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FANKLE Flashcards

1
Q

pathophys of charcot bone destruction

A

hypervascularity of bone

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2
Q

best tendon to augment for PTTI correction

A

FDL - plantaris is inferior

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3
Q

what can prohibt a talar head dislocation from reduction

A

Post tib tendon

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4
Q

spring ligament components and tears

A

2 bands -supmedial/inf medial - generally sup medial is torn

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5
Q

which nerve is NOT covered by popliteal block

A

saphenous

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6
Q

pes planovalgus leads to what on lateral ankle

A

subfibular impingement

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7
Q

what ligament tears are seen with adult flat foot

A

spring lig damaged; (Sup/Med band)

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8
Q

what is lateral impaction syndrome

A

when calc and talus sublux in flat foot and impinge to fibula on eversion

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9
Q

what is down side of k-wire for listfranc

A

recurrence after pin removal

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10
Q

what is subtalar arthroeresis

A

implant in subfibular space to limit eversion - often a/w persistent pain

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11
Q

anatomic risk factors for 2nd mt stress frx

A

hallux rigidus, long second MT; hallux valgus

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12
Q

what is the Chopart joint

A

talonavicular and calccuboid

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13
Q

long term tx for sequelae of chopart joint dislocation

A

usually develo OA and a rigid rocker bottom or carbon fiber insert can help

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14
Q

most accurate way to measure syndesmotic disruption on XR

A

TIB FIB Clear space > 6mm

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15
Q

tx of sx of talar OCD

A

if CYSTIC - OCD graft ; if non-cystic < 1.5cm - debride + drilling if cartilage disrupted; NON-cystic <1.5cm AND cartilage is good – retrograde drilling and grafting

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16
Q

what percent of lisfranc are missed

A

20% missed on original xray;

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17
Q

what causes hammertoe deformity

A

contracted Flexor digitorum LONGUS from EDL OVERPULL

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18
Q

hammertoe vs mallet toe

A

Hammer is PIP FLEXION; DIP hyperextension; MTP is also extended

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19
Q

etiology of plantar ulcers in diabetes

A

NOT vascularity but rather neuropathy

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20
Q

after removal of border digit for osteo what must happen

A

custom molded shoe insert to prevent shift of weight

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21
Q

m/c location for mortons neuroma

A

second and third webspace

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22
Q

r.f for plantar fascitis

A

bMI > 30

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23
Q

what exericses are best for Plantar fasciitis

A

PF specific stretching not just achilles

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24
Q

risk factor for mortons neuroma

A

female gender

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25
Q

tx of longitudinal peroneus brevis tears

A

can suture repair to prevent tear propagation and to avoid tenodesiis to longus

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26
Q

risk factor for poor outcome of coaltion resectio

A

adult age and > 50% facet invovlement

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27
Q

m/c sequelae after calc frx

A

Subtalar OA

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28
Q

which muscles affected first in CMT

A

intrinsics bc longest axons; then p brevis and tib ant

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29
Q

what can cause peroneal retinaculum injury

A

sudden dorsiflexion

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30
Q

complication after steroid for morton neuroma

A

hammertoe

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31
Q

after calc fracture what causes ant ankle pain

A

impingement due to lost calc height, need to restore talar declination

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32
Q

causes of turf toe

A

usualy hyperdorsiflexion with axial load;less common is same with a valgus force (beach volleyball players)

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33
Q

best clamp postion for syndesmostic reduction

A

inline with ankle axis

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34
Q

FDL transfer to extensor hood is for

A

flexible hammer toe

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35
Q

tx for flexible mallet toe

A

FDL tenotomy

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36
Q

what radiographic sign indicates hallux will recurr

A

medial sesamoid position. It should be well centered otherwise recurrence

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37
Q

when evaluating surgery for flat foot consider

A

TMT fusions if mid foot collapse; don_t jump straight to medializing calc osteotomy

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38
Q

diabetic foot infection on IV abx what next

A

debridement; no immediate amputation unless unstable

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39
Q

diabetic nec fasciitis organism

A

usually polymicrobial; if single isolate then Group A strep

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40
Q

chopart amputation is through

A

HINDFOOT - between Talonavic and Calccuboid

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41
Q

does steroid help with mortons’ neuroma

A

not for long term

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42
Q

why do you need two incision for talar neck

A

bc need to restore medial comminution to avoid varus collapse and then use better bone on lateral side for fixation

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43
Q

dorsomedial cutaneous nn over great toe is branch of which nn

A

Sup peroneal nn

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44
Q

does timing of talar neck oRIF impact osteonec

A

NO

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45
Q

tx of kohlers

A

self limting so no cast; but generally just supportive arches and activity modification

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46
Q

cut offs for wound healing (ABI, TcO2, Toe pressure)

A

ABI> 0.45; TcO2 > 30; or toe pressure > 40 (can be skewed by calicified vessels)

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47
Q

where does sup peroneal nn exit

A

10-12cm above tip of lateral malleolus; intermediate branch is for dorsal lateral foot

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48
Q

p brevis tendon repairs vs debridement

A

if > 30% debride tendon and tubulerize; tenodsesis after 50-60%

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49
Q

ankle fracture in poor controlled DM consider what surgery

A

perc fixation and NWB

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50
Q

tx of chronic lateral process talus fractures

A

fragment excision - look for sinus tarsi pain

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51
Q

tx of bunnionette

A

type 1 - cut head; type 2 chevron; type 3 is with wide IMA and do dipahyseal oseotomy

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52
Q

best IMAGING study for syndesmosis injury

A

MRI

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53
Q

what is the goal of the gravity stress

A

to assess deltoid ligament injury in setting of lateral malleolar injury

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54
Q

when to use bulk talar allograft

A

shoulder talus lesions that are too big for OCD transplat - in younger patients to avoid fusion

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55
Q

what is the approach for talocalc coalition

A

between FDL and FHL

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56
Q

what is the approach for calcaneonavicular coaliton

A

latearl over sinus tarsi

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57
Q

most effective non op for PTTD

A

AFO

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58
Q

anterior ankle impingment first step tx

A

consider steroid injection before scope bc uusally not a bony impingement but rather a fat pad

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59
Q

anke OA with adjacent degen whats best option

A

TAA if possible bc fusion will exacerbate adjacent OA

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60
Q

nerve at risk during retro TTC nail

A

lateral plantar nn

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61
Q

achilles gap options

A

<2cm primary repair; 2-5cm - V-Y; > 5cm or chronic do turn down and FHL augment

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62
Q

which coalitions are hard to see on plain film

A

Talocal - need ct or MRI

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63
Q

what exercises are a.w achilles ruptures

A

PLYometric; isometric and isotonic are NOT effect for tendinosis

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64
Q

transverse tarsal amputaiton is same as

A

chopart - b/w Talonavic and calccuboid - needs achilles lenghten and tib ant transfer to talar neck

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65
Q

patient with recalcitrant plantar foot pain with several injections - consider_

A

heel pad atrophy and tx is more heeling padding

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66
Q

INITIAL bracing for PTTD

A

AFO; then can consider a custom orthosis with medial support

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67
Q

non healing plantar hallux IP ulcer

A

if tissue conditions are good then consider Keller resection; any fusion would worsen then problem.

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68
Q

when does post tib function during gait

A

during terminal stance to iniate elevation and inversion of hindfoot

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69
Q

TAA vs Fusion in function

A

increased stride length, cadence, and velocity in ankle arthroplasty.

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70
Q

failed ankle replacement due to PJI what next

A

staged fusion

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71
Q

flatfoot recon options don_t forget to evaluate

A

MIDFOOT collapse - must fix this

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72
Q

indications for supramalleolar ankle osteotomy

A

near normal ROM; minimal talar tilt or varus heel; MEDIALLY ankle OA no worse than A or 3A on Tanaka Scale

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73
Q

Tanaka Ankel OA classification

A

1 -early sclerosis, osteophytes NO joint space narrowing; 2 is meial joint space narrowing; 3 is subchondral bone contact with lost MEDIAL joint space; 3b is whole dome is involved, 4 is complete bone contact

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74
Q

medial vs lateral OCD

A

medial - no trauma; more posterior; and larger/deeper; Lateral - trauma; superifical/shallow; central or anterior; less likely to heal spontaneously and more symptomatic

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75
Q

tx of plantar fascia ruptures

A

cast immobilization

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76
Q

diagnosis of charcot vs infection via imaging

A

MRI and Indium 111 bone scan

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77
Q

posterior tarsal tunnel defined by

A

flexor retinaculum (lacinate lig); calcaneous is medial; talus is medial; abductor hallicus is inferior - includes tibial nn, post tib artery, FHL, FDL, PT

78
Q

tibial nerve branchign in foot

A

medial and lateral plantar (each has their own sheath and bifurcation is distal to tarsal tunnel) medial calcaneal nerve

79
Q

Anterior tarsal tunnel space defined by

A

inf ext. retinaculum; fascia over talus and navicular - contents include DP nn, EHL, EDL, and dorsalis pedis

80
Q

role of the subtalar joint in gait

A

during early stance it convets internal tibial rotation to foot pronation and calc eversion

81
Q

medial subtalar dislocation features

A

more common; inversion, plantar flexion mxn; foot locked in supination; sus tali acts as a fulcrum for neck of talus; a/w post proces talus, navicular frx, reduction is usually blocked by peroneal EDB talonavic joint capsule

82
Q

lateral subtalar dislocaitons features

A

open; eversion/plantar flexion; ant process of calc is the fulcrum; foot locked in pronation; a/w lat process talus frx, ant calc; cuboid; fibula - reduction blocked by PT, FHL, FDL

83
Q

after subtalar dislocation is reduced - whats next step

A

CT - look for associated fractures

84
Q

optimal position of ankle fusion

A

neutral DF; 5-10 ext rot; 5 hindfoot valgus; 5mm post talar translation

85
Q

risk factors for ankle fusion NONunion

A

previous substalar fusion and VARUS

86
Q

scope vs ankle fusion

A

shorter hospital stays with scope with SIMILAR outcomes and fusion rates

87
Q

dorsal vs lateral plates for fibula frx

A

dosral is stronger but peroneal irritation

88
Q

muller weiss disease

A

adult onset navicular AVN - typiall talus goes lateral - requires medial column fusion

89
Q

when to perform Lapidus for Hvalgus

A

in addition to OA, or severe IMA deformity; also look at second MT for transfer stress reaction caused by hypermobile 1st TMT joint

90
Q

ideal tx of transfer metatarsalgia

A

pad directly proximal to MT head to offload area

91
Q

main imbalance in CMT

A

P longus overpowers the Tib Ant forcing first ray in PF leading to varus

92
Q

TMT amputation requires

A

Achilles lengthening; transfers wont heal and arent strong enough to balance out achilles

93
Q

upposed pull of post tib can result in

A

HINDfoot valgus as midfoot gets pulled into supination

94
Q

when is distal MT osteotomy enough for Hvalgus

A

if IMA < 13-15 and HVA < 25

95
Q

indications for distal and prox MT osteootomy for H valgus

A

HVA 40-50 AND IMA > 16

96
Q

when to MTP fuse for h valgus

A

CP, Downs; RhA, Gout, Ehlers Danlos

97
Q

when to lapidus

A

MT primus varus; concomittent pes planus; very large IMA; 1st TMA OA; or hypermobile TMT (look for stress frx at MT 2)

98
Q

tx of heel pad atrophy is

A

more padding

99
Q

what is displaced inferiorly in calc frx

A

lateral aspect of posterior facet. Medial aspect is the constant fragment

100
Q

p brevis vs p longus at peroneal tubercle

A

p tubercle is on calc, Brevis is DORSAL

101
Q

tx algorithm for peroneal tendon tears

A

if small tears - debride, repair/tubulerize, if type 2 (one is unsuable and one is good -then tenodesis to each other); if type 3 - both are useless, then allograft transfer if muscle excrusion is present, otherwise FHL transfer

102
Q

FHL transfer to achilles vs debride and repair - whats the diff

A

FHL transfer has increased ankle PF without compromising Hallux PF

103
Q

eval of turf toe requires

A

MRI; stress dorsiflexion view is not usually possible in acute setting

104
Q

high IMA noted by

A

lateral sublux of the sesamoids; needs a proximal osteotomy

105
Q

lateral placement of saw in h valgus correction can lead to

A

hallux varus

106
Q

best approach for TTC fusion

A

lateral; allows acces and prep of TT and Talocalc surfaces

107
Q

first line tx of freibergs

A

metatarsal pads

108
Q

what is first portal in ankle scope and structure at risk

A

Tib Ant bc first make medial portal and use visualization to make anterolateral inorder to avoid SPN

109
Q

where does DPN and dorsalis pedis live

A

b/w TA EHL

110
Q

medial and lateral plantar nerves sit on what layer

A

plantar aspect of layer 2 - QP; lumbricals and FHL, FDL tendons

111
Q

achilles myotendinous junction turns which way at insertion

A

90 deg medial so superficial fibers insert laterally

112
Q

third layer of foot contains

A

Adductor Hallucis (oblique, transverse heads), FHB, FDMB

113
Q

talar body main blood supply

A

retrograde via arter of tarsal canal; more recent studies show blood supply comes from post tib.

114
Q

where are navicular stress fractures

A

dorsal third

115
Q

Deep peroneal innervates

A

Tib Ant, EHL, EDL, and innervates EDB and EHB in foot

116
Q

transverse tarsal joints during heel strike

A

subtalar everts making these joints PARALLEL and UNLOCKED for uneven ground

117
Q

ATFL is under greatest strain in what postion

A

PF, inversion, int rot.

118
Q

CFL is under greatest strain when

A

DF and inversion

119
Q

tibia rotation and DF vs PF

A

DF is coupled with tibia internal rotation; PF is coupled with tibia EXT rotation

120
Q

what percentage of H valgus is familial

A

70% have a familial history

121
Q

normal IMA

A

<9-10.

122
Q

HVA normal

A

< 15deg

123
Q

PPAA

A

is prox phalanx base angle vs diaphysis ; should be < 15

124
Q

what is AKIN osteootmy and when

A

prox phalanx medial closing wedge - done for > 10 deg difference

125
Q

When to usse Chevron

A

IMA < 13; HVA < 30; if DMAA >10 need a biplanar

126
Q

when to perform MTP fusion for h valgus and how much

A

if HVA > 40; fuse with 10-15 of valgus and 10-15 DF - done in CP, RhA

127
Q

what is presentation of a severe turf toe

A

MTP hyperextesion with IP flexion (intrinisc minus)

128
Q

what happens if you see sesamoid migrated PROXIMALLY

A

plantar plate rupture

129
Q

problem with bone scan and sesamoid injury

A

25-30% increased uptake on asympomatic patients

130
Q

juvenile H valgus features

A

up to 50% can have congruent high DMAA; higher recurrence, can be a/w metatarsus adductus

131
Q

surgery for freiberg

A

dorsal closing wedge to bring unaffacted plantar cartilage up and also causes shortening which helps

132
Q

Mallet Toe joint positions

A

MTP is neutral; PIP neutral; DIP flexed

133
Q

Hammertoe joint positions

A

MTP extended; PIP flexed; DIP extended

134
Q

Claw

A

MTP extended; PIP flexan DIP Flex

135
Q

tx of mallet toei

A

if flexible - perc FDL tenotomy

136
Q

Hammer toe surg

A

resection arthroplasty with FDL tenotomy

137
Q

pathophys of claw toe

A

tight flexors pull IP joints in flexion while MTP extends and MT head is depressed pulling plantar plate distally

138
Q

normal 4-5 IMA

A

< 9; tx with diaphyseal rotation if > 12

139
Q

dwyer calc osteotomy moves which direction

A

LATERAL

140
Q

what is mod Bronstrom

A

using Inf peroneal retinaculum to make anatomic augment of lateral ATFL and CFL

141
Q

what is normal tib fib clear space

A

MORE THAN 6mm on AP; 1mm on mortise

142
Q

main downside to NON-anatomic lateral lig recone

A

subtalar stiffness

143
Q

where is antero medial portal in ankle

A

MEDIAL to Tib ANT at level of tip of malleolus - if placed too medial (m/c error) then malleolus blocks view

144
Q

Anterolateral ankle impingment 2 locations

A

seen with lateral ankle instability; m/c location is sup border of ATFL; and then distal aspect of AITFL

145
Q

best way to diagnosie ankle impingement

A

exam - PF and direct pressure; better than MRI

146
Q

what is basset ligament

A

inferior aspect of AITFL invoveld in syndesmotic antero lateral impingment

147
Q

supramalleolar ostoetomy for varus deformity_

A

medial opening wedge; if > 10deg need a fibular osteotomy too

148
Q

supramalleolar ostoetomy for valgus deformity_

A

medial closing wedge with oblique fibular osteotomy for lengthening

149
Q

limitations of scope fusion

A

cant correct deformity

150
Q

what is consequence of fusion in ankle PF

A

knee goes into recurvatum to accommodate

151
Q

main downside of TAA vs fusion

A

MUCH higher revision surgery rate

152
Q

hindfoot OA m/c caused by

A

trauma

153
Q

isolated TN OA caused by

A

inflammatory conditions (RhA)

154
Q

which joint OA limits hindfoot motion most

A

Talonavicular - 90% of motion is limted if TN is fused - therefore if TN is bad - do a triple fusion anyways

155
Q

which joint fails to fuse in Triple fusion

A

Talonavicular

156
Q

pain with extreme PF in hallux rigidus is caused by

A

draping of dorsal capsule and EHL over a osteophyte

157
Q

best fixation for MTP fusion for h rigidus

A

compression screw and plate - goal is 15 deg valgus; and 25 deg DF

158
Q

does achilles invert or evert hindfoot

A

INVERT - even though hindfoot is valgus - achilles inserts on medial aspect of axis of rotation

159
Q

when to add tendon transfer to achilles injury

A

if > 50% is inflammed or older patients > 55 (FHL, FDL or even P brevis)

160
Q

diff in wound size for achilles repair

A

perc and mini open do have lower wound issues but higher sural nerve issues with perc vs regular open

161
Q

inssertions of Post tib

A

anterior limb to navic and first cuneiform; middle limb to 2-3cuneiform, cuboid and 2-5MT: and final limb is to sus.tali

162
Q

post tib during stance phase

A

eccentric contracture to take load off spring ligament

163
Q

main antagonnist of post tib

A

p brevis

164
Q

what is evans osteotomy

A

lateral column opening via ant proces of calc

165
Q

if you need to perform triple fusion but tissue is bad

A

consider medial incision only talonavic and subtalar fusion; CC can be ignored

166
Q

Pb tears vs p longus tears

A

P brevis tears are more common at level of FIBULAR groove

167
Q

tib ant insertion

A

1st cuneiform and medial 1st met base

168
Q

when to repair hallucis flexor laceration

A

if both FHL and FHB are out. Isolated FHL is controversial

169
Q

FHL vs FDL at knot of henry

A

FHL crosses dorsal to FDL

170
Q

posteromedial ankle pain with toe motion

A

consider FHL pathology - tenosynovitis

171
Q

how to acute P brevis/longus tears occur

A

acute inversion to a dorsiflexed ankle

172
Q

tx of calc stress frx

A

do not need NWB - but walking cast or boot 4-6 weeks is enough

173
Q

common deformity in lesser toes with CMT

A

claw toe - due to strong intrinsics

174
Q

order of muscle involvement in CMT

A

intrinsics; P brevis then tib ant

175
Q

TAR vs fusion in adjacent OA

A

TAR has less progression of degen on XR

176
Q

pain that dreases with traction across toe and motion

A

phys exam test for synovitis

177
Q

what does RhA do to lesser MTP joints

A

valgus deviation and clawing

178
Q

how does mortons extension work

A

limits MTP dorsiflexion to minimize pain

179
Q

if both peroneals are damaged and no excursion

A

FHL transfer

180
Q

if recalcitrant plantar fascitis and sx of nerve sx what is surgery

A

distal tarsal tunnel release AND partal PF release

181
Q

what is best stretching protocol for plantar fascitis

A

NWB Achilles stretches is better than WB stretches

182
Q

what does baxters nn innervates

A

sensation and motor to FDB and abductor quinti minimi - often compressed with people who spend time on toes (ballet, sprinters)

183
Q

how long should non -op for baxters last

A

at least 6 months

184
Q

pain with fat pat atrophy of heel vs PF pain

A

Fad pat atrophy pain is more proximal and more lateral

185
Q

patho of neuroma

A

not a true neuroma - has perineural fibrosis and endoneural thickening

186
Q

local analgesic vs steroid for neuroma

A

equal effectiveness at 3 and 6 months

187
Q

what position worsesns tarsal tunnel

A

DF and eversion

188
Q

pathoanatomy of CMT foot

A

first week intrinsics lead to high arch and clawing; then weak tib ant gets over powered by P longus in 1st ray; then p brevisis weak and overpowered by PT

189
Q

what soft tissue procedures for CMT

A

transfer p longus to brevis; release TN joint and medial tissue and post tib lengthening to counter the varus forces; can also transfer Post tib to front

190
Q

what is ABI cutoff for POOR healing in feet

A

if ABI <0.45 poor wound healing

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