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