Part 3 Podiatry exam Flashcards
wound healing
Hemostasis Phase.- is the process of the wound being closed by clotting. …starts when blood leaks out of the body
Inflammatory Phase. …econd stage of wound healing and begins right after the injury when the injured blood vessels leak transudate (made of water, salt, and protein) causing localized swelling. Inflammation both controls blleding and prevents infections
Proliferative Phase. …wound healing is when the wound is rebuilt with new tissue made up of collagen and extracellular matrix. In the proliferative phase, the wound contracts as new tissues are built. In addition, a new network of blood vessels must be constructed so that the granulation tissue can be healthy and receive sufficient O2 and nutrients
Maturation Phase.the maturation phase is when collagen is remodeled from type III to type I and the wound fully closes. The cells that had been used to repair the wound but which are no longer needed are removed by apoptosis, or programmed cell death.
2 main approaches for fracture plate fixation
Interfragmentry compression and internal splinting
2 test to evaluate progression of OM
ESR
CBC
2nd layer muscle on the plantar foot
Quadratus Plantar (Lateral plantar Nerve)
1st Lumbricals Medial plantar branch nerve)
FHL and FDL run in this layer
3rd layer of the foot
Flexor Hallucis Brevis (Medial plantar nerve,proper digital N to hallux)
Adductor Hallucis(Lateral plantar nerve, deep branch)
Flexor digitii minimi brevis( Lateral plantar nerve, superficial)
4 stages of bone healing
Inflammation, soft callus, hard, callous, remodeling
4th layer
Interosseous
PAD
DAB
5 Minute reactive hyperemic test
Patient lies supine legs raided 30 degress
foot DF and PF several time to empty venous blood
Apply and inflate cuff to 100mm above ankle systolic
Place foot heart level
After 5 minutesquickly deflate cuff
Time the interval between cuff let down and color returns to foot
Normal= instant with max erythema t 1 minute
Vasospastic disease- Return of color is uniform slight delayed 5-8 seconds-max erythema 2 minutes
Organic Occlusive Disease-Return uniform requires 15 seconds to reach toes,erythema less then normal
5th ray runs at
proximal, lateral plantar, distal medial dorsal
;Conization
remove cone shape bone
A 2 agonst
reduce central and peripheral sympathetic overflow and via peripheral presynaptic receptors may reduce peripheral neurotransmitter release. Alpha 2 agonists lower blood pressure in many patients either alone or in combination with diuretics.
Drugs: Guanabenz, guanfacine, clonidine, tizanidine, medetomidine, and dexmedetomidine are all α-2 agonists that vary in their potency and affinities for the various α-2 receptor subtypes. Clonidine, tizanidine, and dexmedetomidine ha
A antagonist
Phentolamine
Phenoxybenzamine also use for pheochromocytoma
Will cause reflex tachycardia and 1st dose syncope
A farmer ran over his brother’s foot with a plow, causing
a degloving injury and comminuted fracture of the first
metatarsal. He makes it to the hospital within 1 hour
Take a culture. Start a cephalosporin,
aminoglycoside and Penicillin G. Surgical
repair.
A patient received an allograft bone graft while
undergoing surgical excision of active osteomyelitis. The
graft is rejected. Which type of hypersensitivity reaction
TYPE IV
A Type 4 Hawkins talar neck fracture represents:
displacement of the ankle joint
Displacement of the talar neck, subtalar
joint, ankle joint and talonavicular joint
Abduction test
supine, hips and knees flexed to 90 degrees
Abduct the knee to resistance
A dislocated hip will have limitation of abduction on affected side
Absorable sutures
Plain gut-natural multifilament-digested own enz, tensile strength maint 7-10 days–70 days complete
Chromic gut-natural multifilament- chromeic NacL solution resist body enz, prolong>>90 days]
Vicryl-Synthetic monofilament-75% of original tensile strength remains day 14, absorpt 56-60 days by hydrolysis
Monocryl- synthetic monofilament-tensile strength-60% at 7 day 30% 14 day, original strength lost 21 day absorbed at 91-119
PDS (polydiazone)-synthetic monofil-70% original strength at day 14, absorption minimal until 90 days and complete absorbed 6 months
Ace inhibitors
Angiotensin converting enzyme inhibitors (ACE inhibitors) are medications that slow (inhibit) the activity of the enzyme ACE, which decreases the production of angiotensin II. As a result, blood vessels enlarge or dilate, and blood pressure is reduced
Benazepril (Lotensin) Side effects
Captopril. Cough and hyperkalemia by inhib of aldosterone
Enalapril (Vasotec)
Fosinopril.
Lisinopril (Prinivil, Zestril)
Moexipril.
Perindopril.
Quinapril (Accupr
acetabular index
angle greater then 30 is dislocated
Acrocyanosis
Acrocyanosis is persistent blue or cyanotic discoloration of the extremities, most commonly occurring in the hands, although it also occurs in the feet and distal parts of face.
Can mimic Raynauds contrictive S/S
adult range in malleolar position
13-18 degrees
Alcoholic Neuropathy
dAngthrapist
similiar to beri beri
Thiamine essential for CHO catabolism
Decrease Thiamine (B1)=CVD>>Wet beri beri
N Sys Dz>>Dry Beri beri
Dry Beri beri–Wernicke-Korsakoff Syndrome which alcohol related brain damage>>>language & thinking(xs alcohol consuption
TX-100mg IV Thiamine
Alkaline Phosphatase
30-85
Mainly in liver and bone
released by osteoblast when secreted into bone
Increased-Live/bone DZ,healing fracture &bone growth,hyperparathyroidism,obstructive biliary dz, Pagets,Sarcoma
Decreased-Hypothyroidism, malnutrition,scurvy, pernicous anema, Diabetes
Alkaline Phsphatase ALP
30-85
Liver-heat stable
Bone- heat labile
Most often measure bile duct obstruction
INCREASED- Liver DZ/Bone DZ/Hyperparathyroidism/Healing bone growth/Obstruction biliary DZ
Decreased- Hypothyroidism/Malnutrition/Pernicous anemia/
A Jones fracture occurs
Metaphyseal/diaphyseal junction
allodynia
r pain out of proportion
Allograft
a tissue graft from a donor of the same species as the recipient but not genetically identical.
Allografts
osteogenesis
osteoconduction
immogenicity
individual of same species but different genertic background
Dynamization of an external fixator
The process of making the fixator more
flexibleDyn
An axis is a straight line around which an object rotates. Movement at the joint takes place in a plane about an axis. There are three axes of rotation.
Name the 3 axises
Sagittal axis - passes horizontally from posterior to anterior and is formed by the intersection of the sagittal and transverse planes.
Frontal axis - passes horizontally from left to right and is formed by the intersection of the frontal and transverse planes.
Vertical axis - passes vertically from inferior to superior and is formed by the intersection of the sagittal and frontal planes.
Anatomy associated with Lisfranc complex
- Complex composed of dorsal (weakest) Plantar (strongest) and interosseus ligaments
- 2nd TMT joint is the keystone of the arch
- No interosseus ligament between 1st and 2nd MT
Anatomy CT
High density to Low
Cortical
cancellous
muscle
nerve
tendon
ligament
fat
air
Anatomy of nerve
Perikarya
Axon
Dendrite
Oligodentrocytes
Schwann Cell
Myelin
Ganglia
Nuclei
Nissl bodies
Node of Ranvier
ANATOMY OF SCREW
Head
Land-underside of head
shank- only in cancellous screw
run out- weakest point of screw-starts at the beginning of the threads
pitch-distance between threads
rake angle- thread to axis angle
core diameter-diameter of the screw between the threads
thread diameter- describes the screw size(ie: 2.7mm has a2.7 mm thread diameter
tip angle- tip to axis
Anchor sign
baby prone, legs adducted and extended
look for asymmetry of thigh and gluteal fold
more fold on the dislocated side
Andersons disease
rare genetic disorder of glycogen metabolism. It is caused by the deficient activity of the glycogen-branching enzyme, resulting in accumulation of abnormal glycogen in the liver, muscle, and/or other tissues. The disease is inherited as an autosomal recessive trait.
Anesthesic Supplementary medication
1- Opoids-
Fentanyl- Short-term analgesia during anesthetic periods, premedication, induction and maintenance; and in the immediate postoperative periods as need arises.
Morphine- Serves to alleviate periop pain and decrease somatic and autonomic response to airway manipulation, improve hemopdynamic stability, lower req for inhales anes and decrease anxiety. Older
Demerol-(meperidine) Induces amnesia and controls post anesthetic shivering. Can casue tachycardia and caution with pts with heartt ireg. like narcotics SE: N&V, constipation (vistaril used in conjunction)
2- IV Pain management
1-Toradol NSAID reduce post op pain, however risk of bleed
2- Acetaminiophen (IV Ofirmev) deecrease risk of bleed
ANGINA PECTORIS
PRESSURE SQUEEZINF, IMPENDING DOOM
LOCATION- ARM AND JAW
TIME-15 MINUTES
CAUSE: CAD<<<
TREATMENT: NITROGLYCERIN
Anterior Motor Horn Disease
Diseases that cause selective damage that affect voluntary movement and rarely attack other path in S.C
Poliomyelitis
Symp: malaise & Myalgias- flu-like symptoms, low grade fever
muscle tightness in hamstring, thigh and back
LMN weakness or parylsis>>gradual tightening muscle spasm, muscle weakness
Amyotrophic Lateral Sclerosis (Lou Gerhigs )
Lateral colum and anterior gray matter which are close connect with SC
ALS involves voluntary motor system inv/ degeneration of corticospinal tracts and alpha motor neurons
Presents with both UMN and LMN
Anterior Spinalthalamic tract
information about pain and temperature.touch
Anti-Angina Meds
Nitrates-
CA+ channel blockers
B Blockers
Anticoagulant
Indication::Venous thrombosis, DVT/PE/A-FIB WITH EMBOLI/MI, SURGICAL PROPHYLAXIS
TYPES:HEPARIN:LMWH-ENOXAPRIN(LEVENOX =COUMADIN
Production Vit K dependent factors-II,VII,IX,X
Contraindication: Allergy//active bleed, CNS sx//eye ex//Severe HTN, Ulcer
Heparin-works faster then warfarin-injectable
Warfarin-Slows down process in liver that use Vit K to make certain Proteins (clotting factor) that causes clotting
Coumadin-oral outpatient-stop 5 days prior to Sx
Antidysrythmiacs
Class Ia NA channel blocker-Quinidine
Procainamide
Disopyramide
Class 1b Weak NA channel blockers-Lidocaine
Phenytoin
Class 2 Beta blockers vent arrhythmias
Class 3 K channel blocker Amiodarone Sotol
Btretylium
Class 4 L-type CA channel blocker Verapamil
Antiplatelet Types
ASA (-) Cox
2) PDEinhibitor
Persantine-PDE III inhibitor >>decrease cAMP>>decrease platelet aggregation
Pletal(clopidiel) PDE III inhibitor>>decreases cAMP>>decreases platelet aggregation
3)Ticlid-250Mg PO BID
4)Trental (pantoxyfilline) alters rheology RBC>>increase flexibility>>decrease blood viscosity by decrease RBC>>decrease elevated plasma level of fibrogen>>and release plasminogen activator thereby promoting fibrinolysis
Arterial and Venous testing
Duplex ultrasound-8-10 hx of U/S triphasic-faster Q wave form resemble a teepee
biphasic may be normal in patients with diabetes
monophasic-slow Q indicates signaficant abnormal
Arthrograms for ankle ligament injury
ruputure of C-F ligament is always associated with the ATFL with dye flowing into the anterior and lateral malleolus
ASA Classification Anesthesia
ASA-
PS1 Healthy non smoker
PS2-Mild dz without substantive func limits. ie: smoker, well controlled DM/HTN mild lung disease (30
PS3 Severe systemic dz with substantive functional limitation. 1 or more moderate to severe disease
ie: poor controleed dm, HTN,COPD (BMI>40), acute hepatitis, reduction of ejection fraction
PS4 Incapacitating Systemic dz-threat to life ie; < MI,CVA,TIA or CAD/stents, severe reduction ejection fraction
PS5 Moribund patient not expected to live ie; ruptured abdominal/thoracic aneuysm
PS6 Declared brain dead
PS7 If procedure is an emergency, physical status is followed by E
Assmann DZ
Osteochondritis of the 1st metatarsal
At what point during tendon healing can isometric
exercises begin?
3 weeks
Atropine Sulfate
Scopolamine
Glycopyrrolate
Reduce resp tract secretion
protect reflex bradycardia, decrease gastric secretion
Used gen+endotracheal tube insertion
SE: Dry sore mouth, poor visual, relax lower spincter bofy temp rise
if use with preanesesthetic combo with atropine and meperidine
GLLCOPYRROLLATE-MORE POP BC NO CNS EFFECT
ANTODOTE:PHYSOSTIGMINE
Autogenerous bone graph has
a. osteoconduction
b. osteoinduction
c. viable osteocytes
Autogenous bone grafts have
oeteogenesis
osteoconduction
osteoinduction
Autograft
An autograft is a bone or tissue that is transferred from one spot to another on the patient’s body
Barlow sign
thumb on lesser trochanter and middle finger of the same hand is on the greater trochanter
The dislocated hio become displaced with a palpable clunk as the head slips over the posterior aspect of the acetabulum
Basal Ganglia Disorders
Huntingtons Chorea
Sydenhams Chorea (St Vitus Disease
Parkingtons Disease (PARK) Wilson Disease
Basophilia
Bands
Platelet count
Basophilia- Polycythemia, chronic myelogenous leukemia
chicken pox- hypothyroid myxoderma Renal DZ
Bands increase-shift to the left– acute bacterial infection
Platelet Count- 140-340,000
Increased Vascular Dz, iron def, acute infection, cardiac Dz, malignancy, PCV, cancer, RA,
BEBAX SHOE
TREAT RF ABNORMALITIES (MET ADDUCTUS)
USE AFTER SERIAL CASTING FOR MET ADDUCTUS
Best meds for post op shivering
Demerol
Best treatment for osteochondral bone lesion
osteochongral autogenous graphs
Beta blockers
Beta blockers, also known as beta-adrenergic blocking agents, are medications that reduce your blood pressure. Beta blockers work by blocking the effects of the hormone epinephrine, also known as adrenaline. Beta blockers cause your heart to beat more slowly and with less force, which lowers blood pressure.
atenolol (Tenormin) and metoprolol (Toprol,Lopressor)
Side effects—-
Dizziness.
Headaches.
Flushing of your face and neck.
Upset stomach or throwing up.
Low blood pressure (hypotension)
Irregular heart rhythms (arrhythmia
Bier Block
Intravenous reghional anesthesia
Bilirubin
.1-1.3
Is breakdown of HGB
Catabolism of HGB and breakdown myoglobin,cytochromes,catalose
Unconjugated (indirect) is lipid soluable and doesn’t spill into the urine
BREAKDOWN- occurs in Kupffer cells using cytochrome P450 to breakdown heme
INCREASED- Bile duct obstruction hemolytic anemia,hepatocellar damage, Crigler-Najjar Syndrome/Gilbets disease,XS destruction of RBC or Liver unable to excrete noram amt produced
DECREASED-MEDS:PENICILLIN/SULFONAMIDES
Conjugated (direct) increase is obstructive Jaundice
Increase in Unconjugates (indirect) destruction of RBC
>>3 jaundice
Bimalleolar equivalent
rupture of the deltoid ligament instead of medial malleolar fracture. More unstable than actual fracture of the medial malleolus
bioburden testing
is the measure of microbial contamination levels on or in a product. Bioburden can be introduced from the raw materials used in the manufacturing process, or be introduced via the workforce or manufacturing environment.
biological lock plates provide
indirect healing
Biomaterials suture
Nature and synthetic
absorable and non absorable
monofilament and multifilament
Synthetic materials cause less rxn with less inflam rxn
Absorable applies to a wound that heals quickly and need minimal temp support. ITS PURPOSE TO ALLEVIATE TENSION ON WOUND EDGES
New synthetic sutures retain their strength until the absorption process starts
Non-absorable sutures offer longer mechanical support
Mono-filament less drag thru tissue but susceptible to instrumentation damage.Infection is avoided unlike braided multifilimant can cause sustain bacterial inocula
biopsy of lesion <2 cm
b. Excisional biopsy using 2 semi-elliptical incisions
c. Dimensions should be 3 to 1 width of the lesion
d. Full thickness, including fat
Bleck classification of metatarsal adductus
bisect heel and extend line distally to see where it falls on the toes
Normal-2-3rd toe
Mild-line to 3rd toe
Moderate- line thru 3-4th toe
Severe-Line thru 4-5th toe
Bleeding time
INR
2-9 Minutes Bleeding Time
3 - 4 INR
measure the primary phase of hemostasis, the ineraction of the platelets with the blood vessel wall and the formation of the hemostatic plug
Forearm scratch
Increased–Von Willibrand,Thrombocytopenia
DIC Platelet dysfunction and ASA/ NAIAD therapy
Blood Gas coefficient for anesthesia(Ostswald)
Solubility of an agent, speed of induction
The blood:gas partition coefficient is an important determinant of the speed of anesthetic induction and recovery. It describes the partition of an agent between a gaseous phase, such as alveolar air, and the blood. The greater the blood:gas partition coefficient, the greater the solubility in blood.
High BGC=more soluble=more agent needed in blood before equilibrium is met
High BGC=More potent, slower induction
MIC=amount of inhaled at 1 ATM that prevents movement and response to noxious stimulus in 5-% pts
Blood work muscle
Creatine kinase( CK or CPK) 6-30
Cardiac ezymes- CK-MB 20% Cardiac-hi during 48 hrs MI and flip LDH-DX made
CK-BB brain 90%
CK-MM-80% cardiac muscle, high in skeletal muscle injury
Myoglobin- sensitive indicator muscle injury
Troponin increase 3-12 hour after injury
Aldolase-glycolytic involved in metabolism of glucose
Increase AST and LDH w/n 1-2 days after episode chest apin=Pulmonary infact
BLOUNT DZ
OSTEOCHONDROSIS OF MEDIAL PORTION PROXIMAL EPIPHYSEAL OSSIFICATION CENTER IN TIBIA CAUSING BOWLING OF LEGS
SYMPTOMS INCLUDE LIMPING, LARERAL BOWING
RADIOGRAPH- SCLEROTIC MEDIAL CORTEX WITH SPURRING
BEFORE 6 YEARS OLD
CAUSE EARLY WALKING AND OBESITY
blount dz
true tibial varum
progressive tibial varum
disruption of the medial capital ephiphysis
BMI
BMI <25 Desirable
26-27 Mild obese
28-29 Moderately obese
>30 Morbid obese
Bone graphs
Autogenous bone grafts provide both
osteoconductive and osteoinductive properties
Bone metabolism
Alkaline Phosphatase 30-85
Calcium 8.5-11
Phosphous 3-4.5
Bone scan of reflex sympathetic dystrophy
Increased blood flow
3rd phase of affected limb reveals increased periarticular activity
Bone scan scintigraphy phases
technetium-99m (commonly Tc-99m-methylene diphosphonate (MDP)) as the active agent. The study has 4 phases which follow intravenous injection of the tracer. Sometimes a fourth (delayed/delayed) phase is performed.
The scan is positive for osteomyelitis if images show progressively increasing lesion to background activity ratios over time.
1st Phase ====Dynamic
2nd- Blood pool image and 5 minutes after injection
3rd- after 3 hours when urinary excretion has decreased the amount of the radionuclide in soft tissues.
4th- after 24 hours
Bone stimulaors good used
An oligotrophic nonunion.
Bosworth definition
avulsion fracture of the fibula from the PITFL
Brachymetatarsia
Type I=shortening of 1st metatarsal only
Type II-Shortening of 1 or 2 lesser metatarsal (usually 3rd or 4th)
Type III-Shortening of the 1st and one or more of the lesser metatarsals
Type IV-shortening of all the metatarsals
Broden view: position of foot and beam
- Ankle is dorsiflexed, with leg internally rotated 30 degrees
- X-ray beam is cephalic tilt of 10-40 degrees
Brodie Abscess
rare form of osteomyelitis. It involves a subacute or chronic infection of the bone with development of a localized abscess, usually within the metaphysis of long bones. The tibia is the most common bone involved and staphylococcus aureus is the most common organism identified.
Buchingham classification
Type A-Medial STJ disloc-AKA basket-ball or acquired clubfoot,calcaneus medial to talus
Type B-Lateral STJ dislocation,calcaneus lateral to talus
Type C- Anterior & posterior STJ dislocation
Buergers Disease
Thromboangiitis Obliterans
inflam changes small and medium vessels
20:1
Raynauds phenomenon common
Decrease pulse
Inflammatory occlusions more distal
Patient usually have HLA-A9,,HLA-B5
BUN
10-20%
End produce of amino group removal in degrdation of amino acids
Measure urea produce in liver
Measure of liver function and kidney excretion
INCREASED-Renal DZ/Dehydration/ High protein diet/DM
DECREASED-Severe Liver damage,ie: poison//hepatits
BUN alone not reliable indicator of renal function because it depends on many extra renal factos
Buschke DZ
Osteochondritis of the cuneiforms
c. Muscular dystrophy with a waddling gait.
d. Cerbral palsy with a scissoring GAIT
hemiphagia with circumductive gait
Calcaneal erosions on xray
R.A,
Reiters
Ankylosing Spondylitis
Psoriatic OA
Hyperparathyroidism
Lipid dermata OA
Calcaneonavicular Coalition CN
45 % extra articular
8-10 y.o
Pain localized to the area of coalition
decrease ROM STJ and MTJ
MEDIAL OBLIQUE- calc and nav are close proximity or connet
LATERAL VIEW shows classic elongated ant process of calc-ANTEATER SIGN
TX- Resection and place the EDB belly in void (Cowell procedure)
Calcium
8.5-11
98% stored in skeletal and teeth
acts main resevoir for maintaining blood levels needed for muscle contraction
kidney important regulation of calcium
Any condition causing bone deminerization or atrophy>>>increase Ca Level
Hypo-Hypoparthyroidism,Vit D dif, renal failure secondary alkalosis
Hyper-cancer,hyperparathyroidism,Iatrognic, multiple myeloma
parathyroidism,m sarcoidosis, acidosis(CHIMPS), Lymphoma
Cause of congenital flatfoot
Compensated FF varus and valgus
RF equinus
abducted and adducted foot
neutrophic feet
muscle imbalance
PTT rupture
Ligamentous laxity (ehler-danlos, Marfans, osteogenesis imperfecta)
Calcaneal valgus
Enlarged or accessory navicular
Cavus foot description
elevated arch
primary sagittal plane deformity
less surface area touching the ground
painful callous may develop under met heads
chronic ankle sprains
CIA-norm 20-25 in cavus->30 degrees
Angle od meary 0 in cavus >6
Angle of Hibbs 135-140 cavus >150
Cavus foot cause and types
usually congenitial
due to failure of segmentation of primitive mesenchyme
TYPES
1-Syndesmosis-fibrous
2-Synchondrosis-cartilaginous
3-Synostosis-osseous
Cavus foot causes
neuromuscular ie: spina bifida, CMT, Friedreich ataxia
polio, spinal cord tumors, myelomeningocele
CP, infection, stphillis, trauma and S.C. lesions
Cavus foot treatment osseous
Cole-DF osteotomy Cuneiform-Nav Jt
Japas- V osteotomy thru entire forefoot, apex usually at the navicular
Devries-DF fusion at MTJ
Dwyer- Lateral closing wedge or open medial wedge calcaneal
McElvenny-Caldwell Procedure- DF fusion 1st metatarsal-medial cuneiform JT, if severe
nav-cuneiform jt
DFWO- DF wedge osteotomy 1sr metatarsals or all of the metatarsals
Jahss- DF wedge osteotomy across tarsometatarsal joint
Cavus foot treatments surgical soft tissue
Plantar fasciotomy
Steindler Stripping- plantar fascia with long plantar lgt, abductor hallucis,FDB, abd digiti quinti are stripped
Jones tenosuspension
Heyman procedure- transfer all 4 extensor tendons to their met heads
Hibbs procedure
Splitt T.A..T (STATT)
Peroneus longus tendon transfer
TPT transfer
Cavus foot treatments conservative
Shoe modification
extra depth shoes with metatarsal abr
Young patient passive stretching, manipulation
CBC
Measure total # of White cells in blood
HGB–Male 13.5-17
female 12.5-16
HCT- Male 40-50
Femal 37-47
RBC Male 5.4-
Female-4.8
WBC 5,000-10,000
CBC Diff
WBC Granulocytes ( 5,000-10,000)
Neutrphils (40-60%)
Eosinphiles (1-5%)
Basophils( .1%)
Bands
Lymphocytes 20-40%
Monocytes 4-8%
Cefdinir
For type 1 DM toe infections
Cerebellar disorders
Cerebellar-smooth coordination of voluntary, skilled movements.
Helps maintain normal posture, balance and unconscience propioception
Contibutes to vestibular function>>>maintains equilibrium
Cerebellar lesion >>>awkwardness and uncoordination of voluntary movements
Cerebellar Disorders Test
PATTING TEST; ASSESES THE INTEGRITY OF EPS OR SPINOCEREBELLAR TRACT
Alternative tap the heel and toe and ask to maintain heel against floor and abduct, the adduct foot
Heel-Knee Test- Asses integrity of EPS or spinocerebellar tract**MOST RELIABLE OF CEREBELLAR FUNCTION OF LOWER EXTREMITY
Romberg’s Test-test propioception. ability sense where one is-propioception 2 tracts-
conscience proprioception on the dorsal column
unconscience propioception spinocerebellar
Cerebellar and dorsal column-Eyes open and eyes closed= sway
Cerebellar if Eyes open steady and eyes closed sway
Clinical Muscle testing-0=absent- no evidence of contractility
1=Trace-evidence of slight contracture-no joint motion
2=Poor-complete ROM w/ gravity eliminated
3-Fair-Complete ROM against gravity
4-Good-complete ROM vs gravity with some resistance
5=Normal ROM vs gravity with full resistance
Cerebellar Lesion movement disorders
Asthenia- muscle tiring easy
Hyporeflexia decease DTR
Dysmetria-loss of ability to gauge distance, speed, power or movements
Speech- slurred, jerky or explosive in nature
Intention tremor- with initiation of voluntary movement often intesifies as goal is neared
Nystagmus- dancing eye
Cerebral palsey
Non-progressive neuromuscular disorder from brain damage
Spastic CP- most common 25%
Athetoid CP-20%
Ataxic CP-10%
Rigidity CP
Tremor CP
Atonic CP
SCISSOR GAIT SECONDARY TO SPASTIC ADDUCTOR MUSCLES.
Speech defect, retardation, seizures, visual defects, ankle equinus
TX-PT-OT-Splinting-Bracing
Charcot Marie Tooth discription
cavus foot type, decreased distal sensation,
decreased distal muscle power and
decreased nerve conduction velocity
Charcot-Marie Tooth
- Signs of muscle weakness in your arms, legs, hands and feet 2. Decreased muscle bulk in your lower legs, resulting in an inverted champagne bottle appearance 3. Reduced reflexes 4. Sensory loss in your feet and hands 5. Foot deformities, such as high arches or hammertoes 6. Other orthopedic problems, such as mild scoliosis or hip dysplasia provide information about the ext…
PERIPHERAL NERVE DISORDER
Chemical matrixectomies application
Phenol- 89% X 3 for 30 seconds Sodium hydrozide-1980
no neutralizer>>>flush with alcohol 10% NaOH X 2 15 seconds each
longer shelf life neutralizer-5 % acetic acid
recurrence 5-10% d/t old phenol or inadeq application LOW
or not removing enoug nail-need to remove nail
matrix is integral to prevent recurrence
Chloride
98-109
major excellular
acid/base balance
depletes with massice loss of G.I, fluid
Hypo-N&V, Ulcerative colitis,severe burns heat exhaustion, DM ketoacidosis
Hyper-Dehydration,XS IV fluid, kidney disease
CHOLESTEROL
LESS THEN 180
L=LOUSY LDL= IF HIGH…BAD
HDL=
DIRTY======TRIGLYCERIDES-fat in blood from food we eat
Choreoathetosis
A rapid (chorea) or slow (athetosis) involuntary movements of the fingers or toes (flexion–extension, adduction–abduction, writhing, sometimes piano-playing movements) which are irregular, nonrhythmic, and purposeless (Fahn, 1997).
Classification of metatarsal adductus
TYPE 1
Flexible- FF will crrect past neutral into slight over correction
TYPE II
Partial Flexible (doesn’t correct to neutral actively, but does passively)
Type III
Rigid (doesn’t correct to neutral)
Classification of Syndactyly
Type 1-(MMost common)-Zyngodactyly- partial or complete webbing 2.3rd toes
Type II- Synpolydactyly- 1 soft tissue mass covering 4th, 5th and 6th toe
Type III_ass/ with metatarsal fusion
Claudication causes
1-ASO
2-Deep thrombophlebitis of tibial, popliteal or femoral veins
3-Popliteal entrapement
4-Sciatica
5-Femoral or popliteal arterial calcification
6-Anemia (hypochromic, microcytic, sickle cell, thalassemia
Clinical presentation of Calcaneal fracture
Mondors sign
back pain between T12 and L2
Compartment syndrome
Hoffa’s sign- less taut Achilles tendon
Lateral wall blowout
Clinical presentation of compartment syndrome
6p’s
Pain out of proportion
Paresthesia
Pallor
Pulselessness
Paresis
Paralysis
Pressure
Clinical presentation sign seen with posterior process fractures talus
Nutcracker sign: pain with forced ankle PF
Clinical signs present with Lisfranc injury
Plantar ecchymosis sign
Apprehension sign: with FF DF and abduction
Stress exam of midfoot: unstable TMTJ with pronation and eversion
RULE OUT COMPARTMENT SYNDROME
clinodactyly
the medical term for an abnormally bent or curved finger. The affected finger abnormally curves to the side and may overlap other fingers. While the condition is relatively rare among the general population (3 percent), it affects one in four children born with Down syndrome (trisomy 21).
Club foot evaluation
Normal Club foot
Kite angle 20-40 0-15
Calc Inclination angle 20-25 17
Talar neck Add 10-20 80-90
Plantarflex 25-30 45-65
CMT Foot
Active plantarflexion of the medial forefoot
by the peroneus longus in conjunction with
loss of strength in the anterior tibial muscle
CNS disorders
Progrfessive Multifocal Leukoencephalopathy
CMV
Cerebral Toxoplasmosis
Multiple Sclerosis
Tabes Dorsalis
Coagulation Cascade
Extrinsic Pathway- Activated by external trauma cause blood to escape from vascular system
Intrinsic Pathway- Activated by trauma inside vessel system and activated by plaelet, exposed endothelium,or chemical
Cell injury..Vessel constrict..platelet adhesion>>stabilization and reinforcement of plug by intrinsic and extrinsic system>>>>Fibrinolysis
Phase I Generation of tissue thromboplastin (factorIII) intrinsic
Phase II-Activation of thromplastin end product of intrinsic and extrinsic
FINAL COMMON ATHWAY BEGINS WITH ACTIVATION OF FACTOR X
Phase 3- Concersion prothrombin>>>thrombin by factor Xa
Phase 4- Conversion of fibrogen into fibrin by thrombin which stabilzed by factor XIII
Coagulation Pathway part 2
Coagulation factors
Intrinsic- III + VII + VIIa>>>>activates X>>>Xa
Extrinsic XII>>>XIIa by surface contact>> XI>XIa>IX>IXa>VIIIa>>X>>Xa
Factors require Vit K
Heparin intrinsic
Codman triangle
periosteal elevation and spicules
formation represents tumor extensions into the perisoteum and calcification
Cohort studies
Cohort studies are a type of medical research used to investigate the causes of disease and to establish links between risk factors and health outcomes. The word cohort means a group of people. These types of studies look at groups of people.
Collagen diseases that affect microcirculation
1-R.A. 6-Giants Cell Arteritis
2-SLE 7-Erythema nodosum
3-Systemic Sclerosis 8-Erythema Induratum
4-Polymyositis 9-Nodular Vasculitis
5-Polyarteritis nodosum 10-Nonsuppurative panniculitis
Color Changes to nail
Yellow-Addisonsdz- Diabetes
Blue-Cyanosis
Red-Cancer
Green-Pseudomonas-Candida
Black/brown-Normal-Addison Dz-Junctional nevi, melanoma-
White-heredity-anemia-fungal infection
White lines-Arsenic poison pr drug toxicity
White spots- Injury-psoriasis
White & Pink- Anemia of chronic dz-nephrotic syndrome
Common Peroneal N Injury
L4-L5-S1
Sensory & Muscular
Vulnerable to external compression injury–NEUROPRAXIA-crossing leg c/p paresthesia,hyperesthesia,
entrapement more unusual
Diagnosis: NC studies; radiculopathy L5>>EMG IN GLUTEAL AND PARASPINAL
Clinical signs>> weakness TA& EH muscles>>>>DROP FOOT
weakness of anrterior muscle group (NC Studies)
Radiculopathy-L5 EMG
Common site for OATS procedure
non-portion weight bearing of the knee
Restores hyaline cartilage
Compartment syndrome is best characterized
A predictable, recurrent, well-localized pain
relieved by rest.
Component of open chain pronation
dorsiflexion, adbuction, evrsion
Components to look for on X-ray with ankle injury (5). The measurements and which is most reliable
-Medial clear space: >4mm abnormal
-Tib fib clear space: greater than or equal to 6mm abnormal. MOST RELIABLE
- Inversion stress view
Talocrural angle
Congeniotal Vertical talus open reduction
3 months of age
most procedure posterior release and reduction of the talonavicular joint
3-6 years-extra articular arthrodesis (Green-Grice type)
>6 wait until 10-14 when bones mature
Congenital dislocated hip signs
females, usually occurs 2 weeks after birth
children with older siblings, breech, joint laxity, first born
Classic signs in older children– limited abduction
asymmetric thigh fold, (+) trendelenburg test, externaslly rotates foot
Waddling gait.
when dislocation occurs, femeral head posterior and superior to the acetabulum
Assc/ with met adductus, calcaneal valgus
gohydramnios, torticollis
Congenital Vertical talus
congenital covex pes planovalgus assoc wi arthrogyrosis, right foot more common
reverse clubfoot, persian slipper, rockerbottom flatfoot
The talus is perpendicular so severly the navicular dislocated dorsally ontot he talus neck, locking the talus
Forefoot is abducted and DF at the MTJ and Calc is in valgus
Rgidity is the hallmark of this
gastroc soleus is contracted, spring lgt is elongated
usually are B/L/STJ facet abnormal/
Talus –Anterior absent/middle hypoplastic, posterior malformed
Congestive Heart Failure
Inability of heart to pump blood throughout body orrequiring elevated filling pressure in oprder to pump effectively. The pooling of blood leads to congestion in body tissue
Cause-famaliar-infection, alcohol,anemia,thyrotoxicosis, arrhythmia and HTN
Plaque, stress, smoking, age. no exercise, overwork heart, obesity
S/S-Pulm edema,,peripheral edema, enlarged or pulsatile liver/ JVD(jugular vein distension)
NEVER USE PNEUMATIC COMPRESSION DEVICES
Treatment- maintaining a euvolemic state>>>diuretics>>vasodilator agents and positive inotropes
Delaying the progression>>>ACE inhibitors, beta blocker and aldosterone antagonist(diurectics)
Angiotensin converting enzyme inhibitors (ACE inhibitors) are medications that slow (inhibit) the activity of the enzyme ACE, which decreases the production of angiotensin II. As a result, blood vessels enlarge or dilate, and blood pressure is reduced.
CONSERVATIVE TREATMENT CLUBFOOT
stretch and manipulation prior to casting
apply TOB to skin
2” cast applied, ussually long cast
correction n order
1-ADDUCTION (A.V.E)
2-VARUS
3-EQUINUS
Coonradd bugg trap
interposition of PTT prevents reduction of medial malleolar fragment
Correct sequence in soft tissue reliease in bunion surgery
adductor tendon, suspensory ligament,
tenotomy of the lateral head of FHB,
excision of the fibular sesamoid
Counter rotational system Langer
correct torsional abnormalities
several hinges allow greater frredom of motion
BEST TOLERATED SPLINT, ALLOW UNENCUMBERED CRAWLING
Creatinie Clearance
Ceatinine
140-Age x weight (kg)==male 97-137
72 X Serum= female 88-128
Creatinine found in muscle
increase in age up too 20 yo
CLINICAL MARKER FOR KIDNEY
MOST SENSITIVE MARKER OF GFR>>>DOSING MEDICATION
Cross sectional studies
involves looking at data from a population at one specific point in time. The participants in this type of study are selected based on particular variables of interest.
CT views for middle subtalar facet coalition
axial and coronal because facet lies at 45 degree and is equidistant from both planes
CVD MAJOR CARDIAC
ANGINA PECTORIS-
MYOCARDIAL INFARCTION
DISSECTING ANEURYSM
ESOPHAGITIS GERD
TIETZE’S
PERICARDITIS
GALLBLADDER CHOLECYSTITIS
Cyma line: pronation vs supination
- Anterior break (pronated)- TN joint over CC
- Posterior break (supinated)-TN joint posterior to CC
Davis and German classification
Incomplete-webbing doesn’t extend to the distal toes
Complete- extends to distal toes
Complicated-phalanges involved
DDX based on Jt Fluid Analysis Chart
Group 1-Non inflammatory
DJD,trauma,osteochondritis charcot,
hyperparathyroid Pulm OA,Pigmented villous nodular
Group 2-Inflammatory condition-RA-Gout-Pseudogout
Group 3-Septa OA secondary to Bacterial Infection
Hemathrosis-results in hemorrahgic Jt fliud speciman caused by hemophilia and other bleeding diathesis, lgt with and without FX, neuropathis arthropathy, Pigmented Syn, hemangioma
DEEP PERONEAL NERVE ENTRAPEMENT
Anterior tibial nerve` SENSORY AND MOTOR
Supplies TA,EDL,EHL,PT,EDB resonsible for DF and frontal plane movement
Innervates lateral halklux and medial aspect 2nd toe
Anterior Tarsal Tunnel Sdyndrome-BLUNT TRAUMA to ant ankle///entrapped under ext ret or irriated by superior edge of Inf ext Ret (tarsal spur) compresses the DPN over ankle (max point of contact)
Clinical Finding: paresthesia dorsum of foot with numbness 1st met space//nocturnal pain relieve by movement d/t motor innervation of EDB
DX- distal motor latencies woth NCS >7ms (5 norm)
also reproduce sym PF of ankle with ext toes>>palpate the N of the ant ankle medial to dorsalis pedis
Deep Tendon Reflex
4+ associated with clonus
3+ Hyper-reflexic
2+ average
1+ low normal-hypo-reflex’
0 Absent
Patella DTR-L3 & L4 knee slight extend
Achilles S1 & S2 foot plantarflex
Define dive punch piece
- Triangular wedge of tibia that drives the rest of a pilon fracture
Defivitive treatment of atrophic non union
Decortication and stabilization of the
fragments
Delayed healing
2-6 months post
Dennis brown bar
treat met adductus
convex pes planovalgus
bar is screwed or riveted on shoes
Describe Amberry
McKeever
reverse Hohmann
long oblique distal osteotomy
Amberry-Davis+removal of base of proximal phalanx
McKeever-resection of 1/2-2/3 of 5th met
Reverse Hohmann-transverse osteotomy in neck
L. Oblique Distal -Weil osteotomy like cut at the MT neck
Describe DeVries 5th metatarsal
removal of lateral plantar condyle
Describe Hibbs tenosuspension
-EDL stlips combined and transferred to lateral cuneiform
Describe Jones tenosuspension procedure
transfer of EHL to 1st MT head
Describe Lawrence and Bott classification
1) Avulsion fracture due to lateral band of plantar fascia or PB contractures
2) Jones fracture due to ground reactive force with failure of the foot to evert
3) Diaphyseal fracture due to chronic stress, and repetitive distractive forces
Describe Steindler stripping procedure
-Sectioning of plantar fascia, 1st layer of plantar muscles, long plantar ligament
Disadvantage::::can active Charcot
Describe the Cobb procedure
-TA split proximally and rerouted through medial cuneiform. Tenodesed to PTT
Disadvantage-
sacrifices major inverter/adductor of the foot
Describe the Heyman tenosuspension procedure
transfer EDL to met necks
Describe the Stewart classification
1) Extra-articular Jones fracture
2) Intra-articular non comminuted fracture
3) Extra-articular avulsion fracture (PB)
4) Intra-articular comminuted fracture
5) Apophysis fracture
Describe the Young tenosuspension
-Reroute TA through Keyhole in the Navicular with insertion still intact
Describe Torg Classification
Type I: acute injury
Type 2: delayed union
Type 3: Nonunion
Diabetic Peripheral Neuropathy
1-Hyperglycemia and duration of disease
Small unmyelinated C fibers compose autonomic and sensory axons that transmit thermal perception and sympathetic function
-sensory changes do not correlate with N conduction deficits
2-presents prominent paresthesias and ANS with presence of orthostatic hypotension, resting tacycardia, and distal andydrosis
3-Large myelinated- (motor and sensory)- symptoms are tingling, burning, numbness, allodynia or deep lancinating pain
DTR attenuated or absent with possible distal motor wearkness
Neuopathy develps distal-proximal (Stocking & Glove) which is a cause of ulceration in 85%
Diabetic peripheral neuropathy TX
Capasaicin- to target P baciophen, muscle relax, TCA, anti-seizure meds
GAPAPENTIN-
Neurontin (900mg)initial,>>(1 tab)300mg>>(2 tbs)600mg>>900mg(3tabs)
Amytriptiline( 25mg @pm dose. if neurontin does work) +DOPA and NE receptor
OD-dizzy, drousy.. , Excrete unaltered>>no kidney stress
Gout Diagnosis
1-Light microscope-needle like crystal piercing WBC yellow needle crystals appear negatively birefrignant.Parallel to axis of lens and blue when perpendicular
2-X-Ray Rat bites, cloud sign, punched out lesions
3-Martel sign (overhanging margins)
diastematomyelia
more common in female
DIAZEPAM
LORAZEPAM
MIDAZOLAM
CNS DEPRESSES AND REDUCE ANXIETY
IV DIAZEPAM- PAIN BUT ORAL REACHES HIGHER BLD LEVEL
LORAZEPAM- 8 HR AMNESIA BC NO PRE-MED GIVEN TO OUT PT
VERSED= HIGHER % ANTEROGRADE AMNESIA-GREAT FOR ANXIOUS PT (POP)
KETAMINE DISSOCIATIVE SEDATION CAN BE COMBINE WITH VERSED OR VALIUM/ IF ADMIN ALONE-NIGHTMARES AND DELUSION
**MOA FACILITATES GABA ACTION BY INCREASE GREQ OF CL CHANNEL OPENING
ANTIDOTE: FLUMAZENZIL
DOPERIDOL+FENTANYL=NEUROLEPTIC ANESTHESIA=LIGHT GENERAL ANESTHESIA OR COGNATIVE DISS
Difference in shapes between medial and lateral OCD’s of the talus
medial: cup (PIMP CUP)
lateral: wafer
DISSECTING ANEURYSM
SHARP KNIFE LIKE SEVERE RIPPING
LOCATION-GENERALIZE
TIME->15 MIN
CAUSE-VARIES>>STROKE
TREATMENT-SURGERY AND PREVENTION
Distal Tarsal Tunnel Syndrome
Entrapment distal segments of the prox Tib N
Medial Plantar Nerve=JOGGERS FOOT SEONDARY TO COMPRESSION INTO THE PLANTAR B/C NAVICULAR TUBEROSITY AND ABDUCTOR HALLUC BELLY
Lateral plantar Nerve-1st branch to abductor digit M.Q. (BAXTERS NERVE) Enrtrap between quadratus plantar &Abductor Hallucis is accos with chronic heel spur synd and is MOST COMMON TYPE DISTAL TARSAL
TUNNEL SYNDROME
Give S/S post static dyskinesia and described as afterburn
DM Neuopathy Intrinsic muscle
Atrophy of intrinsic musculature>>> digit contracture
plantar prominence of metatarsal
abnormal distribution of the weight bearing load with ambulation
Advanced stages>>foot drop secondary gastroc complex lost its antagonist muscle group
DM neuropathy ANS
Profound vasodilation
presents::warm, erythematous and dry>>Increase blood flow
>>>>>deminerization of bone>>>>“wash away”
CHARCOT JOINT DISEASE
DM Neuropathy Sensory changes
Sensory doesn’t always correlate with Nerve conduction studies
DTR-attenuated or absent with possible distal motor weakness
Devlops in legth dependent fashion>>STOCKING GLOVE
Decrease sensory loss>>>ulceration or breakdown
LOSS OF VIBRATORY AND POSITION SENSE>>>Ulcer
CAUSE-Oxidative stress>>breakdown intraneural glucose
DM peripheral neuropathy pathology
Small ummyelinated C fibers composed autonomic & sensory axons that transmit thermal perception and sympathetic function SEEN EARLY
-Prominent paraesthesia + ANS dysfunction ie:orthostatic hypotension
resting tachycardia
distal anhidrosis
Large myelinated axons-both motor & sensory—conducts propioception, light touch & pain
Sensory does not correlate with nerve conduction deficit
Symptons:Tingling,burning, numbness, allodynia, deep lacinatying paon
Drugs for tubercolosis
Isoniazid-pyrodoxidine def is major side effect
Rifampin-cytoP50—will decrease effectiveness of co-administered drugs,::protein inhibitor, BCP, warfarin,quindine,zidovudine,itraconazole, lfluconazolw and ketakononazole
Pyrazinamide
Ethambutol or Streptomycin
Duchenne Muscular Dystrophy
DMD) is a severe type of muscular dystrophy that primarily affects boys. Muscle weakness usually begins around the age of four, and worsens quickly. Muscle loss typically occurs first in the thighs and pelvis followed by the arms.
GOWERS SIGNS-pathognomonic where child rises from sitting position by climbing on her legs
During which phase of Tendon healing do you start
cross training with lower impact exercises?
Phase 3
Ganleys closing abduccory cuboid calcaneal osteotomy
Dynamization
The process of making the fixator more
flexible
Electrolytes
Sodium (NA) 135-145
Potassium(3.5-5.5)
Chloride-(98-109)
CO2
Electromagnetic fields
low frequency magnetic fields.
Magnetic fields are created by electricity flowing through wires
Emollients
Aquaphor
Calamine
Cetaphil
Eucerin
Lac-Hydrin
Lanolin
Moisturel
Entrapement neuropathy
Definition-compression neuroapathy to gradual contriction anatomic structures about anerve
S/S- insidious & mil;d; motor and sensory changes painful
DX: EMG and NCV
TX Surgical decompression
Esses-Lopresti
Intra-articular calcaneal fracture
type 1-tongue fx d/t vertical fall primary line exist plantar secondary fx line exist posterior
Type 2-joint depression fx d/t posterior fall, primary line exist plantar and 2nd fx line posteriorsuperiorly(dorsally)
Etiology of Lisfranc fracture
- most injuries in Dorsal direction
- Forced abduction
- Twisting with an axial loading of a PF foot
- Motor vehicle accident
Etiology of posterior process fractures
-Shepard’s or cedell fractures occur with forced PF of the foot.
Steida process: intact medial tubercle
Evans procedure
procedure best treats a flat foot with a severe transverse plane abduction deformity
Exam that can be done in the OR for syndesmosis injury
Cotton test/hook test- best test for syndesmosis injury
Femur development infants
In Adults
135-155 infant
120-135 Adults
Fillauer Bar
Same as Denis-Browne Bar except the bar clamps to sole of pts shoes
Need rigid shoes
Flexible vs rigid pes planus foot
Flexible Rigid
+ Hubscher manuever (-)
+ Resupination test (-)
NOT PAINFUL PAINFUL
LA arch on weight bearing coalition, vertical talus
FRIEDMAN COUNTER SPLINT OF FLEXOSPLINT
DYNAMIC SPLINT CONSIST OF A BELT AROUND THE POSTERIOR HEEL
ALLOWING MOTION IN ALL PLANES EXCEPT INTERNAL ROTATION
INDICATED FOR INTERNAL TIBIAL TORSION
Frontal plane corection of flatfoot deformity
Chambers-raise the posterior facet of the STJ using a bone graph
Baker- Osteotomy inferior to the STJ post facet with bone graph
Selakovich- open wedge osteotomy of the sustentaculum tali with bone graph
which restricts abnormal STJ motion
Gleich- Oblique osteotomy displaced anterior- help to increase cal-inc.angle
Silver- Lateral opening wedge with graph
Koutsogiannis- Medial side calcaneal osteotomy
Triple Arthrodesis- reserved for salvage
Grice-Green Extra-articular Subtalar arthrodesis -bone graph inserted laterally in
sinus tarsi bewteen the talus and calc. good for children. Provides excellent stability
Galeazzi Sign
also known as Allis sign
hip and knees flexed, supine position
dislocated hip results in lower knee positiob on affected side
Galium 67
1/2 life 78.3 hours
diagnose if you have certain types of cancer, such as Hodgkin’s disease, lymphoma, or lung cancer.
identifies the cells that are dividing most quickly in your body. It can help detect some cancer cells. It can also help show cells that are rapidly reproducing or responding to an infection somewhere in your body. People with lymphoma (cancer of the lymph system) may need gallium scans.
principal organs that localize gallium are the liver, spleen, and bone marrow.
Ganley splint
1st splint to treat combo foot and leg disorders
Similiar to Denis-Browne
If treating internal rotation, bar placed bewteen RF plates
If treating external rotation, place bar forefoot plate
General anesthesia staging based on Guedel’s
Phases on anesthesia
1- Induction
Begins with induction agent and ends with loss of consciousness. The patient can still feel pain in this stage
Stage 2-Hyperexcitable state. The time where the patient looses consciousness and when they regain autonomic stability. The patient losses the ability to maintain temperature, blood pressure and may experience irregular breathing, uncontrolled movement, GI issues (vomiting). This stage last a very short amount of time.
2-Maintenace-
Stage 3-This is desirable state or target debt of anesthesia. Patient regains autonomic stability
Plane 1-eye rolling which progresses to eyeball centrally fixed
Plane 2- Loss of corneal and laryngeal
Plane 3- Pupils dilate and loss of light reflex
Plane 4-Intercostal paralysis, Short shallow abdominal respiration (diaphragmatic respiration)
Stage 4 Overdose. Autonomic instability will begin to reemerge. Loss of BP, decrease breathing, circ failure
Emergence-Starts at stage 3 surgical anaesthesia) thru stage 2>>> stage 1 conscience awake
General induction Anesthesia
A-IV short acting Other induction agents>>Fentanyl>>>Sulfematil>>>>Alfemtanil (uses narcotic as induction reduces need for pre-medication)—-SIDE EFFECT–RESP DEPRESSION>> USE NALOXONE
B-Barbituate- 1- Thiopental-(3-5MG)-short act depress. SE long recovery>metaboloze in liver, PORPHYRIA
2- Methohexital (Brevital)short acting, faster return to consc SE: cough/singultus/ PORPHYRIA/cardiac failure/ not used with recent MI or air obstruct or severe liver damage
3 Propofol(Diprivan)-** sedative-hypnotic- metabolized fast in liver. Rapid return to clear head
SE: cause greater CV and resp depression
4- Ketamine- IV/IM great for un coop Kids ( SE dissociative anesthesia- pt appears awake eyes open but pt is unaware of surrounding)
C- Benzodiazepine 1-Midazolam-No analgesia>>Resp depression>>decrease BP-shortest act
D- Butyrophenone 1-Droperidol -if combined with other narcotic like fentanyl>>Neuroleptic Anesthesia
Giant cell tumor
This tumor usually affects patients in their 2nd and 4th
decade of life. It has a predilection for the female
population. Symptoms are often a dull ache that is
intermittent in nature and may be accompanied by a
palpable mass. The areas most commonly affected are
the distal radius, proximal tibia and the distal femur.
Radiographically one may see an expansile lesion, a
central area of radiolucency, destructive, and can extend
to the articular surface of the bone. What is
Glide and thread hole
Insertion of a fully-threaded lag screw requires drilling a glide hole in the near cortex, on the same axis as the thread hole in the far cortex.
Glide hole: The cortex under the screw head is drilled to the size of thread diameter so that the thread gets no purchase.
Thread hole: A drill hole which is the same diameter as the core of the screw is drilled, and a tap is used to cut the spiral groove that receives the thread of the screw. The result is a thread hole.
One can drill both cortices with the thread hole sized drill and then overdrill the near cortex. Alternatively, the gliding hole is drilled first, and a drill sleeve is placed within it to direct the drill bit for the thread hole in the far cortex
Goals of AO
The first screw should be placed centrally
and perpendicular to the long axis of the
bone. The secondary screw should be
placed perpendicular to the fracture line and
placed on either side of the first screw
GOUT
Affect peripheral joints, esp 1st MPJ
Monosodium crystals forms
Supersatuated hyperuricemic body fluid crytalizes
UA Crystals in joints from xs breakdown or overproduction of purines
CLASSIC BEGINS: evening or early morning
S/S=Asymmetrical monarticular OA
Sudden onset: red hot swollen with possible low fever
Joint sparing, but in chronic, joint destructive
Usually 1st attacks 1st MPJ
Crunchy tophi in ears
Ground reactve force peak in which 2 phases of gait cycle
contact, prolpulsion
GTT
Present in renal tubular epithelium and in liver
sensitive to detect chronic alcohol consumption
Guillame Barre Syndrome Landry’s Ascending Paralysis
danGthrapist
sysmetrical motor and sensory paresis
Schwann cell surface membrane targeted
frequest infection organism—Camphlobacter jejuni
Pathology Edema of nerve–degeneration of nerve and myelin sheath
S/S=distal limb first (weakness)>>decrease tednon reflex>>inv ANS>>motor and sensory weakness
TX- Plamsa phoresis with immunomodulation via infusion IgG shortens DZ
hallus abducto valgus and associated complications
prominent metatarsal head
*hypermobility of the 1st ray ( usually insufficient)
* callus
hammer toe on 2nd digit
*rearfoot valgus deformity
*gait evaluation- overpronation
arch collapse (VERY MUCH SO) {*the peroneus longus tendon is stretched with collapsed arch. }
*1st MTPJ: 60 degree ROM, 45/15 ( should be under 25 and 15)
may also see ingrown nail.
Hallux limitus and rigidus destructive procedure
Keller
Implant arthroplasty
Stone-oblique osteotomy resects 1/4 of met head leaves plantar condyle
Mayo-excise 5mm met head
Mckeever=1st MPJ arthrodesis-df 5-10 degrees
Valenti-V shape osteotomy
Lapidus-fusion of the MC joint
1st MPJ Joint preserving procedures
Cheilectomy
kessel & Bonney
Regnauld-Mexican hat prox phalanx- shorten 1st ray
Waterman
Waterman-Green-shorten and PF met head
Youngswick
Van-Ness-PF wedge base 1st met
Cotton-Open base wedge
Labrinudi-PF wedge correct met primus elevatus
Hansen’s disease (leprosy)
Leprosy is caused by infection with the bacterium Mycobacterium leprae. It mainly affects the skin, eyes, nose and peripheral nerves.
Symptoms include light colored or red skin patches with reduced sensation, numbness and weakness in hands and feet.
Leprosy can be cured with 6-12 months of multi-drug therapy. Early treatment avoids disability.
Hilgenreiner line (Y line)
Ombredanne (Perkins vertical line)
dislocated hip will be femoral head outer upper quadrant
IPOS
ANTI-ADDUCTUS ORTHOTIS TYPE 2
INDICATED METATARSAL ADDUCTUS
Lange Hansen Classification
Supination Adduction
1-LRupture of the AITF/PITF lgt tear,or avulsion fibular fracture(weberA)
2-Spiral fracture of the fibula DWB POSTERIOR SPIKE ON LATERAL XRAY
3- Volkmans fracture or PITF rupture
4- Rupture of the deltoid lgt/ transverse fracture of the medial malleolus
Lateral ankle artery supply
Measuring for metatarsal adductus angle
line drawn medial proximal aspect of the 1st metatarsal base and medial distal aspect of T-N articulation
2nd line-between lateral prox asp 4th metatarsal base and lateral distal aspect of the C-C joint
3rd Line- between the bisection to 2 lines
4-perpendicular line to the 3rd line down the shaft of the 2nd metatarsal
Metatarsal adductus angle a>>20 is adducted
MTA at birth 25-30 degree
Ankle blood supply
Medial view of ankle soft tissue
MRI for OM
Cortical bone destruction
bone marrow edema low signal T1
Reactive surface
well defined
Adjacent rim, well define
T2 increased signal
What does the MRI reveal in a stress fracture
Low intensity T1 linear zone poorly defined
T2 linear is dark
1st Plantar layer
Abductor hallucis( medial plantar Nerve)
Flexor digitorum brevis( Medial plantar nerve)
Abductor digital minimi(Lateral plantar nerve)
Radiograph congrenital vertical talus
Lateral view-witha second the foot plantarflexed showing the talo-navicular relationship doesn’t change
Navicular not evident on x-ray until age 3
line bisecting the talus is parrallet to the tibia
TC angle on A/P is increased to >>40 degrees
Talar neck hypoplastic may have hourglass shape and flat surface
Navicular articulates witht he dorsal talus
Negative hubscher maneuver
Rowe classification 4
Type 4-Fx involving STJ w/o joint depression or comminution
Salter Harris Functure
S.A.L.T.ER
Saphenous Nerve
Branch of the femoral
Parallels the great saphaneous vein
Gives off branches to the medial crural nerve
Saphenous nerve
from the femoral and it is the only branch
branches to the medial crural nerves’
Screws
Cortical-fully threaded
fine threads with small pitch to anchor the cortical bone
cancellous-partially threaded (historically), usually lag. threads are coarser with hugh pitch inted to engage medullary bone
shoe anatomy
Sneppen group 4
Fx lateral process of talus
2nd most common talar body fracture
AKA Snowboard FX eversion injury with lateral process caught b/t fibula and calcaneus
Soft tissue lateral view of ankle
Superficial Nerve
Common peroneal nerve within the tunnel of the P.L and neck of the fibula
upper part innervate the P.L. and PB
supplies most of anterior skin to ankle and dorsum
Superficial Peroneal Nerve
Divides into (2)medial and intermediate (1) dorsal cutaneous nerve
medial dorsal cutaneous nerve divides into 2 dorsal digital Nerve-1-Medial proper dorsal digital nerve to the hallux(skin)
2-Common dorsal digital nerve-innervates skin 2nd & 3rd toe
3-Intermediate dorsal cutaneous nerve-splits into 2 digits nerve 3rd & 4th IDS
Sural Nerve Anatomy
Strictly cutaneous
Forms in leg by combining branches tibial and common peroneal Nerve
Medial sural cutaneous branch is branch of tibial nerve
Sural comminicating branchof the peroneal N at fibula head
As Sural enter the foot>>lateral dorsal cuntaneous nerve0
Talocalcaneal Coalition
45% and almost all the middle facet
starts around 12-14 y.o.
pain usually over the sinus tarsi
decrease ROM STJ and MTJ
X-RAY- Lateral and Harris-beath best views
TC on lateral C sign or halo sign
(this C chape is a line formed from medial outline of talar dome and inf outline of Sust tali.
thiis C shape is specific
May be absent STJ middle facet and diminished facet
Talar beaking
Medial oblique- shortening talar neck/ dysmorphic sust tali (or ovoid shape)
Talus in ankle mortise more rounded (ball and socket)
Twister cables
cables around waist
inside pant leg
CONTROLS DEGREE OF ABDUCTION AT HEEL CONTACT
TREAT SCISSOR GAIT OF CP PATIENTS
Unibar
Same as denis brown bar except has ball and socket joint beneath each foot
tighten for varus position (preventing STJ and MTJ subluxation) elimninating the need to bend the bar
Wheaton Brace
used for metatatsal adductus
alternative to serial casting
Wheaton Brace System
Additional AK piece is design to lock into BK component
Knee flexed at 90 degrees prevent twisting of femur or hip and allowing isolated unilateral tx of tibial torsion
Wiberg CE Angle
if femoral head is inadequately, wil develop DJD
this test reveals how much DJD will develop
treatment: aligning the femoral head in the actabulum and holding it there
