Foot Ankle/Hand 12OCT Flashcards
What drives the Cavovarus foot?
The plantarflexion of first ray- PL mainly (antagonists by weak TA)
- Coleman blcok hindfoot corects then you can correct with forefoot osteotomy
- NO correct- then need hindfoot osteotomy
Treatment for cavovarus foot
- calc- lateral clsoing wedge- no flexible
- PL to PB transfer
- Lengthening procedure
- Plantar flacia release
- dorsiflexion osteotomy
- Overload of lateral forefoot- stress fractures
Rigid flatfoot (PTTI) will need what
ARTHRODESIS- Triple
Orthosis for fixed versus NON fixed deformities:
For FIXED you simply support and accommodate
for mobile yo counteract
With corrected hindfoot in PTTI and forefoot varus (supintation) will need what?
Will need plantarflexion of the first ray some how (arthrodesis or osteoetomy (Cotton))
What transfer is used in conjunction with flatfoot surgery?
FDL transfer
DMAA normal shoulder be?
<8d
- IF increase DMAA the need osteotomy distally is joint congruent
- IF incrase DMAA and INCONGRUENT- needs lateral release, medial capsulorraphy
If you see OVERPRONATION on Hallux Valgus then
you know you have to do soft tissue release (laterally)
What is deformity of talar neck non-union or mal union with medial compression screws?
VARUS malunion
- will lose EVERSION
Camper Chiasm is where
When FDP goes thorugh FDS slips at level of PIP
How many strands do you need to have active motion protocol in flexor tendon repair
- need at least 4
Where is A2 and A4 pulleys?
A2- Proximal proximal phalanx
A4- middle middle phalanx
When is tendon repair the weakest?
between 2-3 weeks( goes down before it goes up), dorsal placement is stronger, usually rupture at knots
LeDDY type of flexor tendon injury?
type 1- tendon to palm- disrupts the blood supply, have to get to it soon.
Type 2- most common- FDP to campers chiasm- don’t have to be as urgent
Proximal Pole of scaphoid and displaced?
DORSAL approach and ORIF (even if 1mm displaced)
ORIF scaphoid indications:
- proximal pole
- any displacement
- humpback deformity
- intrascaphoid angle greater than 35
What is position of wrist with scaphoid fracture occurs?
extension an radial deviation
- the proximal POLE has greatest risk for AVN
What is the scaphoid view?
PA, 30d extension, 20d ulnar deviation
What is the best study to look for union of scaphoid/
CT
Get an MR with
Non op scaphoid?
- Non-displaced waist
- Distal poles
Proximal pole non-union after some time treatment in young person:
- Need new vascular supply
- free vascularized medial femoral condyle graft
MFC graft
- based on the descending genicular artery
- used for proximal pole non-union or non-union of scaphoid with AVN
What is most sensitive test for carpal tunnel?
Durkens compression test
Good prognostic factors for CTR?
- nighttime symptoms,
- relief with steroid injections
What is associated with poor prognosis after CTR?
EMG changes pre-op NCV - Sensory only- mild - sensory and otor- modA ANY EMG changes means CTR should be first line of treatment
NCV : increased latencies
DSL: >3.5
DML >4.3
any EMG changes makes it sever (fibrillations
Volar Middle PHalanx with NO tenosynovian flap?
Cross finger flap (use reverse cross finger when the exposed portion is DORSAL ratehr than volar)
- can also do reverse cross finger flap
(Moberg is a volar advancedment flap for thumb defects?
What does it mean when they report NO tenosynovium over tendons when asking about flaps
Means you CANNOT use skin graft to cover
Distal figner tip amps?
Transverse: (VY advancement, Moberg(thumb))
Dorsal Oblique: (VY OR bone shortening with volar flap
Volar Oblique: NO VY, so see cross finger flap, thenar flap, island flaps
What is a complication of a thenar flap?
Stiffness and adhesions
What about dorsal proximal thumb flap used to cover?
1st dorsal metacarpal arter flap
FDMA
A 60d Zplasty give you how much length?
75%
45d give you 50%
Absolute indications for replant:
- children
- thumb
- multiple metacarpals (fingers)
- wrist or proximal
Contraindications for replant?
- crush a avulsion
- segemental
- prolong ischemia time (
Warm ischemia time
PROXIMAL to carpus- 6 hours
Cold is 12 hours
Distal to carpus ischemia time:
12 hours of warm
24 hours of cold
Orders of Structures for replant
- Bone
- Extensors
- flexors
- Artery
- Vein
- Nerve
- SKin
Leeaches questions?
- Huiridin- anticoagulant
- aueroguinosa hydrophillis
- cipro and bactrim
What size gap do you have to nerve graft?
For greater thatn 2.5cm nerve defets
- if 7mm to 2.5 cm you can use collagen conduits or other grafts, greaterter athatn 2.5 need nerve graft
Which is most favoral nerve to repair in UE?
Radial» median»»ulnar is bad
What structure is vilated in dorsal PIP dislocation?
volar plate
- need to splint in flexion to approimate volar plate, NOT let swan neck occur
PIP fractrue dislocaiton, when to ORIF?
if greater than 40% of join invovled
With volar PIP dislocation splinting after reduction?
- central slip is injury, need to splint in extension after reduction
- if you Dont splint right you get boutinerres
Elsons test?
central slip injruy detection
- PIP at 90 degrees with extension the DIP will hyper extend via the lateral bands- central slip njry dur to lanteral bands falling forward
Hook of Hamate Fx: best view?
carpal tunnel view
- chornic or delayed presenation: excision of HofH
- parasthesia to small and ring
- CT if not seen on plain films
Ulanr nerve compression
- arcade of struthers
- Medial intermuscule septum
ME - Cubital tunne
- FCU apaneurosis
Warternburgs Sign:
cant addcut toe SSF due to EDM unoppsoed- first sign of ulnar nerve neruopathy
Froments sign?
Use FLP to hold paper pinch: Adductor pollicus is out, ulnar nerve deficits , appears AFTER Wartenburgs sign
revision ulnar nerve transposition locations?
needs to be sub muscular
What is most common ulnar nerve entrapment at guyon?
ganglion cyst
Fleshy nodules on the dorsal joints associated with Dupuytresn treatments?
DO NOTHING
What it type of colagen in dupuytrenas and cell type
Type III and myofibroblasts
Operative indications for Dupuytrens
> 30mcp, ANY PIP contractures
Nerve is PUshed centrally and Volarly
SPIRAL CORD (spiral band is nomrla structure) spiral cord causes the the PIP
Pretendionus cord is where?
is in the palm and cases MCP joint contracture (central Cord)
What causes webspace contracture in duputryns ?
Natatory chord
cords are pathologic, bands are normal
Herpetic Whitlow buzz fingers words:
- herpetic whitlow- TX is observtion or Acyclovir
- no I&D
- Acyclovir
- Tzank Prep
- vesicular ting on fingers
- dental hygenist, toddlers
Typical bacteria for Nec Fasc?
Group A Strep
- dishwater puss
- how quikcly to I&D
Atypical Mycobateria- insideious onset: what type of staining
Zeihl Nielsen staining
Lowenstien-Jensen stain/culture medium?
used for atypical mycobacterium
-
SLAC_ scapho-lunate advanced collapse
- SL ligament injury at some point
1. radial scahpoid
2. entire radioscahpoid
3. capitolunate joint (
radiolunate joint is usuallly preserved
When can yo NOT do the PRC?
- when the proximal capitate is alreayd arthritic-
- would need to do a four corner fusion
- when you see narrowing at the mid-carpal joint you CANT do PRC- if not scaphoid excision at 4cf
Dorsal Hand Wound reconstruction?
- Groin flap
- reverse radial forearm flap (needs intact Allens Test)
- Posterior interosseous artery flap
Kienbocks associated with ulnar variances?
- ulnar negative variance, can sometimes shorten the radius
Staging system of Kienbocks?
- no changes on Xray, only MRI
- Sclerosis no collapse
3A- COLAPSE
3B- collapse and rotaiton of scaphoid
4- endstage arthritis
Radial core decomprssion for keinboacks stage?
Stage II- NO collapse, sclerosis
can also do joint leveling procedures - if ulnar negative (radial shortening osteotomy)
Stage III Kienbocks
you have lunate collapse
Stage iiiA-
Stage IIIB: PRC, fixed rotation of the scaphoid
What makes the lunate too far gone in Kienbocks for salvage?
Fixed scaphoid rotaiton- keinbocks
CRPS vitamin C dosing (prevention)
500mg for 8 weeks
EPL rupture are non-op radius treatment- tendon transfer?
EIP transfer
Tendon rputures ove a volar plate?
FPL> FDP to the index
Lumbriclas attached where?
From FDP to the RADIAL Lateral band
- if you disarticualr the DIP, FDP retract, pulle on lumbricle to radial lateral band. Will paradoxical EXTENSION of PIP when making a fist
TX: release of radial lateral band
Bennet Fractrue reduction manuever?
Traction, IR, ABDuction
- deforming forcces are APL and Adductor pollicis
- volar oblique ligamanet
The most common location for metatarsal fracture in patient <5 yo?
The 1st Metatarsal
Claw two treatment based on what?
Flexible or non-flexible (MTP Hyper extension, PIP/DIP flexion)
Flexible- FDL transfer (tendon transfers)
Non Flexible- Osteotomyies, capsulotomies
What improves the wear properties of polyethylelne the most?
Gamma Irradiation
- Cross linking in inert gas
ACtive form of Vitamin D?
1.25- dihydroxycholecalciferol
Unique Aspect of 1st and 2nd Lumbricals?
Unipenate
- Arise from the radial aspect of Profundus
ALL insert on lateral band
Normal Sensory Latency?
<3.5ms
What is hypothenar hammer syndrome?
Injury, ulnar artery aneurysm at Guyon canal . Can lead to digital artery necrosis. Surgery if DBI < 0.7
General Electrodiagnostic parameters of Carpal Tunnel?
Distal Motor Latency >4.5ms
Distal Sensory Latency > 3.5ms
NCV <52m/s
What is involved in Dupuytryen contracture? Graysons or Clelands?
Graysons ligament
- More volar than Clelands
What is the treatment of Giancell Tumor Of tendon Sheath?
Marginal Excision- recurrance is high with complete excision
In treatment of CMC arthritis, when should you combine a MCP joint arthrodesis with CMC resection arthroplasty?
With MCP hyper extension >30d
Progression of SLAC wrist (Scapho-lunate advnaced collapse?
1- Scaphoid- radiostyoid
- Works Radio-scaphoid to llunate
- Proximal Migration of the Capitate- lunate capitte
Intersection Syndrome occurs where and between what dorsal compartments ?
Between 1st and s@nd (APL,EPB) and ECRL/ECRB
AIN muscle innervation?
FPL
Radial FDP
Pronator Quadratus
How long can you Non-op Pediatric trigger thumb?
Don’t have to do surgery until 2 years old
EMG changes on preop EMG in CTR symptoms at one year?
20%
What contributes to web space contracture in Dupuytrens?
Natatory cord
What ligament is involved in dupytyrens? Clelands or graysons?
Graysons
What happens when central slip is injured?
Lateral bands move more volar, flx PIP, extend DIP- Boutineres
What does a lumbarical do to MCP, PIP, DIP?
Caused MCP flexion
PIP/DIP Extension
Attached to FDP
What is NOT out in PIN versus radial nerve palsy at level of wrist?
ECRL is supplied by the radial nerve
PIN pretty much supplies every thing else common extensors, deep extensors
FCR–> finger extensors
Palmaris__> EPL
What anatomic structure must be excised during volar plate arthroplasty?
Collateral ligament
Flexion contractures that involve the PIP joint of small finger
Camptodactyly
- non op for <30d
- FDS tenotomy /transfer
What do you do when EPL rupture with ND radius fracture? Fix or transfer
EIP to EPL
- usually nutritional in nature,
radial to ulnar ligaments looking from 3,4 portal
Radial (RSC->LRL–>SRL)
Leddy Type of Flexor Tendon Injuries?
Type I: Retracts to the level of the palm- Vincula is disrupted and needs to be fixed within 1 week
Type II: Retaracts to Level of PIP- Held out by FDS and vincula- Can be fixed up to 6 weeks
What Symptoms are good prognositc indicators for relief following CTS?
NIGHTTIME SYMPTOMS
RElief with CSI
Replant Times? Proximal to Carpus and distal to carpus
PROXIMAL TO CARPUS?
Warm- 6 hours
Cold 12 HOurs
Distal to Carpus Amputaiton?
Warm: 12 hours
Cold: 24 hours
Leeches Complication?
Aeromonas Hydrophilia
BACTRIM OR CIRPO
Arcade of Struthers Compresses what Nerve?
Ulnar Nerve
At level of proxmal IM septum
Arcade of Frosh Compresses what nerve?
PIN ( radial Nerve)
The proximal portion of the suppinator muscle
What nerve is most at Risk in elevating Groin Flap ?
Elevated on superficial circumflex A
and Lateral femoral cutaneous N is at risk
What is the vessel that supplies that Lattisimus Flap?
Thoracodorsal A.
Operative INidcations for Dupys?
30 degrees at MCP
ANy contracture at PIP
What is most common organism of Nec Fasc?
Group A Beta Hemolytic Strep ( GABHS)
Inidcations for Palmar Fascia Release in Dupy?
MCP >20-30
PIP ANY Flexion
Structures that case Flexion in Dupy PIP? DIP? Web Space? MCP?
PIP- Spiral Chord
MCP: Central Chord
Web Space? Natatory chord
DIP: Retirvascular chord
Gram Stain of P Acnes?
Gram Positive
Anaerobic Bacillis
Lives IN skin not ON it
What is stainless steel made of?
IRON CARBON CHROMIUM NICKEL MAGNENESE MOLYBBENUM
What is cobalt chrome made out of?
Cobalt
Chrom
Molybdenum `
enneking of MSTS Staging System?
I- Low grade II- High Grade A- Intracompartmental B- Extracompartmental III Metastatic
