V ur era Review Booklet

( & a f e w o t h e r f o r i m p o r t a n t i t e m s e x t e r n s h i p s ) O C p M ' s O f f i c e r s f ^ C f f l l ) o f 2 0 0 5

typjzd, e d i t e d . U p d a t e d

b y

t h ^ J p M d i f l

in 2 0 0 9

All pictures came from class notes / handouts. Most of the pictures were referenced from Dr. Hetherington's book.

Tabliz of Contents: Topic Charting

Surgical Consult Pre-Op Note Post-Op Order Admission Order & Note Post-Op Note Post-Op Visit

Page #
6 6 6 6 7 7

Layers of the Foot Key Lab Values Hospitalization Indications Post-Op Fever Etiologies Sutures
Types Selection Technique

8 8 9 9
10 11 11 12 13 14 15 16 17 18

Classification Systems
Stewart, Salter-Harris Gustillo-Anderson, WatsonJones, Freiberg Berndt-Hardy, Hawkin Sneppen, Watson & Dobas, Kuwada Rowe, Sander's Hardcastle, Dias, Danis-Weber Lauge-Hansen

MRI Anesthesia Anesthetics Dosing Onset/Duration Increasing Comfort Ankle Block Hemostasis = Tourniquet Pressures
3

19 20 20 20 21 21 21

Tablsz o j Contents (Continued): Topic Corticosteroid Injections Types Side Effects Cocktails Radiographic Data Joint Deformities Osteotomies Proximal Shaft Distal Internal Fixation Principles Rule of 2's K-Wires Steinmann Pins Monofilament Wire Tension Band Wiring Staples Screws Anatomy Types Fixation Technique Selection Soft Tissue Anchors Plates Page # 22 22 22 23 24 25-27 29-30 31-33 34 34 34 34 35 36 37 38-39 40-41 42-43 44 45 45-46

Table of Contents (Continued): Topic External Fixation Principles Complications Types Dynamics Care & Management Forefoot Pathologies / Surgical Procedures Hallux Limitus/Rigidus Hammertoes Etiologies for Contracted Digits 5th Digit Arthroplasty Rearfoot Surgery Plantar Fasciotomy Haglund's Deformity Keck & Kelly Osteotomies Tendon Transfers & Indications Adductor Hallucis Abductor Hallucis Extensor Hallucis Longus Jones Suspension Hibbs Tibialis Anterior STATT Cobb Tibialis Posterior Peroneus Longus Bunions based on Angles Other things to know... Pase # 47 48 48-49 50 50 51-52 53-56 57 58 59 59 60 60 60 60 60 61 61 61 62 62 63 67

CHARTING SURGICAL CONSULT

1. 2. 3. 4. 5. 6. 7.

Chief Complaint HPI (NLDOCAT) Allergies Medications Social History Medications Family History

8. Primary Care Dr 9. Hospitalizations 10. RoS > Vitals / Vascular / Neuro / Derm / Musculoskeletal 11. Ancillary (x-rays, labs, ect...)

PRE-OP NOTE

Surgeon Medications Pre-Op Dx Allergies Planned Procedure Diagnostic Data - Labs, x-rays, EKG, ect... Consent Form: Describe Procedure & Care / Complications / Alleviations / Expected Outcomes / Arrange Pre-Op Testing "Consent form was reviewed with patient, signed and placed in chart." "All risks, possible complication and alternative treatments have been discussed with the patient in detail. All patients' questions have been answered to satisfaction. No guarantees to the outcome have been made."
POST-OPERATIVE ORDERS: ADMISSION O R D E R S & NOTE:

VANDIMAX Date/Time/Signature Vitals Activities Nursing Diet Ins/Outs Meds Ancillary X-ray

ADC - VAAN DILM A X Date/Time/Signature Admit to Dx Condition -

Vitals Activities Allergies Nursing Diet Ins/Outs Labs Meds Ancillary X-ray

P O S T - O P NOTE: S A P P A I T E M I F C 2 P 3

Findings Surgeon Hemostasis - type Pathology Assistants Estimated Blood Loss Prophylaxis Pre-Op Diagnosis Materials - sutures/hardware Post-Op Diagnosis Injectables - any post-incision Complications Condition Procedure Anesthesia - type / how much "Patient tolerated procedure and anesthesia well. Patient transported to recovery by anesthesia with vital signs stable and vascular status intact." Also may include.. Pathology - bone, ST; Condition - stable, guarded, fair, poor; Prophylaxis

P O S T - O P VISIT: S O A P

Subjective 1. POV# , PVD # 2. Procedure 3. N,V,C,F,SOB 4. Activity status 5. Pain / How controlled 6. Other Complaints Objective 1. How patient presents - walking, wheelchair 2. Vascular, Neuro, Derm, Musculoskeletal Assessment 1. Status Post-Op 2. Compliance Plan 1. Treatment 2. Dr & Residents
7

L A Y E R OF T H E F O O T

1st Layer 1. Abductor Hallucis M. 2. Abductor Digiti Minimi M. 3. Flexor Digitorum Brevis M. 2nd Layer 1. Quadratus Plantae M. 2. Lumbricales M. 3rd Layer 1. Flexor Hallucis Brevis M. 2. Flexor Digiti Minimi M. 3. Adductor Hallucis M. 4th Layer 1. Dorsal Interossei M. (4) 2. Plantar Interossei M. (3)
KEY LAB VALUES

(136-145mEq/L) (97-107mEq/L)

Chem 7 Na K

(5-20mg/dL)

CI CO

BUN / Glucose Cr
(<13 Omh/dL) (M: <1.2 W:<l.lm'g/dL)

(3.5-5mEq/L) (23-29mmol/L)

CBC WBC
(4500 11,000/LV,

(M: 14.4-16.6g/dL) (W: 12.2-14.7g/dL)

HgB HCT
(M: 43-49%) (W: 37-43%)

Platelets
(150.000-450,OOOpL)

INDICATIONS FOR HOSPITALIZATION P O S T - O P

1. Fever >101.6 2. Ascending Cellulitis / Suspect Osteomyelitis 3. Lymphangitis / Lymphadenopathy 4. Immunosuppressed 5. Virulent / Resistant Organisms 6. Need for I&D Procedure 7. Need for IV Antibiotics 8. Failed response to outpatient therapy 9. Need a consult
P O S T - O P FEVER ETIOLOGY

1. Wind - Pulmonary a. Aspiration / Pneumonia b. Occurs 24-48h c. Get chest x-ray 2. W a t e r - U T I a. Occurs in 2-6d 3. Wound a. Occurs in 3~5d 4. Walk - DVT / Pulmonary Embolism a. Within l s l week b. Virchow's Triad i. Hypercoagulation ii. Venous Stasis iii. Endothelial Damage 5. Wonder - drugs / fever / benign / medicines

SUTURES

Absorbable Sutures Chromic Gut Monocryl Maxon Vicryl

Filament Type

Monofilament Monofilament Monofilament or Braided Mono- or Dexon Multifilament Mono- or Dexon Plus Multifilament Multifilament Dexon S Monofilament PDS Non - Absorbable Sutures Filament Type Mono- or Stainless Steel Multifilament Monofilament Ethilon Nylon Monofilament Prolene Monofilament Novafil Silk Nurolon Nylon Mersilene Ticron Ethibond Multifilament Multifilament Multifilament Braided Multifilament

Total Absorption 70d 90d 90-120d 56-70d 90-120d 90-120d 90-120d 180d Advantages High strength, low tissue Rxn Elasticity/Memory Minimal Tissue Rxn Elasticity/Tensile strength Good Handling Consistent Tension Minimal Tissue Rxn Good Handling

10

S U T U R E SELECTION

5. Subcutaneous Fat 1. Bone a. Vicryl a. Stainless Steel 6. Subcuticular 2. Tendon a. Monocryl a. Prolene b. Vicryl b. Ethibond 7. Capsule c. Nylon a. Vicryl d. Polyesters 8. Skin 3. Muscle a. Nylon a. PDS b. Silk b. Vicryl c. Prolene Deep Tissue taper needle; 3-0 suture 4. Fascia Subcutaneous Tissue -> taper needle; 4-0 suture a. Prolene Dermal Layer precision needle; 5-0 suture b. PDS Capsule 2-0 or 30 suture Subcutaneous 4-0 suture Subcuticular 5-0 clear suture Skin 4-0 clear suture
SUTURE T E C H N I Q U E S

1. Simple Interrupted Good for infected wounds Individual know for each throw 2. Horizontal Mattress Everts skin edges well 3. Vertical Mattress Everts tissue edges well 4. Continuous Running Good to save time Good for large wound areas 5. Subcuticular (Running Intradermal) Leaves the best scar
IT

S T E W A R T CLASSIFICATION OF 5 M E T F R A C T U R E S

Type I

Supra-articular @ metaphyseal-diaphyseal junction True Jones! Type II Intra-articular avulsion, 1 or 2 fracture lines Type III Extra-articular avulsion, PB tears small fragment from the styloid process Type IV Intra-articular, comminuted fracture, assoc. with crush injury Type V Extra-articular avulsion @ of physis in children (SH Type I)
S A L T E R - H A R R I S CLASSIFICATION OF E P I P H Y S E A L INJURIES

Type I Epiphysis is completely separated from metaphysis Type II Epiphysis, and the growth plate, is partially separated from the metaphysis, which is cracked Type III Fracture runs through the epiphysis, across the growth plate from the metaphysis Type IV Fracture runs through the epiphysis, across the growth plate, and into the metaphysis Type V The end of the bone is crushed and the growth plate is compressed Type VI (Rang's Addition) Avulsion of peri-chondral ring Type VII (Ogden's Addition) Avulsion fracture of the epiphysis without involvement of the physis

12

G U S T I L L O & A N D E R S O N O P E N F R A C T U R E CLASSIFICATION SYSTEM

Type I Fracture with open wound < lcm in length Clean, minimal soft tissue necrosis Usually traverse or short oblong Type II Fracture with open wound >lcm in length Clean, minimal soft tissue necrosis Usually traverse or short oblon Type III Fracture with open wound >5cm in length Contamination and/or necrosis of skin, muscle, NV, & ST Comminuted > Type Ilia Adequate bone coverage > Type Illb Extensive soft tissue loss with periosteal stripping and bone exposure > Type IIIc " Arterial injury needing repair
NAVICULAR FRACTURE - WATSON JONES

Type 1 Navicular tuberosity fracture Type II Avulsion fracture of dorsal lip Type III A: Transverse body fracture - Nondisplaced B: Transverse body fracture - Displaced Type IV Stress fracture
F R E I B E R G CLASSIFICATION - A V N OF 2 N D M E T

Type I Type II Type III Type IV

No DJD Articular cartilage intact Peri-articular spurs Articular cartilage intact Severe DJD Loss of Articular Cartilage Epiphyseal dysplasia; multiple head involvement
13

B E R N D T - H A R D Y CLASSIFICATION OF T A L A R D O M E L E S I O N S

Stage I Compression lesion or non-visible lesion Stage II Fragment attached Stage III Non-displaced fragment without attachment Stage IV Displaced fragment
T A L A R N E C K F R A C T U R E CLASSIFICATION - H A W K I N ' S

Type I Non-displaced talar neck Disrupts blood vessels entering dorsal talar neck and intra-osseous vessels 20% chance AVN Type II Displaced talar neck fracture with subluxed or dislocated STJ Disrupts dorsal neck arterial branches and branches entering from inferiorly from sinus tarsi & tarsal canal 40% chance AVN Type III Displaced talar neck fracture with dislocated STJ & ankle joint Disrupts all 3 major blood supplies 100% chance AVN Type IV Displaced talar neck fracture with complete dislocation of STJ Ankle joint + subluxation or dislocation of the talonavicular joint Disrupts all 3 major blood supplies 100% chance AVN
14

SNEPPEX CLASSIFICATION OF T A L A R B O D Y LESIONS

Group I Transchondral / Compression fracture of the talar dome Group II Coronal/Sagital/Horizontal shearing fracture of the entire body Type I Coronal or Sagital A: Non-displaced B: Displacement of trochlear articular surface C: Displacement of trochlear articular surface with associated STJ dislocation D: Total dislocation of the talar body Type II Horizontal A: Non-displaced B: Displacement Group III Fracture of posterior tubercle of talus Group IV Fracture of lateral process of talus Group V Crush fracture of the talar body
W A T S O N & D O B A S CLASSIFICATION POSTERIOR L A T E R A L T U B E R C L E OF T A L U S ( S H E P A R D ' S F R A C T U R E )

Stage Stage Stage Stage

I II III IV

Normal Lateral talar process with no clinical significance Enlarged posterior lateral tubercle of the talus (Steida's Proccss) Accessory bone / Os Trigonum that may be irritated by trauma Os Trigonum + cartilaginous/synchrondrotic union with talus
K U W A D A CLASSIFICATION OF A C H I L L E S R U P T U R E

Type I Type II Type III Type IV

Partial rupture Complete rupture Complete rupture Complete rupture

<3 cm gap 3-6cm gap >6cm gap

15

R O W E CLASSIFICATION OF C A L C A N E A L F R A C T U R E S

Type

A B C A B

Medial Tuberosity fracture Sustentaculum Tali fracture Anterior Process fracture Posterior break fracture withow? Achilles involved Posterior break fracture with Achilles involvement Extra-articular body fracture Intra-articular body fracture without depression

Type

II

Type Type Type

III IV V A B

Comminuted, Intra-articular fracture with depression Comminuted fracture with severe joint depression

S A N D E R ' S C T CLASSIFICATION OF C A L C A N E A L F R A C T U R E S

* Fractures are classified according to the number of intra-articular fragments and location of fracture lines # of Fractures Type I Any non-displaced intra-articular fracture Type II 1 fracture through posterior facet creating 2 fragments Type III 2 fractures through the posterior facet creating 3 fragments Type IV 3~ intra-articular fracture lines Location of Fracture Lines:

16

LISFRANC'S F R A C T U R E CLASSIFICATION - H A R D C A S T L E

Type A: Total or Homolateral - Disruption of the entire Lisfranc joint - Transverse or Sagital plane - Most common type Type B: Partial B1 - Medial incongruity with the first met forced medially - Involves 1st met OR mets 2,3,4 but NOT 5 B2 - Lateral incongruity with lesser mets forced laterally Type C: Divergent CI - Partial divergence with the I s ' met medial and 2nd met laterally displaced C2 - Total divergence with the 1st met displaced medially and lesser mets displaced laterally
D I A S CLASSIFICATION OF L A T E R A L A N K L E L I G A M E N T INJURY

Grade Grade Grade Grade

I II III IV

> Partial rupture of CFL = > Complete rupture of ATFL = <> Complete rapture of ATFL, CFL, &/or PTFL = <> Complete rapture of all 3: ATFL, CFL, & PTFL = + Partial rupture of the Deltoid Lig
INVOLVED IN A N K L E F R A C T U R E S

D A N I S - W E B E R CLASSIFICATION OF F I B U L A R F R A C T U R E S

Type A Type B TypeC

Transverse avulsion fibular fracture BELOW... (SAD) ) Spiral fracture AT... (SERorPAB) ( the level of Fibular Fracture ABOVE... t h e syndesmosis

17

L A U G E - H A N S E N CLASSIFICATION OF A N K L E F R A C T U R E S SUPINATION ADDUCTION (SAD)

a Stage I

Transverse avulsion of fibula @/below AJ level Rupture of the Lateral Collateral Ligament n Stage II Oblique to Vertical fracture of the Medial Malleolus
PRONATION ABDUCTION (PAB)

n Stage I

Transverse avulsion fracture of Medial Malleolus - or - Rupture of Deltoid Lig n Stage II Rupture of AITFL & PITFL - or - Tillaux-Chaput / Wagstaffe fracture n Stage III Short oblique fracture of the fibula @ lvl of syndesmosis (SER) *** Most Common! Rupture of AITFL - or - Tillaux-Chaput / Wagstaffe fracture n Stage II Spiral/Oblique fracture of fibula @ lvl of syndesmosis n Stage III Rupture of PITFL - or - Avulsion fracture of Posterior Malleolus (Volkmann's Fracture) n Stage IV Transverse fracture of Medial Malleolus - or - Rupture of Deltoid Lig n Stage I (PER) *** Longest healing time! Transverse fracture of Medial Malleolus - or - Rupture of Deltoid Lig n Stage II Rupture of AITFL & Interosseous membrane - or - Tillaux-Chaput / Wagstaffe fracture n Stage III High Spiral Oblique fracture (Maisonneuve Fracture) n Stage IV Rupture of PITFL - or - Avulsion fracture of Posterior Malleolus

SUPINATION EXTERNAL ROTATION

PRONATION EXTERNAL ROTATION

a Stage I

18

MRI

Tl-Weighted -> good for showing anatomical detail + Short TE + TR + Tissue with short T1 are brighter + Fat T2-Weighted good for highlighting areas of pathology + Long TE + TR + Tissue with long T2 are brighter + Water, Edema STIR -> Short Tau Inversion Recovery + Fat suppression + Heavily water-weighted image + Very Sensitive for bone marrow abnormalities
Gadolinium (best for infection)

+ Contrast-enhanced chemical agent + Shortens T1 relaxation times -> Increases signal intensity on T1 weighted images + Usually used in conjunction with fat suppression + Good for identifying ST masses, inflammation processes, & for staging bone and ST infection TE = Time to Echo TR = Time of Repetition dec TE + dec TR = Tl-Weighted inc TE + inc TR = T2-Weighted

19

ANESTHETICS

Esters Higher incidence of allergies Metabolized in Blood (Cholinesterase in plasma) Types ~ Cocaine ~ Procaine ~ Chloroprocaine ~ Tetracaine Amides Metabolized by CYP450 system in Liver Types ~ Lidociane / Xylocaine (0.5, 1, 1.5, or 2% solutions) ~ Bupivicaine / Marcaine (0.25, 0.5, or 0.75% solutions) "* C/I<l2y/0 ~ Mepivicaine / Carbocaine (1, 1.5, 2, or 3% solutions) Dosing: 0.25% solution = 2.5 mg/cc drug 0.5% solution = 5 mg/cc drug 1% solution = 10 mg/cc drug

lcc = lmL

Ex: 5cc of 1% Xylocaine (lidocaine) = 50mg of Xylocaine given Ex: 3cc of 0.5% Marcaine (bupivicaine) = 15mg of Marcaine given Toxic Doses: Lidocaine Plain = 300mg w/ Epi = 500mg Marcaine Plain = 175mg w/ Epi = 225mg Onset & Duration: Onset: 5min Duration: l-2h Onset: Duration:
20

10-15min 6-8h

6 Ways to Increase Comfort of the Injection: 1. Quick Stick 2. Slow Injection 3. Small Gauge Needle (large # = small gauge) 4. Small Syringe (less pressure) 5. Cold Spray 6. Warm the Solution (to body temp)

Draw up with 18G Inject with 25 or 27G

Ankle Ring Block: Superficial = Saphenous N., Sural N., Superficial Peroneal N. Deep = Posterior Tibial N., Deer Peroneal N. ** Fact: If you mix Lidocaine and Marcaine, you will only have partial anesthesia deep into surgery. Only mix to avoid toxic doses. ** Fact: If you need to inject more volume, use a small percent of drug solution.
Deep F i b u l a r N.

(IDCN.MDCN)

Saphenous N. Talar Trochlea

Superficial Fibular N

Post. Tibial N. S u r a l N.

Ex: 30cc of 1% gives more anesthesia than 15cc of 2%

Saphenous N Posterior Tibial N Sural N Deep Peroneal N Superficial N .5-lcc l-3cc .5-lcc .5-lcc .5-lcc give the most here since this N is the largest between 2 Long Extensor Tendons plantarflex & invert

Hemostasis = Tourniquet Pressures: Ankle: +100 over systolic ~250mmHg Thigh: +200 over systolic ~ 350mmHg
21

CORTICOSTEROID INJECTIONS

Corticosteroid injections are used to control local inflammatory reactions Phosphates: Acetates: short-acting (clear) long-acting (cloudy)

All corticosteroids are collagenilytic and therefore should not be injected into the same area of soft tissue more than 3-4 times per year. Side Effects: ~ Soft tissue atrophy ~ Tendon rupture ~ Skin discoloration (lightening) Cocktails Commonly used in Podiatry: Always draw up the Lido/Marc 1" 1. Plantar Fasciitis j followed by Dex or Kenalogl a. lcc Kenalog-10 (lOmg/mL) b. 0.75cc 1% Lidocaine c. 0.75cc 0.5% Marcaine 2. Joint Injections a. 0.2cc Dexamethasone Phosphate b. 0.5cc 1% Lidocaine 3. Intermetatarsal Neuromas a. 0.3cc Dexamethasone Phosphate b. 0.5cc 1% Lidocaine

22

RADIOGRAPHIC D A T A

Angle: Normal: Hallux Abductus Angle 0-15 Proximal Articular Set Angle (PASA) 0-8 Distal Articular Set Angle (DASA) 0-7 Intermetatarsal Angle
1-2 0-8

2-5 16 4 4-5 8 + 2 Hallux Interphalangeal Angle (HIA) 0-10+ 2 Metatarsal Length + 2mm Metatarsus Adductus 0-8 Tibial Sesamoid Position Positions 1-3 1 = Medial to midline of hallux 2 = Touching midline medially 3 = 2/3 medial + 1/3 lateral to midline 4 = 1 / 2 medial + 1/2 lateral to midline 5 = 1/3 medial + 2/3 lateral to midline 6 = touching midline laterally 7 = lateral to midline of hallux Calcaneal Inclination Angle 18-22 Talar Declination Angle 210 TaloCalcaneal Angle (Kite) 17-21 Bohler's Angle 25-40 Angle of Gissane 125-140
| Calcaneal Fracture resulting in ! Joint Depression => Bohler's Angle J. Angle of Gissane

23

C L A S S I F I C A T I O N OF J O I N T D E F O R M I T I E S

Positional De+formities: PASA + DASA < HAA PASA and DASA within normal range (0-8) Joint is Subluxed Structural Deformities: PASA + DASA = HAA PASA and DASA abnormal Joint is Congruous Combined Deformities: PASA + DASA < HAA PASA and DASA abnormal Joint is Dislocated

fr.

(A) Congruous: (B) deviated: (C) surtaxed.

24

PROXIMAL OSTEOTOMIES

IM between 15-22, normal PAS A NOT for a short metatarsal I. Closing Base Wedge 1-1.5cm from met-cuneiform joint 4-6weeks NWB

Indications: Structural Lg IMA Splayfoot Juvenile/Recurrent HAV Met Primus Elevatus HAV + MetAdductus C/I in Elderly

II.

Juvara - Types A,B,C A: Oblique, distal lateral to proximal medial with an intact medial cortical hinge B: same as A but the medial hinge is sectioned after wedge resection C: Oblique, without wedge resection

25

PROXIMAL OSTEOTOMIES CONTINUED.

III. Opening Base Wedge (Trethowan) Good for a short metatarsal Use medial eminence for the graft

IV. Crescentic 1.5cm from met-cuneiform joint Easy traverse plane correction Good for short metatarsal

26

PROXIMAL OSTEOTOMIES CONTINUED.

V.

Double Osteotomy IM and PASA correction

VI. Proximal V Good screw fixation Unlikely to get elevates

VII. Lapidus I M > 18 Fusion of the base of 1st met to the medial cuneiform Indications: Pain with motion at met-cuneiform joint Hypermobility of 1st met-cuneiform j oint

27

<

MIDSHAFT OSTEOTOMIES

** Troughing is unique to midshaft osteotomies t. Ludloff Osteotomies IM 1-2 angle: 13-20 Abnormal HAA Normal to short I s ' metatarsal Elevatus is a risk

J /

II.

Mau IM 1-2 angle: 13-20 Abnormal HAA Normal to short 1st metatarsal Due to cut, decreases elevates potential

29

MIDSHAFT OSTEOTOMIES CONTINUED.

III. S c a r f - " Z " Dorsal to Plantar - 50:50 or 66:33 cut Very Stable, technically difficult 2 screw fixation

IV. Off-Set "V" Modification of the Austin Cut angled <55

MO

30

DISTAL OSTEOTOMIES

HAV angle - 35 IM angle 16 0 Some PASA correction I. Reverdin Some PF possible

II.

Hohmann Very unstable; Rigid Fixation necessary Shortening occurs with fragment removal

31

DISTAL OSTEOTOMIES CONTINUED.

III. Mitchell - "Step-down Osteotomy" Used for long 1st metatarsal Good visualization of possible change

IV. Wilson Dramatic shortening possible

32

DISTAL OSTEOTOMIES CONTINUED.

V.

Austin / Chevron / Distal "V" Transpositional - PASA, IM, DF/PF possible Joint preserving Possible of Juvenile HAV Displace capital fragment 'A to 'A bone width

VI. Reverdin Green / Distal "L" Cut 2/3 way through bone, then plantar cut

33

INTERNAL F I X A T I O N

4 Main Principles of Internal Fixation: 1. Anatomical Reduction 2. Rigid Internal Fixation 3. Atraumatic Technique 4. Early active RoM Rules of 2's: Fracture / Osteotomy site should be 2x's the diameter of the bone 2 points of fixation is better than 1 2 threads should purchase the distal cortex 2 finger tightness Kirschner Wires (K-wires): Steel wires used as permanent or temporary fixation Dependent on diameter Available in both smooth and threaded Threaded wires provide more stable purchase BUT are weaker & harder to remove Both are measured by outer diameter ONLY maintain compression Sizes: 0.028, 0.035, 0.045, 0.062 inches Steinmann Pins: Very similar to K-wires Larger diameter than K-wires Provide Inc Stability Measured in 64ths Sizes: 8/64 (1/8), 7/64, 6/64...

34

INTERNAL FIXATION CONTINUED

Monofilament Wire: Malleable Steel Provide interfragmentary compression Measured in Gauges (small gauge = large diameter) Techniques: > Cerclage fashion circling around a bone > Interfrag fashion placed in between 2 fragments always pull on the proximal fragment most stable

35

INTERNAL FIXATION CONTINUED.

Monofilament Wire Continued... > Box Wire fashion 2 boxes at 90 to each other One wire is placed medial to lateral Other is placed dorsal to plantar

Tension Band Wiring: Combines K-wire with MF wire Requires that there is a soft tissue structural component Two K-wire's placed the parallel fashion across fracture site with the MF wire in a figure 8 pattern around the K-wire on the site opposite to the tendon's anatomical pull. Size of wire measured in gauges Lower gauge; thicker wire 26 & 28 are common in Podiatry

36

INTERNAL FIXATION CONTINUED. ..

Staples: Primarily used for fractures, osteotomies & fusions Inserted manually or with pneumatic gun Provide compression, distraction or maintain compression Be careful about thickness of bone - DO NOT use if cortical bone is greater than 2-3mm, may cause cortical fractures or not seat in bone properly Pre-Drills:

Neutralization-^

Compression 4

Divergent Lines

Distraction

= Convergent Lines

Richards Staple: Os Staple: Uniclip:

GOLD STANDARD for major fusion Heat activated Has an aperture Requires a tool to compress the legs after insertion

37

INTERNAL FIXATION CONTINUED. ..

Screws: These features can differ depending on the function of the screw. Flead Land Has various configurations; hexagonal, cruciate, slotted... The curve-contoured underside of the screw head Increases the surface contact between the screw and the bone Reduces the chance from stress-risers Area of the screw that is void of the thread pattern

Shaft/Shank Thread

The means by which the screw purchases the bone The diameter across the thread width

Thread Diameter

Measurement is the value used to describe the screw size Core Diameter Diameter between the thread patterns

Pitch Distance between the adjacent threads Run-Out Junction where the shaft meets the thread Weakest point on the screw Avoid placing the run-out near the fracture / osteotomy site Lead Distance that the screw advances with each turn (360) Thread to axis angle Tip to axis angle Either rounded (needs pre-tapping) or fluted (self-tapping)
38

Rake Angle Tip Angle Tip

INTERNAL FIXATION CONTINUED

Screw Diagram:
HEAD Hexagonal allows for the most efficient translation of torque and reduce CAM-OUTfiifting out of the screw driver from the screw head)

LAND Undersurface of the head of the screw which comes in contact with bone

SHANK Only present in cancellous screws

RUN OUT weakest point in screw < PITCH Distance between threads, cortical screws have a smaller pitch than cancellous screws F r RAKE ANGLE Thread to axis angle

C O R E DIAMETER Diameter of the screw between the threads THREAD DIAMETER f This value is used to describe the t screw sizeO.e. a 2.7mm screw has a 2.7 millimeter thread diameter)

<

TIP A N G L E Tip to axis angle

39

INTERNAL FIXATION CONTINUED . . .

Types of Screws: 1. Cortical Screws Threaded the entire length of the screw Have smaller pitch for greater number of contacts between the screw and the dense cortical bone 2. Cancellous Screws Partially threaded Larger pitch to provide greater distance of contact between the screw and the less dense, porous cancellous bone 3. Cannulated Screws Hollow center down the length of the screw to be used over a guide wire Offers easier placement and less complications May have decreased pullout strength 4. Herbert Screws Ho head and two set of threads proximally not distally Proximal threads have greater pitch than the distal threads Indicated for intra-articular fractures Compressive strength of Herbert screw are less than conventional screws 5. Interference Screws Fully threaded, headless screw Does not provide interfragmentary compression but resists axial displacement of one fragment on another Indicated for stabilization of tendon grafts to bone and tendon reattachment
40

INTERNAL FIXATION CONTINUED. ..

Types of Screws Continued: 6. Absorbable Screws Available in natural / synthetic polymers Most common absorbable polymers used are based on alphahydroxy acids such as L-lactic acid, glycolic acid, & para-dioxanone Need to be able to last 6-8 weeks

Basic Properties for the Ideal Absorbable Implant: ~ Posses and initial strength to meet biomechanical demands ~ Degrades in a predictable manner over time ~ Undergoes complete absorption without harm to surrounding tissues

41

INTERNAL FIXATION CONTINUED. ..

General Screw Fixation Technique: ~ Place one screw perpendicular to the fracture / osteotomy line for maximal compression. Place the 2nd screw perpendicular to the longitudinal axis of the bone this provides greatest resistance to the axial loading forces on the bone. ~ If only a single screw placement is allowed - place the screw in an angle that is halfway between the angle that is perpendicular to the fracture line and perpendicular to the long axis of the bone Diagram: A. 2 Screw Technique B. 1 Screw Technique

b.
42

INTERNAL FIXATION CONTINUED

General Screw Fixation Technique Continued: Load Screw Technique This technique is commonly used in plate fixation. Involves placement of 2 screws in the plate that is closest to the fracture line to be drilled offset away from the fracture line. As the screws are advanced the bone segments between the two screws are further compressed. Lag Screw Technique Placement of the screw so that ONLY the thread engages the distal cortex of the bone. Thus further advancement of the screw results in approximation and subsequent interfragmentary compression. Most effective in fracture / osteotomy that is 2x's the width of the bone or has a fracture angle that is less than 40. Partially Threaded Screw Insertion Technique 1. Thread / Pilot Hole 2. Countersink (increases surface contact between screw head and the bone) 3. Depth gauge (measures distance between the proximal and distal cortex) 4. Tap 5. Insert Screw Fully Threaded Screw Insertion Technique 1. Thread / Pilot Hole 2. Countersink 3. Glide Hole 4. Depth gauge 5. Tap 6. Insert Screw
43

INTERNAL FIXATION CONTINUED . . .

Screw Selection Chart: Thread Diameter Mini-Fragment 1.5 2.0 2.7 Small-Fragment 3.5 4.0 (partial/cancel) 4.0 (full/cancel) Large-Fragment 4.5 4.5 (mall) 6.5 (partial/cancel) 6.5 (full/cancel) Thread Hole 1.1 1.5 2.0 2.5 2.5 2.5 3.2 3.2 3.2 3.2 Gliding Hole 1.5 2.0 2.7 3.5 NA NA 4.5 NA NA NA Tap Diameter 1.5 2.0 2.7 3.5 3.5 3.5 4.5 4.5 6.5 6.5

44

INTERNAL FIXATION CONTINUED. ..

Soft Tissue Anchors: S Used for reattachment of tendons or ligaments S 2 basic types: Expandable / Screw type S Complications: Improper Placement / Failure of Suture / Pullout Plates: S Various size and shape - allow alignment of the bones and stability across the fracture / osteotomy site S Stability allows for early passive RoM S Adequate screw fixation is important for the plate to function properly S Plate designs include semitubular, 1/3 tubular, Vi tubular, T - plate, L - plate, calcaneal plate... Types of Plates: 1. Neutralization Plate a. Prevents torsional / bending forces from acting on the lag screws b. The ridge extension of the plate on the bone proximal & distal to the fracture / osteotomy site helps neutralize any extra forces along the bone segment 2. Compression Plate a. Generate compressive forces along the fracture / osteotomy site by either placing the plate on the tension side of the bone, offset drilling (AKA load screw technique) or pre-bending the plate.

45

INTERNAL FIXATION CONTINUED. ..

Plates Continued... 3. Dynamic Compression Plate (DCP) a. Employs the concepts of offset drilling with unique plate designs to optimize the compressive forces of the plate b. Disadvantage is it increases periosteal damage and decrease intramedullary blood supply to the area, decreasing the overall strength of the bone segment 4. Limited Contact Dynamic Compression Plate a. Has a series of recessed undercuts on the undersurface of the plate which allows limited contact between the bone and the plate b. Generates less disruption to the vascular supply 5. Buttress Plate a. Anchored to the main stable fragment b. Supports the load-bearing bone c. Indicated in impacted fracture that results in comminution (e.g. tibial plateau and the tibial pilon fractures) 6. Bridge Plate a. Useful in unstable comminuted fractures by spanning the length of the comminution b. Frequently used with bone grafts to fill the voids in the bone

46

E X T E R N A L FIXATION

External fixation implements the use of wires, pins, and rods to keep bone segments in alignment or compression. Furthermore they allow distraction of bone segments by the principle of tension-stress effect. Advantages: > Use in open fractures, acute, fractures, infected fractures and nonunions > Requires minimal tissue dissection > Allows compression, neutralization, or fixed distraction of bone segments > Length can be maintained in a comminuted fracture > Allows access to the wound site for care, monitoring and dressing changes > Full weight bearing is allowed immediately post-operatively Disadvantages: > Requires skin and pin tract care > Difficult frame construction > Bulky frame > Fracture through the bone is possible > Refracture possible after frame removal > Expensive Basic Principles of External Fixation: 1. Frame should avoid and respect all vital structures in the area 2. Allow access to the wound site 3. Frame must meet the mechanical demand of the patient and injury

47

EXTERNAL FIXATION CONTINUED. ..

Complications: S Pin irritation - avoid pin placement in muscle S Pin tract infection - most common complication (30%) S Neurovasculature Impalement - Anterior Tibial A. & Deep Fibular N. and they are most commonly involved S Delayed Union / Non-Union - due to faulty frame construction S Compartment Syndrome - due to increase in the intracompartmental pressures (mmHg) f Refracture - once the frame has been removed due to tension shielding, a rare complication Types of External Fixators: 1. Unilateral Fixators S Produces compressive or distraction forces S Used to fixate fractures, fuse joints, and lengthen S Available in small or large, it is attached to the bone by multiple half-pins screwed into the bone and attached to the fixator with the clamp S Main disadvantage - not create any sagital plane stability & therefore should not weight bear immediately post-op

48

EXTERNAL FIXATION CONTINUED

Types of External Fixators Continued... 2. Circulator Fixators S Produces compressive and distraction forces S Used to fixate fractures, treat non-unions, limb-lengthening , soft tissue lengthening, and correction of congenital deformities. S Utilizes trans-osseous wires with half-pins to position the wires in different plane stability S Limited by the circular frame's ability to fit the extremity and patient's comfort of wearing the apparatus 3. Hybrid Fixators S Combination of unilateral and the circular fixator S Used to treat tibial plafond fractures and pi Ion fractures S Utilizes trans-osseous wires and half-pins and footplate to allow early weight bearing 4. Taylor Spatial Frame Fixators S Newest external fixation device S Allows for reduction and stabilization of fracture S Its unique feature allows for reduction of complex triplane deformities

49

EXTERNAL FIXATION CONTINUED. ..

Dynamization: After removal of the plate, the bone may be prone to re-fracture during weight-bearing because of weakening of the bone from disuse osteopenia. To prevent this complication it is important to gradually release tension in the trans-osseous wires and loosen the pins to allow the bone to gradually strengthen as it bears weight.

Fixator Care & Management: Pin sites need to be kept clean with sterile solution and applied antibiotic cream in order to prevent infection and seal the opening around the pins. Avoid applying Betadine around the pins in order to avoid corrosion.

50

COMMON FOREFOOT PATHOLOGIES AND SURGERIES

Hallux Limitus / Rigidus Decreased or absent RoM at the 1st MPJ Normal RoM = 90 (20-25 PF + 60-65 DF) Radiographic Appearance AP > Focal joint space narrowing > Joint mice > Spurring > Asymmetry > Squaring of metatarsal head Etiologies = T I N - M A C Trauma Infection Neoplasm of bone or soft tissue Metabolic Anatomic Structural = short/long 1st ray, Met Primus Elevatus 1. Meary's Angle deviation (b/s talus should b/s 1st met) 2. Parallelism between 1st & 2nd metatarsals 3. Metatarsal parabola / protrusion deviation Biomechanical = pronation, hypermobile 1st ray Congenital

Lateral > Dorsal Flag Sign > Spurring P- Sclerosis > Metatarsus Primus Elevatus

51

COMMON FOREFOOT PATHOLOGIES AND SURGERIES CONTINUED. ..

Hallux Limitus / Rigidus Continued... Joint Procedures: Joint Preserving 1. Cheilectomy = Valenti (V-cheliectomy) 2. Osteotomies > Proximal Phalanx = Bonny-Kessel (proximal DFWO) > 1st Metatarsal Waterman = Distal DFWO Mitchell = step-down shortening procedure Youngswick = chevron double dorsal cut elevates Sagital Z = corrects for elevates Lambernudi = diaphyseal PFWO, for elevatus Joint Destructive 1. Keller = Proximal Phalanx arthroplasty / for elderly / less functional > Complications - transfer metatarsalgia, stress fracture of 2" , proximal migration of sesamoids 2. Implant = Hemi or Total - must cover cortical surfaces 3. McKeever = 1st MP J arthrodesis - positioned dorsiflexed and abducted with no rotation > DF = 10-15 off weight bearing - one finger under toe > 5-10 of abduction > Toe will no longer bend so patient cannot squat down Joint Distraction with External Fixator: 1. Cheilectomy, mini rail 2. 7mm distraction intra-operatively, 2 weeks rest, then 1mm distraction qd for 7d = Total 14mm Distraction

52

COMMON FOREFOOT PATHOLOGIES AND SURGERIES CONTINUED. ..

Hammertoes Function of Lesser Digits: > Decelerate the foot ^ Stabilize the forefoot > Aid in propulsion > Provide kinesthetic sensation Function of Musculature: > EDL / EDB = dorsiflex MPJ - passive flexion at PIPJ / D1PJ > FDL / FDB = actively plantarflex MPJ, PIPJ, DIPJ > Interossei = prevent buckling > Lumbricales = hold digits rectus (plantarflex MPJ, dorsiflex PIPJ / DIPJ) Types of Deformities: Hammertoe Claw Toe Mallet Toe MPJ Extension Extension Rectus PIPJ Flexion Flexion Rectus DIPJ Extension Flexion Flexion

Etiologies for Contracted Digits: 1. Flexor Stabilization (Most Common) > Weakness of intrinsic Interossei Ms > Adv. of Quadratus Plantae > Pronated foot type - flexors fire longer and harder > Causes AdductoVarus deformity on 4th and 5th > Late stance phase biomeehanical abnormality > Tx = Derotational Arthroplasty

53

COMMON FOREFOOT PATHOLOGIES AND SURGERIES CONTINUED. ..

Hammertoes Etiologies Continued: 2. Flexor Substitution (Least Common) > Weakness of Triceps Surae - Flexors gain mechanical advantage over extensors > Supinated foot type - late stance phase abnormality > Tx = suture FDL to Achilles tendon to strengthen muscles S Must perform Arthrodesis 3. Extensor Substitution > Weak Tibialis Anterior - extensor gains mechanical advantage over Lumbricales > Begins flexible and becomes rigid -> reduce early w/ weight bearing > Pes Cavus / Ankle Equinus / TA weakness / EDL spasticity and pain are frequent symptoms > Swing phase biomechanical abnormality > Tx = Arthrodesis if Rigid Hibb's Tenosuspension if Flexible

54

COMMON FOREFOOT PATHOLOGIES AND SURGERIES CONTINUED.

Hammertoes Surgical Procedures:

SOFT TISSUE

1. Tenotomy = stab incision medial or lateral to tendon deformities only S PF digit with blade in place - flexible deformities only S Older population only - lose strength & stability 2. Capsulotomy 3. Tendon Transfer 4. Girdlestone S Transfer FDL & FDB to dorsal head of proximal phalanx to restore intrinsic function 5. Hibbs S Transfer EDL to base of proximal phalanx or met head 6. Kuwada & Dockery S Modification of Girdlestone - drill hole in base of proximal phalanx and bring tendons up through it 7. Lengthening 8. Z-Plasty at level of MP J 9. Percutaneous stab incision and splint """Complications: Muscle spasm caused by overcorrection, tenosynovitis, scarring, adhesion, weakness, bowstringing, and nerve entrapment
OSSEOUS

1. Arthroplasty S Post - resection of base of proximal phalanx S Gotch & Kreuz - resect base of proximal phalanx and syndactylize digits 2. Arthrodesis S Lambrinudi - fusion of PIPJs and DIPJs S Young-Thompson - Peg-in-Hole Fusion (Peg from Prox.Phalanx) S High amount of shortening 3. Taylor - PIP J fusion using K-Wire
55

COMMON FOREFOOT PATHOLOGIES AND SURGERIES CONTINUED. ..

Hammertoes Sequential Reduction: 1. Z-Plasty 2. Arthroplasty 3. Extensor Hood Release 4. MP J Capsulotomy 5. Volar Plate Release 6. Tendon Transfer (Girdlestone, Kuwanda & Dockery, Hibbs) ** Kelikian Push-Up Test: Performed between each step to determine if sufficient correction has been established. If you get dorsiflexion when placing GFR on the met head then do the next step. Hallux Hammertoe: Etiology: > Muscle imbalance > Iatrogenic after sesamoid removal or detachment of FHB > IPJ sesamoid binding FHL tendon Treatment: Flexible - IPJ fusion with EHL lengthening Rigid - IPJ fusion with Jones Tendon Transfer ~ Cut EHL distally from insertion ~ Drill hole transversely through 1st med head ~ Insert tendon through drill hole and suture back on itself

56

5 DIGIT ARTHROPLASTY

1. Lazy "S" Incision S Lateral condylectomy of distal and middle phalanges with resection of head of proximal phalanx 2. Derotational Arthroplasty S Distal Medial Proximal Lateral Incision 3. Complications S Floppy Digit S Edema (sausage digit) S Floating Toe with Metatarsalgia S Regeneration of Proximal Phalanx / Infection ^ Decreased sensation S Blue toe

57

REARFOOT SURGERY

Spurs are incidental findings only and are rarely the cause of pain. 1. May be painful if directed plantarly 2. Must be present to be approved for orthotics Conservative therapies should be used for the first 3-9 months Plantar Fasciotomy: 1. Plantar L shaped incision at the medial midfoot 2. Release of the medial band of the plantar fascia 3. NWB for 3 weeks 4. Sutures out after 3 weeks Endoscopic Plantar Fasciotomy: 1. Small incision in the medial rearfoot 3 fingers from the posterior heel and 2 fingers up from the plantar foot 2. Blunt dissection to the fascia 3. Insert spatula across plantar aspect of foot, dissecting fascia from plantar fat pad - remove spatula 4. Insert trochar into slotted tube and insert through dissected incision - remove trochar 5. Insert scope into tube laterally and blunt probe medially - separate medial and central bands of plantar fascia 6. Insert cutting tool into medial tube and cut medial band of plantar fascia while pulling instrument out of the tube 7. Visually observe abductor hallucis muscle belly before removing tube and irrigating incision site

58

REARFOOT SURGERY CONTINUED. ..

Haglund's Deformity: Angles: Philip-Fowler Angle = normal 44-69, >75 pathological Total angle of Ruck = Philip-Fowler + Calcaneal Inclination Angle Normal up to 90, pathological i f > 110 Parallel Pitch Lines - most objective method of determining a Haglund's deformity Procedures: Longitudinal incision lateral to TA Dissection down to posterosuperior calcaneus Aggressive removal of pathologic bone, but don't chase the bump If you need to reflect the TA, reattach with a soft tissue anchor and remain NWB for 3 weeks Keck & Kelly Osteotomy: Indicated for increased CIA angle with no Haglund's deformity Dorsal wedge osteotomy of the posterior calcaneus Rotate posterior aspect of Calcaneus dorsally after wedge removal MAINTAIN PLANTAR HINGE Secure with cancellous screws NWB for 6 weeks

59

TENDON TRANSFERS

Tendon Transfer - detachment of the tendon from insertion then relocate to new position Tendon Transplantation / Translocation - rerouting the tendon without detachment from its insertion Types: 1. Adductor Hallucis S Resect at insertion, pass under the joint capsule and reattach at medial aspect of the capsule S Indicated in HAV to realign the sesamoid apparatus 2. Abductor Hallucis S Transected at insertion, rerouted inner 1st met head and fixated at lateral base of proximal hallux S Indicated in Hallux Varus with an osteotomy 3. Extensor Hallux Longus S Transected at origin, rerouted under DTIL, fixated to lateral base of proximal hallux S IPJ needs fused S Indicated when have sagital component with Hallux Varus 4. Jones Suspension S EHL excised from insertion, drill a hole transversely through 1st met head, rerouted through hole and sutured on itself S Indicated with cock-up deformity, flexible cavus, lesser metatarsalgia, chronic ulcers, weak TA, flexible plantarflexion of 1st met 5. Hibb's Tenosuspension S EDL detached from insertion, bundled together and placed through midfoot at the base of the 3rd met or lateral cuneiform S Indicated to release retrograde buckling at MPJs, met equines, flexible cavus, claw toes

TENDON TRANSFERS CONTINUED. ..

Types Continued... 6. Tibialis Anterior Transfer S 3 incisions at (1) proximal dorsal leg, (2) TA insertion at medial plantar cuneiform / tubercle 1st met, and (3) the new area of insertion in the midfoot S Release from insertion, reroute out the proximal incision, with tendon, with tendon passer brought to new insertion (usually 3rd cuneiform) S Indicated for recurrent clubfoot, flexible forefoot equines, dropfoot, tarsometatarsal amputation, Charcot Marie Tooth deformity 7. Split Tibialis Anterior Tendon Transfer (STATT) S 3 incisions at (1) base of 1st met, (2) anterior leg over TA just lateral to medial malleolus and (3) over peroneus tertius at base of 5th met S Split tendon through proximal insertion, lateral slip passed through peroneus tertius sheath and sutured to tendon fixated to cuboid S Indicated for spastic RF equines, spastic equinovarus, fixed equinovarus, FF equines, flexible cavovarus deformity, DF weakness, excessive supination in gait Cobb Procedure S ST ATT but reroute to TA to PA tendon S Indicated for PT dysfunction

8.

61

TENDON TRANSFERS CONTINUED. ..

Types Continued... 9. Tibialis Posterior Tendon Transfer S 3 incision (1) insertion of the PT at navicular tuberosity, (2) anterior leg, middle 1/3 just lateral to tibial crest and (3) one at new insertion at dorsal midfoot / Tendon released from navicular Tuberosity, dissected free at the medial leg insertion to expose the IM and the PT pulled through this opening then brought to new insertion level (usually 3rd cuneiform) S Indicated for weak anterior muscles, equinovarus, spastic equinovarus, recurrent clubfoot, dropfoot, complications from Charcot Marie Tooth, peroneal nerve plaste, leprosy, Duchenne's MS S Muscle goes from a stance to a swing muscle during gait 10. Peroneus Longus Tendon Transfer S 3 incisions (1) lateral, lower leg, (2) lateral cuboid and (3) base of 3rd met/lateral cuneiform S Suture the Peroneus Longus to the Brevis , cut the longus at the level of the cuboid and the tendon is brought through the proximal incision and back through the medical incision to the 3rd cuneiform S Indicated for anterior muscle weakness, dropfoot

62

B L I N I O N P R O C E D U R E S T D K N O W B A S E D O N ANT.I KS

Austin Hohman (Neck) Trapaziodal Normal: 0-8 Mitchell (Neck) Wilson (Neck) f Revcrdin Laird (Distal L) . Short Z Waterman Youngswick >16 Proximal Base Wedge Osteotomy Lapidus (Met-Cuneiform Fusion)"^"" 0 4 '' 2 Cresentic Juavara Proximal V of Kotzengerb 1 Comments: with a thin Met shaft 4 may need to use a proximal procedure Mitchell - shortens the length of met shaft -> used in Long Met Length ( > 2 m m longer than 2 nd met) Taylor's Bunion = Symptomatic when IM4.S >9 ' Splayfoot = IM|.2 + IM4.5 >20 1M Angle
1

8-16

Distal Osteotomy

DASA Normal: 0-8"

>8

Proximal Osteotomy

4 ^
1 Comments:

Proximal Akin cylindrical akin w/ long prox phalanx oblique transverse Bonnel-Kessel ->DF wedge

PASA 1 Normal: 0-8 1 Comments: 1

>8

Distal Osteotomy

Reverdin Reverdin Green

PASA

63

Abnormal IM: 12-16 + Abn P PASA + IM Angle

IM: >16 + Abn P

Distal Biplane Austin PASA + IM Osteotomy Reverdin Laird (Distal L) Reverdin Green Biplane Mitchell ->Roux Hohmann Shaft Mau Osteotomy Ludloff Scarf / "Z" Klotzcnbcrg Juvara Lapidus w/ Reverdin Proximal Osteotomy V Osteotomy Logroscino (Base Wedge Reverdin) Cresentic Juavara Proximal V of Kotzengcrb

h K u K k J K K K

Comments:

HAA Normal: 0-16

> 16

Silver McBride Adductor Hallucis Tenotomy Lateral Capulotomy

Comments: ST or Osseous Abnormality t HAA + IM,. 2 13-20 = Lodloff + Mau (+ t PASA) = Scarf Z
HIA

> 10

Distal Akin
K

Normal: 0-10 Comments:

64

1 Tibial Sesamoid Position ^ N o r m a l : 0-3 Comments: 1 Lateral Deviation 1 Angle Normal: 2.5 IM: 8-12" Normal 2 Slight Increase

4-7

Fibular Sesamoidectomy Fibular Sesamoid Release

Distal Osteotomy

exostectomy clist. metaphyseal osteotomy

Proximal Osteotomy

Reverse Reverse Reverse Reverse Reverse

Austin Mitchell Hohmann Wilson Mercado

LDA: Inc IM4.5 1 Normal: 0-8 I M : > 15/16 Marked Inc J,

1

Base Wedge

LDA: T Severe Lat Bowing Comments:

( C < ( < ( ( . (

I ( ( ( ( ( ( ( ( (

C ( ( (

Othgr Important Things to Know for 3rd y ^ a r "Rotations & Cxtszrnships

Dr. Bodman's Drugs Dr. Caldwell's Drugs Dr. Caldwell's Wound Care Ankle Scopes p. 68 p. 74 p. 84 p. 90

67

GROUP

CLASS Macrolide

GENERIC erythromycin topical erythromycin

BRAND % Benzamydn 3

Erygel Bactroban Bacitracin

2 2 500 u/g

'2 -S 3 aa Ti

Protein Synthesis Inhibitor Broad

mupirocin bacitracin

VEHICLES SIZE 46.6 gm gel jar or 60 packets 30.60 gel gm tubes 1 gmto cream or ointment 30 gm tubes ointment 30 gm tube

SIC BID

INDICATION Acne Vulgaris

qdor BID TID 7-14 davs BID or TID 7 davs qdBID Qd Impetigo or infections (bacterial) Superficial Infections

<
silver sulfadiazine Silvadene polymycinB sulfate Betadine 1 cream 50 gm tube l Aoz tubes or 1/32 oz packets

10.000 ointment U/g

2 Bd /3 fd degree bums Superficial Infections

>

.)

"

GROUP

CLASS GENERIC AHylamine terbinafine butenafine

BRAND Lamisil Mentax Lotrimin Ultra

% 1 1 1 1 2 2 1

VEHICLES SIZE cream 30 gm cream cream cream cream solution cream, lotion, solution solution cream, gel, lot, susp

SIC Qd

Azoles

econazole miconazole

Spectazole Monistat Deim Fungoid Lotrimin

1 '2

clotrimazole

Olamines

ciclopiroxolamine Penlac ciclopirox Loprox

8 0.77

15-30 BID gmtube 15-30 BID gmtube 7 days 15,30, Qd 85 gm tubes BID 1530 gmtube 29.57 BID ml sol 15,30. BID 45 gm tubes or 10-30 ml sol 3.3 ml qhsx 48 wks lOOgm BID gel

INDICATION Onychomycosis or Tinea Tinea pedis Tinea pedis Tinea Tinea Tinea pedis Tinea

Mild Onychomycosis Tinea

TOPICAL STEROIDS diflorasone diacetate Most I. Potent desoximetasone II. III. IV. Mid Potent V.

vi. vn.

Least Potent

cream, ointment 0.05 and cream, Topicort 0.25 gel, ointment Cutivate 0.05 cmi cream, fluticasone and 0.00 5 ointment oint 02 ointment hydrocortisone valerate Westcort cream 0.1,0.5 Kenalog triamcinolone cream, cm and lotion, 0.025,0.1 ointment lot and 0.1 aerosol oint and 63 g aerosol hv dro cortisone/lido caine Lidamanfle 0.5 and 3 cream, lotion 1-2.5 Hytone hydrocortisone cream, lotion, ointment

Psorcon

0.05

15,30,60 gm 15,60gm 15,30,60 gm 15,45,60 mi 60 ml lotion, 15, 60 gm ointment 15,20,60, 80 gm cream 85 gm

qdto TIB BIB BID

LSG Psoriasis Eczema

Eczema qdto QID BIB to Eczema. QIB

BIB to TIB 28.4,60 gm BIB to cream and QIB 30 gm ointment and60 ml lotion

Itching "Winter itch

) ) ) ) ) ) ) ) ) ) ) ) ) ) } ) ) ) ) ]

>

GROUP Scabicide Emollients

INDICATION Scabies Xerosis

GENERIC BRAND pemiethiin Elimite

% 5

ammoiium lactate

La c-Hy drin 12

lactic acid pramoxine HCL Keratolytics hyperkeratosis urea urea. Ve, lactate

Lactinol Amlactin Cannol Carmol Kerala c

10 1 40 40

Urea Antiviral Antiperspirant hyperhidrosis acyclovir Alum. Chloride

Vanamide Zovirax Drysol

50 gel, 35 lotio n 40 Cream 5 ointment 20 Solution

SIC CONDITION 8-14 Infestation h 140.385 BID Xerosis cream, gm lotion cream and225, 400 gm bottle lotion lotion 354.84 BID Xerosis ml bottle cream 140 gm BID Xerosis tubes 28.35,85 BID Hypercream, gmtube keratosis lotion BID Onvchauxsis Gel 15ml bottle gel. lotion 18ml gel BID Keratodemia and325 ml lotion VEHICLE SIZE cream 60 gm 85 gm 15gm tube 35,37.5, 60 ml BID Kerato derma 6x/d Herpes x 7d qhs Macerated Webspaces

GROUP

Antipsoriatks

INDICATION | GENERIC betamethasone dipropionate

BRAND Diprolene

calcipotriene

Dovonex

tazarotene Deodorant Depigmenting

Tazorac

Panafil chlorophvlline copper/papain /urea hydro quinolone Melanex

VEHICLE SIZE % 0.05 ointment, 15.50 gel, lotion gmtube ointme ntand 30,60 ml lotion 60,120 .005 cream, ointment, gmtube cream solution and 60 ml solution and60, 120gm tube ointment 30,100 0.05. gel gm tubes 0.1 0.5, ointment 30 gm 10 tube 3 solution

SIG CONDITION qdto Psoriasis BID

BID

psonasis

psonasxs, acne vulgaris qdto ulcer BID BID

qhs

) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) } ) )

>

) SIC

GROUP

Waittx's

INDICATION vemicae vemicae hyperhidrosis

GENERIC

BRAND

Imiquimod sabcycBc acid Formaldehyde Ivermectin Gent amy cin

Aldara Compound W

% 5 17

Anti-Par asitics Miscellaneous

Formalyde- 10 10 Stromectol PO Garamycin 0.1 cream, ointment

VEHICLE SIZE cream 12 packets 0.31 floz geL liquid. or 7 gm pads tube spray 60ml 3mg 15 gm tube

CONDITION

3x/w recalcitrant eek qd or pt applied

BID

qd qd TID or QID

pt applied scabies Skin Infections

) ) ) ) ) } ) ) ) ) ) ) ) ) ) ) ) ) ) ) ) )

B - LACTAMASE'*; SENSITIVE PENICILLIN'S

Penicillin V (po) Penicillin G, Aqueous (iv) G+: Strep G-: Eikenella corrodens" >HumanBites Nisseria gonorrhea^STDSEPticilnt Anaerobes: Clostridium perfringens
HELPS2: Haemophilus E. coli Listeria Proteus mirabellus Shigella Salmonella

** Tx: Clostridium Tetani if allergic to Tetanus Toxoid

Penicillin G, Procaine (IM) -Ampicillin

+

** Tx: Treponema Palidum (Syphilis) Tx: Strep Throat & Otitis Media

Amoxicillin

** Used in kids instead of Augmentin!

G : Strep G-: Eikenella corrodens Nisseria gonorrhea HELPS2 Anaerobes:

R E S I S T A N T P E N I C I L L I N ' S ( 3 R D G E N E R A T I O N S ) RESISTMONDAY'SI

Methacillin (iv)

** Toxic, not used!

Oxacillin (Bactocil)[po)
V i p-Lactamase Resistant Staph Aureus

Nafcillin (Unipen)(po) Dicloxacillin (po)

If resistant to this = MRSA!

E X T E N D E D SPECTRUM PENICILLIN'S ( 4 G E N E R A T I O N S )

Carboxypenicillins ^ Carbenicillin A
High Na+ loads \ avoid pts w/ HTN \ Beware of Hypokalemia! \ Ticaricillin

Ureidopenicillins-

- Mezlocillin

Broad Spectrum"*00 N0Tcover P-Lactamasc G+: Good Coverage G~: | Coverage Anaerobes: | Coverage

Piperazine Penicillin Piperacillin

DRUG INTERACTIONS:

** Tx: Pseudomonas aeruginosa

Warfarin, Oral Contraceptives, Probenecid, Aminoglycosides

C / I w i t h p t s o n M e t h o t r e x a t e Mw'rmVoiogtaDocs ten pts theyanc/n

R - I.ACTAMASK'S COMBINATION DRUGS

Piperacillin / Tazobactam (Zosynjfiv)

Tx: Pseudomonas aeruginosa & Proteus mirabilis Needs 4.5g q6h for pseudomonas

Amoxicillin / Clavulanic Acid (Augmentin) (po)

**Staph aureus is susceptible Augmentin to < 35% due to MRSA

Ticarcillin / Clavulanic Acid (Timentin)(iv) Ampicillin / Sulbactam (Unasyn}pv)

**Unreliable against G~ infections!

Broad Spectrum G+: Strep, Staph aureus G-: Neisseria gonorrhea.. Anaerobes: 0

DOSAGE BOX:

Zosyn = 3.375g q6h Augmentin = 875mg q l 2 h Timentin = 3.1g q6h Unasyn = 3.0g q6h

76

1ST GENERATION

Cephalexin (KefIex)(poj Cephadroxil (Duricef}(po) > Cefazolin (Ancef) (Parenteral) J

< 80% susceptibility to Ancef
2 N GENERATION

Staph aureus Staph e p i d e r m i d i s / ; HEN - PEcKS: Strep Haemophilus influenza G-: Some PEcK Enterobacter aerogens An: Some not B.fragilis Neisseria species
Proteus mirabilis E. coli Klebsiella pneumonia NSerratia

G+: Good

Cefuroxime (Ceftin) (P o) 1 I G*: Almost as good as 1 s t G (ZinaceQ(paranterai) vj G~: Extended HEN - PEcKS Cefoxitin (Mefoxin)(parcnterai) J ;
3
RD

,An:

GENERATION

Cefixime (Suprax)(po) Cefpodime (Vantix) (po)

C e f t r i a x o n e (Rocephin)(parenterai) V *Not good for Staph [

Ceftazidime (Foitaz)(Parenteral)

Cefdinir (Omnicef)

G+: Significantly J.J4 G-: Superior Coverage (Fortaz Pseudomonas) (Rocephin Neisseria) An: 13 " '
DOSAGE BOX:

*Covers Staph & Strep better than 1 s t G. MIC levels are superior to Cephalexin 4x's better for Staph / / 7x's better for Strep

4T" G E N E R A T I O N Cefipime (Maxipime)

Omnicef = 300mg q l 2 h

! G+: More active against Staph aureus than 3 r d G i | G~: Good Coverage (+ Pseudomonas)

i An: S
EXTENDED GENERATION

j
G*: 0 - Active against MRSA G-: 0

Ceftobiprole

Mn:
D R U G I N T E R A C T I O N S : Avoid Cephalosporins i f p t allergic to Penicillin! Cefdinir(2 nd G) & Cefuroxime(3 rd G) are allowed for Penicillin allergy!

Due to differen t structure.

CARBAPKNAM'S

Imipenam-Cilastin (Primaxin)
*ID specialists ONLY!

Broad Spectrum G+: 0 - Most G-: 0 - Most [pseudomonas - resistant) (mycoplasma - resistant) An: 0 - Excellent

I^~\

Meropenam (Merrem)
*Mostly ID specialists I Seizure Risk!

G+: Staph & Strep only [Inferior to Imipenam) G": 0 (Superior to Imipenam) An: SI

Ertapenam (Invanz)(iv/iM) G*: 0 G~: Limited An: 0 Doripenam

DOSAGE B o x :

Invanz = lg qd CrCl < 30ml/min = 500mg 6h pre-diaiysis

Broad Spectrum G+: 0 G-: 0 (pseudomonas) An: 0

DRUG INTERACTIONS:

C/I in pts with Penicillin allergy C/I in pts with Seizure History Ertapenam interacts with Probenicid.

78

MONOBAfTAM

Aztreonam (Azactam](iv/iM)
*OKfor Penicillin Allergy No major renal toxicities; only dose adjust for renal insufficiency or dialysis

G+: 13 G-: 0 (?pseudomonas) An: 13

Gentamycin Tobramycin Amikacin

G*:0 G-: 0

* NOT use on Diabetics or My Gravis Peak (30min post dose) & Trough (30min before next dose) levels are recommended

MRSA Proteus mirabilis Pseudomonas Klebsiella E. coli Salmonella Shigella

ADVERSE DRUG REACTIONS:

I I j

Ototoxicity (Irreversible) Nephrotoxicity (Reversible) HypoK* Gentamycin HypoMg+ Amikacin

\ An: 13

GlYCOPEPTIDES
1ST GENERATION

Vancomycin (po/iv)
Tx: Endocarditis Prophylaxis for pts allergic to (i-lactams - Keep for reserve cases!
DOSAGE B o x :

G:0 G-: 0 An: 0

IV

^MRSA ^Clostridium difficile

DOSAGE ADIUSTMENT B o x :

50kg:

750mg

Vancomycin = lg slow push IV Cover 60min)

2ND GENERATION

r n -7/11 50-74kg: 75-90kg: >90kg:

,nnA Normal Trough = 5-10mg/dL lOOOmg [ if trough range >15mg/dL-> 1 2 5 0 m g j cloubln the dose time interval 1500mgJ

G+: 0 -- MRSA, VRSA, Strep, C.difficile Dalbavancin(po/iv) G-:? ADVERSE DRUG REACTIONS: An:? Ototoxicity (Reversible) Nephrotoxicity (Reversible) 3"" GENERATION , i G*: 0 - MRSA, VRSA, Strep Red Man Syndrome Telavancin | Vestibular Imbalance G:? Thrombophlebitis An:?

TETRACYCI.INF'S

Absorption is limited by: ~ Food ~ Milk ~ Antacids ~ Iron

Doxycycline
* Some Anti-Inflammatory properties seen on OA

G+: 0 G-: 0

Minocyline Methacycline Tetracycline HCL

ADVERSE DRUG REACTIONS:

Staph aureus MRSA E. coli Klebsiella Enterobacter Vibrio vulnificans" >SaltWater Rickettsia Chlamydia

An: H
before bed erosive esophagitis

N o n s p e c i f i c GI I s s u e s ~ Don't give Doxycylcine

Photosensitivity Photo-Onycholysis [Doxycycline) ?Acute Pancreatitis

CONTALNDICATIONS:

No P r e g n a n t / K i d s ~ tooth discoloration

in kids under 8y

C/I for pts on Digoxin -- f Toxicity C/I for pts on Accutane4Acne - | ICP, Pseudomotor Cerebri Risk

MACROLIDE'S * Erythrasma Coral Red Woods L

G+: 0 Staph / Strep / Corynebacterium minitussimum* ! Rarely used poor G-:E /' ST penetration An: 0 ANVPRSK DRUG REACTIONS: GI Upset Oral Dose = 2x Risk of Sudden Death 4 Prolonged Heart Depolarization ~ Torsades de Pointer Combined with Ca2+ Chanel Blockers D R U G I N T E R A C T I O N S : Potent Inhibitors of CYP 3A4 = 5x Risk of Sudden Death Cyclosprine / Sirolimus / Tacromilus (Verpamil, Diltiazam) C/I for pts on Carbazepine & Theophyline Azithromycin + [Zithromax) G : 0 Staph / Strep A D V E R S E D R U G R E A C T I O N S : GI Upset G-: IS Detox in Liver Excreted in Bile Prolonged Heart An: HI D R U G LNTERACTIONS:Potent Inhibitors of CYP 3/. DOSAGE BOX: fDigoxin / / ^Coumadin Zithromax= 500mg 1 s t Day HMGcoA Reductase f (z-pack) 250mg qd next 4 days

Erythromycin

Clindamycin (Cleocin)
* Good Bone Penetration * Poor CNS Penetration

G+: 0

Fulminate Group A Strep^ Necrotlzln s Fasditis Group B Strep -may Show resistance
M R S A ~ may show resistance

DOSAGE BOX:

Cleocin = 600mg l h r pre-op Given as prophylaxis for bacterial endocarditis

Staph Aureus
G~: E ^n: [yj

B. fragilis

A D V E R S E P R U G REACTIONS:

Diarrhea Pseudomembranous Colitis

D R U G - D R U G INTERACTION:

*Staph Aureus resistant to erythromycin on C&S can develop inducible resistance to Clindamycin *C&S of organism is sensitive to Clindamycin but resistant to erythromycin ^ do NOT give Clindamycin because it will develop resistance

^Respiratory Paralysis with m. relaxants (Baclofen / Diazepam]

CHLORAMPHENICOL

' G*: 0 G": 0 An: 0

A D V E R S E DRUG REACTIONS:

Serious Infections Last resort for VRE

Gray Baby Syndrome Severe Bone Marrow Toxicity Aplastic Anemia

SULFONAMIDES

Trimethoprim-Sulfamethoxazole (Bactrim / Septra)* Beware G:0 G-: 0 An: HI

+

in pts over

so year

old

Staph & Strep MRSA

ADVERSE DRUG REACTIONS:

Acute pancreatitis
DRUG-DRUG i N T E R a r n n N :

T-S + Methotrexate ~ f Bone Marrow Suppression T-S + Coumadin/Digoxin = T Toxicity of C/D T-S + Oral Sulfonylureas = Hypoglycemia

81

Metronidazole (Flagyl)
* Tx Pseudomembranous Colitis

ADVERSE DRUG REACTIONS:

G-: S An: 0

fragilis

Peripheral Neuropathies N/V with Alcohol Consumption Dark Brown Urine

D R U G - D R U G INTERACTION:

DOSAGE BOX:

Flagyl = 15mg/kg loading dose 7.5mg/kg q6h IV -or- 500mg tid

f Anti-Coagulation effects of Warfarin

FI.IIORINATRD 4-OUINOLONES

Ciprofloxacin (Cipro)
DOSAGE B o x :

Cipro = 750mg bid

G+: IS G~: 0 most active against P, aeruginosa

infection of bones & joints

CONTRAINDICATIONS:

Under age 18 Pregnant / Nursing

* Attacks joints *Can cause Tendonitis / Rupture

An: IS Levofloxacin (Levaquin),' + {' Vl G : 0 Strep G": 0 N. gonorrhea : DOSAGE BOX: :; Levo = 500mg qd [po/IV) ; | An: IS
* Post antibiotic effects (G+)
ADVERSE DRUG REACTIONS:

GI / Headache / Phlebitis a"are rare! !

Moxifloxacin (Avelox)
* Good in ST * Good for diabetic foot infections with inoperable atherosclerosis * May work against TB

Broad Spectrum G+: 0 staph^ s o m e resistallce Strep 4enhanced G": 0 An: 0 B. fragilis

! DRiir.-DRiir. I N T R R A C T I O N : I Not give within 2hr of: Multivitamins, Antacids, Sulcralfate MANY interactions! - Theophyline, Caffeine, Warfarin, NSAIDs, ddl (HIV) ! May see... Torsades de Pointes & Ventricular Fibrillation
\ **Mav produce a false (+) on viral assav for opiates

82

RIFAMYCIN

Rifampin
* Turns fluids Orange *CYP450 system * Tx Leprosy * Tx Vanco Resistant MRS A

D O S A G E BOX: Broad Spectrum G*: 0 Staph aureus Not given alone Strep epidermidis MRSA G~: 0 N. gonorrhea Mycobacterium An: S

Give with Cipro / Bactrim i

STREPTOr.RAMINS

Dalfopristin/Quinopristin (Synercid)___
* Reserve this drug!!!

ADVERSE DRUG REACTIONS:

G+: 0 VRE MRSA MRSE G-: (H An: 0

OXAZOLIDINONES

Arthralgia / Myalgia Nausea Thrombophlebitis t LFT's Injection Site Reaction

Linezolid (Zyvox)
* Good bone penetration * Check weekly CBC's

G : 0 VRE MRSA VRSA G-: HI An: 13

A D V E R S E DRUG REACTIONS:

Mylosuppresion
N / V * ' a c t ' c acidosis

Optic Neuropathy* Tx>imo

CYCLIC-I,IPOPFPTIDE

Daptomycin (Cubicin)
* Check weekly CPK's
D O S A G E BOX:

0 MRSA VRSA An: IS

DRIIC INTERACTIONS:

: 4mg/kg qd

Tobramycin Statins * M a > ypu y

Gl.YCVI.rYn.IMFS

Tigecycline (Tygacil)
* Check weekly CPK's ! D S Q BOX: QA K .j IV: lOOmg Loading Dose , 50mgbid

Broad Spectrum G+: 0 MRSA VRSA G~: 0 An: 0

DRIir, R F A C T I O N S : N/V Tooth Discoloration

APVRRSR

ORAI. ANTIBIOTICS

Itraconazole (Sporanox)
Onychomycosis Tinea pedis(ff'
aber

>

Dermatophytes Candida Molds

AIWERSR DRUG REACTIONS:

GI upset / Rash / Headache Hepatotoxicity -> LFT's A L T S A S T

D R U G INTERACTIONS:

DOSAGE BOX:

Pulse Dosing = 2x lOOmg tabs in AM & PM with food Take for 1 week of the mo. for months ;

Statins Tikosyn

Ca2+ Channel Blockers Erythromycin

CONTRAINDICATIONS:

Patient with CHF! Terbinafine (Lamisil) i Dermatophytes

Onychomycosis Tinea pedisCff^abe^
; DOSAGE B o x : ADVERSE DRUG REACTIONS:

; Pulse Dosing = 250mg qd 1 week/mo over 2mo : Normal = 250mg qd 3mo

Rare Headache / Abnormal Taste Green Vision DRUG I N T E R A C T I O N S : CYP450 2D6 Cimetidine Cyclosporine Rifampin Nortriptyline Caffeine

Fluconazole [Diflucan)
DOSAGE BOX:

Pulse = 300mg/week

Dermatophytes Candida Molds

ADVERSE DRUG REACTIONS:

Severe Skin Rash Alopecia Drug Interactions: CYP450 3A4 j

Griseofulvin (Gris-PEG);
Chronic Tinea pedis
I DOSAGE BOX:

Dermatophytes

ADVERSE DRUG REACTIONS:

Paresthesia / Rash / Headache

D R U G INTERACTIONS:

250mg tid (x4-8 weeks)

Oral Contraceptives Warfarin Barbituates

Thiabendazole (Mintezol)
* Cutaneous Larva Migrans

DOSAGE B o x :

Ivermectin

Mintezol = 10% aqueous solution qid Ivermectin = 200fig/kg po x l d o s e for l-2days

84

W O U N D CARE & DRESSINGS \ C T I C O A T = Nanocrystalline Silver (antimicrobial effect up to 7 days) ft Reduces Exudates while maintaining a moist wound environment ft Moisten with Sterile water (NOT SALINE!!! Silver reacts with Saline) ft Effective against VRE & MRSA IODOSORRGEI.

/ I O D O F L E X D R E S S I N G = Absorbent iodine Cadexomer & Slowly releases small amounts of a 0.9% elemental iodine

ALLEVYN FOAM

ft Moderate to High Exudate ft Never use the adhesive type!

HYPAFIX

ft Adhesive, non-woven fabric ft Hold post-op dressings / catheters / drainage tubes in place
HYDROGEI. SHEETS

ft ft ft ft ft ft ft ft ft ft ft ft ft

= ElastoGel, Nu-Gel, Vigilon, Amerigel Low Exudate Re-Epithelializing wounds NonAdhesive Gas permeable (+) Provides Moisture qd change for infected wounds (+) No trauma upon removal (-) Potential to macerate surrounding skin = Duoderm Gel, Nu-Gel, Restore, Hypergel Low Exudate Partial -> Full thickness wounds Use once granulation tissue is present (+) No trauma upon removal (+) Provides Moisture (-) Potential to macerate surrounding skin

HYDRO-GEL

85

TRANSPARENT FILMS

= Opsite, Tegederm, Bioclusive, Epivew A Adhesive, Polyurethane film ft Low Exudate ft May be used over absorptive wound filter or hydrogels A NOT for INFECTION! A Superficial Wounds (Blisters) ft [+) Up to 7d wear time [semi-permeable) ft (+) Allows visual assessment ft (+) Provides Moisture ft (-) Potential to macerate surrounding skin with excessive drainage ft (-) NOT absorptive ft (-) Adhesive may tear healthy skin
HYDROCOLLOIDS

= Duoderm, Duoderm CGF00"'1"0'Gel Formula, Tegasorb, Restore ft Adhesive, Occlusive Low Exudate ft Granulating & Epithelializing Partial Thickness Wounds ft May be used over absorptive wound filter or hydrogels A NOT for INFECTION! ft Cover @ least linch of surrounding skin ft (+) Up to 3d wear time ft (-) May tear healthy skin ft (-) Potential to macerate surrounding skin with excessive drainage ft Change dressing before it leaks ft Odor/Drainage are Normal = Acticoat Moisture Control, Allevyn, Polymem, TeilIeAdhcsiveBorder "ft Polyurethane ft Adhesive or NonAdhesive ft Moderate to High Exudates ft Varying Thickness ft Infected wounds if changed daily -ft Venous Leg Ulcers ft (+) Up to 7d wear time ft (-) May tear healthy skin
FOAM

86

ALGINATE = Sorbsan, Dermacea Alginate, Kaltostat, Curasorb A Seaweed Polymer & Gel formed when fibers interact with wound fluid A Pad or Rope Form A Partial/Full Thickness Granulating Wounds A Moderate to High Exudates & (V) Haemostatic effect A (+) Up to 7d wear time A (-) Requires 2 dressing A Infected wounds if changed daily A Tan mucoid appearance upon removal A ALGINATE W I T H COLLAGEN = Fibracol 90% Collagen, 10% Alginate A A L G I N A T E IMPREGNATED W I T H SILVER ABSORPTIVE W O U N D FILTERS

A Sheets, Rope, Paste, Granules, Powder made of Starch Polymers A Deep Wounds A Heavy Exudate
COLLAGEN B A S E D P R O D U C T S :

A A A A A

Medifil Particles/Pads/Gels, SkinTempNy|onMeshovcr Use Collagen Gels for Dry Wounds collagen membrane Use Sheets for Low -> Moderate Exudative Wounds Use Powders, Particles, Pads for Moderate Heavy Exudative Wounds Actions: Absorbent, Hemostasis, Chemotaxis, Provisional Matrix in wounds for Granulation tissue formation PRISMA colonized or contaminated wounds 55% Collagen / / 44% ORC Oxidized Regenerated Cellulose 1% Silver
PROMOGRAN

55% Collagen / / 44% ORC Only matrix proven to bind & reduce MMPs Matrbi MetaloProtinase ORC/Collagen combo binds more MMPs in the dressing the ORC or Collagen alone A P E G A S U S = Unite Biomatrix Enzyme resistant collagen scaffold - Fenestrated

87

RECOMBINANT D N A TECHNOLOGY

ft

= Becaplermin " Recombinant PDGF Platelet-derived growth factor / Attracts monocytes & fibroblasts -- inflammatory phase / Stimulates granulation tissue Refrigerate Regranex Gel 0.01% / 15g tube, apply qd, spread evenly and thin (l/16 t h inch) S Cover in moist saline gauze dressing ft P R O C U R A N = Thrombin-Induced Platelet Releasate GF from patients own blood 50-200cc of blood drawn from patient ^ Spin down, separate, activate the thrombin 1 blood draw = 3mo of daily application
REGRANEX

GRAFTS

ft

= Bilayered Skin Equivalent Epidermis & Dermis Dermls slde down Newborn foreskin FedEx in 24hr in petri dish - use immediately Place a compressive wrap over it ft D E R M A G R A F T = Human Dermal Replacement Newborn foreskin Cover with Allevyn & Hypofix tape DO NOT use with any other topical agent
APLIGRAFT

ft

OASIS

Small Interstine Submucosa Pig/Porcine SIS scaffold attracts patients cells Store @ room temp up to 18mo
ftINTERGRA

Collagen-GlycosAminoGlycan Biodegradable Matrix Cow/Bovine Porous Matrix of cross-linked bovine tendon collagen/GAGs Semi-Permeable Polysilxane (Silicone) layer Sterile Preperation

V G R A F T JACKET

Processed Human Dermal Membrane 3-D Bioactive Frame - supports granulation tissue Deep Wounds
ft G A M M A G R A F T

Irradiated human skin allograft Epidermis & Dermis Store @ room temp After 24hr in place remove secondary covering and allow area to airdry for 2-3hr -> once dried in place there is no need to recover it (+) Patients can do this at home

ropir.AI. F.NZYMES:

ft

= Collagenase Digests collagen in necrotic tissue Collagen in healthy tissue or in newly formed granulation tissue is not attacked May be used as an Antibiotic Powder Stop use when granulation tissue is well established ft Accuzyme, Gladase Papain ^Proteolytic enzyme from papaya Urea Protein denaturing agent May have a burning sensation in patients "A"13 Cleanse with normal saline, NOT water ft Panafil Papain Urea Chlorophyllin Copper Complex Sodium > Inhibits hemagglutinating & = inflammatory properties of protein degradation products in the wound ft Elase = FibrinolysinDesoxyribonuclease RARE 2 Flnd
SANTYL T O P I C A L AC.ENTS FOR LOCAL B L O O D F L O W ft XENADERM OINTMENT

Balsum of Peru O Increased blood flow to wound site Castor Oil > Creates a moist environment = Trypsin >> Maintains moist wound bed = Aluminum Magnesium Hydroxide Stearate ^ Fluid Repellent
89

A N K L E SCOPES PORTALS:

Anterior o AnteroMedial Medial to Tibialis Anterior Visualize: medial gutter & medial transchondral margins Caution: TA, Saphenous V & N o Accessory AnteroMedial o AnteroLateral Lateral to EDL or Peronial Tertius " Visualize: lateral gutter Caution: EDL, Peronial Tertius, Superficial Peroneal N o Accessory AnteroLateral o AnteroCentral Lateral to EHL Caution: AntTibial A, Deep Peroneal N, EHL & EDL tendons o Medial Midline Portal Posterior o PostcroMedial Medial to the Achilles Tendon Caution: Sural N, Lesser Saphenous V o Accessory PosteroMedial o Modified PosteroMedial o PosteroLateral Lateral to the Achilles Tendon Visualize: the posterior process of the talus & posterior media talar dome Caution: T-D-A-N-H o Accessory PosteroLateral o TransAchilles 6 Central Points o Coaxial Portals o Med / Central / Lat - TibioTalar Art. o Posterior Inferior TibioFibular Lig 21 POINT EXAM: o Transverse TibioFibular Lig 8 Anterior Points o Capsular Reflection of the FHL tenr1 o Deltoid Lig 7 Posterior Points o AntMed Gutter o PostMed Gutter o Med / Central / Lat - Talar Dome o Med / Central / Lat - Talar Dome o Ant TibioFibular Articulation o Post TibioFibular Artie o AntLat Gutter o PostLat Gutter o Anterior Gutter o Posterior Gutter