Lower Extremity Flashcards
Which of the following conditions is a relative CONTRAINDICATION for use of the flap in the image - posteromedial wound of LE and reverse sural aa flap - shown for reconstruction of an 8 x 10-cm anterior ankle wound?
A) Diabetes mellitus B) Hypertension C) Joint exposure with loss of the joint capsule D) Occlusion of the peroneal artery E) Underlying osteomyelitis
The correct response is Option D.
Hypertension does not preclude the use of any fasciocutaneous flaps in the lower extremity.
Diabetes mellitus can be associated with peripheral vascular disease, but by itself, would not prevent successful use of the reverse sural artery flap for foot or ankle reconstruction. Appropriate preoperative workup would include noninvasive ultrasound study of the lower extremity vasculature to prove the peroneal artery was patent.
Vascularized flaps, including the reverse sural artery flap, provide excellent coverage for foot/ankle wounds, including those with underlying osteomyelitis. Effective treatment would necessitate adequate debridement and antibiotic therapy as part of the reconstructive paradigm.
The distally based sural artery flap receives its blood supply from a few sources, the most robust of which are perforators from the peroneal artery. The most distal of these perforators arise between 4 and 7 cm proximal to the lateral malleolus. Additional perfusion arises from neurocutaneous perforators from the sural nerve and venocutaneous perforators from the lesser saphenous vein.
2018
A 61-year-old man comes to the office for evaluation of a 3 x 3-cm calcaneal defect with exposed bone. Medial plantar flap reconstruction is planned. The principal blood supply to this flap arises from which of the following arteries?
A) Arcuate B) Dorsalis pedis C) Peroneal D) Plantar arch E) Posterior tibial
The correct response is Option E.
The primary blood supply to the medial plantar flap is the medial plantar artery, a terminal branch of the posterior tibial artery. The dorsalis pedis is the continuation of the anterior tibial artery and does not contribute to this flap. The peroneal artery is a proximal branch of the posterior tibial artery and descends in the deep posterior compartment posterior to the tibialis posterior and anterior to the flexor hallucis longus; it does not contribute to this flap. The arcuate artery is the terminal branch of the anterior tibial artery. The plantar arch runs on the plantar aspect of the foot at the level of the metatarsals; it is formed from a confluence of the lateral plantar artery and the deep plantar artery from the dorsalis pedis.
2018
A 60-year-old man sustains a Gustilo type IIIB open fracture of the distal left tibia during a boating accident. There is severe contamination of the wound, and the patient undergoes multiple formal washouts in the operating room. There is no neurovascular compromise of the extremity. He undergoes external fixation to stabilize the limb. Which of the following is the most appropriate next step in treatment?
A) Coverage with a free tissue transfer
B) Negative pressure wound therapy until secondary healing is achieved
C) Pedicled gastrocnemius muscle and skin grafting
D) Primary bone allografting
E) Split-thickness skin grafting
The correct response is Option A.
The Gustilo classification describes open fractures of the tibia by the severity of the soft tissue injury overlying the fracture. In patients with IIIB injuries, there is extensive soft-tissue loss and periosteal stripping, but no vascular compromise requiring repair.
Gustilo classification:
Type I: The wound is less than 1 cm long. There is little soft-tissue damage and no sign of crush injury. There is no or minimal comminution of the fracture.
Type II: The laceration is more than 1 cm long but there is no extensive soft tissue damage, flap, or avulsion. There is slight to moderate crushing injury, moderate comminution of the fracture.
Type III: Extensive damage to the soft tissues, including muscle, skin, and neurovascular structures, and a high degree of contamination.
- Type IIIA: Soft tissue coverage of the bone is adequate.
- Type IIIB: Extensive injury to or loss of soft tissue, with periosteal stripping and exposure of bone, massive contamination, and severe comminution of the fracture from high-velocity trauma
- Type IIIC: Any open fracture with a vascular injury requiring repair.
Free tissue transfer will bring healthy, nontraumatized tissue into the area to cover the exposed broken bone. Multiple recent studies have shown equivalence of muscle versus skin/fat/fascia flaps for coverage of the open fracture even in patients with osteomyelitis. Negative pressure wound therapy has proven to be an excellent adjunct in the management of patients with these injuries. Between washouts, negative pressure devices can help decrease edema and isolate the wound and bone from the outside world. In a patient with a IIIB injury, there is insufficient tissue available to cover the wound. Therefore, secondary intention would not close the wound.
Split-thickness skin grafting provides an epithelial barrier to help seal off a wound from outside contamination. Grafts require a viable wound bed to survive. There must be a pliable bed to help grafts resist minor trauma in the future. With the periosteal stripping in this type of injury, a graft would not survive. In addition, graft placed directly on bone with periosteum would be very vulnerable to breakdown from minor trauma.
Bone allografting can be used to bridge defects in many circumstances. In the patient described, the severe contamination of the initial injury would make bone allografting much less appealing than autografting. Because of contamination, any type of bone grafting may need to be delayed until after achieving stable soft tissue coverage of the fracture.
A pedicled gastrocnemius muscle flap provides excellent coverage for defects about the knee, including the proximal tibia. Although the free gastrocnemius muscle flap could be transferred to any location, the pedicled flap would not be able to reach the distal tibia.
2018
A 50-year-old man comes for evaluation 8 weeks after dislocating the right knee when he tripped on a railroad tie at work. Physical examination shows a right footdrop and dysesthesia along the lateral lower leg and dorsolateral foot. Electromyography and nerve conduction studies are most likely to confirm injury to which of the following nerves?
A) Femoral B) Peroneal C) Plantar D) Sural E) Tibial
The correct response is Option B.
The peroneal nerve innervates the tibialis anterior and extrinsic extensors of the toes, thereby extending the ankle. Paralysis of these muscles leads to footdrop. The sural nerve is a cutaneous nerve about the lateral ankle. The tibial nerve innervates the ankle and toe flexors, and paralysis of this nerve would not lead to a footdrop. The femoral nerve runs in the anterior thigh and is not likely to be affected by a knee dislocation; it innervates the extensors of the leg at the knee. The plantar nerves are the terminal branches of the tibial nerve and provide intrinsic innervation to the foot and sensation to the medial and lateral plantar foot.
2018
A 40-year-old man sustains an avulsion of the weight-bearing portion of the medial heel. Coverage with an instep flap is planned. Sensation to this flap is provided by which of the following?
A) Lateral plantar nerve from the deep peroneal nerve
B) Lateral plantar nerve from the superficial peroneal nerve
C) Lateral plantar nerve from the sural nerve
D) Medial plantar nerve from the deep peroneal nerve
E) Medial plantar nerve from the tibial nerve
The correct response is Option E.
The medial plantar artery flap, or instep flap, provides sensate, full-thickness glabrous skin and subcutaneous tissue that can be transferred as a pedicled or free flap. The tissue is well suited for weight-bearing areas of the foot but has also been used as a free tissue transfer for palmar defects. Because the instep donor site is non–weight-bearing, the donor site can be covered with a skin graft. The innervation of the medial instep flap comes from the medial plantar nerve, a branch of the tibial nerve.
2018
A 65-year-old man is referred for evaluation of a 3 x 4-cm wound with exposed tendon over the distal anterior tibia after sustaining fracture to the lateral malleolus, which was successfully treated with cast immobilization. The wound had been managed with local wound care for the past several weeks. Physical examination shows a clean wound with some fibrinous exudate. Periosteum and peritenon are intact. Pulses cannot be palpated. Pencil Doppler signals in dorsalis pedis and posterior tibialis are noted. Which of the following studies is the most appropriate next step in management?
A) Ankle brachial index B) CT angiography C) MRA D) MRI E) Percutaneous angiography
The correct response is Option A.
This patient has a pressure sore from cast immobilization. He also has asymptomatic peripheral vascular disease, as is evidenced from his clinical examination. For the lower extremity to heal, adequate blood flow is required and this can be most effectively quantified with an ankle brachial index measurement. Ankle brachial index less than or equal to 0.9 establishes the presence of peripheral artery disease. Ankle brachial index between 0.5 and 0.79 yields wound healing issues and less than 0.5 results in rest pain and arterial insufficiency.
CT angiography, MRI, MRA, and percutaneous angiography can assist in delineating anatomy but they do not yield clinically helpful information about perfusion, prognosis, or stratification of peripheral artery disease.
2018
A 50-year-old man comes to the office because of a persistent nonhealing wound 6 months after he underwent open reduction and internal fixation of an open ankle fracture. Examination shows palpable pedal pulse with retained protective sensation of the foot. Which of the following is the most appropriate initial step in management of this patient?
A) Application of collagenase ointment B) Core needle bone culture C) Coverage with a free flap D) Operative debridement E) Referral for hyperbaric oxygen therapy
The correct response is Option D.
The patient is at high risk for fracture nonunion and osteomyelitis. The best next course of management is operative debridement ideally along with the treating orthopedist to make judgments about bone viability and debridement and the risks and benefits of hardware removal. Enzymatic wound debridement would not address the concerns about the deeper wound issues. The role for hyperbaric oxygen in the scenario presented is not well established. Bone cultures at the time of operative debridement should be obtained; but, percutaneous core needle cultures alone would not likely be adequate to obtain best healing. Free flap coverage may be required but is not indicated at this time.
2018
A 50-year-old woman with systemic lupus erythematosus is evaluated because of a nonhealing ulcer of the right lower extremity. It started as a small pustule 3 months ago and steadily worsened to an ulcerative lesion. Examination of a biopsy specimen ruled out malignancy. Cultures have been negative for more than 4 weeks. Debridement of the wound and skin grafting are attempted but result in loss of the graft and development of similar ulcerative areas at the donor site. Which of the following is the most appropriate next step in management?
A) Bilayer skin substitute B) Fasciocutaneous flap C) Hyperbaric oxygen therapy D) Long-term antibiotic therapy E) Systemic corticosteroid therapy
The correct response is Option E.
The most appropriate next therapy option for this patient is systemic corticosteroids. These ulcerative lesions are most likely pyoderma gangrenosum (PG), an ulcerative cutaneous condition of unknown etiology. This condition is most likely associated with other systemic diseases like inflammatory bowel disease, or immunologic diseases. This diagnosis is usually one of exclusion, and one must have a high index of suspicion for ulcerative wounds that are persistent despite adequate workup and treatment. One must be especially aware of PG’s association with a condition known as pathergy. This is a phenomenon in which surgical manipulation of the area or distant sites may trigger worsening of the ulcerative condition and/or development of the condition in an area of skin trauma. First-line therapy for PG involves the use of prednisone. Other anti-inflammatory agents, including immunosuppressive agents, and biologic agents have also been used. The prognosis is generally good; however, the disease can recur and residual scarring is common. Because of these factors, the other options are not the most appropriate next steps in the treatment of this patient.
2017
A 55-year-old man comes to the office because of an exposed knee prosthesis. Repair with a gastrocnemius flap is planned, using the entire muscle for reconstruction of the anterior knee defect and hardware coverage. The biomechanical consequence of using this flap is most likely to be observed by which of the following motions?
A) Dorsiflexion B) Foot eversion C) Foot inversion D) Leg extension E) Plantar flexion
The correct response is Option E.
The most appropriate answer is plantar flexion. The gastrocnemius muscle originates as two heads off the femur. The medial head comes off the medial condyle of the femur, just above the condyle and the lateral head comes off just above the lateral condyle. The muscle inserts onto the posterior calcaneus via the calcaneal tendon. This is the common tendon shared with the soleus muscle. Because of this fact, both heads can be harvested and the patient still maintains 75% of plantar flexion strength. The function of the gastrocnemius muscle is to plantar flex the foot and also flex the leg at the knee. Plantar flexion is the only biomechanical consequence listed above, although minimal. The blood supplies to the gastrocnemius muscle are from the sural branches of the popliteal artery and are independent. The medial head is the larger of the two and will have a larger arc of rotation. The innervation is via separate branches to each head off the tibial nerve.
2017
A 68-year-old man presents 3 months after undergoing reconstruction of a large mandibular defect following tumor resection with a right fibula osteocutaneous flap. Postoperatively, immediate footdrop is noted. Which of the following is the most appropriate next step in management?
A) Clinical observation, conservative management, and re-evaluation in 3 months
B) Exploration of the peroneal nerve, neurolysis, and primary repair if transected
C) Exploration of the sural nerve, neurolysis, and primary repair if transected
D) Exploration of the tibial nerve, neurolysis, and primary repair if transected
The correct response is Option B.
It is recommended that the proximal 4 to 8 cm of the fibula be preserved in order to prevent knee instability and to avoid injury to the peroneal nerve. In large resections, more fibula length is required and the fibular head is often useful in the reconstruction. The common peroneal nerve is formed by the lateral division of the sciatic nerve. The peroneal nerve wraps around the lateral surface of the biceps femoris tendon and fibular head and courses into the anterolateral portion of the leg. The common peroneal nerve trifurcates into the superficial peroneal nerve, the deep peroneal nerve, and the recurrent articular branch. The deep peroneal nerve innervates the anterior compartment muscles of the leg, and provides ankle dorsiflexion. Injury to the common or deep peroneal nerve can result in footdrop or weakened dorsiflexion. Given that this patient had a large resection, the footdrop is indicative of a peroneal nerve injury. Exploration is warranted. The tibial nerve is a branch of the sciatic nerve and runs in the popliteal fossa to pass below the arch of the soleus muscle. The sural nerve is a sensory nerve in the calf. Injury to the tibial or sural nerve would not cause a footdrop.
2017
A 40-year-old man is brought to the emergency department because of a grade IIIB open fracture of the right distal aspect of the tibia and fibula sustained during a motorcycle collision. The plastic surgeon is consulted after initial debridement and external fixation of the fracture. Examination shows a 10-cm open wound of the right medial ankle with complete transection of the tibial nerve. The tibia fracture is comminuted but without marked bone loss. The foot is well perfused, but single-vessel run-off through the anterior tibial artery is noted. Which of the following is the most appropriate management of this patient’s condition?
A) Debridement and free muscle flap without nerve repair
B) Debridement, tibial nerve repair, and coverage with a bilaminar acellular dermal regeneration template
C) Debridement, tibial nerve repair, and coverage with a free fasciocutaneous flap
D) Debridement, tibial nerve repair, and coverage with a pedicled reverse sural fasciocutaneous flap
E) Primary below-knee amputation
The correct response is Option C.
The answer is debridement with repair of the tibial nerve and coverage with an anterolateral thigh (ALT) free flap. This patient is presenting with a grade IIIB open fracture of the distal tibia and fibula with an open medial wound. Traditionally, lower extremity injuries with an insensate plantar foot were considered unsalvageable. However, more recent data have demonstrated that an insensate foot by itself should not be considered a contraindication to limb salvage if repair is otherwise possible. Studies have shown equivalent long-term outcomes with limb salvage and primary amputation and that half of the patients with tibial nerve injuries will regain plantar sensation within two years post-injury. This vignette describes a situation in which one could reasonably expect a successful outcome.
The size and location of the wound are most amenable to coverage with a microvascular free flap. In this instance, a fasciocutaneous flap will provide adequate soft-tissue coverage with minimal donor morbidity and potentially better long-term outcome if secondary bone grafting or hardware revision is required.
The reverse sural fasciocutaneous is a versatile flap that can be used for reconstruction of many different wounds of the distal lower extremity. The flap is a neurocutaneous flap supplied by the vascular axis of the sural nerve as well as distal peroneal artery perforators. In this case, the peroneal artery was damaged from the trauma and the pedicle of the flap is in the zone of injury, making it an inappropriate choice for reconstruction when better options are available.
The use of biologic materials such as bilaminar acellular dermal regeneration templates have been used successfully to cover wounds with exposed vital structures such as bone, tendon, and nerve. However, its use is best suited for smaller wounds or in patients in whom microvascular reconstruction is contraindicated or not desired. This patient required soft-tissue coverage over a major nerve repair and a comminuted fracture with internal hardware. A microvascular free flap would be the method of choice in this patient when feasible.
As stated previously, up to fifty percent of patients with tibial nerve injuries will recover plantar sensation after nerve repair. Nerve repair should be attempted to improve the overall outcome.
2017
A 49-year-old man comes to the office because of dull, aching pain over the dorsum of the foot. Nerve study shows no abnormalities of the nerves around the knee but chronic denervation in the extensor digitorum brevis at the dorsum of the foot. Which of the following nerves is most likely to be entrapped?
A) Anterior tibial B) Deep peroneal C) Lesser saphenous D) Medial plantar E) Medial sural
The correct response is Option B.
The deep peroneal nerve emerges from the leg anterior compartment musculature, from beneath the extensor retinaculum of the ankle. The nerve gives off a motor branch to the extensor digitorum brevis, and then terminates into the first web space of the foot, after running beneath the tendon of the extensor hallucis brevis. Entrapment of this nerve, as it exits the extensor retinaculum of the ankle, can manifest itself as pain, weakness, or numbness or tingling over the dorsum of the foot. The saphenous nerve innervates the cutaneous region over the anterior-medial aspect of the distal leg and ankle. The medial sural nerve innervates the cutaneous region over the posterior lateral aspect of the lower leg. The tibial nerve innervates the plantar surface of the foot. It divides into the medial and lateral plantar nerve over the plantar aspect of the foot. The medial and lateral plantar nerves innervate the cutaneous aspect of the plantar foot and the intrinsic musculature of the foot.
2017
A 62-year-old man comes to the office because of an open ankle fracture with exposed hardware. Use of a sural artery flap for reconstruction is planned. Which of the following veins must be harvested within the flap?
A) Anterior tibial B) Lesser saphenous C) Peroneal D) Popliteal E) Posterior tibial
The correct response is Option B.
The sural artery flap is a cutaneous flap located on the posterior aspect of the lower leg. The flap is based on the arteries that accompany the lesser saphenous vein and sural nerve; the vein and nerve must be included in the flap. The axial pattern flap can cover defects around the knee and upper third of the leg. The reverse flow flap was first introduced by Masquelet in 1992 and is a workhorse flap for pedicle reconstruction of the lower third defects in the leg. The anterior tibial, posterior tibial, popliteal, and peroneal veins do not contribute to the vascular anatomy of this flap.
2017
A 26-year-old man comes to the office for evaluation after sustaining an open injury to the right knee during a motorcycle collision 2 weeks ago. Physical examination shows a 2-cm defect over the patella. A medial gastrocnemius flap is planned to close the defect. Which of the following is the dominant vascular supply to this muscle?
A) Anterior tibial B) Inferior geniculate C) Medial sural D) Posterior tibial E) Superior geniculate
The correct response is Option C.
The gastrocnemius flap is the primary flap used to cover soft-tissue defects of the upper third of the tibia and knee. The gastrocnemius muscle is a bipennate muscle located on the posterior surface of the lower leg. The muscle originates from the medial and lateral condyles of the femur and inserts into the Achilles tendon. The dominant blood supply of the muscle is the medial and lateral sural arteries, which are branches of the popliteal artery. Generally only one head of the gastrocnemius flap is harvested to cover soft-tissue defects. The muscle alone is generally taken and is covered with a split-thickness skin graft for lower extremity reconstructions. The geniculate arteries primarily supply the bone around the knee joint.
2017
A 30-year-old man is evaluated after sustaining multiple gunshot wounds to the right leg and thigh. X-ray study shows no retained foreign bodies and no fractures. On physical examination, the patient’s foot is warm, with palpable pulses at the ankle. He is able to extend the toes, dorsiflex the ankle, and evert the ankle. He is unable to flex his toes. He has normal sensation to the dorsum of his foot and medial-most part of the instep and lateral-most midfoot/hindfoot. Which of the following nerves is most likely injured in this patient?
A) Common peroneal nerve B) Femoral nerve C) Saphenous nerve D) Sural nerve E) Tibial nerve
The correct response is Option E.
Gunshot wounds can create a range of nerve injuries from contusion to transection. Electrodiagnostic testing can be very helpful in later diagnosis and intraoperatively during nerve reconstruction but will not demonstrate changes in the nerve on the day of injury. EMG/nerve conduction testing will not demonstrate changes in findings until 2 to 6 weeks after injury. An accurate sensory and motor examination is the best initial step to identify abnormalities that can be tracked over time.
The common peroneal nerve provides motor axons to the anterior and lateral compartment muscles. It also provides sensory axons to the dorsal foot, primarily via the terminal branches of the superficial peroneal nerve. Its only branch above the knee is to the lateral knee joint capsule.
The saphenous nerve receives the terminal branches of the femoral nerve. It provides sensation to the medial-most plantar surface of the instep.
The femoral nerve provides sensation to the thigh via cutaneous nerve branches as well as motor axons to the quadriceps muscle. Its terminal sensory fibers reach the foot via the saphenous nerve.
The sural nerve is a terminal branch of the tibial nerve. It provides motor axons to the gastrocnemius muscle and sensory fibers to the lateral-most forefoot and midfoot dorsally and lateral-most midfoot and hindfoot plantarly.
The tibial nerve provides sensation to the majority of the plantar surface of the foot via the medial and lateral plantar nerves. It also provides motor axons to the muscles of the deep posterior compartment, including the toe flexors. For the patient in this scenario, the tibial nerve is injured distal to the takeoff of the sural nerve.
2017
A 30-year-old man comes to the office because of stage IV heel pressure ulcer of the right foot. Reconstruction with a medial plantar artery flap is performed. The pedicle for this flap derives from which of the following arteries in the lower extremity?
A) Anterior tibial B) Dorsalis pedis C) Lateral plantar D) Peroneal E) Posterior tibial
The correct response is Option E.
The medial instep flap (or medial plantar artery flap) is an ideal choice for coverage of a heel defect in a patient with adequate peripheral vasculature. This flap is based on the medial plantar branch of the posterior tibial artery. This vessel lies between the abductor hallucis and flexor digitorum brevis muscles.
The lateral plantar artery supplies the lateral aspect of the sole and digits but does not supply the medial instep. The anterior tibial artery and dorsalis pedis supply the dorsum of the foot and digits and are not involved in this flap. The peroneal artery is used in a fibular flap but not in the foot.
2017
A 60-year-old man with type 2 diabetes mellitus comes to the office because of a diabetic ulcer on the sole of the right foot. Treatment of the ulcer with a medial plantar artery flap is planned. Against which of the following muscles is the arterial perforator located?
A) Adductor hallucis B) Flexor hallucis C) Lumbrical D) Plantar interosseous E) Quadratus plantae
The correct response is Option B.
The medial plantar artery flap is elevated starting at the plantar aspect, deep to the muscular fascia. The perforator is identified between the flexor hallucis and abductor hallucis muscles. The perforator is then dissected toward its origin on the medial plantar artery in the intermuscular space.
2017
A 19-year-old man is brought to the emergency department after being thrown from his motorcycle. The trauma team has ruled out intracranial, thoracic, abdominal, and spinal injury. A comminuted tibia fracture is visible through a 7-cm full-thickness soft-tissue avulsion of the lower one third of the leg. Which of the following is the most appropriate next step in management?
A) Intraoperative debridement and washout of the wound, external fixation, and immediate cross-leg flap
B) Intraoperative debridement and washout of the wound, external fixation, burring of the tibia, and formation of granulation tissue over the next several weeks
C) Intraoperative debridement and washout of the wound, placement of external fixator, serial debridement, and free tissue transfer within 1 week of injury
D) Irrigation of the wound, stabilization of reduction with a cast, and application of suction wound dressing
E) Serial debridement of the wound and coverage with a gastrocnemius muscle flap
The correct response is Option C.
Lower extremity open fractures are described using the Gustilo classification. The patient in this scenario has a Gustilo IIIB: extensive soft tissue avulsion or degloving, from high velocity injury and gross contamination. The best treatment for such injuries is intraoperative debridement and washout with early or immediate fracture stabilization, often with an external fixator. Immediate soft-tissue reconstruction is not done due to the high-energy mechanism and gross contamination. This mandates repeat evaluation to assure all nonviable tissue and foreign material are removed prior to reconstruction. Definitive and stable soft-tissue reconstruction should be done as soon as possible and is classically thought to be best when provided within 72 hours of injury. Soft-tissue reconstruction done as quickly as possible reduces the risk of nonunion and osteomyelitis. In the proximal third of the leg, the gastrocnemius flap is indicated, while the soleus flap is for the middle third. Most often, free tissue transfer is the best option for the distal third wounds. Cross-leg flap is seldom used because of the prolonged immobilization that is required. Delayed reconstruction beyond the one week window is sometimes necessary because of other confounding factors in a multiple-trauma patient. In such situations, preventing desiccation of the bone is necessary, for which negative pressure wound therapy is useful. Soft tissue reconstruction is then accomplished when feasible with preference for flap reconstruction.
2017
A 65-year-old man comes to the office because of an infected wound to the left plantar region. Medical history includes type 2 diabetes mellitus. Dorsalis pedis and posterior tibial pulses are not palpable but are located with a handheld Doppler probe. Ankle brachial index cannot be obtained because of noncompressible vessels in the left lower extremity, below the knee. Which of the following is the most appropriate next step in evaluating the arterial perfusion of this patient’s foot?
A) Computed tomography arteriography B) Magnetic resonance arteriography C) Percutaneous arteriography D) Repeat ankle brachial index E) Toe brachial index
The correct response is Option E.
The most appropriate next step when evaluating the arterial perfusion of this diabetic patient’s foot is obtaining a toe-brachial index (TBI). TBI is calculated by dividing the great toe systolic pressure by the brachial systolic pressure. An index of >0.7 is considered normal.
Patients with diabetes mellitus have a higher incidence of peripheral arterial disease than the non-diabetic population. Atherosclerotic lesions in diabetic patients tend to favor the arteries below the knee, which also commonly display medial calcinosis, causing stiffening of the arterial walls, poor compressibility, and an unreliably high ankle-brachial index (ABI). Interestingly, the small vessels of the great toes are usually spared of disease, therefore the diagnostic advantage of TBIs. These features should be taken into consideration whenever assessing arterial blood flow to the distal lower extremity of a diabetic patient.
Percutaneous arteriography is an invasive procedure and should be reserved for when surgical or endovascular therapeutic interventions are anticipated. Computed tomography arteriography and magnetic resonance arteriography may also be used in the diagnosis of peripheral artery disease in the lower extremities, but a normal TBI would most likely preclude their need. Repeating the ABI would most likely render a similar result, as the inability to compress the arteries in the leg is due to stiffened vessel walls.
2017
A functional 56-year-old woman who has a 20-year history of diabetes mellitus is referred for evaluation of a chronic calcaneal ulcer. The wound has failed to heal with bedside debridement, local wound care, and pressure offloading. On examination, the wound measures 6 × 8 cm with exposed bone and presumed osteomyelitis. CT angiography shows single-vessel flow to the foot through the posterior tibial artery. Clinically, the patient’s foot is warm to the touch with capillary refill time of 2 seconds. Which of the following is the most effective management?
A) Below-knee amputation
B) Hyperbaric oxygen therapy
C) Microsurgical free flap reconstruction
D) Operative debridement and placement of a collagen bilayer wound matrix dressing
E) Repeat bedside debridement and negative pressure therapy
Please note: Upon further review, this item was not scored as part of the examination.
The correct response is Option C.
The optimal choice in this patient is free flap reconstruction.
When possible, limb salvage is the ultimate treatment goal for patients with diabetic ulcers. As many as 25% of diabetic patients will develop lower extremity ulcers. In addition to significant physical, psychological, and economic impact, patients with diabetic ulcers have an eightfold increased chance of lower extremity amputation. Furthermore, studies show the 5-year mortality rate following lower extremity amputation ranges from 39 to 80%.
This patient has a nonhealing diabetic foot ulcer that has failed adequate nonoperative treatment. Treatment of diabetic ulcers is multifactorial and should include optimizing glucose control and other associated medical comorbidities. If the progress of the wound has stalled despite adequate infection control, edema control, vascular inflow, and pressure offloading, the patient is a candidate for soft-tissue reconstruction. Studies show greater than 90% flap survival with microsurgical reconstruction and limb salvage greater than 80%. Microsurgical free flaps allow the transfer of well-vascularized tissue to provide wound coverage and adequate soft tissue thickness to cover a weight-bearing surface of the foot.
This patient has not had success with bedside debridement and local wound care. Negative pressure dressings often are used as advanced wound care but are not appropriate when underlying infection or necrotic tissue is present. Bedside debridements are not adequate to treat osteomyelitis.
Hyperbaric oxygen therapy can be used as an adjunct to local wound care or following flap surgery to optimize perfusion and wound healing. However, hyperbaric oxygen therapy is not the most effective treatment for a wound this large in a patient who is able to undergo surgery.
The goal of treatment in diabetic ulcers should be limb salvage. The indications for amputation in diabetic foot ulcers include systemic sepsis, major tissue loss, multiple comorbid conditions, patient noncompliance, and nonreconstructable vascular disease. These are not present in this patient.
Collagen bilayer matrix allows for the formation of a neodermis and is a useful adjunct for the management of chronic wounds or wounds with exposed vital structures when autologous tissue is unavailable or inappropriate. The collagen matrix provides a scaffold for cellular ingrowth and angiogenesis. In this case, a bilayer wound matrix may allow for wound closure but would be inferior to a free flap for durability and improving foot vascularity.
2016
A 25-year-old surfer who sustained a shark bite to the left thigh is brought to the emergency department. The patient is hemodynamically stable. Physical examination shows a bleeding mid-thigh wound. The left foot is pale and cool; sensibility in the foot is decreased. The ankle pulses are absent. On surgical exploration, a 6-cm injury to the superficial femoral artery is identified. After local debridement, which of the following is the most appropriate next step in management of the artery?
A) End-to-end anastomosis
B) End-to-side anastomosis
C) Interposition prosthetic grafting
D) Interposition vein grafting
The correct response is Option D.
The patient has a major vascular injury that is greater than 5.5 cm in length. A shark bite is considered contaminated and requires debridement. Because of the length of arterial injury, vein grafting is the most appropriate management option. End-to-end and end-to-side anastomoses are incorrect because the arterial defect is too long. The use of prosthetic material is incorrect because this is a contaminated wound, increasing the risk for infection.
2016
Which of the following compartment pressure measurements is the minimum threshold that is most consistent with compartment syndrome?
A) 10 mmHg B) 20 mmHg C) 30 mmHg D) 40 mmHg E) 50 mmHg
The correct response is Option C.
The absolute minimum compartment pressure measurements ranging from 25 to 50 mmHg are quoted as absolute indications for fasciotomy. The most frequently quoted absolute measurement is 30 mmHg.
2016
A 28-year-old man is flown by helicopter to the emergency department after sustaining a deep, isolated, lateral abrasion to the right lower leg in a motorcycle collision. On physical examination, he has a segmental injury to the common peroneal nerve. Repair with a sural nerve autograft is planned. Which of the following is the maximum length at which any functional recovery is expected?
A) 3 cm B) 6 cm C) 9 cm D) 12 cm E) 15 cm
The correct response is Option D.
Nerve repair outcomes are related to mechanism of injury, need for a graft and graft length, and timing of surgery relative to injury. Although results vary, good results are typical for grafts measuring less than 6 cm, and may be possible in approximately 25% of patients with grafts measuring 6 to 12 cm. Almost no studies report an M4 motor recovery or better when a graft greater than 12 cm is used.
2016
A 35-year-old man who was involved in a motorcycle accident sustains fractures to the right tibia and fibula. On physical examination, he has numbness in the dorsum of the right foot and inability to dorsiflex the foot. Vascular status of the right lower extremity is normal. Which of the following nerves has most likely been injured?
A) Calcaneal B) Common peroneal C) Lateral plantar D) Lateral sural cutaneous E) Posterior tibial
The correct response is Option B.
The common peroneal nerve derives from the dorsal branches of the fourth and fifth lumbar and first and second sacral nerves. The common peroneal nerve lies between the biceps femoris and lateral head of the gastrocnemius muscle; it continues around the neck of the fibula between the peroneus longus muscle and the fibula, and then branches into the superficial fibular and deep fibular nerves. The common peroneal nerve innervates the peroneus longus, peroneus brevis, and biceps femoris muscle. Injury to this nerve results in a foot drop and sensory loss to the dorsal surface of the foot.
The lateral sural nerve is a cutaneous nerve arising from the common fibular nerve. It supplies sensation to the posterior and lateral surfaces of the leg. This nerve does not supply motor innervation.
The posterior tibial nerve, also known as the tibial nerve, is derived from L4, L5, S1, S2, and S3. It is a branch of the sciatic nerve. The nerve gives branches to the gastrocnemius, popliteus, and soleus muscles. Below the soleus muscle it supplies the tibialis posterior, the flexor digitorum longus, and the flexor hallucis longus muscles.
The lateral plantar nerve is a branch of the tibial nerve. It supplies the quadratus plantae and the abductor digiti minimi muscles. Its sensory component supplies the skin of the fifth toe and the lateral half of the fourth toe.
The lateral calcaneal nerve is a branch of the sural nerve supplying cutaneous sensation to the lateral aspect of the heel skin. This nerve is a cutaneous nerve with no muscle innervation.
2016
A 35-year-old man is brought to the emergency department because of an injury to the left lower leg after being involved in a motorcycle collision. X-ray studies confirm a Gustilo IIIB tibia-fibula fracture. After debridement, there is a bone defect measuring 12 cm in the mid shaft of the tibia. Which of the following is the most appropriate technique to restore the bone defect?
A) Autogenous bone grafting
B) Cadaveric bone grafting
C) Coverage with a fibular free flap
D) Osteodistraction
The correct response is Option C.
Although various techniques have been used successfully to reconstruct large bony defects of the lower extremity, the most reliable technique for such a large bone gap is the fibular free flap reconstruction. The Ilizarov osteodistraction technique can be used for large defects, but would necessitate a very long period of immobilization and fixation. Neither autogenous nor cadaveric bone graft would be as reliable as vascularized bone.
2016
A 27-year-old man is brought to the emergency department because of compartment syndrome of the lower left leg. Release of the deep posterior compartment includes decompression of which of the following muscles?
A) Flexor hallucis longus B) Peroneus brevis C) Plantaris D) Soleus E) Tibialis anterior
The correct response is Option A.
The flexor hallucis longus flexes the great toe and is located in the deep posterior compartment. The soleus and plantaris muscles are located in the superficial posterior compartment, just deep to the gastrocnemius muscles. The peroneus brevis is located in the lateral compartment. The tibialis anterior is located in the anterior compartment.
2016
A 24-year-old man is brought by ambulance to the emergency department after sustaining a tibial fracture in a motorcycle collision. On physical examination, there is an open, segmental fracture with a 4-cm wound and a large avulsion flap, but adequate soft-tissue coverage. Which of the following Gustilo-Anderson fracture classifications best describes this injury?
A) Type I B) Type II C) Type IIIA D) Type IIIB E) Type IIIC
The correct response is Option C.
The Gustilo-Anderson classification of open fractures is a primary method of classification and communication in orthopedic and plastic surgery when limb injury and reconstruction are required. The types are as follows:
- Type I: an open fracture with a wound less than 1 cm long and clean
- Type II: an open fracture with a laceration 1 - 10 cm long without extensive soft-tissue damage, flaps, or avulsions
- Type III: either an open segmental fracture, an open fracture with extensive soft-tissue damage, or a traumatic amputation; open wound >10cm; includes fractures/injuries open for more than 8 hours prior to intervention, industrial or farming injuries
- IIIA: adequate soft tissue coverage of a fractured bone despite extensive soft tissue lacerations or flaps, or high energy trauma irrespective of the size of the wound
- IIIB: extensive soft tissue injury with periosteal stripping and bone exposure; there is usually associated massive contamination
- IIIC: open fractures associated with arterial injury requiring repair
2016
A 37-year-old postal worker is brought to the emergency department 2 hours after he sustained a crush injury to his right leg when his truck rolled downhill and pinned him to a wall. He reports progressive, intense burning pain of the right leg. On examination, the leg appears swollen and there is a tense woody feeling anterolaterally associated with severe tenderness on passive range of motion of the ankle. There is decreased sensation between the first and second toes. Palpable dorsalis pedis and posterior tibial pulses are noted. The difference between diastolic blood pressure and the anterior compartment pressure (delta pressure) is 15 mmHg. X-ray studies show no fracture. Which of the following is the most appropriate next step?
A) Perform emergency fasciotomy
B) Recheck anterior compartment pressure in 1 hour
C) Test electromyographic activity of the anterior tibialis
D) Test serum creatinine kinase activity
E) Wean analgesics to reduce variability in serial review
The correct response is Option A.
This patient is manifesting signs and symptoms of progressive acute compartment syndrome (ACS). ACS is a surgical emergency, and the next step in management is acute fasciotomy to fully decompress all involved compartments. Delays in fasciotomy increase unrecoverable tissue injury leading to permanent functional loss and morbidity such as muscle contractures, sensory deficits, paralysis, and infection.
Compartment syndrome occurs when increased pressures within unyielding fascial compartments lead to progressive cellular anoxic injury to tissues within the compartment. Symptoms of ACS include pain out of proportion to injury and deep aching or burning pain. Complaints of paresthesia suggest progressive ischemic nerve dysfunction. Signs of ACS include pain with passive ranging of muscles in the affected compartment, a tense compartment with a firm and indurated “woody” feeling, and diminished sensation.
Most cases of ACS occur with long-bone fractures, and risk increases with comminuted fractures. Other common forms of trauma including crush injury, severe thermal burns, constrictive bandages, penetrating trauma, vascular injuries, and ischemia-reperfusion injuries can lead to ACS. The anterior compartment of the leg is the most common site for ACS. Early signs of ACS affecting this compartment include loss of sensation in the distribution of the deep peroneal nerve, and weakness of dorsiflexion.
Normal compartment pressures fall between 0 and 8 mmHg. Pain develops as compartment pressures increase, and tissue ischemia occurs as compartment pressures approach diastolic pressure. Differences between diastolic blood pressure and measured compartment pressure (delta pressure) less than 20 to 30 mmHg indicate a need for fasciotomy.
As ACS evolves, muscle breakdown can lead to elevations in serum creatine kinase and myoglobinuria. Sensory deficits typically preclude motor deficits and EMG abnormalities progressing to total paralysis will occur. These are relatively late findings in ACS; they should not delay fasciotomy once progressive ACS is diagnosed.
There is no diagnostic role for withholding analgesics in extremity trauma.
2016
A 28-year-old man presents 8 days after open reduction and internal fixation of an unstable distal tibia fracture. Postoperatively, the incision has dehisced. Examination shows a 5 × 2-cm open wound with marginal skin necrosis and exposed hardware. Which of the following is the most appropriate next step in soft-tissue coverage?
A) Debridement with application of skin substitute
B) Hardware removal, casting, and wound care
C) Hyperbaric oxygen and wound care
D) Operative debridement and placement of a VAC for a bridge to skin grafting
E) Operative debridement and vascularized reconstruction with a flap
The correct response is Option E.
The best treatment that would allow salvage of the fracture fixation is operative debridement and vascularized flap reconstruction. Stable fixation has been achieved and subacute wound dehiscence has occurred because of ischemia or devitalization of the overlying soft tissue. This is due to the forces of the original trauma as well as potential further traumatic insult of the tissue during surgical repair. In the absence of infection, immediate soft-tissue reconstruction will provide stable vascularized soft-tissue coverage of the fracture site and the hardware. As such, vascularized flap reconstruction is appropriate. In the distal leg, this often requires free tissue transfer, but depending on the location and size of the defect, soleus flap or perforator propeller flaps can be used.
Gustilo provided a classification of open fractures of the leg in which the fracture site was exposed through a disruption of soft-tissue integrity.
Determination of the type of flap reconstruction required requires assessment of not only the location and size of the defect, but also the zone of injury. Greater degrees of force are associated with the increasing Gustilo classification such that type III fractures often require free tissue transfer because of concomitant damage of the regional and local tissues.
Operative debridement and placement of a VAC for a bridge to skin grafting is a potential treatment for an open wound with exposed bone without hardware. The period of time in which the wound remains open and granulates during this process provides a very high risk for hardware infection, nonunion, and osteomyelitis.
Debridement with skin advancement and closure is likely to fail because of the difficulty in providing appropriate tension-free advancement flaps in the leg, combined with the need to accommodate for tissue loss from the debridement and ischemia of the advancing skin edges. The reliability of this treatment is poor and would have high risk for failure and subsequent hardware infection and nonunion or osteomyelitis.
Hardware removal, casting, and wound care is not indicated since the fracture repair is intact and no signs of infection are present. However, if hardware removal were required because of overt infection, the most appropriate treatment would be placement of an external fixator and soft-tissue flap reconstruction.
Hyperbaric oxygen and wound care is not the best option in this acute situation in which prompt soft-tissue reconstruction and vascularized coverage of the fracture site are required to salvage the existent fixation and avoid mal/nonunion or osteomyelitis.
2016
An otherwise healthy 65-year-old man is evaluated because of a 2-month history of a nonhealing wound to the back of the left heel. He has a history of smoking 50 packs of cigarettes yearly but quit 1 year ago. Physical examination shows a clean wound with exposed bone and palpable distal pulses in the lower extremities. Coverage with a distally based fasciocutaneous sural flap is planned. Because of the patient’s history of smoking, a “delay” procedure is performed first. Division of which of the following is required for this procedure?
A) Distal greater saphenous vein B) Distal lesser saphenous vein C) Perforator 5 cm proximal to the lateral malleolus D) Proximal greater saphenous vein E) Proximal lesser saphenous vein
The correct response is Option E.
The surgical step required as part of the “delay” procedure in a distally based sural flap is division of the proximal lesser saphenous vein. The distally based sural flap is a neurofasciocutaneous flap used to reconstruct ankle, heel, and foot defects. The classically described and possibly most important arterial supply to the distally based sural flap is provided by septocutaneous perforators arising from the peroneal artery. The most distal of these is located 4 to 7 cm proximal to the lateral malleolus. However, there are at least three other sources described: fasciocutaneous perforators from the posterior tibial artery, venocutaneous perforators from the lesser saphenous vein, and neurocutaneous perforators from the sural nerve. The skin and fascia of the flap are drained primarily by the lesser saphenous vein. The lesser saphenous vein contains numerous valves that prevent retrograde blood flow. There are, however, one or more smaller collateral veins that run parallel to the lesser saphenous vein. These veins have anastomotic connections to the lesser saphenous vein, which can allow blood to bypass the valves of the lesser saphenous vein and flow in a retrograde fashion.
In attempts to redirect blood flow and decrease the risk of flap necrosis and other complications, several authors have described sural flap delay procedures. Two distinct delay procedures have been described. In one, the flap is first elevated without completely incising the proximal edge of the skin island. A powder-free glove is then placed between the elevated fascia and the gastrocnemius muscle, and the skin is closed. Two weeks later, the flap is completely elevated and transferred into the defect site. This procedure has the goal of redirecting blood flow in a longitudinal direction before complete elevation of the flap. In the other technique, the flap is raised in its entirety and then sutured back into its donor site. The flap is then transferred into its recipient site as a second procedure. This technique allows the flap to become viable on its distal vascular pedicle before causing the additional trauma of transferring the flap, which can potentially compromise that pedicle.
Division of the greater saphenous vein is not indicated because it is not in the vicinity of the flap. Similarly, division of the perforator 5 cm proximal to the lateral malleolus is not appropriate because this is the major pedicle supplying the flap.
2015
A 56-year-old man who is an active smoker sustains a degloving injury of the left foot from a motorcycle collision. The heel was avulsed from the calcaneus by a deep posterior laceration but has normal capillary refill. No tissue is missing, but the wound is heavily contaminated and the calcaneus has an abrasion that is imbedded with grit. After irrigation and debridement in the operating room, which of the following is the most appropriate next step in management of this wound?
A) Coverage with a free gracilis muscle flap
B) Healing by secondary intention
C) Layered closure over a drain
D) Negative pressure wound therapy and skin grafting
E) Serial debridement and delayed closure
The correct response is Option E.
The most appropriate management of this wound is serial debridement and delayed closure. With such a high level of contamination of both the soft and hard tissues, layered closure after the initial debridement will very likely lead to infection, especially in a patient with a history of smoking. It would be a mistake to perform a free tissue transfer in a highly contaminated wound. Furthermore, there is no missing or ischemic tissue. Negative pressure wound therapy followed by skin grafting would not be appropriate for a deep wound with bone exposure when local tissues are available for closure; this would be more appropriate for a superficial wound with missing skin. Healing by secondary intention is an option; however, serial debridement and delayed closure will take less time, is less painful, and avoids scar formation in the heel.
2015
A thin 40-year-old woman has an 8 × 5-cm skin defect in the distal third of the anterior leg extending to the dorsum of the foot, with tibia denuded of periosteum and exposed tendon, after undergoing stabilization of the fracture with internal hardware 3 days ago. The distal posterior tibial artery was ligated before surgery at the distal third of the leg. There are no signs of infection or osteomyelitis. Which of the following is the most appropriate method of reconstruction?
A) Application of bilaminate neodermis (Integra) and negative pressure wound therapy
B) Coverage with a dorsalis pedis flap
C) Coverage with a free anterior lateral thigh (ALT) flap
D) Coverage with a free tranverse rectus abdominus myocutaneous (TRAM) flap
E) Coverage with a reverse sural flap
The correct response is Option C.
A free anterior lateral thigh flap is large enough to close the defect, can be thinned for aesthetics and shoe wear, and may allow for primary closure of the donor site. Although free tranverse rectus abdominus myocutaneous (TRAM) flap coverage is a possibility, the potential complications of taking muscle and unpredictable control of the final contour make them less ideal options. The reverse sural flap is not an option because of the ligation of the posterior tibial artery. In addition to having severe donor site morbidity, the dorsalis pedis would remove the remaining blood supply to the foot. The vascular nature of the defect’s wound bed makes bilaminate neodermis (Integra) and negative pressure wound therapy a less optimal choice.
2015
A 15-year-old girl sustained an isolated open tibial fracture in a motor vehicle collision. At the proximal third of the tibia, 15 cm of anterior soft-tissue loss is noted. Despite fracture reduction, the foot is warm but pulseless without dopplerable signals. The patient is otherwise stable. Which of the following is the most appropriate next step in management?
A) Below-knee amputation
B) CT angiography
C) Four-compartment fasciotomy
D) Internal fixation and soft-tissue coverage
E) Surgical exploration of the popliteal artery
The correct response is Option B.
Lower extremity fractures with combined soft-tissue and neurovascular trauma have high rates of complications, and a percentage of these injuries lead to amputation. Risk factors for amputation include Gustilo IIIC injuries, sciatic or tibial nerve injuries, prolonged ischemia (more than 4 to 6 hours), significant soft-tissue injury, significant wound contamination, multiple injured extremities, advanced age, lower versus upper extremity trauma, and futile attempt at revascularization. While tibial nerve injury is a risk factor and relative indication for amputation, it is never an absolute indication for amputation.
Hard signs for vascular injury include: active hemorrhage, expanding hematoma, bruit or thrill, absent distal pulses, and distal ischemic signs and symptoms (five P’s). In the face of these hard signs, imaging such as CT angiography should be used to evaluate for vascular injury. With that said, most hard signs can be explained by soft-tissue or bone bleeding, traction of intact arteries due to unreduced fractures, or compartment syndrome.
Early soft-tissue coverage is associated with a lower complication rate. The goal is to close wounds within 7 to 10 days to decrease the risk for infection, osteomyelitis, nonunion, and further tissue loss.
It is best to get wound control prior to bone grafting, avoiding the risk of losing valuable limited bone; therefore, bone grafting is generally postponed until 8 to 10 weeks after soft-tissue wound coverage.
2015
A 20-year-old man has purulent breakdown 5 months after sustaining a Gustilo type IIIB open fracture treated with intramedullary rod placement and skin grafting over a medial gastrocnemius flap. A postoperative x-ray study and current photograph are shown (mid shaft tibia defect, medial aspect). The intramedullary rod is removed and an external fixator is placed. There is 1.5 cm of bone without periosteum surrounding the fracture exposed in the wound. Which of the following is the most appropriate next step in wound reconstruction?
A) Full-thickness skin grafting with a bolster dressing
B) Reconstruction with an anterior tibial artery perforator flap
C) Reconstruction with a lateral gastrocnemius muscle flap and skin grafting
D) Reconstruction with a pedicled descending medial genicular artery flap
E) Split-thickness skin grafting with negative pressure wound therapy
The correct response is Option B.
Perforator flap reconstruction, whether free or pedicled, has become increasingly popular over the past decade. Perforator flap use allows for the creation of an axial pattern flap without the sacrifice of a major artery and can often be done for areas once considered to require free flaps for coverage. Prior transfer of a medial gastrocnemius flap might disrupt perforators from the posterior tibial artery to the medial leg skin, but would not have disturbed anterior tibial artery perforators through the skin of the anterolateral leg.
Skin grafting, whether split- or full-thickness, would not be successful on fractured bone without periosteum, regardless of the type of dressing used.
The lateral gastrocnemius muscle is smaller and cannot reach as far as the medial gastrocnemius. It would not be able to reach the mid-shaft tibia defect shown in this patient.
The descending medial genicular artery is the pedicle of the medial femoral condyle flap. It is normally used as a bone graft donor, although an overlying skin paddle can be harvested with it. When used in a pedicled fashion, it can be transposed proximally onto the thigh, but not distally onto the leg.
2015
A 35-year-old man is referred to the office after undergoing prolonged failed attempts at local wound care of an exposed Achilles tendon. Physical examination shows that the tendon is beginning to desiccate. Coverage with a flap is performed, as shown (reverse sural fasciocutaneous flap). The blood supply to this flap is derived from which of the following arteries?
A) Anterior tibial B) Geniculate C) Peroneal D) Popliteal E) Superficial femoral
The correct response is Option C.
The flap used to cover the Achilles tendon in the patient described is the reverse sural fasciocutaneous flap. It is based on perforators from the peroneal artery through a network of small vessels. The general axis of the flap follows the sural nerve from behind the lateral malleolus to the mid portion of the gastrocnemius muscle bellies. Sural nerve injury results in loss of lateral foot sensation. This is often of no functional consequence because its harvest does not result in loss of a major neurovascular structure.
The other vessels noted do not supply inflow to the flap.
2015
A 66-year-old man comes for evaluation because of a chronic left lower extremity wound. He reports that the wound has been present for the past 15 years. Physical examination shows an 8 × 10-cm wound on the lateral aspect of the left calf. Which of the following is the most appropriate next step in diagnosis?
A) Angiography B) Biopsy C) Bone scan D) CT scan E) MRI
The correct response is Option B.
The most important next step in establishing a diagnosis in this patient is an excisional biopsy. The clinical appearance and duration of the chronic wound is highly suggestive of a Marjolin ulcer in the setting of a chronic venous stasis ulcer. Marjolin ulcers are defined as malignant generation in the presence of a burn wound or other chronic inflammatory conditions. The most common etiology is a burn wound; however, malignancies have been found in chronic wounds secondary to pressure ulceration, trauma, venous stasis, and others. The most common pathologic diagnosis is well-differentiated squamous cell carcinoma (SCC), but basal cell carcinoma and various other sarcomas have been reported in the literature. Marjolin ulcers are thought to be aggressive forms of SCC with metastatic potential related to tumor grade. The incidence of metastasis is 10% for Grade 1 lesions, 59% for Grade 2, and 86% for Grade 3.
Diagnosis is based on clinical appearance, history, and most importantly biopsy. Patients should also receive a thorough regional lymph node exam, CT scan or MRI, and routine laboratory analysis. Sentinal lymph node biopsy may be indicated. Treatment is generally wide excision of the chronic wound and rapid coverage with skin grafts or tissue flaps. Depending on tumor characteristics, adjuvant radiation therapy may be recommended.
Angiography will evaluate the arterial flow of the extremity and may be important in planning coverage of the wound, but it is not required to rule out a malignancy. MRI, CT scan, and x-ray studies can also be helpful as adjunctive diagnostic techniques to evaluate the extent of the tumor and presence of metastasis, but they are not used for diagnosis alone.
2015
An otherwise healthy 30-year-old man is evaluated because of left foot drop after posterior knee dislocation. The common peroneal nerve is explored at the level of the knee shortly after the time of injury and found to be in continuity. The patient does not return for follow-up examination within the next year. Eighteen months after the injury, the patient returns for follow-up examination and shows no improvement of the foot drop. Passive range of motion of the ankle is full. Which of the following transfers is most likely to correct this patient’s foot drop deformity?
A) Peroneus brevis tendon with graft to calcaneus bone
B) Peroneus longus tendon to calcaneus bone
C) Peroneus longus tendon to talus bone
D) Tibialis anterior nerve to tibialis posterior nerve
E) Tibialis posterior tendon to tibialis anterior tendon
The correct response is Option E.
Common peroneal nerve injury is common after posterior knee dislocation, usually occurring at or near where the nerve crosses the fibula neck. After surgical exploration to confirm the peroneal nerve is intact, initial management consists of supportive care with an ankle brace to correct foot drop. Patients are observed clinically for recovery, often with serial electromyography and nerve conduction studies.
Tibialis posterior to anterior transfer will restore the patient’s ability to dorsiflex the ankle. The donor muscle is innervated by the tibial nerve, which is not commonly injured in a posterior knee dislocation. The tendon is dis-inserted from the tarsus and brought out through the medial leg.
It is transferred through the interosseous membrane to the tibialis anterior tendon.
By 18 months after injury, the motor end plates to the tibialis anterior have degenerated, making a nerve transfer no longer an option. Earlier after injury, a nerve transfer from the tibialis posterior to the tibialis anterior might be a feasible option.
Peroneus longus and brevis would also be paralyzed in the setting of a common peroneal nerve injury such as this patient’s. In certain situations, such as with some patients with leprosy, the deep peroneal nerve is not paralyzed. For these patients, the peroneus longus can be used as a tendon transfer, but it is normally used to provide toe extension in conjunction with a tibialis posterior transfer to provide ankle dorsiflexion.
2015
A 45-year-old man is brought to the emergency department after sustaining a fracture of the neck of the fibula after being struck by a baseball. Physical examination shows major nerve deficit. Which of the following actions will the patient be unable to perform?
A) Dorsiflex the foot B) Extend the leg C) Flex the leg D) Invert the foot E) Plantar flex the foot
The correct response is Option A.
The most commonly injured nerve in the leg is the common peroneal nerve because of its superficial location as it courses around the neck of the fibula. The common peroneal nerve then divides into the superficial and deep branches. The superficial branch will evert the foot by innervating the lateral compartment of the leg, while the deep branch will dorsiflex the foot by innervating the anterior compartment. The superficial branch also provides sensation for the anterior and lateral sides of the leg and the majority of the dorsum of the foot and toes, including the medial side of the big toe. Paralysis of the common peroneal nerve would lead to foot drop and foot inversion, abnormal “steppage” gait, and loss of sensation.
2015
A 47-year-old woman is referred by orthopedic surgery for evaluation and discussion of soft-tissue reconstruction at the time of nonvascularized allograft reconstruction of recurrent Achilles tendon rupture. The patient has a history of congenital clubfoot and multiple previous Achilles tendon repairs. Physical examination shows atrophied skin and multiple longitudinal scars along both the medial and lateral distal posterior calf. Which of the following is the most appropriate management?
A) Cross-leg fasciocutaneous flap B) Fasciocutaneous free flap C) Reverse sural artery flap D) Soleus muscle flap E) Tissue expansion
The correct response is Option B.
On the basis of the scenario described, fasciocutaneous free flap is the most appropriate management option.
The soleus muscle flap is appropriate for defects of the middle third of the leg but lacks adequate reach for soft-tissue coverage of the distal third of the leg.
Tissue expansion has been described for soft-tissue reconstruction of congenital talipes equinovarus but is usually reserved for children and in the setting of primary correction. When comparing tissue expansion in the limb versus non-limb sites, the incidence of complications associated with tissue expansion is significantly higher in the limb. Because a nonvascularized allograft is to be used, and the patient has a contracted and scarred soft-tissue envelope, tissue expansion would be associated with higher risk of expansion failure and complications when compared with free tissue transfer soft-tissue reconstruction.
Cross-leg flaps are rarely used because of the availability of free tissue transfer. This flap is more appropriate in children than elderly patients, in whom stiffness is a factor.
A reverse sural artery flap is not appropriate given the patient’s multiple past surgeries and local scars.
2014
A 29-year-old man undergoes open reduction and internal fixation of an open fracture of the proximal right tibia. There is no tissue loss, and there is little wound contamination. The wound is closed with 2-cm raised flaps. Reconstruction of the popliteal artery is required. Which of the following Gustilo fracture classifications is most likely in this patient?
A) I B) II C) IIIA D) IIIB E) IIIC
The correct response is Option E.
Gustilo initially classified long-bone fractures into three types in order to establish a treatment algorithm. Essentially, this classification subdivided fractures according to the energy of the initial trauma that resulted in significant soft-tissue injury, periosteal stripping, and fracture comminution in the worst subtype. Debridement, antibiotics, and primary or delayed wound closure were advocated dependent on fracture severity. Type III fractures were subsequently subdivided into A, B, and C subtypes. Subtypes were stratified according to potential for complications such as infection, osteomyelitis, non-union, and amputation rates. Type IIIC had open fracture with arterial injury requiring repair (the case in this patient, even though there appears to be adequate soft-tissue coverage).
Although fracture fixation methods have substantially improved since the original publications of Gustilo, the ability to transport bone into segmental traumatic defects has also since developed, and free flaps have extended our ability to cover large wounds. This classification system has stood the test of time and still forms the basis of prognosticating and determining the optimum treatment algorithm.
The Gustilo grading scale:
Type Findings
I: Clean wound bed, simple/minimally comminuted bone injury, wound <1 cm
II: Wound contaminated, moderate comminution of bone, wound >1 cm
IIIA: Wound highly contaminated, severe comminution, wound 1 to 10 cm
IIIB: Wound highly contaminated, severe comminution, wound >10 cm
IIIC: Major vascular injury requiring repair for limb salvage
2014
A 57-year-old man comes to the office 4 weeks after undergoing a free osseocutaneous fibula flap. He says he has pain with walking. A photograph is shown. X-ray studies show 6 cm of fibular bone remains proximally and distally. Sensation of the right foot shows no abnormalities; pain is noted on plantar flexion. Which of the following is the most appropriate next step in management?
A) Cast immobilization of the lower extremity (above the knee)
B) Cast immobilization of the lower extremity (below the knee)
C) Operative exploration and bone grafting
D) Operative exploration and nerve grafting
E) Reassurance that the pain is self-limiting
The correct response is Option E.
Vascularized bone flap is typically needed for defects >6 cm regardless of location in the body. The fibula is a common donor for vascularized bone. Understanding the postoperative course and complications is needed both in terms of discussions with the patient preoperatively and management of the patient’s condition after surgery. Common sequelae of fibula harvest include pain in the leg (especially when walking). Four weeks is relatively early in the postoperative course and reassurance should be given.
Risks of fibula harvest include damage to the peroneal nerve (increased when <6 cm of bone is left behind or when the head of the fibula is included in the harvest); destabilization of the ankle (increased when <6 cm of bone is left behind); and damage to the posterior tibial nerve.
A free-fibular flap design with hash marks left intact is shown.
2014
A 32-year-old woman comes to the office because the toes of the right foot “drag” when she walks. She underwent vein stripping of the right leg and ligation of the lesser saphenous vein 4 weeks ago. Physical examination shows absent dorsiflexion and eversion of the ankle. Electromyography findings show:
Muscle Group: Recruitment:
- Biceps femoris +
- Tibialis posterior +
- Peroneus longus -
- Tibialis anterior -
- Extensor hallucis longus -
Which of the following is the most likely site of nerve injury in this patient?
A) Common peroneal nerve at the knee
B) Superficial peroneal nerve at the knee
C) Sural nerve at the knee
D) Tibial nerve at the knee
E) Tibial nerve at the mid calf
The correct response is Option A.
The most likely site of injury would be the common peroneal nerve at the knee. Injuries to the common peroneal nerve are well documented in both traumatic (knee dislocation) and iatrogenic settings. Patients have footdrop and numbness over the first dorsal web space of the foot. History and clinical examination are the mainstays for diagnosis, but electromyography can be helpful in less-clear circumstances. The absence of recruitment of the lateral compartment muscles (peroneals) and the anterior compartment muscles (tibialis anterior, extensor hallucis longus) strongly suggest common peroneal involvement. The presence of recruitment of the biceps femoris and the tibialis posterior rules out tibial nerve involvement. An isolated superficial peroneal nerve injury would spare the anterior compartment muscles.
The sural nerve is a sensory nerve and provides no motor function.
2014
A 24-year-old man is brought to the emergency department 2 hours after sustaining injuries to the left lower extremity when he was hit by a motor vehicle. Physical examination shows avulsion of the soft tissue of the posterior thigh. A fracture of the femur is stabilized by an intramedullary rod; the sciatic nerve is noted to be intact but ecchymotic at the level of the mid posterior thigh. Soft tissue is available for coverage. Which of the following is the most appropriate management?
A) Acute resection of the ecchymotic nerve and repair with a nerve graft
B) Delayed resection of the ecchymotic nerve at 10 days and repair with a nerve graft
C) Electromyography after 3 weeks and repair with a nerve graft if fibrillations occur
D) Serial electrodiagnostic studies after 3 weeks and again after 3 months with repair if no improvement
The correct response is Option D.
In cases in which the nerve has undergone a significant crush component, it is important to get a sense of nerve viability and recovery. The nerve conduction study at 3 weeks largely serves as a baseline study as it rarely provides more information than physical examination other than the presence of fibrillations, which indicates at least some axonal loss. The nerve conduction study at 3 weeks is not a reliable indicator of possible nerve recovery; therefore, resection and reconstruction are not advisable at this time point. The 3-month nerve conduction study is able to pick up subtle signs of recovery that may not be evident on physical examination. If at the 3-month mark there are no signs of recovery on physical examination or nerve conduction study, repair is indicated. Acute resection of a possibly viable nerve is not indicated. If the nerve were noted to be transected at the time of initial exploratory surgery, the viability of the nerve ends would not be stable until 7 to 10 days post trauma, making this a good time for definitive repair. In the scenario described, the nerve is in continuity and viability cannot be ascertained intraoperatively at 10 days; therefore, resection and reconstruction are not indicated.
2014
A 35-year-old man is brought to the emergency department 2 hours after sustaining a severe crush injury to the right distal thigh in a motor vehicle collision. Physical examination shows an open fracture of the femur; the leg and foot are pale and cool. There are no palpable popliteal, dorsalis pedis, or posterior tibialis pulses. Closed reduction does not restore perfusion. Which of the following is the most appropriate next step?
A) Arterial repair with a polytetrafluoroethylene graft
B) Arterial repair with reverse saphenous vein graft
C) CT angiography
D) Intramedullary fixation of the femoral fracture
E) Placement of a temporary vascular shunt
The correct response is Option E.
Gustilo Type IIIC fractures involve arterial injury requiring repair irrespective of the degree of soft tissue and often represent significant limb-threatening injuries. Early recognition and management of lower extremity vascular injury is crucial to limb salvage. CT angiography is of little benefit in the presence of hard signs of vascular injury and can delay operative intervention as well as increase limb ischemia time.
The combination of vascular and orthopedic injuries requiring repair is rare, with a reported incidence as low as 1.5%. Data exist from both wartime and civilian groups evaluating the sequence of management of such injuries. The recommended algorithm suggests improved ischemia times and favorable limb salvage rates with temporary vascular repair, using shunts as the initial adjunct to restore perfusion followed by debridement and fracture fixation.
Definitive vascular repair should follow debridement and fracture fixation. Both synthetic polytetrafluoroethylene and autologous (reverse saphenous vein) interposition grafts are reported to be used in traumatic reconstruction, although autologous tissue is often preferred in the setting of gross contamination.
2014
A 25-year-old man is brought to the emergency department after he sustained a knife wound to the right lower extremity. Examination shows numbness of the lateral aspect of the leg and weakness in plantar flexion and eversion of the foot. Which of the following nerves was most likely injured in this patient?
A) Femoral B) Obturator C) Peroneal D) Sural E) Tibial
The correct response is Option C.
The patient appears to demonstrate symptoms of a superficial peroneal nerve injury. The superficial peroneal nerve arises from the common peroneal nerve at the fibular neck. It supplies the lateral compartment of the leg, giving motor branches to peroneus longus and brevis, as well as sensory contribution to the lateral aspect of the leg. Injury to the superficial peroneal nerve results in anesthesia of the lateral aspect of the leg and weakness in eversion and plantar flexion of the foot.
The deep peroneal nerve arises from the common peroneal nerve at the fibular neck. It travels in the anterior compartment of the leg and gives branches to the tibialis anterior, extensor hallucis longus, and extensor digitorum longus and brevis, as well as peroneus tertius. The sensory distribution is in the area of the first web space. Injury to the deep peroneal nerve causes weakness in dorsiflexion of the foot.
The femoral nerve innervates muscles of the anterior thigh, including the quadriceps group, iliacus, and sartorius. Injury to the femoral nerve results in weakness of leg extension.
The obturator nerve provides innervation to the medial thigh muscles (adductor group), including adductor brevis, longus, and magnus, as well as the gracilis and obturator externus. The cutaneous branch provides sensation of the medial thigh. Injury to the obturator nerve results in weakness in thigh adduction and sensory deficits in the medial thigh.
The sural nerve travels on the posterior aspect of the leg between the lateral malleolus and calcaneus. It provides sensation to the lateral aspect of the foot and does not have a motor component. It is commonly sampled in nerve biopsy and used as a source of nerve graft.
Injury or sacrifice of the sural nerve would result in numbness of the lateral foot.
The tibial nerve is a branch of the sciatic nerve. It travels through the popliteal fossa and gives off branches to gastrocnemius, soleus, plantaris, and popliteus muscles. The tibial nerve travels in proximity to the posterior tibial artery. In the leg, it gives off branches to the flexor digitorum longus, tibialis posterior, and flexor hallucis longus. Distally in the foot, it branches to give rise to the medial and lateral plantar nerves, which provide sensation to the plantar surface of the foot. Injury to the tibial nerve results in deficits of plantar flexion, as well as anesthesia to the plantar surface of the foot.
2013
A 24-year-old man comes to the office 3 months after closed reduction of a right knee dislocation. His knee is stable, but he still depends on an ankle/foot orthosis for ambulation. Physical examination shows decreased light-touch sensation along the dorsolateral aspect of the foot. Ankle eversion is absent. Sensation and motor function are otherwise intact. Nerve conduction testing is most likely to demonstrate a block in which of the following nerves?
A) Common peroneal B) Lateral plantar C) Medial plantar D) Posterior tibial E) Superficial peroneal
The correct response is Option E.
Common peroneal nerve injuries involving motor function loss have been reported in up to 50% of knee dislocations. If isolated sensory disturbances are also included, the incidence of nerve injury approaches 75%. If no recovery is noted by 3 to 6 months following injury, then surgical treatment is warranted. Physical exam primarily determines the nerve to be explored, neurolysed, and possibly grafted, but nerve conduction studies can be useful pre- and intraoperatively.
The common peroneal nerve divides into three branches at the knee, an articular branch that innervates the joint capsule and lateral collateral ligament of the knee, the superficial, and deep branches. The superficial branch innervates the muscles of the lateral compartment of the leg and provides sensation to the lateral calf and dorsal foot. The deep branch innervates the anterior compartment and provides sensation to the first web space of the foot. The scenario given above is most consistent with compromise of the superficial peroneal nerve. If dorsiflexion of the ankle and toe extension had also been lost, then common peroneal nerve injury would have been suggested.
The posterior tibial nerve proper innervates the muscles of the posterior calf, mediating ankle plantar flexion and toe flexion. The medial and lateral plantar nerves are terminal branches of the posterior tibial nerve. They provide motor innervation to the deep plantar muscles of the foot and sensation to the plantar surface of the foot.
2013
A 25-year-old construction worker has a 4-cm-diameter posterior calcaneal ulcer with exposed bone on removal of a short-leg cast applied 6 weeks ago for an ankle fracture. Coverage with a lateral calcaneal artery flap is planned. The lateral calcaneal artery is usually the terminal branch of which of the following arteries?
A) Anterior tibial
B) Dorsalis pedis
C) Lateral malleolar
D) Peroneal
The correct response is Option D.
Anatomic dissections by Drs. Grabb and Argenta found that the lateral calcaneal artery is usually the terminal branch of the peroneal artery but occasionally may arise from the posterior tibial artery. The branches of the peroneal include the nutrient artery which supplies the fibula, the perforating branch which gives branches to the tarsus, the communicating branch and the lateral calcaneal.
2013
During harvest of a plantaris tendon graft, which of the following structures is at greatest risk for injury?
A) Dorsalis pedis artery B) Extensor hallucis brevis muscle C) Medial plantar artery D) Sural nerve E) Tibial nerve
The correct response is Option E.
When multiple tendon grafts are needed or when it is necessary to harvest grafts long enough to reach from the forearm to the fingertip, lower extremity tendon graft harvest is necessary. The plantaris tendon is a good source of tendon graft and is present in about 80% of limbs.
The graft is harvested through a vertical incision just anterior to the medial aspect of the Achilles tendon. Then the graft is followed proximally using either a tendon stripper or with further incisions. As such, dissection of the plantaris tendon begins behind the medial malleolus and close to the tibial nerve. The sural nerve lies about the lateral malleolus and thus is not likely to be inadvertently injured during plantaris harvest. The medial plantar artery is on the sole of the foot and would be distal to the field of dissection. The extensor hallucis brevis muscle is a small muscle that lies over the dorsum of the foot and thus, like the dorsalis pedis artery, would not be injured in the dissection.
2013
The primary blood supply to a free anterolateral thigh fasciocutaneous flap arises from vessels that perforate which of the following muscles?
A) Gluteus maximus B) Rectus femoris C) Sartorius D) Tensor fascia lata E) Vastus lateralis
The correct response is Option E.
The anterolateral thigh (ALT) flap has proven to be one of the most versatile free tissue transfers in reconstructive surgery. Based on perforators from the descending branch of the lateral circumflex femoral artery that traverse the vastus lateralis (VL) (80%) or the septum between the rectus femoris and VL (18-20%), this flap can be fashioned as large as 10 cm wide by 25 cm long. Occasionally, no large perforator will be identified during dissection; in this circumstance, the flap may be carried on multiple perforators along with the vastus lateralis muscle.
Branches of the lateral circumflex femoral artery also supply the sartorius (partial, as the supply is segmental), rectus femoris (descending branch), and tensor fascia lata (ascending branch). Vascular supply to the gluteus maximus arises from the superior and inferior gluteal arteries.
2013
A 30-year-old man is scheduled to undergo great toe-to-thumb transfer 7 months after traumatic amputation of the dominant thumb. During dissection of the toe, the first dorsal metatarsal artery is most likely to be found branching from which of the following vessels?
A) Deep plantar B) Dorsalis pedis C) Plantar arterial arch D) Posterior tibial E) Proper digital
The correct response is Option B.
The origin and course of the first dorsal metatarsal artery (FDMA) are key to dissecting the first or second toe and the variety of available toe flaps. This anatomy is quite variable. In two thirds of cases, this artery emanates from the dorsalis pedis artery as its distal continuation. This course can then be superficial, within, or deep to the interosseous muscle. However, in one third of patients, the metatarsal artery may arise from the deep plantar artery that communicates with the plantar arch or actually from the plantar arch itself, in which case the FDMA may be vestigial. In the latter two situations, the metatarsal artery passes plantar to the deep transverse metatarsal ligament. The proper digital arteries are the distal continuations of the FDMA. The posterior tibial artery runs longitudinally in a superficial plane to the forefoot on the plantar surface. It is the larger lateral plantar artery that travels deeply to become the plantar arterial arch.
2013
An otherwise healthy 47-year-old man is transferred to the hospital because of an infection of the leg. He sustained the initial injury in a fall 6 weeks ago that was treated with internal fixation. The infection is now under control, and the internal hardware has been removed. Examination shows a 9-cm bony defect of the lower extremity. Neurovascular status of the foot is normal. Angiography of both lower extremities shows no abnormalities. A photograph and x-ray study are shown. Which of the following considerations favors vascularized bone grafting in this patient?
A) Length of time since the initial injury B) Mechanism of the injury C) Method of injury stabilization D) Patient age E) Size of the bony defect
The correct response is Option E.
The injury described is a Gustilo IIIB lower extremity wound complicated by infection. The sequence of reconstruction is often bony stabilization and debridement until bacterial balance. Bony deficits can be reconstructed in a variety of ways, including non-vascularized grafts, vascularized grafts (free of pedicle), and bone transport.
Generally, for defects greater than 6 to 8 cm, vascularized bone grafting is indicated.
Other indications for vascularized bone grafting are the presence of infection and prior failure of conventional (non-vascularized) grafting.
Age of the patient is not a contraindication to reconstruction per se, as long as he or she is medically stable to undergo a prolonged operation.
Gustilo Classification
I: open fracture; clean; wound less than 1 cm
II: open fracture; wound greater than 1 cm
IIIA: open fracture; extensive soft-tissue injury but adequate tissue for coverage
IIIB: open fracture; extensive soft-tissue injury but inadequate tissue for coverage
IIIC: any of the above with a vascular (arterial) injury
2013
A 37-year-old man comes to the office because of wound breakdown 2 weeks after he sustained a calcaneal fracture. Orthopaedic stabilization was performed in the emergency department at the time of the injury. Examination today shows a 3 × 4-cm wound over the lateral calcaneus. Coverage with a propeller fasciocutaneous flap from the lateral leg is planned. Which of the following blood vessels supplies the perforators of this flap?
A) Anterior tibial artery B) Lateral plantar artery C) Lateral sural artery D) Peroneal artery E) Posterior tibial artery
The correct response is Option D.
Propeller flaps are a useful method of lower extremity reconstruction. These flaps were initially popularized by Teo and have been utilized for a variety of defects in the lower leg and foot. The propeller flap is based on perforating blood vessels from the peroneal artery to reconstruct lateral defects and perforators from the posterior tibial artery to reconstruct defects on the medial aspect of the leg wound. The propeller flaps can often replace the need for a sural artery, neurocutaneous artery flap or a free tissue transfer. Laterally based plantar flaps may be used to cover small defects on the weight-bearing surface of the foot but are not reliable for larger or lateral defects. The posterior and anterior tibial arteries do not have perforator in the desired location for a distally based propeller flap. The lateral sural vessels are too proximal for heel coverage.
2013
A 55-year-old man is evaluated in the emergency department for foot salvage after he was involved in a motorcycle collision. Flow is restored after 6 hours from the time of injury. On examination, the foot is cold, and no plantar sensation is noted. The posterior tibial nerve is disrupted. A temporary external fixator is placed. A photograph and an x-ray study are shown (large open wound, complete fracture of tibia and fibula through shaft). Which of the following is the most appropriate classification of this injury and recommendation for management?
A) Gustilo type IIIB; amputation
B) Gustilo type IIIB; reconstruction
C) Gustilo type IIIC; amputation
D) Gustilo type IIIC; reconstruction
The correct response is Option C.
The patient described has a Gustilo IIIC injury. Based on the best available data, he should undergo amputation.
Ultimately, the choice to reconstruct versus amputate is a gestalt of the situation and the patient, as well as the capabilities of the hospital and the care team. In this case, the factors influencing the decision would be the warm ischemia time of 6 hours and severed posterior tibial nerve, as well as the extensive soft-tissue injury.
Some of the newer data suggests that absence of plantar sensation is no longer criteria for amputation in and of itself. However, an anatomically disrupted nerve in an adult strongly favors amputation.
In addition, there is evidence supporting the notion that limb salvage might involve less cost in the long term versus reconstruction.
Gustilo Classification
I: open fracture; clean; wound less than 1 cm
II: open fracture; wound greater than 1 cm
IIIA: open fracture; extensive soft-tissue injury but adequate tissue for coverage
IIIB: open fracture; extensive soft-tissue injury but inadequate tissue for coverage
IIIC: any of the above with a vascular (arterial) injury
2013
A 48-year-old man comes to the office because of drainage from the distal aspect of the wound 2 weeks after he underwent soft-tissue coverage with a free latissimus dorsi muscle flap for a degloving injury of the left lower extremity sustained in a motorcycle collision. Examination in the emergency department showed a Gustilo type IIIB tibia/fibula fracture and 6 cm of tibial loss. Debridement of the bone and stabilization with an external fixator were performed at the time of the injury. The patient underwent soft-tissue coverage 8 days after the injury. Examination today shows purulent drainage at the lower portion of the flap. Which of the following is the most likely cause of this complication?
A) Age of patient
B) Delay in soft-tissue coverage
C) Distal flap necrosis
D) Inadequate debridement
The correct response is Option D.
Posttraumatic reconstruction of the lower extremities with significant soft-tissue defects that expose bone, joints and tendons generally require free tissue transfer. The Gustilo-Anderson fracture classification system is widely used to describe the injury when associated with a long bone fracture. Gustilo type IIIB fractures are associated with periosteal stripping and exposure of bone with contamination. In 1986, Godina emphasized coverage of these soft-tissue defects within the first 72 hours of injury. Given the nature of these poly-trauma injuries, coverage of these wounds is not always possible in the given time frame. Staged debridement and negative pressure therapy have become common in the management of these injuries. Inadequate bone or soft-tissue debridement prior to reconstruction is a common cause of failure. The wound has to be free of all contaminants prior to reconstruction; thus, it is unlikely that an 8-day delay is the cause of breakdown. Distal flap necrosis would show more superficial breakdown and, in this case, is not the cause for a deep space infection. The patient’s age does not have any bearing on this complication.
2013
Which of the following is the most likely cause of congenital constriction band syndrome of the lower extremity?
A) Defect in the zone of polarizing activity
B) Deletion of the gene responsible for the apical ectodermal ridge
C) Early amnion rupture
D) Exposure to retinoic acid
E) Use of thalidomide during pregnancy
The correct response is Option C.
Early amnion rupture with subsequent entanglement of fetal parts (mostly limbs and appendages) by amniotic strands is the primary theory of pathogenesis.
A wide spectrum of clinical deformities is encountered and range from simple ring constrictions to major visceral defects. Lower extremity limb malformations are extremely common and consist of asymmetric digital ring constrictions, distal atrophy, congenital intrauterine amputations, acrosyndactyly, lymphedema, and clubfoot.
Amniotic band syndrome is not a rare anomaly, as first described more than 150 years ago, and appears to be rising. Once believed to have an incidence of 1:100,000, recent literature supports the incidence today as 1:1200 to 1:5000 births.
No distinct sex predilection has been determined. Nearly 60% of the cases documented have some sort of abnormal gestation history. Prenatal risk factors associated with amniotic band syndrome include prematurity (less than 37 weeks), low birth weight (less than 2500 g), maternal illness during pregnancy, maternal drug exposure, and maternal hemorrhage. Attempted abortion in the first trimester is also a highly associated finding. Family history seldom shows any direct inheritance pattern since the syndrome occurs in no particular association with known genetic or chromosomal disorders.
The zone of polarizing activity signals the developing limb bud towards anterior/posterior polarity and does not result in truncation.
Proximodistal limb growth is the result of the apical ectodermal ridge. Deletion of the gene responsible for the apical ectodermal ridge will result in shortening of the limb but not in congenital constriction band syndrome. Experiments in which the apical ectodermal ridge has been removed show truncated limb growth. Scientific evidence supports that the pattern of limb anomalies in the offspring of mothers exposed to exogenous retinoids, such as retinoic acid, causes interference with apical ectodermal ridge function, resulting in similar deformities.
Thalidomide results in various limb deformities, including phocomelia (hands/feet attached close to trunk w the limbs grossly under-developed or absent), dysmelia, amelia (absence of 4 limbs), and bone hypoplasticity, with as little as a single dose of thalidomide during gestation. It does not, however, result in constriction bands. It is postulated that thalidomide-associated malformations are the result of the drug’s interference with vasculogenesis.
2013
A 17-year-old boy sustains an avulsion injury to the anterior ankle with exposed tendon in a motorcycle collision. The wound is evaluated and reconstruction with a reverse sural artery flap is planned. During elevation of the flap, which of the following is most likely to compromise flap viability?
A ) Injury to the lesser saphenous vein
B ) Injury to the median superficial sural artery
C ) Injury to the sural nerve
D ) Ligation of the gastrocnemius muscle perforators
E ) Ligation of the peroneal artery perforators
The correct response is Option E.
The predominant blood supply to the reverse sural artery flap relies on perforators from the peroneal artery, which primarily originate at a point 5 cm proximal to the lateral malleolus.
The median superficial sural artery and perforators from the gastrocnemius are involved in anterograde blood supply to the flap. Thus, these vessels are typically ligated in the reverse form of the flap.
Likewise, injury to the lesser saphenous vein would not cause significant problems with venous outflow. In dissections and venous flow studies, small concomitant veins were found along both sides of the lesser saphenous vein and were considered to be venae comitantes of accompanying arteries of the vein. These accompanying veins played a role in bypassing the valves of the lesser saphenous vein.
The sural artery flap can be harvested as a neural-veno-adipofascial flap. In this context, the sural nerve can used to provide sensation to the flap. This nerve does not provide primary blood supply to the flap, and injury would not compromise flap viability.
2012
A 55-year-old man comes for evaluation of a nonhealing foot ulcer. He has a 10-year history of type 1 diabetes mellitus. Physical examination shows a deep, 4-cm plantar ulcer at the great toe metatarsal head. Which of the following is the most likely cause of this ulcer?
A ) Atherosclerosis B ) Lymphatic obstruction C ) Peripheral neuropathy D ) Poor hygiene E ) Venous stasis
The correct response is Option C.
Sensory neuropathy leads to loss of protective sensations. This then leads to neuropathic imbalance with loss of coordination which increases mechanical stresses, unperceived trauma, Charcot foot, and ulcers. Sympathetic neuropathy leads to warm, dry feet which are prone to skin breakdowns. Patients with diabetes who also have peripheral vascular disease are more prone to ischemic ulcers. Patients with diabetic foot ulcers have not been associated with large-vessel atherosclerosis.
2012
A 25-year-old man undergoes open reduction and internal fixation of a Gustilo Type IIIB tibia-fibula fracture. Coverage of the resultant soft-tissue defect with a free flap is planned. Which of the following is the ideal length of time after the injury that this procedure should be performed?
A ) 3 Days B ) 10 Days C ) 21 Days D ) 60 Days E ) 90 Days
The correct response is Option A.
Godina defined the timing of posttraumatic microsurgical lower extremity reconstruction in 1986 with recommendations for flap coverage of Gustilo Type IIIB/C fractures within 72 hours of injury. Godina’s study showed the highest risk of infection and flap loss in the delayed period (72 hours to 90 days). Subsequent authors have also cited lower rates of flap loss and infection when repair was performed.
Many authors have reported good flap survival when surgery is done within 3 days and 3 months after injury, but it is accepted that this delayed time frame necessitates more meticulous dissection and going well outside the zone of injury to a patent venous system to decrease the incidence of free flap loss.
2012
A 66-year-old man comes to the office with a 2-year history of progressive ulceration at the right medial malleolus. He says he has marked calf pain when he is active, and that it has worsened progressively over time. Medical history includes cardiovascular disease and a 40-year history of smoking. Physical examination shows that the wound margins are well demarcated with a yellow fibrinous wound base. Which of the following is the most appropriate management of this patient’s condition?
A ) Biopsy of the wound edge B ) Debridement and dressing changes C ) Debridement and local flap coverage D ) Revascularization by vascular surgery E ) Use of topical debriding agents
The correct response is Option D.
Arterial ulcers most commonly occur in male patients with atherosclerosis, usually in association with cardiovascular disease, diabetes, hypertension, or smoking. Patients typically have symptoms of claudication and rest pain. The leg pain improves when the leg is dependent and is exacerbated when the leg is elevated. The base of the arterial ulcer generally does not bleed and has a “punched-out” appearance. Ulcers associated with an ankle brachial index of less than 0.45 (normal range 0.90 to 1.30) generally do not heal without revascularization. Aggressive debridement would create a larger wound without the potential to heal. Continued wound care would provide no long-term benefit. The clinical picture described is not consistent with malignant degeneration of the wound.
2012
An otherwise healthy 25-year-old man is evaluated because of footdrop and paresthesia 4 weeks after undergoing open reduction and internal fixation of a fracture of the proximal tibia. Electrodiagnostic testing shows no conduction of the nerve. Which of the following is the most appropriate next step in management?
A ) Ankle arthrodesis B ) Peroneal nerve decompression C ) Posterior tibial nerve decompression D ) Posterior tibial tendon transfer E ) Repeat electrodiagnostic testing in 4 weeks
The correct response is Option E.
Peroneal nerve palsy may lead to severe disability with footdrop and paresthesia. Traumatic peroneal palsy may result from supracondylar femoral fracture, knee dislocation, and proximal tibial fracture involving both motor and sensory changes. On examination, the motor deficit manifests as a footdrop, and the sensory deficit results in a loss of sensation along the dorsum of the foot. Unlike the loss of sensation associated with the peroneal nerve, the posterior tibial nerve is clinically morbid, as it is on the plantar aspect of the foot. The chronic injury may result in wounding of the plantar aspect of the foot, which may ultimately result in amputation.
Electrodiagnostic testing should be performed within 1 month of the injury to confirm sensory and motor deficits. In patients with partial nerve palsy, greater than 80% will recover completely and can be expected to recover with observation alone. A patient with complete palsy will have a much worse prognosis, with only 40% of patients with a functional recovery. If there is no neurologic improvement after 2 to 3 months, operative decompression should be performed. If the nerve is noted to be in continuity, and nerve action potentials are transmitted across a lesion, then there may be continuity of the nerve, and neurolysis is performed. If there is a transected nerve, a direct repair or nerve grafting may be performed.
When neurolysis and nerve grafting do not provide satisfactory results, the remaining surgical options are salvage procedures such as tendon transfer or arthrodesis. Posterior tibial tendon transfer is the most commonly used tendon transfer for this injury.
2012
A 58-year-old man comes to the office for follow-up 3 weeks after undergoing mandibular reconstruction with a fibular free flap. The patient reports numbness of the operated extremity and says he has difficulty walking. Which of the following sensory and motor deficits is most likely in this patient?
Absence of Sensation / Weakness
A) First web space of foot / Extensor hallucis longus + tibialis anterior
B) Medial aspect of calf / Soleus + extensor digitorum braves
C) Medial malleolus + heel / Soleus + tibialis anterior
D) Third web space of foot / Soleus + extensor digitorum brevis
E) Upper lateral calf / Flexor hallucis longus + extensor digitorum brevis
The correct response is Option A.
The injury in the patient described is to the common peroneal nerve.
Both the first web space of the foot and the extensor hallucis longus and tibialis anterior muscles are innervated by branches of the common peroneal nerve. The finding of absence of sensation over the medial aspect of the calf and weakness of the soleus and extensor digitorum brevis muscles is eliminated by numbness of the medial calf, which is innervated by the saphenous nerve, a branch of the femoral nerve. Absence of sensation over the medial malleolus and heel with weakness of the soleus and tibialis anterior muscles is eliminated by numbness of the medial malleolus, which is also innervated by the saphenous nerve. In addition, the soleus is innervated by the tibial nerve. The finding of absence of sensation in the third web space of the foot and weakness of the soleus and extensor digitorum brevis muscles is eliminated by the soleus muscle. The finding of absence of sensation over the upper lateral calf and weakness of the flexor hallucis longus and extensor digitorum brevis muscles is eliminated by the flexor hallucis longus, which is innervated by the tibial nerve.
2012
A 46-year-old man is brought to the emergency department after sustaining an open comminuted fracture of the left tibia during a motor vehicle collision. Physical examination shows a wound greater than 10 cm with marked periosteal stripping near the mid shaft. Which of the following is the appropriate Gustilo classification of this patient’s injury?
A ) I B ) II C ) IIIA D ) IIIB E ) IIIC
The correct response is Option D.
The Gustilo classification of open fractures is based on the severity of soft-tissue injury and the presence or absence of concurrent vascular injury. A higher grade implies a more severe injury, and correlates with a greater incidence of complications and need for amputation.
The patient in this item has a wound greater than 10 cm and a heavily comminuted tibia fracture. There is no mention of vascular injury. He has a Gustilo type IIIB injury.
The Gustilo grading scale: Type / Findings
I: Clean wound bed, simple/minimally comminuted bone injury, wound < 1 cm
II: Wound contaminated, moderate comminution of bone, wound > 1 cm
IIIA: Wound highly contaminated, severe comminution, wound 1 to 10 cm
IIIB: Wound highly contaminated, severe comminution, wound > 10 cm
IIIC: Major vascular injury requiring repair for limb salvage
2012
A 23-year-old man is brought to the emergency department 4 hours after sustaining an open tibia and fibula fracture to the middle third of the leg in a motorcycle collision. A proximally based soleus flap is chosen to reconstruct the defect. Which of the following arteries is the most likely blood supply of this flap?
A ) Anterior tibial B ) Inferior geniculate C ) Peroneal D ) Profunda femoris E ) Superior geniculate
The correct response is Option C.
The soleus muscle is a broad, powerful muscle of the posterior calf which, along with the gastrocnemius muscle, forms the triceps surae. The soleus takes its origin from the upper third of the fibula and medial border of the tibia and inserts into the calcaneus with the gastrocnemius muscle by way of the Achilles tendon. The blood supply of the soleus muscle is from the peroneal artery proximally and the posterior tibial artery distally. This soleus muscle flap is used as a pedicle muscle flap for coverage of defects of the middle third of the lower leg.
2012
Which of the following is the most likely indication to consider replantation of a lower extremity?
A ) Bilateral sharp injury B ) Crush mechanism of injury C ) Ischemia time over 8 hours D ) Multilevel injury E ) Patient over age 50 years
The correct response is Option A.
The indications for lower extremity replantation are limited. The best candidate for a lower extremity replantation would be a young patient who has had both legs amputated with a clean mechanism. Contraindications for lower extremity replantation include crush mechanism of injury, ischemia time over 8 hours, multiple-level injury, poor baseline health, and a patient of advanced age.
2012
A 17-year-old boy undergoes resection of the right distal femur to treat osteosarcoma. A large allogeneic corticocancellous bone graft is used for skeletal reconstruction of the 10-cm bony defect. An intramedullary vascularized fibular free flap is also placed in the construct. Which of the following is the most likely purpose of this additional procedure?
A) Decrease the immunogenicity of the allograft
B) Decrease the rate of infection
C) Increase creeping substitution in the allograft
D) Increase the immediate strength of the construct
E) Shorten union time
The correct response is Option E.
The most likely reason to place an intramedullary fibular free flap in the allogeneic bone graft is to shorten union time. Free fibular flaps contain an intrinsic blood supply and osteogenic cells. These offer an alternative to the allograft and the capability of osteogenesis through osteoinduction. Thus, the biologic advantage of fibular free flaps is a shortened union time compared with the allograft, which solely depends upon creeping substitution for healing. Union times may be as short as 3 to 5 months. The healing of massive allografts is generally slow, superficial, and incomplete. The union times for allograft healing have been reported at 14 to 23 months for intercalary defects.
Nonvascularized massive allografts provide a biologic spacer with strong cortical bone. These grafts give great strength to the construct; however, despite this advantage they have many disadvantages, including their lack of blood supply, lack of osteogenic cells, and potential for immunologic reaction. The fibula may add some strength to the overall construct but this is not the primary reason for its use in the scenario described. It also does not mitigate any potential antigenicity that the graft may have. The graft heals by creeping substitution and as such is only osteoconductive, unlike vascularized bone. This process in the allograft remains unchanged by the presence of the fibular flap; however, it does provide the additional process of osteoinduction as described above, which helps in healing. It is the avascular status of the allograft that predisposes these reconstructions to infection, not the dead space in the medullary canal.
2011
A 67-year-old man comes to the office because of an open wound of the right groin and exposed distal anastomosis of a vascular graft 3 weeks after aortofemoral bypass grafting. Reconstruction with a sartorius muscle flap is planned to cover the graft. The blood supply of the sartorius muscle flap originates directly from which of the following arteries?
A) Deep circumflex iliac B) Lateral circumflex femoral C) Medial circumflex femoral D) Profunda femoris E) Superficial femoral
The correct response is Option E.
The sartorius muscle has a Type IV vascularization pattern consisting of 8 to 10 pedicles from the superficial femoral vessel, which enter the muscle medially. The other arteries do not contribute to the blood supply of the sartorius muscle.
2011
A 70-year-old man undergoes open reduction and internal fixation of an open fracture of the ankle. Debridement of nonviable tissue results in the exposure of the joint and hardware. Coverage with a reverse sural artery flap is planned. A photograph is shown. Which of the following is the most likely adverse outcome associated with the use of this flap?
A) Infection B) Insufficient bulk C) Insufficient flap coverage D) Partial flap loss E) Wound dehiscence
The correct response is Option D.
The utility of the flap has been proven in both healthy and compromised wounds; neither peripheral arterial disease nor diabetes has precluded its success. Of the possible complications, partial flap loss has occurred most commonly. As a result, numerous modifications to the flap have been proposed. These include maintaining a narrow (2 cm wide) pedicle, including a cutaneous “tail” along the length of the pedicle and maintaining a mesentery between the sural nerve and the deep fascia.
Infection rates have been low, ranging from 0 to 2.5%. The fasciocutaneous variety of the reverse sural flap is often malleable enough to conform to most defects. When a deeper defect exists, a fasciomusculocutaneous variation of the flap has been designed to carry a portion of the gastrocnemius muscle via one of the larger proximal perforators typically found deep to the cutaneous paddle in the proximal leg.
Cutaneous paddles have been harvested with dimensions of up to 12 × 15 cm, allowing coverage of most ankle and heel wounds.
Reconstruction of larger donor defects with split-thickness skin grafts makes dehiscence unlikely.
2011
A 33-year-old woman is brought to the emergency department after sustaining a 6 × 8-cm soft-tissue defect over the tibial tuberosity after being hit by a motor vehicle while riding her bicycle. Physical examination shows exposed bone at the proximal third of the leg. Which of the following muscle flaps is most appropriate for this patient?
A) Lateral gastrocnemius B) Lateral soleus C) Medial gastrocnemius D) Medial soleus E) Sartorius
The correct response is Option C.
The gastrocnemius is a powerful muscle in the superficial posterior compartment of the leg that acts to plantar flex the foot at the ankle joint and flex the leg at the knee joint. It is involved in standing, walking, running, and jumping.
The lateral head originates from the lateral condyle of the femur, while the medial head originates from the medial condyle of the femur. Its other end forms a common tendon with the soleus muscle; this tendon is known as the calcaneal tendon or “Achilles tendon” and inserts onto the posterior surface of the calcaneus.
The medial head is longer, and its muscular fibers extend more inferiorly. The gastrocnemius can be harvested as a muscular or musculocutaneous flap if the soleus is intact and plantar flexion of the foot will be preserved. Medial and lateral heads may be used independently based on the tissue defect present. Footdrop is possible with the use of the lateral muscle belly.
The soleus is the other powerful muscle of the superficial posterior compartment of the leg. With the gastrocnemius, it acts to plantar flex the foot at the ankle joint. Specifically, the soleus plays an important role in standing; if not for its constant pull, the body would fall forward. The muscle originates from the posterior surfaces of the head of the fibula and its upper quarter, as well as the middle third of the medial border of the tibia. Its other end forms a common calcaneal tendon with the gastrocnemius muscle.
The soleus muscle, when freed from its insertion on the Achilles tendon and based proximally, covers defects in the middle third of the tibia. It may also be used as a hemisoleus to cover distal third tibia defects as well.
The sartorius flap may be raised as a muscle or myocutaneous flap based on segmental branches of the superficial femoral artery and vein. Because it has a Type IV segmental blood supply, the arc of rotation both superiorly and inferiorly is limited. Its best indication is for coverage of the femoral vessels.
2011
A 40-year-old woman is referred by her orthopedic surgeon for reconstruction because of an exquisitely tender scar over the site of the anterolateral portal for arthroscopy of the left ankle. Examination shows a 1-cm scar over the lateral malleolus. Tinel sign is present over the scar. Sensation is diminished over the middle part of the dorsum of the foot. Which of the following nerves is most likely to have been injured during the arthroscopy?
A) Lateral malleolar B) Medial plantar C) Saphenous D) Superficial peroneal E) Sural
The correct response is Option D.
In the patient described, the dermatomal distribution of numbness of the middle of the dorsum of the foot suggests injury of the superficial peroneal nerve (SPN). The SPN supplies the sensation to the middle portion of the dorsum of the foot, except for the skin in the great toe web space (which is innervated by the deep peroneal nerve).
The lateral malleolar nerve is a terminal branch nerve supplying the skin of the lateral malleolus.
The medial plantar nerve supplies the medial three fourths of the plantar surface of the foot.
The saphenous nerve travels to the dorsum of the foot, medial malleolus, and the area of the head of the first metatarsal. At the level of the ankle, the saphenous nerve is found between the medial malleolus and the anterior tibial tendon, just lateral to the saphenous vein.
The sural nerve is located at an average of 7 mm posterior to the lateral malleolus and supplies sensation to the lateral aspect of the foot. A diagram is shown.
According to one study, in ankle arthroscopy the risk of SPN injury is maximal in the 0 to 3 mm lateral to the peroneus tertius tendon. To avoid injury to the SPN, the safest placement of the anterolateral portal is 4 mm lateral to the peroneus tertius tendon.
In another study, in 82% of specimens, the SPN ran between the lateral border of the talocrural joint and the peroneus tertius tendon at the talocrural joint level, where the anterolateral portal was placed. Therefore, the SPN was at high risk for injury with anterolateral portal placement.
2011
A 62-year-old man is brought to the emergency department by helicopter after sustaining severe injuries to the head, neck, and right femur during a motor vehicle collision. The patient’s condition is stabilized, and the femur is temporarily reduced and splint immobilized. Peripheral pulses in the right leg are not palpable and capillary refill is noted; handheld Doppler shows weak pulses. Which of the following is the most appropriate next step to establish lower extremity vascular injury in this patient?
A) CT angiography
B) Doppler ultrasonography
C) Measurement of ankle brachial index
D) Serial physical examinations
The correct response is Option A.
As with many patients who have sustained severe upper or lower extremity trauma, the vascular status of the limb in the patient described is in question. Because of significant collateral blood flow in the upper and lower extremities, capillary refill and handheld Doppler tones can often be found even with complete disruption of major arteries. Although traditional angiography is known as the “gold standard” for the diagnosis of vascular injuries, it is not without its difficulties. A special suite, technicians, and physicians are needed to perform traditional angiography, and the potential for morbidity has been noted. As a result, CT angiography is fast becoming the new “gold standard” for the diagnosis of vascular injuries. Coupled with the fact that many trauma patients will be brought to the CT suite for other injuries, CT angiography is a rapid and natural next step to be taken when the head or abdomen is being scanned.
Serial physical examination, ankle brachial index, and Doppler ultrasonography are adequate techniques, but they may be operator-dependent or sometimes have difficulty localizing the actual injury. Both traditional and CT angiography will localize the injury, but, for obvious reasons, CT angiography has overtaken traditional angiography in the diagnosis of acute vascular injury in the trauma patient.
2011
A 25-year-old man is brought to the emergency department after he was hit by a motor vehicle while walking across the street. Physical examination shows a Gustilo Type IIIB open fracture of the tibia. Reconstruction with an anterolateral thigh flap is planned. An incision between which of the following structures is the most appropriate approach to access the posterior tibial vessels?
A) Lateral malleolus and the Achilles tendon
B) Lateral malleolus and the extensor hallucis longus tendon
C) Medial malleolus and the Achilles tendon
D) Tibialis anterior and the extensor hallucis longus tendons
The correct response is Option C.
The sural nerve is located at the distal leg between the lateral malleolus and the Achilles tendon.
The greater saphenous vein is located between the medial malleolus and the extensor hallucis longus tendon.
The posterior tibial vessels are located between the medial malleolus and the Achilles tendon.
The dorsalis pedis artery is located between the tendons of the tibialis anterior and the extensor hallucis longus.
2011
An otherwise healthy 35-year-old man is brought to the emergency department after he collided with a parked bus while riding his motorcycle at 20 mph. On admission, he is cleared by the trauma service to undergo orthopedic exploration of an open fracture of the tibia and fibula. The surgeon achieves external fixation and begins washout of a 15-cm anterior wound with exposed denuded bone. A consultation regarding initial evaluation for soft-tissue coverage is requested. Which of the following additional findings is most likely to lead to the decision to recommend eventual below-the-knee amputation rather than reconstruction for this patient?
A) Gap of the tibial nerve of 4 cm
B) Grade 2 liver laceration
C) Ipsilateral full-thickness anterior plantar skin avulsion with associated metatarsal fractures
D) New-onset absence of the pulses in the foot following external fixation
E) Parietal contusion requiring endotracheal intubation and neurosurgical consultation
The correct response is Option A.
Avulsion of the tibial nerve is one of the two absolute indications for amputation in the context of Gustilo Type IIIB and IIIC open tibial fractures. This is because outcomes of microsurgical reconstruction of the insensate foot in these cases are very poor.
The other absolute contraindication to reconstruction is a warm ischemia time of 6 hours or greater, which the patient described does not have. The patient has just lost pulses after manipulation and fixation. This is a new finding, with very recent ischemia time. This is a potentially fixable situation, and not necessarily a contraindication to reconstruction. Recent loss of pulses could contribute to a need for amputation in the future but would not require that decision now.
Polytrauma, such as a liver laceration or an intracranial injury, can evolve into relative contraindications to reconstruction, but they are not absolute contraindications by themselves. The liver laceration could resolve and allow safe microsurgical reconstruction. Even the delay of time to reconstruction that polytrauma can necessitate can be managed with bony fixation, wound care, and vacuum-assisted closure placement until construction of a flap can be performed.
The loss of plantar skin and metatarsal fractures by themselves are also not an absolute contraindication to reconstruction. This is a potentially reconstructible problem that should not push the plastic surgeon to recommend amputation. The additional foot trauma can potentially be reconstructed either with a skin graft or a flap.
The intracranial injury can evolve to a point where neurosurgery would eventually release the patient for a free flap. So, the parietal contusion is not necessarily an absolute contraindication to reconstruction, depending on the eventual outcome from the head injury. The patient may very well get better from that, and become a limb salvage candidate. It all depends on severity.
2011
A 17-year-old boy is brought to the emergency department after sustaining a traumatic injury to the left lower extremity in a motor vehicle collision. Physical examination shows a large area of crush injury, loss of soft tissue, and open fracture of the tibia with exposed bone. The lower leg is cool to touch and pale. No distal pulses are palpable. Angiography shows transsection of the popliteal artery. Which of the following is the most appropriate Gustilo classification of this patient’s fracture?
A ) Type I B ) Type II C ) Type IIIA D ) Type IIIB E ) Type IIIC
The correct response is Option E.
The most appropriate classification for this injury is Gustilo Type IIIC.
The Gustilo classification is the most widely accepted method for characterizing open fractures of the lower extremity. Injuries are divided into three grades.
- Type I open fractures involve soft-tissue lacerations smaller than 1 cm.
- Type II fractures include lacerations of 1 to 10 cm, with moderate soft-tissue damage.
- Type III fractures are greater than 10 cm and involve extensive soft-tissue damage. These injuries create difficulties in coverage of bone or fixation hardware. Gustilo
- Type III fractures are further subdivided into A, B, and C subtypes.
- Type IIIA fractures have sufficient soft tissue to provide for bony coverage.
- Type IIIB fractures involve periosteal stripping and extensive tissue damage, and local soft-tissue coverage is not possible. These typically result from high-energy mechanisms, such as high-velocity gunshot wounds or significant crush injuries. Gustilo Type IIIB fractures are the most common injuries for which plastic surgeons are consulted.
- Gustilo Type IIIC fractures include vascular injuries that require repair. The presence of a vascular injury significantly increases the probability of amputation.
2010
A 15-year-old boy is brought to the emergency department 1 hour after his left foot was severed when his leg was run over by a train. Photographs are shown - amputated foot w tendons avulsed. Which of the following is the most appropriate management?
A ) Construction of a foot filet free flap
B ) Replantation and ankle fusion
C ) Revision amputation to the level of the skin edge and primary closure
D ) Split-thickness skin grafting
E ) Temporary revascularization with shunts and delayed replantation
The correct response is Option C.
The patient described has a limb amputation that includes a significant avulsion component, exemplified in the long tendon stumps that appear ripped off from their muscle bellies, and ankle disarticulation. Avulsion amputations of the lower extremity are not suitable for replantation because of the extended neurovascular damage that is present on both ends well beyond the level of the injury. The incidence of thrombosis at the anastomosis is high. Use of vein grafts on a free flap could be considered, but, in this case, they may have to be connected as high as knee level to ensure patency. The amputated part likely has massive microscopic endothelial damage extending to terminal vessels and could only be used as a donor site for skin grafts. Therefore, there is no role for immediate or delayed replantation.
While preservation of maximum tibial length is desirable in preparing the amputation stump, prosthetic fitting for ankle disarticulations is fraught with trouble. Some tibial shortening is required to have a comfortable, reliable prosthesis. In the scenario described, tibial shortening of 2 and 4 in would have equivalent results because there is still ample length of proximal tibia available to provide the same functionality and equivalent energy expenditure. Therefore, use of a free flap to protect an additional 2 in of tibia adds no advantage for this patient. When the level of amputation is through the proximal tibia, some benefit could be found in that a minimum of 6 in of proximal tibia is available for prosthetic fitting. Split-skin grafts are generally unstable in weight-bearing surfaces and take longer to heal and mature, which causes delay in rehabilitation. Skin grafts will not take or perform well when applied over an articular surface.
2010
A 43-year-old man has footdrop and numbness of the left foot following reconstruction of a soft-tissue defect resulting from a Gustilo Type IIIB fracture of the proximal tibia. Which of the following pedicled flaps was most likely used for reconstruction?
A ) Gracilis B ) Lateral gastrocnemius C ) Reversed sural artery D ) Sartorius E ) Soleus
The correct response is Option B.
The pedicled gastrocnemius flap has been shown to be a reliable source of vascularized soft tissue for injuries of the distal thigh, knee, and proximal leg. The lateral or medial head may be harvested. Lateral gastrocnemius harvest risks damaging the common peroneal nerve, with an incidence of 7.7%. Medial gastrocnemius harvest, for obvious anatomical reasons, does not carry this risk.
There are few data on the morbidity of donor sites, but those studies that have been done demonstrate no functional debility at a walking gait for less than 200 m. Patients do notice difficulty standing on their toes and have slowing with variable calcaneal gait when walking fast. Forty-two percent of patients could run, 22% had pain in the donor site at rest, and 20% had pain when walking more than 200 m. Seventy percent had pain and weakness in the operated leg when attempting to run. Range-of-motion deficit existed in the operated limb, with average loss of 27% flexion and 14% extension.
The gracilis and sartorius muscles are not routinely used for pedicled reconstruction of the proximal tibia, nor would their harvest cause the symptoms of the patient described.
The reversed sural artery flap is an adipofascial flap that could be used for this described defect; however, its dissection does not jeopardize the common peroneal nerve.
The soleus muscle has better venous muscle pump function than the gastrocnemius, and edema, not nerve damage, is more common after use of the soleus. The limited data available suggest that the functional deficit with resulting limitation to ankle flexion is also more severe with soleus harvest.
2010
A 62-year-old man is scheduled to undergo reconstruction of a 7-cm bone defect (shown) resulting from excision of a tumor of the distal radius. He has hypertension and has smoked one pack of cigarettes daily for 30 years. Which of the following is the most appropriate technique for reconstruction of the defect?
A ) Allograft bone graft
B ) Fibula free flap
C ) Locking fixation plate
D ) Pedicled ulna bone flap
The correct response is Option B.
Composite tissue reconstruction after tumor ablation is a significant challenge to the plastic surgeon. Generally, bony defects greater than 6 cm require vascularized bone for reconstruction. For large defects, the optimum choice of bone is the vascularized fibula. The fibula also has a reliable blood supply from the peroneal artery and can be harvested with a cutaneous skin paddle. The fibula free flap is the most appropriate technique. Reconstruction with free flaps can be successfully performed in a patient with a smoking history and, in fact, is often the optimal method of reconstruction in smokers. The use of allograft cadaver bone is not indicated, especially in a patient with a history of smoking. For defects of the size shown in the photograph, the locking fixation plate would not give adequate long-term support. A local bone flap is also not a viable option.
2010
A 70-year-old man is brought to the emergency department after he was hit by a car while walking across the street. Numerous fractures of the ribs, a nonoperative laceration of the spleen, a fracture of the right humerus, and a Gustilo Type IIIC fracture of the middle third of the left lower leg are noted. Examination shows an 8 × 7-cm soft-tissue defect over the anterior aspect with exposed bone. The patient is unable to plantar flex his left foot, and sensation is absent over the plantar aspect. Surgical exploration shows transection of the posterior tibial artery and tibial nerve. Which of the following is the most appropriate management of the injured leg?
A ) Above-knee amputation
B ) Below-knee amputation
C ) Irrigation, debridement, external fixation, free tissue transfer, and delayed repair of the nerve
D ) Irrigation, debridement, external fixation, immediate repair of the artery and nerve, and free tissue transfer
E ) Irrigation, debridement, internal fixation, immediate repair of the artery and nerve, and skin grafting
The correct response is Option B.
The treatment goal in the management of open tibial fractures and lower extremity salvage is to preserve a limb that will be more functional than an amputation. If the extremity cannot be salvaged, the goal is to maintain the maximum functional length.
Given the advanced age of the patient described, his associated injuries, and an insensate injured lower extremity, the most appropriate management of the injured leg would be a below-knee amputation.
Below-knee amputations provide better prosthetic function and require less energy for ambulation than above-knee amputations.
Although improved microvascular techniques have allowed for nerve repair and nerve grafting, the results of nerve repair and grafting in the lower extremity have been poor. In addition, the repair of the posterior tibial artery would not be necessary if the anterior tibial and peroneal arteries were to remain patent.
Free tissue transfer might be indicated for the soft-tissue defect. However, any anticoagulation used would increase the chance of serious bleeding complications because the patient is being treated nonoperatively for a splenic laceration.
Skin grafting over exposed bone would not be a good option.
2010
An 18-year-old man is brought to the trauma center after sustaining an injury to the right lower extremity. Examination shows an open fracture of the right tibia. Which of the following mechanisms of the injury is most likely to require the most extensive surgical debridement?
A ) A collision on the rink during which one skater runs over another
B ) A fall from a bicycle onto a curb after a collision with a pedestrian
C ) A fall from a 6-ft ladder onto a ceramic floor
D ) A fall from a shopping cart onto a parking lot
E ) A vehicle crash into a highway barrier while speeding
The correct response is Option E.
All of the mechanisms could have caused an open fracture requiring surgical intervention. Only the vehicle crash represents a high-energy injury. The approach to high-energy injuries must take into account a wider zone of injury beyond just the fracture site and skin laceration.
Open fractures in high-energy soft-tissue injuries have a high incidence of malunion and infection, especially with tibia fractures. These injuries require emergent debridement of both devitalized soft tissue and bone. Aggressive debridement will decrease the incidence of infection and increase the likelihood of successful reconstruction. Wounds frequently require multiple debridements followed by soft-tissue coverage including pedicled and free flaps. Vacuum-assisted closure applies negative pressure to an open wound causing increased granulation tissue, decreased edema, and decreased wound size. This technique has lowered the need for free flaps even in high-energy Gustilo Type III fractures.
The other options listed are not appropriate because the mechanisms of injury are low energy.
- Free-fall physics shows the housepainter hit the ceramic floor at a maximum of 13 mph. The patient’s weight does not affect speed at impact. Distance = 1/2 × Gravity × Time (squared), Velocity at impact = Gravity × Time, Gravity = 32 ft/s2.
- The ice-skater sustained a sharp injury of low energy.
- The incident with the shopping cart is a low-energy injury, as is the bicyclist/pedestrian collision.
- The bicyclist hit a pedestrian and then fell. Average speed for a serious bicyclist is 13 to 18 mph. Colliding with a pedestrian would further decrease that speed.
A 40-year-old man undergoes open reduction and internal fixation of an open fracture of the ankle. Debridement of nonviable tissue results in the exposure of the lateral joint and hardware. Coverage of the lateral malleolus with the flap shown is planned. Which of the following arteries must be intact for this flap to be viable?
A ) Anterior tibial B ) Dorsalis pedis C ) Lateral genicular D ) Lateral plantar E ) Peroneal
The correct response is Option E.
The reverse-flow sural flap has become one of the more dependable solutions in distal third leg wound and heel reconstruction. Survival of the flap depends on intact flow into the superficial sural arterial network via perforators from the peroneal system. The largest perforator arises roughly 5 cm cephalad to the lateral malleolus and typically marks the lowest pivot point for the flap.
None of the remaining choices would provide adequate perfusion for this flap.
2010
A 48-year-old woman undergoes coverage of a defect with an anterolateral thigh flap. Which of the following branches of the lateral femoral circumflex artery is the most likely dominant vascular supply for the flap perforator?
A ) Ascending
B ) Descending
C ) Oblique
D ) Transverse
The correct response is Option B.
In recent studies by Wong, et al, and Rozen, et al, attempts have been made to clarify the vascular perforator anatomy of the anterolateral thigh flap. It has been noted that sizeable vascular perforators may arise from the ascending, transverse, or descending branch of the lateral circumflex femoral artery. The most common supply, however, comes from the descending branch, followed by the transverse and ascending branches.
The descending branch is dominant in about 85% of cases.
A variable oblique branch, which can occasionally be the primary supply, has also been noted. This branch, when it exists, is usually the primary supply of the flap in 15% of cases. It typically is an offshoot of the descending or transverse branch.
2010
A 40-year-old man is diagnosed with a posterior thigh sarcoma. He undergoes resection of the tumor as well as some of the surrounding muscle. Partial sacrifice of the sciatic nerve is required, leaving a 40% circumferential defect and an 11-cm gap between proximal and distal ends. A photograph is shown. Which of the following is the most appropriate method of nerve reconstruction?
A) Mobilization and primary coaptation B) Polyglycolic acid nerve tube C) Processed human allograft conduit D) Saphenous vein graft E) Sural nerve cable graft
The correct response is Option E.
Fundamentals of nerve repair include coaptation in a tension-free manner. If there is any tension, nerve grafts or conduits are indicated. In this clinical scenario, there is a large nerve gap that precludes tension-free primary coaptation, even with extensive proximal and distal mobilization. Therefore, a nerve graft is indicated. Common choices include sural, lateral, or medial antebrachial cutaneous. For the size and length of the defect and the fact that multiple cable grafts would be needed, the sural is the most appropriate choice.
Nerve conduits such as PGA tubes and processed human allograft conduits serve as scaffolds to promote nerve regeneration, although these are typically used for gaps less than 3 cm. Given the distance involved, a sural nerve graft using a grouped fascicular or epineurial repair is the most appropriate choice, although a gap this large is almost certain to leave permanent deficits. Appropriate levels of expectation must be set with the patient.
2019
An 18-year-old woman comes to the office because of a large osteosarcoma of the distal shaft of the right femur. A 15-cm bone resection is planned, with a resulting large intercalary segmental defect. The overlying skin and soft-tissue is not involved. The patient is very motivated to proceed with limb preservation. Which of the following is the most appropriate option for reconstruction of this defect?
A) Bone allograft
B) Contralateral vascularized fibula free flap
C) Contralateral vascularized fibula free flap with bone allograft
D) Ilizarov bone transportation
E) Ipsilateral pedicled vascularized fibula flap
The correct response is Option C.
In a young patient who desires limb preservation after sarcoma resection, a contralateral vascularized fibula free flap with bone allograft (Capanna technique) is the most appropriate option for a large intercalary segmental defect. This involves placing the fibula flap within an allograft construct and bridging both osteotomy sites. There are advantages to using the allograft with the fibula flap, as a fibula flap alone may have difficulty with weight-bearing and potential fracture. In select cases a double barrel configuration can be used; however, in this patient the defect is too large. An ipsilateral pedicled flap would have difficulty reaching this large defect and would still have issues with fractures from weight-bearing. Ilizarov bone transportation can be performed for smaller defects (4 to 6 cm), but not in a defect this large. Finally, bone allograft alone is an option; however, this has a high rate of nonunion (34% versus 8 to 10%).
2019
A 45-year-old woman who underwent Achilles tendon repair through a posterior midline incision 3 weeks ago develops a postoperative wound infection and subsequent skin necrosis. Physical examination shows a 3 x 3-cm wound directly overlying the Achilles tendon in the absence of peritenon. A fasciocutaneous propeller flap from the medial leg is designed to cover this defect. The septal perforators to this flap run between which of the following structures?
A) Flexor hallucis longus and gastrocnemius
B) Gastrocnemius and soleus
C) Peroneus longus and peroneus brevis
D) Soleus and flexor digitorum longus
E) Tibialis anterior and extensor digitorum longus
The correct response is Option D.
This defect may be reconstructed with a posterior tibial artery perforator propeller flap. These vessels emerge between the flexor digitorum longus and the soleus muscle. In one anatomic study, there were three clusters of perforators: 4 to 9 cm, 13 to 18 cm, and 21 to 26 cm from the intermalleolar line. The peroneal artery perforators often arise through the posterior peroneal septum, and the anterior tibial artery perforators are often found between the extensor digitorum longus and the peroneus longus or between the tibialis anterior and the extensor digitorum longus.
2019
A 27-year-old woman sustains a Grade IIIB degloving injury of the left lower extremity in a motor vehicle collision. Latissimus dorsi free flap placement is planned. Which of the following is the most likely outcome in this patient in terms of donor site morbidity?
A) Decreased seroma formation but increased hematoma formation
B) Inability to maintain sitting-up position when back is not supported
C) Initial decreased shoulder range of motion that improves by one year
D) Permanent loss of external rotation of the shoulder and inability to reach forward
The correct response is Option C.
Most studies that demonstrate shoulder weakness and loss of motion show that the loss of function is greatest in the early postoperative period and returns to baseline, or close to baseline, at 1 year or more after surgery.
All studies comparing types of latissimus flaps demonstrate less morbidity with perforator or muscle-sparing flaps as compared to traditional or extended latissimus dorsi (LD) flaps. Lower functional morbidity is observed with more native muscle preserved as is other flaps. This assumes that the muscular branches of the motor nerve to the latissimus are spared.
A recent meta-analysis does show higher functional impairment than expected after latissimus flap transfer. The number of patients who required a change in occupation was less than 10%. This was likely because of difficulty with activities such as ladder climbing, painting overhead, and sustained reach overhead.
The function of the latissimus dorsi muscle is shoulder adduction, extension and internal rotation. Other muscles of the rotator cuff perform similar functions and will assist in compensation for the loss of the latissimus. Patients who do develop weakness report it in activities involving shoulder adduction and internal rotation. Paradoxically, limitations in range of motion are mostly in shoulder flexion and abduction possibly related to tight skin closure and internal scarring.
Donor site seroma formation is particularly problematic, with published rates ranging from 3.9 to 79%.
Core muscles such as rectus abdominis, external oblique, gluteus maximus, medius, and minimus, and erector spinae all contribute to rotation, balance, and stabilization during sitting and standing.
2019
A 67-year-old man comes to the office because of nerve deficit of the left lower extremity which occurred after undergoing a femoral-distal bypass 5 days ago. Physical examination shows numbness of the plantar surface of the foot and weakness in plantar flexion. Which of the following nerves is most likely injured in this patient?
A) Femoral B) Obturator C) Peroneal D) Sural E) Tibial
The correct response is Option E.
This patient appears to demonstrate symptoms of a tibial nerve injury. The tibial nerve is a branch of the sciatic nerve. It travels through the popliteal fossa and gives off branches to gastrocnemius, soleus, plantaris, and popliteus muscles. The tibial nerve travels in proximity to the posterior tibial artery. In the leg, it gives off branches to the flexor digitorum longus, tibialis posterior, and flexor hallucis longus. Distally in the foot, it branches to give rise to the medial and lateral plantar nerves, which provide sensation to the plantar surface of the foot. Injury to the tibial nerve results in deficits of plantarflexion, as well as anesthesia to the plantar surface of the foot.
The femoral nerve innervates muscles of the anterior thigh, including the quadriceps group, iliacus, and sartorius. Injury to the femoral nerve results in weakness of leg extension.
The obturator nerve provides innervation to the medial thigh muscles (adductor group), including adductor brevis, longus, and magnus, as well as the gracilis and obturator externus. The cutaneous branch provides sensation of the medial thigh. Injury to the obturator nerve results in weakness in thigh adduction, and sensory deficits in the medial thigh.
The peroneal nerve is divided into superficial and deep branches at the area of the fibular neck. The superficial peroneal nerve supplies the lateral compartment of the leg, giving motor branches to peroneus longus and brevis, as well as sensory contributions to the lateral aspect of the leg. Injury to the superficial peroneal nerve results in anesthesia of the lateral aspect of the leg and weakness in eversion and plantarflexion of the foot. The deep peroneal nerve travels in the anterior compartment of the leg, and gives branches to the tibialis anterior, extensor hallucis longus, and extensor digitorum longus and brevis, as well as peroneus tertius. The sensory distribution of the deep peroneal nerve is in the area of the first web space. Injury to the deep peroneal nerve causes weakness in dorsiflexion of the foot.
The sural nerve travels on the posterior aspect of the leg between the lateral malleolus and calcaneus. It provides sensation to the lateral aspect of the foot, and does not have a motor component. It is commonly sampled in nerve biopsy and used as a source of nerve graft. Injury or sacrifice of the sural nerve would result in numbness of the lateral foot.
2019
A 21-year-old man undergoes reconstruction with a free flap. Photographs are shown. This procedure places the patient at risk for claw toe with loss of active flexion of the great toe. The muscle responsible for this functional loss is located in which of the following compartments in the lower leg?
A) Anterior
B) Deep posterior
C) Lateral
D) Superficial posterior
The correct response is Option B.
Claw toe or loss of active flexion of the great toe interphalangeal joint can result from harvest of the flexor hallucis longus for free fibula flaps. The flexor hallucis longus is present within the deep posterior compartment of the lower leg and should be resuspended to the interosseus membrane and posterior tibial muscles as needed to maintain proper tension. Physical therapy is initiated after adequate wound healing to maintain the mobility of the great toe and ankle. The deep posterior compartment musculature is composed of the tibialis posterior, the flexor digitorum longus, the flexor hallucis longus, and the popliteus.
The superficial posterior compartment musculature is composed of the gastrocnemius, soleus, and plantaris.
The anterior compartment musculature is composed of the tibialis anterior, the extensor digitorum longus, extensor hallucis longus, and the peroneus tertius.
The lateral compartment musculature is composed of the peroneus longus and brevis muscles.
2019
A 54-year-old woman sustains an open fracture of the right ankle in a motorcycle collision. Flap coverage of the associated distal-third leg wound is planned. Which of the following is the most significant advantage of using a fasciocutaneous flap instead of a muscle flap?
A) Better fill of dead space B) Higher flap survival rate C) Improved clearance of osteomyelitis D) Less donor site morbidity E) Quicker dissection
The correct response is Option D.
Muscle flaps were “workhorses” for lower extremity reconstruction for years, but harvest of muscle always leaves some donor site functional morbidity because of loss of the muscle function. Survival rates, speed of dissection, and treatment of osteomyelitis are not significantly different between the flap types. Muscle flaps tend to fill dead space easier than fasciocutaneous flaps.
2019
A 42-year-old man presents with an open tibia fracture sustained during a motor vehicle collision 4 hours ago. Physical examination shows a 3-cm puncture wound at the fracture site, no dirt or debris in the wound, and no exposed bone. X-ray studies show a transverse fracture of the tibia and fibula without comminution. Which of the following is the appropriate initial antibiotic coverage?
A) First generation cephalosporin
B) First generation cephalosporin, aminoglycoside, and penicillin
C) First generation cephalosporin and aminoglycoside
D) Third generation cephalosporin
E) Third generation cephalosporin, aminoglycoside, and penicillin
The correct response is Option A.
The Gustillo-Anderson classification system is used to grade open fractures based on the extent of bone and soft tissue injury, and the extent and nature of wound contamination. Aggressive debridement, administration of prophylactic antibiotics, application negative pressure dressing while the wound is open, and early definitive wound coverage (less than 5 days) reduces the infection risk. The open fracture described is a grade II injury and a first-generation cephalosporin alone provides appropriate antibiotic coverage. A concurrent vascular or neural injury or gross contamination could escalate this into a grade III injury, but there is no mention of these factors in the clinical scenario described.
2019
A 12-year-old boy is referred to a multidisciplinary sarcoma treatment center because of a deep localized rhabdomyosarcoma of the right thigh. After neoadjuvant radiotherapy, radical resection with curative intent, including a 20-cm segmental intercalary resection of involved distal femoral diaphysis, is performed. Skin and major neurovascular structures will be spared. Postoperative chemotherapy is planned. Which of the following is the most appropriate method for management of the bony defect in this patient?
A) Distraction osteogenesis
B) Free fibula transfer with femoral allograft (Capanna technique)
C) Induced membrane (Masquelet) technique
D) Lower extremity rotationplasty (Van Ness procedure)
E) Pedicled medial femoral condyle flap
The correct response is Option B.
Rhabdomyosarcomas represent the most common soft-tissue sarcoma of childhood and are responsible for approximately half of all soft-tissue sarcomas in this age group. They are thought to originate from immature cells that are destined to form striated skeletal muscle, although they can arise anywhere in the body. With modern multimodal management, the cure rates for localized disease are generally greater than 70% overall. The primary goal of local tumor control in extremity rhabdomyosarcoma is limb-sparing complete resection where possible.
Vascularized bone grafting represents the gold standard for reconstructing segmental bone loss greater than 6 cm associated with a compromised local soft-tissue environment that occurs with radiotherapy and chemotherapy. For large weight-bearing intercalary reconstruction, significant literature supports the combination of a large structural allograft combined with vascularized fibula as described by Capanna in 1980. With this combination, the neoosteogenic properties of the free fibula are supplemented by the immediate structural support of the bulk allograft and provide a durable single-stage biological reconstruction.
Distraction osteogenesis is a technique of de novo bone formation that capitalizes on normal bone healing with gradual, surgically controlled distraction of adjacent osteotomy defects and has the advantage of simultaneously expanding surrounding soft-tissue envelopes. The technique requires viable bone in proximity to one another following a latency phase and is useful in limb lengthening and craniofacial procedures but has limited utility in long segmental tumor reconstruction.
The induced membrane technique proposed by Masquelet is a two-step procedure where a segment of bone loss is first filled with an acrylic spacer and later replaced by cancellous bone graft in the so-called self-induced reactive “periosteal” membrane. The technique requires two stages and is less favored in the setting of planned radiation or chemotherapy where experience has shown that vascularized flaps or supplemented vascularized allografts are beneficial. The medial femoral condyle flap has been used for small osteoperiosteal, corticoperiosteal, and osteocartilaginous flaps based off either the articular descending genicular or superomedial genicular arteries. It would be insufficient in size for a 20-cm-long bone defect.
The Van Ness rotationplasty is a type of autograft where functional limb below the knee is used to reconstruct more proximal defects. It can be a useful “spare part” reconstructive option in composite proximal extremity resections by repurposing a functional ankle joint more proximally in a rotated configuration for preserved gait advantage at the repurposed knee. A rotationplasty would not be indicated for intercalary resections sparing joint and metaphysis.
2019
An otherwise healthy 62-year-old woman presents with mild edema, some hemosiderin deposition, and a clean, shallow, painful ulcer about 2 cm in size above the left medial malleolus. Medical history includes a left ankle fracture 15 years ago. She does not smoke cigarettes. She has a job which requires that she stand for 8-hour shifts. Distal pulses are present and ankle brachial index is .94. Which of the following is the most appropriate initial management?
A) Debride the wound and apply a split-thickness skin graft
B) Elevate and apply serial compression dressings (Unna boot)
C) Hyperbaric oxygen therapy (HBOT)
D) Optimize the wound bed with bilaminate neodermis (Integra)
E) Strip the greater saphenous vein and ligate the perforators
The correct response is Option B.
Venous insufficiency is staged using the CEAP (clinical, etiologic, anatomical, and pathophysiologic) classification. The patient presented in this scenario meets the criteria for C6 (Clinical 6) criteria with the presence of an active ulcer. Compression and keeping the wound clean are the initial, primary, and mainstay therapies for healing venous ulcers. The only option listed that provides compression and wound care is to clean the wound, elevate, and apply serial compression dressings (Unna boot). After a trial of compression and wound bed optimization, closure can be considered. The literature does not provide conclusive evidence that skin grafting is a superior or desired closure. There are studies that demonstrate the superiority of Apligraf in achieving wound closure. If the perforators are found to be the source of the issue, ligation may reduce the recurrence of ulcers in the area but studies comparing ligation and wound care do not show earlier closure of ulcers present. Hyperbaric oxygen therapy (HBOT) is not indicated in this situation.
2019
