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Hershey Board Certification Review

Outline Study Guide

Jonathan M. Singer, D.P.M.
Diplomate American Board of Podiatric Surgery
Fellow American College of Foot and Ankle Surgeons
Diplomate American Board of Podiatric Orthopedics & Primary Podiatric
Fellow American College of Foot & Ankle Orthopedics & Medicine

Edited by
James Lawton, D.P.M., Gene K. Potter, D.P.M., Ph.D.,
and Samuel L. Deitch, D.P.M.

Peter F. Kelly, D.P.M., Gene K. Potter, D.P.M., Ph.D.,
Steven J. Berlin, D.P.M., Steven Kravitz, D.P.M., Guido
LaPorta, D.P.M., M.S., James Lawton, D.P.M., Arthur E.
Helfand, D.P.M., Fredrick E. Youngblood, M.D., Douglas
Glod, D.P.M., Christopher E. Attinger, M.D., Libby Cone,
M.D., Edwin J. Juda, D.P.M., William H. Simon, D.P.M.,
John Walter, D.P.M.
© 1998 Pennsylvania Podiatric Medical Association
William Goldfarb D.P.M. and Nancy Sullivan, for
supporting me and believing this book could be done

James Lawton D.P.M., and Gene Potter, D.P.M. for their

invaluable contributions in the general editing these
review notes

Jordon Fersel, M.D., for editing the chapters on

Anesthesia, and Emergency Medicine,

Deborah Wozniak, M.D., for editing the chapters on

Perioperative Management, Fluid Management, and
Postoperative Complications

Warren Joseph, D.P.M., and Steven Maffei, D.P.M. for

editing the chapter on Infectious Diseases

Steven Kravitz, D.P.M., for editing the chapter on


George Vito, D.P.M. for editing the chapter on Internal


Peter F. Kelly, D.P.M. for writing the chapter on Lasers

and Laser Physics

Gene K. Potter, D.P.M., Ph.D. and Steven Berlin, D.P.M.

for editing the chapters on Dermatology, Bone Tumors,
and Soft Tissue Tumors

Gene K. Potter, D.P.M., Ph.D., for proof reading, editing,

and adding his phenomenal talent to this book

Guido LaPorta, D.P.M., M.S. for writing the chapter on

Ankle Arthroscopy
The Hershey Board Certification
Review Outline Study Guide
is prepared for distribution by the
Hershey Surgical Seminars Committee
Pennsylvania Podiatric Medical Association
Guido La Porta, D.P.M., General Chairman

Author: Jonathan M. Singer, D.P.M.

General Editor: James Lawton, D.P.M.
Copy/Content Editor: Gene K. Potter, D.P.M., Ph.D.
Cover Design: Marissa Singer
Coordinator: Nancy Sullivan
Published by the Pennsylvania Podiatric Medical Association
ISBN # 0-9639030-04

Copyright © 1998
Pennsylvania Podiatric Medical Association 757 Poplar Church
Road Camp Hill, Pennsylvania 17011 (800)-841-3668
All rights reserved

This book is protected by copyright. No part of this book may be reproduced

in any form or by any means, including photocopying, or utilized by any
information storage or retrieval system without written permission from the
copyright owner.

Accurate indications, adverse reactions, and dose schedules for drugs are
provided in this book, but It is possible that they may change. The reader is
urged to review the package information data of the manufacturers of the
medications mentioned.

The author has made every effort to ensure the accuracy of the information
herein. However, appropriate information sources should be consulted,
especially for new or unfamiliar procedures. It is the responsibility of every
practitioner to evaluate the appropriateness of a particular opinion in the
context of actual clinical situations and with consideration to new
developments. The author, editors, and publisher cannot be held responsible
for any typographical or other errors found In this book.

Printed in the United States of America.

Table of Contents
Chapter 1: Emergency Medicine Fever: page 64-65
Cardiopulmonary Resuscitation: page 2-3 Altered Mental States: page 65
Advanced Life Support: page 3-4 Water and Electrolyte Imbalance: page 65-
Office Emergencies: page 5-7 66
Medical Emergencies (Cardiac Oliguria: page 66
Dysrhythmias): page 7-9 Chest Pain: page 67
Summary of CPR: page 9 Postoperative Hypertension: page 67
Other Medical Emergencies: page 9-12 Postoperative Infection: page 67-68
Shock: page 12-13 Anxiety and Pain Management: page 68-
Blood and Blood Products for Emergency 69
Use: page 13-17 Nausea: page 69
Constipation: page 69
Chapter 2: Anesthesia Shivering: page 69
Anesthesia Classifications: page 20 DVT: page 69-70
General Anesthesia: page 20-23 Compartment Syndrome: page 70-73
Intravenous Anesthesia: page 23 Hemorrhage: page 72-73
Local Anesthesia: page 23-26 Septic Syndrome: page 73
Special Cases for Lowering the Maximum Thyroid Storm: page 73-74
Allowable Dose: page 26
Pediatric Anesthesia: page 26-27 Chapter 6: infectious Diseases
Lumbar Epidural and Caudal Specific Diseases: page 76-81
Anesthesia: page 27-28 Principles of Antiinfective Therapy: page
Complications of Endotracheal Intubation: 81-84
page 31 Antibiotics: page 84-90
Nerve Injury During Anesthesia: page 31- Drug Fever: page 90-91
32 Specific Antimicrobial Therapy: page 91-92
Other Medical Compliccations From Surgical Considerations: page 92-93
Anesthesia: page 32-34 Necrotizing Infections: page 93-94
Osteomyelitis: page 94-102
Chapter 3: Perioperative Management Septic Arthritis: page 102
The Healthy Patient: page 36 Mycology: page 102-103
The Diabetic Patient: page 36-38 Viral Diseases: page 104
The Hypertensive Patient: page 38-39 Rickettsial Diseases: page 104
The Patient on Steroid Therapy: page 39- Protozoan and Metazoan Infections: page
40 104-105
The Asthmatic Patient: page 40-41
The Alcoholic Patient: page 41 Chapter 7: Wound Healing
The Patient on Anticoagulant Therapy: Repair of Skin: page 108-111
page 41-42 Factors That Interfere With Wound
The Patient With Clotting Abnormalities: Healing: page 111-113
page 42 Growth Factors in Wound Repair: page 113
The Rheumatoid Patient: page 43 Surgical Approaches: page 113-114
The Sickle Cell Patient: page 43-44 Wound Dressings: page 114
The Cardiac Patient: page 44-45 Suture Materials and Needles: page 115-
The Pulmonary Disease Patient: page 45 116
Perioperative Management of the Infant Tourniquets: page 116-118
and Child: page 45-47
Mitral Valve Prolapse patient: page 47-48 Chapter 8: Plastic Surgery
The Gouty Arthritis Patient: page 48 Skin Grafting: page 120-122
Local Cutaneous Flaps: page 122-124
Chapter 4: Preoperative Evaluation Local Muscle and Cutaneous Flaps: Page
Screening Procedures: page 50-61 124
Summary of Perioperative Lab testing: Fasciocutaneous Flaps: page 124-125
page 61-62 Microsurgery and Free Flaps: page 125-
Chapter 5: Postoperative Care & Diagrams of Skin Flaps: page 126-130
Chapter 9: Bone Healing Patient Evaluation: page 202-212
Primary Bone Healing: page 132 The Vascular Diseases: page 212-215
Complications of Bone Healing: page 133-
135 Chapter 16: Internal & External Fixation
Treatment of Nonunions: page 135 Objectives of Fixation Devices: page 218
Fusion: page 135 Requirements of Implant Materials: page
Bone Grafting: page 135-137 218
Aseptic Necrosis Following 1st Metatarsal Principles Affecting Internal Fixation: page
Osteotomy: page 138-139 218
Electrical Bone Stimulation: page 40 Internal Fixation Devices: page 219-229
Cartilage Healing: page 140 AO Objectives: page 229
AO Principles: page 229-230
Chapter 10: Burns and Frostbite AO Technique: page 230-235
Assessment and Treatment of Burns: page Jumping Screws: page 235-236
142-145 Other Techniques: page 236-238
Burn Deformities: page 145-146 Complications of Fixation Devices: page
Other Types of Burns: page 146 238
Frostbite: page 146-147 External Fixation: page 239
Large Bone Fixation: page 239-252
Chapter 11: Fluid Management and Small Bone External Fixation: page 253-
Replacement in the Surgical Patient 254
Fluid Management: page 150-152
Complications of Total Parenteral Chapter 17: Nail Disorders & Surgery
Nutrition: page 152 Nail Entities: page 256-260
Replacement Therapy: page 152-153 Nail Anatomy: page 260
Blood Products and Indications for Use: Surgical Nail Procedures: page 262-263
page 153-156
Composition of IV Fluids: page156-157 Chapter 18: Neurology
Neurological Pathways: page 266
Chapter 12: Bone Tumors Presenting Features: page 266-270
Introduction: page 160 Assessment of Clinical Problems: page
Staging Techniques: page 160-161 270-278
Surgical Staging System: page 161 Innervation of the Lower Extremity: page
Radiology of Bone Tumors: page 161-162 278-281
Bone Tumors: Page 163-168 Tarsal Tunnel Syndrome: page 282-284
Cystic Lesions of Bone: page 168-169 Classification of Nerve Injuries: page 284-
Other Tumors and Cancers: page 169-170 285
Bone Tumors: A Quick Reference Chart: Neuromuscular Causes of Cavus Foot:
page 170-171 page 285
Phases in Cancer Development: page 171 Types of Nerve Surgery: page 285-288
Benign vs. Malignant: page 172
Chapter 19: Pediatrics
Chapter 13: Dermatology Evaluation of the Pediatric Patient: page
The Skin: page 174 290-293
Dermatological Lesions: page 175-182 Pedicatric Biomechanics-Normal Values:
Newborn to Adult: page 293
Chapter 14: The Arthropathies Congential Deformities: page 293-302
Causes of Joint Pain: A Summary: page Pediatric Radiology: page 302-304
184 Pediatric Gait Patterns: page 304-305
The Arthropathies: page 184-195 Intoe Gait: page 306-307
Lab Testing for the Arthropathies: page Pediatric Fractures: page 307-318
195 The Limp in Childhood: page 318-319
Articular Disorders Affecting the Heel: Juvenile Hallux Valgus: page 319-320
page 195-196 Biomechanical Examination of the Child:
Synovial Fluid Analysis: page 197 page 320-323
Charcot Foot: page 198-199 Corrective Casting Techniques in Infants:
page 323-324
Chapter 15: Peripheral Vascular Disease The Toe-Walking Child: page 324-326
Anatomical Facts of the 1st MPJ:
Chapter 20: Drugs and Drug Interactions page 410-411
Introduction to Drug Interactions: page Predisposing Factors: page 412
328 Biomechanics: page 412-414
Antibiotic Drug Interactions: page 328-329 Etiology of HAV: page 414-415
Anticoagulant Drug Interactions: page 330 Deformity Types: page 416-417
Antihypertensive Drug Interactions: page Radiological Measurements for HAV:
330-331 page 417-418
Antipsychotic Drug Interactions: page 331 Physical Examination: page 418-419
Cardiac Drug Interactions: page 331-332 Preoperative Considerations: page
Diuretic Drug Interactions: page 332 419
Non Steroidal Anti-Inflammatory Drug Arthroplasty Procedures: page 419
Interactions: page 332-333 420
Oral Contraceptive Drug Interactions: Capsule-Tendon Balancing
page 333 Procedures: page 421-422
Mechanisms of Drug Interactions: page Implant Arthroplasty Procedures:
333-335 page 422-426
Specific Drugs: page 335-344 Arthrodesing Procedures: page 426
Chapter 21: Surgery of the Congenital Foot Proximal Phalangeal Osteotomies:
Flatfoot Surgery (flexible): page 346-355 page 429-431
Subtalar Joint Blocking Procedures: Distal Metatarsal Osteotomies: page
(Arhroereises and Arthrodesis): page 355- 432-436
356 Proximal Metatarsal Osteotomies:
Flatfoot Surgery (rigid): Convex Pes Plano page 436-438
Valgus: page 356-358 Shaft Osteotomies: page 438-439
Metatarsus Adductus Surgery: page 358- Combination Procedures: page 439
362 Other Procedures: page 439-440
Cavus Foot Surgery: page 362-367 Hallux Rigidus and Limitus: page
Clubfoot Surgery: page 368-373 440-445
Hallux Varus: page 445-446
Chapter 22: Generalized Disease Hallux Hammertoe: page 446
Conditions of Bone Diff. Diagnosis of Pain In the
Soft Tissue Overgrowth: page 376 Sesamoid Area: page 446
Abnormalities of Alignment: page 376-377 Complications of HAV Surgery: page
General Increased Bone Density: page 377 447
Osteopenia: page 377-378 HAV Procedure Chart and Their
Marrow Abnormalities: page 378- Indications: page 448
The Dysplasias: page 379-380 Chapter 25: Trauma
Medical Management and General
Chapter 23: Radiology Assessment of the Trauma Patient:
Standard Radiographic Techniques page 450-451
of the Foot and Ankle: page 382- Assessment of Lower Extremity
383 Injury: page 451
Specific Radiographic Studies: page General Evaluation and Treatment
383-391 of Fractures: page 451-452
Anatomic Angles: page 391-396 Calcaneal Fractures: page 452-460
Common Structural Measurements Talar Fractures: page 460-463
(Diagrams): page 396-402 Osteochondral Fractures: page 463
Pediatric Radiology: page 402-406 465
The Osteochondritities: page 406-407 Navicular Fractures: page 466-470
The Accessory Bones of the Foot: Cuboid Fractures: page 470-472
page 407 Cuneiform Fractures: page 472
Fifth Metatarsal Base Fractures: page
Chapter 24: Hallux Valgus & 472-474
Related Disorders Metatarsal Fractures: page 474-480
Goals of HAV Surgery: page 410 Ankle Fractures: page 480-493
Midtarsal Joint Dislocations: page 494 Peroneal Tendon Pathology: page
Tarsometatarsal Joint 560-562
Dislocations/Fractures: page 494-498 Achilles Tendon Rupture: page 562-
Ankle Inversion Sprain: page 498 566
505 Lateral Ankle Stabilization
Deltoid Ligament Ruptures: page Procedures: page 566-571
506-507 Postoperative Care and Training
Compartment Syndrome: page 507 Following Tendon Transfer: page
508 571-572
Open Fracture Classification System Tenosynovitis: page 572
and Tx: page 508-510
Soft Tissue Injuries: page 510-511 Chapter 28: Lesser Metatarsal
Crush, Gunshot, and Lawnmower Surgery
Injuries: page 511-512 Anatomy (Metatarsals 2-3-4): page
Puncture Wounds: page 512 574-575
Epiphyseal Plate Injuries: page 512-514 Differential Diagnosis of
Digital Fractures and Dislocations: Metatarsalgia: page 575
page 514-515 Surgical Treatment of the IPK: page
1st MPJ Trauma: page 516-517 575-578
Nail Bed Trauma: page 517-518 Lesser Metatarsal Joint Replacement:
Toe Tip Injuries With Tissue Loss: page 578-579
page 518-519 Panmetatarsal Head Resection: page
Dog and Cat Bites: page 519 579-581
Metatarsus Adductus: page 581-585
Chapter 26: Digital Deformities Freiberg's Disease: page 585-587
and Surgery Tailor's Bunion: page 587-589
Hammertoe Syndrome: page 522- Splayfoot: page 589
528 Brachymetatarsia
Mallet Toe Syndrome: page 528-529 (Brachymetetopody): page 589-591
Claw Toe Deformity: page 529 Skewfoot: page 591-592
Overlapping 5th Toe: page 529-532
Hallux Hammertoe: page 532-533 Chapter 29: Ankle Conditions
Lesser Digital Arthrodesis: page 533 Differential Diagnosis of Chronic
Hallux Interphalangeal Arthrodesis: Ankle Pain: page 594
page 533 Tarsal Tunnel Syndrome: page 594-
Lesser Digital Arthrodesis: page 533- 597
534 Sinus Tarsi Syndrome: page 597-
Overlapping 2nd Toe: page 534 599
Syndactylization: page 534-535 Peroneal Subluxation: page 599-
Digital Implants: page 535-537 600
Floating Toe Syndrome: page 537 Ankle Arthrodesis: page 600-602
Blue Toe Syndrome: page 538-539 Lateral Ankle Instability: page 603
Polydactylism: page 539-541 Chronic Lateral Ankle Instability:
page 604-607
Chapter 27: Muscle and Tendon Chronic Medial Ankle Instability:
Pathology page 607
Muscle Physiology: page 544-548 Ankle Equinus: page 607-611
Principles of Tendon Repair: page Malunion and Nonunion of the
548-552 Malleolei: page 611-614
Tendon Lengthening and
Tenotomy: page 552-554 Chapter 30: Heel Conditions
Tendon Transfers: page 554-556 Anatomy of the Heel: page 616-617
Tendon Grafts: page 556-557 Radiological Evaluation of the Calcaneus:
Posterior Tibial Tendon Rupture: page 617-618
page 557-559 The Heel in Systemic Disease:
Posterior Tibial Tendon Dysfunction page 618-621
(Acquired Adult Flatfoot Syndrome): Seronegative Arthritis and Heel Pain:
page 559-560 page 621-622
Heel Spurs and Heel Spur Physical Modalities and Diseases:
Syndrome: page 622-623 page 718-720
Tumors of the Heel: page 623-626 Therapeutic Modalities and
Tarsal Coalitions: page 626-629 Procedures: page 720-730
Sever's Disease: page 629-630
Causes of Heel Pain (a summary): Chapter 36: Arthroscopy
page 630-631 Ankle Arthroscopy: page 731-740
Haglund's Deformity: page 631-632
Chapter 37: Laser Applications in
Chapter 31: Amputations Podiatric Surgery
General Surgical Technique: page Laser and Laser Physics:
634 page 741-751
Digital Amputations: page 634-635 Clinical Applications in Podiatric
MPJ Amputations: page 635 Surgery: page 751-775
Transmetatarsal Amputations: page
635-636 Chapter 38: Specific Radiological
Tarsometatarsal Amputations Pathology
(Lisfranc's): page 637 MRI Pathology: page 777-800
Midfoot Amputations (Chopart's):
page 638
Amputation of the Ankle (Syme's,
Boyd, Pirogoff): page 638-639
Below Knee Amputation: page 639-

Chapter 32: Biomechanics

Normal Values: page 641
Criteria of Normalcy in the Lower
Extremity: page 642-643
Adult Biomechanical Examination:
page 643-645
Common Structural Variations: page
Planes of Motion: page 648-649
Axes of Joint Motion: page 649-653
Angular and Axial Deformities in
Children: page 654-656
Anatomy of Gait: Activity of Muscles:
page 656-663
Observation of Gait: page 663-664
Subtalar Joint Measurements: page
Subtalar Joint Function: page 666-
Midtarsal Joint Function: page 667-

Chapter 33: Anatomy

Neuroanatomy: page 670-676
Angiology: page 676-680
Myology: page 680-695
Arthrology: page 695-704

Chapter 34: Soft Tissue Tumors

Soft Tissue Tumors: page 706-715

Chapter 35: Physical Medicine

and Rehabilitation