7

Chapter 17 -Special Studies pg 138

Chapter 18 The Social Interview pg 142

Crozet-Keystone Residency Manual 2004, Arranged by Brett Chicko, DPM

Introduction

Dear Student:

In the pages that follow is useful information that will help make your externships, interviews and transition from student to resident a little bit easier. This information contained within is not the end all on the subject, but the tidbits that need to be on your "Mind's Fingertips".

Tills booklet is a useful guide on the need-to-know, need-to-keep information. Please use it as it was intended--a guide on the ever-changing world of medical information. My thanks go out to the Podiatric Surgical Residents at Crozer-Keystone Health System for the formation of this manual.

Sincerely,

William M. Urbas, DPM Crozet-Keystone Residency Director

Crozer-Keystone Residency Manual 2004, Arranged by Brett Chicko. DPM '!

Authers Introduction

This manual is NOT meant to replace "McGlarnry's", the "Presbyterian Manual", the "Podiatry Institute Manual" or any other reference source. Those manuals are excellent resources and should be used to continue to learn the information. To this day, I still use those texts for information and reference.

This manual is based on questions I came across as an extern or a resident, either from my own questions or questions from a superior. 1 would write these questions down and after I looked up the answers, I would keep the questions with their answers in a log.

Later, as a resident, 1 was quizzing a student in order to get her ready for her interviews. The student asked me, "Why can't there be a book of these questions?" After that, I started to put together the manual. ] also added some additional items to complete the manual.

In no way, shape or form do I claim that the answers written here are the only answers possible, nor do I even claim that they are all 100% correct. These answers are the ones that I came up with when] researched the questions. It is up to you to go to the true references--not only to make sure that the answers are correct, but also to make sure that you understand why.

Therefore, the purpose of this manual is so that the reader can have some questions and answers so that he or she can go to the sources and really learn podiatry.

I am not able to provide all of my sources because when I started writing down the answers, I had no idea of turning it into a manual. However, my major sources are, "The Comprehensive Textbook of Foot Surgery", "The Presbyterian Manual" and "The Podiatry Institute Manual". A special thank you to my attendings and co-residents at the Crozer-Keystone Health Systems in Springfield, P A.

Good Luck and Happy Studying,

Brett Chicko, DPM

P.S. I wrote this book for the sole purpose of helping my profession of Podiatric Surgery and Medicine. I have not received any compensation, nor will I, for writing this book.

Crozer-Keystone Residency Manual 2004, Arranged by Brett Chicko, DPM 3

Crn7p-r-~_evstone Residencv Manual 2004. Arranged by Brett Chicko. DPM

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Antlbtotics

What do you always want to check before giving an antihietic?

1. Kidney function (as seen on bun and creat in an sma-"): if the antibiotic to be used is metabolized by the kidney (most are) you want to make sure the kidneys are functioning properly

2. Allergies

3. lftbe patient is on an antibiotic already. Often someone will prescribe an ABX without checking if the patient is already on one. Don't do this. Always know what medications a patient is on before you prescribe something.

4. If a gram stain and C&S has been done and if the results are in

5. Any other reason you mayor may not want to give the antibiotic

N a.rne that drug

What is in Augmentin? Amoxacillin/clauvulonic acid

Unasyn?

Ampicillin! sulbactam

Timentin?

Ticarcillinl clauvulonic acid

Bactrim?

Tmp/smx (trimethoprim/sulfamethoxazole)

Primaxim? Imipenem/cilistatin

Zosyn'! Piperacillin/tazobactam

Roccphin?

Ceftriaxone (3rd generation Cephalosporin)

Which drug is nicknamed "Gorillamycin'?

Imipenem because it has the broadest spectrum of any drug.

Avelox?

Moxitloxacin hydrochloride

Invanz? Ertapenem sodium

"What is the dosing for Unasyn? 3.0g IV q 6°

1.5g IV q6° for p1 with renal impairment

Unasyn

'When is Unasyn usually used'!

It is a good initial IV choice for a polymicrobial infection.

What is an alternative to Unasyn for a patient with a J)CN allergy? Cipro/Clinda

Levaquin

(There are others)

Will Unasyn work against Psuedomonas? No.

Augmentin

"That is in Augmentin? Dosing? Amoxicillinlclauvulonic acid

500 or 875 rug one tab po bid

How much clauvulonic acid is in Augmentin 500mg? For Augmentin 875 rug? Both have 125 rug

"Then is Augmentin usually used?

It is a good oral drug for a polymicrobial infection.

Does Augmentin work on Pseudomonas? Nope.

Zosyn

Indications for Zosyn?

Infections of skin and skin structures, including DM foot infection

Dosing

3.375g IV q 4_6°

Renal dose 2.25 g IV q 4_6° Alt does 4.5g IV q4-6°

"Till Zosyn work on Pseudomonas? Yes


Timentiln

What is Timentin? Ticarcillin/clauvulonic acid

Vi/hat to watch out for with ticarcillin? Increased Na+ load by 5.2 meq/gram

What is the Na+ load ofticarcillin? 5.2 meq/ gram

Dosing?

3.1g IV q4-6°

What is Timentins coverage?

Polymicrobial, broad spectrum including pseudomonas

Penicillin

What is the drug of choice for a diabetic foot infection with a penicillin allergy'? Clindamycin

How are PCN's excreted?

All are renal except for mezlocillin, azlocillin, piperacillin (the ureidopenicillins are 20- 30% renal)

Name 2 IV alternative antibiotics for peN anergic patients Clindamycin

Levaquin

Vancomycin

Bactrim

(There are others)

Which PCN's are anti-psuedomonal" (The fourtb and fifth generation PCN's) Ticarcillin. Timentin

Piperacillin, Zosyn

Carbenicillin, Mezlocillin. Azlocillin

Cepha!osporins

'X. of cross sensitivities between cephalosporins and peN'! ] -5% (depends who you talk to).

An: Cephalosporins contraindicated for a patient with a peN ALL'?

Many people will say yes, but according to Dr Warren Joseph, DPM"Cephalosporins are only contraindicated when a patient has an anaphylactic response to a penicillin. Cephs can usually be used safely when there is a history of "rash" or "stomach upset".

Personally, ] will give a cephalosporin to a pi with a PCN ALL if all he or she had was a stomach upset and J document this. However, J do not give a cephalosporin to apt with a PCN ALL with a history of rash unless the pi has a past history of taking a cephalosporin without any complications. 1 am sure to document the pi's hlo no side effects with cephalosporins.

How are cephalosporins excreted?

Renal except for ceftriaxone and cefoperazone

How to treat serious hospital acquired gram negative's 3 rd gen ceph, aminoglycoside

(i.e. rocephine, gentamycin)

Name 2 oral cephalosporin for each class.

(There are others, these are the ones I chose to remember) 1 st generation- Keflex, Duricef

2nd generation-Ceftin, Ceclor

3rd Generation-Suprax, Vantin

What is the coverage for cephalosporins at each class? 1st Gen-gram positives (staph and strep)

certain gram negatives (proteus, E. Coli, Klebsiella Samonella Shigella) pneumonic-PECKSS

2nd Gen- gram positives-staph (less than 1 st gen) and strep

gram negatives H. influenza, Neisseria, Proteus, E. Coli, Klebsiella Samonella

Shigella pneumonic HEN PECKSS

3rd Gen-gram positives (staph and strep but less than 1 st and 2nd)

gram neg (ceftazadine and cefoperazone active against pseudomonas)

4th G .. 11 3rd, . lus I'l aen' ..

en- coverage IS essentia y gen s gram negative p us gen s gram posrtive

"That is the 4tb Generation Ceph? Cefipine (Maxipime)

Vancomycin

What is Vanco's main indication MRSA

"That is Vanco's coverage?

Gram positives including MRSA and MRSE

Crozet-Keystone Residency Manua12004, Arranged by Brett Chicko, DPM 7

Crozer-Kevstone Rcsidencv Manual 2()04.I\.rranged by Brett Chicko. DPM

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Dosing of Vance '!

1 gm IV C] J 2 hours slow infusion

When do you give oral vance?

C. difficile colitis (give 125 mg po qid)

What happens when you give "allen too fast'!

Red neck syndrome- erythema and pruritis usually to the head, neck and upper torso. It is caused by an anaphylactoid reaction where histamine is released by mast cells. (Some people will call it Redman syndrome. Otbers will say Redman syndrome is caused by Rifampin)

What are the peaks and troughs of vanco? Peak 15-30 mg/rnl

Trough <10 mg/rnl

How are vanco levels taken and how do you adjust the levels'!

For vanco you take the peak and troughs (sometimes called pre and posts)

Peak: take the level 30 min after the 3rd dose. Trough: take the level 30 min before the 4th dose.

If the peak is too high, decrease the amount of the dose. If the peak is too low, increase amount of dose.

lfthe trough is too high, increase the interval between doses. If the trough is too low, decrease the interval between doses.

How can you decrease the risks of Van co causing red neck syndrome? Slow infusion, give dose over one hour

How do you treat a too rapid infusion of Vancomycin? Antihistamines (Benadryl 1 0-50mg IV tid) until symptoms go away

What are the major side effects of Vance? Ototoxicity

Nephrotoxicity

Does the duration of time a pt has been Oil Vanco increase the risk of side effects? Yes, Vanco bas a reservoir effect meaning the more times one gives Vanco to the pt. the higher the chances of getting either ototoxicity or nephrotoxicity. Therefore. use Vanco carefully-it is a powerful drug with severe side effects.

Amino~lvcosides

What are the side effects of aminioglycosides? Which one is irreversible'! Ototoxicity-irreversible

Neprotoxicity Neuromuscular blockade

'What is the aminoglycosidcs coverage'! Gram-negative aerobic rods

"What are the major aminoglycosidcs? Gentamycin, Tobramycin and Amikacin

Gent and Tobramycin Amikacin

What are the doses, peaks and troughs of the aminoglycosides?

Dose Peak (ug/rul) Trough (ug/ml)

3-5 mg/kg q8° 4-10 2

15 rug/kg q8° 20-30 10

How to dose gentamycin? I , Get the creatine clearance

cc= (140-age)(weight in kg) (72)(serum creatinine)

For females, multiply the CC by .85

The result ofthe CC is the Renal Function .. I.e. if the CC is 75%, then the patient has 75% of the kidney function. Then you want to use only 75% of a normal dose of Gent.

2. Loading dose is 2 mg/kg (regardless of CC)

3. Give 3-5 mg/kg g8° with adjustments for the cc.

What is Bactrim? Trimethoprimlsulfamethoxazole (TMP/SMX)

Bactrim

How to dose Bactrim? How much of each? One tab po bid

Single strength 80mg TMPI 400 mg SMX Double strength CDS) 160 mg TMPI 800mg SMX

How does Bactrim work?

TMP-inhibits bacterial dihydrofolate reductase (stops production offolinic acid) SMX-inhibits folic acid production

What allergy to avoid when prescribing bactrim? Sulfa

Spectrum of activity? Broad spectrum

Staph and strep (including MRSA and MRSE) Gram negatives (including pseudomonas)


Crozet-Keystone Residency Manual 2004. Arranged hy Brett Chicko. DPM

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Contraiudications?

PI's on oral hypoglycemics and G-6-PD deficiencies

Adverse reactions'? F-I emu lytic anemia Hypersensitivity

Zythromax

Generic name of Zithromax? Azithromycin

liz life of Zithromax? 68 hours

How to dose Zithromax?

250mg po , two tabs on first day, one tab for the next four days

'What is Zithromax's coverage?

Staph and Strep, and some anaerobes (but not bacteroides)

Can you give Zithromax with a peN ALL? Yes.

Primaxin

What is in Primaxin? lmipenemJCilistatin

How does Primaxin work? Imipenem=antibiotic

Cilistatin=renal dihydropeptidase inhibitor (prevents imipenem from being metabolized by the liver)

Spectrum of Activity ofPrimaxin? Very Broad spectrum

Most gram positives.

Most gram negatives including pseudomonas Most aerobes and anaerobes

Dosing of Primuxin '?

500 mg IV g6-8° (most common) or J gm IV q6_8°

Side effect and frequency of Primaxin '! Seizures with p1 with history of seizures -J % risk with 500mg dose

-] 0% risk with ] gram dose

Aztreonam What is aztreonam's major side effects?

None, nada, zippo

What is aztreonam's coverage?

Gram negatives, aerobes, psuedomans (it's main indication)

Dosing?

1-2 gram IV g8°

Why isn't Aztreonam used more often? It is expensive

Ouinolones What are the two most common quinolones?

Cipro and Levaguin

What is their coverage?

Gram negative bacilli including pseudomonas

Staph (levaguin has increased gram positive coverage)

Who can you not give a quinolone?

Children-it is contraindicated because it may lead to a defect in cartilage Pneumonic-' quinolones kills children's cartilage' -sort of rhymes

"That is Cipro's dosing? 200-400 mg IV q12° 250-750 mg PO bid

What is Levaquin's dosing'! 250-500 mg IV or PO

What is Avelox's generic name? Moxifloxacin

Avelox

"That is Avelox's dosing? 400 mg q24 ° IV or PO

Crozer-Keystone Residency Manual 2004, Arranged by Brett Chicko, DPM JJ

What is A velox class and coverage '! A fluoroquinolone.

Its coverage is broad-spectrum and has excellent coverage against Gram-positive cocci while retaining good activity against Gram-negative bacteria and atypical pathogens. In addition, it has good in-vitro activity against anaerobes.

Invanz

What is Invanz's generic name'! Ertapenem sodium

What is Invanz's dosing? 1 gm IV q14°

What are Invanz's indications'!

Invanz is approved for use in adults for the treatment of moderate to severe infections caused by common gram-positive and gram-negative aerobic and anaerobic bacteria.

What is Invanz drug class?

Invanz is a structurally unique l-tbeta) methyl-carbapenem related to beta-lactams

Antibiotic Associated Diarrhea

What are the two main causes of Antibiotic associated diarrhea? Psuedomembranous Colitis-closridium dificle

Non-specific Colitis-Staph aureus

How to test for C Diff?

(Write the order) 'Check stool for C Diff

What gives you Clostridium difficille-mc cause? Clindamycin (although any antibiotic can give it to you)

How do you treat for C Diff! Vanco 125mg po tid or

Flagyl 500rng po bid

YKE

How to treat VRE'?

Linczo lid or Dalfopristin-Quinupristin

What is the only PO for VRE? Linezolid (can also be given l V)

Crozet-Keystone Residency Manual 2004. Arranged by Brett Chicl;o. DPM

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Why isn't Zyvox used more often'! 11 is expensive.

What is the generic name for Synercid? Dalfopristin-Quinupristin

Dosing for Zyvox

400-600mg IV q 12° infuse over 1 hour Tabs 400 or 600 mg

Psuedomonas

Name drugs you can treat pseudomonas with. Aztreonam

Aminoglycosides-gentamycin, tobramycin, amikacin Cipro

Cabencillin

Ceftazamine, Cefeprime, Cefoperazone Ticaracillin, Timentin

Piperacillin, Zosyn

l\1RSA

What antibiotic do you use against MRSA? 'What oral agents can you use? 'What topical?

MRSA-IV

Vancomycin Linezolid Minocycline Cipro/rifampin Bactrimlrifampin Synercid

PO forMRSALinezolid Minocycline Cipro/rifampin Bactrimlrifampin

Topical for MRSA Bactroban


SUlr~]Ca] prophylaxis

When should OIl(' use surgical prophylaxis'! 1. Prolonged cases (greater than :2 hours) 'I Trauma surgery

3. hnmunocompromised patient

4. Implants (joint. internal fixation)

5. Endocarditis (SBE)

VI'hat antibiotics are most commonly used for surgical prophylaxis? Ancel' (Cipro is PCN ALL). Vanco (if concerned about MRSA)

J't1:isceHaneolLlls What antibiotics are metabolized by the liver? Antibiotics excreted by liver- 4 C's and IE C-Cefmandole

C-Clindomycin

C-Cefoperazone

C-Chloramphenicol

E-erythromycin

Can antibiotics affect PT/J[]\TR?

Yes, ABX can affect normal flora, which alters Vit K. The PTIINR can go up.

What antibiotic has the side effect of discoloring body fluids red/orange? Rifampin

What can Beta Lactams cause? Leucopenia

When do fever peaks occur? Between 4-8 pm

\\'hat open fr-actures should be treated with antibiotics? Grades :2 and 3.

ws« gives Red ManfRed Neck syndrome Red Man7Rifampin (makes body fluids red) Red Neck7 Vancomycin

What ar-e the Macroiidss MOA'?

11 binds to 50s bacterial ribosome inhibition protein synthesis

What is the Aminoglycosidess MOA'!

It binds to 30s bacterial ribosome inhibition protein synthesis

Crozer-Keystone Residency Manual 2004. Arranged by Brett Chicko, DPlvl

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Pneumonic for the above questions-

A boy at 30 does n01 become a Man until 50

Aminoglycosides-binds to 30s bacterial ribosome inhibition protein synthesis Macrolids-binds to 50s bacterial ribosome inhibition protein synthesis

Drug of Choice (DOC) and Alternatives

(Also see Bugs and Drugs section)

"That is the drug of choice (DOC) for a diabetic with a peN allergy? Clindamycin

DOC for severe limb threatening infection? Primaxin

DOC for bite wounds? Augmentin

Gram Positives

Drug of choice for staph? Keflex for PO, Ancef for IV

Alternative for staph?

Clindamycin, Levoquin, Vanco, Azithromycin, Dicloxacillin, Napheillin

Alternative for staph if peN all? Clindamycin, Levoquin, Azithromyein, Vaneo

DOC for Strep?

Keflex for PO, Aneef for IV

Alternative for Strep? Clindamyein, Levoquin, Vanco

Alternative for Strep ifPCN all? Clindamycin, Levoquin, Vanco

DOC for MRSA?

Vancoruycin for IV, for PO-Bactrirn if sensitive or Linezolid

Alternative for MRSA? Synercid or Linezolid

Crozer-Keystone Residency Manual 2004, Arranged by Brett Chieko, DPM 15

Doe for VIm?

Linezolid or Dalfopristin-Quinupristin (Synercid)

DOC for enterococcus? Amoxicillin PO or Vancomycin TV

Alternatives for enterococcus? Augmentin PO, Linezolid PO or IV

Gram Ne2"atives

DOC for E. Coli? Keflex or Aneef

Alternative for E. Coli if peN aU? Cipro or Levaquin

DOC for proteus? Keflex or Ampicillin

Alternative for proteus if peN allergic? Cipro or Levaquin

DOC for E/C/SIM group? Quinolone (Cipro/Levaquin)

Alternatives for the E/C/S/M group?

-s rd h bactri

:) gen cep , aztreonam, actnm

DOC for Psuedomouas Aeruginosa? Cipro IV or PO

Alternatives for Psuedomonas Aeruginosa? Ceftazamine (a 3rd gen cephalosporin), aztreonam, bactrim

Anaerobes DOC for bacteroides (anaerobes) for the diabetic foot? Augmentin PO, IV -Unasyn, Timentin, Zosyn

Alternatives for bacteroides (anaerobes) for the diabetic foot ifPCN allergy? Clindarnycin/cipro, primaxin, flagyl

Less Common Or2:a.nisms Drug choices for Clostridium?

PCN. clindamycin, tetracycline

Crozer-Keystone Residency Manual 2004. Arranged by Brett Chicko. DPM

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Alternative for Aeromonas? Bactrim

Doc for Xanthamonas? Bactrim

Alternative for Xanthomas? Ceftazidime

DOC for Pseudomonas Cepacia? Bactrim

Alternative for P. Cepacia? Ceftazidime

DOC for Diptheroids? Vanco

DOC for Lyme disease (Borrelia)? Rocephin, doxycycline

Alternative for Lyme disease? Amoxicillin

Antibiotic for superficial thrombophlebitis? Timentin

Topical ABX against MRSA? Bactroban

Why is gas gangrene a surgical emergency?

Because it progresses rapidly to shock and renal failure. Fatal in 30% of cases.

Treatment for Ghonnorhea? Ceftriaxone, or PCN if sensitive

DOC for Necrotizing Fasciitis?

Prirnaxin 250-1000 IV q6-8° (most commonly 500 mg IV g8°)

Treatment for Lyme disease?

Doxycycline 100 mg po qd or Rocephin 19 IV qd


Treatment of Cutaneous Larva h1fignw.s? Prornethia under occlusion


1 \) J 0

Anatomv

How many foot hones'!

26 (not including sesmoids)

How many foot joints? 35

What are the layers of the foot? Going from superficial to deep

1. Abductor hallucis, flexor digitorum brevis, abductor digiti minimi

2. Quadratus plantae, 4 lumbricles

3. Flexor hallucis brevis, adductor hallucus, flexor digiti minimi

4. 4 dorsal interossei, 3 plantar interossei

N arne the accessory ossides Os Tibiale Externum

Os Vesalianum

Os Peroneum

Os Supra Navicular Os Sustentaculi

Os Calcaneous Secondarius

accessory navicular

off tip of 5th met tuberosity sesmoid bone in PB tendon dorsal aspect of navicular post aspect of sustentac. tali dorsal and ant process of calc:

At junction of calc, cuboid, talus + nav distal to lat malleolus

distal to medial malleolus

plantar of 1 st met-med cuneiform post aspect of talus

Os Subfibulare Os Subtibiale

Os Cuneo-lmet-f-plantare Os Trigonum

"That layer of the foot does the FDL run? 2nd

Think, the FDL is the origin of the lumbricals and the insertion of QP so it must run in their layer.

How is EDL attached to proximal phalanx?

Sling wraps around capsule attaches to plantar plate, DTML, flexor tendon sheath-thus attaches to plantar proximal phalanx, not dorsal. No direct insertion to prox phalanx

Are the scsmoids capsular or extra-capsular? Capsular

How is periosteum attached to bone? Sharpey's fibers

What is Hoke's tonsil?

Fibrous fatty plug in the sinus tarsi


'What is the superficial and deep portion of the Deltoid iigmnent'.' Deep-Anterior tibiotalar

Superficial-talocalcaneal lig, Posterior tibiotalar, Tibionavicular

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What structures attach til fibular sesmoid? Plantar met-phalanx lig

Lat met-sesmoid lig.

Intersesmoid lig.

Phal-sesrnoid Jig.

FHB tendon

ADH tendon

What ligaments compose the bifurcate ligament? Calcaneocuboid and calcaneonavicular

Which ankle ligaments are capsular? Which are extra-capsular'! Calcanofibular ligament is extra-capsular, all others are capsular

Which is the strongest part of the lateral ankle Iig.? Post-talofibular

Which is the deepest of the deltoid ligaments? Anterior tibiotalar lig.

Which is stronger-lateral ankle ligaments or deltoid ligaments? Deltoid ligaments

"That is another name for the laciniate ligament? Flexor Retinaculum

What is another name for the transverse crural ligament? The superior portion of the extensor retinaculum

What is another name for the crura! cruciate ligament'! The inferior portion of the extensor retinaculum

In what [ayers of the foot do the plantar nerves run? Lateral plantar nerve-between 1 sl and 2nd

Medial plantar nerve-in 1 st layer (between FDB and abductor hallucis)

Name the nerves that make up the sural nerve?

Medial sural cutaneous nerve of the tibial nerve and the sural communicating branch. The medial sural cutaneous nerve comes off the tibial nerve. The sural communicating branch is a branch off the lateral sural cutaneous nerve, which comes off the common peroneal nerve.

Crozer-Kcvstone Residency Manual 2004. Arranged by Brett Chicko, DPM

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What i& Pes Anseritis?

Bursa between Gracilis, semitendinosis, and sartorious (bursa medial proximal tibia)

Does the deep transverse intermetatarsal ligament lie above or below the neuroma? Dorsal to the neuroma

Name the osteuchrondritities Theiman

Freiberg

Islen

Buschke

Kohler

Lance

Severe

Osgood-Schlatter

Blount

Kohler

phalanges

met heads

5th met base cuneiforms navicular

cuboid

calcaneous

tibial tuberosity prox tibial epiphysis patella

What is the blood supply to the talus? Essentially the 3 major blood supplies to the foot

1. Branch to superior surface of neck from anterior tibial artery or dorsalis pedis

2. Medial side of body-posterior tibial artery approx ] ern before bifurcation

3. Lateral turbercle-anastamosis of branch of peroneal artery with medial calcaneal branch.

Tell us the path of drop of blood from left ventricle to the big toe. Ascending aorta

Aortic arch

Descending aorta

Thoracic aorta

Abdominal aorta

Common iliac a.

External iliac a.

Femoral a.

Deep femoral a.

Popliteal a.

Ant tibial a.

Dorsalis pedis

1 st dorsal met a.

1 st dorsal digital a.

What is the innervation to the plantar muscles of the foot? Blood supply? Never LAFF at A FAD

l , Medial plantar Nerve-I" Lumbrical, ABH, FHB, FDB (innervated by both medial and lateral plantar nerves)

2. Medial plantar Artery-FDB, ABH, 1 st Dorsal interossei

Crozer-Keystone Residency Manual 2004, Arranged by Brett Chicko, DPM 2]

VVhat is the most common coalition ill the foot'!

lvIC of foot if coalition of distal and middle facet of 51h toe

Name 3 types of coalitions in the rearfoot. Which is most common'! Which is the most symptomatic?

For the subtalar jt: Talonavicular, calcaneonavicular and talocalcaneal middle facet MC of rear foot is T-C middle facet although C-N is close 2nd

The C-N is the most symptomatic

3 causes for brachymetatarsia? Tumers

Downs

H yperparatbyroidisrn Poliomyelitis

Hbs

Plus many, many more

5 causes for hallux varus? Congenital

Trauma

Staking the head (cut into sagital groove) Removal of fibular sesmoid

Bandaging too far into varus Overzealous medial capsuloraphy

What is staking the head?

When doing the sagital cut (dorsal medial prominence) of a bunionectomy, you want to preserve the sagital groove for articulation of tibial sesmoid. If not, then you strike the head ~ hallux varus.

Name the types of non-unions Hypertrophic

Elephant foot Horsehoof

Oligotrophic

Atrophic

Torsion wedge Comminuted Defect Atrophic

What are the stages for skin graft healing? Stages of skin graft healing

J. Plasmatic stage

Crozet-Keystone Residency Manual 2004. Arranzed by Brett Chicko. DPM

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3. Re-organization

4. Re-innervation

Me complication of skill grafts'! 1 st seroma

2nd hematoma

What are the phases of wound healing? Phases of wound healing.

Substrate phase (day 1-3 or 4) a.k.a. lag phase Proliferative phase (day 3 or 4 to 21) a.k.a. repair phase Remodeling phase (day 21 +) a.k.a. maturation phase

What are the bone graft phases of healing'! Bone graft phases of healing

1. Vascular ingrowth

2. Osteoblastic proliferation

3. Osteoinduction

4. Osteoconduction

5. Graft remodeling

What are the phases of bone healing?

Bone either heals via primary (with no motion) or secondary (with micro-motion). Primary healing (does not have any callus formation)

1 .Inflammation 2. Induction 3.Remodeling

Secondary healing- (callus formation) I.Inflammation

2. Induction

3. Soft: callus

4. Hard callus 5.Remodeling

What are the angles for a Tailor's bunion? Angles for a tailor's bunion

4tb lMA-6° norm, pathological 8.7°

-As described by Fallat and Buckholz: angle between bisection of 4th met and medial cortical border of 5th met (note Schoenhause says 4th IMA norm =8°) Lateral Deviation angle-lateral bowing

-As described by Fallat and Buckholz) norm 2.64°, pathologic >8°: angle ofline bisecting head and neck of 5th met and line adjacent to medial cortex lntermetarsal angle of 2nd and 5th met

-Bisection of 2nd and 5th met, norm 14-18° Intermetarsal angle of I st and 2nd met

Crozer-Keystone Residency Manua12004, Arranged by Brett Chicko, DPM 23

/12°-7me1 primus adductus. high predilection of splayfoot ThereforeifIMA of 1 sl ancl2nd /12" and IMA of 4th and 5th >W'-7splay foot

What are the branches of the femoral nerve? 1. Nerve to femoral artery

J Small muscular branch to pectineus 3. Anterior division (cutaneous)

a. Anterior femoral cutaneous

b. Nerve to sartorious

c. Lntermediate femoral cutaneous nerve

d. Medial femoral cutaneous nerve

4. Posterior division (muscular)

a. Saphenous nerve

b. Infrapatellar branch

c. Medial crural cutaneous n.

d. Nerve to rectus femorus

e. Nerve to vastus medial us

f. Nerve to vastus intermedialus

g. Nerve to vastus lateralus

What are the branches of the femoral artery? Branches of Femoral Artery

1. Superficial epigastric a.

2. Superficial circumflex iliac a.

3. Superficial external pudendal a.

4. Deep femoral (profunda femoris) a.

5. Medial femoral circumflex a.

6. Lateral femoral circumflex a.

7. Descending genicular a.

Popliteal a. is the continuation of the femoral a.

What is Haglund's deformity? Pump bump

Name the x-ray measurements for Haghmrl's deformity Fowler and Phillip

Total angle of Vega

Parallel pitch lines

Crozet-Keystone Residency Manual 2004. Arranged by Brett Chicko. DPM

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Post Op Fever

Name reasons for post op fever Wind ( J :2-24 hours) J. Atelelctasia

2. Post op hyperthermia I.UTI

1. Thrombophlebitis

2. Pulmonary embolism.

Wound (~72 hours) I . Post op wound infection

Wonder Drugs (anytime) 1. Drug fever

Water (c~:24 hours) Walk (·-48 hours)

Treatments of post op fever Wind-7atelectasia (from muscle relaxers)

To prevent use incentive spirometer (blow into tube) Get chest x-ray

Water-7strait catheter, drain 500cc

Get urine gram stain, culture and sensitivity Urine analysis (UA)

Treat with antibiotic if necessary Walk-e-heparin protocol

To prevent use TEDS stocking, SCD or get the patient up and out of bed Wound-7antibiotic, x-ray, gram stain, culture and sensitivity, blood cultures

Wonder Drug-7d/c drug, give drug to reverse if necessary.

Triad of Pulmonary embolism

1. Dyspnea

2. Chest pain

3. Hemoptysis (although tachycardia is more common)

Virchow's Triad

Venous stasis Hypercoaguability Abnormalities of vessel walls

What is Virchow's triad used for'! Risks ofDVT

Diagnosis of D VT -clinicully Classic symptoms

I. Pain. heat, swelling in affected limp 'I Homan . s and Pratt's test

3. Pulmonary embolism

Crozet-Keystone Residency Manual 2004, Arranged by Brett Chicko. DPM

Crozer-Keystone Residency Manual 2004, Arranged by Brett Chicko, DPM

26

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For long term DVT prophylaxis, what drugs do you order and why? Heparin and Coumadin.

Heparin works right away

Coumadin takes 3-5 days and causes an initial transient hypercoaguabJe state.

Risks for DVT?

I AM CLOTTED l-immobilization A-arrhythmia

M-Ml, past history C-coaguable states L-longevity (old age) a-obesity

T-Tumor

T-trauma

T-tobacco E-estrogen

D-DVT, previous history

What to do with patient with prior DVT? Greenfield filter

At what level of the body is a Greenfield filter inserted? In inferior vena cava below the renal veins

V\'hat is heparin's half-life? 1/2 -2 hours

How long before Coumadin works? 3-5 days

What are the INR values? Normal=l

Intense anticoagulation=2-3 High imensity=z.S-S

Advantages of Lovenox vs. regular Heparin? Disadvantages? Advantages- longer plasma Yz life

Significant anticoagulation in trough

Disadvantage- increased post-op complications when used with spinal/epidural anesthesia No way to test effects of Loven ox

What pathway does heparin use? Intrinsic

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Increases activity of antithrombin ITI 100 fold, which inhibits the serine protease (in the clotting cascade)

How to reverse heparin?

Protamine Sulfate] mg per 1 DO units of heparin

How does Coumadin work? Extrinsic pathway

Interferes with clotting factors Il, VII, IX, X

How to reverse Coumadin Fresh frozen plasma, Vitamin K

How do you check Lovenox? No real test

Dosing for Lovenox 30mg subq bid

How to use Heparin in DVT prophylaxis? 5000 units SQ 2 hours before surgery

5000 units SQ q 12 hours until patient ambulates

What is Lovenox (Enoxaprin)? Low molecular weight heparin

Peri-operative Management for Coumadin

Minor procedures (under local): keep them on their meds ifP.T. is stable.

Major procedures: stop oral meds 3 days prior to surgery and start back post-operatively.

How much control for Heparin and Coumadin Coumadin-keep 2 times normal INR Heparin-keep 2 to 3 times normal PTT

Dosing for Lovenox? 30 mg Bid SubQ

Local AnesthetDcs

Mechanism of action for local anesthetics'!

BlockNa+ channels and conduction of action potentials along sensory nerves

Only local anesthetic with vasoconstriction? Cocaine

Crozet-Keystone Residency Manual 2004, Arranged by Brett Chicko. DPM =,7


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Toxic doses of Lidocaine

300mg plain (30cc of 1 % plain) or 500mg w/ epi (50ce of .5% w/ epi) or 4.5 rug/kg plain or 7.0 rug/kg wi epi

Toxic doses of Bupivicaine

175 mg plain (35 cc if .5% plain)or 225mg with epi (45cc of .5% wi epi) or 2.5 mg/kg plain or 3.2 mglkg with epi

How are amides broken down? Liver-hepatic enzymes

(amides are lidocaine and marcaine)

How are esters broken down? Plasma psuedocholoesterase

"That does MAC (as in local with mac) stand for Monitored anesthesia care

"That breaks down cocaine?

Plasma psuedocholoeresterace Gust like other esters)

Pain Medications

Pain management with a codeine allergy? Stud-n (sttuddd-n)

S-Stadol

T-Toradol

T-Talwin

U-Ultram

D-Darvocet

D-Darvon

D-Demerol

N-Nubain

First choice for oral is Darvocet N-50 one to two tabs po q4-6° prn pain or Darvocet N- 100 one tab po q4-6° pm pain

First choice for non narcotic oral Ultram (Tramadol) 50 mg one to two tabs po q4-6° prn pain, max daily dose of 400 mg per day. I usually give this with Vioxx because it has a synergistic effect with Ultram

First choice for non-narcotic IV Toradol 30-60 mg IV

Choice narcotic IV pain med Demerol. ***Note, many hospitals, including our own, does not allow the use of Demerol due to its side effects.

N arne two non-narcotic analgesics. Ketoralac (toradol)

Tramadol (ultram)

Percocet?

Oxycodone and Acetaminophen, 5/325

(5/325 =5mg Oxycodone and 325 mg Acetaminophen) 1-2 tabs po q4-6" pm pain or 1 tab po q3 (0 prn pain

Vicodill

Hydrocodone and Acetaminophen, 51500

J -2 tabs po q4-6° prn pain or 1 tab po q3° prn pain

Darvocet?

Propoxyphene and Acetaminophen, N50= 50!325,N 1 00=1 00/650 ForN50 1-2 tabs po q4-6° pm pain or 1 tab po q3° pm pain

For N 1 00 J tab po q4-6D pm pain

Darvon?

For Darvon -Propoxyphene Hydrochloride and Acetaminophen

For Darvon 65 Pulvules-Propoxyphene Hydrochloride, ASA and caffeine 65mg/389/32.4 I tab po q4-6° pm pain

For Darvon N-IOOmg of Propoxyphene Napsylate

Tor-adol?

Ketorolac (an NSAlD) do not use more than 5 days IV dose is 30 mg IV q 6°

PO dose 10 mg q4-6° prn pain.

Toradol is not to be used more than 5 days due to kidney side effects

Ultram? Tramadol 50 mg

1-2 tabs po q4-6° pm pain or 1 tab po q3° prnpain

Morphine? Morphine sulphate

Variable dosing. For severe pain (post surgery) dosing: 2-4 mg IV q2-4 hour For a very painful dressing change or bedside debridement: 2mg TV x one dose

Demerol? Meperidine,

Our hospitals do not use this due to its side effects

Dilaudid? Hydromorphone

2 mg tabs: 1-2 tabs po q4-6° pm pain or J tab po q3° prn pain TV: O.5-2mg IM/SC

This drug is very. very strong,

Crozer-Keystone Residency Manual 2004, Arranged by Brett Chicko. DPlv129


30

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Tylenol #3?

30 mg Codeine phosphate and 300 mg acetaminophen 1-2 tab po q4-6 hours

MS Contin?

Morphine sulfate controlled release Start at 30mg tab, 1 tab po q8-12°

Oxycontin?

Oxycodone, narcotic agonist, controlled release One tab po p4°

What is the difference between Percoeet and Percodan?

Pereocet has 325 mg of acetaminophen and Percodan has 325 mg of ASA

RSD

",That is RSD?

Reflex Sympathetic Dystrophy

RSD is when the body doesn't heal in an orderly manor and pt will have an unexpected degree of pain, swelling, stiffness and dysfunction even though proper treatment was given,

Me Causes of RSD? General

1. Abnormal response in sympathetic nervous system

2. Abnormal reflex leading to vasomotor instability and pain

Specific

1. Trauma

2. Peripheral nerve injury

3. Drugs-anti-TB, barbiturates, cyclosporines But anything can cause it.

What are the stages ofRSD?

I. Acute-constant pain (intense burning) Possible edema, muscle wasting

Pain increased by light touch, movement and emotion

2. Dystrophic- increased edema that is indurated Constant pain by any stimulus

Skin is coo] pale and discolored

X-ray shows diffuse osteoporosis

3. Atrophic- intractable pain spreads proximally to involve entire limb Decreased dermal blood flow, thin shiny skin

Fat pat atrophy

Joint stiffen, may proceed to ankylosis

Call. RSI) show up on X-ray'?

Plain film findings in RSD include periarticular, mottled, irregular bony demineralization (seen in 30-60(1t, of cases) and cortical thinning.

Will RSD show up on a bone scan?

The 3-phase bone scan has sensitivity of %% and specificity of 98% ill detecting RSD. A normal scan does not exclude the diagnosis of RSD. The result of the bone scan is based OIl the RSD phase

Stage 1: (Early 0 to 8-20 weeks)

Increase flow and blood pool activity in the affected extremity. Increased activity, particularly in a periarticular distribution is noted on delayed images.

Stage 2: (Mid 2 to 6 months, possibly up to 1 year)

Flow and blood pool abnormalities begin to normalize, but increased activity on delayed linages persists.

Stage 3: (Late Over 6 -12 months)

Flow and blood pool activity can be normal or decreased (in about 113 of patients) in the involved extremity. Normal or decreased activity is commonly seen on delayed images, however. persistent increased delayed activity (3rd phase) has been reported in up to 40% of pts. Decreased flow in advanced RSD may be related to disuse, which is a common feature of post-hemiplegic RSD.

Diseases

"What is Haglund's Disease? Osteochondrosis of accessory navicular

Describe Malignant Hyperthermia

A side effect of general anesthesia includes tachycardia, hypertension, acid-base and electrolyte abnormalities, muscle rigidity and hyperthermia

Treatment of Malignant Hyperthermia?

Dantrolene (for muscle relaxation) 2.Smg/kg IV x l , then 1 rug/kg rapid IV push q6° until symptoms subside or until max dose of J Omg/kg

Treatment of cutaneous larva migraus Prometbia under occlusion

For diabetics, who gets diabetic ketoacidosis and who gets diabetic coma? Ketoacidosis-IDDM

Coma-NIDDM

Treatment for Lyme disease

Doxycycline 100 mg po qd or Rocephin J g IV gel

Crozet-Keystone Residency Manual 2004. Arranged by Brett Chicko. DPM 3 J

HOC for necrotizing fasciitis?

Primaxin 250-] 000 IV q6-8° (most commonly 500 mg IV gSD)

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Avascular necrosis of navicular bone in children

Triad for Reiters Arthritis Conjunctivitis Urethritis

(Pneumonic-can't see, can't pee, can't climb a tree)

'What is another name for Paget's disease? What is it?

Osteitis deformans- abnormal bony architect caused by increased osteoblast and increase osteoclast. More common in elderly

What are the stages of Paget's?

1. Osteolytic

2. Mixed osteolytic and osteoblastic

3. Late

"'hat is Felty's syndrome? Splenomegaly

Neutropenia

Rheumatoid arthritis

What is mycosis fungoids?

A cutaneous t-cell Iymphoma that presents as a erythematous eczematoid or psoriasiform ~plaque~tumor

What is erythrasma?

Superficial infection, asymptomatic, intertriginous (interdigital). Cause: comeybacterium minutissumum


What is erysipelas?

Superficial type of cellulitis involving lymphatics. Margin of lesion is raised and sharpley demarcated

What is ecthyma? How is it treated?

MC cause Staph Aureus and Strep pyogenes. Superficial infection extending into dermis characterized by crust erosion and ulcers. Treatment is Dicloxacillin

What is psoriasis?

Hereditary disorder me presentation in chronic scaling papules and plaques in areas of body related to repeated minor trauma. Koebner phenomenon and Auspitz sign are

present. Also present are nail pitting, beau's lines, oil spot subangual hyperkeratosis discoloration and destruction.

What is lichen planus?

Acute or chronic inflammatory dermatosis involving skin or mucous membranes characterized by flat top violaceous, shiny pruritic papules. Usually on flexor aspects of wrist and forearms. Histologically it has saw tooth acanthosis. Nails thinning. ridges and onycholysis

Derrnatologic presentation of Rheumatoid?

1. Rheumatoid nodules over pressure points ') nail fold infarcts, splinter hemorrhage

3. leucocytoclastic angiitis

4. dry eyes

5. skin looks like wet tissue paper

What is cellulitis?

Acute spreading infection of dermal and subcutaneous tissues Me cause group A strep or staph aureus

Red hot tender skin

Phases of Charcot?

1. acute or developmental

2. coalescence

3. reconstruction

l\lisceHaneo1llls Dru2:s

What can cause 'Gru)' Baby Syndrome"? Chloramphenicol

What is chloramphenicol? An antimicrobial

Which is the longer acting steroid. phosphate or acetate Acetate-crystallizes, only use every 3-4 months

What is diazepam'?

Trade name is Valium, a benzodiazepam, an anxiolytic/hypnotic/anticoI1vulsant

How to reverse diazepam '!

Flumazenil (Rornazicon) for benzodiezepam reversal

0.2 mg JV over J 5 seconds, then 0.2 mg TV pm over 1 minute up to J gram total

Common complication with steroid injection Post injection flare-s give ice

Crozer-Keystone Residency Manual 2004, Arranged by Brett Chicko. DPM

How are glocoeorticoids broken down? Liver, excreted in urine

Function of Biguanide Antihyperglycemic (not hypoglycemic)

What is Trentals generic name? Pentoxify liine

Rx fro sleeplessness BERARD B-Benadryl F-Estazolam H-Halicon A-Ambien R-Restoril D-Dalmane

Most commonly used are Benadryl 25 mg po qhs or Ambien 5 mg po qhs

What drngs leave a metallic taste in the mouth? Flagyl

Lamasil

'Who does Lamasil work? Inhibits ergosterol synthesis

What do you give with a Tylenol overdose? N-Acetyleyteine (mueo mist)

l\llSC

"'hat do you always ask with a break in the skin? Tetanus status

Signs of hypoglycemia Nervousness, tachycardia etc

Me gram negative for dog bite? DF-2

What is the most accepted theory about clubfoot? Germ plasma defect-malposition of head and neck in talus

What should the Bet and Hemoglobin be for elective surgery Hemoglobin 10 gmJdJ or greater

Hct 30 % or higher


34

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What part of the bruin regulates the body's temperature? f-J ypothalarnus

MC inflammatory arthritis ill men over 30'! Gout

MC time for post operative Myocardial infarction? Day 3

What are the hugs of bite wounds H uman-eikenella corroden Dog/cat-pasturella multicida

Another name for menopausal lipoma? Juxtamalleolar lipoma

How to culture osteomyelitis'!

1. Take one from middle of infection of bone

2. Take proximal cut-healthy bone at the edge of the remaining bone (to make sure you took out enough bone.

For a culture, how do you grow ghonorrhea? Chocolatelblood agar

Treatment for gonorrhea? Ceftriaxone

What type of bacteria is gonorrhea? Gram negative dipplococci

Most common cancers that metastasize to foot (bone?) LEAD KETTLE (PB for lead)

P-prostate

B-brain

K-kidney

Tvthyroid

L-lung

Where is Regranex made'? Puerto Rico

(1 was really asked this once)

What is Regrunex essentially'!

PDGF-l (platelet derived growth factors)

Crozet-Keystone Residency Manual 2004. Arranged by Brett Chicko. DPM 35

Crozer-Keystone Residency Manua12004, Arranged by Brett Chicko, DPM

36

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Clinical Podiatry

Describe the anterior drawer test (l have seen variations of this)

5-8 mm drawer-s-rupture of A TF

10-15 rum drawer -7rupture of ATF + CF >15 nun drawer -7rupture of ATF, CF + PTF

Describe the talar tilt test

> 1 0 degrees indi citive of rupture of CFL

Describe the stress inversion test SO inversion -7 A TF

10-30 -7 ATF + CF

What is Hooke's law?

For a material under load, strain is proportional to stress

What is Young's modulous?

After a load is removed, the material will spring back to its original shape, the resulting slope represents the stiffness of a material or Young's modulous

What is the Silverskiold test? For gastroc equinus

Dorsiflex the ankle with knee strait and then with the knee bent. If the dorsiflexion of the ankle with the knee strait displays equinus, then it is due to the gastroc. muscle.

Describe the 3 hammertoes

Flexor stabalization-pronated foot, late stance MC Flexor substitution-supinated, high arch foot, late stance

Extensor substitution-anterior cavus, ankle equinous, swing phase

What is Simon's rule of 15?

For clubfoot, children <3 years -7 talo-nav subluxation 1fT -C angle is <15°, talo-l st met angle is > 15°

"'hat to do if patient has edema with a cast If it goes down in am -7 gravity edema ~normal If it does not go down in am -7 abnormal

Clinical test for fracture?

Point tenderness over fracture site

What is Mulder's sign? For Morton's neuroma

Silent palpable click when you move mel heads together and up and down

How do you treat calcaneovalgus? Manipulation

Serial casting for 3-6 months-pluntarflex, Forefoot adduction, Rearfoot neutral Followed by gauley splints

Surgery

Lengthen or resect tight soft tissues Arthrodesis

Vi/hat type of acid is phenol and the .1., '! Carbolic acid. 89%

5 malignant bone tumors of the foot? Ewings

Osteosarcoma

Chondrosarcoma

Fibrosarcoma

Periosteal sarcoma

Name benign bone tumors of foot FOGMACHIHE

F -fibrous displasia O-osteochondroma

G-Giant cell tumor

M-Myeloma

A -aneurysmal bone cyst

C-chondroblastoma, chondrornyxoid fibroma, clear cell H-hemangioma

I -infection

N-non-ossifYing fibroma

E-Eosinophillic granuloma, Enchondroma, epidermoid inclusion cyst S-solitary bone cyst

What are the 3 components of clubfoot? What is the order of corr-ection? FF adductus, RF varus, ankle equinus

Correct the FF and RF together first. then the ankle equinus

Tests for lateral collateral ligament pathology

1. A TF- anterior drawer test

Push pull late stress radiograph

2. Calcaneofibular-stress inversion mortise radiograph 3. ankle arthrogram, peroneal tonography

"'hat is Q angie'!

The angle between the axis ofthe femur and the line between patella and tibial tuberosity

Crozer-Keystone Residency Manual 2004. Arranged by Brett Chicko. DPivl _, /

What do you do for anesthesia if pi is allergic to all local anesthetic and you're doing a nail avulsion?

Saline block (pressure induced block) Pressure cuff

Benadryl block (blocks histamine release)

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Note-Also see the section on Classifications

Name the fractures Pott's

CottOIJ'S Bosworth's Maisonnueve Volkman's

Tillaux

Wagstaff Shepard's

Cedell's

Foster's

bimalleolar fx trimalleolar fx

lat melleolar fx witb ankle displacement proximal fibular fx

posterior tibial malleolar fx

avulsion fx of the ant lat tibia

avulsion fx ofthe ant med fibula

fx of post lat process

fx of post med process

entire posterior process

What is Lange-Hansen type V? Pronation dorsiflexion

Stage l-verticle fx of tip of tibial malleolus 2-& of ant tibial lip

3-spramal1eolar fib ]-X

4-transverse fx of post tibial, level with prox aspect of ant tib fx

0;;, of fractures of tarsus that involve the calcaneus? 60%

Of these fractures, how many ivolve the involve the joint? 75%

Me complication of fracture J. Delayed union

2. Non-union

3. Pseudo arthrodesis

4. OAIAVN

Iv[C cause of non-healing for a bone fracture Improper immobilization

What is Rosenthal's classification? For nail trauma.

Classification is based 011 level of injury and direction Level- Zone l-distal to bony phalanx

Zone 2-distal to lunula

Zone 3-proximal to distal end of lunula Direction

Crozet-Keystone Residency Manual 2004, Arranged by Brett Chicko. DPM 39

Dorsal (oblique) Transverse Plantar (oblique)

Axial (tibial or fibular oblique) Central (gouge)

What is Sneppen 's classifcation? For talar body fractures

What is a high fibular fracture called? 'What is the mechanism of action? Massoneuve fracture

Pronation external rotation

W11at is the most common locations oftalar dome lesions and their mechanisms of injury?

DlM,A PIMP

Dorsiflex inversion-7anterio lateral lesion Plantarflex lnversiorr+medial posterior

What are classifications for talar dome lesion Bernt-Hardy

Fallot and Wy

Name the appropriate classification (See classification section for more info.) Ankle fracture

Phalangeal/nail

Anterior process calcaneal fracture Lis Franc Jt

Talar body

1 st Metatarsophalngeal Frostbite

Calcaneous

Physeal ankle fx

Talar dome

Achilles rupture

TP based on MRI findings Talar neck

Navicular

Epiphyseal fx

Pilon fracture (distal metaphysis oftibia) Ankle sprains

5th met base Open fracture Non-unions

Lauge-Hansen Rosenthal Degan

Quenu and Kuss, Hardcastle Sneppen

Jams

Orr and Fainer, Washburn

Rowe, Essex and Lopresti, Sanders Dias and Tachdjian

Bernt-Harty, Fallot and Wy Kuwada

Conti

Hawkins

Watson Jones

Salter-Harris

Ruedi and Allgower

O'Donoghue, Leach" Rasmussen, Dias and Tachdjian, New Dias Stewart

Gustillo

Weber and eech


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VI'ha! do you test clinically test via Toe Test of Jack'! Foster's Fx rfx of entire posterior process)

What is ~t Stida process'!

Enlarged Os trigonum

What is Mandors Sign?

A hematoma in sole that is pathognmonic of calc. fx.

"'hat is HOml'S Sign'!

An upward & forward displacement of tuberosity which relaxs Achilles &: decreases plantar flexion

What is the mechanism of injury (MOr; to the ankle with a transverse fibular fracture? The foot is supinated with adduction motion. Lange-Hansen SAD

What is the MOl to the ankle with a verticle tibial fx?

The foot is supinated with adduction motion. Lange-Hansen SAD

What is the MOl to the ankle with a oblique fx to fibula on i\P and transverse fibular fx on lat?

Foot is pronated with an abduction motion. Lauge-Hansen P AB

What is the MOr to the ankle with a fibular spiral fibular fx? Foot is supinated with external rotation. Lange-Hansen SER

What is a Maissonueve FK and' how as it caused?

A fibular oblique fracture about the mortise jt. It is caused by the foot being pronated with external rotati on.

What is a Thurston-Holland sign

It is when the epiphysis is separated from the physis with the fracture extending into the metaphysis. It makes a triangular fracture fragment.

'Vhat is aF!ag sign '!

It is also called a Thurston-Holland sign. It is when the epiphysis is separated from the physis with the fracture extending into the metaphysis. It makes a triangular fracture fragment

What is a Huwkins sign '!

It is a subcondral radiolucencv under the talar bodv on an ankle AP. This means that that

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the talus does not have anA VN

Crozer-Keystone Residency Manual 2004. Arranged by Bre11 Chicl;o. nPM 41

Between week 6-8 an AP of the ankle reveals the presence or abscense of subchondral atrophy. Subchondral atrophy is indicative of vascularity of the talar body thereby excluding the diagnosis of A VN.


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Whar orders should you order for an inhouse pt for surgery? Labs-cbc with diff pr/ptr/inr, sma-?

X-ray;; OR in AM

Anesthesia to see pt

npo after midnight

Chest x-ray, ECG (if necessary)

(Y OLI might also have to call for medical clearance of the patient)

What other factors does one have to be concerned with when getting the patient ready for surgery?

lfthe patient is taking steroids, insulin, anticoagulants or anything else that might put the patient at risk.

Note: it is usually best to dear any non-routine orders with the patient's primary service.

CBC with Diff

What is in a CBC?

liVBC (white blood cell count), hemoglobin, hematocrit and platelets.

Normal lab values of CBC?

Note: every lab has different lab values.

'NBC 5000 to 10,000

Hemoglobin For males is 14-] 8 g/dl

For females is 12-16 g/dl

Hematocrit For males is 40-54% For females is 37-47%

Platelets 150,000 -450,000

When dealing with an infection, what do you expect to happen to the WBC count after surgery?

Eventually it should go down, but in post-op days 1-2 the WBC may go up a point or two. This is believe to be because surgery stirs up the body's reaction to the infection. It lS a common occurrence.

What to do if ""Be is over 10

First decide if the patient has an infection or not.

l. 11' the patient has an infection. then the antibiotics and the possible incision and drainage (I&D) should eventually decrease the WBe count.

2. If non-infected pt. then you must find out the cause. Is then is the patient taking corticosteroids? Is the increase acute or chronic? Is there a combination of medical condition causing this? Notify your attending/senior resident (as always).

Crozet-Keystone Residency Manual 2004, Arranged by Brett Chicko. DPlvl 43

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What to do if platelets are low (under 150,006-350,OOO/mL)? Notify your attending/senior resident

Can transfuse platelets, but it is not commonly done.

What should the Bet and Hemoglobin be for surgery'! Hemoglobin 10 gm/dl or greater

Hct 30 % or higher

What to do if the Hemoglobin/Hematocrit if below 10/30? Notify your attending/senior resident

Can give patient packed red blood cells (PRBC)

What is the condition called? Anemia.

'What is in a sma-7?

Sodium, potassium, chloride, carbon dioxide, BUN (blood urea nitrogen), creatinine, glucose

What is in a sma-12?

Sodium, potassium, chloride, carbon dioxide, BUN (blood urea nitrogen), creatinine, glucose plus calcium, cholesterol, phosphatase (alkaline), transaminases (alanine and aspartate)

What are the normal values of a sma-7? Note values change with different labs

Na+ 134-149 meq/l

Potassium 3.2-5.2 meq/l

Chloride 94-110 mmol

Carbon dioxide 19-32 mmol/l

Bun 6-26 mg/dl

Creatinine 0.4-1.59 mg/dl

Glucose 56-124 rng/dl

What does Na+, K+, CI and CO tell you? Nutritional status. These are your electrolytes

Wbat to do if N a+ is low? Give NSS or regular salt.

What should your K+ levels be?

For K+, ifpt is on digoxin worry if the K + level is around 3, ifnot worry ifbelow 2.8. This condition is called hypokalemia.

The K + should be below 5.2. If it is above that the condition is called hyperkalemia.


What to do if K + is too low?

Notify your attending and the anesthesiologist

Give K rider (potassium chloride supplement). also give potassium food in diet i.e., banana

What to do with an elevated K+ (Hyperkalemia)? Witb a K + over 5.2 meq/L,

1 st get ECG.

2nd manage the hyperkalemia

Calcium gluconate 10<X, give 10 ml over 2-5 minutes Sodiwn bicarbonate 7.5%, give I ampule IV over 5 minutes Manage the glucose and insulin

What does bun and creat tell you? Kidney function

What to do if creatinine is high?

Consult renal if creat is over 1.5 for a couple of results. Note creat may be increased after muscle loss or breakdown.

Which is more important-Bun or creat? Why?

Creat is more important because bun is influenced by hydration state. In other words, if bun is high but creat is normal, then the patient is most likely dehydrated and rehydration (i.e .. NSS at 80 cc per hour) should correct the bun.

However, if bun and creat are both high, then the patient most likely has kidney damage.

""hat do PT/PTTIINR tell you? The coaguable state of the patient

If one of these is high, it means that the patient will take longer to stop bleeding or it is harder for the pt to develop a blood clot. It only takes blockage of one of the pathways to anticoagulate the patient.

PTIPTTlINK

What causes the PTT to he high 'l Heparin

What is the normal value for PTT'! I 0.1-1 3.J seconds

'Which pathway does rTT check? Intrinsic

Crozet-Keystone Residency Manual 2004. Arranged by Brett Chicko. Dl'M 45


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Which pathway does PT check? Extrinsic

'What call cause the J>TfINR to he high'! Coumadin (rnostlikely)

Malnutrition

Alcoholism

Antibiotics

Metabolic disorders

What does INR stand for and why was it developed? International Normalized Ratio.

The INR was developed because there are different ways to determine the PT and thus there are different lab values of normal and abnormal. INR was developed to take all off the different P'T's and make it into a set oflab values (the INR) that would be constant regardless of the method to develop the PT.

"That are the INR values? Normal=I

Intense anticoagulation=z-S High intensity=2.5-3

What do you want the INR to be for most surgeries? Under 1.4

What to do if the INR is over 1.4? Tell your attending/senior resident

Transfuse Fresh Frozen Plasma (FFP). Under normal circumstances, one unit of FFP should decrease the INR 0.2, however, this is not a hard rule.

Vit. K is an option, but it will only bring it the INR a small bit and it takes over 24 hours to work.

When is it ok to have an INR higher than 1.4?

l , The risk of surgery outweighs the risk of excessive bleeding (i.e .. If it is an emergency surgery and you have anesthesia's ok)

2. With a patient with PVD and you are doing a debridement or amputation. I have seen debridements with an INR at 1.6.

Note: if the patient has PVD, make sure you have Vascular Surgery's OK for surgery. In this case it is acceptable for the patient to bleed a little extra-that is what we are hoping.

!fyou do surgery 011 a patient that has a high ThTR, what to you want to watch? The hemoglobin and Hematocrit. Make sure the patient is not anemic. lfthe Hemoglobin goes below 8, think about transfusing with prbc's.

When to discontinue aspirin before surgery? 7 days

When to die the coumadin before surgery? 3-5 days

When to die the heparin before surgery? g hours before surgery

Crozet-Keystone Residency Manual 2004. Arranged by Brett Chicko. D PM 47

Surgery

Fixation Devices

AO internal fixation principles (2002)

1. Anatomic articular reduction, adequate shaft reduction

2. Stablelbiologic fixation

3. Preservation of blood supply

4. Early ROM

Note: in 1958 the AO principles were:

1. Anatomic reduction

2. Rigid internal fixation

3. Preservation of blood supply

4. Early ROM

Describe mini fragment screws

Sizes 1.5,2.0, 2.7-aU fully threaded and all cortical

Bow much of a screw do you want to show past the far cortex? 1- Yi threads

What is the screwdriver handle made out of? Pressed linen

Difference between cortical and cancellous screw

1. Cortical has smaller pitch

2. Cortical has smaller rake angle

3. Cortical has smaller difference between thread diameter and core diameter

"That are tbe steps to inserting a fully threaded screw? Predrill the length of the bone

Overdrill near cortex

Countersink

Measure

Tap

Insert

What is the purpose of tapping? Gives a path for the screw threads

Why do you countersink a screw? Stress risers

Soft tissue irritation

Even compression from screw head (land)


48

Descrtbe a malleolar screw

For fixation of medial malleolus. partially threaded. same thread profile and pitch as cortical screw. trephedine self-cutting tip

Why do you use ~I fluted tip screw'? Self-tapping

What arc the screw shes'! What are their predrill sizes'; What are their overdrill & countersink sizes?

Mini Fragment

Sizes 1.5 2.0 2.7 ;l'**AIl are fullv threaded
Predrill 1.1 1.5 2.0
Countersink 1.5 2.0 2.7
OverdrilI 1.5 2.0 2.7 SmaH Fragment

Sizes 3.5

4.0 fullv threaded

4.0 nartiallv threaded

Predrill 2.5

Overdrill 3.5

Countersink 3.5

2.5 4.0 4.0

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4.0 4.0

Large Fra~meIrlt

Sizes 4.5
Predrill ..., ')
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Countersink 4.5 4.5 malleolar

6.5 partnaHv threaded

6.5 fullv threaded

3.2 4.5 4.5

3.2 6.5 6.5

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6.5 6.5

What sizes are in the Synthes modular hand screw system? Screws sizes of 1.0, 1.3, 1.5.2.0.2.4,2.7

What are the canulated screw sizes? For Synthes 3.0.4.0

For Smith & Nephew 4.0 & 6.5. 5.5 and 7.0

What arc the steps for inserting a 4.H canulated screw? Insert 1.3 mrn guide pin to appropriate distance

Measure

Ream near cortex with 4.0 canulated cortex reamer (optional)



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(for soft bone this is unnecessary) Tap (unnecessary with self tapping screws) Countersink

Insert screw

What is a Herbert screw?

Headless, can insert through articular cartilage. Threaded portion proximal and distal, smooth in-between. Prox tighter pitch for compression. For met osteotomies, Aikins.

'What is a Reese screw?

Headless, to create compression through arthrodesis. Prox part clockwise threads. Distal part counterclockwise. Smooth in between

What are the K-wire sizes and their width in millimeters?

Sizes .028 .035 .045 .062

Millimeters 0.6 0.9 1.2 1.6

Why did I ask you a question about K-wires in a screw set section?

Because Kvwires can be used for the pre-drills if the situation arises (the predrill is missing or it dropped on the floor).

The .062 can be used for the 1.5 predrill (for the 2.0 screw) The .045 can be used for the 1.1 predrill (for the 1.5 screw)

What are the K wire sizes and their appropriate caps?

.028 .035 .045 .062

yellow blue

(young boys wear green)

white

green

Size of Steinman pins

Everyone from 5/64 to 12/64 except for 11164

For a download of the Smith and Nephew catalog go to http://www.smithnephew.com!Downloads1711804 n.pdf

Suture and Absorbable fixation devices What is orthofix?

PoJygJycolic acid (same as dexonjtdexon=orthofig)

What is orthosorb? PDS (PD.s.=ortho~orb)

In terms of fixation, what is the time difference between absorbable and non-absorbable? Absorbable gets absorbed within one year.

How long before PDS loses strength? ,.Vhcn ahsnrbed? Loses strength-s-f weeks

Absorbed 3-6 months

What are the two sutures that are tilt' least reactive to tissue'! Stainless steel (least reactive)

Prolenc

Should you usc vicryl with all infection'! Not if you can avoid it"'" vieryl is too reactive

How long does it take vicryl to absorb '! 80% absorbed in 21 days

~A...rthroscopv

Name a few indications for ankle scope Synovitis

Chondromalacia

Osteochondral lesion/fracture Impingenent lesion

Erosion

Name some scope techniques Scanning-side to side, up and down Pistoning-in and out

Rotation- 360°

What is the light intensities for arthroscopes

Tungsten 2900 kelvins

Metal halide lamps 5800 kelvins

Xenon 6000 kelvin

What are the cameras for a scope?

Saticon-good for low light not submersible for sterility CCD integrated-circuit camera-needs more light less bulk

Who first describe arthroscopy? Takagi

First podiatrist to describe a podiatric use for arthroscopy? Heller and Vogel in 1 Y82

Name 3 surgical treatments for plantar fasciitis? Endoscopic plantar fasciotomy (EPF)

Crozer-Keystone Residency Manual 2004< Arranged by Brett Chicko. DP!v1 5]

Durvies Griffith

MC complication of EI)F

Lateral column instability -7 calcaneal-cuboid joint pain

1st Rav Surgery

MC indication for lapidus? Hypermobile 1 st ray

Order of lateral release for a McBride?

1. Extensor hood

2. AdH tendon

3. fibular sesmoid ligament

4. lateral collateral ligament

5. FRB

6. fibular sesmoid excision (if performing)

Purpose of an implant?

To maintain space between bony surfaces

Difference between a Vogler and Kalish and a Y oungswick? Vogler-offset V (apex at metaphyseal-diaphyseal joint) Kalish-Austin with angles of approx 55° for screw fixation

Y oungswick-Austin with a slice taken dorsally to allow the capital fragment to PF

Correction of P ASA Reverdin

Peabody

Biangular Austin Offset V with swivel

Correction of DASA Proximal Aikin

Correction for hallux abductus Interphalangeous Distal Aikin

Plasti c Surgery

"That is an anti-tension line? S shaped or zigzagged


52

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Vi'hac is the order of wound graft closure'!' J. direct closure

grail

3. local Gap

4. distant Gap

To dose a lesion properly, what must the length vs, the width he'! 3: I length X width

How long for orthofix to lose strength/absorb '! Loses strength in 6-12 weeks

Resorbs in 1-3 years

"'kite and Brack TOle Post-Op

Causes of a white toe post surgery Arterial in nature, usually acute Signs-pain, pale, pareshesia, pulselessness

Treatment of white toe? 1. avoid nicotine

") clIc ice and elevation

3. put foot in dependent position

4. loosen bandages

5. rotate k-wire

6. proximal warm compresses

7. local nerve block proximally

8. nitroglycerine paste proximally

9. consult vascular surgery

What are causes of a blue toe?

Either from poor arterial inflow or sluggish venous outflow If. ..

Blue toe due to slu[!£!ish venous outflow-s-toe is warm and will blanch with pressure I. inspect dressing, loosen/change if needed

") d/c ice (not elevation)

3. avoid dependency

4. don't attempt to increase vascular perfusion

5. consult vascular surgery

hlue toe due to arterial insufficiencv-s toe is cold and doesn '( blanch with pressure

(Treat like white toe)

1. inspect dressing, loosen/change if needed '1 rotate/remove Kvwirc

3. d/c ice and elevation

4. avoid nicotine and caffeine

Crozer-Keystone Residency Manual 2004. Arranged by Brett Chicko. DP)vl 53

5. heat to popliteal fossa or anterior groin

6. thermostat controlled heat lamp, not to exceed 90(; F

7. vasodilators

a. oral-niacin, nifedipine, cyclospasmol

b. nitroglycerine paste

'What to do if you drop the capitol fragment on the floor'!

1. rinse with saline

2. bacitacin soak for 15 minutes


4. bacitracin soak for ] 5 minutes


6. document and tell patient

Rearfoot Surgery

What is the Valente procedure

An STJ block using a polyethylene plug witb screw tbreads. Allows just 4-50 of STJ pronation afterwards

What is Mondor's sign?

Ecchymosis in the rearfoot the goes to the sole of the foot. Indicative of calcaneal fx.

Name 3 treatments of Haglund's deformity? Keck and Kelly

Duvries

Foller and Phillip Dickerson

Treatment for Equinous (tendon)

1. Stretching/exercises

2. Nightsplints

3. Gastroc recession

A. Vulpius

B. Strayer

C. Baker

D. McGlammary and Fulp

4. Tendoachilles lengthening

A. open/closed z

B. Hauser

C. White

D. Hoke

E. Sglarto

F. Stewart


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Name a sur-gical pr-ocedure for pe~ pi:ums in each of tilt: planes Transverse

Evans

c-c distraction arthrodesis Kidner

Sagital

Lowman Cotton Hoke

Miller Young Cobb

Frontal

Chambers Baker-Hill Dwyer

Gleich

Lord Koutsoganis

What is a Keck and Kelly procedure'!

For Haglund's deformity with cavus foot with high calcaneal inclination angle. Remove wedge from posterior-superior aspect of calcaneous. The posterior superior prominence is moved anteriorly.

What is arthroesis?

An operation to limit joint mobility (i.e. MBA plug in sinus tarsi)

What order do you resect and what order do you fixate the joints in a triple arthrodesis?

Resection-I: midtarsal joints (T-N, CCJ) 2. subtalar joints (T-C) Fixation-opposite order

1. subtalar joints

2. midtarsal joints

Types of fixation in a triple arthrodesis

MC- 6.5 mm-7.0 mm interfragmental compression screws Others-blount staples, pneumatic staple designed by 3M company

How does a bone stimulator work?

Piezoelectric principle-side under compression makes a negative charge that leads to bone growth. Therefore, put a cathode in non-union and its negative charge will stimulate growth.

Etc.

What is in antibiotic beads?

PoJymethylmethalcralate with antibiotic (usually use gentamycin because it is heat stable, good diffusion coefficient small surface area, a lot of research has been done on it. Tobramycin is also used)

Crozet-Keystone Residency Manual 2004, Arranged by Brett Chicko. DPM 55

For surgery, what can you not give to a patient if they have an egg shell injury? Propophol (diprovan)

'What is a Blair and Humbrey knife? A knife for skin graft.

Contraindications to a tourniquet'! Open fracture of a leg

Severe crushing injury

Severe hypertension

Skin grafts in pi where bleeding must be distinguished Compromised vascular circulation or arterial graft DM-(not absolute contra-indicaton)

Sickle cell dx

Infection

What ABI is inadequate for healing in diabetics <.6

What is needed to heal digital wounds? 30mmHg

What is the lag time for osteomyelitis on an x-ray? 10-14 days

'What is the direction 'of the cut for reverse 'Wilson of the sth toe? Distal lat to proximal medial

1 st to describe arthrodesis? Soule

Name the order of hammertoe surgery

1.PIP] tendon

capsule-dorsal collaterals capsule-plantar artbrop lasty

2. MPJ hood

tendon capsule plantar plate arthrodesis

3. PIPJ

* do Kelikian push up in between each step to determine if the next step is needed.


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Much of the information in this section is also found in the Antibiotics section.

However, in this section, the emphasis is on the clinical presentation or the test results and how to proceed from there. I believe this would be useful because often the decision on choosing a drug is based on the gram stain or clinical presentation.

Obviously, thanks to Dr. Joseph, DPM for much of this information.

-Brett

Common Bugs. Dr1Ll!~s and Alternatives

What is catalase positive, gram positive co cci in clusters'! Staph Aureus

Drug of choice for staph? Keflex for PO, Ancef for IV

Alternative for staph?

Clindamycin, Levoguin, Vanco, Azithromycin, Dicloxacillin, Naphcillin

Alternative for staph if PCN all? Clindamycin, Levoquin, Azithromycin, Vance

'What if the cultures and sensitivities (C&S) come back and the bug is resistant to the above antibiotics?

It is Iv1RSA (methacillin resistant staph aureus)

DOC for MRS A ?

Vancomycin for IV, Bactrim (if sensitive) or Linezolid for PO

Alternative for MRS A ? Synercid or Linezolid

What is a gram positive cocci, single, paired or chained? Strep.

DOC for Strep?

PCN (or more commonly Keflex for podiatry) for PO, Anceffor rv

Alternative for Strep?

CI indamycin, Levoquin, Vanco



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DOC for VRE'!

Linezolid (IV or PO) or Dalfopristin-Quinupristin (Synercid)

What is small, polarly flagellated, gram negative rod with pili? Pseudomonas aeruginosa

DOC for Psuedomonas Aeruginosa? Cipro

Alternatives for Psuedomonas Aeruginosa? 3rd gen cephalosporin, aztreonam, bactrim

How do you expect Psuedomonas to present? Blue-green pus and a grape like sweet odor?

What is a gram negative, anaerobic rod? Bacteroides Fragilis.

DOC for bacteroides (anaerobes) for the diabetic foot? Unasyn, Augmentin, Timentin, Zosyn

Alternatives for bacteroides ( anaerobes) for the diabetic foot if PCN allergy? ClindamyciniCipro, Primaxin, FlagyI

DOC for enterococcus? Amoxicillin PO OT Vancomycin IV

Alternatives for enterococcus? Augmentin, Linezolid

DOC for Lyme disease (Borrelia)? Rocephin, Doxycycline

Alternative for Lyme diseas? Amoxicillin

DOC for Diptheroids? Vaneo

"That is gram negative diplococcus, oxidase positive? Neisseria gonorrhoeae

DOC for N. GOllorrhocae?

PCN (if susceptible). although a 3rd generation cephalosporin such as ceftriaxone (Rocephin) appears to be the DOC

What is anaerobic, spore forming, large gram positive rod? Clostridium perfringens

What are the two soft tissue clinical manifestations caused by Clostridium?

1. anaerobic cellulitis

2. myonecrosis (gas gangrene)

Why is gas gangrene a surgical emergency?

Because it progresses rapidly to shock and renal failure. Fatal in 30% of untreated cases.

Less Common (To Podiatrv) Bugs~ Dnl£:s and Alternatives

What is a gram negative short rod? E Coli

DOC for E. Coli? Keflex or Ancef

Alternative for E. Coli if peN all? Cipro or Levaquin

DOC for proteus? Keflex or Ampicillin

Alternative for proteus if~)CN allergic'! Cipro or Levaquin

DOC for E/C/S/M group'! Quinolone (Cipro/Levaquin)

Crozer-Keystone Residency Manual 2004. Arranged by Brett Chicko. DPM 59

Alternatives for the E/C/SfM group? 3rd gen ceph, aztreonam, bactrim

DOC for Aeromonas? Cipro

Alternative for Aeromonas? Bactrim

DOC for Xanthamonas? Bactrim

Alternative for Xanthomas? Ceftazidime


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A DOC for P. Cepacia? Bactrim

Alternative for P. Cepacia? Ceftazidime

Miscellaneous

What is the drug of choice (DOC) for a diabetic with a peN allergy? Clindamycin

DOC for severe limb threatening infection? Primaxin

DOC for bite wounds? Augrnentin

What is B-hemolytic and coagulase positive staph? Staph Aureus

What is gram positive, catalase negative? Strep

What has blue-green pus and a grape like sweet odor? Psuedomonas aeruginosa

Which type of step causes impetigo, cellulitis and erysipelas? Group A strep

What is the difference between cellulitis and erysipelas?

Cel1ulitis is if the lesion is confined, erysipelas applies if the lesion spreads most likely through lymphatics

Vi/hat is gram positive, anaerobic filamentous hacternnn? Actimomyces

What are the organisms most likely to cause gas in tissues'? (Nemonic BECK-SP)

Bacteroids

Escherichia

Clostridium

Klebsiella

Serratia

P eptostreptococcus


61

Gout

How to treat acute and chronic gout? Acute-colchicine NSAIDS-indomethacin Corticosteroids

ACTH

Chronic-colchicine (prophylactically) Allopurinol

Uricosurics (probenecid sulfinpyrazole)

Stages of Gout?

1. Asymptomatic Hyperuricemia

2. acute gouty arthritis

3. intercritical gout

4. chronic gouty tophaceous gout

Can you use Allopurinol, P.robenicid or Sulfinpyrazole for acute gout? No, because they may cause a initial hyperuremia.

How do you test for gout?

Uric Acid level (normal is under 7 mg/dL) Aspirate the joint and send to pathology

What is a positive test for gout in pathology?

Monosodium urate crystals are needle shaped and display a negative birefringence under a polarizing light microscope.

For gout, how do you tell if someone is an overproducer or underexcreter? Take a 24 hour uninalysis

Which is more common-to be an underexcretor or an overproducer? Underexcreter make up approx 90%

Me inflammatory arthritis in men over 30? Gout

What medication to give a patient with gout if the pt is an overproducer or underexcretor? Pneumonic-OverAchieving, UnderPaid

Overproducer-s allopurinol

Underexcreter-sprobenecid

What is a martini sign?

For gout-s histo shows glucophage engulfing crystal (looks like martini and olive)

Crozet-Keystone Residency Manua12004, Arranged by Brett Chicko, DPM 62

What to send specimcnr in if you suspect gout'!

One in formaldahyde (dissolves gout, but is the usual medium for sending most specirnents)

One in alcohol (does not dissolve gouty tophi)

Dosing of colchicines?

There are two tablet forms-O.5mg and 0.6 mg

Both are one tablet po q2° until the gout pain is gone or until pt develops the gastrointestinal side effects

Daily max dose of colchicines? Po 8mg, IV 4 mg


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Case Studv 1

A 23 yo pt presents ill the Emergency Department with foot trauma.

1. What do you do first?

Get a quick history and check neurovascular study.

2. Results

History-pi has his foot run over at work.

The patient states that his foot is ] Oil 0 pain, toes feel cold and numb.

NV check-You check his pulses and they are present, his toes feel cold, he can

not feel you touching the toes, his toes are changing color (purple or white) and he cannot move his toes. What is going on?

Compartment syndrome


64

3. What do you do next?

Remove dressings casts etc. If compartment syndrome persists, prepare pt for surgery-this is a surgical emergency. Compartment syndrome is a clinical diagnosis, according to The AO principals course. It is better to get the patient up to surgery than it is to find an instrument to measure the pressure.

Preparation for surgery-call your attending and senior residents, x-rays, labs, npo, anesthesia to see patient, consent.

What is compartment syndrome?

A condition with increased tissue in a limited space compartment which compromises the circulation and function of the tissues. It can lead to ischemia of the tissues.

What are some of the causes of compartment syndrome?

Fractures, crush injuries, prolonged limb compression and postischemic swelling. In a sense, any injury can cause compartment syndrome.

What are the signs of compartment syndrome'! Pain out of proportion (most important) Paresthesia

Pallor

Pulses present Poiklothermia (cold) Paralysis

What are some forms of measuring pressure?

Wick catheter, slit catheter, needle technique, continuous infusion technique But as stated before, this should be a clinical diagnosis.

What is the treatment'?

Fasciotomy oftbe compartment. In the leg surgical access should be made to access all four compartments.

To do a leg fasciotorny, make one incision medial to Tibia and one lateral. From the Medial incision, open the superficial and deep posterior compartments, From the lateral incision, open the anterior and lateral compartments.

What are some absolute indications for a fasciotomy? Motor and sensory loss

Tissue pressure above 35 mml-lg Pain out of control

Crozer-Keystone Residency Manual 2004, Arranged by Brett Chicko. DPM 6:5


66

Case study 2

A patient who you prescribed pain medication has wheels, hives, itching and trouble breathing after taking the medication.

What is most likely going on? Anaphylaxis

What is anaphylaxis?

A rapid, generalized immunolgical1y mediated events that occur after exposure to foreign antigen substances in previously sensitized persons. This syndrome can affect any organ in the body, but most commonly it affects pulmonary, circulatory, cutaneous, neurologic, and GI.

"That causes anaphylaxis?

It is the interaction of a foreign antigen with specific IgE antibodies found on tissue mast cells and peripheral blood basophils. Their release of histamine and other mediators cause smooth muscle spasm, brochospasm, mucosal edema and inflammation, and increased capillary permeability.

Clinical symptoms of anaphylaxis

Common (mildj-uticaria, weakness, dizziness, flushing, angioedema, congestion and sneezmg

More severe-upper respiratory tract obstruction, hypotension, vascular collapse, GI distress, cardiovascular arrhythmias and arrest.

What is the difference between anaphylaxis and anaphylactoid reaction?

They present the same clinically, but anaphylactoid reaction is not mediated by IgE antibody and not necessarily requiring previous exposure to inciting substance.

What is the best way to prevent anaphylaxis?

History and elimination and avoidance of offending substances.

How do you treat anaphylaxis?

1. First thing is to stop the offending agent and other possible agents. lfthat means to dlc all meds, then do it.

2. If the patient is having life threatening problems like the case above, get them to an emergency department if they are at horne. Get the right people involved (attendings, senior residents etc.)

3. Treat the symptoms. Airway-bronchospasm

Initial therapy-epinephrine 0.5 ml of 1: 1 000 dilution (0.5mg) subq every 10-20 min Oxygen 40- ] 00 percent

Meraprcterenol 0.3 ml (Y!;() solution) in 2.5 ml of saline in a nebulizer, 2- 3 puffs every 3-4 hours

Second therapy

Amiophylline loading dose omg/kg IV over 30 min period. Maintenance 0.3 -0.9 rng/kg/hr rv (for bronchospasm)

Corticosteroids 250 mg of hydrocortisone or SO mg of methylprednisone TV q6° for 2-4 doses (bronchospasm)

Cardiovascular reactions-(hvpotension}

Initial therapy-TV fluids 1 L q20-30 min as needed. Maintain systolic BP >80-100mmHg Epinephrine l mg in I :100(J dilution in SOOml ofD5W IV at a rate of .25- 2.5 ml/min

Secondary therapy-Norepinephrine 4mg in IL ofD5W IV at 0.5-3mI/min Antihistamines (as above)

Cutaneous reaction-

lnitial therapy-epinephrine 0.5 ml of 1: 1000 dilution (O.Smg) subq every 10-20 min Secondary therapy-Antihistamines hydroxyzine (atarax or vistaril) or

diphenhydramine (benadryl) 25-50 rug IM or PO g6-8° pm

4.Document offending agents and educate patient for future avoidance.


NSAIDS

'What pathway do NSAIDS work on? COX (J gave you an easy one to start)

'What are the selective COX-2 inhibitors

Celebrex (celecoxib), Vioxx (rofecoxib), Bextra (valdecoxib)

What are the NSAIDS with the least nephrotoxicity? COX-2's, Relafen, Lodine

"What effects do NSAIDS have on asthma? NSAIDS can increase the symptoms of asthma,

What NSAIDS are safest for someone with asthma? Diclofenac, Ketoprofen

What NSAIDS do not inhibit platelet aggregation? COX-2 inhibitors

Which treat collagen vascular disease? Ibuprofen, tolmentin, sulindac

Which NSAIDS are non-renal clearance? Indomethacin, and sulindac

What effects can NSAIDS have on cardiovascular? Can increase blood pressure and cause vasoconstriction.

What NSAIDS have the least effect on cardiovascular? Diclofenac, Ketoprofen

What NSAIDS do not decrease the chance of a DVT post-surgery? COX-2 inhibitors (because they do not inhibit platelet aggregation)

What are the most hepatotoxic? Ibuprofen, naprosyn, aleve, diclofenac.

Indications for Vioxx?

Osteoarthritis, rheumatoid arthritis, menstrual cramps

Most common side effect for NSAIDS?

G1 disturbance (except with cox-2 inhibitors)


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.,. V1fhat is the only IV NSAIT},! Ketorolac tromethamine (Toradol)

Does giving NS..AJDS rv decrease the GI disturbances?

]'-10, because NSAIDS still inhibits COX-I. COX-J has cyptoprotective agents

"That to give with an Indomethacin over-dose'! Benadryl (decreases serotonin and histamine release)

What is in arthrotec?

Misoprostol and diclofenac (an NSAID with protection for the stomach, pretty much a dinosaur after the cox-? inhibitors came)

What is the anti-inflammatory dose of ibuprofen? 1200-3200mg/day in divided doses

What NSAIDS work on both the lipooxygenase and cyclooxygense pathway? Ketoprofen and diclofenac

What is the difference between cataflam and voltaren? Cataflam is diclofenac K + and immediate release Voltaren is diclofenac Na+ and delayed release

What are the only Pro-drugs (for NSAIDS)? Nabumentone and Sulindac

What is the only nonacidic NS~4.ID? Nabumentone

Which NSAIDS have fewer pulmonary problems? Ketoprofen and diclofenac

Which NSAIDS only have anti-inflammatory effects? Indomethacin, tolmentin sodium

Do NSAIDS decrease joint destruction? No. thev only decrease inflammation

, " -

What NSAID causes in-eversible inhibition of platelet aggregation? Aspirin

What are some once a day NSAIDS?

Rofecoxib (Vioxx), celebrex (celecoxib), piroxicam (feldene), oxaprozm (daypro), naburnentone (relafen), bextra (valdecoxib) plus others

Crozet-Keystone Residency Manual 2004. Arranged by Brett Chicko, DPM

69

What are the three mechanisms of action for most NSAIDS'! Analgesic, Antipyretic, Anti-inflammatory

Which NSAll) is often given during surgery or immediately post-op to decrease pain and inflammation'!

Ketorolac (Toradol) 30mg or 60 mg IV

What drugs do NSAIDS interact with and what are the effects? Coumadin-increases action of coumadin

Sulfonylureas-increases action of sulfonylurea Corticosteroids-increases GI risk

Antiepileptic meds-increases antiepileptic toxicity Antihypertensive meds-antagonizes antihypertensive meds Digoxin-increases digoxin's effects Methotrexate-decreases methotrexate's clearance Lithium-decreases lithium's clearance Probenecid-increases concentration ofNSAIDS


70

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ClassificatEons

Author's note: Although all of the classifications are important the ones in bold, capitalized and underlined (i.e. LA lUGE-HANSEN) are the most common or most used ones.

A special thank you to Michael Younes, DPM for his help in this section. -Brett

ANKLE FRACTURES

LAUGE-HANSEN CLASSFICATION:

-based on a two word system

1 st word=position of foot w/respect to the leg

2nd word=motion that causes fx pattern (where talus moves w/respect to the tibia and fibula)

*=hallmark

SUPPINATION-ADDUCTION -remember adduction=inversion

Stage 1: *transverse fx of fibula OR rupture oflateral collaterals Stage 2:*vertical fx of medial malleolus

-NO tib-fib diastasis

PRONATION-ABDUCTION -remember abduction=eversion

Stage 1: transverse avulsion fx of medial malleolus OR rupture deltoid ligament Stage 2: rupture of anH/-post distal rib-fib ligaments

Stage 3: *short fibular fx (oblique on AP, trans. on lateral)

SUPINATION-EVERSION -also called SER

-eversion=external rotation

-rnedial axis is medial mal1eolus

Stage 1: anterior tib fib ligament disruption OH one of the following tib-fib ligament avuIsions:

Tillaux-Chaput: tibia Wagstaffe. fibula

(*most common)

Stage 2: *spiral oblique fx fibula

Stage 3: rupture of post tib-fib lig OR Volkmann's fx (avulsion of tibia from post tib-fib. )

Stage 4: transverse fx rned. malleolus OR ruptured deltoid


71

I>RONATJON-EVERSION

-also called PEE (eversion=ext. rot)

-talus ext. Rotated around lat malleolar axis

Stage 1: rupture deltoid OR transverse avulsion ofmed mal.

Stage 2: ant tib-fib lig. Disruption Chaput fx-tears interosseous lig with it Stage 3:~· high fibular fx tears interosseous membrane

Stage 4: Posterior tib-fib lig OR Volkmann's fx.

Pronation-Dorsiflexion (Arch. Surgery #67: 813-820,1953) Used to describe pilon fracture

Stage I: Medial malleolar fx (oblique or transverse) or deltoid ligament rupture. Stage IT: Fracture of the anterior lip of the tibial piafond.

Stage ill: Fibular fracture above the level of the syndesmosis.

Stage IV: Transverse fracture of the distal part of the tibia at the same level as the proximal margin of the large tibial fracture.

DANIS WEBER condensed Describes fractures of fibula

Type A: Transverse avulsion fx. below the level of the ankle jt, (corresponds with Lange-Hansen SAD)

Type B: Spiral or oblique fx at the level of the ankle joint (corresponds with Lange-Hansen SER and P AB)

Type C: Fx above the level of the ankle joint a.k.a. Maissoneuve fx. (corresponds with Lange-Hansen PER)

DANIS-WEBER (Ortho Clinics ofNA 661.1980)

- Based on location offx of fibula. Corresponds w/Lauge-Hansen,

• Type A: Transverse avulsion fx of fibula below the level of ankle mortise M Ol-supination-adduction

TX: k-wire wi tension band for fibular fx, 2 interfrag screws for the med malleolus.

• Type B: At Level of ankle mortise MOl-pronation-abduction OR SER

IX: interfrag screws &/or plate. repair A TFL

• Type C: Above level of ankle mortise MOl-PER

TX: interfrag screws & plate OR just a plate. repair ATF & interoseous memb. wi transfixation screw.

PILON FRACTURE RUED! & ALLGO\VER condensed

Pilon Fractures -distal tibial metaphyseal fx


72

Type 1-110 displaced fragments of tibia

Type 2-intraarticubr fx of tibia but not comminuted

Type 3-comminuted & disruption of articular surface of tibial

Rlllledi arrH] AUgo"",'er CClin. Orthop. #138: 105-110,1979)

Type 1: Mile! displacement and no comminution without major disruption of ankle jt. Type 2: Moderate displacement & no comminution with significant dislocation ofthe ankle joint.

Type 3: "Explosion Fracture", Severe comminution and displacement of the distal tibial metaphysis

femoral distractor -will bring tibia out to length before fixation if-type 3 fix tibia 1 st

40-80% failure of ankle fusion

La uge- Hansen.

(Lauge-Hansen Pronation-Df describes a pilon fracture) Pronation-Dorsiflexion (Arch. Surgery #67: 813-820, 1953)

Stage I: Medial malleolar fracture (oblique or transverse) or deltoid ligament

rupture.

Stage IT: Fracture of the anterior lip of the tibial plafond. Stage ill: Fibular fracture above the level of the syndesmosis.

Stage IV: Transverse fracture of the distal part of the tibia at the same level as the proximal margin of the large tibial fracture.

Medial maUeo1a:r FractUlres~ A vldsion

Mulier

Type A: Avulsion of the tip of the medial malleolus, horizontal orientation Type B: Avulsion fracture at the level of the anlde joint, horizontal orientation Type C: Oblique fracture

Type D: Vertical fracture

Fibular Avulsion Fractures

Pankovich: Wagstaffe-LeFort Fracture (Clinics Ortho ReI. Res. 143: 138. 1979) Type 1: Avulsion fracture maintaining attachment to both the anterior talofibular and anterior-inferior tib-fib ligaments

Type 2: Avulsion fracture associated with an oblique fracture of the fibula originating distal to the anterior-inferior tib-fib ligament. Spiral fracture ofthe fibula with a proximal fibular spike and a transverse fracture associated with the avulsion fragment.

Type 3: Avulsion fracture of the anterior tibial tubercle followed by a type 2

Crozer-Keystone Residency Manual 2004" Arranged 1.1)' Brett Chicko. DPIvl 73


AO SYstem (Anldt' Fractures) Type A: extra-articular Type B: partially articular Type C: completely articular All 3 can involve:

A. No comminution or impaction in the articular or metaphyseal surface B. impaction involving the supra-articular metaphysis

C. Comminution and impaction involving the articular surface with metaphyseal

impaction

Destot System

Subgroup 1: Posterior marginal fracture of the tibia Subgroup II: Anterior marginal fracture of the tibia Subgroup ill: Explosion fracture of the tibia

Subgroup IV: Supra-articular fracture of the tibia with extension into the ankle

joint

Kellam and Waddell (Journal of Trauma, #19: 593-601, 1979)

Type A: Rotational pattern consisting of 2 or more large tibia] articular fragments, minimal or no

anterior cortical comminution, and a transverse or short oblique fibular fracture at the level of the tibial plafond.

Type B: Compressive fracture pattern with multiple tibial fragments with marked anterior tibial

cortical comminution.

Maale and Seligson (Orthopedics #3: 517-521, 1980) Modification ofRuedi and Allgower

Type 1: Distal tibial compression fracture

Type 2: External rotatory fracture with a large posterior fragment

Type 3: Spiral fracture extending from the articular surface into the metaphysis

Ovadia and Beals (JBJS 68A: 543-551, 1986); modified the Ruedi and Allgower Type II classification

Type I: Non-displaced articular fracture resulting from rotational forces Type ll: Minimally displaced fracture resulting from articular forces Type ill: Displaced articular fracture with several large fragments due to

compressive forces

Type IV: Displaced articular fracture with multiple fragments including a large metaphyseal fragment resulting from compressive forces.

Type V: Severe comminution due to compressive forces

Mast System (Clinics of Ortho 230: 68-82, 1988)

Type I: Malleolar fracture with significant axial load at the time of the injury producing a large posterior fragment

Type II: Spiral extension fracture

Type ill: Central compressive injury divided into A, Band C

ilCHILLES TEN'DON R1JPTITRE

KUVVADA

Type 1: Partial Tear <50%, Treat with casting (foot plantarflexed)

Type 2: Complete tear with <3cm defect after debridement. Treat with end-To-end attachment

Type 3: Complete tear with 3-6cm deject after debridement. Treat with end-to end attachment and tendon flap.

Type 4: Complete tear >6cm defect after debridement. Treat with end-to-end, recession, or graft.

Radioopagllle lesions of the Achilles Tendon

Morris and Giacopelli (Journal Foot Surgery, 1990)

Type I: Opacities at the Achilles insertion. Calcification in within the tendon and remains partially attached to the calcaneus.

Type Il: Opacities 1-3cm proximal to the insertion. Lesions separate from the calcaneus.

Type llIA: Lesions> 3cm proximal to the insertion. Partial tendon calcification. Type IIrn: Lesions> 3cm proximal to the insertion. Total tendon involvement.

Late:ral Anlde Trauma

Note: you should learn one of the classifications in this section, but it really doesn't matter which one.

Leach- Lateral Ankle

Ist Degree: Rupture of the ATF

2nd! Degree: Rupture of the A TF and CF

3rd Degree: Rupture of the ATF, CF, and PTF

o 'DolJogh lie-condensed:

Grade I: partial ATF tear Grade IE: complete ATF tear

Grade ill: complete ATF & CFL tear

OfDollogillle -expanded (Northwest Medicine, October 1958. pl:277) Grade 1: Partial tear ofATF, mild tenderness and swelling. No loss of function or instability. Pt can walk. play

Grade 2: Complete tear of ATF, moderate pain and swelling with ecchymosis

Crozet-Keystone Residency Manual :2004, Arranged by Brett Chicko. DPM

Some loss of function and moderate instability. Pt limps after injury

Grade 3: Complete tear of ATF and CFL, severe pain, swelling, and ecchymosis Unable to bear weight and severe instability. PI cannot walk after injury

Dias (Journal of Trauma, 19: 266-269, 1979) Grade I: Partial rupture of the CFL Grade ll: Rupture of the A TF

Grade ill: Complete rupture of the ATF, CF, and/or PTF

Grade IV: Rupture of all lateral collateral ligaments and partial failure of the deltoid ligament

T ALAR DOME FRA..CTURES

BERNT AND HARDY -condensed

Stage I-compression oftalar dome without displacement. Stage 2-osteochondrallesion oftalar dome, partially detached

Stage 3-osteochondrallesion of talar dome completely detached but not displaced. Stage 4-osteochondrallesion of talar dome, displaced

BERNT AND HARDY(JBJS 41A: 988-1020, 1959) Mechanism: DIAL A PIMP

Stage 1: Osteochondral compression of the talar dome. TX: conservative

Stage 2: Partially detached, non-displaced osteochondral fracture. TX: conservative

Stage 3: Fully detached, non-displaced osteochondral fracture. TX (mediallesion)-conservative

TX (lateral lesionj-Surgical excision of the fragment, saucerize the crater, and fenestration to increase vascularity and fibrocartilage production.

Stage 4: Displaced osteochondral fracture.

TX: Surgical excision of the fragment, saucerize the crater, and fenestration to increase vascularity and fibrocartilage production.


* Mechanism ofInjury: DIAL A PIMP or DIAL-A-PIMPER

1. DIAL-Dorsiflexion and Inversion leads to Anterior-Lateral lesion:. Wafer-shaped

lesion, assoc. w/trauma

2. PIMPER-flantarflexion and Inversion with ~xternal Rotation. fosterior-Medial

lesion: small, deep, round cup-shaped fragment, 80% not* * assoc. w/trauma

Treatments

* TX: Stage 1, 2, and medial 3: NWB Short leg cast for 6-12 wks

TX: Lateral stage 3 and 4: Surgical excision of the fragment, saucerize the crater, and fenestration to increase vascularity and fibrocartilage production.

Crozer-Keystone Residency Manual 2004" <\rranged by Brett Chicko. DPM

77

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HA \VKINS- Talar neck fx condensed

Vertical fx. oftalar neck. Nondisplaced

Vertical fx. oftaJar neck. ST.I dislocation/subluxation

Vertical fx. of talar neck, STJ and ankle dislocation/subluxation Vertical fx. oftalar neck. STJ and ankle and TN dislocation/subluxation

• Type 1:
• Type 2:
• Type 3:
" Type 4: HA WKINS(JBJS 60A: 143-156,1978); Modified by Canele and Kelly MOl - hyperdorsiflexion of the foot on the leg

• Type 1: Vertical fracture of the talar neck without displacement.

Disruption of 1 blood vessel (12% risk of A VN)

TX: BK cast immobilization for 8-12 weeks.l'~T'\{{B for 6-8 wks.

- Need to see trabeculation across the fracture site to start weightbearing.

• Type If-Displaced fracture of the talar neck with subluxation of the STJ (ankle jt remains aligned)

Disruption of 2 blood vessels (42% risk of A VN)

TX: 1. Trial of closed reduction by pushing backwards on a plantarflexed foot while pulling forward on the distal tibia.. If tins is successfuL percutaneous pinning is performed. If successfuL cast in equinus for 4 wks with subsequent casting bringing the foot out of equinus. Total casting time - 3 mos ofNWB casting.

2. If after one unsuccessful attempt at closed reduction, ORIF is indicated. A void multiple attempts at closed reduction. Longitudinal anteromedial incision along the neck of the talus, just medial to the TA. 6.5mm canulated cancellous screws. Use titanium screw to facilitate the later use of IvIRI to monitor the progress of osteonecrosis.

• Type 3: Vertical fracture of the neck of the talus, dislocation of the STJ~ and dislocation of the Talus from the ankle joint.

Disruption of 3 blood vessels (91 % risk of A Th').

TX: ORIF important not to dissect off the deep fibers of the deltoid ligament which may remain attached to the talar body (osteotomize the medial malleolus rather than reflect the deltoid)

-25% of these are open

•

Type 4: Vertical fracture of the neck of the talus, with dislocation of the talus from the ST.L ankle joint and the talonavicular joint.

Disruption of 3 blood vessels (91 (0) risk of A \IN).

TX: ORJF

(seen il1 one patient - this modification was attributed to Canale and Kelly JbJs J 978)

-osteonecrosis is the most common complication associated with this injury

] 0% incidence of calcaneal fractures assoc. with talar neck fractures

19-28°Ic, incidence of medial malleolar fractures assoc with talar neck fractures

X-rays - place ankle in maximum equinus, place foot on a cassette pronated 15 deg, x-ray tube is directed cephalad at a 75 deg angle from the horizontal. This will give the best view of the talar neck.

Sclerotic (apparent increase in density)

Surrounding bones become osteopoaotic due to disuse & acute hyperemia

(Aviator's Astragulus) 1952 Jbjs Cohart -is hyperdorsiflex of foot by rubber bar in airplane impact

Rates of Osteonecrosis -type I - 0-13%

-type II - 20-50%

-type III, IV - 83-100%

Hawkin's sign - between week 6-8 an AP of the ankle reveals the presence or absence of subchondral atrophy. Subchondral atrophy is indicative of vascularity of the talar body thereby excluding the diagnosis of A VN.

MR1 can define the presence and the extent of osteonecrosis in the body of the talus as early as 3 weeks.

Up to 36 months are required for complete creeping substitution of the body after union has occurred. Ideally you want to protect the patient from -VVB until complete revascularization occurs - Patellar Tendon Bracing is an excellent adjunct to partially relieve the load on the talar dome once WB is initiated.

If the talar dome collapses - Blair Fusion - excise the avascular talar body and place a sliding corticocancellous graft from the anterior distal tibia into the residual, viable talar head and neck

Talus - Body Fractures

S:NEPPEN condensed

Type 1: Compressive fracture of the talar dome usually involves the medial or lateral aspect

Type 2: Shearing fracture of the talar body 2A: Coronal shearing force

2B: Sagittal shearing force

2C: Horizontal shearing force

Crozet-Keystone Residency Manual 2004, Arranged by Brett Chicko, DPM 78

Type 3: Fracture of the posterior tubercle Type 4: Fracture of the lateral process Type 5: Crush fracture

SNEPP'EN CLASSIFTICAT]ON (Acta. Ortho. Scand. 45: 307, 1(74)

• Type 1 - Tr-anschondral or compression fracture of the talar dome (including osteochondritis of the talus)

• Type n Coronal, sagital, or horizontal shearing fracture involving the entire body

2A: Coronal shearing force 2B: Sagittal shearing force 2C: Horizontal shearing force

-MOA unknown but thought to be forced dorsiflexion with the foot locked, combined with axial compression

-Fractures displaced> 2-3 mm @ trochlear surface should undergo ORIF

-75% incidence of OA of STJ accompanies these injuries

• Type ill-Fracture of the posterior tubercle of the talus Shepard's FX= post lat tubercle FX.

Do not confuse with Os trigonum a.k.a, Intern's FX.

-MOA 1) hyperplantarflexion, or 2) avulsion of posterior talofibular ligament

-Sometimes confused with os trigonum can do a bone scan to differentiate

- TX -short leg NWB cast with foot in mild equinus. If pain persists - excise fragment

• Type IV-Fracture of the latera! process of the tali us -MOA dorsiflexion with inversion

-A.k.a. "snowborder's ankle"

- Tx-owks ofN'W'B cast immobilization in slight equinus. Large fragments can be

internally fixated.

"' Type V-Cmsh fr-acture of the talar body -Poor prognosis

-Primary arthrodesis after 2-3 weeks due to risk: of soft tissue envelope if performed

immediately

Studies show 23% of open talar fractures went on to Osteomyelitis and may result in future taiectomy

Boyd and Knight (South. Med. J. 35: 160, 1(42)

Type 1: Coronal or Sagittal shear fractures IA: Non-displaced

lB: Fracture with displacement at the talc-crural joint l C: Type IB with displacement of the STJ


79

Calcaneal Fractures

ID: Fracture with total displacement of the talar body Type 2: Horizontal shear fracture

2A: Non-displaced

2R Displaced

Lateral Talar Process

Hawkins-Lateral Process (JBJS 47 A: 1170, 1965)

Type 1: Simple fracture of the lateral process that extends from the talofibular articular surface down to the posterior talocalcaneal articular surface of the STJ.

Type 2: Comminuted fracture of the lateral process that involves both the fibular and posterior calcaneal articular surfaces of the talus and the entire lateral process

Type 3: Chip fracture of the anterior and inferior portion of the posterior articular process of the talus

Posterior Lateral Talar Process Fracture

Dobas and Watson (Arch. Pod. Med. Foot Surg. 3: 17, 1976)

Stage 1: Normal posterior lateral process; no clinical significance Stage 2: Enlarged posterior lateral process

Stage 3: Non-fused os trigonum

Stage 4: Synchondratic union of the os trigonum to the talus

McGougall (JBJS 37B: 257-265, 1955)

Stage 1: A line of cleavage occurs at the impingement point

Stage 2: Posterior lateral process begins to separate from the main body of the talus

Stage 3: Complete separation of the posterior lateral process from the talar body

ROVvE condensed:

Type I:

A-fx of medial tubercle B- fx of sustentaculm tali C-fx of anterior process A-beak FX

Type II:

B-avulsion off Achilles insertion Type ill: Oblique FX not involving STJ

Type IV: Fractures involving STJ

Type V: Central depression FX of STJ w/comminution

Note, Rowe is usually used for extra-articular fractures. Intra-articular fractures: Rowe IV and V are usually replaced by Essex and Lopresti.


ESSEX-LO/PRESTI condensed Type I: tongue fx (vertical Ex line)

Type :n: joint depression fx (horizontal fx line)

RO\NE (.lAMA Ig4: C)g-lOl, 1963)

• Type 1:

A. Fr-acture of the medial tuberosity due to inverted or everted foot TX: Non-displaced: CR and BK WB cast for 6 weeks. Displaced: ORIF

B. Fracture of the sustentaculum tali due to twist on a supinated foot TX: Non-displaced: CR and BK cast for 6 weeks

Displaced: OR1F

C. Fracture of the anterior tubercle due to plantarflexion on a supinated ft.

Most common type I and most common in females.

TX: CR and BK WB cast for 6 weeks. If symptoms persist excise the fragment.

• Type 2:

A. Beak fracture without Achilles insertion involvement TX: NWB BK cast for 6 weeks in plantarflexed position

B. Avulsion fracture of the Achilles tendon

TX: ORIF or attempt percutaneous pinning

• Type 3:

A. Fracture of the body without STJ involvement. Most common extra-articular.

TX: NWB iVZ cast with knee flexed if non-displaced. Displaced: ORIF

• Type 4: Fracture of the body with STJ involvement.

• Type 5: Comminution of' the body of the calcaneus.

ESSEX-LOPRESSTI (Br. J. Surg 39: 395-419, 1952)

• Type 1: Tongue type fracture with a primary fracture line running superior to inferior with a secondary fracture line exiting the posterior aspect of the calcaneus.

• Type 2: Joint depression fracture with a primary fracture line running superior to inferior with a secondary fracture line surrounding the STJ.

** 75% of all calcaneal fractures are intra-articular.

TX of Intra-articular Fractures

Essex-Lopresti Technique: A percutaneous pinning technique using a Steinmann pin introduced into the tuberosity. The tongue fragment in reduced and the pin is placed into the anterior calcaneus or cuboid. No cast is required and motion is performed immediately. The pin is removed in 8-10 weeks at \VB is begun. Indicated for Sanders 2C (87% success rate).

Closed Reduction: Used if <Zrnrn displacement.

Crozet-Keystone Residency Manual 2004, Arranged by Brett Chicko. DPJv1 81


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ORIF

a) lncisional Approaches

Medial Approach: Burdeaux

Combined Approach: Stephenson Extended Lateral Approach: Benirschke

b) Procedure:

Goal is to restore the STJ and C-C articulation

Need to perform the surgery within 6-8 hours of the injury otherwise it has to wait until the swelling is reduced.

Reduction is performed by placing a Steinmann pin through the tuberosity fragment to restore the STJ posterior facet. Once aligned, the tuberosity fragment is fixated to the constant fragment (sustentaculum fragment). Various plates can then be used to act as a buttress.

Before arthrodesis is performed, CR or ORlF should be attempted.

DEGAN (JBJS 64: 519,1982)

Type I: Non-displaced fracture of the anterior process tip

Type IT: Displaced fracture of the anterior process not involving the articular surface ( extra-articular)

Type ill: Displaced fracture of the anterior process involving the articular surface (intra-articular of calcaneal-cuboid jt)

SANDERS (used for CT evaluation from coronal & axial CT) (Clinics ofOrtho 290: 87-95, 1993)

-classified by # of pieces

-use letter & number

* lines A and B divide the inferior portion of the talus's posterior facet into 3 equal portions. Line C is used to separate the medial and posterior facets.

A: lateral, B: midline, C: medial

I: non-displaced, non-intra-articular fx.

Any number offx lines. All non-displaced fractures no matter how many

fragment

II: 2 pieces of posterior facet

One fx line. 2 part fractures of the posterior facet. Use 1 letter (2A, 2B, and 2C) Ill: 3 pieces of posterior facet

Two fx lines. 3 part fracture of posterior facet. Use 2 letters (3AB, 3AC, & 3BC) IV: 3 pieces of posterior facet + sustentaculum fragment

Three fx lines. 4 part fracture with high degree of comminution

Anterior Process of the Calcaneous Fx.

Hannover (Clinics ofOrtho 290: 76-86, 1993)

CT scan evaluation based on the fragments involved and the number of joint fractures 5 Fragments:

1. Sustentaculum

'") Tuberositv 3. STJ

4. Anterior process

5. Anterior STJ fragment

*~:*Most common is the 5 fragrnent/? joint fracture

NA V]CULAR FRACTURES

WATSON-.MONES condensed

Tvpe 1 Tuberosity fx

(Nutcracker Syn.)- severely displaced fx. & compression fx. of cubiod &/or calcaneus Tvpe 2 Dorsal Lip fx

Tvpe 3 Bodv

3A Fx. of body without displacement

3B Fx. of body with displacement

Type 4 Stress Fx.

W ATSON-JONES(Fracture and Joint Injuries, Watson and Jones, 5th ed., p1200)

Type I: Fracture of the navicular tuberosity-usually an avulsion fx -24% of navicular fxs.

Nutcracker Syndrome: severely displaced fracture and compression fracture of the cuboid and/or calcaneus.

MOI:1)forceful eversion wlmedial avulsion of the pt off of the tuberosity.

2)direct blow to the tuber.

*need to DID OTE vs. true fx, thus take BIL films:LO#l TX: BK cast with partial "\N13 x 4 weeks

Type ll: Fracture of the dorsal lip. Most common. TX: BK cast with partial Vv13 x 4-6 weeks

Type ill: Fracture through the body of the navicular:

ITIA: without displacement

TX: BK walking cast x 6-8 weeks TI]LB: with displacement

TX: ORIF and BK NWB cast for 6-8 weeks Type IV: Stress fracture of the navicular

[1' non-displaced, BK NWB cast for 4-6 weeks. If displaced, ORIP followed by BK NWB 6-8 weeks.

Accessory N 2lvicular-Os Tibials Exterrnrm

Geist-(1914) First described by Bahin 1605

II

Type! sesamoid in tendon

TypeZ articulating os center (Sella-Clin Ortho-86, Footz.Ankle-S'Z) 2A synchondrosis acute angle

•

Crozer-Keystone Residency Manual 2004. Arranged by Brett Chicko. DPM 83

2B synchondrosis obtuse angle .. Typc3 fused accessory os center

Navicular Classification.s

vVilson- chip/comminuted/crush

'Watson Jones- tubersoity, dorsal lip,& transverse

DePalma- dorsal lip, avulsion, tuberosity & Fx dislocation

Rockwood & Green- body Fx w/ & w/o dislocation, chip, tuberosity

Goidman- chip, tuberosity, body, displaced, osteochondral Fx

STJ DISLOCATIONS

Buckingham

Type 1: Medial STJ dislocation (FF goes medially and Talar head moves laterally)

Type 2: Lateral STJ dislocation

Type 3: Anterior and posterior STJ dislocation

TARSAL COALITIONS

DOWNEY (JAPMA 81: 187-197, 1991) Juvenile (Osseous Immature)

• Type I: Extra-articular coalition A: No secondary arthritis

TX: Badgley procedure B:Secondll0'arthritis

TX: Resection, Triple

• Type H: Intra-articular A: No secondary arthritis

TX: Resection, Isolated arthrodesis, Triple B: Secondary arthritis

TX: Triple

Adult (Osseous Mature)

• Type I: Extra-articular

A: No secondary arthritis TX: Resection, Triple B: Secondary arthritis

TX: Triple


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Type n: Intra-articular A:l'-Jo secondarv arthritis TX: Isolated. Triple B: Secondary arthritis

TX: Triple

CHO'P ART FR_t\_CTlJRES

Main and Jowett (JBJS 57B: 89, 1975)

Classification is based on the direction of the deforming force and the resulting displacement

1. Medi.al Force

Type A: Flake fracture of the dorsal talus OR navicular and of the lateral calcaneus OR cuboid

Type B: Medial displacement of the forefoot with medial disassociation of the TN and C-C joints

Type C: Forefoot rotates medially around the interosseous talocalcaneal ligament, with T -N disassociation and the C-C joint intact

2. Longitudinal Force

Type A: Maximally plantarflexed ankle giving a characteristic pattern of through

and through navicular compression fracture:

AI: Force through the 1st ray: Crushes the medial3rd with the tuberosity displaced medially

A2: Force through the 2nd ray: Crushes the middle 3rd with the middle 3rd and tuberosity displaced medially

A3: Force through the 3rd ray: Crushes the lateral 3rd with the medial 2/3rds and tuberosity displaced medially

Type B: Submaximally plantarflexed ankle resulting in a dorsal displacement of the superior navicular and the crush of the inferior portion on the?

3. Lateral Forces

Type A: Forefoot forced into valgus with a resulting fracture of the navicular tuberosity OR dorsal talus and a compression fracture of the C-C joint (Nutcracker Fracture)

Type B: T-N joint displaces laterally with comminution of the C-C joint

4. Plantar Forces

Type A: Avulsion fracture of the dorsal navicular OR talus and the anterior

process

Type B: Impaction fracture of the inferior C-C joint

Lis Franc's Dis~ocatlolI1

Crozer-Keystone Residency Manual 2004, Arranged 0:' Brett Chicko. DPM 85

Hardcastle Type A

Type HI & B2 Type CI s: C2

Quenv & Kuss Convergent Homolateral Isolateral

Divergent

QUENU AND KUSS (Rev. ChiT. 39: 28]-336, 720-9], ]093-134, ](09)

• Convergent homolateral ] -5 mets sublux laterally

All 5 metatarsals are displaced in the transverse plane laterally

• Isolateral

1st met sublux med or 2-5 mets sublux laterally

1 or 2 metatarsals are displaced in the transverse plane laterally

• Divergent

1st met sublux med & 2-5 sublux laterally Displacement is in both the sagital and transverse plane

HARDCASTLE (JBJS 64B: 349,1982)

• Type A Total Incongruity Al-Lateral A2-Dorsoplantar plane Type B Partial Incongruity

Bl Partial medial displacement

1st met med displaced &/or in combination with 2,3,4 mets B2 Partial lateral displacement

lat displacement of 2-4 one or more lesser mets Type C Divergent

Divergent: Ist metatarsal is displaced medially and lesser mets laterally Cl- Partial incongruity

1st met med displaced & any combination of2,3,4 mets displaced lat C2-Total displacement

1st met med displaced & mets 2-5 displaced laterally

•

•

TREA TMENT OPTIONS:

] .cast immobilization=sprains 3-5 weeks. 2.closed reduction & percutaneous pinning. 3.0RIF

REDUCING SEQUENCE:

1. 2nd met on middle cuneiform. once stabilized lesser mets will follow.

2. next stabilize 1st met, then lat mets.

POST OP CARE:

BK casting for 6 to 12 weeks. initial NWB 6-8 weeks partial WE approx 6 weeks.


86

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begin arnbulation in stiff soled shoe. PT ASAP. accommodative orthotics.

COMPLlCATIONS:

IvlAJORITY-post DJD

SERJ 0 US-circulatory comprom ise

Myerson (Foot and Ankle 6(5): 225, 1(86)

Type A: Total displacement in any plane or direction Type Bl: Medial Displacement of 1st met

Type B2: Lateral Displacement affecting 1 or more lesser mets

Type Cl: Partial displacement of 1st met medially and lesser mets laterally Type C2: Total displacement with a divergent pattern with total incongruity

PT Ruptu.re Classifications

IvllTELLER

I. direct injury

II. pathologic rupture(RA)

ID. idiopathic

IV. functional abnormality

:rvrRI Rupture Sta2es

CONTI

I. 1-2 fine, longitudinal tears

IT. intramural degeneration, variable diameter

III. diffuse swelling

Peroneal ten.don slUlbhlxations

Eckert

Grade 1 - retinaculum & periosteum separated from fibro-cartilaginous lip Grade 2 - fibrous lip elevated along wi retinaculum

Grade 3 - thin fragment of bone elevated along wi fibrous lip

FOREFOOT FRt\CTURES

5 TH METATARSAL FRA.CTURES

STEW ART CLASSIFICATION-condensed

• Type 1: True Jones fx. Extra-articular fx of metaphysis. (approx 1 em from the joint)


87

• Type 2: Intra-articular fx of 5th met base.

• Type 3: Avulsion fx. of styloid process (5th met base)

• Type 4: Comminuted intrarticular fx of 5th met base.

• Type 5: Partial avulsion of epiphysis in children

STWEART1960 Clin Ortho(5th Met fx) Stewart described onJy the first 4 types

Tvpe 1: True Jones Fracture at the metaphysis ofthe 5th metbase approx 1 em from the articular cartilage. Either transverse or oblique fracture. (This is due to rotation of the forefoot with the base of the 5th met remaining fixed; not seen with inversion ankle sprains). This type of injury has a high propensity for non-union. (Sir Robert Jones 1902- 4 fxs including his own)

MOl-internal rotation, PF ankle and adduction offorefoot

TX: Non-displaced, BK N\VB cast x 4-6 weeks. If displaced, ORIF.

Tvpe2: intra-articular fracture of the base 5th met into 5th met-cuneiform jt.

MOI- Shear force. Resulting from contraction of the peroneus brevis. TX: If non-reducible, ORIF. Ifreducible, BK NVlB cast for 4-6 weeks.

Tvpe 3: Avulsion of the base of the 5th (styloid process). AKA Tennis Fx. MC 5th met fx.

MOl-contraction ofPB with DF of ankle

TX: If reducible, BK NVV7B cast for 4-6 weeks. If non-reducible, ORIF (possibly tension band wiring).

Tvpe 4: Comminuted intra-articular fracture of the base of the 5th.

MOl-crush

TX: BK NWB cast for 4-6 weeks. If severely displaced, bone grafting and ORIF.

Type 5: Partial avulsion fracture of the epiphysis (located in a longitudinal direction) in children. Risk of Iselin's A VN. AKA Salter-Harris type 1

TX: BK NWB cast 4-6 weeks.

REVIEW ARTICLE - Lawrence F&A '93 Confusion of3 fx.'s

1) Jones fx.

2) diaphyseal stress fx.

3) tuberosity avulsion fx.

ShereffF&A '91

Spalteholtz tech. of 5tb blood supply/nutrient art. prox & med 1/3 med shaft On X-ray it heals med. to lat.

FIXATION; tension band wire, low profile plate, screws, cross k-wires, 4.5 malleolar screw

COMPLICA TIONS; sural nerve entrap apophysis fused at 9-12

Torg et al JBJS 1984

Torg

Type 1: Acute Jones fracture


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Champ man

Type IA: Jones fracture

Type ill: Displaced Jones fracture with possible comminution Type ll: Delayed or non-union of a Jones fracture

Type ilIA: Avulsion fracture of the styloid

Type run: Intra-articular fracture of the styloid

J\,fetatarsal Head

\

FRIEBERG~S INFR_4RCTION

Type 1 - met head dies but heals by replacement: articular surface preserved

Type 2- head collapses but articular surface remains: Peripheral osteophytes (dorsal) Type 3 - head collapses with articular cartilage loosening: joint is destroyed

Type 4 - multiple heads involved

1st Met Dislocation

J AHASS condensed

Type l Dorsal dislocation of prox phalanx & sesamoids with intersesamoid lig intact Type2 Dorsal dislocation of prox

phalanx & sesamoids with rupture of intersesamoid lig 2A no sesamoid fx.

2B transverse fx of a sesamoid

JAHSS (Foot and Ankle 1: 15,1980) "Secondary to extreme dorsiflexion

Type 1: Dorsal dislocation of Proximal phalanx and sesamoids with the intersesamoidal ligament intact (Requires ORIF)

Type 2A: Dorsal dislocation of proximal phalanx and sesamoids and rupture of the intersesamoidal ligament.

TX: CR and Reece shoe or B K walking cast.

Type 2B: Dorsal dislocation of proximal phalanx and sesamoids and rupture of the intersesamoidal ligament and fracture of one sesamoid.

Crozer-Keystone Residency Manual 2004, Arranged by Brett Chicko. DPM

OQ

0"

TX: CR and followed by Reece shoe or BK NVlB cast or excision of the fractured sesamoid.

Nail injuries

ROSENTHAL -(Ortho Clinics ofNA 14(4): 695, Oct, 1983) Zone 1 Distal to phalanx

Zone 2 Distal to lunula

Atasoy=plantar V - Y advance Kutler=bi-axial V-Y advance Zone 3 Proximal to the distal end

of lunula (TX. amputation) If nail bed is lacerated = open fx.

Physeal Inj uries:

SALTER-HARRIS

1. fx througb physis Same

n. physis/metaphysis Above

ill. physis/epiphysis Lower

IV. epiphysis/metaphysis Through

V. crush injury E

Real Bad

SALTER-HARRIS CLASSIFICATION OF FRACTURE Site: epiphyseal, metaphysis, diaphysis.

Extent: complete vs. non-complete

Configuration: transverse>oblique>spiral>communited Position: rotated ,angulated

distracted, impacted overiding, lateral shift Environment: open vs. closed

SALTER-HARRIS (Skeletal Radiology 6: 237-253,1981) Describes pbyseal injuries

Type 1: Complete transverse separation of the epiphysis from the metaphysis through the physis. Epiphysis separates from the metaphysis without any bone fragments-germ cells remain with epiphysis

-shearing force-seen in pathologic fractures

-common in infants


-reduction not necessary.

-growth is not disturbed, LIDless associated aseptic necrosis and premature closure

of the physis.

TX: CR if seen within 7 days of the injury, followed by 3-4 weeks of casting. Type 2: Epiphysis is separated from the physis with the fracture extending into the metaphysis (Thurston-Holland sign)

TX: CR if seen within 7 days of the inj ury, followed by 3 -4 weeks of casing. Type 3: Partial separation of the physis with an intra-articular break into the epiphysis (Tillaux fragment)

Type 4: Intra-articular fracture extending from the epiphysis into the metaphysis.

Type 5: Impaction of the epiphysis into the physis and metaphysis resulting in comminution.

TX of 3,4, and 5: Should attempt to close reduce, but usualJy requires the anatomic reduction of the physis. Fixation should be kept within the metaphysis.

Rang

Type 6: Perichondral injuries produced by a shearing force resulting in a cupshaped fragment of epiphyseal, physeal, and metaphyseal bone with possible degloving (tear of the 'ring of Lacroix')

Osden

~

Type 7: Intra-epiphyseal fracture that does not involve the physis

Type 8: Transverse fracture of the metaphysis only

Type 9: Diaphyseal growth injury resulting in periosteal elevation and possible degloving of the periosteum.

Peterson (J Pediatric Ortho 14: 439, 1994)

Type 1: Transverse fracture of the metaphysis with extension to the physis by way oflongitudinaI compression (15.5%).

Type 2: Separation of part of the physis with a part of the metaphysis attached (Thurston-Holland sign). Salter-Harris type 2 (53.6%).

Type 3: Separation of the epiphysis from the diaphysis through the physis. S-H type 1 (13.2%).

Type 4: Separation of a portion of the physis with extension of a fracture into the joint. S-H type 3 (l0.9%).

Type 5: Fracture involving the metaphysis, physis, and epiphysis. S-H type 4 (6.5%)).

Type 6: Fracture involving a missing portion of the physis. Often caused by open fractures, lawn mower injuries, farm machinery, or other power equipment.

Crozet-Keystone Residency Manual 2004. Arranged by Brett Chicko, DPivl C) 1


Poland

Type ] : Separation of the epiphysis from the metaphysis

Type 2: Partial separation of the epiphysis from the metaphysis with fracture of the diaphysis (Thurston-Holland sign)

Type 3: Partial separation of epiphysis from the metaphysis with a fracture of the epiphysis.

Type 4: Complete separation of the epiphysis from metaphysis with a fracture of the epiphysis.

Weber

Type A: Extra-articular

A1: Separation of the epiphysis and metaphysis A2: Fragments in the epiphysis or metaphysis Type B: Intra-articular

B 1: Within the physis extending into the epiphysis B2: Through the epiphysis, physis, and metaphysis.

OPEN FRACTURES GUSTILO & ANDERSON condensed

Type 1- wound <1ern & clean

inside-outside wound

Type 2- wound> 1 ern & no extensive soft tissue damage

Type 3- extensive skin, soft tissue, muscle, & neurovasc. damage 3A-adequate tissue coverage

-high energy

3B-periosteal stripping,

-massive comminution

3C-arterial injury

GUSTILO AND ANDERSON (JBJS 58A: 453, 1976)

Type I: Open fracture with a wound < 1 em. and clean. Simple, transverse or short oblique fx with little comminution. No crush involved.

Type Il: Open fracture with a laceration> Icm, without extensive soft tissue damage, slight or moderate crushing injury, moderately comminuted fx, moderate contaminati on.

Type ill: Open fracture with extensive soft tissue damage> Scm wound, high degree of contamination, severe comminution, assoc. with high velocity injury. Special types include: gunshot, farm injuries, arterial injuries, and motor vehicle accidents lIlA: Adequate soft tissue coverage

IIIB: Extensive soft tissue loss/damage with periosteal stripping, requires local or free flap.

,

rnc: Any open fracture associated with arterial injury requiring repair. Type !lIC is assoc. with amputation rate of2:>-l)()%. Absolute indications for primary amputation:

H._4-LLITX LI~lITITS

REGNAULD(The Foot, 1(86) Grade 1- functional hallux limitus, dorsal spurring

sesmoids intact with no-disease assoc. with them no jt, dx.

Arthrosis, <400 dorsiflexion and <200 plantarflexion, joint enlargement, but joint space narrowing.

Grade 2- broad flat met head, narrow jt. space, structural elevatus, sesmoid hypertrophy,

osteochondral defects in the met head, significant spurring.

Pain at rest, 75% decrease in total ROM, joint space hypertrophy,

-An ex.ample is an osteochondral defect surrounded by chondromalascia

Grade 3- severe loss of jt. space, extensive peri-articular spurs, extensive 1st met-sesmoid dx., osteochondral defect with jt mice present -must have collapse of the jt.--bone on bone.

Ankylosis, articular hypertrophy, FDL contracture, hypertrophy of sesamoids, osteophytes.

I\10DlIFIED REGNAULD/O'LOFF (ACFAS, 1994) Stage 1: Functional Hallux Limitus

Limited dorsiflexion with weightbearing, but normal with non-weightbearing, NO

DID changes on x-ray, NO pain on end ROM.

Stage 2: Joint Adaptation

Pain on end ROM, Flattening of met head, small dorsal exostosis. Stage 3: Joint Deterioration

Crepitus on ROM, non-uniform joint space narrowing, subchondral sclerosis and cyst, osteophytes, severe flattening of met head.

Stage 4: Ankylosis

Obliteration of the joint space, osteophyte fragmentation, ROM minimal to none.

Drago, Oloft, and Jacobs (JFAS. J 984)

Grade 1: Pre-hallux limitus: Metatarsus primus elevatus. subluxed proximal phalanx.

and pain on end ROM.

Grade 2: Flattening of metatarsal head. osteochondral lesion, pain on end ROM.

Crozer-Keystone Residency Manual 2004. Arranged by Brett Chicko. DPIvl (l3

Posterior Tibial Tendon Dysfunction

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Grade 3: Severe flattening of the met head, osteophytes, dorsal exostosis, pain on full ROM.

Grade 4: Obliteration on joint space, joint mites, <10° ROM (may be asymptomatic if ankylosed.

Hanft (JFAS, 1993)

Grade I: Metatarsus primus elevatus, mild dorsal exostosis, and sclerosis around

MPJ.

Grade ll: Grade I, flattening of met head, j oint space narrowing, dorsal and lateral osteophyte.

Grade lIB: Grade II, and DID findings (osteophytes, subchondral sclerosis and

cyst)

Grade ill: Grade II and severe flattening, sesamoid hypertrophy. Grade IllB: Grade III and DID findings

Kravitz, Laporta, Lauton 1994 : 1- zero to mild flattening of the head 2- minimal narrowing,

3a- dorsal spurring, cysts with irregular narrowing, 3b- minimal space, loose bodies, large dorsal flag

4- no space, sesmoid fusion, large exostosis formation

JOHNOSON AA"1> STROM STAGES

1. medial foot and ankle pain, and normal tendon length with mild degeneration

Il, supple flat foot,too many toes sign, attenuation or PT rupture, increased talar 1st met angle, abducted forefoot, uncovering oftalar head

ill. rigid flat foot, calcaneal fixed valgus, de stj ROM (complete PT rupture)

IV. valgus tilt oftalus/ankle mortise leads to lateral tibiltalar degeneration

Wilson (JBJS 54B: 677, 1972) Inversion Injury

Stage 1: 4 lesser mets move laterally; divergent diastasis

Stage 2: Stage 1 and the 1st met moves dorsolateral with other mets Eversion Injury

Stage 1: Medial dislocation of the 1 st met

Stage 2: Lesser 4 mets dislocate dorsolateral; divergent diastasis


'VVAGNER (Foot and Ankle 2: 64-122, 1981)

Gradt~ 0: No open lesions in the skin. Bony prominence and structural deformity

present.

Grade 1: Superficial ulcer without penetration to the deep layers.

Grade 2: Deep ulcer penetrating to tendon, bone, joint capsule, or ligament. Grade 3: Cirade :2 depth with the presence of infection.

Grade 4: Ci angrene of the forefoot

Grade 5: Gangrene of the entire foot

Wound, Ostomy and Continence Nurses Society (formerly l.A.E.T.) in their Standards of Care 1987

This classification is often used in the hospitals

Stage I-Nonblanchable erythema of intact skin

Stage 2-Partial thickness loss of skin involving epidermis, dermis or both. Ulcer is superficial and presents clinically as an abrasion, blister or shallow crater

Stage 3-Full-thickness tissue loss involving damage to or necrosis of subcutaneous tissue that many extend down to, but not through underlying fascia. The ulcer presents clinically as a deep crater with or without undermining of adjacent tissue.

Stage 4-Full thickness tissue loss with extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures (e.g. tendon, joint capsule) Undermining and sinus tracts also may be associated.

USAHSC (Journal of Foot and Ankle Surgery 35: 528-531, 1996)

Grade 0: Pre or Post ulcerative lesion completely epithelialized Grade 1: Superficial wound not involving tendon, capsule, or bone Grade 2: Wound penetrating to tendon or capsule

Grade 3: Wound penetrating to bone or joint

Within each grade there are 4 subtypes:

A: non-ischemic, clean wound B: infected wound

C: ischemic wound

D: infected and ischemic wound

DIABETIC FOOT lTLCERS

Meade and Mueller (Med Times 96: 154-169. 1968)

Type 1: Dorsal foot phlegmon (non-localizing, cellulitic. infectious process) Type 2: Deep plantar space infection

Type 3: Mal perforans neuropathic foot ulcers (subclassed by Wagner and USATBC)

Crozer-Kcystone Residency Manual 2004. Arranged by Brett Chicko. DPM 95

Non-Union Of Fracture

~1ALIGNANT IvlELANOl\1A

Clarks (Cancer Res 29: 705-727, 1969)

Based on the histological level of invasion

Levell: Located in the epidermis or epidermal-dermal junction Level 2: Located in the papillary dermis

Level 3: Located in the papillary to reticular dermis Level 4: Located down into the reticular dermis Level 5: Located within the subcutaneous tissue

Breslow's (Ann Surg. 172: 902-908, 1970) Based in the thickness of the melanoma Levell: < .75mm (99% cure)

Level 2: .76-1.5mm

Level 3: 1.51-4.0mm

Level 4: > 4.0mm

'VEBER AATJ) CECH

Hypervascular (Hypertrophic )90%

1. Elephant foot

2. Horse Hoof

3. Oligotrophic

Avascular (Atrophic) 1 0%

1. Torsion Wedge

2. Comminuted

3. Defect

4. Atrophic


96

PERONEAL SUBLUXATIONS

EKERT AND DAVIS (JBJS 58A: 670, 1976)

Grade 1: Retinaculum ruptures from the cartilaginous lip and lateral malleolus Grade 2: Distal edge of the fibrous lip is elevated with the retinaculum

Grade 3: Thin fragment of bone is avulsed from the deep surface of the peroneal retinaculum and deep fascia

P'VD CILA..SSIFI C_t\TION JvfEDICA_RE

CLASS A:

A J -nontraumatic amputation of foot or integral portion thereof

CLASS B

B I-absent PT pulse B2-advanced trophic changes

such as (3 required) 2a-hair growth dec. Or absent 2b-nail changes (thickened) 2c-pigmentary changes 2d-skin texturerthin, shiney) 2e-skin color (rubor, redness) B3-absent dorsalis pedis pulse

CLASS C

C] -claudication C2-temperature changes ( cold

feet) C3-edema C4-parathesias C5-burning

Soft Tisslille Injury

Tscheme and Gotzen Grade O-Little Of no soft tissue inj.

Grade l-Significant abrasion or contusion.

Grade 2-Deep contaminated abrasion with local contusional damage to skin or muscle. Grade 3-E!,_'tensive contusion or crushing of skin or destruct. of muscle, also includes subq. avulsions, decompen

Posterior Tibial MaHeoEar Fx

Volkmans

Type A: Large intra-articular fracture (>25% of surface area) with displacement Type B: Small intra-articular fracture «25%)) with impaction

Type C: Small fracture with minimal impaction and articular damage

Type D: Avulsion of the posterior-inferior tib-fib ligament without articular involvement

Crozcr-Keystone Residency Manual 2004. Arranged by Brett Chicko, DPM 97

Polvdactyly

Blauth & Olason

Radiographic and morphological presentation of the deformity.

Describes the position ofthe duplication in both the longitudinal and transverse planes.

I~

Charcot

1. Longitudinal Type: describes degree of duplication of the ray from distal to proximal, with a division into 5 types:

1. Distal phalanx

2. Middle phalanx

3. Proximal phalanx

4. Metatarsal

5. Tarsal

2. Transverse Type: indicates which rays are involved in the duplication, classification in roman numerals starting with the 1st ray and ending with the 5th ray.

Roman numerals starting with the 1st ray and ending with the 5tb ray.

Sanders & Freykberg

1) ipj & phalanx, mpj & metatarsals

2) tmj (Lis Franc's)

3) nc & tn cc

4) ankle

5) calcaneous

Classifications of Osteomyelitis:

't! W ..

~ IP

" ~

@

~ ~ @

9' ..

.7

Waldvogel

• Hematogenous: Spread via the Blood, starts inside the bone and works out towards the cortex. SEEN MOST COMMONLY IN THE METAPHYSEAL REGION OF CHILDREN with open plates

• Direct Extension: secondary to trauma or sx, affects periosteum 1st, then cortex and marrow. Proteolytic enzymes destroy Sharpey's fibers

• Contiguous: Spread of infected soft tissue to underlying bone

• Vascular Insufficiency--> PVD


98

• ..

• • ..

.. ... .,

Cierny and Mader

• Anatomic Type 1. Medullary

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