Crozer Podiatry Manual 2nd Edition
What is the post-op care for Lis-Franc's injuries
BK casting for 6 to 12 weeks Initial NWB for 6-8 weeks Partial WB approximately 6 weeks Begin ambulation in stiff-soled shoe PT ASAP Accommodative orthotics
What are treatments for symptomatic tarsal coalitions
Orthotics or supportive therapy Immobilization NSAIDs Badgley - surgical resection of coalition or bar with interposition of muscle belly Isolated fusion or triple arthrodesis
What are radiographic findings of tarsal coalitions
Rounding of lateral talar process Talar beaking due to increased stress on talonavicular ligament Asymmetry of anterior subtalar facet Narrowing or absence of middle and posterior subtalar facets Halo sign - circular ring of increased trabecular pattern due to altered compressive forces Anteater sign - C-N coalition in which calcaneus has elongated process on lateral view Putter sign - T-N coalition in which neck of talus unites with broad expansion of navicular
How to calculate IV fluid input rate
"421 Rule" calculates IV mL/h First 10 kg x 4 = 40 mL/h Second 10 kg x 2 = 20 mL/h Remaining kg x 1 = ___ mL/h (e.g. 70 kg patient requires 40 + 20 + 50 = 110 mL/h)
What antibiotics are metabolized by the liver
(3 C's and 1 E) - Clindamycin - Cefoperazone - Chloramphenicol - Erythromycin
What are drugs for insomnia
(BE HARD) B - Benadryl E - estazolam H - Halcion A - Ambien R - Restoril D - Dalmane Most commonly used are Benadryl 25 mg PO qhs or Ambien 5 mg PO qhs
What are the common locations of talar dome lesions and their mechanisms of injury
(DIAL a PIMP) Dorsiflexion Inversion: Anterior Lateral (unstable, shallow, wafer-shaped lesion) Plantarflexion Inversion: Medial posterior (deep, cup-shaped lesion)
What are the only FDA-approved drugs for treating diabetic foot infections?
(The 3 Z's) Zosyn Zyvox Invanz
What are the stages of CRPS
*1. Acute - early (0 to 8-20 weeks)* Constant pain out of proportion (intense burning) Possible edema, muscle wasting Hyperhidrosis Pain increased by light touch, movement, emotion *2. Dystrophic - mid (2-6 months, possibly up to 1 year)* Increased edema that is indurated (brawny edema) Constant pain by any stimulus Skin is cool pale and discolored X-ray shows diffuse osteoporosis *3. Atrophic - late (over 6-12 months)* Intractable pain spreads proximally to involve entire limb Decreased dermal blood flow causing cool, thin shiny skin Fat pat atrophy Joint stiffen, may proceed to ankylosis
What are radiographic findings of OA?
*1. Asymmetric joint space narrowing 2. Broadening and flattening of articular surfaces 3. Osteophytes at joint margins 4. Subchondral sclerosis 5. Subchondral bone cystic changes*
What are some effects of steroids
*Anti-inflammatory* -Decreases production of prostaglandins, cytokines, and interleukins -Decreases proliferation and migration of lymphocytes and macrophages *Metabolic* Decreases osteoblast activity
What are the different types and causes of CRPS
*CRPS Type I (reflex sympathetic dystrophy)* - Nerve injury cannot be immediately identified - Spontaneous pain not limited to single nerve distribution - Abnormal response in sympathetic nervous system - Abnormal reflex leading to vasomotor instability and pain *CRPS Type II (causalgia)* Distinct, "major" nerve injury has occurred - Trauma - Peripheral nerve injury - Drugs - anti-TB, barbiturates, cyclosporine - Continued pain not necessarily limited to injured nerve distribution
What are the different types of plate fixation
*Compression* -Provides axial compression of fracture -Pre-bend plate -Eccentric drilling of hole adjacent to fracture; remaining holes drilled centrally -Place plate on tension side of bone *Neutralization* -Protects against shear, bending, and torsional forces at the fracture site -Interfragmental compression obtained by lag screws -All holes drilled centrally *Anti-glide* -Neutralization plate placed on the posterior aspect of the fibula *Buttress* -Maintains alignment of unstable fracture fragments -No interfragmental compression
What are 2 uses for Gadolinium?
*Intravenously* -It will be distributed to places with increased vascularity, such as neoplasms and inflammation -Cellulitis and walls of abscesses will enhance, but the pus will not. *Intra-articular* -Tests cartilage integrity
what is the jahss classification
*Secondary to extreme dorsiflexion Type 1: dorsal dislocation of proximal phalanx and sesamoids with intact intersesamoid ligament Tx: requires ORIF Type 2A: dorsal dislocation of proximal phalanx and sesamoids with ruptured intersesamoid ligament Tx: closed reduction and surgical shoe or BK walking cast Type 2B: dorsal dislocation of proximal phalanx and transverse fracture of sesamoid with intact intersesamoid ligament Tx: closed reduction and surgical shoe or BK NWB cast or excision of the fractured sesamoid
What are treatments of post-op fever
*Wind* - Encourage incentive spirometer, -Chest x-ray *Water* - Straight catheter, -Urine analysis (UA) with Gram stain, culture and sensitivity -Treat with antibiotics if necessary *Walk* - Heparin or Lovenox protocol -Use SCDs, TEDs, or get patient out of bed *Wound* - X-ray, Gram stain, culture and sensitivity, blood cultures -Begin antibiotic *Wonder drug* - D/C drug -Give reversal drug if necessary
Name a couple cephalosporins for each generation
- 1st Generation - cefazolin (Ancef), cephalexin (Keflex) - 2nd Generation - cefaclor (Ceclor), cefuroxime (Ceftin) - 3rd Generation - ceftriaxone (Rocephin), ceftazidime (Fortaz), cefdinir (Omnicef) - 4th Generation - cefepime (Maxipime) -5th generation: Ceftaroline
What is the dose of Cipro
- 250-750 mg PO q12h - 200-400 mg IV q12h
What ligaments support the ankle syndesmosis
- Anterior-inferior tibiofibular ligament - Posterior-inferior tibiofibular ligament - Interosseous tibiofibular ligament
What are treatments of CRPS?
- Anti-inflammatory drugs - Antidepressant drugs - Local peripheral nerve blocks - Paravertebral sympathetic ganglion blocks - Physical therapy
What drugs cover Pseudomonas?
- Aztreonam - Aminoglycosides - gentamycin, tobramycin, amikacin - Cipro - Ceftazidime, cefepime - Timentin - Zosyn
What structures attach to the fibular sesamoid
- Plantar metatarsal-phalangeal ligament - Lateral metatarsal-sesamoidal ligament - Intersesamoidal ligament - Phalangeal-sesamoidal ligament - FHB tendon - ADH tendon
Alternatives for Enterococcus
- augmentin - linezolid
Alternative for Strep in PCN allergy
- clindamycin - levaquin - vancomycin -Doxycycline
How do you treat Clostridium Difficile colitis
- vancomycin (125mg PO q6h) - flagyl (500mg PO TID)
AO principles of internal fixation (2002)
-Anatomic articular reduction, adequate shaft reduction -Stable/biologic fixation -Preservation of blood supply -Early ROM
AO principles (1958)
-Anatomic reduction -Rigid internal fixation -Preservation of blood supply -Early ROM
What are clinical findings of gout
-Asymmetrical, monoarticular arthritis -Sudden onset of red, hot, and swollen joint -Excruciating pain with acute attack -Tophaceous deposits -Most commonly affects 1st MPJ
Treatment options for Hardcastle
-Cast immobilization (sprains 3-5 weeks) -Closed reduction and percutaneous pinning -ORIF
What are radiographic findings of RA?
-Clinical symptoms may present several years prior to radiographic findings -Peri-articular edema -Periosteal elevation and ossification -Marginal erosions -Subluxation and contractures (Swan neck deformities) -Fibular deviation of digits -Osteoporosis -Symmetric joint space narrowing and destruction (late stage finding)
What are treatments for a white toe
-D/C ice and elevation -Loosen bandages -Place foot in dependent position -Rotate K-wire -Apply warm compresses proximally -Apply nitroglycerine paste proximally -Local nerve block proximally -Avoid nicotine -Consult vascular surgery
What are treatments for blue toe due to arterial insufficiency
-D/C ice and elevation -Loosen bandages -Place foot in dependent position -Rotate K-wire -Apply warm compresses proximally -Apply nitroglycerine paste proximally -Local nerve block proximally -Avoid nicotine -Consult vascular surgery
What are some conditions associated with brachymetatarsia
-Down Syndrome -Turners Syndrome -Cri du chat -Pseudo or Pseudohypoparathyroidism -May be idiopathic
Where are bone tumors typically located? Metaphysis
-Enchondroma (also diaphyseal) -Osteochondroma -Nonossifying fibroma -Unicameral bone cyst -Aneurysmal bone cyst -Giant cell tumor (extends into epiphysis) -Medullary osteosarcoma -Parosteal osteosarcoma -Chondrosarcoma
What are radiographic findings of PA
-Erosions with bony proliferation -Symmetric narrowing of joint space -Increased periosteal activity -Pencil-in-cup appearance -Osteopenic changes
What are radiographic findings of RS
-Fluffy periosteal reactions -Large, bilateral heel spur formation -Inflammation and widening of Achilles tendon insertion -Deossifications
What are laboratory findings for PA
-HLA-27: positive -Rheumatoid factor: negative
What are laboratory findings for Ankylosing Spondylitis
-HLA-27: positive -Rheumatoid Factor: negative
What are laboratory findings for RS
-HLA-27: positive -Rheumatoid Factor: negative -ESR: elevated -Synovial Fluid Analysis: Pekin Cells
When should a patient with an INR >1.4 be allowed to proceed to surgery
-If the risk of not doing surgery outweighs the risk of excessive bleeding (i.e. if it is an emergency surgery and you have anesthesia's approval) -If the patient has PVD and the surgery is a simple debridement or amputation. Note: if the patient has PVD, make sure you have Vascular Surgery's approval for surgery. In this case, it is acceptable for the patient to bleed a little extra.
What are indications for the use of antibiotics
-Implants (joint or internal fixation) -Prolonged surgery (>2 h) -Trauma surgery -Revisional surgery -Immunocompromised patient -Extensive dissection required -Intra-operative contamination -Endocarditis (SBE)
What are radiographic findings of Ankylosing Spondylitis?
-Irregular Joint Widening with erosions -Reactive scelrosis -Bony Ankylosis -Sacroiliac Joint Fusion -Bamboo Spine
What are clinical findings of Ankylosing Spondylitis
-Mostly males affected -Bilateral sacroilitis: low back pain and stiffness -Heel Pain -Peripheral Joint Pain
What is the perioperative management for patients with diabetes
-NPO after midnight -Start D5W1⁄2NSS in AM -Accu-Check -If insulin-controlled, hold regular insulin, give 1⁄2 NPH dose, and cover with SSI -If oral-controlled, hold oral meds and cover with SSI -If diet-controlled, cover with SSI
What pre-op orders are needed for an in-house patient?
-NPO after midnight, except AM meds with sips of water -Hold all AM hypoglycemics and cover with SSI (if patient with DM) -Accu-Check on call to OR (if patient with DM) -Begin 1⁄2NSS @ 60 mL/h at 0600 (D5W1⁄2NSS if patient with DM) -Labs - CBC with diff, PT/PTT/INR, BMP -Chest X-ray, EKG (if necessary) -Consult medicine for medical clearance (if not already done) -Anesthesia to see patient (if necessary)
What is the treatment for Septic Arthritis
-Needle drainage of joint -Open arthrotomy if osteomyelitis, joint implant, or chronic infection -Initial joint immobilization followed by passive ROM -Appropriate IV antibiotics for 2 weeks followed by 2-4 weeks of oral antibiotics
What are radiographic findings of Septic Arthritis
-Normal in early stages -Joint effusion -Juxta-articular osteopenia
What are clinical symptoms of tarsal coalitions
-Pain -Limited ROM of STJ and possibly MTJ -Peroneal spastic flatfoot
What are clinical findings of OA?
-Pain relieved with rest -Stiffness aggravated with activity -Crepitus with motion -Asymmetric joint swelling
What are clinical findings of Septic Arthritis
-Painful, hot, swollen joint -Systemic signs of infection including fever, N/V, tachycardia, confusion
What are clinical findings of PA
-Polyarthritis including DIPJ involvement -Sausage digits -Psoriatic skin changes -Nail lesions
What are clinical findings of RS
-Polyarticular, asymmetric arthritis of lower extremity (mostly affects small bones of feet, ankle, knee, SI joint) -Most affects males -Capsulitis with digital edema -Bony erosions -Reiter Syndrome Triad: (can't see, can't pee, can't climb a tree) (Conjunctivitis, Urethritis, Arthritis, Also keratoderma blenorrhagicum)
What test confirms tinea pedis or onychomycosis
-Potassium hydroxide (KOH) preparation of skin or nail specimen -Septate hyphae confirms diagnosis
What are radiographic findings of gout
-Radiographic findings appear late in the disease after multiple attacks -Bone lysis in acute stages -Periarticular swelling with preserved joint space -Tophi at joint margins -Rat bite: punched-out, periarticular erosions -Cloud sign: tophaceous material -Martel sign: periarticular overhanging shelf
What are laboratory findings of RA?
-Rheumatoid factor: positive -RBC: slight to moderate anemia -WBC: elevated in acute cases and normal to decreased in chronic -ESR & CRP: moderate to marked elevation -Synovial fluid analysis: elevated WBCs with cloudy fluid
What are clinical findings of RA?
-Symmetric, progressive, polyarticular, and degenerative inflammatory arthritis -Age of onset between 3-4th decades -Females > males -Pain first thing in morning -Stiffness after rest and reduced with activity -Rheumatoid nodules (25%) -Nail fold infarcts, splinter hemorrhages -Swan neck deformities: flexed DIPJ and extended PIPJ -Boutonniere deformities: extended DIPJ and flexed PIPJ -Other: bullous dermatosis, Raynaud phenomenon, vasculitis
What are laboratory tests for gout
-Uric acid - males >7 mg/dL, females >6 mg/dL, though may be normal during attack -Synovial fluid analysis provides a more accurate diagnosis
What are laboratory findings for Septic Arthritis
-WBC: elevated -ESR: elevated -CRP: elevated -Blood Cultures: positive -Synovial Fluid analysis: elevated WBC with cloudy white or gray color
What is the dose of colchicine?
0.6 mg PO q1h until symptoms resolve, GI side effects occur, or max dose of 6 mg reached
Mueller posterior tendon ruptures
1 - direct injury 2 - pathologic rupture (RA) 3 - idiopathic 4 - functional abnormality
Angle of inclination of femur
1 year: 146 degrees 4 years: 137 degrees Adult: 120-136 degrees (avg is 127)
Angle of declination (antetorsion angle) of femur
1 year: 39 degrees 10 years: 24 degrees Adult: 6 degrees
How much of a screw should pass the far cortex?
1 ½ threads
What is the cross reactivity of cephalosporins with PCN
1-10% (depending on whom you talk to)
What is the dosing for Aztreonam
1-2g IV q8
What are the plantar muscle layers of the foot from superficial to deep
1. Abductor Hallucis, FDB, Abductor Digiti Minimi 2. Quadratus Plantae, 4 Lumbricals 3. Flexor Hallucis Brevis, Adductor Hallucis, Flexor Digiti Minimi 4. 3 Plantar Interossei, 4 Dorsal Interossei
What are the stages of Charcot
1. Acute or destructive 2. Coalescence 3. Remodeling
What are the stages of gout
1. Asymptomatic hyperuricemia 2. Acute gouty arthritis 3. Intercritical gout 4. Chronic tophaceous gout
What are the stages of avascular necrosis
1. Avascular - loss of blood supply, epiphyseal growth ceases 2. Revascularization - infiltration of new blood vessels, new bone deposited on dead bone, flattening or fragmentation of articular surface 3. Repair and remodeling - bone deposition replaces bone resorption 4. Residual deformity - restoration of epiphysis, sclerosis, deformed articular surface
What are characteristics of a giant cell tumor
1. Benign but locally aggressive, lytic lesion with ground glass, "soap bubble" appearance 2. May destroy cortex and have soft tissue mass 3. More common in females 4. 3rd to 4th decades of life 5. Painful
What are characteristics of nonossifying fibromas
1. Benign connective tissue lesion with fibrous replacement of bone 2. Expansive, radiolucent, medullary lesions 3. 1st to 2nd decades of life 4. Lesions typically resolve with age 5. Do not biopsy
What are characteristics of an aneurysmal bone cyst
1. Benign, expansile, lytic lesion with blood-filled cavities 2. May extend into soft tissue 3. Fluid-fluid levels seen on MRI 4. 1st to 3rd decades of life 5. More common in females 6. Painful, especially with pathological fractures
What are characteristics of a fibrous dysplasia
1. Benign, geographic, fibro-osseous lesion with ground glass matrix 2. Presents with deformity 3. Sometimes painful 2° to fracture
What are characteristics of a unicameral bone cyst
1. Benign, geographic, medullary lesion that is fluid-filled 2. Commonly found in calcaneus 3. Fallen fragment sign - pathologic fracture in which cortex lies within lesion 4. 1st to 2nd decades of life 5. Asymptomatic until fracture
What are characteristics of a Chondroblastoma
1. Benign, geographic, osteolytic, lesion with sclerotic margins 2. 2nd to 3rd decade of life 3. Pain and joint effusion
What are characteristics of an enchondroma
1. Benign, well-defined, intramedullary, cartilaginous lesion 2. Geographic lesions with punctuate calcified matrix 3. 3rd to 4th decades of life 4. Painless swelling unless pathologic fracture
What are characteristics of a Chondrosarcoma
1. Common, malignant, moth-eaten, lesion with medullary and soft tissue calcifications 2. May arise from malignant transformation of enchondromas or osteochondromas 3. 5th to 6th decades of life 4. Painful
What are characteristics of a Ewings Sarcoma
1. Common, malignant, primary bone tumor 2. Aggressive, permeative, lytic lesion with hair-on-end, Codman triangle, and onion skin (wings and onion rings) 3. May have large soft tissue mass 4. Usually under 20 y/o 5. Painful with fever, weight loss, and elevated ESR 6. Poor prognosis
What are the stages of Paget?
1. Destructive: osteolytic 2. Mixed: osteolytic and osteoblastic 3. Sclerotic: osteoblastic
What is the order of wound graft closure
1. Direct closure 2. Graft 3. Local flap 4. Distant flap
What is the order of the lateral release for a McBride
1. Extensor Hood 2. ADH tendon release 3. Fibular sesamoid ligament 4. Lateral collateral ligament 5. FHB 6. Fibular sesamoid excision
What is the reduction sequence for LisFranc injuries
1. First realign 2nd metatarsal on middle cuneiform. Once stabilized, lesser metatarsals will follow. 2. Next stabilize 1st metatarsal and then lateral metatarsals
What are the stages of wound healing
1. Inflammatory (lag) phase Days 1-3 Initial vasoconstriction (minutes) followed by vasodilation (days) Neutrophils and macrophages are recruited 2. Proliferative (repair) phase Days 3-21 Collagen synthesis provides tensile strength of wound At 14 days, tensile strength of would equals that of suture 3. Remodeling (maturation) phase Days 21 up to one year
What are the steps for inserting a 4.0 cannulated screw
1. Insert 1.3mm guide pin to far cortex 2. Measure 3. Drill near cortex with 4.0 cannulated bit (optional) 4. Drill far cortex with 2.7 cannulated bit 5. Tap (unnecessary with self tapping screws) 6. Countersink 7. Screw
How to dose gentamycin?
1. Loading dose is 2 mg/kg for Gent and Tobra (7.5 mg/kg for Amikacin) 2. Determine creatinine clearance (CC) CC = (140 - Age) x Weight (in kg) 72 x Serum Creatinine (For females, multiply the CC by 0.85) 3. Maintenance dose is adjusted for CC (e.g. If the CC is 0.75, then the patient has 75% kidney function. Give 75% of a normal dose.)
What are characteristics of an Osteochondroma
1. Most common benign primary bone tumor 2. Cartilage-capped, hyperplastic bone pointing away from the joint 3. 2nd to 4th decades of life 4. Suspect malignant transformation with growth after skeletal maturity, pain, or cap >2 cm
What are characteristics of a multiple myeloma
1. Most common primary malignant bone tumor 2. Punched out lesions or diffusely osteopenic with hair-on-end radiating spicules 3.Affect 45-80 y/o 4. Painful with weakness or neurologic symptoms 5. Bence-Jones protein found within urine
What are characteristics of an osteosarcoma
1. Most common primary malignant bone tumor ? 2. Sunburst periosteal reaction with Codman triangle and cloud-like, dense bone formation 3. 2nd to 3rd decades of life 4. Dull aching pain 5. Medullary o Poor prognosis 6. Parosteal o More common in females o Better prognosis than medullary 7. Periosteal o Slightly better prognosis than medullary
What is Maffucci syndrome?
1. Multiple enchondromas with soft tissue hemangiomas 2. Most become malignant 3. 1st decade of life
What is Ollier disease?
1. Multiple enchondromatosis 2. May become malignant 3. 1st decade of life
What are the branches of the femoral nerve
1. Nerve to femoral artery 2. Small muscular branch to pectineus 3. Anterior division (cutaneous) a. Anterior femoral cutaneous b. Nerve to sartorious c. Intermediate 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 medialus f. Nerve to vastus intermedialus g. Nerve to vastus lateralus
What are the steps to inserting a fully threaded screw
1. Overdrill near cortex 2. Underdrill through far cortex 3. Countersink 4. Measure 5. Tap 6. Screw
What are the stages of skin graft healing
1. Plasmatic 2. Inosculation of blood vessels 3. Re-organization 4. Re-innervation
What should be done if the capital fragment falls on the floor
1. Rinse with Saline 2. Bacitracin soak for 15 minutes 3. Rinse with Saline 4. Bacitracin soak for 15 minutes 5. Rinse with Saline 6. Document and inform patient
What are the branches of the 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 are the stages of bone graft healing
1. Vascular ingrowth 2. Osteoblastic proliferation (osteogenesis) 3. Osteoinduction 4. Osteoconduction 5. Graft remodeling
What is Virchow's triad?
1. Venous stasis- tourniquet, immobilization 2.Hypercoagulability- birth control, coagulopathy, history of DVT 3. Trauma to a vessel- surgical manipulation, trauma, smoking
What should you always consider before starting an antibiotic
1. What is the most likely infecting organism 2. Have a gram stain and C&S been done? What are the results? 3. Allergies? 4. Kidney function (Check BUN and Cr)? 5. What medications is the patient currently taking? 6. Any other reason you may or may not want to give the antibiotic
What sizes are in the Synthes modular hand screw system?
1.0, 1.3, 1.5, 2.0, 2.4, 2.7
What is the half-life of heparin
1.5 hour
What are characteristics of an osteoid osteoma
1.Benign, osteolytic lesion with central nidus (<1 cm) that may have calcifications 2. 1st to 2nd decades of life 3. Dull pain, worse at night, relieved with ASA
What is the lag time for presentation of osteomyelitis on an X-ray?
10-14 days
What angle do the ATFL and CFL create
105°
What is the anti-inflammatory dose of ibuprofen?
1200-3200 mg/day in divided doses
What is the toxic dose of bupivacaine (Marcaine)
175 mg plain (2.5 mg/kg) 225 mg with epi (3.2 mg/kg)
What is the maximum length that a metatarsal may be acutely lengthened for correction of brachymetatarsia
1cm graft allows acceptable stretching of neurovascular structures
What is the dosing for Vancomycin
1g IV q12 with slow infusion Renal dose: 0.5g IV q12
What is the dose of Invanz (Ertapanem)
1g IV q24
How much lengthening is typically achieved with callus distraction?
1mm per day (0.25mm q6)
Splayfoot angle
1st IM angle > 12 degrees and 4th IM angle >8 degrees *With Met primus adductus, there is a high predilection of splayfoot
What structures in the LisFranc joint are not connected by ligaments
1st and 2nd metatarsals
What is the coverage of cephalosporins for each class
1st generation: -Gram Positive: Staph (not MRSA) and Strep -Gram Negatives: Proteus, E. coli, Klebsiella, Salmonella, Shigella (PECKSS) -Anaerobes: Not bacteriodes 2nd generation: Gram positive: similar to 1st gen Gram Negatives: more coverage, H. Influenza, Neisseria, Proteus, E. coli, Klebsiella, Salmonella, Shigella (HEN PECKSS) 3rd generation: Gram positive: less than 1st and 2nd gen Gram Negative: expanded coverage, Ceftazadime covers Pseudomonas 4th generation: Gram Positive: similar to 1st gen Gram negative: similar to 3rd gen, including pseudomonas No anaerobic coverage
How long does it take for a Gallium-67 test to work
2-3 days (48-72 hours) *Note it is expensive
Morphine sulfate?
2-4 mg IV q2-6h mod-severe pain For very painful dressing change or bedside debridement: 2mg IV x one dose
Where is the most common location for the Achilles tendon to rupture
2-6 cm proximal to the calcaneal insertion *Crozer says 1.5-4cm
What is the half-life of Coumadin
20-60 hours
What is the dose of Zithromax
250 mg PO Two tabs on the first day Then one tab for the next four days
What is the dose of Levaquin
250-500 mg PO/IV q24h
How many bones are in the foot
26 (not including sesamoids)
What layer of the foot does FDL run
2nd layer - it is the origin of the lumbricals and the insertion of QP
When should NSAIDs be discontinued prior to surgery
3 days due to reversible binding to platelets
Following a transfusion of PRBC, when will changes in H/H be seen
3 hours so new labs need to be drawn 4 hours after last unit given
When should Coumadin be discontinued prior to surgery
3-4 days (monitor PT/INR)
How long before Coumadin is therapeutic
3-5 days
What is the dosing for Unasyn
3.0g IV q 6° 1.5g IV q6° for pt with renal impairment
What is the dose of Timentin
3.1g IV q4-6
What is the dosing for Zosyn
3.375g IV q4-6h Renal dose 2.25g IV q 4-6h Alt dose 4.5g IV q4-6h
What is a normal value for serum albumin
3.4-5.0 g/dL
Lesser MPJ dorsiflexion/plantarflexion
30-40° Dorsiflexion and 50-60° plantarflexion
What is the toxic dose of lidocaine (Xylocaine)
300 mg plain (4.5 mg/kg) 500 mg with epi (7.0 mg/kg)
How to dose Lovenox for perioperative DVT prophylaxis?
30mg SC q12 for 7-12 days (adjust dose to q24 for renal patients)
How many joints are in the foot
35
Oblique midtarsal joint Angles
38° from frontal plane 52° from transverse plane 57° from sagittal plane
To close a lesion with minimal tension, what should the ratio of length to width be
3:1 length:width
Alternatives for E/C/S/M group
3rd gen ceph, aztreonam, bactrim
Alternatives for Pseudomonas
3rd gen cephalosporins, Aztreonam, Zosyn and Timentin
How to treat serious hospital acquired Gram negative infections?
3rd generation cephalosporins, aminoglycoside (Rocephin and Gentamycin for ex)
What is the half-life of Lovenox
4.5 hours
What is the dose of Avelox?
400 mg PO/IV q24h
What is the dose of Zyvox
400-600mg PO/IV q12
What is the max daily dose of acetaminophen?
4g *Some sources now say 3g
Which Pencillins cover pseudomonas
4th and 5th generations Pipercillin , Zosyn Ticarcillin, Timentin Carbenicillin, Mezlocillin, Azlocillin
How to dose Coumadin?
5-10 mg PO daily for 3-4 days then adjust for INR
Describe the anterior drawer test
5-8 mm drawer-> rupture of ATF 10-15 mm drawer-> rupture of ATF + CF >15 mm drawer-> rupture of ATF, CF + PTF
What percentage of tarsal coalitions are bilateral
50%
What is the dose of Augmentin
500 or 875mg PO BID
How to dose Heparin for perioperative DVT prophylaxis?
5000 units SC 2h prior surgery 5000 units SC q12 until patient ambulates
What is the dose of Primaxin
500mg IV q6-8 (most common) or 1gm IV q6-8
What is dose of flagyl
500mg PO TID
Iselen's disease
5th Metatarsal Base
Describe the stress inversion test
5° inversion → rupture of ATF 10-30° inversion → rupture of ATF + CF
What is the half-life of Technectium-99
6 hours
What is the max daily dose of colchicine
6 mg
How long should elective surgery be delayed following an MI or CABG
6 months
What are some types of fixation for a triple arthrodesis
6.5-7.0 mm interfragmental compression screws, staples and plates
What percentage of fractures of the talus involve the calcaneus? Of these fractures, how many involve the joint?
60% 75%
What is the dose for Clindamycin
600-900mg IV q8 or 150-300mg PO BID-TID
What is the half-life of Zithromax
68 hours
When should aspirin be discontinued prior to surgery
7 days due to irreversible binding to platelets
What is the incidence of peroneus quartus
7%
How much lengthening can be achieved with a 60° Z-plasty?
75%
Longitudinal Midtarsal Joint Angles
75° from frontal plane 15° from transverse plane 9° from sagittal plane
When should Heparin be discontinued prior to surgery
8 hours (monitor PTT)
What is phenol?
89% carbolic acid
What is the maximum tourniquet time
90-120 minutes After that, allow 5 minutes of perfusion for every half hour over
What should the INR be for elective surgeries?
<1.4
Describe the talar tilt test
>10 degrees indicative of rupture of CFL or greater than 5 degrees versus contralateral side
What are indications for ordering an EKG
>40 years of age, any history of cardiac disease
What are indications for ordering a chest X-ray
>40 years of age, smoker, any history of cardiac or pulmonary disease
What is the Thompson test
A positive test results when squeezing of the calf muscle does not plantarflex the foot
What are the Ottowa Ankle Rules
A series of ankle X-ray films is required only if there is any pain in the malleolar zone and any of the following findings: Bone tenderness at posterior edge or distal 6 cm of lateral malleolus Bone tenderness at posterior edge or distal 6 cm of medial malleolus Inability to bear weight both immediately and in ED A series of foot X-ray films is required only if there is any pain in midfoot zone and any of the following findings: Bone tenderness at base of 5th metatarsal Bone tenderness at navicular Inability to bear weight both immediately and in ED
What is malignant hyperthermia?
A side effect of general anesthesia - tachycardia, hypertension, acid-base and electrolyte abnormalities, muscle rigidity, hyperthermia *Can be caused by halothane, enflurane, isoflurane and sevoflurane and also muscle relaxants such as succinylcholine
What is an arthroereisis
A surgical procedure to limit joint mobility (i.e. MBA implant in sinus tarsi) Typically want 2-4° of STJ eversion with implant
Hip Abduction/Adduction
Abduction 24-60° (avg 36°) Adduction <30°
What is TissueMend?
Acellular collagen matrix derived from fetal bovine dermis
What is given for a Tylenol overdose
Acetylcysteine (Mucomyst)
What is the Murphy procedure
Achilles advancement for spastic equinus
Melanoma typically found on the palms, soles and nail beds
Acral Lentinginous melanoma
What is anaerobic gram positive filamentous bacteria
Actinomyces
What does Gallium-67 test for
Acute inflammation and infection (indium detects acute infections better)
What is cellulitis?
Acute spreading infection of dermal and subcutaneous tissue commonly caused by group A Strep or Staph aureus. Affected area is erythematous, warm, edematous, and tender.
How to treat acute and chronic gout
Acute: -Colchicine -NSAIDS: indomethacin -Corticosteroids -ACTH Chronic: -Colchicine (prophylactically) -Allopurinol -Uricosurics: probenecid and sulfinpyrazone
What is the result of accidentally severing the quadratus plantae
Adductovarus deformity of digits 4 and 5 as the pull of FDL is unopposed
What are the advantages of using Lovenox vs regular Heparin? Disadvantages?
Advantages: Lovenox has longer plasma half life with significant anticoagulation in trough Disadvantage: increased post-op complications when used with spinal/epidural anesthesia
What is the Young modulus
After a load is removed, the material will spring back to its original shape, the resulting slope represents the stiffness of a material or the Young modulous.
What is the most common offending organism of septic arthritis All ages? Neonates? Children? Teenagers? Puncture wounds? Adults with sickle cell?
All ages: staph aureus Neonates: Strep or Gram Negatives Children: H. Influenza Teenagers: N. Gonorrhea Puncture wounds: Pseudomonas Aeruginosa Adults with sickle cell: Salmonella
How are PCN's excreted?
All are renal except for mezlocillin, azlocillin, piperacillin (the ureidopenicillins are 20- 30% renal)
What is the spectrum of activity for Vancomycin
All gram positives including MRSA and MRSE
What is the spectrum of activity of Zyvox
All gram positives, including MRSA and VRE (vancomycin resistant enterococci)
What is the MOA of aminoglycosides? Macrolides?
Aminoglycosides bind to bacterial 30s ribosomes inhibiting protein synthesis Macrolides bind to bacterial 50s ribosomes inhibiting protein synthesis (A boy at 30 does not become a Man until 50)
Alternative for Lymes disease
Amoxicillin
DOC for Enterococcus
Amoxicillin PO or Vancomycin IV
Unasyn is a combo of
Ampicillin/Sulbactam
What is Cholramphenicol
An antimicrobial
What are two soft tissue clinical manifestations caused by Clostridium
Anaerobic cellulitis and Gas Gangrene
What therapeutic effects are with acetaminophen
Analgesic and anti-pyretic
What therapeutic effects are seen with most NSAIDs?
Analgesic, anti-pyretic and anti-inflammatory
What antibiotics are most commonly used for surgical prophylaxis
Ancef Clindamycin if PCN allergy Vancomycin if concerned about MRSA
What is the condition called when the Hemoglobin/Hematocrit is below 10/30
Anemia
Fallat & Buckholz 4th IM angle
Angle between bisection of 4th metatarsal and proximal-medial cortical border of 5th metatarsal Normal 6° Pathologic 8.7°
What is the Q angle?
Angle between the axis of the femur and the line between the patella and tibial tuberosity
Gissane Angle
Angle formed by the intersection of a line along the posterior facet and another line along the middle and anterior facets Normal is 125-140° *Increases with intra-articular calcaneal fracture*
Bohler Angle
Angle formed by the intersection of a line from the superior aspect of the anterior process to superior aspect of the posterior facet and another line from the superior aspect of the posterior facet to superior point of the calcaneal process Normal 25-40° *Decreases with intra-articular calcaneal fracture*
Fowler & Philip angle
Angle formed from the intersection of a line along the anterior tubercle and the plantar tuberosity and another line along the posterosuperior prominence at the Achilles tendon insertion Normal <70° Haglunds deformity >75°
Fallat & Buckholz Lateral Deviation angle (lateral bowing)
Angle of line bisecting head and neck of 5th metatarsal and line adjacent to proximal-medial cortex Normal: 2.64 Pathologic: >8
What is an ABI?
Ankle Brachial Index - compares ankle to arm pressures -Normal 1 -PVD <0.9 -Intermittent claudication 0.6-0.8 -Rest pain 0.4-0.6 -Ischemic ulcerations <0.4
Which X-rays provide best view of talar neck injuries
Ankle in maximum equinus Foot in pronated position X-ray tube directed 75 degree from horizontal *Called Cannale View
What conditions are associated with positive HLA-B27
Ankylosing Spondylitis, Reiter Disease, Psoriatic Arthritis, Reactive Arthritis, Enteropathic arthropathies
What is the effect of NSAIDs on anti-hypertensives
Antagonizes
What is the most common location to obtain a split thickness skin graft
Anterior Lateral thigh
What are tests for ligament pathology
Anterior drawer test Calcaneofibular-stress inversion Abduction stress Ankle arthrogram Peroneal Tenography
How do you treat Red Man Syndrome
Antihistamines (Benadryl 25-50 mg IV q2-4h) until symptoms resolve Symptoms are self limiting
What is the function of a biguanide
Antihyperglycemic (not hypoglycemic)
What is fibular hemimelia?
Aplasia or hypoplasia of the fibula
What is the indication for Zosyn
Approved for use in adults for the treatment of moderate to severe diabetic foot infections
What is the indication of Invanz
Approved for use in adults for the treatment of moderate to severe diabetic foot infections
What direction should transsyndesmotic screws be inserted
Approximately 30 degrees from sagittal plane from posterior-lateral to anterior-medial *1cm above the joint
What are causes of a white toe post-operatively
Arterial in nature, usually acute Signs - pain, pale, parasthesia, pulselessness
Trace the path of a drop of blood from left ventricle to the hallux
Ascending aorta -> Aortic arch -> Descending aorta -> Thoracic aorta -> Abdominal aorta -> Common iliac artery -> External iliac artery -> Femoral artery -> Superficial femoral artery -> Popliteal artery -> Anterior Tibial artery -> Dorsalis Pedis -> 1st dorsal metatarsal artery -> 1st dorsal common digital artery -> 1st dorsal proper digital artery
What NSAID causes irreversible inhibition of platelet aggregation?
Aspirin
If a patient is currently on antibiotic, how long should it be stopped before taking a wound culture?
At least 48 hours (if possible)
What is the LisFranc ligament
Attaches lateral aspect of medial cuneiform to medial base of 2nd metatarsal
DOC for cat and dog bites?
Augmentin
DOC for Bacteroides
Augmentin, Zosyn, Unasyn, Timentin
What type of bone graft is osteogenic, osteoinductive and osteoconductive
Autograft
Should you use Vicryl with an infection
Avoid it if possible, since Vicryl is too reactive
Another name for Zithromax
Azithromycin
BERNDT & HARDY classification
BERNDT & HARDY - Talar dome fracture Stage 1 - nondisplaced compression of talar dome Stage 2 - partially detached osteochondral lesion Stage 3 - completely detached, nondisplaced osteochondral lesion Stage 4 - completely detached, displaced osteochondral lesion
What is an a CMP
BMP with ALP (alkaline phosphate), ALT (Alanine amino transferase), AST (aspartate amino transferase), bilirubin, albumin, total protein, calcium
Alternative for Aeromonas
Bactrim
DOC for Pseudomonas Cepacia
Bactrim
Topical DOC for MRSA
Bactroban
Clark Malignant Melanoma Classification
Based on histological level of invasion Level 1: located within epidermis or epidermal-dermal junction Level 2: located within papillary dermis Level 3: located within papillary-reticular junction (through papillary dermis) Level 4: located down into reticular dermis Level 5: located within subcutaneous tissue
Breslow Malignant Melanoma Classification
Based on thickness Level 1: <0.75 mm (99% cure) Level 2: 0.76-1.5 mm Level 3: 1.51-4.0 mm Level 4: >4.0 mm
What is the perioperative management for patients at risk for gout
Begin colchicine 0.6 mg PO daily 3-5 days pre-op and continue 1 week post-op
What should be given for an indomethacin overdose
Benadryl - decreases serotonin and histamine release
What is the classification for Talar dome lesions
Berndt & Hardy
When do fever peaks occur
Between 4-8 pm
What is integra
Bilayer graft composed of bovine tendon collagen with chondroitin-6-sulfate and a silicone layer to control moisture loss
What is Apligraf
Bilayer graft derived from neonatal foreskin with dermal and epidermal layers
Tibial Torsion
Birth 0 degrees 6 years 13-18 degrees Adult 18-23 degrees
Knee valgum/varus (bow leg, knock knee) Birth 2-4 yrs 4-6 years 6-12 years 12-14 years > 14 years
Birth = 15-20° (genu varum) 2-4 yrs = 0° (straight) 4-6 years = 5-15° (genu valgum) 6-12 years = 0° (straight) 12-14 years = 5-10° (genu valgum) > 14 years = 0° (straight)
Angle of anteversion of femur
Birth: 60 degrees Adult: 10-12 degrees
What is the mechanism of action for local anesthetics
Block Na+ channels and conduction of action potentials along sensory nerves
What bone tumors do not form matrix
Bone cysts Ewings sarcoma Giant cell tumor
What are the stages of bone healing?
Bone heals either primarily or secondarily Primary healing - no motion and no callus formation 1. Inflammation 2. Induction (Reparative) 3. Remodeling Secondary healing - micro-motion with callus formation 1. Inflammation 2. Induction 3. Soft callus 4. Hard callus 5. Remodeling
What study can distinguish between a hypertrophic and an atrophic non-union?
Bone scan - positive for hypertrophic and negative for an atrophic (avascular) non-union
What Gram negative spirochete causes Lyme disease?
Borrelia burgdorferi
How much clavulonate is in a 500mg augmentin tab compared to an 875mg augmentin tab
Both have 125mg
What are the most common cancers that metastasize to foot
Breast, Prostate, Lung, Kidney
What is the indication of Timentin
Broad spectrum antibiotic for polymicrobial infections
What is the spectrum of activity of Bactrim
Broad spectrum covering Gram positives (MRSA) and Gram negatives
Which coalition is most symptomatic?
C-N
What are the side effects of lidocaine and bupivacaine associated with systemic exposure
CNS effects: initial excitation (dizziness, blurred vision, tremor, seizures) followed by depression (respiratory depression, loss of consciousness) Cardiovascular effects: hypotension, bradycardia, arrhythmias, cardiac arrest
CONTI Classification
CONTI - MRI rupture Stage 1 - 1-2 fine, longitudinal tears Stage 2 - intramural degeneration, variable diameter Stage 3 - diffuse swelling
If a risk of malignant hyperthermia is suspected, what pre-operative test may be performed?
CPK- elevated in 79% of patients with malignant hyperthermia *CPK=Creatinine Kinase test (blood test)
ROWE Classification
Calcaneal fx Type 1 - 1A - fracture of plantar tuberosity 1B - fracture of sustentaculum tali 1C - fracture of anterior process Type 2 2A - ―beak fracture‖ 2B - avulsion fracture of Achilles insertion Type 3 3A - simple oblique fracture of body not involving STJ 3B - comminuted oblique fracture of body not involving STJ Type 4 - intra-articular fracture involving STJ Type 5 - intra-articular, comminuted, depression fracture with STJ involvement Note: Rowe is primarily used for extra-articular fractures. Intra-articular fractures (Rowe 4 & 5) are usually replaced by Essex & Lopresti.
Which ankle ligaments are extra-capsular? Which are capsular?
Calcaneofibular is extra-capsular, all others are capsular
What are some extra-articular coalitions of the foot
Calcaneonavicular Coalition
Severe's disease
Calcaneus
What are radiographic findings of CCPV (Congenital Convex Pes Valgus aka Vertical Talus)
Calcaneus in equinus, plantarflexed talus, dorsally dislocated navicular, increased talo-calc angle
What are components of CREST
Calcinosis Raynauds Esophageal Dysmotility Sclerodactyly Telangiectasis
If more than 1cm of lengthening is required, what procedure maybe performed
Callus distraction with Mini-Rail fixation
What to do if platelets are low (under 150-350 k/mL)?
Can Transfuse platelets, but this is not commonly done
What are the cardiovascular side effects of NSAIDs
Can cause vasoconstriction and increase blood pressure
What is the effect of NSAIDs on asthma
Can increase symptoms of asthma
Are the sesamoids capsular or extra-capsular?
Capsular
What is the difference between Cataflam and Voltaren
Cataflam is diclofenac potassium and has an immediate release Voltaren is diclofenac sodium and has a delayed release
Alternative for Pseudomonas Cepacia
Ceftazidime
Another name for Rocephin
Ceftriaxone
DOC for gonorrhea
Ceftriaxone
What is the treatment for Gonorrhea
Ceftriaxone
What are the NSAIDs with the least nephrotoxicity
Celebrex, Relafen, Lodine
What does it mean if the bone scan lights up in Phases 1-2 but not in 3
Cellulitis most likely
What is the difference between cellulitis and erysipelas
Cellulitis: confined superficial infection Erysipelas: superficial infection that extends into the lymphatics
Name a way to test between Charcot disease and osteomyelitis
Ceretec scan or Indium-111
What should be obtained prior to surgery on a patient with rheumatoid arthritis
Cervical Spine X-ray
What tests can be ordered to diagnose a PE?
Chest X-ray Ventilation perfusion scan Pulmonary angiography *Spiral CT
In what age group should bupivacaine be avoided
Children <12 year of age
What can cause Gray Baby Syndrome
Chloramphenicol
What is gonorrhea cultured on
Chocolate agar
Where are bone tumors typically located? Epiphysis
Chondroblastoma Giant cell tumor (forms in metaphysis)
Name malignant bone tumors of the foot
Chondrosarcoma Osteosarcoma Periosteal sarcoma Ewings sarcoma Fibrosarcoma Multiple myeloma
What are the clinical patterns of Tinea Pedis? What are common infecting organisms?
Chronic (mocassin or papulosquamous) -Trichophyton Rubrum Acute (interdigital or vesicular) -Trichophyton Mentagrophytes Ulcerative -Trichophyton Mentagrophytes with Pseudomonas or Proteus
What is erythrasma?
Chronic, superficial infection of intertriginous skin caused by Cornyebacterium minutissimum. Interdigital lesions appear as maceration.
What is Pletal?
Cilostazol
DOC for pseudomonas
Cipro
DOC for Aeromonas
Cipro PO/IV
Alternative for E.Coli if PCN allergy
Cipro or Levaquin
Alternatives for Proteus if PCN allergy
Cipro or Levaquin
What are some common quinolones
Ciprofloxacin (Cipro) Levofloxacin (Levaquin) Moxifloxacin (Avelox)
What is the ASA classification for general anesthesia?
Class 1: Healthy Class 2: Mild Systemic disease Class 3: Severe systemic disease Class 4: incapacitating systemic disease that is a threat to life Class 5: moribound patient who is not expected to live without surgery Emergency
What is an alternative antibiotic for a patient with a PCN allergy
Clinda/Cipro Levaquin (there are others) Doxycycline for gram positive
Alternatives for Bacteriodes if PCN allergy
Clinda/Cipro, Primaxin and Flagyl
Another name for Cleocin
Clindamycin
What is the DOC for a patient with diabetes and a PCN allergy
Clindamycin
Alternatives for Staph if PCN allergy
Clindamycin Levaquin Vancomycin Azithromycin
Alternative drugs for Staph Aureus
Clindamycin Levaquin Vancomycin Azithromycin Dicloxacillin Nafcllin
what are the IV alternatives for patients allergic to penicillin
Clindamycin Vancomycin Levaquin
What is the most common cause of Clostridium Difficile colitis
Clindamycin (although any antibiotic can cause it)
Alternative for Strep
Clindamycin, Levoquin, Vanco, Doxy
What is a large, Gram positive, anaerobic, racquet-shaped rod that forms spores?
Clostridium Perfringens
What is the difference between a coalition and a bar
Coalition: intra-articular fusion of two bones Bar: extra-articular fusion
What is the only local anesthetic with vasoconstriction?
Cocaine
Tibial varum/valgum
Compare distal 1/3 of tibia to ground Birth 5-10° varum >2 years 2-3° valgum
What is CRPS
Complex regional pain syndrome (previously known as RSD - reflex sympathetic dystrophy) is a progressive disease of the nervous system causing constant, extreme pain that is out of proportion to the original injury
What are some causes of Hallux Varus
Congenital -Clubfoot -Metatarsus adductus Traumatic -MPJ dislocation -Fracture Iatrogenic -Overcorrection of intermetatarsal angle -Excessive resection of medial eminence or staking the head -Fibular sesamoidectomy -Overaggressive capsulorrhaphy -Bandaging too far into varus
Types of joint deformities
Congruent - joint lines are parallel Deviated - joint lines intersect outside Joint Subluxed - joint lines intersect inside joint
What should be done if the creatinine is too high
Consult renal if creatine is over 1.5 for a couple of results
What are etiologies of septic arthritis
Contiguous, hematogenous, direct implantation, surgical contamination
What are 3 planes of a CT scan
Coronal Axial Sagittal
What are the differences between cortical and cancellous screws
Cortical has smaller pitch Cortical has smaller rake angle Cortical has smaller difference between thread diameter and core diameter
What can cause an elevated PT/INR
Coumadin Malnutrition Alcoholism Antibiotics Vitamin K disorders
What is the purpose of tapping
Creates a path for the screw threads
Which is a more important indicator-BUN or creatinine
Creatinine is more important, because BUN is influence by hydration state. If the BUN is high but the creatinine is normal, then the patient is most likely dehydrated and rehydration should correct the BUN. However, if both BUN and creatinine are high, then the patient most likely has renal damage. *BUN is for liver function and kidney excretion
What is another name for the inferior extensor retinaculum
Cruciate crural ligament
Lance's disease
Cuboid
Buschke Disease
Cuneiforms
What is mycosis fungoides?
Cutaneous T-cell lymphoma that can resemble eczematoid or psoriasis
What pathway do NSAIDs work on?
Cyclooxygenase (COX) NSAIDs nonselectively inhibit both COX-1 and COX-2 pathways
What are treatments for blue toe due to sluggish venous outflow
D/C ice (but not elevation) Loosen Bandages Avoid dependency Don't attempt to increase vascular perfusion Consult vascular surgery
DEGAN Classification
DEGAN - Calcaneal fx Type 1 - non-displaced fracture of the anterior process Type 2 - extra-articular, displaced fracture of the anterior process Type 3 - intra-articular, displaced fracture of the anterior process involving C-C joint *Best seen in MO view
What gram negative rod is associated with dog bites
DF-2
DOWNEY classification
DOWNEY - Tarsal Coalitions *Juvenile (Osseous Immature)* Type 1 - extra-articular coalition A - no secondary arthritis Tx: Badgley procedure B - secondary arthritis Tx: resection or triple Type 2 - intra-articular A - no secondary arthritis Tx: resection, isolated arthrodesis, or triple B - secondary arthritis Tx: triple *Adult (Osseous Mature)* Type 1 - extra-articular A - no secondary arthritis Tx: resection or triple B - secondary arthritis Tx: triple Type 2 - intra-articular A - no secondary arthritis Tx: isolated or triple B - secondary arthritis Tx: triple
Another name for Synercid
Dalfopristin-Quinupristin
What is the treatment for malignant hyperthermia
Dantrolene (for muscle relaxation) 2.5mg/kg IV x l, then 1 mg/kg IV rapid push q6h until symptoms subside or until max dose of l0 mg/kg
Another name for Cubicin
Daptomycin
First choice oral pain medication
Darvocet N-100 one tab PO q4-6 PRN pain
What is the most common time for post-operative myocardial infarction
Day 3
What is a low serum albumin level (<3.5 g/dL) associated with?
Decreased wound healing Edema Impaired cellular immunity Decreased collagen synthesis Decreased fibroblast proliferation
What is the effect of NSAIDs on lithium
Decreases Lithium clearance
What is the effect of NSAIDs on methotrexate
Decreases methotrexate clearance
How is the Bohler angle affected by a calcaneal fracture?
Decreases with intra-articular calcaneal fracture
What are possible complications of fractures
Delayed union Non-union Pseudoarthrodesis OA AVN
Which is stronger- the lateral ankle ligaments or the deltoid ligaments
Deltoid
Choice narcotic IV pain med?
Demerol Note: many hospitals, including our own, do not use Demerol due to its side effects
Are cephalosporins contraindicated in patients with PCN allergy
Depends on who you talk to
What device is more commonly used to harvest skin grafts
Dermatome
Lauge Hansen Pronation-dorsiflexion
Describes Pilon Fracture Stage 1 - rupture of deltoid ligament or fracture of medial malleolus (oblique or transverse) Stage 2 - fracture of anterior lip of tibial plafond Stage 3 - fracture of fibula above the level of the syndesmosis Stage 4 - transverse fracture of the distal tibia at the same level as the proximal margin of the large tibial fracture
Danis-Weber Classification
Describes location of fibular fracture Type A - transverse avulsion fracture below the level of the ankle joint (corresponds with Lauge-Hansen SAD) Type B - spiral or oblique fracture at the level of the ankle joint (corresponds with Lauge-Hansen SER and PAB) Type C - fracture above the level of the ankle joint (Maisonneuve fracture) (corresponds with Lauge-Hansen PER)
What is the Silfverskiöld test?
Determines gastroc vs. gastroc-soleus Positive test Dorsiflexion of the foot to neutral or beyond with the knee in flexion Gastroc equinus Negative test Lack of dorsiflexion of the foot to neutral with knee in flexion and in extension Gastroc-soleus equinus
What is the Lachman test
Determines if there is a plantar plate tear or rupture. While stabilizing the metatarsal, a dorsal translocation of the proximal phalanx greater than 2 mm is suggestive of rupture.
What are the safest NSAIDs for a patient with asthma?
Diclofenac and Ketoprofen
Which NSAIDs have the least cardiovascular effects
Diclofenac, ketoprofen
What is DISH?
Diffuse Ideopathic Skeletal Hyperostosis - characterized by multiple ossifications at tendinous or ligamentous insertions
What deformity will result from cutting QP?
Digits 4 and 5 will become adductovarus
What are complications associated with a Keller
Diminished propulsion of digit, loss of hallux purchase, stress fracture of 2nd metatarsal
What is radiographic finding of an Achilles tendon rupture
Disruption of Kagers triangle (FHL, Achilles and Superior surface of calcaneus)
What procedure corrects hallux interphalangeus
Distal Akin
What is the direction of the cut for reverse Wilson of the 5th metatarsal
Distal Lateral to Proximal Medial
What are clinical patterns of Onychomycosis? What are common infecting organisms?
Distal Subungual Onychomycosis (DSO) 90%: -Most Common -Trichophyton Rubrum Proximal Subungual Onychomycosis (PSO) 1%: -Seen in Immunocompromised patients -Trichophyton Rubrum Superficial White Onychomycosis (SWO) 10%: Trichophyton Mentagrophytes Candidal Onychomycosis: Candida Albicans
What is the most common coalition of the foot
Distal and middle phalanx of 5th digit
To correct a 5th digit adductovarus rotation, how should the skin incision be oriented?
Distal medial to proximal lateral
What are the advantages of using a split thickness skin graft
Donor site heals spontaneously May cover large wounds
What tests can be ordered to diagnose a DVT?
Doppler ultrasound Venogram D-Dimer
Are dorsal or plantar Lisfranc dislocations more common?
Dorsal - the plantar ligaments are stronger than dorsal
Os calcaneus secondarius
Dorsal anterior process of calcaneus
What ligaments compose the bifurcate ligament
Dorsal calcaneonavicular and calcaneocuboid ligaments
What is the treatment for Lyme disease
Doxycycline 100mg PO daily OR Rocephin 1g IV daily
DOC for lyme disease
Doxycycline or Rocephin
What are the only FDA-approved drugs for treating diabetic neuropathy?
Duloxetine (Cymbalta) Pregabalin (Lyrica)
What is Achondroplasia
Dwarfism - all bones short with tibia undergrowth and fibular overgrowth causing genu varum
What is the triad of pulmonary embolism?
Dyspnea (SOB) Chest pain Hemoptysis (although tachycardia is more common)
What is the main screening test if AIDS is suspected?
ELIZA (Enzyme Linked Immunosorbent Assay)
Essex-Lopresti
ESSEX-LOPRESTI - Calcaneal fx Type 1 - tongue fracture (vertical fracture line) without STJ involvement Type 2 - joint depression fracture (horizontal fracture line) with STJ involvement
What nonpharmacologic measures are used for perioperative DVT prophylaxis?
Early ambulation: most important TEDs: thromboembolic deterrent stockings SCDs: sequential compression devices
What are causes of acute arterial occlusion
Embolism - detached thrombus, air, fat, or tumor Thrombus - occlusion of vessel by plaque or thickened wall Extrinsic occlusion - traumatic, blunt, penetrating
What is the indication for Unasyn
Empiric therapy for polymicrobial diabetic foot infections
What are the centrally located bone tumors
Enchondroma Unicameral Bone cyst
What are other uses for an arthroscopy
Endoscopic plantar fasciotomy (EPF) or endoscopic gastroc recession Ankle Fusion Arthroscopy of STJ or 1st MPJ
What is Steida Process
Enlarged Os Trigonum
Another name for Invanz
Entrapenem
What is the Thurston-Holland sign?
Epiphysis is separated from the physis with the fracture extending into the metaphysis resulting in a triangular fracture fragment (AKA Flag sign)
What anatomic structures normally lights up on bone scan
Epiphysis of a growing child Fracture Tips of scapula Bladder Sternum Intercostals (ribs)
What causes the fibular deviation of digits
Erosive changes of medial plantar metatarsal heads compromises the integrity of medial collateral ligaments leading to lateral deviation of digits
What is a short, gram negative rod
Escherichia coli
What are the sources of blood supply to the talus
Essentially the 3 major blood supplies to the foot: 1. Superior surface of head and neck - artery of sinus tarsi and branch from anterior tibial artery or dorsalis pedis 2. Medial side of body - artery of tarsal canal and posterior tibial artery 3. Lateral turbercle - anastamosis of branch of peroneal artery with medial calcaneal branch
What is fat saturation used for
Evaluation of fat...c'mon, that's obvious
With an infection, what is expected to happen to the WBC count after surgery?
Eventually it should go down, but in post-op days 1-2, the WBC may actually increase a bit. This may occur because surgery activates the body's reaction to the infection.
What are the sizes of Steinman pins?
Every one from 5/64 to 12/64 except for 11/64
What is staking of the head?
Excessive resection of the 1st metatarsal head with cutting into the sagittal groove *may lead to hallux varus*
What is GraftJacket?
Extracellular matrix derived from human tissue with intact vascular channels
Which pathway does PT (Prothrombin Time) check
Extrinsic (PET)
How does Coumadin work?
Extrinsic pathway Interferes with clotting factors II, VII, IX, X *Inhibits Vitamin K epoxide reductase
Name benign bone tumors of the foot (FOG MACHINES)
F - fibrous dysplasia O - osteochondroma G - giant cell tumor M - myeloma A - aneurysmal bone cyst C - chondroblastoma, chondromyxoid fibroma, clear cell H - hemangioma I - infection N - non-ossifying fibroma E - eosinophillic granuloma, enchondroma, epidermal inclusion cyst S - solitary bone cyst
What are the 3 components of clubfoot
FF adductus, RF varus, ankle equinus
What causes increased signal intensity on a T1 image
Fat
Legg-Calve-Perthes Disease
Femoral Epiphysis
What is the Master Knot of Henry
Fibrous connection between FHL and FDL tendons
What is the Hoke Tonsil
Fibrous, fatty plug within the sinus tarsi
Trevor's disease
Fibular sesamoid
What is the Stewart classification
Fifth met base fractures Type 1 - extra-articular fracture at metaphyseal-diaphyseal junction (true Jones fracture) Type 2 - intra-articular avulsion fracture of 5th metatarsal base Type 3 - extra-articular avulsion fracture of styloid process of 5th metatarsal base Type 4 - intra-articular comminuted fracture of 5th metatarsal base Type 5 - extra-articular avulsion of epiphysis in children
How to calculate daily fluid input requirements
First 10 kg x 100 = 1000 mL/day Second 10 kg x 50 = 500 mL/day Remaining kg x 20 = ___ mL/day (e.g. 70 kg patient requires 1000 + 500 + 1000 = 2500 mL/day)
What should be done if the patient's WBC is over 10
First, decide if the patient has an infection -If there is an infection, then antibiotics and possible I&D should decrease the WBC count -If there is not an infection, then the cause must be determined. Is the increase acute or chronic? Is there another source of infection? Is the patient on corticosteroids? Is there a combo of medical conditions causing this?
What drugs leave a metallic taste in the mouth?
Flagyl and Lamasil
What are differences between flexible, semi-rigid, and rigid deformities?
Flexible - reducible when NWB and WB Semi-rigid - reducible when NWB only Rigid - non-reducible
Knee Flexion/Extension
Flexion 130-150° Extension 5-10°
Describe the type of hammertoes
Flexor Stabilization -Most Common -Stance Phase -Flexors overpower Interossei -Pronated Foot Extensor Sub -Swing Phase -Extensors overpower lumbricals -Anterior cavus, ankle equinus, anterior compartment muscle weakness -Flexor Sub -Least common -Stance Phase -Deep Compartment muscles overpower interossei -Supinated, high arch foot or weakened Achilles
What causes increased signal intensity on a T2 image
Fluid, Infection, Inflammation, Tumor (F.I.I.T)
How to reverse diazepam?
Flumazenil (Romazicon) for benzodiazepine reversal 0.2 mg IV over 15 seconds, then 0.2 mg IV prn over 1 minute up to 1 gram total
Describe a Keck & Kelly procedure?
For Haglund deformity with cavus foot and high calcaneal inclination angle. Remove wedge from posterior-superior aspect of calcaneus. The posterior superior prominence is moved anteriorly.
Venn-Watson classification
For Polydactyly; Post-Axial -Wide metatarsal head -T Metatarsal -Y metatarsal -Complete duplication
What are the cannulated screw sizes?
For Synthes 3.0, 4.0 For Smith & Nephew 4.0, 6.5, 5.5 and 7.0
What is the Hooke Law
For a material under load, strain is proportional to stress
What is the Simon rule of 15?
For clubfoot (talipes equinovarus), children <3 years → talo-navicular subluxation T-C angle is <15° and talo-1st metatarsal angle is >15°
Describe a malleolar screw
For fixation of medial malleolus, partially threaded, same thread profile and pitch as cortical screw, trephedine self-cutting tip
What do you clinically test via Jack Toe Test
Foster fracture - a fracture of the entire posterior process
Total angle of Ruch
Fowler & Philip angle + calcaneal inclination angle Normal 90° Haglunds deformity >90°
Smillie Classification
Freiberg's classification: Stage I - fissuring of the epiphysis Stage II - early collapse of the MT head with alteration of articular surface Stage III - depression of the articular surface into the MT head with medial and lateral projections of bone Stave IV - failure of the plantar cortical hinge with development of loose bodies Stage V - end stage arthrosis with marked flattening of the MT head and joint space narrowing
STJ ROM
From neutral, 2/3 motion in inversion (20°) and 1/3 in eversion (10°)
What is the coronal plane of a CT scan represent
Frontal Plane
What is the most common side effect of NSAIDs
GI disturbance (except with COX-2 inhibitors, because COX-1 protects the stomach lining)
What are some major aminoglycosides
Gentamycin, Tobramycin and Amikacin
What are the different patterns of bone destruction
Geographic: well-defined, short zone of transition -> benign or low-grade malignancy Moth-eaten: more aggressive, intermediate zone of transition -> benign or malignant Permeative: poorly defined, wide zone of transition -> malignant
What is the most accepted theory about clubfoot
Germ plasma defect-malposition of head and neck of talus
What primary bone tumors are more frequent in females?
Giant Cell Tumor ABC Parosteal Osteosarcoma
What bone tumors are eccentrically located within medullary canal
Giant Cell Tumor Chondrosarcoma Osteosarcoma
What should be done if Na+ is too low
Give NSS or regular salt
What must you D/C before an A-gram
Glucophage because patient may develop metabolic acidosis
Describe the procedure of calcaneal ORIF
Goal is to restore the STJ and C-C articulation Perform surgery within 6-8 hours of the injury or wait until the swelling is reduced Reduction is performed by placing a Schanz 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 be used as a buttress. Before arthrodesis is performed, CR or ORIF should be attempted
What is the most common inflammatory arthritis in men over 30
Gout
UTSA CLASSIFICATION
Grade 0: completely epithelialized pre- or post-ulcerative lesion 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
What open fractures should be treated with antibiotics?
Grades 2 and 3
What are disadvantages of using split thickness skin graft
Grafts are fragile Contraction of graft during healing May be abnormally pigmented
What organisms may form gas in soft tissue
Gram Positive: Clostridium Perfringens, Staph, Strep, Peptostreptococcus Gram Negative: Bacteriodes and Fusobacterium
What is the spectrum of activity of Aztreonam
Gram negative Pseudomonas (its main indication) **NO GRAM POSITIVE ACTIVITY
What is the spectrum of activity of aminoglycosides
Gram negative anaerobes
What type of bacteria is gonorrhea?
Gram negative diplococci
What is the spectrum of activity of the quinolones
Gram negative, including Pseudomonas Cipro - limited Gram positive Levaquin and Avelox - better Gram positive
What is the spectrum of activity of Invanz
Gram positive, gram negative and anaerobes
What is pannus
Granulation tissue that secretes chondrolytic enzymes which break down articular cartilage
What is a surgical treatment for a patient with prior DVTs or recurrent PEs
Greenfield filter
Which type of Strep can cause impetigo, cellulitis and erysipelas
Group A Strep
HAWKINS Classification
HAWKINS - Talar neck fx Type 1 - vertical fracture of talar neck that is nondisplaced (0-15% AVN) Type 2 - vertical fracture of talar neck with STJ dislocation/subluxation (20-42% AVN) Type 3 - vertical fracture of talar neck with STJ and ankle dislocation/subluxation (75-91% AVN) Type 4 - vertical fracture of talar neck with STJ, ankle, and T-N dislocation/subluxation (100% AVN)
How does hyperbaric oxygen therapy assist wound closure?
HBOT increases the partial pressure of O2 in arterial circulation, which increases diffusion of O2 at the wound site. This is believed to increase growth factors promoting angiogenesis and collagen synthesis.
What is the modified Regnauld/Oloff classification
Hallux Limitus Stage 1: functional hallux limitus Limited dorsiflexion with weightbearing but normal ROM with non-weightbearing No DJD changes on x-ray No pain on end ROM Stage 2: joint adaptation Flattening of metatarsal head with small dorsal exostosis Pain on end ROM Stage 3: joint deterioration Severe flattening of metatarsal head with non-uniform joint space narrowing, osteophytes, and subchondral sclerosis/cysts Crepitus on ROM Stage 4: ankylosis Obliteration of joint space with osteophyte fragmentation Minimal to no ROM
What is the Regnauld classification
Hallux Limitus Classification Grade 1: functional hallux limitus with dorsal spurring. Intact sesamoids with no associated disease. Joint enlargement but joint space narrowing and arthrosis <40° dorsiflexion and <20° plantarflexion Grade 2: broad flat metatarsal head with structural elevatus and significant spurring. Pain at rest. Osteochondral defects in metatarsal head and sesamoidal hypertrophy. Joint space hypertrophy and narrowing 75% decrease in total ROM Grade 3: ankylosis and articular hypertrophy with extensive peri-articular osteophytes. Osteochondral defect with joint mice and extensive 1st metatarsal-sesamoid disease. Severe loss of joint space or collapse of joint → bone on bone FDL contracture
The middle and posterior facets are best seen by which radiographic view?
Harris Beath
Who was Lisfranc
He was a field surgeon in Napoleon's army
Talar torsion angle
Head is laterally rotated on the body Fetus 18-20° Childhood 30° Adult 40° Note: this motion brings the supinated foot in utero to a more pronated adult position
What is a Reese screw?
Headless - create compression through arthrodesis. Proximal threads run clockwise, and distal threads run counterclockwise. Smooth in between.
What is a Herbert screw?
Headless screw - can be inserted through articular cartilage. Threaded portion proximally and distally and smooth in between. Proximal portion has tighter pitch for compression.
Who were the first podiatrists to describe a podiatric use for arthroscopy
Heller and Vogel (1982)
What is the most common vascular proliferation
Hemangioma
Waldvogel and Lew Classification
Hematogenous - spread via blood starting inside the bone and working out towards the cortex Seen most commonly in metaphyseal region of children with open growth plates Direct extension - secondary to trauma or surgery first affecting periosteum, then cortex, and then marrow Proteolytic enzymes destroy Sharpey fibers Contiguous - spread of infected soft tissue to underlying bone Vascular insufficiency - PVD
What are the minimum levels for Hemoglobin and Hematocrit for elective surgery
Hemoglobin: 10gm/dL Hct: 30%
What are the side effects of Bactrim
Hemolytic anemia and Hypersensitivity
What causes the PTT to be high
Heparin
What are levels of Heparin and Coumadin for DVT/Anticoagulation prophylaxis
Heparin: maintain 2-3 times normal PTT (25-35 seconds) Coumadin: maintain 2 times normal INR (PT normal is 10-15 seconds)
For long term DVT prophylaxis, what drugs can be ordered? Why?
Heparin: works right away Coumadin: takes 3-5 days and causes an initial transient hypercoagulable state
What is psoriasis?
Hereditary disorder with chronic scaling papules and plaques in areas of body related to repeated minor trauma. Positive Koebner phenomenon and Auspitz sign. Also present are joint pain and nail changes including pitting, beau lines, oil spot, subungual hyperkeratosis, and discoloration.
If a patient with a high INR undergoes surgery, what labs should be carefully monitored
Hgb and Hct
What does Indium-111 test for
Highly sensitive and specific for acute soft tissue and osseous infections
What is a martini sign
Histology showing a PMNC engulfing a crystal
What are most common organisms of bite wounds
Human - Eikenella corrodens Cat and dog - Pasteurella multocida
What should be done if the K+ is too high
Hyperkalemia may cause cardiac arrhythmias, lethargy, respiratory depression, coma *Order EKG -Calcium Gluconate -Sodium Bicarbonate -Dextroxe with Insulin -Kayexalate
What is the most common indication for Lapidus
Hypermobile 1st ray
Name the types of Non-Unions
Hypertrophic: Elephant foot Horse hoof Oligotrophic Atrophic: Torsion wedge Comminuted Defect Atrophic
What should be done if K+ is too low
Hypokalemia may cause cardiac arrhythmias, muscle weakness, paresthesias, cramps Management: -Give K-dur (potassium chloride supplement) -Give potassium rich foods (bananas)
What part of the brain regulates the body's temperature
Hypothalamus
Lauge Hansen Pronation - Abduction (PAB)
I - Rupture of deltoid ligament/medial malleolar fracture II - AITFL and PITFL rupture/avulsion III - Fibular Fx (at level of tibial plafond); Danis-Weber B
Lauge Hansen Supination - Adduction (SAD)
I - transverse fracture of the lateral malleolus Lat. Collateral rupture; fibular fx - Danis-Weber A II - vertical fracture of the medial malleolus Muller D fx
What stages of Berndt & Hardy are often associated with lateral ankle ligament ruptures?
II, III, IV
True IM Angle
IM angle + Met Adductus - 15
Which NSAIDs are the most hepatotoxic?
Ibuprofen, naproxen, diclofenac
Which NSAIDs treat collagen vascular disease?
Ibuprofen, sulindac, tolmetin
What is the Mulder sign?
Identifies a Morton neuroma by a palpable click when compressing metatarsal heads and palpating the interspace
When should a RBC transfusion be given?
If Hgb <8 or Hct<24, consider transfusing 1-2 units PRBC One unit of PRBC will increase Hct by approximately 3 percentage points
What to do if patient has edema with a cast?
If edema goes down in AM → gravity edema → normal If edema does not go down in AM → abnormal
What should be done if the INR is >1.4
If necessary, transfuse Fresh Frozen Plasma (FFP) One unit of FFP will decrease INR by approximately 0.2 Vitamin K can be given but is slow-acting
What is the perioperative management for patients with hypertension
If the patient has been on long-term diuretics (e.g. HCTZ, Lasix), check for hypokalemia Avoid fluids high in sodium; may use 1⁄2NSS at low rate
How do you adjust the Vancomycin dose
If the peak is too high, decrease the dose If the peak is too low, increase the dose If the trough is too high, increase the interval between doses If the trough is too low, decrease the interval between doses
What is a Blair fusion
If the talar dome collapses, excise the avascular talar body and place a sliding cortico-cancancellous graft from the anterior distal tibia into the residual, viable talar head and neck
Primaxim is a combo of
Imipenem/Cilastin
How does Primaxin work
Imipenem=antibiotic (inhibits cell wall synthesis by binding to PBPs) Cilistatin=renal dihydropeptidase inhibitor (prevents imipenem from being metabolized by the kidneys)
What do each of the phases of the bone scan test for?
Immediate: Blood flow Pool: Soft tissue Delayed: Bone activity Fourth phase: Bone uptake for patient with PVD
What is the most common cause of non-healing for a bone fracture
Improper Immobilization
What is the difference between an incisional and excisional biopsy
Incisional: only a portion of the lesion is removed Excisional: the entire lesion is removed
When giving Timentin, what electrolyte should you watch out for
Increased Na+ load (5.2 meq/gram)
What is the Hoffa sign
Increased dorsiflexion compared to the contralateral side along with the inability to perform a single leg rise test
What is the effect of NSAIDs on corticosteroids
Increases GI risk
What is the effect of NSAIDs on Coumadin
Increases action
What is the effect of NSAIDs on Sulfonylureas
Increases action
What is the effect of NSAIDs on anti-epileptics
Increases anti-epileptic toxicity
What is the effect of NSAIDs with Probenecid
Increases concentration of NSAIDs
What is the effect of NSAIDs on Digoxin
Increases effect
How is the Gissane angle affected by a calcaneal fracture?
Increases with intra-articular calcaneal fracture
Peroneus Longus Tendon Transfer
Indication: Drop foot Anterior muscle weakness Flexible cavus deformity Procedure: 1. Cut PL near PB insertion site, suture distal PL to PB 2. Reroute it dorsally to 3rd cuneiform
Selakovich Procedure
Indication: Flexible pes planus + Ages 5-9 years oldCongenital vertical talus (flexible/supple deformity) + Ages 5-9 years old Procedure: 1. Osteotomy and grafting of sustentaculum tali a. Osteotomy performed midway between interosseous talocalcaneal ligament and post margin of sustentaculum tali b. Wedge bone graft inserted to redirect the middle and anterior facets 2. Tightening of medial structures (tightening redundant spring ligament and repositioning of the TP) 3. Reroute half or all of TA into navicular
Peroneus Brevis Tendon Transfer
Indication: Type 1 vertical talus Severe pes planovalgus Procedure: Detach PB and reroute dorsally to talar neck ALT - Detach PB and transfer to lateral cuneiform or 3rd metatarsal
Elmslie Procedure
Indication: Lateral ankle instability To reinforce ATFL and CFL Procedure: Tensor fascia lata routed through calcaneus, then lateral malleolus, then talus, back through lateral malleolus and back through calcaneus
Dwyer Osteotomy for Flatfoot
Indication: Pes planus to produce calcaneal varus Procedure: Closing wedge osteotomy from medial side (difficult due to possible nerve entrapment)
Baker Procedure
Indication: Achilles Tendon Lengthening Procedure: Tongue-in-groove cut in aponeurosis with the tongue distal, facing upward *Gastroc Soleus recession in Zone II Suture aponeurosis bands to one another in retracted position Paley/Lamm: Zone 2
Hoke Achilles Procedure
Indication: Achilles Tendon Lengthening Procedure: 1. Incision 5 cm in length over medial aspect of tendon 2. Triple hemisection of Achilles tendon a. Cut Achilles in half in 3 sections: posteriorly in proximal and distal aspects of incision and anteriorly in central portion of incision b. Modification - cuts med/lat instead of ant/post, can be percutaneous 3. Forcibly DF the foot to allow for sliding into lengthened position
White Procedure
Indication: Achilles Tendon Lengthening Procedure: 1. Section anterior 2⁄3 of distal Achilles and medial 2⁄3 of Achilles (5-7.5 cm proximal to this point) 2. This lengthens the gastroc in relation to its twisting before its insertion Paley/Lamm: Zone 1 Firth: Zone 3
Sliding Z Lengthening
Indication: Achilles Tendon Lengthening Procedure: Cuts most commonly done in frontal plane but can be in sagittal plane Usually percutaneous, recommended open in McGlamry DF the foot after cutting to separate and lengthen ends of the tendon If open procedure, suture ends of "Z" together in lengthened position
Lynn Procedure
Indication: Achilles Tendon Ruptures Procedure: End to end reapproximation of ruptured Achilles that maybe reinforced with PLANTARIS
Fulp & McGlamery Modification (of Baker's Technique)
Indication: Achilles tendon lengthening Correction of non-spastic gastroc equinus Procedure: Tongue-in-groove cuts in aponeurosis with the tongue distal, facing downward (inverted version of Baker's technique)
Baja Project
Indication: Clubfoot Procedure: 1. Cuboid decancellation procedure 2. Laterally based triangular wedge of bone removed from cuboid and lateral cuneiform
Lund Procedure
Indication: Clubfoot (neglected or arthrogryphotic neuromuscular type) + Ages 2-5 years old (ideally, occasionally in adults) Procedure: Talectomy (foot posteriorly displaced allowing for correction in sagittal and frontal planes) Optional - portions of navicular and fibula may need to be resected. Also may use midfoot wedges adjunctively. Often multistaged. Fixation with Steinmann pin from calc to tibia for pseudojoint space. Long leg casting for 1 month to BK cast for 4 months.
Stoffel Procedure
Indication: Correction of spastic muscular forms of ankle equinus Procedure: Selective denervation of tibial nerve
Chambers Procedure
Indication: Flexible pes planus (more often in children, <8 years old) Rarely performed anymore Procedure: 1. TAL 2. Bone graft under sinus tarsi (similar to location of arthroereisis to block translocation of talus on the calcaneus)
STJ Arthroereisis
Indication: Flexible pes valgus + patient not yet at skeletal maturity (or if arthrodesis not appropriate in older patient) Procedure: 1. Incision 2-4 cm long parallel to relaxed skin tension lines over sinus tarsi. Incise deep fascia to expose lateral talar process, post facet and sinus tarsi floor. 2. Further steps of dissection depend on the specific device you are using a. MBA (Maxwell-Brancheau Arthroereisis) implant, STA-peg device
Strayer Procedure
Indication: Gastroc Equinus Procedure: 1. Distal recession with the complete transverse cutting of gastroc aponeurosis 2. Proximal retracted portion of gastroc is sutured into the deeper soleus Paley/Lamm: Zone 3 Firth: Zone 1
Bauman Procedure
Indication: Gastroc Equinus Procedure: Isolated gastroc recession in the deep interval between soleus and gastroc muscles *Paley/Lamm: Zone 4
Mitchell Osteotomy
Indication: HAV Procedure: Distal metaphyseal osteotomy with rectangular block of bone removed and preservation of lateral cortical ―"spur" (width of spur varied depending on amount of correction needed) that hangs over shaft when transposed.
Stamm Osteotomy
Indication: HAV Procedure: OBWO in medial cuneiform (wedge of graft inserted into medial cuneiform)
Vogler Osteotomy (Offset V)
Indication: HAV Procedure: V-osteotomy made in the neck of the 1st metatarsal (similar to Kalish but more proximal); arm is 35 degrees
Opening Base Wedge Osteotomy (OBWO, a.k.a. Trethowan)
Indication: HAV Procedure: Opening base wedge osteotomy (osteotomy across base of 1st metatarsal, then insert a pie-shaped piece of bone graft into the side of the 1st metatarsal cut)
Wilson Osteotomy
Indication: HAV (IMA 12-14); HAV + Long 1st Metatarsal Procedure: Oblique (dist-med to prox-lat) through and through osteotomy at the 1st metatarsal neck, capital fragment slides laterally on shaft (unstable and slow healing)
Scarf Bunionectomy
Indication: HAV (IMA 12-18) Procedure: Z-type osteotomy through the shaft of the 1st metatarsal
* Crescentic Osteotomy (aka Weinstock or Arcuate)
Indication: HAV (IMA >13) Procedure: Cresentic osteotomy, concavity directed proximally *Plantar Shelf vs no shelf Shelf provides biplanar correction No shelf provides triplanar correction *Good for pediatrics (according to Dr. Moore)
* Closing Base Wedge Osteotomy (CWBO, aka Louisan-Balaceau)
Indication: HAV (high IMA) Procedure: Lateral based closing wedge osteotomy straight across the base of 1st metatarsal
Lapidus Procedure
Indication: HAV + 1st ray hypermobility Procedure: Fusion of 1st metatarsal base to medial cuneiform (with the resections of bone angled to correct the deformity)
Lambrinudi Osteotomy
Indication: Hallux Limitus Procedure: Plantarflexory wedge osteotomy of 1st metatarsal base *Joint sparing
Kessel-Bonney Procedure
Indication: Hallux Limitus Procedure: Removal of a pie-shaped dorsiflexory wedge of bone from proximal phalanx *Joint sparing
Watermann Osteotomy
Indication: Hallux Limitus Procedure: Removal of closing wedge of bone from 1st metatarsal head to DF capital fragment *Dorsiflexory Osteotomy *Joint Sparing
Watermann-Green Osteotomy
Indication: Hallux Limitus Procedure: Watermann osteotomy but with a plantar shelf to preserve sesamoid articulation
Reverdin-Green-Laird-Todd Osteotomy
Indication: Hallux Limitus + HAV; Allows for correction in 3 planes Procedure: Triangle-shaped wedge removed from both the top and side of the distal 1st metatarsal
Valenti Arthroplasty
Indication: Hallux Limitus/Rigidus Procedure: Removal of angled (usually 45°) dorsal wedges from the 1st metatarsal and proximal phalanx to increase ROM
Kelikian Procedure
Indication: Lateral ankle instability Reinforces ATFL and CFL Procedure: 1. Isolate the plantaris tendon 2. Reroute it from the calcaneus into lateral malleolus through a drill hole (posterior to anterior), back through the calcaneus then sutured on itself
Hambly Procedure
Indication: Lateral ankle instability Reinforces ATFL and CFL Procedure: 1. Split PL 2. Reroute into talus (or attached through it), through a lateral malleolus drill hole (anterior to posterior), through calcaneus and attached to the other half of the PL
Whinfield Procedure
Indication: Lateral ankle instability Reinforces ATFL and CFL Procedure: 1. PB detached proximally while maintaining distal attachment 2. The detached portion is rerouted through a lateral malleolus drill hole (anterior to posterior) and inserted into calcaneus
Seeburger Procedure
Indication: Lateral ankle instability Reinforces ATFL and CFL Procedure: 1. Use a hemi-section of PL 2. Reroute it from talus into lateral malleolus and into calcaneus
Watson-Jones Procedure
Indication: Lateral ankle instability Reinforces ATFL only Procedure: 1. PB detached proximally 2. Reroute it through lateral malleolus (drill hole posterior to anterior ~2 cm from distal tip of fibula) into talar neck (vertical drill hole dorsal to plantar), then back through lateral malleolus (along ATFL course) and sutured on itself posterior to fibula 3. Proximal PB attached to PL
Lee Procedure
Indication: Lateral ankle instability Reinforces ATFL only Procedure: 1. PB detached proximally 2. Reroute it through lateral malleolus drill hole (post → ant) and sutured upon itself (peroneal anastomosis) 3. Periosteal flap from dist fibula reinforces new ligament 4. Prox PB attached to PL
Nilsonne Procedure
Indication: Lateral ankle instability Reinforces ATFL only Procedure: 1. PB detached proximally at musculotendon junction 2. Reroute it through subperiosteal groove through fibula (post-superior → ant-inferior), CFL primarily repaired if necessary 3. PB secured in subperiosteal tunnel (this approximates ATFL course) 4. Prox PB attached to PL
Silver bunionectomy
Indication: Medial 1st MPJ pain Mild HAV (but does not correct the true HAV deformity) Procedure: Isolated resection of medial eminence of 1st metatarsal head
Lange Procedure
Indication: Met Adductus + Ages 2-6 years old Procedure: Capsulotomy of 1st metatarsal-cuneiform, followed by serial casting
Lepird Procedure
Indication: Met Adductus + age 8 years or older Procedure: 1. 3 dorsal incisions 2. Transverse plane osteotomies in bases of metatarsals 2-4 from dorsal-dist to plantar-prox, parallel to WB surface of foot, fixated with compression screws 3. Oblique base wedge osteotomies of 1st and 5th metatarsals, fixed with compression screws
McBride bunionectomy
Indication: Mild HAV (does not truly correct the HAV deformity) Procedure: Silver plus soft tissue, capsular releases/tightening
Lord Procedure
Indication: Pes planus Procedure: A Gleich (oblique calcaneal osteotomy) displaced anteriorly, medially, and inferiorly
Chiappara Procedure
Indication: Pes planus Procedure: Silver (opening wedge calc osteotomy from lateral side) with TP advancement TA tenodesis to TP
Silver or Opening Wedge Dwyer
Indication: Pes planus Procedures: 1. Opening wedge calcaneal osteotomy from lateral incision a. Oblique osteotomy from just post to post facet inferiorly to just prox to C-C joint b. The more proximal and anterior the osteotomy, the greater correction 2. Graft insertion into osteotomy a. Average wedge size 1⁄4 inch, no fixation needed
Baker & Hill Procedure
Indication: Pes planus (to restore alignment of STJ and reduce heel valgus and excess pronation); Cerebral palsy Procedure: Horizontal osteotomy inferior to posterior facet of STJ (in calcaneus, medial cortex intact as hinge) and a wedge-shaped graft inserted
Gleich Procedure
Indication: Pes valgus foot deformity (especially frontal plane dominant) Procedure: Oblique calc osteotomy (posterior calc osteotomy) displaced anteriorly (to ―restore the normal angle of the long axis of the calc to the floor‖)
OATS (Osteochondral Autograft Transfer System)
Indication: Posterior medial talar dome osteochondral lesion Procedure: 1. Take a plug of bone with articular cartilage from the knee 2. Through a trans-tibial approach, insert it into the talus (matching the contours of cartilage on graft to dome of talus)
The Murphy Procedure (anterior advancement of AT)
Indication: Spastic equinus Procedure: Anterior transfer of TA into calcaneus Modification - route under FHL
Silver & Simon Procedure
Indication: Spastic equinus Procedure: 1. Proximal release of gastroc without reinsertion of heads 2. Neurectomy of tibial branches to medial head of gastroc
Yancey Osteotomy
Indication: Tailor's Bunion Procedure: Oblique or transverse (most stable) wedge osteotomy at 5th metatarsal prox mid- diaphyseal area. Fixation used.
Mercado Osteotomy
Indication: Tailor's Bunion Procedure: Oblique wedge osteotomy at 5th metatarsal neck
Reverse Wilson Osteotomy
Indication: Tailor's Bunion Procedure: Osteotomy from dist-lat to prox-med to shorten the 5th metatarsal and medial transposition of metatarsal head. Fixation not usually used. *Provides most correction of distal osteotomies
Reverse Hohmann Osteotomy
Indication: Tailor's Bunion Procedure: Transverse Osteotomy in distal metaphysis of 5th metatarsal with medial transposition of the capital fragment. Fixation not usually used.
reverse austin or chevron osteotomy
Indication: Tailor's Bunion Procedure: Transverse plane V-osteotomy in distal 5th metatarsal with medial transposition and impacted on shaft for fixation (or pin fixation) *Most stable of distal osteotomies
Gerbert Osteotomy
Indication: Tailor's Bunion Procedure: Wedge Osteotomy (transverse or oblique) at 5th metatarsal base. K wire or screw fixation.
Hibbs Procedure
Indication: To decrease MPJ buckling and increase DF Procedure: 1. EDL is detached from insertion and reattached to lateral cuneiform or 3rd metatarsal 2. Distal stubs of EDL are attached to EDB at metatarsal head area
Peabody Osteotomy
Indication: abnormal PASA Procedure: Reverdin done in the 1st metatarsal neck
*Akin procedure
Indications: Large DASA -> Proximal Akin Long Proximal Phalanx -> Central Akin High Hallux Abductus Interphalangeus Angle -> Distal Akin Procedure: Medially Based Wedge osteotomy of the proximal phalanx
Jones Tenosuspension
Indications: Cock-up hallux Weak TA (procedure enhances DF) Procedure: 1. EHL is detached and inserted into 1st metatarsal head via a med → lat drill hole 2. IPJ fusion 3. Stump of EHL is attached to EHB
Loison Osteotomy
Indications: HAV Procedure: Transverse CBWO
Hohmann Osteotomy
Indications: HAV (12-14) Procedure: Through and through transverse osteotomy at the metatarsal neck (unstable osteotomy)
Kalish Osteotomy
Indications: HAV (12-14) *Crozer says >15 Procedure: Similar to Austin but with a long dorsal arm for screw fixation (utilizes two screw fixation)
Juvara Closing Base Wedge Osteotomy
Indications: HAV (>15) Procedure: Oblique CWBO (apex prox-med, wedge laterally with the base ending in mid 1/3 of the metatarsal, direction allows for better fixation) *Uses two screw fixation: -Compression screw: placed perpendicular to the osteotomy site, compresses the osteotomy site -Anchor screw (proximal): placed perpendicular to the long axis of the 1st MT, prevents shortening and rotation/shifting of bone if the hinge fails
* Austin (a.k.a Distal Chevron Osteotomy)
Indications: HAV (IMA 12-14) Procedure: V-shaped Osteotomy with the apex in the center of the metatarsal head and the arms forming a 60 degree angle
Logroscino Bunionectomy
Indications: HAV (IMA >15 in rectus foot, 13 degrees with adductus) + abnormal PASA Procedure: CBWO (or Crescentic) → to correct HAV Reverdin (or Peabody) → to correct cartilage orientation
Youngswick Osteotomy
Indications: HAV + DF 1st Metatarsal; HAV + Hallux Limitus Procedure: Austin but with an extra slice taken out on the dorsal arm to allow the head to drop plantarly and decompress the 1st MPJ
McKeever (a.k.a. 1st MPJ Arthrodesis/Fusion)
Indications: HAV with dislocation Hallux limitus/rigidus Polio, CP, previous joint surgery Procedure: 1. Removal of cartilage on 1st metatarsal head and base of proximal phalanx 2. Remodel the opposing sides to be a matching cone-in-cup shape Hallux Position: Abducted 5°-10° (or parallel to lesser digits) DF 5°-10° off WB surface 0-5 degrees of Valgus
* Cheilectomy
Indications: Hallux Limitus Procedure: Removal of the dorsal bone spur and dorsal 1/3 of the 1st metatarsal head *OPTIONAL: removal of the bony prominences from proximal phalanx base
DRATO=Derotational, Angulational, Transpositional Osteotomy
Indications: Large 1st IMA + Abnormal PASA + Valgus Rotation of 1st Metatarsal Procedure: derotational osteotomy of the 1st Metatarsal head (vertical cut through metatarsal head, cartilage is rotated for realignment, very unstable)
Hoffman-Clayton Procedure
Indications: MPJ subluxation secondary to rheumatoid arthritis and fat pad atrophy Procedure: Resection of metatarsal heads 2-5 AND bases of proximal phalanxes
Brown Procedure
Indications: Met Adductus + Ages 2-6 years old Procedure: 1. Transfer TP into navicular 2. Medial capsulotomy of nav-cun joint
Steytler and Van Der Walt Procedure
Indications: Met adductus + Age 8 or older Procedure: Oblique V-osteotomy (apex of "V" toward rearfoot) of all metatarsal bases Modified from original to include fixation
Peabody and Muro Procedure
Indications: Met adductus + Age 8 years old or older Procedure: 1. Excise bases of metatarsals 2-4 2. Osteotomy of 5th metatarsal 3. Mobilize and reduce subluxation of 1st metatarsal -cuneiform joint 4. Correction of any abnormal insertion of TA tendon 5. Optional - Hoke triple arthrodesis to realign rearfoot when necessary
McCormick & Blount Procedure
Indications: Met adductus + Age 8 years or older Procedure: 1. Arthrodesis of 1st metatarsal-cuneiform joint 2. Osteotomy of bases metatarsals 2-4
Ghali Procedure
Indications: Met adductus + Ages 2-6 years old Procedure: 1. Heyman, Herndon & Strong procedure 2. PLUS ant-medial release of naviculocuneiform joint
* Heyman, Herndon & Strong (a.k.a. Tarsometatarsal soft tissue release)
Indications: Met adductus + Ages 2-6 years old Procedure: 1. 3 dorsal incisions (originally one dorsal transverse incision) 2. Capsulotomies and ligament releases of all tarsometatarsal joints (metatarsals 1-5) a. Keep plantar lateral ligaments and joint capsules intact (modification from original to prevent dorsal subluxation) b. Optional - syndesmotomy of naviculocuneiform joint and release of TA tendon, also could use K-wires to maintain corrected positions 3. Manipulate metatarsals and foot into rectus position and cast for 3 months
Thompson Procedure
Indications: Met adductus + Ages 2-6 years old + hallux varus (a.k.a. hallux abductus, severe contraction of abd hallucis) To release abductor hallucis Procedure: Resect Abductor Hallucis
Chondrotomy by Johnson
Indications: Met adductus + Ages 6-8 years old Procedure: 1. Resect 2.5 mm lateral based wedges (apex medial) of cartilage in metatarsals 2-5, enlarge bases medially 2. Lateral base wedge osteotomy distal to epiphysis of 1st metatarsal 3. Lengthen ABductor hallucis
Reverdin-Green Osteotomy
Indications: Mild HAV + Abnormal PASA Procedure: Reverdin osteotomy but in an L-shape (or trapezoidal) to preserve sesamoid articulation
Reverdin Osteotomy
Indications: Mild HAV + Abnormal PASA Procedure: Medially based wedge (proximal cut perpendicular to long axis 1st metatarsal and distal cut parallel to articular cartilage surface) resection in 1st metatarsal head
Reverdin-Laird Osteotomy
Indications: Moderate HAV + Abnormal PASA Procedure: Reverdin-Green with lateral shift of capital fragment to correct IMA
Kidner Procedure
Indications: Pes planus Kidner foot type (accessory navicular and/or enlarged navicular) Medial column repair Procedure: 1. Detach TP from navicular medially 2. Resect accessory navicular and/or bump from navicular 3. Reattach TP to navicular more plantarly (tendon bone anchors commonly used)
Miller Procedure
Indications: Pes planus (more often appropriate in adults than children) Medial column repair Procedure: 1. TAL 2. Medial column fusion (navicular to medial cuneiform to 1st metatarsal) 3. Resect hypertrophy of navicular (use as bone graft for fusion sites) 4. Advance medial soft tissues
Cotton Osteotomy
Indications: Pes planus PTTD Medial column repair (to get structural PF of medial column) Procedure: 1. Medial cuneiform (and sometimes intermediate cuneiforms) osteotomy dorsal to plantar (maintaining plantar cortex intact) 2. Triangular shaped bone graft (base measuring 4-7mm) inserted in osteotomy. No fixation necessary.
Lowman Procedure
Indications: Pes planus; Medial Column Repair Procedure: 1. TAL 2. Talo-navicular wedge arthrodesis 3. Reroute TA under navicular and suture into spring ligament 4. Tenodesis of medial arch by taking slip of TA and reflect downward (leave its insertion to the calcaneus intact) along medial arch
Which NSAIDs are not renally cleared?
Indomethacin, sulindac
Kite angle (Talocalcaneal) - AP view
Infant 30-50° Adult 20-40° Pronation - increases Supination - decreases
What are contraindications to using a tourniquet
Infection Open fracture Sickle cell disease Peripheral vascular disease Recent arterial graft Previous DVT Hypercoagulability Skin grafts application where bleeding must be distinguished
What level of the body is a Greenfield filter inserted?
Inferior Vena Cava below the renal veins
What is lymphangitis?
Inflammation of the lymphatics as a result of a distal infection
What is lichen planus?
Inflammatory dermatosis involving skin or mucous membranes with pruritic, violaceous papules clustered into large, flat-topped lesions with distinct borders. Lesions possibly covered with Wickham striae (white streaks). Ridges, onycholysis, subungual hyperkeratosis, and discoloration.
In what stage of healing do chronic wounds stop progressing?
Inflammatory phase
How does Lamisil work?
Inhibits ergosterol synthesis
Bankart Procedure
Inidcations: Met Adductus + age 8 years or older; Congenital absence of medial cuneiform Procedure excise cuboid (to balance out lack of medial cuneiform)
What is the Vassal principle?
Initial fixation of the primary fracture will assist stabilization of the secondary fractures
What is an early radiographic finding of bone graft healing
Initial radiolucency of the graft due to increased osteoclastic activity which is followed by osteoblasts laying down new bone
What is the pes anserinus?
Insertion of sartorius, gracilis, and semitendinosus (anteromedial aspect of proximal tibia) where bursa may cause knee pain (pes anserinus bursitis)
If the patient is on Coumadin for anticoagulation, what should the INR be
Intense anticoagulation 2-3
Rotation of Hip
Internal:- Adult = 35-40° Child = 20-25° External:- Adult = 35-40° Child = 45-50°
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 PT's and make it into a set of lab values (the INR) that would be constant regardless of the method to develop the PT.
Where do these muscles run in relation to the deep transverse inter metatarsal ligament? Interossei Lumbricals
Interossei- Dorsal Lumbricals- Plantar
Hibb angle - Lateral view
Intersection of longitudinal axis of calcaneus and 1st metatarsal
Meary angle - Lateral view
Intersection of longitudinal axis of talus and 1st metatarsal Normal 0° Increases with either pronation or supination Pronation - moves axis of the talus plantar to 1st metatarsal Supination - moves axis of the talus dorsal to 1st metatarsal
What can be given to help reverse local anesthetic-induced cardiovascular collapse?
Intravenous fat emulsion (Intralipid)
Which pathway does the PTT (Partial Thromboplastin Time) check
Intrinsic (PITT)
How does heparin work
Intrinsic pathway Potentiates antithrombin III 100-fold, which inhibits the serine protease in the clotting cascade
What is the mechanism of injury for an anterior process fracture
Inversion with plantarflexion
What are the causes of microcytic, hypochromic anemia
Iron deficiency Thalassemias Lead Poisoning
What other factors should be considered prior to surgery?
Is the patient on any insulin, anticoagulants, steroids or anything else that might put them at risk.
What are advantages of using a muscle flap
It brings immediate blood supply to donor site
What class is Invanz
It is a structurally unique 1-B-methyl-carbapenem related to B-lactams
Why is gas gangrene a surgical emergency
It rapidly progresses to shock and renal failure and is fatal in 30% of cases
Who should not be given quinolones
It's contradicted in children with open growth plates. Risk of cartilage degeneration.
What is another name for menopausal lipoma
Juxtamalleolar lipoma
Why is there a question about K-wires in a screw set section?
K-wires can be used for the underdrill if the situation arises (e.g. underdrill bit is missing or it fell on the floor) The 0.062 can be used for the 1.5 underdrill (for the 2.0 screw) The 0.045 can be used for the 1.1 underdrill (for the 1.5 screw)
KUWADA Classification
KUWADA - Achilles Tendon Ruptures Type 1 - partial tear <50% Tx: cast with foot plantarflexed Type 2 - complete tear with <3 cm defect after debridement Tx: end-to-end attachment Type 3 - complete tear with 3-6 cm defect after debridement Tx: end-to-end attachment and tendon flap Type 4 - complete tear with >6 cm defect after debridement Tx: end-to-end attachment, recession, or graft
What vascular malignancy appears as red-blue plaques or nodules and has a high incidence in AIDS?
Kaposi Sarcoma
DOC for proteus?
Keflex or Ampicillin
DOC for E. coli
Keflex or Ancef
DOC for Staph Aureus?
Keflex or Ancef
DOC for strep
Keflex or Ancef
Who first describe arthroscopy
Kenji Takagi
Toradol?
Keterolac 30mg IV q6 initial dose 1 tab (10mg) PO q4-6 prn pain An NSAID not to be used more than 5 days due to possible significant side effects
What NSAIDS work on both the lipooxygenase and cyclooxygenase pathways?
Ketoprofen and Diclofenac
Which NSAIDs have fewer pulmonary problems?
Ketoprofen and diclofenac
Name two non-narcotic analgesics
Ketoralac (Toradol) Tramadol (Ultram) *Mobic (Meloxicam)
What is the only IV NSAID?
Ketorolac (Toradol)
What are Blair and Humbky knives
Knives for harvesting skin grafts
What is another name for the flexor retinaculum
Laciniate ligament
What is the most common complication following an EPF
Lateral column instability-> Calcaneal cuboid joint pain
Ankle axis
Lateral, posterior, plantar → medial, anterior, dorsal
STJ axis of motion
Lateral, posterior, plantar → medial, anterior, dorsal 48° from frontal plane 42° from transverse plane 16° from sagittal plane
What conditions may be associated with plantar fibromatosis
Ledderhose disease Dupuytren Contracture Peyronie disease
Most benign melanoma?
Lentigo melanoma - typically found on back, arms, neck, and scalp
What can B-lactams cause
Leukopenia
Lindholm Procedure
Lindholm: Achilles tendon ruptures Procedure: Two flaps taken proximally from Achilles and reflected distally to fill defect
Toyger Angle
Line drawn down posterior aspect Normal should be a straight line (180°) Decreases with Achilles rupture
Another name for Zyvox
Linezolid
What is the only PO therapy for VRE
Linezolid
How do you treat VRE
Linezolid or Dalfopristin-Quinupristin
QUENU & KUSS Classification
Lisfranc Dislocation *Convergent homolateral* -All metatarsals subluxed laterally -All 5 metatarsals displaced laterally in the transverse plane *Isolateral* -1st metatarsal subluxed medially or metatarsals 2-5 subluxed laterally -1 or 2 metatarsals displaced laterally in the transverse plane *Divergent* -1st metatarsal subluxed medially and metatarsals 2-5 subluxed laterally -Displacement in both sagittal and transverse planes
HARDCASTLE Classification
Lisfranc Dislocation A1 - homolateral A2 - homomedial Type B - partial incongruity -Bl - partial medial displacement -1st metatarsal displaced medially and/or in combination with metatarsals 2-4 B2 - partial lateral displacement -Lateral displacement of one or more lesser metatarsals Type C - divergent Cl - partial displacement 1st metatarsal displaced medially with any combination of metatarsals 2-4 displaced laterally C2 - total displacement 1st metatarsal displaced medially with metatarsals 2-5 displaced laterally
How are amides (lidocaine and bupivacaine) metabolized?
Liver
Os intermetatarseum
Located between the first cuneiform and first and second metatarsal bases
Talar neck angle
Long axis of head and neck with long axis of the body Birth: 130-140 Adult: 150-165
What are effects of a long term high dose course of steroids
Long-term therapy suppresses adrenal function -Risk of poor or delayed wound healing. Decreased inflammatory process. -Risk of infection. Low WBC may mask infection.
Metatarsal Protrusion
Longest 2 > 3 > 1 > 4 > 5 shortest
Metatarsal Length
Longest 2>3>5>4>1 shortest
How long before PDS loses its strength? When is it absorbed?
Loses strength in 4-6 weeks Absorbed in 3-6 months
How long for orthofix to lose strength/absorb?
Loses strength in 6-12 weeks Absorbed in 1-3 years
What additional radiographic study should be obtained for neonates with CCPV
Lumbosacral films
What is the best study for evaluating avascular necrosis
MRI - decreased signal intensity within medullary bone in both T1 and T2 images
What is the main indication for Vancomycin
MRSA
What if the organism is resistant to methicillin
MRSA (methacillin-resistant Staph aureus)
Why are joint implants used?
Maintain space between bony surfaces Relieve pain
What are complications following LisFranc injuries
Majority: post-op DJD Serious: circulatory compromise
The anterior facet is best seen by which radiographic views?
Medial Oblique, Isherwood
What is the innervation to the plantar muscles of the foot? Blood supply?
Medial Plantar Nerve: 1st Lumbrical Abductor Hallucis Brevis FHB FDB (and lateral plantar nerve) Medial Plantar Artery FDB Abductor Hallucis Brevis 1st Dorsal Interossei
Where does Plantaris insert
Medial aspect of tendo-Achilles into the calcaneus
What layers of the foot do the plantar nerves run?
Medial plantar nerve - in the 1st layer (between FDB and abductor hallucis) Lateral plantar nerve - between the 1st and 2nd
Knee rotation with knee flexed
Medial rotation 40° Lateral rotation 40°
What nerves form the sural nerve?
Medial sural cutaneous nerve - branch of the tibial nerve Sural communicating branch - branch of the lateral sural cutaneous nerve, which originates from the common peroneal nerve
Which T-C facet is most commonly fused?
Medial/Middle > anterior > posterior
Demerol?
Meperidine
How do you prevent seroma/hematoma from occurring when applying a skin graft
Mesh or Pie crust graft and apply compressive dressing
How are glucocorticosteroids metabolized
Metabolized in the liver and secreted in urine
Freiberg's disease
Metatarsal Heads
What does MDP stand for
Methyldiphosphate
Another name for Flagyl
Metronidazole
What are some tests for sickle cell anemia
Microscope and observe Hemoglobin electrophoresis
What are advantages of using a full thickness skin graft
Minimal contraction of graft Better appearance
What are disadvantages of using full thickness skin grafts
More difficult to take Must close donor site
MS Contin?
Morphine sulfate extended release (15-30mg) 1 tab PO q8-12h prn pain
What is the spectrum of activity for clindamycin
Most gram positives and most anaerobes
How to convert percentage of solution to mg/mL?
Move decimal point of percentage one place to right (e.g. 1% solution has 10 mg/mL)
Another name for Avelox
Moxifloxacin
What is the most common, malignant, primary bone tumor
Multiple Myeloma
What is Apert Syndrome
Multiple bony coalitions
What are the sources of blood supply to tendons
Myotendinous junction, paratenon, and at the insertion to bone
How does negative pressure wound therapy (e.g. Wound VAC) assist wound closure?
NPWT applies mechanical shear stress to the wound site. This is believed to promote granulation by decreasing bacterial bioburden, reducing edema, and inducing capillary budding.
Do NSAIDs affect bone healing?
NSAIDs and COX-2 inhibitors may inhibit bone healing via their anti-inflammatory effects
What is a BMP
Na, K, BUN, Creat, Gluc, HCO3-, Cl-
What is the only nonacidic NSAID?
Nabumetone
Rosenthal classification
Nail Injury Zone 1 - distal to bony phalanx Zone 2 - distal to lunula Tx: V-Y advancement Zone 3 - proximal to distal end of lunula If nail bed is lacerated, it is considered an open fracture Tx: amputation
Kohler's disease
Navicular
WATSON-JONES classifications
Navicular Fractures Type 1 - navicular tuberosity fracture Type 2 - dorsal lip fracture Type 3 - transverse body fracture 3A - fracture of body without displacement 3B - fracture of body with displacement Type 4 - stress fracture
What would a joint aspirate of gout show?
Needle-shaped monosodium urate crystals that are negatively birefringent under polarized light (CPPD are rhomboid-shaped and positively birefringent)
What are signs of hypoglycemia
Nervousness, tachycardia, diaphoresis, nausea, headache, confusion, tremor, seizures, coma
According to Seddon, what are the different types of nerve damage?
Neuropraxia: nerve contusion resulting in conduction block that recovers promptly Axonotmesis: interruption of axons with Distal Wallerian degeneration. Supporting connective tissue sheaths remain intact allowing regeneration Neurotmesis: complete severance of the nerve that is irreversible
Does Bactrim cover pseudomonas?
No
does augmentin cover pseudomonas?
No
does invanz cover pseudomonas
No
Does Primaxin cover MRSA? Pseudomonas?
No and No
Can allopurinol, probenecid or sulfinpyrazone be used for acute gout?
No, because they cause an initial hyperuremia
Do NSAIDs decrease joint destruction?
No, they only decrease inflammation
Should transsyndesmotic screws be inserted using a lag technique?
No. Fully-threaded cortical screws are placed across both cortices of the fibula and the lateral cortex of the tibia. The goal is stabilization rather than compression.
Most malignant melanoma?
Nodular melanoma - may be misdiagnosed as pyogenic granuloma
What minimum ABI is necessary for wound healing?
Non-diabetic patient - 0.35 Diabetic patient - 0.45
Using transcutaneous oximetry, what minimum pressure is necessary for wound healing?
Non-diabetic patient: 30 mmHg Diabetic patient: 40mmHg
What are indications for bone stimulators
Non-union, failed fusion
What are the major side effects of Aztreonam
None
1ST Metatarsal Protrusion distance
Normal +/- 2 mm compared to the 2nd metatarsal
Hallux interphalangeal angle
Normal 0-10°
Metatarsal abductus angle
Normal 0-15°
Calcaneal-cuboid abduction
Normal 0-5° Increases with pronation
What are the INR values
Normal 1 Intense anticoagulation 2-3
Tibial sesamoid position
Normal 1-3
Hallux abductus angle
Normal 10-15°
Ankle dorsiflexion/plantarflexion
Normal 10-20° dorsiflexion and 20-40° plantarflexion
IM angle of 2nd and 5th metatarsals
Normal 14-18°
Metatarsus adductus angle
Normal 15°
Calcaneal inclination angle
Normal 21 degrees Pronation: decreases Supination: increases
Metatarsal declination angle
Normal 21°
Talar declination angle
Normal 21° Pronation - increases Supination - decreases
1st Metatarsal-medial cuneiform angle
Normal 22°
Talocalcaneal angle - Lateral view
Normal 25-50° (does not change with age)
ROM 1st MPJ
Normal 65-75° dorsiflexion and 40° plantarflexion
DASA (distal articular set angle)
Normal 7.5°
PASA (proximal articular set angle)
Normal 7.5°
Talo-navicular head coverage
Normal 75 degree coverage Pronation: decreases coverage Supination: increases coverage
IM angle (intermetatarsal angle)
Normal 8-12° Head procedure if mild 10-13° Shaft procedure if moderate 14-17° Base procedure if severe 18-21° Lapidus procedure if hypermobile 1st ray
Forefoot abductus
Normal 8° (0-15°)
Hip flexion with knee flexed
Normal flexion 120-130°
Hip flexion/extension with knee extended
Normal flexion: 90-100 Normal extension: 10-20
1st ray ROM
Normal: 5 mm- dorsiflexion + 5 mm - plantarflexion = 1 cm total ROM
IM angle 4th and 5th metatarsals
Normal: 4-5 degrees Pathologic: >9 degrees (Schoenhause says normal 4th IMA is 8 degrees)
Brostrom-Gould Procedure
Note: Common procedure used, see Special Surgery Section for details Indication: Lateral ankle instability For primary repair Procedure: 1. Incise lateral ankle capsule 2-3 cm distal to lateral malleolus 2. Evert foot and tighten capsule including ATFL and CFL in pants over vest fashion with non-absorbable suture 3. Mobilize extensor retinaculum, pull it over capsule and suture down
Christman & Snook
Note: Could use PL instead of PB for this procedure Indication: Lateral ankle instability To reinforce ATFL and CFL Procedure: 1. Detach half of PB from its insertion 2. Reroute it through a drill hole in the talar neck and distal lateral malleolus (through widest part, anterior to posterior). Suture graft tendon to periosteal flap at level of CFL. 3. Distal half of PB then sutured to proximal half
Cobb Procedure
Note: Good procedure because FDL preserved Indications: PTTD Pes valgus Procedure: 1. Hemi-section of TA (more medial portion released, other half left intact at insertion near ankle level) 2. Lay released portion of TA along TP tendon and suture together
Tachdijian-Grice Procedure
Note: Grice procedure = STJ arthrodesis Indications: Congenital convex pes planovalgus (vertical talus!) + Ages 4-6 years old Procedure: 1. First stage: TAL with posterior ankle and STJ capsular release 2. Second stage: (3 weeks later) STJ extraarticular arthrodesis
Dwyer Clubfoot Procedure
Note: Indicated also for pes planus but wedge done laterally instead of medially (calcaneus goes into varus) Indication: Clubfoot Cavus foot deformity Procedure: Opening wedge medial calcaneal osteotomy Calcaneus goes into a more valgus position
Silfverskiold Procedure
Note: Makes a 3 joint muscle into a 2 joint muscle Indication: Achilles tendon lengthening Procedure: 1.Release the gastroc heads at their attachments to the femoral condyles (above knee joint) 2. Reinsertion into the posterior proximal tibia area (below knee joint) Paley/Lamm: Zone 5
Berman and Gartland procedure
Note: Most popular osseous procedure for met adductus Indications: Met adductus + Age 6 years or older Procedure: 1. Panmetatarsal base wedges dome-shaped or crescentic osteotomiesa. Optional - rearfoot procedures to correct combined deformities 2. Manipulate foot into corrected position, use pin fixation in all metatarsals and cast for 6 weeks
Hoke Arthrodesis
Note: Not to be confused with the Hoke Achilles procedure Indication: Pes planus Medial column repair Usually done in conjunction with ankle equinus correction and calcaneal osteotomies or arthroeresis Procedure: 1. TAL 2. Fusion of navicular to medial and intermediate cuneiforms
Young Tenosuspension
Note: Often done in conjunction with other procedures Indications: Pes planus + Age 10 years or older Patients with navicular-cuneiform fault but no DJD yet Helps to PF 1st ray (takes away TA antagonist action against PL) Procedures: 1. TAL 2. Reroute TA through keyhole in navicular (do not detach TA from insertion) a. Alternate - detach TA from insertion and reattach after passing through a trephine hole in navicular 3. TP reattachment beneath navicular (creates a powerful plantar navicular-cuneiform ligament)
Fowler Procedure
Note: Often done in conjunction with other procedures, especially if more rigid deformity Indications: Residual clubfoot deformity Cavovarus deformity; Met adductus + Age 8 years or older Procedure: Bone graft inserted into medial cuneiform with opening wedge osteotomy to lengthen medial column Modification - closing wedge osteotomy of cuboid and lateral cuneiform, then use this bone as the graft for the opening medial cuneiform osteotomy. Good with ages 3-10 years old, residual adduction, or varus deformity in forefoot/midfoot.
Hoffman procedure
Note: Often done with Keller arthroplasty Indications: MPJ subluxation secondary to rheumatoid arthritis and fat pad atrophy Procedure: Resection of metatarsal heads 2-5
Mau Osteotomy
Note: Opposite orientation to Ludloff Indication: HAV Procedure: Oblique bone cut diagonally (dorsal-dist to plantar-prox) through the 1st metatarsal. Rotational osteotomy.
Ludloff Osteotomy
Note: Opposite orientation to Mau Indication: HAV Procedure: Oblique bone cut diagonally (dorsal-prox to plantar-dist) through the 1st metatarsal. Transpositional osteotomy.
Split Tibialis Anterior Tendon Transfer (STATT)
Note: Same as TATT but only half the tendon is used. See Special Surgery Section for details. Indications: To increase true ankle DF and decrease long extensor swing phase To decrease adductovarus forefoot Procedure: 1. Detach half of TA from its insertion 2. Reroute and insert it into peroneus tertius (or cuboid, if peroneus tertius isn't present)
Lichtblau Procedure
Note: Same name as a procedure for met adductus Indication: Clubfoot Procedure: Closing base wedge osteotomy of anterior calcaneus (base of wedge lateral, shortens lateral column)
Evans procedure for lateral ankle
Note: Same name as osteotomies indicated for pes planus and clubfoot. Similar to Nilsonne but with an osseous tunnel instead of subperiosteal tunnel. Indication: Lateral ankle instability Reinforces ATFL only (this does not reconstruct ATFL or CFL anatomically) Procedure: 1. PB is detached proximally 2. Reroute it through fibular drill hole (anterior-most and distal-most → post-prox location). PB secured posteriorly at prox aspect of superior peroneal retinaculum. 3. Prox PB is attached to PL
Lichtblau Procedure
Note: Same name as procedure for clubfoot Indications: Met adductus + Ages 2-6 years old To release abductor hallucis Procedure: Sectioning of abductor hallucis through a small medial incision
Evans Calcaneal Osteotomy
Note: Same name as procedures indicated for clubfoot and lateral ankle instability Indications: Pes valgus foot deformity To lengthen calcaneus Procedure: 1. Incision over C-C joint, reflect EDB 2. Osteotomy of calcaneus parallel and 1-1.5 cm (dist 1⁄3) prox to C-C joint 3. Wedge of graft inserted into osteotomy (lateral side of graft up to 1 cm in kids and max 7mm in adults)
Evans Clubfoot Procedure
Note: Same name as procedures indicated for pes planus and lateral ankle instability Indication: Clubfoot Procedure: Shorten lateral column by calcaneal-cuboid fusion
Tibialis Posterior Tendon Transfer (TPTT)
Note: See Special Surgery Section for details. Indications: Drop foot Procedure: 1. TP is detached at its insertion site on the navicular 2. It is then rerouted through the interosseous membrane of the tibia and fibula, brought anteriorly and then inserted into the lateral cuneiform
Koutsgiannis Procedure
Note: Sometimes combined with Evans osteotomy for PTTD Indication: Pes valgus foot deformity Restores heel valgus, less so in restoring medial longitudinal arch. Also shifts the functional insertion of the Achilles medially. Procedure: 1. Medial displacement of an oblique osteotomy of calcaneus from lateral incision a. Posterior portion of calcaneus ―slides‖ medially 1⁄3 to 1⁄2 the width of calcaneus until it sits just below sustentaculum tali 2. K-wire, Steinmann pins, or lag screw fixation
Tibialis Anterior Tendon Transfer (TATT)
Note: The STATT is slightly preferred due to fewer complications. See Special Surgery Section for details. Indications: To decrease forefoot supinatory twist To increase true ankle DF Procedure: 1. TA is detached from its insertion 2. Reroute and insert it into lateral cuneiform or 3rd metatarsal (or inserted into peroneus tertius if present)
Keller Procedure
Note: Used in patients >50-55 years old Indications: HAV (IMA 16° or less) + Hallux limitus/rigidus Procedure: Resection of the proximal 1⁄4 to 1⁄3 base proximal phalanx (1⁄3 more commonly, cut perpendicular to long axis of bone), and cheilectomy with capsular tissue sewn into 1st MPJ space
What are normal values for PT/PTT/INR
Note: normal values vary between labs PT 11.7-14.5 sec INR 0.9-1.1 PTT 23-36 sec
What are the normal values for BMP
Note: normal values vary between labs Sodium 135-146 mmol/L Potassium 3.5-5.1 mmol/L Chloride 96-106 mmol/L CO2 24-32 mmol/L BUN 10-20 mg/dL Creatinine 0.7-1.3 mg/dL Glucose 70-110 mg/dL
Vulpius & Stoffel Procedure
Note: originally a transverse cut in aponerurosis Indications: Gastroc Equinus Procedure: Distal resection of gastroc aponeurosis using an inverted "V" But DON'T suture to soleus Paley/Lamm: Zone 2 Firth: Zone 2
When should a posterior malleolar fracture be fixated?
ORIF when fragment is greater than 25% of the posterior malleolus *McDaniel and Jaskulka
How many phases in a Ceretec scan
One
If gout is suspected, what should a specimen be sent in?
One in formaldehyde (dissolves gouty tophi) and one in alcohol (does not dissolve gouty tophi)
What is the dose of Bactrim
One tab PO BID Single strength -- TMP 80 mg / SMX 400 mg Double strength -- TMP 160 mg / SMX 800 mg
GUSTILLO & ANDERSON Classification
Open Fractures GUSTILLO & ANDERSON Type 1 - wound <l cm without extensive soft tissue damage Type 2 - wound >l cm without extensive soft tissue damage *Type 3 - extensive skin, soft tissue, muscle, and neurovascular damage* - 3A - adequate tissue coverage, high energy trauma - 3B - periosteal stripping, massive comminution - 3C - arterial injury
What is an indication for Zyvox
Oral Zyvox maybe used for outpatient treatment of MRSA infections
What should be done if the patient is thrombocytopenic
Order a six pack of platelets, which is a concentration of six pooled platelet units and consult hematology
What is the origin and insertion of the capsularis tendon
Origin: EHL muscle or tendon Insertion: First MTPJ capsule
What is Paget's Disease
Osteitis Deformans -abnormal bone architecture caused by increased osteoblastic and osteoclastic activity. More common in elderly.
What is the most common, benign, primary bone tumor
Osteochondroma
What bone tumors are located within the periosteum
Osteochondroma Periosteal Osteosarcoma
What are different bone graft properties
Osteogenic - able to synthesize new bone -Mesenchymal stem cells from autologous bone or bone marrow aspirate Osteoinductive - contains factors that induce host tissue to form new bone -Demineralized bone matrix -Bone morphogenic protein -Platelet-derived growth factors Osteoconductive - provides scaffold for host tissue to propagate new bone -Allografts -Hydroxyapatite -Calcium phosphate -Calcium sulfate
What bone tumors are located within the cortex
Osteoid Osteoma Nonossifying fibroma
Where are bone tumors typically located? Diaphysis
Osteoid Osteoma Osteoblastoma Enchondroma (also metaphyseal) Ewings Sarcoma (also meta-diaphysis) Periosteal Osteosarcoma
What is the most common bone tumor associated with Paget disease
Osteosarcoma
What malignant bone degeneration maybe seen with Paget Disease
Osteosarcoma
What are other side effects of Vancomycin
Ototoxicity and Nephrotoxicity
What are the side effects of aminoglycosides
Ototoxicity- irreversible Nephrotoxicity- reversible Neuromuscular blockade- prevented by slow infusion
What medication should be given if patient is an overproducer? Underexcretor?
Overproducer -> Allopurinol Underexcretor -> Probenecid
Oxycontin?
Oxycodone extended release
What is the MOI causing a short, oblique lateral malleolar fracture (AP view)?
PAB III
What is Regranex
PDGF-1 (platelet derived growth factor)
What is orthosorb
PDS (PDS=orthosorb)
What is the MOI to the ankle with a high fibular fracture? What is this fracture called?
PER III Maisonneuve Fracture
What is in antibiotic beads
PMMA or Poly(methyl methacrylate). Gentamycin or tobramycin are often used since they are heat stable with good diffusion coefficiencies. Vancomycin and cefazolin may also be used.
What is the indication for Augmentin
PO antibiotic for outpatient therapy of polymicrobial infections
What antibiotics cover MRSA
PO- Linezolid, Minocyclcine, Cipro/Rifampin, Bactrim/Rifampin IV- Vancomycin, Linezolid, Minocycline, Cipro/Rifampin, Bactrim/Rifampin, Synercid, Tigecycline, Telavancin Topical- Bactroban
what is MRA used for in the lower extremity
PVD, DVT, neoplasm and anatomic studies Most commonly ordered by a vascular surgeon for further description of occlusions/stenosis
What are clinical symptoms of an Achilles tendon rupture
Pain with history of "pop" Weakness or loss of function Palpable dell in area of ruptured tendon Inability to perform single leg rise Increased ankle dorsiflexion
How is a DVT diagnosed clinically?
Pain, heat, swelling, erythema of unilateral limb Positive Pratt sign - squeezing of posterior calf causes pain Positive Homan sign - abrupt dorsiflexion of foot causes calf pain Pulmonary embolism
Should a skin incision typically be made parallel or perpendicular to the RSTL?
Parallel incisions will remain approximated and heal better while perpendicular incisions may gap apart due to increased transverse forces
What x-ray measurements evaluate a Haglund deformity?
Parallel pitch lines: Perpendicular post. lip of the talar articulation onto a line that joins the medial and anterior calcaneal tuberosity; Any prominence above the top is pathologic Fowler & Philip: Ant. Tubercle + med. Process of plantar tuberosity to Poster superior prominence + posterior tuberosity; Greater than 75 degrees is Pathologic Total angle (of Rusch) = Sum of calcaneal inclination angle + Fowler and Philip angle; >90 strongly correlates with Haglund's deformity in a Cavus foot
IM angle of 1st and 2nd metatarsals
Pathologic of 12 degrees
What are the contraindications of Bactrim
Patient on oral hypoglycemic or with G6PD deficiencies
When are Vancomycin levels drawn?
Peak taken 30 min AFTER the 3rd dose Trough taken 30 min BEFORE the 4th dose
What should the Vancomycin peaks and troughs be
Peak: 15-30 mg/ml Trough: <10 mg/ml
DOC for Clostridium?
Penicillin, imipenem, clindamycin, tetracycline
What is Trental?
Pentoxifylline
What is the difference between Percocet and Percodan
Percocet has 325 mg of acetaminophen and Percodan has 325mg of ASA
Essex-Lopresti Technique
Percutaneous pinning technique placing a Steinmann pin into the tuberosity. The tongue fragment is reduced, and a pin is placed into the anterior calcaneus or cuboid. No cast required, and motion is performed immediately. The pin is removed in 8-10 weeks and WB is begun. Indicated for Sanders 2C (87% success rate).
What is the order for hammertoe surgery
Perform a Kelikian push-up test to determine if the next step is required *1. PIPJ* Tendon Dorsal capsule Collaterals Plantar capsule Arthroplasty *2. MPJ* Hood Tendon Capsule Plantar plate *3. PIPJ* Arthrodesis
What is the perioperative management for patients on long term high dose steroids
Peri-op IV steroid supplementation. Hydrocortisone 100 mg IV given the night before surgery, immediately prior to surgery, and then q8h until postoperative stress relieved
What are radiographic findings of CRPS?
Periarticular, mottled, irregular bony demineralization (30-60% of cases) and cortical thinning
Eckert and Davis Classification
Peroneal Tendon Subluxation Grade 1: retinaculum and periosteum ruptures from the cartilaginous lip and lateral malleolus Grade 2: distal edge of fibrous lip elevated with retinaculum Grade 3: thin fragment of bone with fibrous lip avulsed from deep surface of peroneal retinaculum and deep fascia
What tendons pass over the lateral ankle ligaments
Peroneus Brevis and Longus
How are relaxed skin tension lines (RSTL) oriented?
Perpendicular to the long axis of the leg and foot (medial to lateral)
Theiman Disease
Phalanges
What are the phases of bone scan? When is each phase done?
Phase 1 - Immediate, early, blood flow, or angiogram (it goes by all these names) 2-3 seconds Phase 2 - Blood pool 2-3 minutes Phase 3 - Delayed 2-3 hours Phase 4 - Fourth phase 24 hours
During a P&A procedure, why is alcohol used after phenol
Phenol is soluble in alcohol, and the alcohol will irrigate excess phenol from the nail groove
What are differences between phosphate and acetate-based steroids
Phosphate-based: soluble with shorter half-life (Minimize inflammatory reaction and edema) Acetate-based: insoluble with longer half-life (May delay inflammatory process or healing and can mask infection)
How does a bone stimulator work?
Piezoelectric principle - side under compression makes a negative charge that leads to bone growth. Therefore, placing a cathode in a non-union site will stimulate growth.
What is Hutchinson's sign?
Pigment changes in the eponychium seen with subungual melanoma
Zosyn is a combo of
Piperacillin/Tazobactam
Does a neuroma lie dorsal or plantar to the deep transverse intermetatarsal ligament?
Plantar
Is the tension side of a metatarsal on the dorsal or plantar aspect?
Plantar
What is the Spring Ligament
Plantar calcaneonavicular ligament
What is a Mondor sign
Plantar, rearfoot ecchymosis that is pathognomonic for calcaneal fractures
Talar head and neck
Plantarflexed 25-30 degrees Medially aligned 15 degrees to body
How are esters (Novocaine) metabolized
Plasma Pseudocholinesterase
How is cocaine metabolized?
Plasma pseudocholinesterase (just like other esters)
What is a locking plate?
Plate in which threaded screws are secured in to threaded plate holes. Does not rely on the bone for stability but rather forms a fixed-angle construct Good for osteoporotic, comminuted fractures, or revision surgeries
What is a clinical test for a fracture
Point tenderness over fracture site
Temtamy & McKusick Classification
Polydactyly Pre-axial: located on the medial side of a line that bisects the second digit (15%) Post-axial: located on the lateral side (80%)
What is Vicryl?
Polyglactin 910 (a copolymer of 90% glycolide and 10% lactide)
What is orthofix?
Polyglycolic acid (same as dexon)
What are signs of hyperglycemia
Polyuria, polydipsia, weight loss
What is the technique for correction of clubfoot called
Ponseti technique Serial casting - First correct the FF and RF deformities, and then correct ankle equinus - During manipulation, pressure is applied to the head of the talus (not the calcaneus) 4-8 casts - Percutaneous Achilles tenotomy (last cast for 3 weeks), Occasional TA transfer, and D-B bar brace until age 3 y/o to prevent relapse
What are causes of blue toe
Poor arterial inflow - toe is cold and doesn't blanch with pressure Poor venous flow - toe is warm and will blanch with pressure
Os Trigonum
Posterior aspect of Talus (Steida's Process)
Os Sustentaculi
Posterior aspect of sustentaculum tali
What muscles/tendons are contracted in clubfoot (posterior/ medial/ anterior)?
Posterior: Achilles and Plantaris Medially: PT, FDL, FHL and Abductor Hallucis Anterior: Tibialis Anterior
What posterior and medial ligaments/capsules are contracted in club foot?
Posterior: Posterior tib-fib, Posterior talo-fib, Lateral calcaneofibular, Syndesmosis Medial: Superficial deltoid Tibionavicular Calcaneonavicular Talo-Navic, Navic-Cunei, and Cunei-1st MT joints Spring ligament
What is brachymetatarsia?
Premature closure of epiphyseal plate of metatarsal resulting in short metatarsal *Usually the 4th met is affected
What is Hawkins sign?
Presence of subchondral talar dome osteopenia seen 6-8 weeks after talar fracture signifying intact vascularity. Absence of the sign implies AVN.
What is the screw driver handle made out of
Pressed Linen
Why do you countersink a screw
Prevents stress risers and soft tissue irritation Provides even compression from screw head (land)
What should be done when assessing a patient with trauma
Primary Survey (ABCDE) -Airway -Breathing -Circulation with hemorrhage control -Disability: assess neurologic status -Exposure of patient and environmental control Secondary Survey (APMLE) -Full History: medical and drug -Thorough examination (evaluate tenderness and stability as well as neurovascular status of each limb; is there injury to joint above or below) -X-rays and/or CT of all suspected fractures
DOC for necrotizing fasciitis?
Primaxin
DOC for severe limb-threatening infection?
Primaxin
DOC for necrotizing fasciitis?
Primaxin 250-1000 IV q6-8h (most commonly 500 mg IV q8h) *Clindamycin
What concern is there of a patient on both PCN and Probenecid
Probenecid will increase duration of serum levels of PCN and most cephalosporins
What is creeping substitution?
Process in which the host's cutting cone (osteoclasts followed by osteoblasts) invade bone graft
What is the treatment for cutaneous larva migrans
Promethia under occlusion
DOC for cutaneous larva migrans
Promethia under occlusion ??? *Thiabendazole
What is a Lauge-Hansen Type V?
Pronation Dorsiflexion 1. Vertical tibial malleolar tip fracture 2. Anterior tibial lip fracture 3. Supramalleolar fibular fracture 4. Transverse posterior tibia fracture level with proximal aspect of anterior tibial fracture
For anesthesia, what cannot be given to a patient with an egg shell allergy?
Propofol (Diprivan)
How is Heparin reversed
Protamine sulfate 1 mg per 100 units of heparin
os vesalianum
Proximal 5th metatarsal base
What procedure corrects DASA
Proximal Aikin
Blount's disease
Proximal, medial tibial epiphysis
What are contraindications for bone stimulators
Pseudoarthrosis, gap greater than 1⁄2 bone diameter
What are two main causes of antibiotic associated diarrhea
Pseudomembranous colitis-clostridium difficile Non-specific colitis- Staph Aureus
What is a small gram negative rod with pili and polar flagella
Pseudomonas
What is the most common organism that causes OM following a puncture wound
Pseudomonas Aeruginosa
Where is Regranex made?
Puerto Rico (I was really asked this once)
What are different biopsy techniques
Punch, shave, curettage, surgical excision
DOC for E/C/S/M group?
Quinolone (Cipro/Levaquin)
What is Felty's syndrome?
RA, leukopenia, splenomegaly
RUEDI & ALLGOWER Classification
RUEDI & ALLGOWER - Pilon fractures - distal tibial metaphyseal fracture. Type 1 - non-displaced tibial fragments Type 2 - intra-articular tibial fracture without comminution Type 3 - comminution and disruption of tibial articular surface
What is Raynaud's phenomenon?
Recurrent vasospasm of digits usually in response to stress or cold
What happens if you infuse Vancomycin too quickly
Red Man Syndrome - erythema and pruritus to the head, neck and upper torso. It is caused by an anaphylactoid reaction where histamine is released by mast cells. (A different Red Man syndrome is associated with excessive Rifampin that causes reddish-orange pigmentation of the skin)
How are cephalosporins excreted?
Renally except for ceftriaxone (renal/hepatic) and cefoperazone (hepatic)
What order do you resect and what order do you fixate the joints in a triple arthrodesis?
Resection 1. Midtarsal Joints (T-N, CCJ) 2. Subtalar Joint (T-C) Fixation 1. Subtalar Joint 2. Midtarsal Joints
What procedures correct PASA
Reverdin Peabody Biangular Austin DRATO Offset V with rotation
What does the Virchow triad predict?
Risk of DVT Previous DVT is #1 risk factor for having another DVT
Who first described the triple arthrodesis?
Ryerson
Cyma Line
S-shaped line formed by the articulation of T-N and C-C joints Pronation - moves line anteriorly Supination - moves line posteriorly
What is an anti-tension line
S-shaped or zig-zagged incision when exposure needed is not parallel to RSTL
What is the MOI causing a transverse lateral malleolar fracture?
SAD 1
What is the MOI causing a short, oblique medial malleolar fracture (AP view)?
SAD II
Salter-Harris Classification
SALTER-HARRIS - Physeal Injuries (SMACK - Same, Metaphysis, Articulation, Continuous, Krush) (SALTR - Same, Above, Lower, Through, Really bad) 1 - fracture through physis 2 - fracture through physis into metaphysis 3 - intra-articular fracture through physis into epiphysis 4 - intra-articular fracture through epiphysis, physis, and metaphysis 5 - crush injury
SANDERS classification
SANDERS - Calcaneal fx -Used for CT evaluation from coronal and axial views -Classified by number of pieces -Lines A and B divide the inferior portion of the posterior talar facet into 3 equal portions. Line C separates the medial and posterior facets. A - lateral B - midline C - medial (at sustentaculum tali) 1 - any number of fracture lines - All non-displaced, extra-articular fractures 2 - one fracture line Two-part fracture of posterior facet Use one letter (2A, 2B, or 2C) 3 - two fracture lines Three-part, intra-articular fracture of posterior facet with depressed central fragment Use two letters (3AB, 3AC, or 3BC) 4 - three fracture lines Four-part, intra-articular fracture of posterior facet and sustentaculum fragment with high degree of comminution
What is the most common mechanism of injury (MOI) causing an ankle fracture
SER
What is the MOI causing a spiral, lateral malleolar fracture with a posterior spike (AP and Lateral views)?
SER II
SNEPPEN Classification
SNEPPEN - Talar Body Fractures Type 1 - compressive fracture of the talar dome usually involving medial or lateral aspect Type 2 - shearing fracture of the talar body 2A - coronal shearing force 2B - sagittal shearing force 2C - horizontal shearing force Type 3 - fracture of the posterior tubercle Type 4 - fracture of the lateral process Type 5 - crush fracture
What is the Valente procedure?
STJ block using a polyethylene plug with screw threads. Allows 4-5° of STJ pronation.
Subtalar Joint axis direction
STJ goes through 1st ray in neutral, 2nd ray in supination, and is medial to 1st ray in pronation
Which CT scan plane is computer reconstructed
Sagittal
For a nail avulsion, what can be done for anesthesia if the patient is allergic to all local anesthetics?
Saline Block (pressure induced block) Pressure Cuff Benadryl block (blocks histamine release)
What are the different scope techniques
Scanning (Sweeping) - side to side, up and down Pistoning - in and out Rotation - 360°
Describe mini fragment screws
Screw sizes of 1.5, 2.0, 2.7-all fully threaded, cortical screws
What other tests are typically performed with an ABI?
Segment pressures -Measured at high thigh, above the knee, below the knee, ankle, midfoot, and toe -Normal 70-120 mm Hg -Drop between segments >30 mm Hg indicate disease in vessel above Pulse volume recordings (PVRs) - Doppler like waves -Normal waveforms are triphasic -Waveforms are widened and blunted with severe disease
What is a side effect of Primaxin
Seizure in patients with a history of seizures 1% risk with 500mg dose, 10% risk with 1g dose
What screw has a fluted tip?
Self-tapping
What is the Sullivan sign?
Separation of digits caused by a mass within the interspace
What is the most common complication of skin grafts
Seroma/Hematoma
Os Peroneum
Sesamoid bone in Peroneus Longus Tendon
What is a fabella?
Sesamoid bone occasionally found in tendon of lateral head of gastrocnemius
What attaches periosteum to bone
Sharpey Fibers
Galeazzi (or Allis) sign?
Sign of unilateral congenital hip dislocation in infants. With infant supine and hip and knees flexed, the knees should be level. If a knee is lower, that hip is dislocated.
What are the different patterns of periosteal reactions
Single layer: benign but sometimes malignant Onion Skin: malignant, multiple layers of periosteum Sunburst: spiculated rays Hair on end: parallel rays Codman triangle: triangular elevation
How much is in the single strength tablet of Bactrim? Double Strength?
Single strength -- TMP 80 mg / SMX 400 mg Double strength -- TMP 160 mg / SMX 800 mg
How is EDL attached to the proximal phalanxes?
Sling wraps around capsule which attaches to plantar plate, DTML, and flexor tendon sheath thus attaching to plantar proximal phalanx. No direct insertion to proximal phalanx.
How can you decrease the risks of Red Man Syndrome
Slow infusion over one hour
What are some factors that negatively affect bone healing
Smoking, antimetabolic or steroid therapy, anemia, osteoperosis
Tscheme and Gotzen
Soft Tissue Injuries Grade 0: little or no soft tissue injury Grade 1: significant abrasion or contusion Grade 2: Deep, contaminated abrasion with local contusion to skin or muscle Grade 3: extension contusion or crushing of skin or destruction of muscle
What is the spectrum of activity of Flagyl
Some gram positive anaerobes and most gram negative anaerobes
Who was the first to describe an arthrodesis
Soule
What skin cancer may appear cauliflower-like?
Squamous cell carcinoma - found on sun-exposed parts of the body
What is the Hallux Valgus classification (Stages 1-4)
Stage 1 Excess pronation causes hypermobility of 1st ray. Tibial sesamoid ligament gets stretched& fibular sesamoid ligament contracts.Lateral subluxation of proximal phalanx occurs Stage 2 Hallux abductus progresses, touches against 2nd digitFHL & FHB gain lateral mechanical advantageCrista starts to erode Stage 3 Further subluxation at 1st MPJ, formation of IMAIMA increases secondary to retrograde forces from abductor hallucis Stage 4 Hallux subluxes & dislocates on 1st metatarsalIncreased crista erosion
Johnson and Strom classification
Stage 1 - normal tendon length with mild degeneration Medial foot and ankle pain Stage 2 - supple flatfoot with attenuation or PT rupture ―"Too many toes" sign Abducted forefoot, increased talar-1st metatarsal angle, and uncovering of talar head Stage 3 - rigid flatfoot with complete PT rupture Fixed calcaneal valgus with decreased STJ ROM Stage 4 - rigid flatfoot; Valgus tilt of talus/ankle mortise leading to lateral tibial/talar degeneration
Lauge Hansen Supination-Eversion (SER)
Stage 1: disruption of anterior tib-fib ligament with either a tibial avulsion (Tillaux-Chaput) or a fibular avulsion (Wagstaffe) Stage 2: * spiral oblique fracture of the fibula at level of ankle joint Stage 3: rupture of posterior tib-fib ligament or tibial avulsion (Volkmann) Stage 4: ruptured of deltoid or transverse fracture of medial malleolus (Weber B)
Pronation - External Rotation (PER)
Stage I - Disruption of deltoid ligament or transverse avulsion fracture of medial malleolus. 2. Stage II - rupture of anterior-inferior tibial-fibular ligament or fracture of Wagstaf or Tillaux-Chaput. 3. Stage III - Interosseous membrane torn above syndesmosis and below fibular head and then a classic high fibular fracture occurs approx. 4-5 cm above joint line. 4. Stage IV - disruption of posterior-inferior tibial-fibular ligaments or avulsion fracture of tibia (Volkman) or fibula
What are the two sutures that are the least reactive to tissue
Stainless steel (least reactive); Prolene
What is the most common organism that causes acute hematogenous OM
Staph (adults) Gram Negative Rods (elderly)
What is the spectrum of activity for augmentin
Staph (not MRSA), Strep, Enterococci, Gram negatives and anaerobes
What is the spectrum of coverage for Zosyn
Staph (not MRSA), Strep, Enterococci, Gram negatives, anaerobes
What is the spectrum of activity for Unasyn
Staph (not mRSA), Strep, Enterococci, Gram Negatives and Anaerobes
What is the spectrum of activity for Timentin
Staph (not mRSA), Strep, Gram Negatives and Anaerobes
What are gram positive, catalase positive cocci in clusters
Staph Aureus
What are the most common organisms of cellulitis
Staph and Strep
What is the spectrum of activity of Zithromax
Staph, Strep, some anaerobes (but not bacteriodes)
What is Gradient Echo also known as
Steady state magnetization
What is a common complication following steroid injection
Steroid flare: hypersensitivity reaction. Apply ice.
What is a Keith needle
Straight needle
What are gram positive, catalase negative cocci that are in pairs or chains
Streptococcus
What are treatments for Equinus
Stretching/exercises Night splints Gastroc recession Strayer Vulpius Baker McGlamary & Fulp Tendoachilles lengthening Open/closed Z Hauser White Hoke Sgarlato Stewart
Structural - Bony deformity - Abnormal PASA and DASA - PASA + DASA = HA Positional - Soft tissue deformity with subluxed or deviated joint - Normal PASA and DASA - PASA + DASA < HA Combined - Elements of both structural and positional with subluxed or deviated joint - Abnormal PASA and DASA - PASA + DASA < HA
Structural - Bony deformity - Abnormal PASA and DASA - PASA + DASA = HA Positional - Soft tissue deformity with subluxed or deviated joint - Normal PASA and DASA - PASA + DASA < HA Combined - Elements of both structural and positional with subluxed or deviated joint - Abnormal PASA and DASA - PASA + DASA < HA
Pain management with a codeine allergy
Stud-n (sttuddd-n) S-Stadol T-Toradol (Ketorolac) T-Talwin U-Ultram (Tramadol) D-Darvocet D-Darvon D-Demerol N-Nubain
Is there a risk with intra-articular injections of bupivacaine
Studies have shown chondrocyte death following prolonged exposure to bupivacaine
What is a Brodie abscess? What is the treatment?
Subacute osteomyelitic lesion usually found in children. It is a well-circumscribed, lytic lesion with sclerotic borders found in the metaphysis, epiphysis, and rarely diaphysis. Painful with periods of exacerbation and remission. Tx: curettage and packing with autologous bone
What allergy should be avoided when prescribing Bactrim
Sulfa
What are the components of the deltoid ligament
Superficial - tibionavicular - tibiocalcaneal - posterior tibiotalar Deep - anterior tibiotalar
What is erysipelas?
Superficial infection that extends into the lymphatics. Lesions are erythematous, indurated with sharply-demarcated margins, and have erythematous, ascending streaks.
What is the most common type of melanoma
Superficial spreading melanoma - found on any part of the body
What is a Baker's cyst?
Swelling of the bursa between the tendons of the medial head of the gastrocnemius and the semimembranosus muscles
What are the three different types of coalitions
Syndesmosis - fibrous Synchondrosis - cartilaginous Synostosis - osseous
Alternatives for MRSA
Synercid or Linezolid
What are a few indications for an ankle scope
Synovitis Osteochondral lesion/fracture Soft tissue impingement Osteophytes Loose bodies
Which is the most common coalition
T-C > C-N > T-N
Which coalition is most asymptomatic
T-N
What are the ages of fusion of coalitions
T-N (3-5 years) C-N (8-12 years) T-C (12-16 years)
What will a stress fracture show up as on MRI?
T1 - Linear zone of decreased signal intensity surrounded by a less defined area of signal intensity T2 - Linear zone of decreased signal intensity surrounded by an increased signal intensity due to edema STIR: Increased signal intensity because fatty bone marrow is suppressed
How will AVN show up on MRI?
T1 and T2 Decreased signal intensities STIR and Long T2 Double rim sign: Inner margin will show an increased signal intensity (this represents granulation tissue). Outer margin will show decreased signal intensity (this shows mineralization).
How will osteomyelitis show up on MRI?
T1- Break in cortex, decreased signal in the bone marrow T2- Break in cortex, increased signal in the bone marrow
How to determine if the patient is an overproducer or underexcretor
Take a 24 hour urinalysis
How to culture osteomyelitis?
Take one culture from the infected bone, and take a second culture proximal to the clearance margin to ensure remaining bone is not infected
What is the Sneppen classification?
Talar body fractures
What is the most common coalition of the rear foot
Talocalcaneal
What are some intra-articular coalitions of the foot
Talocalcaneal coalition Talonavicular Coalition
What are three coalitions of the rearfoot
Talocalcaneal, calcaneonavicular, and talonavicular
Diaz Disease
Talus
What is the only bone in the foot without any muscle origin or tendon insertion
Talus
What are some common needle point configurations
Taper point - for soft, easily penetrated tissue (subcutaneous tissue, fascia) Cutting - cutting edge on inner curve (skin) Reverse cutting - cutting edge on outer curve for tough, difficult to penetrate tissue
Name surgical procedures for pes cavus
Tendon Jones Hibbs STATT PT Bone Dorsiflexory osteotomy of 1st metatarsal Cole Japas
What are the side effects of quinolones
Tendonitis and tendon ruptures
How long does it take to absorb Vicryl
Tensile strength 75% @ 2 weeks 50% @ 3 weeks 25% @ 4 weeks Absorbed completely in 10 weeks
Should a plate be placed on the tension or compression side of a fracture?
Tension
What is the Barlow test?
Test for a hip that is dislocatable but not dislocated in infants. With infant supine and hip and knees flexed, push posteriorly in line with the shaft of femur. An unstable femoral head will dislocate posteriorly from acetabulum.
What is the Ortolani test?
Test for congenital hip dislocation in newborns. With newborn supine and hip and knees flexed, the hips are adducted while pressing downward and abducted while lifting upward. An unstable hip will dislocate when adducted and reduce when abducted.
Trendelenburg test
Test for weak hip abductors. As patient stands on affected limb, pelvis drops to opposite side.
What should always be asked with a break in the skin
Tetanus Status
What are bone scan findings of CRPS?
The 3-phase bone scan has sensitivity of 96% and specificity of 98%. A normal scan does not exclude the diagnosis. The findings of the bone scan are based on the phase. *1. Acute* Increased flow and blood pool activity in the affected extremity Increased activity particularly in a periarticular distribution on delayed images *2. Dystrophic* Flow and blood pool abnormalities begin to normalize Increased activity on delayed images persists. *3. Atrophic* Flow and blood pool activity can be normal or decreased (in about 1/3 of patients) Normal or decreased activity is commonly seen on delayed images, however, persistent increased delayed activity has been reported (up to 40%) Decreased flow in advanced stages may be related to disuse, which is a common feature of post-hemiplegic CRPS
What NSAID does not inhibit platelet aggregation?
The COX-2 inhibitor, Celebrex
To correct a skin contracture, how should the Z-plasty incisions be oriented?
The central arm of the "Z" should be parallel to the contracture
what do PT/PTT/INR tell you
The coagulable state of the patient. If the levels are high, it will take longer for the patient to develop a clot and stop bleeding. It requires blockage of only one pathway to anticoagulant the patient.
In evaluating a bunion, what does the position of the tibial sesamoid indicate? Why isn't the fibular sesamoid evaluated?
The tibial sesamoid indicates the abnormal affects of the ADDUCTOR and flexor brevis tendons. Once the fibular sesamoid reaches the intermetatarsal space, it travels in the frontal plane (as opposed to transverse), therefore the tibial sesamoid is a more reliable indicator of deformity.
How do you check Lovenox
There is no test for the effects of Lovenox
What do Na+, K+, Cl and CO2 tell you?
These electrolytes indicate nutritional status
What is a major side effect of Zyvox
Thrombocytopenia (check CBC)
What are treatments for DVT
Thrombolytic agents Heparin 5000 Units IV bolus, then 1000 Units IV q1h and monitor PTT
Osgood-Schlatter disease
Tibial Tuberosity
Renandier Disease's is AVN of which bone
Tibial sesamoid
What tendons pass over the deltoid ligament
Tibialis posterior and FDL
Timentin is a combo of
Ticarcillin/Clavulonic aid
Another name for Tygacil
Tigecycline
DOC for superficial thrombophlebitis?
Timentin
Which NSAID is often given during surgery or immediately post-op to decrease pain and inflammation?
Toradol 30mg IV
First choice for non-narcotic IV?
Toradol(Ketorolac) 30-60 mg IV
What study is most useful in searching for metastatic bone disease?
Total skeletal bone scan: malignant lesions will show increased uptake
Ultram?
Tramadol 50mg 1-2 tabs PO q4-6 prn pain
What should be done if the Hemoglobin/Hematocrit is below 10/30
Transfuse 1-2 units of packed RBC
What is the most stable fracture pattern
Transverse
Name surgical procedures for pes planus
Transverse Evans Kidner C-C distraction arthrodesis Sagittal Cotton Young Lowman Hoke Miller Cobb Frontal Koutsogiannis Dwyer Chambers Gleich Baker-Hill Lord
What are common fracture patterns
Transverse Greenstick Torus Oblique (spiral) Comminuted
What is another name for the superior extensor retinaculum
Transverse Crural ligament
What does the axial plane of a CT scan represent
Transverse Plane
When should PO vancomycin be used?
Treatment of Pseudomembranous colitis (125 mg PO q6h)
How does Bactrim work
Trimethoprim and sulfamethoxazole inhibit folate synthesis in bacteria which prevents DNA replication
Bactrim is a combo of
Trimethoprim/Sulfamethoxazole
What are FDA-approved total ankle implants
Two-component devices Agility Eclipse INBONE Salto Talaris Three-component devices STAR (Not FDA-approved - Buechal-Pappas, TNK, HINTEGRA)
Freiberg Infraction Types
Type 1: Type 2: Type 3: Head collapses with articular cartilage loosening. Joint is destroyed Type 4: multiple heads involved
Muller Classification
Type A - avulsion of the tip of the medial malleolus, horizontal orientation Type B - avulsion fracture at the level of the ankle joint, horizontal orientation (transverse avulsion fracture) Type C - oblique fracture Type D - vertical fracture
For diabetic patients, who gets diabetic ketoacidosis and who gets diabetic coma?
Type I (IDDM)-DKA Type II (NIDDM)-coma
OVADIA & BEALS CLASSIFICATION
Type I - intra-articular injuries that are not displaced Type II - minimally displaced intra-articular fractures Type III - moderately displaced intra-articular fx w/ several large fragments Type IV - intra-articular w/ moderate displacement and large metaphyseal defects Type V - severe comminution of both distal tibial metaphysis and articular surface
What is a pseudoarthrosis?
Type of non-union in which fibrocartilaginous tissue forms between fracture fragments
What is ecthyma?
Ulcerative pyoderma of the skin often caused by Streptococci. Infection extends into dermis and is characterized by ulcers with overlying crusts.
Which is more common - to be an overproducer or an underexcretor
Underexcretors make up 90%
What if the organism is resistant to vancomycin?
VRE (vancomycin-resistant Enterococcus)
What is diazepam?
Valium, a benzodiazepine, is an anxiolytic/anticonvulsant/muscle relaxant
DOC for Diptheroids?
Vancomycin
What are the only FDA-approved drugs for treating MRSA?
Vancomycin Linezolid Daptomycin Tigecycline Telavancin (Vibativ)
DOC for MRSA
Vancomycin for IV PO-Bactrim if sensitive
What antibiotics can be safely used with PMMA beads
Vancomycin, Gentamycin, Tobramycin and Cefazolin -The curing of PMMA is exothermic, therefore the antibiotic must not be heat labile
What are some empiric therapies for polymicrobial infections
Vancomycin/Zosyn Clinda/Cipro Vancomycin/Invanz
What fractures are commonly associated with calcaneal fractures?
Vertebral Fractures, especially L1 Femoral neck Tibial Plateau *Wrist
What is another name for congenital convex pes valgus
Vertical Talus
What is the spectrum of activity of Primaxin
Very Broad spectrum Most gram positives, Most gram negatives including pseudomonas Most aerobes and anaerobes
What may falsely elevate the ABI?
Vessel calcifications/non-compressible vessels
What organism may be found following a puncture wound in the ocean?
Vibrio Vulnificus
What are causes of macrocytic, megaloblastic anemia
Vitamin B12/Folate deficiency
How is Coumadin reversed?
Vitamin K, fresh frozen plasma (FFP has INR of 1.6)
What is the difference between a Vogler, Kalish and Youngswick
Vogler- offset V (apex at metaphyseal-diaphyseal joint) Kalish- long-arm Austin with angles of approximately 55 degrees for screw fixation Youngswick- Austin with a slice taken dorsally to allow decompression and plantar flexion
Wagner Classification
WAGNER *Grade 0* - no open lesions but bony prominence and/or structural deformity present *Grade 1* - superficial ulcer without penetration to the deep layers *Grade 2* - deep ulcer penetrating to tendon, joint capsule, or bone *Grade 3* - Grade 2 depth with the presence of infection *Grade 4* - gangrene of the forefoot *Grade 5* - gangrene of the entire foot
What are normal lab values for CBC
WBC 4.8-10.8 k/μL Hemoglobin ♂ 14.0-18.0 g/dL, ♀ 12-16 g/dL Hematocrit ♂ 42-52%, ♀ 37-47% Platelets 145-400 k/μL
What is in a CBC
WBC, Hgb, Hct, Plt
What does Indium-111 tag
WBCs (as does Ceretec scan)
WEBER & CECH classification
WEBER & CECH- Non-Union of Fractures *Hypertrophic - hypervascular (90%)* Elephant foot Horse hoof Oligotrophic *Atrophic - avascular (10%)* Torsion wedge Comminuted Defect Atrophic
What test should be performed to confirm the diagnosis of AIDs
Western Blot
What are the stages of Raynauds Phenomenon
White → blue → red Pallor (white) - spasm of digital arteries Cyanosis (blue) - deoxygenation of blood pools Rubor (red)- hyperemia
What are reasons for post-op fever
Wind (12-24 hours) -Atelectasis (from muscle relaxers) -Post-Op Hyperthermia Water (24 hours) -UTI Walk (48 hours) -DVT -PE Wound (72 hours) -Post-Op infection Wonder Drug (anytime) -Drug Fever
Can local anesthetics cross the placental barrier?
Yes
can you give zithromax to a patient with penicillin allergy
Yes
does timentin cover pseudomonas
Yes
Can antibiotics affect PT/INR?
Yes. Antibiotics can affect normal flora, which alters Vitamin K. Therefore, the PT/INR can increase.
Does the duration a patient has been on vancomycin increase the risks of side effects?
Yes. Vancomycin has a reservoir effect: the more often a patient receives vancomycin, the higher the chance of getting either ototoxicity and nephrotoxicity. Therefore, use vancomycin carefully; it is a powerful drug with severe side effects
What is the weakest region of the physis
Zone of cartilage maturation
Os Tibiale Externum
accessory navicular
Augmentin is a combo of
amoxicillin/clavulanic acid
What is the Bassett ligament?
anterior inferior tibiofibular ligament
What are the lateral ankle ligaments
anterior talofibular, calcaneofibular, posterior talofibular
What is the most common type of skin cancer?
basal cell carcinoma
How does Pseudomonas typically present
blue-green purulence with grape-like odor
What is the only FDA-approved COX-2 inhibitor?
celecoxib (Celebrex) Others were withdrawn due to increased risk of heart attack and stroke
What are some once a day NSAIDs
celecoxib (Celebrex), piroxicam (Feldene), oxaprozin (Daypro), nabumetone (Relafen), others
What is the Torg classification
classification for jones fractures and and potential for non union Type 1: acute Jones fracture Type 2: delayed union of a Jones fracture or diaphyseal stress fracture Type 3: Non-union of a Jones fracture or a diaphyseal stress fracture
Tylenol #3
codeine/acetaminophen (30 mg/300 mg) 1-2 tabs PO q4-6h
What is Santyl?
collagenase - an enzymatic debrider that digests collagen in necrotic tissue
What is Arthrotec?
diclofenac/misoprostol - an NSAID with protection for the stomach
Os subfibulare
distal to lateral malleolus
Os Subtibiale
distal to medial malleolus
Os supranaviculare
dorsal aspect of navicular
What is oasis
extracellular graft matrix from porcine small intestine submucosa
What does HMPAO stand for
hexamethylpropyleneamine oxime (aka Ceretec scan)
Vicodin 5/500?
hydrocodone/acetaminophen (5 mg/500 mg) 1-2 tabs PO q4-6h prn pain
How is Vicryl broken down?
hydrolysis
Dilaudid?
hydromorphone 2-8 mg PO q3-4h prn severe pain 1-4 mg IV q4-6h prn severe pain This drug is very strong
Which antibiotic is nicknamed Gorillamycin
imipenem (very broad spectrum)
Which NSAIDs only have anti-inflammatory effects?
indomethacin, tolmetin
What is an indication for Pletal or Trental
intermittent claudication
Why isn't Aztreonam used more often?
it is expensive
Why isn't Zyvox used more often?
it is expensive
What is Gradient Echo used for
joint imaging
DOC for VRE
linezolid or Synercid
How is clindamycin metabolized?
liver
What is enoxaparin (Lovenox)?
low molecular weight heparin
What does MRA stand for?
magnetic resonance angiography
What does MAC (as in MAC with local) stand for
monitored anesthesia care
What are the only pro-drugs for NSAIDs
nabumetone and sulindac
Does unasyn cover pseudomonas?
no
How do you test for Clostridium Difficile
order "check stool for c. diff"
Percocet 5/325?
oxycodone/acetaminophen (5 mg/325 mg) 1-2 tabs PO q4-6h prn pain
Roxicet?
oxycodone/acetaminophen (5mg/325mg/5ml) Essentially a liquid form of Percocet that is good for pediatric patients
What is the strongest lateral ankle ligament
posterior talofibular
Darvon?
propoxyphene 1 tab PO q4h prn pain
Darvocet N-100
propoxyphene/acetaminophen (100mg/650mg) 1 tab PO q4 prn pain
What is the side effect of clindamycin
pseudomembranous colitis
What is a Haglund deformity
pump bump
How is Lovenox reversed?
recombinant factor VII
What do BUN and creatinine indicate?
renal function
First choice for non-narcotic oral?
tramadol (Ultram) 50 mg one to two tabs PO q4-6h prn pain, max daily dose of 400 mg per day
does zosyn cover pseudomonas
yes
What are characteristics of an osteoblastoma
―Giant osteoid osteoma -Benign tumor that may become malignant -Osteolytic lesion with well-circumscribed nidus (>1.5 cm) that may have multiple calcifications -2nd to 3rd decades of life -Less symptomatic than osteoid osteoma, pain not relieved by ASA
