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PC F&A > PC Foot and Ankle > Flashcards

PC Foot and Ankle Flashcards

1
Q

Tibiofibular clear space should be (mm)

A

< 5 mm

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2
Q

Tibiofibular overlap on AP view (mm)

A

> 10 mm

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3
Q

Anterior talofibular ligament (ATFL):

Function:
Anatomy:
PE:

A

ATFL

Function: primary restraint to inversion in plantarflexed; weakest lateral ligament
Anatomy: anteroinferior border of fibula to talar nexk
PE: anterior drawer in 20 deg plantarflexion

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4
Q

Posterior talofibular ligament (PTFL):

Function:
Anatomy:
PE:

A

PTFL

Function: strongest lateral lig; limits posterior translation of talus w/in mortise
Anatomy: posterior border of fibular to posterolateral tubercle of talus
PE: no specific test

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5
Q

Calcaneofibular ligament (CFL)

Function:
Anatomy:
PE:

A

CFL

Function: primary restraint to inversion in neurtral/DF position
Anatomy: anteroir border of fibula to calcaneus 13 mm distal to subtalar joint
PE: talar tilt test

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6
Q

Deltoid ligament

Function:
Anatomy:
PE:

A

Deltoid

Function: primary restaint to valgus tilting of talus; eversion
Anatomy: Superficial – anterior colliculus to navicular, nack of talus, sustentaculum tali, posteromedial talar tubercle; ST portion is strongest. Deep – posteromedial medial mal to talus
PE: eversion test with ankle in neutral

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7
Q

Calcaneonavicular ligament (Spring ligament)

Function:
Anatomy:
PE:

A

Spring ligament

Function: static stabilizer of medial longitudinal arch and head of the talus
Anatomy: sustentaculum tali to inferior aspect of navicular
PE: flattening of the arch

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8
Q

Effect of inversion of subtalar joint on transverse tarsal joint

A

Locks the transverse tarsal joint

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9
Q

Effect of eversion of subtalar joint on transverse tarsal joint

A

Unlocks the transverse tarsal joint

transverse tarsal joints are parallel

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10
Q

Action of foot intrinsic muslces

A

Flex the MTP joints and extend the IP joints

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11
Q

Major blood supply to the heel pad

A

Medial calcaneal branch (off the laateral platar arteries from the posterior tibial artery)

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12
Q

Relative position of the anterior tibial artery to EHL in the ankle then foot

A

Medial then lateral to the tendon

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13
Q

Nerve at risk during bunion surgery

A

Dorsomedial cutaneous nerve — terminal branch of SPN

Numbness over medail aspect of hallux

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14
Q

Equinus deformity - strong & weak muscle

A

Equinus:

Strong = Gastroc-soleus
Weak = dorsiflexors
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15
Q

Cavus deformity - strong & weak muscle

A

Cavus::

Strong = plantar fscia, intrinsics
Weak = dorsiflexors
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16
Q

Varus deformity - strong & weak muscle

A

Varus:

Strong = posterior tibialis & anterior tibialis
Weak = peroneus brevis
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17
Q

Supination deformity - strong & weak muscle

A

Supination:

Strong = anterior tibialis
Weak = peroneus longus
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18
Q

Treatment of equinovarus foot after stroke

A

Nonop: AFO, PT — try for 6 mos

Op: SPLATT, gastroc lengthening

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19
Q

Silferskiold test

A

Improved ankle dorsiflexion with knee flexed = gastroc tightness

Equivalent ankle dorsiflexion with knee flexed = Achilles tightness

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20
Q

Os trigonum causes

A

posterior ankle impingement for FHL tenosynovitis

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21
Q

Type II accessory navicular causes

A

posterior tibial tendon dysfunction

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22
Q

Activity of anterior tibialis during heel strike/stance phase of gait

A

Eccentric contraction

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23
Q

Activity of quadriceps during heel strik and then terminal stance phases of gait

A

heel strike = eccentric contraction

terminal stance = concentric contraction

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24
Q

Treatment of equinovarus foot without well functioning tib ant

A

posterior tibialis transfer

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25
Q

Quadriceps atrophy affects what phase of gait cycle most

A

Midstance — causes buckling or knee hyperextension

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26
Q

Antagonist to peroneus brevis

A

Posterior tibialis

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27
Q

Soft tissue precedures performed at the time of bony pes planovalgus deformity correction

A

FDL to posterior tib transfer

Spring ligament reconstruction

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28
Q

Antagonist to tibialis anterior

A

Peroneus longus

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29
Q

Antagonist to peroneus longus

A

Tibialis anterior

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30
Q

Antagonist to posterior tibialsis

A

Peroneus brevis

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31
Q

Common associated injuries with “high ankle sprain”

A 
OCD
Peroneal tendon injuries
Distal fibular fx (weber B/C)
5th MT base fx
Deltoid lig injury
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32
Q

Anatomy of the AITFL

A

Origin: Anterolateral tubercle of the tibia (Chaput)
Insertion: Anterior tubercle of the fibula (Wagstaffe)

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33
Q

Anatomy of the PITFL

A

Origin: Posterior tubercle of the tibia (Volmann)
Insertion: posterior part of the lateral mal

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34
Q

Strongest ligament in the syndesmosis

A

PITFL

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35
Q

Normal medial clear space

A

<= 4mm

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36
Q

Indication for nonop tx high ankle sprain

A

Syndesmosis sprain without diastasis or instability

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37
Q

Nonop tx high ankle sprain

A

NWB in CAM boot or cast x 2-3 wks

PT with brace that limits ER

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38
Q

Indication for operative tx of high ankle sprain

A

Syndesmosis sprain with instability on stress XR OR failed conservative tx

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39
Q

Most common injury in dancers

A

ankle sprain

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40
Q

Mechanism of injury for ankle sprain

A

Inversion injury on a plantarflexed foot

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41
Q

Associated injuries with ankle sprain

A
    • OCD
    • Peroneal tendon injury
    • Subtle cavovarus foot
    • deltoid ligament injury
    • CRPS
    • Fx — 5th MT base, anterior process of calc, lateral process of talus
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42
Q

Order of commonly involved ligaments in low ankle sprain

A

ATFL > CFL > PTFL

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43
Q

Indication for nonop tx low ankle sprain

A

All sprains should be treated nonop first

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44
Q

Nonop tx for low ankle sprian — rehab program

A

Early phase – motion and progress to strengthening/proprioception

Stregthening phase – once swelling/pain subside, work on peroneal strength & proprioception

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45
Q

Indication for operative tx of low ankle sprain

A

persistent instability despite nonop tx

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46
Q

Mechanism of injury for Lisfranc

A

MVA/fall/atheltic

Axial load through hyperplantarlfexed forefoot

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47
Q

Lisfranc ligament

A

interosseous ligament going from medial cuneiform to base of 2nd MT on plantar surface

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48
Q

Indication for nonop tx of Lisfranc

A

NO displacement on WB and stress XR and no e/o bony injury on CT

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49
Q

Indication for op tx of Lisfranc

A

Any evidence of instability (>2mm shift) or bony fx dislocations

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50
Q

Indication for arthrodesis over ORIF in Lisfranc

A

purely ligamentous arch injuries
severe comminution
delayed treatment
chronic deformity

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51
Q

Indication for operative fx of base of 5th MT fx

A

Zone 2 in elite or competitive athlete

Zone 3 with sclerosis/nonunion

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52
Q

Indication for nonop tx of base of 5th MT fx

A

Zone 1 – PWB in stiff soled shoe/boot
Zone 2 in recreational athlete
Zone 3

NWB in short leg case x6-8 wks

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53
Q

Indications for surgery in GSW to hand or foot

A
    • articular involvement
    • unstable fracture patterns
    • presentation >= 8 hrs after injury
    • tendon involvement
    • superficial fragments in palm or sole

Type I (low velocity, <8 hrs from injury) –> stabilize with internal vs external fixation

Type II (high velocity, >8hrs) –> stabilize with ex-fix and repeat debridements

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54
Q

Treatment of navicular stress fx

A

NWB in cast x 6-8 wks

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55
Q

Indication to fix navicular fx

A

> 25% articular surface
tuberosity fx >5mm displacement
displaced body fxs

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56
Q

Risk factor for nonunion after ORIF for MT5 base fx in athlete

A

Return to sport prior to radiographic union

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57
Q

Indication to fix metatarsal fx

A
    • open fx
    • first metatarsal with ANY displacement
    • central metatarsals w >10deg sagittal plan, >4mm translationi, multiple fxs
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58
Q

Treatment metatarsal stress fx

A

WBAT in CAM boot or stiff soled shoe

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59
Q

Risk factor for Achilles tendon rupture

A
    • “Weekend warrior”
    • Fluoroquinolone use
    • Steroid injections
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60
Q

Indications for nonop tx Achilles rupture

A

acute injuries with surgeon or patient preference for non-operative management
sedentary patient
medically frail patients

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61
Q

Outcomes for nonop tx Achilles rupture

A
    • Equivalent plantarflexion strength compared to op
    • Increased risk of rerupture compared to op; but, new studies show not different with functional rehab
    • Fewer complications to op tx
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62
Q

Risk of percutaneous Achilles repair

A

Higer risk of sural nerve damage

Lower risk of wound complication/infxn compared to open

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63
Q

Treatment of chronic Achilles rupture with>3cm defect

A

FHL transfer +/- VY advancement of gastroc

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64
Q

Risk factors for wound complications after Achilles repair

A
    • smoking (most common)
    • Female
    • Steroid use
    • Open technique (vs percutaneous)
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65
Q

Orientation of the peroneal tendons coming around the lateral malleolus

A

Brevis lies anterior & medial to the longus (Brevis on Bone)

Longus is posterior to the brevis (Longus takes the Long way round)

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66
Q

Treatment of acute SPR rupture (snapping peroneal tendons)

A

Short leg case and PWB x6wks

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67
Q

Operative tx of snapping peroneal tendons

A

Acute: repair of SPR & deepening of the fibular groove

Chronic: groove deepending with soft tissue transfer

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68
Q

Operative tx peroneus brevis tears

A

Simiple tear — core repair & tubularization of tendon

Complex tear > 50% tendon — tenodesis of distal & proximal ends of brevis to longus

Complex tear > 50% PB/PL && excursion of muscles — interposition allograft

Complex tear > 50% PB/PL && NO excursion of muscles — FHL transfer

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69
Q

Risk factors for tibialis anterior tendon rupture

A 
older age
diabetes 
fluoroquinolone use
local steroid injection
inflammatory arthritis
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70
Q

Indication for operative treatment of tib ant rupture

A

Direct repair — acute injury (up to 3 months) in active patient

Reconstruction — in chronic injuries (most cases)

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71
Q

Treatment options for tib ant reconstruction

A
    • sliding tendon graft –> harvest one half width of tibialis anterior tendon proximally and turn down to span gap
    • hamstring/plantaris autograft vs allograft
    • EHL tenodesis
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72
Q

Most common cause of soft tissue infection after foot puncture wound

A

Staph aureus

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73
Q

Most common cause of osteomyelitis after foot puncture wound

A

Pseudomonas

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74
Q

Preferred PO abx for foot soft tissue infection

A

Cipro or levofloxacin

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75
Q

Risk factors for posterior tibial tendon insufficiency

A
    • obesity
    • HTN
    • diabetes
    • increased age (usually presents in 6th decade)
    • corticosteroid use
    • inflammatory disorders
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76
Q

Insertion of posterior tibial tendon

A

Anterior limb – navicular tuberosity & first cuneiform

Middle limb – 2/3 cuneiforms, cuboid, MT 2-4

Posterior limb – sustentaculum tali

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77
Q

Actions of posterior tibial tendon

A

PTT lies in an axis posterior to the tibiotalar joint and medial to the axis of the subtalar joint

    • functions as a primary dynamic support for the arch
    • acts as a hindfoot invertor
    • adducts and supinates the forefoot during stance phase of gait
    • acts as secondary plantar flexor of the ankle
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78
Q

Classification of posterior tibial tendon insufficiency

A

I - tenosynovitis
II - flexible flatfoot
III - rigid flatfoot with subtalar arthritis
IV - rigid flatfoot with subtalar arthritis and talar tilt in ankle

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79
Q

Radiographic findings in PTTI/flatfoot

A

AP – inrease TN uncoverage, inc talo-first MT angle

Lateral –

    • Increased talo-first MT angle (>4 deg)
    • Decreased calcaneal pitch (<17 deg)
    • Decreased medial cuneiform-floor height
    • subtalar arthritis (stages III/IV)

Mortise –> talar tilt d/t deltoid insufficiency in stage IV

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80
Q

Nonop tx for PTTI

A

Custom molded orthosis –> medial heel wedge vs UCBL with medial post – stage I/II

AFO –> stage II/III/IV

Cast vs boot for stage I

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81
Q

Surgical treatment of stage II PTTI

A

Calc osteotomy, TAL, +/- forefoot osteotomy/spring lig repair/lateral column lengthening/medial column arthrodesis/PTT debridement

If >40% or 30 deg uncovering of TN, then add lateral column lengthening

If first TMT hypermobility or arthritis –> arthrodesis

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82
Q

Surgical treatment of stage III PTTI

A

Triple arthrodesis vs isolated subtalar

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83
Q

Nonop tx Achilles tendonitis

A

Activity modification, shoe wear modification, PT

PT focuse on ECCENTRIC training, gastroc stretching

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84
Q

Operative treatment of Achilles tendonitis

A

Indication: failed nonop tx

Retrocalcaneal bursa excision, debridement of diseased tendon, calcaneal bony prominence resection

Augment with FDL/FHL/PB if have to take more than 50% of tendon

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85
Q

Risk factors for FHL tendonitis

A

Excessive plantarflexion –> dancers in on pointe position & gymnasts

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86
Q

Orientation of FHL & FDL at the Knot of Henry

A

FHL is “higher” at the knot

FDL is “down” at the knot

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87
Q

Risk factors for plantar fasciitis

A

Obesity
Deceased ankle dorsiflexion in non-athletic pt
Weight bearing endurance activity (eg. Dancing, running)

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88
Q

Treatment of plantar fascia ruptures

A

Cast immobilization

risk factors –> athletes, minimalist runners, corticosteroid injections

89
Q

Management of calcaneal malunion with subtalar arthritis & <10 deg varus

A

Lateral wall exostectomy, peroneal tenolysis, subtalar bone arthrodesis

if >10 deg varus –> lateral calcaneal closing wedge osteotomy +/- triple arthrodesis

90
Q

Associated with chronic lateral ankle instability

A

peroneus brevis tear

91
Q

Fleck sign along the lateral aspect of the distla fibula

A

SPR tear and snapping peroneal tendons

92
Q

Predisposition to Jones fx

A

Hindfoot varus deformity — eg, CMT (duplication of PMP22 gene on Ch17)

93
Q

Best method to maximize muscle mass in post-polio syndrome

A

exercise at sub-exhaustion levels to tone affected muscle groups without causing muscle breakdown

94
Q

Site of compression of the lateral plantar nerve in runners

A

between the fascia of the abductor hallucis longus and medial side of the quadratus plantae

tx: release of abductor hallucis fascia

95
Q

Treatment of acquired spastic equinovarus foot deformity (after stroke) that is not braceable or causing skin problems

A

Achilles tendon lengthening with split tibialis anterior transfer

96
Q

Most common location for Morton’s neuroma

A

between the3rd/4th toes

interdigital nerve lies plantar to the transverse intermetatarsal ligament btw the MT heads

97
Q

Complications of interdigital (Morton’s) neuroma excision

A

– stump neuroma — inadequate retraction or resection

98
Q

“heel pain triad”

A

posterior tibial tendon deficiency (adult-acquired flatfoot), plantar fasciitis, tarsal tunnel syndrome

believed to be due to loss of static and dynamic stabilizers of the medial arch and susequent traction neuropathy on the tibial nerve

99
Q

Best test for tarsal tunnel syndrome

A

compression test
plantar flexion and inversion of ankle
digital pressure over tarsal tunnel
highly senstitive and specific

100
Q

Risk factors for charcot neuropathy

A 
diabetic neuropathy
alcoholism
leprosy
myelomeningocele
tabes dorsalis/syphilis
syringomyelia
101
Q

How to tell the difference btw erythema from charcot arthropathy and infection

A

Charcot: erythema decreases with elevatoin

Infection: erythema unchanged with elevation

102
Q

Most appropriate test for Charcot neuropathy

A

Semmes-Weinstein monofilament testing

103
Q

Difference btw charcot alone and superimposed osteomyelitis on indium WBC scan

A

indium WBC scan

negative (cold) for neuropathic joints

positive (hot) for osteomyelitis

104
Q

Best test for differentiating charcot from infection

A

MRI

105
Q

Labs in charcot foot

A

ESR and WBC can be elevated

106
Q

First line treatment for charcot foot

A

Total contact casting, shoewear modification, medications

Casting – every 2-4 wks changed for 2-4 mos

Othotics: Charcot restraint orthtic walker boot after total contact cast

Double rocker shoe modificatoins reduce risk of ulcers

Meds: bisphosphonate, antidepressants

107
Q

Indication for exostectomy and TAL in Charcot foot

A

“braceable” foot with equinus deformity and focal bony prominences causing skin breakdown

108
Q

Complication rates after deformity correction/arthrodesis in Charcot foot

A

70%

infection
hardware malposition
recurrent ulceration
fracture

109
Q

Factors associated with decreased healing potential in diabetic foot ulcers

A 
uncontrolled hyperglycemia
inability to offload the affected area
poor circulation --- ABI < 0.45; TcpO2 < 30mmHg
infection
poor nutrition
110
Q

Factors associated with increased healing potential in diabetic foot ulcers

A

serum albumin > 3.0 g/dL

total lymphocyte count > 1,500/mm3

111
Q

Treatment of diabetic foot ulcer with skin intact but bony deformities leading to “foot at risk”

A

Shoe modificatoins with serial exams

112
Q

Treatment of diabetic foot ulcer with superficial ulcer

A

Office debridement and contact casting

113
Q

Treatment of deeper, full thickness diabetic foot ulcer

A

Operative formal debridement and contact casting

114
Q

Treatment of deep abscess or osteomyelitis after diabetic foot ulcer

A

Operative formal debridement and contact casting

115
Q

Treatment of partial gangrene of forefoot after diabetic foot ulcer

A

Local vs larger amputation

116
Q

Gold standard to assess wound healing potential in diabetic foot ulcer

A

Transcutaneous oxygen pressures (TcpO2) > 30 mmHg

117
Q

Best shoewear modification to reduce plantar pressure on forefoot

A

rocker sole shoes

118
Q

Innervation of first branch of the lateral plantar nerve (what muscle)

A

Abductor digiti minimi — can get compression of the first branch of the lateral plantar nerve (Baxter’s nerve) between the fascia of abductor hallucis and quadratus platae

119
Q

Treatment of full thickness heel ulcer with exposed calcaneus

A

Partial calcanectomy with primary closure

Risk factors for delayed healing = MRSA, poor nutrition (albumin < 3), peripheral vascular dz, large ulcers

120
Q

Treatment of Charcot foot with deformity and recurrent (now healed) ulcers despite total contact casting

A

Surgical correction of deformity, Achilles lengthening, therapeutic footwear

121
Q

Hallux valgus angle

A

Long axis of 1st MT and prox phalanx

Normal < 15

122
Q

Intermetatarsal angle

A

Btw long axis of 1st and 2nd MT

Normal < 9

123
Q

Distal metatarsal articular angle

A

Btw 1st MT long axis and ling through distal articular cap

Normal < 10

124
Q

Indication for nonoperative treatment of hallux valgus

A

First line treatment

Shoe modifications, pads, spacers, orthoeses

125
Q

Indications for operative tx of hallux valgus

A

Persistent symptoms despite nonop tx

** do not performe for cosmetic reasons alone **

126
Q

Indication for in tx hallux valgus:

distal osteotomy
proximal or combined osteotomy
1st TMT arthrodesis
Fusion procedure
MTP resection arthroplasty
A

distal osteotomy: 10 < IMA < 13, 20< HVA < 40

proximal or combined osteotomy: IMA > 13, HVA > 40

1st TMT arthrodesis: arthritis of TMTJ or instability

Fusion procedure: severe deformity/spasticity/arthritis

MTP resection arthroplasty: elderly, low demand

127
Q

Indication for proximal phalanx medial closing wedge osteotomy

A

Hallux valgus interphalangeus angle (HVI) > 10

AND

DMAA < 10

128
Q

What to do if DMAA > 15

A

Biplanar distal osteotomies for hallux valgus correction

129
Q

Complications of modified McBride

A

Recurrence

Hallux varus

130
Q

Complications of distal Chevron osteotomy for hallux valgus

A

AVN of MT head
Recurrence
Dorsal malunion
Transfer metatarsalgia

131
Q

Complicaitons of Lapidus procedure

A

Nonunion

Dorsiflexion of 1st MT causing transfer metatarsalgia

132
Q

Indication for nonoperative treatment of hallux rigidus

A

Grade 0 or 1 disease

NSAIDs, activity modification, orthotics

Morton’s extension with stiff foot plate

133
Q

Indication for dorsal cheilectomy in hallux rigidus

A

Grade 1 or 2 disease — those with pain with terminal dorsiflexion or pain with shoe wear from dorsal irritation

Remove 25% dorsal MT head during OR

134
Q

Indications for MTPJ arthrodesis for hallux rigidus

A

Grade 3 or 4 disease

135
Q

Strongest construct for hallux MTPJ arthrodesis

A

dorsal plate with compression screw

136
Q

Preferred surgical alignment for hallux MTPJ arthrodesis

A

10 deg valgus

15 deg dorsiflexion

137
Q

Bilateral sesamoiditis — think:

A

Reiter’s disease (urethritis, conjunctivitis/iritis, IBD)
Psoriatic arthritis
Seronegative RA

138
Q

Indication for opertive treatment of sesamoid fracture

A

Failed nonop tx for 3-12 mos

partial or complete sesamoidectomy

139
Q

Complicaiton after sesamoidectomy

A

Cock-up deformity d/t weakneing of FHB tendon
Hallux valgus – excision of tibial sesamoid
Hallux varus – excision of fibular sesamoid

140
Q

Indications for nonop tx turf toe

A

Most injuries (grade I-III ie. sprain to complete tear)

rest, icing, stiff-sole/rocker bottom shoe

More severe injuries –> walker boot or SLC x 2-6 wks

141
Q

Indications for operative tx of turf toe

A

usually Grade III injuries (complete tears)

    • failed conservative treatment
    • retraction of sesamoids
    • fracture of sesamoids with diastasis
    • traumatic bunions
    • loose fragments in the joint
    • hallux toe deformity
142
Q

Causes of hallux varus

A

Congenital –> metatarsal physeal bracket

Acquired –> iatrogenic (overcorrection of bunion), trauma, inflammatory, neurologic

143
Q

Most common complication of claw toe correction

A

Floating toe –> intrinsics migrate dorsal and act as MTP extensors

144
Q

Surgical treatment for flexible claw toe

A

EDB tenotomy, EDL lengthening, FDL flexor to extensor transfer (Girdlestone)

145
Q

Surgical treatment for fixed claw toe

A

Girdlestone (FDL -> extensor transfer) + proximal head/neck resection

146
Q

Claw toe

A

DIP flexion
PIP flexion
MP hyperextension

147
Q

Hammer toe

A

DIP extension
PIP flexion
MP normal to slight extension

148
Q

Mallet toe

A

DIP flexion
PIP normal
MP normal

149
Q

Surgical treatment of fixed hammertoe

A

PIP resection arthroplasty +/- tenotomy

Pin with k-wire for 2-3 wks

Tape PIPJ for additional 3 wks

150
Q

Indication for bunionette correction with:

lateral condylectomy
distal metatarsal osteotomy
oblique diaphyseal rotational osteotomy
metatarsal head resection

A

lateral condylectomy: symptomatic type I deformities

distal metatarsal osteotomy: severely symptomatic type I deformities, or type 2/3 with IMA < 12 deg

oblique diaphyseal rotational osteotomy: IMA >12

metatarsal head resection: salvage

151
Q

Nonop tx Freibergs infraction

A

Early disease –> short leg cast or boot x 4-6 wks followed by stiff soled shoes with MT bars or pads

152
Q

Differences in lateral compared to medial talar OCD

A

Lateral OCDs are:

    • Less common
    • Smaller
    • More shallow
    • Occur more often as a result of trauma
    • Lower rates of spontaneous healing
153
Q

Indication for nonop tx of talar OCD

A
    • Acute injury
    • nondisplaced fragment with incomplete fx

Short leg cast & NWB x 6 wks

154
Q

Indications for microfracture of talar OCD

A
    • chronic lesions
    • size < 1 cm
    • displaced smaller fragment with minimal bone on the osteochondral fragment
155
Q

Indications for retrograde drilling and/or bone grafting of talar OCD

A

– size > 1cm with intact cartilage cap

156
Q

Indications for ORIF vs osteochondral grafting for talar OCD

A

– size > 0.5cm and displaced

157
Q

Most common cause of ankle arthritis

A

post-traumatic

primary OA is only 10%

158
Q

Nonoperative tx tibiotalar arthritis

A

Activity modification, bracing to immobilize the ankle, NSAIDs

single rocker bottom shoe improves gait and pain

159
Q

Indication for supramalleolar osteotomy in ankle arthritis

A
    • near normal ROM
    • minimal talar-tilt or varus heel alignment
    • medially focused ankle OA
160
Q

Complicatoins after tibiotalar fusion

A
    • subtalar arthrosis (50% at 10 yrs)

- - nonunion

161
Q

Risk factors for nonunion in ankle fusion

A
    • smoking
    • adjacent joint fusion
    • h/o failed previous fusions
    • avascular necrosis
    • neuropathy
162
Q

Greatest risk factor for persistent nonunion after revision ankle arthrodesis

A

Neuropathy and pior attempts at revision

163
Q

Contraindications for ankle arthroplasty

A
    • uncorrectable deformity
    • severe osteoporosis
    • talus osteonecrosis
    • charcot joint
    • ankle instability with non reconstructible ligaments
    • obesity
    • young laborers
164
Q

Surgical treatment of anterior ankle impingement

A

Arthroscopic vs open excision

165
Q

Most common complicaiton of positioning of standar anterolateral ankle arthroscopy portal

A

Injury to superficial peroneal nerve

166
Q

Anterior tarsal tunnel syndrome

A

Entrapment of the deep peroneal nerve as it travels beneath the extensor retinaculum — rare, probably not tested

167
Q

Factors associated with recurrent hallux valgus after correction

A
    • Round shape of first MT head
    • Severe lateral displacement of the tibial sesamoid
    • Increased preop IMA
    • Increased preop HVA
168
Q

Cause of entrapment of SPN after ankle sprain

A

Entraped by a fascial band approxiately 12 cm proximal to the lateral malleolus —> benefit from fascial release

169
Q

2 muscles that make up the conjoined tendon inserting on to the lateral base of the proximal phalanx of the great toe

A

FHB and adductor hallucis

170
Q

Difference in gait parameters after total ankle arthroplasty and arthrodesis

A

Increased stride length, cadence and stride velocity in total ankle compared to arthrodesis

171
Q

Contraindications for tibiotalocalcaneal arthrodesis

A
    • active infection
    • profound vascular disease
    • severe malalignment of the tibia
172
Q

Progressive deformity that occurs after rupture of the 2nd toe plantar plate

A

Second crossover toe — ie. second MTPJ instability

173
Q

Best footwear modification to restore gait pattern after ankle arthrodesis

A

rocker sole shoes

174
Q

Treatment of sesamoid fracture that fails nonop tx

A

Sesamoidectomy

175
Q

Risk factors for periprosthetic fx during total ankle

A
    • uncontrolled saw blade excursion
    • excessive medial or lateral placement of tibial component
    • oversized tibial prosthesis
176
Q

Fusion of what joint would have the greatest cumulative effect on midfoot/hindfoot motion:

A

Talonavicular joint

177
Q

Isolated CC, subtalar and TN joint fusion limit hindfoot motion by what amount, respectively:

A 
CC = 25%
Subtalar = 40%
TN = 90%
178
Q

Paramaters that correlate with poor clinical outcome and inability to returnto work in pilon fractures

A
    • lower level of eduction
    • pre-existing medical conditions
    • MALE sex
    • work-related injuries
    • lower income levels

Think of the 3 that fell from scaffolding as R2 at the county

179
Q

Indication for nonop tx of pilon fx

A
    • stable pattern without any articular surface displacement
    • criticlaly ill or nonambulatory pts
    • significant risk of skin problems (DM, vascular, neuropathy)
180
Q

Time to be able to drive after ORIF pilon fx

A

Brake time returns to normal 6 wks after weight bearing

181
Q

Indication for IMN with perc screw fixation in pilon fx

A

Alternative to ORIF for simple intra-articular component (AO 43C1/C2)

182
Q

Preferred surgical approach for pilon fx impacted in valgus or with intact fibula

A

Anterolateral approach to ankle

183
Q

Goals of ORIF pilon fx

A 
anatomic reduction of articular surface 
restore length
reconstruct metaphyseal shell
bone graft
reattach metaphysis to diaphysis
184
Q

Most common complications after ORIF pilon fx

A
    • Wound slough —> free flap for wound breakdown
    • Dehiscence
    • Infection
    • Varus malunion
    • Nonunion (usually at metaphyseal junction)
    • Chondrolysis
    • Post-traumatic arthritis
    • Stiffness
185
Q

Where to place incision in B type pilon fractures

A

Place incision where the Buttress is needed in B types

186
Q

Where to place incision in C type pilon fractures

A

Place incision where the most Comminution in C types (on axial CT)

187
Q

Indication for nonop tx ankle fx

A

Nondisplaed medial mal fx
Isolated lateral mal with < 3mm displacement and no talar shift
Bimal fx in elderly or medially ill
Posterior mal with < 25% joint involvment or < 2mm stepoff

188
Q

Most important factor when treated ankle fracture

A

Anatomic reduction

189
Q

Prognotic of poor outcomes in ankle fx

A

Smoking
Poor education
Alcohol use
Presence of medial mal fx

190
Q

Long-term complications of talar neck fracture (in order of decreasing frequency)

A

Subtalar arthritis
Tibiotalar arthritis
Osteonecrosis
Varus malunion

191
Q

Time to be able to drive after ORIF ankle fx

A

9 weeks after surgery

192
Q

Time to weight bearing after ORIF ankle fx

A

4-8 wks

193
Q

Time to weight bearing after ORIF ankle fx in diabetic pt

A

8-12 wks

194
Q

Indication for nonop tx lateral process of talus fx

A 
Nondisplaced fragment (<1cm in size & <2mm displaced)
Comminuted fragment
195
Q

Indication for op tx of lateral process of talus fx

A

Displaced noncomminuted intraarticular fragment

Comminuted intraarticular fxs that fail nonop tx

196
Q

Most common disadvantage of posterolateral plating for lateral mal fx

A

Peroneal irritation

197
Q

Indication for fixation of posterior mal fx

A

> 25% joint surface
2 mm stepoff
Syndesmosis injury

198
Q

Bosworth Fracture-dislocation

A
    • rare fracture-dislocation of the ankle where the fibula becomes entrapped behind the tibia and becomes irreducible
    • posterolateral ridge of the distal tibia hinders reduction of the fibula

Tx = ORIF

199
Q

Risk of nonop tx in diabetic ankle fxs

A
    • Loss of reduction (greatest risk)
    • Charcot arthropathy
    • Infection
200
Q

Blood supply to the talar neck

A
    • Posterior tibial artery –> via tarsal canal (dominant blood supply) — supplies most of the body
    • Anterior tibial artery — head/neck
    • Perforating peronal artery via artery of the sinus tarsi
201
Q

AVN risk in talar neck fxs by classification/displacement

A

I – nondisplaced – 0-13%
II – subtalar dislocation – 20-50%
III – subtalar & tibiotalar dislocation – 20-100%
IV – subtalar, tibiotalar, TN dislocaiton – 70-100%

202
Q

Canale XR view

A

Foot in maximum equinus, 15 deg pronated, XR 75 deg cephalad from horizontal

203
Q

Indication for nonop tx talar neck fxs

A

Nondisplaced fractures (Hawkins I)

SLC x 8-12 wks

204
Q

Treatment of extruded talus

A

Relace within joint and ORIF

205
Q

Common surgical approaches to treat talar neck fx

A

Dual approach

Anteromedial btw tib ant and post tib
Anterolateral btw tib and fib in line with 4th ray

206
Q

Snowboarder with ankle pain, initial dx of sprain

A

Lateral process of the talus fx

207
Q

Indication for nonop tx talus fx

A
    • nondisplaced (< 2mm) lateral process fractures
    • nondisplaced (< 2mm) posterior process fractures
    • nondisplaced (< 2mm) talar head fractures
    • nondisplaced (< 2mm) talar body fractures
208
Q

Blocks to reduction in medial subtalar dislocation

A

Peroneal tendons
EDB
TN joint capsule

209
Q

Blocks to reduction in lateral subtalar dislocation

A

Posterior tibialis tendon
FHL tendon
FDL tendon

210
Q

Indication for nonop tx subtalar dislocation

A

First line treatment

Closed reduction and short leg cast, NWB, x4-6wks

211
Q

Indications for op tx subtalar dislocation

A
    • Open dislocation

- - Failure of closed reduction

212
Q

Prognostic of poor outcome in calcaneus fxs:

A
    • fall from height
    • smoking
    • early surgery
    • lateral soft tissue trauma
213
Q

Tendon that passes beneath sustentaculum tali

A

FHL

214
Q

Indication for nonop tx calcaneus fx

A
    • small extra-articular fx (<1cm) with intact Achilles & 2mm displacement
    • Sanders Type 1
    • Anterior process involving < 25% CC joint
    • Poor host (smoker, diabetic, PVD)
215
Q

Indication for operative tx anterior process fx of calcaneus

A

> 25% CC joint involvement

216
Q

Factors associated with poor outcome in ORIF calc fx

A
    • Age > 50
    • Male
    • Obsesity
    • Manual labor/workers comp
    • Smoker
    • PVD
    • Bilateral calc fxs
    • Polytrauma
217
Q

Factors most associated with need for secondary subtalar fusion after calc fx

A

Male workers comp who does heavy labor with initial Bohler angle < 0 degrees

218
Q

Supply of the flap for calcaneus extensile lateral L-shaped incision

A

Lateral calcaneal branch of the peroneal artery

219
Q

Goal for treatment of calcaneal malunion

A

Correct hindfoot height, ankle impingement, subfibular impingement, subtalar arthritis

PC F&A (3 decks)

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