PC Foot and Ankle Flashcards
1
Q
Tibiofibular clear space should be (mm)
A
< 5 mm
2
Q
Tibiofibular overlap on AP view (mm)
A
> 10 mm
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
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
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
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
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
8
Q
Effect of inversion of subtalar joint on transverse tarsal joint
A
Locks the transverse tarsal joint
9
Q
Effect of eversion of subtalar joint on transverse tarsal joint
A
Unlocks the transverse tarsal joint
transverse tarsal joints are parallel
10
Q
Action of foot intrinsic muslces
A
Flex the MTP joints and extend the IP joints
11
Q
Major blood supply to the heel pad
A
Medial calcaneal branch (off the laateral platar arteries from the posterior tibial artery)
12
Q
Relative position of the anterior tibial artery to EHL in the ankle then foot
A
Medial then lateral to the tendon
13
Q
Nerve at risk during bunion surgery
A
Dorsomedial cutaneous nerve — terminal branch of SPN
Numbness over medail aspect of hallux
14
Q
Equinus deformity - strong & weak muscle
A
Equinus:
Strong = Gastroc-soleus Weak = dorsiflexors
15
Q
Cavus deformity - strong & weak muscle
A
Cavus::
Strong = plantar fscia, intrinsics Weak = dorsiflexors
16
Q
Varus deformity - strong & weak muscle
A
Varus:
Strong = posterior tibialis & anterior tibialis Weak = peroneus brevis
17
Q
Supination deformity - strong & weak muscle
A
Supination:
Strong = anterior tibialis Weak = peroneus longus
18
Q
Treatment of equinovarus foot after stroke
A
Nonop: AFO, PT — try for 6 mos
Op: SPLATT, gastroc lengthening
19
Q
Silferskiold test
A
Improved ankle dorsiflexion with knee flexed = gastroc tightness
Equivalent ankle dorsiflexion with knee flexed = Achilles tightness
20
Q
Os trigonum causes
A
posterior ankle impingement for FHL tenosynovitis
21
Q
Type II accessory navicular causes
A
posterior tibial tendon dysfunction
22
Q
Activity of anterior tibialis during heel strike/stance phase of gait
A
Eccentric contraction
23
Q
Activity of quadriceps during heel strik and then terminal stance phases of gait
A
heel strike = eccentric contraction
terminal stance = concentric contraction
24
Q
Treatment of equinovarus foot without well functioning tib ant
A
posterior tibialis transfer
25
Quadriceps atrophy affects what phase of gait cycle most
Midstance --- causes buckling or knee hyperextension
26
Antagonist to peroneus brevis
Posterior tibialis
27
Soft tissue precedures performed at the time of bony pes planovalgus deformity correction
FDL to posterior tib transfer
| Spring ligament reconstruction
28
Antagonist to tibialis anterior
Peroneus longus
29
Antagonist to peroneus longus
Tibialis anterior
30
Antagonist to posterior tibialsis
Peroneus brevis
31
Common associated injuries with "high ankle sprain"
```
OCD
Peroneal tendon injuries
Distal fibular fx (weber B/C)
5th MT base fx
Deltoid lig injury
```
32
Anatomy of the AITFL
Origin: Anterolateral tubercle of the tibia (Chaput)
Insertion: Anterior tubercle of the fibula (Wagstaffe)
33
Anatomy of the PITFL
Origin: Posterior tubercle of the tibia (Volmann)
Insertion: posterior part of the lateral mal
34
Strongest ligament in the syndesmosis
PITFL
35
Normal medial clear space
<= 4mm
36
Indication for nonop tx high ankle sprain
Syndesmosis sprain without diastasis or instability
37
Nonop tx high ankle sprain
NWB in CAM boot or cast x 2-3 wks
PT with brace that limits ER
38
Indication for operative tx of high ankle sprain
Syndesmosis sprain with instability on stress XR OR failed conservative tx
39
Most common injury in dancers
ankle sprain
40
Mechanism of injury for ankle sprain
Inversion injury on a plantarflexed foot
41
Associated injuries with ankle sprain
- - OCD
- - Peroneal tendon injury
- - Subtle cavovarus foot
- - deltoid ligament injury
- - CRPS
- - Fx --- 5th MT base, anterior process of calc, lateral process of talus
42
Order of commonly involved ligaments in low ankle sprain
ATFL > CFL > PTFL
43
Indication for nonop tx low ankle sprain
All sprains should be treated nonop first
44
Nonop tx for low ankle sprian --- rehab program
Early phase -- motion and progress to strengthening/proprioception
Stregthening phase -- once swelling/pain subside, work on peroneal strength & proprioception
45
Indication for operative tx of low ankle sprain
persistent instability despite nonop tx
46
Mechanism of injury for Lisfranc
MVA/fall/atheltic
Axial load through hyperplantarlfexed forefoot
47
Lisfranc ligament
interosseous ligament going from medial cuneiform to base of 2nd MT on plantar surface
48
Indication for nonop tx of Lisfranc
NO displacement on WB and stress XR and no e/o bony injury on CT
49
Indication for op tx of Lisfranc
Any evidence of instability (>2mm shift) or bony fx dislocations
50
Indication for arthrodesis over ORIF in Lisfranc
purely ligamentous arch injuries
severe comminution
delayed treatment
chronic deformity
51
Indication for operative fx of base of 5th MT fx
Zone 2 in elite or competitive athlete
| Zone 3 with sclerosis/nonunion
52
Indication for nonop tx of base of 5th MT fx
Zone 1 -- PWB in stiff soled shoe/boot
Zone 2 in recreational athlete
Zone 3
NWB in short leg case x6-8 wks
53
Indications for surgery in GSW to hand or foot
- - 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
54
Treatment of navicular stress fx
NWB in cast x 6-8 wks
55
Indication to fix navicular fx
>25% articular surface
tuberosity fx >5mm displacement
displaced body fxs
56
Risk factor for nonunion after ORIF for MT5 base fx in athlete
Return to sport prior to radiographic union
57
Indication to fix metatarsal fx
- - open fx
- - first metatarsal with ANY displacement
- - central metatarsals w >10deg sagittal plan, >4mm translationi, multiple fxs
58
Treatment metatarsal stress fx
WBAT in CAM boot or stiff soled shoe
59
Risk factor for Achilles tendon rupture
- - "Weekend warrior"
- - Fluoroquinolone use
- - Steroid injections
60
Indications for nonop tx Achilles rupture
acute injuries with surgeon or patient preference for non-operative management
sedentary patient
medically frail patients
61
Outcomes for nonop tx Achilles rupture
- - 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
62
Risk of percutaneous Achilles repair
Higer risk of sural nerve damage
Lower risk of wound complication/infxn compared to open
63
Treatment of chronic Achilles rupture with>3cm defect
FHL transfer +/- VY advancement of gastroc
64
Risk factors for wound complications after Achilles repair
- - smoking (most common)
- - Female
- - Steroid use
- - Open technique (vs percutaneous)
65
Orientation of the peroneal tendons coming around the lateral malleolus
Brevis lies anterior & medial to the longus (Brevis on Bone)
Longus is posterior to the brevis (Longus takes the Long way round)
66
Treatment of acute SPR rupture (snapping peroneal tendons)
Short leg case and PWB x6wks
67
Operative tx of snapping peroneal tendons
Acute: repair of SPR & deepening of the fibular groove
Chronic: groove deepending with soft tissue transfer
68
Operative tx peroneus brevis tears
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
69
Risk factors for tibialis anterior tendon rupture
```
older age
diabetes
fluoroquinolone use
local steroid injection
inflammatory arthritis
```
70
Indication for operative treatment of tib ant rupture
Direct repair --- acute injury (up to 3 months) in active patient
Reconstruction --- in chronic injuries (most cases)
71
Treatment options for tib ant reconstruction
- - 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
72
Most common cause of soft tissue infection after foot puncture wound
Staph aureus
73
Most common cause of osteomyelitis after foot puncture wound
Pseudomonas
74
Preferred PO abx for foot soft tissue infection
Cipro or levofloxacin
75
Risk factors for posterior tibial tendon insufficiency
- - obesity
- - HTN
- - diabetes
- - increased age (usually presents in 6th decade)
- - corticosteroid use
- - inflammatory disorders
76
Insertion of posterior tibial tendon
Anterior limb -- navicular tuberosity & first cuneiform
Middle limb -- 2/3 cuneiforms, cuboid, MT 2-4
Posterior limb -- sustentaculum tali
77
Actions of posterior tibial tendon
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
78
Classification of posterior tibial tendon insufficiency
I - tenosynovitis
II - flexible flatfoot
III - rigid flatfoot with subtalar arthritis
IV - rigid flatfoot with subtalar arthritis and talar tilt in ankle
79
Radiographic findings in PTTI/flatfoot
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
80
Nonop tx for PTTI
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
81
Surgical treatment of stage II PTTI
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
82
Surgical treatment of stage III PTTI
Triple arthrodesis vs isolated subtalar
83
Nonop tx Achilles tendonitis
Activity modification, shoe wear modification, PT
PT focuse on ECCENTRIC training, gastroc stretching
84
Operative treatment of Achilles tendonitis
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
85
Risk factors for FHL tendonitis
Excessive plantarflexion --> dancers in on pointe position & gymnasts
86
Orientation of FHL & FDL at the Knot of Henry
FHL is "higher" at the knot
| FDL is "down" at the knot
87
Risk factors for plantar fasciitis
Obesity
Deceased ankle dorsiflexion in non-athletic pt
Weight bearing endurance activity (eg. Dancing, running)
88
Treatment of plantar fascia ruptures
Cast immobilization
risk factors --> athletes, minimalist runners, corticosteroid injections
89
Management of calcaneal malunion with subtalar arthritis & <10 deg varus
Lateral wall exostectomy, peroneal tenolysis, subtalar bone arthrodesis
if >10 deg varus --> lateral calcaneal closing wedge osteotomy +/- triple arthrodesis
90
Associated with chronic lateral ankle instability
peroneus brevis tear
91
Fleck sign along the lateral aspect of the distla fibula
SPR tear and snapping peroneal tendons
92
Predisposition to Jones fx
Hindfoot varus deformity --- eg, CMT (duplication of PMP22 gene on Ch17)
93
Best method to maximize muscle mass in post-polio syndrome
exercise at sub-exhaustion levels to tone affected muscle groups without causing muscle breakdown
94
Site of compression of the lateral plantar nerve in runners
between the fascia of the abductor hallucis longus and medial side of the quadratus plantae
tx: release of abductor hallucis fascia
95
Treatment of acquired spastic equinovarus foot deformity (after stroke) that is not braceable or causing skin problems
Achilles tendon lengthening with split tibialis anterior transfer
96
Most common location for Morton's neuroma
between the3rd/4th toes
interdigital nerve lies plantar to the transverse intermetatarsal ligament btw the MT heads
97
Complications of interdigital (Morton's) neuroma excision
-- stump neuroma --- inadequate retraction or resection
98
"heel pain triad"
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
Best test for tarsal tunnel syndrome
compression test
plantar flexion and inversion of ankle
digital pressure over tarsal tunnel
highly senstitive and specific
100
Risk factors for charcot neuropathy
```
diabetic neuropathy
alcoholism
leprosy
myelomeningocele
tabes dorsalis/syphilis
syringomyelia
```
101
How to tell the difference btw erythema from charcot arthropathy and infection
Charcot: erythema decreases with elevatoin
Infection: erythema unchanged with elevation
102
Most appropriate test for Charcot neuropathy
Semmes-Weinstein monofilament testing
103
Difference btw charcot alone and superimposed osteomyelitis on indium WBC scan
indium WBC scan
negative (cold) for neuropathic joints
positive (hot) for osteomyelitis
104
Best test for differentiating charcot from infection
MRI
105
Labs in charcot foot
ESR and WBC can be elevated
106
First line treatment for charcot foot
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
Indication for exostectomy and TAL in Charcot foot
"braceable" foot with equinus deformity and focal bony prominences causing skin breakdown
108
Complication rates after deformity correction/arthrodesis in Charcot foot
70%
infection
hardware malposition
recurrent ulceration
fracture
109
Factors associated with decreased healing potential in diabetic foot ulcers
```
uncontrolled hyperglycemia
inability to offload the affected area
poor circulation --- ABI < 0.45; TcpO2 < 30mmHg
infection
poor nutrition
```
110
Factors associated with increased healing potential in diabetic foot ulcers
serum albumin > 3.0 g/dL
| total lymphocyte count > 1,500/mm3
111
Treatment of diabetic foot ulcer with skin intact but bony deformities leading to "foot at risk"
Shoe modificatoins with serial exams
112
Treatment of diabetic foot ulcer with superficial ulcer
Office debridement and contact casting
113
Treatment of deeper, full thickness diabetic foot ulcer
Operative formal debridement and contact casting
114
Treatment of deep abscess or osteomyelitis after diabetic foot ulcer
Operative formal debridement and contact casting
115
Treatment of partial gangrene of forefoot after diabetic foot ulcer
Local vs larger amputation
116
Gold standard to assess wound healing potential in diabetic foot ulcer
Transcutaneous oxygen pressures (TcpO2) > 30 mmHg
117
Best shoewear modification to reduce plantar pressure on forefoot
rocker sole shoes
118
Innervation of first branch of the lateral plantar nerve (what muscle)
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
Treatment of full thickness heel ulcer with exposed calcaneus
Partial calcanectomy with primary closure
Risk factors for delayed healing = MRSA, poor nutrition (albumin < 3), peripheral vascular dz, large ulcers
120
Treatment of Charcot foot with deformity and recurrent (now healed) ulcers despite total contact casting
Surgical correction of deformity, Achilles lengthening, therapeutic footwear
121
Hallux valgus angle
Long axis of 1st MT and prox phalanx
Normal < 15
122
Intermetatarsal angle
Btw long axis of 1st and 2nd MT
Normal < 9
123
Distal metatarsal articular angle
Btw 1st MT long axis and ling through distal articular cap
Normal < 10
124
Indication for nonoperative treatment of hallux valgus
First line treatment
Shoe modifications, pads, spacers, orthoeses
125
Indications for operative tx of hallux valgus
Persistent symptoms despite nonop tx
| ** do not performe for cosmetic reasons alone **
126
Indication for in tx hallux valgus:
```
distal osteotomy
proximal or combined osteotomy
1st TMT arthrodesis
Fusion procedure
MTP resection arthroplasty
```
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
Indication for proximal phalanx medial closing wedge osteotomy
Hallux valgus interphalangeus angle (HVI) > 10
AND
DMAA < 10
128
What to do if DMAA > 15
Biplanar distal osteotomies for hallux valgus correction
129
Complications of modified McBride
Recurrence
| Hallux varus
130
Complications of distal Chevron osteotomy for hallux valgus
AVN of MT head
Recurrence
Dorsal malunion
Transfer metatarsalgia
131
Complicaitons of Lapidus procedure
Nonunion
| Dorsiflexion of 1st MT causing transfer metatarsalgia
132
Indication for nonoperative treatment of hallux rigidus
Grade 0 or 1 disease
NSAIDs, activity modification, orthotics
Morton's extension with stiff foot plate
133
Indication for dorsal cheilectomy in hallux rigidus
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
Indications for MTPJ arthrodesis for hallux rigidus
Grade 3 or 4 disease
135
Strongest construct for hallux MTPJ arthrodesis
dorsal plate with compression screw
136
Preferred surgical alignment for hallux MTPJ arthrodesis
10 deg valgus
| 15 deg dorsiflexion
137
Bilateral sesamoiditis --- think:
Reiter's disease (urethritis, conjunctivitis/iritis, IBD)
Psoriatic arthritis
Seronegative RA
138
Indication for opertive treatment of sesamoid fracture
Failed nonop tx for 3-12 mos
partial or complete sesamoidectomy
139
Complicaiton after sesamoidectomy
Cock-up deformity d/t weakneing of FHB tendon
Hallux valgus -- excision of tibial sesamoid
Hallux varus -- excision of fibular sesamoid
140
Indications for nonop tx turf toe
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
Indications for operative tx of turf toe
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
Causes of hallux varus
Congenital --> metatarsal physeal bracket
Acquired --> iatrogenic (overcorrection of bunion), trauma, inflammatory, neurologic
143
Most common complication of claw toe correction
Floating toe --> intrinsics migrate dorsal and act as MTP extensors
144
Surgical treatment for flexible claw toe
EDB tenotomy, EDL lengthening, FDL flexor to extensor transfer (Girdlestone)
145
Surgical treatment for fixed claw toe
Girdlestone (FDL -> extensor transfer) + proximal head/neck resection
146
Claw toe
DIP flexion
PIP flexion
MP hyperextension
147
Hammer toe
DIP extension
PIP flexion
MP normal to slight extension
148
Mallet toe
DIP flexion
PIP normal
MP normal
149
Surgical treatment of fixed hammertoe
PIP resection arthroplasty +/- tenotomy
Pin with k-wire for 2-3 wks
Tape PIPJ for additional 3 wks
150
Indication for bunionette correction with:
lateral condylectomy
distal metatarsal osteotomy
oblique diaphyseal rotational osteotomy
metatarsal head resection
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
Nonop tx Freibergs infraction
Early disease --> short leg cast or boot x 4-6 wks followed by stiff soled shoes with MT bars or pads
152
Differences in lateral compared to medial talar OCD
Lateral OCDs are:
- - Less common
- - Smaller
- - More shallow
- - Occur more often as a result of trauma
- - Lower rates of spontaneous healing
153
Indication for nonop tx of talar OCD
- - Acute injury
- - nondisplaced fragment with incomplete fx
Short leg cast & NWB x 6 wks
154
Indications for microfracture of talar OCD
- - chronic lesions
- - size < 1 cm
- - displaced smaller fragment with minimal bone on the osteochondral fragment
155
Indications for retrograde drilling and/or bone grafting of talar OCD
-- size > 1cm with intact cartilage cap
156
Indications for ORIF vs osteochondral grafting for talar OCD
-- size > 0.5cm and displaced
157
Most common cause of ankle arthritis
post-traumatic
primary OA is only 10%
158
Nonoperative tx tibiotalar arthritis
Activity modification, bracing to immobilize the ankle, NSAIDs
single rocker bottom shoe improves gait and pain
159
Indication for supramalleolar osteotomy in ankle arthritis
- - near normal ROM
- - minimal talar-tilt or varus heel alignment
- - medially focused ankle OA
160
Complicatoins after tibiotalar fusion
- - subtalar arthrosis (50% at 10 yrs)
| - - nonunion
161
Risk factors for nonunion in ankle fusion
- - smoking
- - adjacent joint fusion
- - h/o failed previous fusions
- - avascular necrosis
- - neuropathy
162
Greatest risk factor for persistent nonunion after revision ankle arthrodesis
Neuropathy and pior attempts at revision
163
Contraindications for ankle arthroplasty
- - uncorrectable deformity
- - severe osteoporosis
- - talus osteonecrosis
- - charcot joint
- - ankle instability with non reconstructible ligaments
- - obesity
- - young laborers
164
Surgical treatment of anterior ankle impingement
Arthroscopic vs open excision
165
Most common complicaiton of positioning of standar anterolateral ankle arthroscopy portal
Injury to superficial peroneal nerve
166
Anterior tarsal tunnel syndrome
Entrapment of the deep peroneal nerve as it travels beneath the extensor retinaculum --- rare, probably not tested
167
Factors associated with recurrent hallux valgus after correction
- - Round shape of first MT head
- - Severe lateral displacement of the tibial sesamoid
- - Increased preop IMA
- - Increased preop HVA
168
Cause of entrapment of SPN after ankle sprain
Entraped by a fascial band approxiately 12 cm proximal to the lateral malleolus ---> benefit from fascial release
169
2 muscles that make up the conjoined tendon inserting on to the lateral base of the proximal phalanx of the great toe
FHB and adductor hallucis
170
Difference in gait parameters after total ankle arthroplasty and arthrodesis
Increased stride length, cadence and stride velocity in total ankle compared to arthrodesis
171
Contraindications for tibiotalocalcaneal arthrodesis
- - active infection
- - profound vascular disease
- - severe malalignment of the tibia
172
Progressive deformity that occurs after rupture of the 2nd toe plantar plate
Second crossover toe --- ie. second MTPJ instability
173
Best footwear modification to restore gait pattern after ankle arthrodesis
rocker sole shoes
174
Treatment of sesamoid fracture that fails nonop tx
Sesamoidectomy
175
Risk factors for periprosthetic fx during total ankle
- - uncontrolled saw blade excursion
- - excessive medial or lateral placement of tibial component
- - oversized tibial prosthesis
176
Fusion of what joint would have the greatest cumulative effect on midfoot/hindfoot motion:
Talonavicular joint
177
Isolated CC, subtalar and TN joint fusion limit hindfoot motion by what amount, respectively:
```
CC = 25%
Subtalar = 40%
TN = 90%
```
178
Paramaters that correlate with poor clinical outcome and inability to returnto work in pilon fractures
- - 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
Indication for nonop tx of pilon fx
- - stable pattern without any articular surface displacement
- - criticlaly ill or nonambulatory pts
- - significant risk of skin problems (DM, vascular, neuropathy)
180
Time to be able to drive after ORIF pilon fx
Brake time returns to normal 6 wks after weight bearing
181
Indication for IMN with perc screw fixation in pilon fx
Alternative to ORIF for simple intra-articular component (AO 43C1/C2)
182
Preferred surgical approach for pilon fx impacted in valgus or with intact fibula
Anterolateral approach to ankle
183
Goals of ORIF pilon fx
```
anatomic reduction of articular surface
restore length
reconstruct metaphyseal shell
bone graft
reattach metaphysis to diaphysis
```
184
Most common complications after ORIF pilon fx
- - Wound slough ---> free flap for wound breakdown
- - Dehiscence
- - Infection
- - Varus malunion
- - Nonunion (usually at metaphyseal junction)
- - Chondrolysis
- - Post-traumatic arthritis
- - Stiffness
185
Where to place incision in B type pilon fractures
Place incision where the Buttress is needed in B types
186
Where to place incision in C type pilon fractures
Place incision where the most Comminution in C types (on axial CT)
187
Indication for nonop tx ankle fx
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
Most important factor when treated ankle fracture
Anatomic reduction
189
Prognotic of poor outcomes in ankle fx
Smoking
Poor education
Alcohol use
Presence of medial mal fx
190
Long-term complications of talar neck fracture (in order of decreasing frequency)
Subtalar arthritis
Tibiotalar arthritis
Osteonecrosis
Varus malunion
191
Time to be able to drive after ORIF ankle fx
9 weeks after surgery
192
Time to weight bearing after ORIF ankle fx
4-8 wks
193
Time to weight bearing after ORIF ankle fx in diabetic pt
8-12 wks
194
Indication for nonop tx lateral process of talus fx
```
Nondisplaced fragment (<1cm in size & <2mm displaced)
Comminuted fragment
```
195
Indication for op tx of lateral process of talus fx
Displaced noncomminuted intraarticular fragment
| Comminuted intraarticular fxs that fail nonop tx
196
Most common disadvantage of posterolateral plating for lateral mal fx
Peroneal irritation
197
Indication for fixation of posterior mal fx
>25% joint surface
>2 mm stepoff
Syndesmosis injury
198
Bosworth Fracture-dislocation
- - 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
Risk of nonop tx in diabetic ankle fxs
- - Loss of reduction (greatest risk)
- - Charcot arthropathy
- - Infection
200
Blood supply to the talar neck
- - 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
AVN risk in talar neck fxs by classification/displacement
I -- nondisplaced -- 0-13%
II -- subtalar dislocation -- 20-50%
III -- subtalar & tibiotalar dislocation -- 20-100%
IV -- subtalar, tibiotalar, TN dislocaiton -- 70-100%
202
Canale XR view
Foot in maximum equinus, 15 deg pronated, XR 75 deg cephalad from horizontal
203
Indication for nonop tx talar neck fxs
Nondisplaced fractures (Hawkins I)
SLC x 8-12 wks
204
Treatment of extruded talus
Relace within joint and ORIF
205
Common surgical approaches to treat talar neck fx
Dual approach
Anteromedial btw tib ant and post tib
Anterolateral btw tib and fib in line with 4th ray
206
Snowboarder with ankle pain, initial dx of sprain
Lateral process of the talus fx
207
Indication for nonop tx talus fx
- - nondisplaced (< 2mm) lateral process fractures
- - nondisplaced (< 2mm) posterior process fractures
- - nondisplaced (< 2mm) talar head fractures
- - nondisplaced (< 2mm) talar body fractures
208
Blocks to reduction in medial subtalar dislocation
Peroneal tendons
EDB
TN joint capsule
209
Blocks to reduction in lateral subtalar dislocation
Posterior tibialis tendon
FHL tendon
FDL tendon
210
Indication for nonop tx subtalar dislocation
First line treatment
Closed reduction and short leg cast, NWB, x4-6wks
211
Indications for op tx subtalar dislocation
- - Open dislocation
| - - Failure of closed reduction
212
Prognostic of poor outcome in calcaneus fxs:
- - fall from height
- - smoking
- - early surgery
- - lateral soft tissue trauma
213
Tendon that passes beneath sustentaculum tali
FHL
214
Indication for nonop tx calcaneus fx
- - 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
Indication for operative tx anterior process fx of calcaneus
>25% CC joint involvement
216
Factors associated with poor outcome in ORIF calc fx
- - Age > 50
- - Male
- - Obsesity
- - Manual labor/workers comp
- - Smoker
- - PVD
- - Bilateral calc fxs
- - Polytrauma
217
Factors most associated with need for secondary subtalar fusion after calc fx
Male workers comp who does heavy labor with initial Bohler angle < 0 degrees
218
Supply of the flap for calcaneus extensile lateral L-shaped incision
Lateral calcaneal branch of the peroneal artery
219
Goal for treatment of calcaneal malunion
Correct hindfoot height, ankle impingement, subfibular impingement, subtalar arthritis
