Wheaton Old Pimp Questions Flashcards
1
Q
What is the correct position for the hallux after an MPTJ arthrodesis?
A
10-15 valgus, 20-30 dorsiflexion and neutral rotation (Aas 2008)
2
Q
What are common iatrogenic causes of hallux varus?
A
- excessive lateral release (adductor hallucis and lateral head of FHB)
- excessive medial capsulorrhapy
- staking the head aka excessive resection of medial eminence of 1st met head (tibial sesamoid destabilizes adding to varus force)
- poor post operative dressing? (crawford 2014)
3
Q
What are the important positions of the foot in ankle fusion?
A
-neutral flexion, 0-5 valgus, 5-10 external rotation -also a more posteriorly displaced talus (Buck 1987)
4
Q
What is the % of subtalar cartilage removed by reaming in a TCC nail?
A
TTC = tibiotalocalcaneal 12 mm reamer destroyed 5.89% and 4.01% of the talar and calcaneal posterior facets of subtalar joint respectively in cadaver study (Lowe 2016)
5
Q
How do you correct the IM angle in the presence of metatarsus adductus?
A
- met adductus measured: line bisecting second met and line bisecting lesser tarsus. - pathological > 20 - true IM = IMA + (MAA - 15) (McGlamry’s)
6
Q
What is the most potent inhalation anesthetic cause of malignant hyperthermia?
A
- Halothane - associated with mutations in the RYR1 and CACNA1S receptors, both of which help control calcium ions in the sarcoplasmic reticulum (rosenberg 2015)
7
Q
What is the watson-jones procedure?
A
- removes proximal end of peroneus brevis and routes the entire tendon through the fibula, through the neck of the talus, back through the fibula and attaches to the posterior fibula with addn’l attachments to peroneus longus - “antomical” non-anatomical repair
8
Q
What is the name of the procedure where the tensor fascia lata is used in lateral ankle stabilization surgery?
A
- elmslie procedure: free tensor fascia lata graft used to recreate the ATFL and CFL - predecessor to “christman-snook” which uses a split peroneus brevis graft (elmslie 1934) (coville 1992)
9
Q
what tx is suggested at each level of the kuwada classification for achilles tendon rupture?
A
- I = partial tear = conservative treatment - II = rupture up to 3 cm defect = end to end anastomosis - III = 3-6 cm defect = tendon graft flap, possible synthetic graft, v-y advancement, bosworth turndown, tendon transfer or combination - IV = greater than 6 cm defect = gastroc recession, turndown, tendon transfer, free tendon graft, synthetic graft or combination
10
Q
what is a bosworth turndown procedure?
A
Posterior midline incision – rupture exposed, ends debrided – 1” strip of gastrosoleus aponeurosis about 2–3” long – detatched proximally ‘turned down’ with fascial surface anterior
11
Q
what is the anchovy pocedure?
A
- ligament reconstruction tendon interposition arthroplastry used in hand for 1st carpometacarpal joint arthritis - flexor carpi radialis is released proximally and passed through a hole drilled in base of 1st metacarpal. trapezium removed along with proximal aspect of first metacarpal. anghovy tendon bulk sutured in place and tissues closed over it. (Elfar 2013)
12
Q
femoral nerve division
A
saphenous
13
Q
tibial comes from
A
sciatic nerve
14
Q
branches off tibial nerve
A
- medial sural cutaneous –> sural - posterior tibial
15
Q
branches off posterior tibial n?
A
- medial calcaneal - medial plantar - lateral plantar
16
Q
branches off medial plantar n?
A
- 1st proper plantar digital - 1st common plantar digital –> 2nd and 3rd proper plantar digital - 2nd common plantar digital –> 4th and 5th proper plantar digital - 3rd common plantar digital –> 6th and 7th proper plantar digital
17
Q
branches off lateral plantar n?
A
- inferior calcaneal/baxter - superficial branch of lateral plantar - deep branch of lateral plantar
18
Q
branches off superficial branch of lateral plantar?
A
- communicating branch to 3rd common plantar - 4th common plantar digital (–> 8th and 9th proper plantar digital) - 10th proper plantar digital
19
Q
branches off common peroneal
A
- lateral sural cutaneous –> sural - deep peroneal - superficial peroneal
20
Q
branches off superficial peroneal n
A
- intermediate dorsal cutaneous (2nd and 3rd common dorsal digital) - medial dorsal cutaneous
21
Q
branches off sural n
A
- lateral calcaneal - lateral dorsal cutaneous (w/ communicating branch to intermediate dorsal cutaneous)
22
Q
what is an atavistic cuneiform?
A
- coined by lapidus to describe 1st tarsometatarsal joint large than average 6.2 degree - varus in joint during development - radiographic artifact ? (Sanicola 2002)
23
Q
when do you administer blood for transfusion?
A
- hemoglobin levels below 7 in stable patients - less than 8 in those with preexisting CVD (Carson 2012)
24
Q
Define SIRS
A
- temperature greater than 38 or less than 36 - heart rate greater than 90 - respiration rate greater than 20 or paCO2 less than 32 mmHg - WBC greater than 12k or less than 4 k or greater than 10% bands RECORD AS 2/4 SIRS (example) - septic shock: hypotension persisting with fluid resuscitation - severe sepsis: sepsis with signs organ dysfunction
25
what are the basic motions in arthroscopy?
- image centering - telescoping (pistoning) - periscoping - probing/triangulation - scanning, pistoning, rotation ( 3 major mtoions)
26
why is the ankle casted at 90?
ankle should be casted at 90 to prevent achilles tendon shrotening (Eiff 2002, Moseley 2005)
27
what are the three most common tumors of the calcaneus?
- intraosseous lipoma - osteoid osteoma - unicameral bone cyst
28
what are five reasons for nonunions?
- infection - poor fixation - insufficient immobilization - impaired blood supply - distraction at fracture site
29
what are the four types of melanoma? what population is most likely to have acroletiginous?
- superficial spreading - lentigo maligna - acral lentiginous - found palms, plantar feet and subunually - more frequently in african american and asian population - nodular
30
what is the rate of complications from a posterior approach for ankle arthroscopy?
8.5% - neurological complications predominant with plantar numbness and CRPS reported (Nickisch 2012)
31
what is the most common complication of ankle arthroscopy?
overall 6.8% complications (80% neurological) with non-invasive distraction (Young 2011) - dorsiflex the foot to minimize distraction (stretches neurovascular bundles) and maximize views
32
what is the amount of distraction force applied to the ankle?
(Dowdy 1996) - paraesthesias correlate with time and force based on nerve conduction studies - recommend 30lb for 1 hr (135 N)
33
saline vs. lactate for arthroscopy irrigation?
- ringers lactate did not show significant changes in cell morphology while saline exposed cells lost their phenotype (maintained cell itnergrity better) (shinjo/shinzo 2002)
34
what is insufflation?
injection of irrigation solution into joint prior to placing the port
35
who performed the first ankle arthroscopy?
- Burman 1931 - reported joint unsuitable due to small intraarticular joint space - Wanatanabe 1972 reported case series after development of fiberoptic cameras
36
What is the 21 point evaluation of ankle arthroscopy?
- Ferkel and fischer - 8 anterior (deltoid, medial gutter. medial talus, central talus, lateral talus, talofibular articulation, lateral gutter, anterior gutter) - 6 central (medial talus, central talus, lateral talus, posterior inferior tibiofibular ligament, transverse tibiofibular ligament) - 7 posterior (medial gutter, medial talus, central talus, lateral talus, tibiofibular articularion, lateral gutter, posterior gutter)
37
what are the size limitations of microfracture technique?
- choi 2009 - lesions greater than 150 mm had an 80% clinical failure rate - chuckpaiwong 2008 - no failures with lesion less than 15 mm
38
what is the name of the OCD classification system?
- Bernt and Harty 1959 - 1: subchondral compression (cartilage damage only) - 2: partially detached lesion (subchondral lesion with edema (a) or w/o edema (b)) - 3: completely detached but undisplaced - 4: displaced - 5: bone cyst (anderson modification)
39
are there any screws with reverse threaded proximal ends?
- reese screw - left and right hand itches at different ends of the screw - developed initially for use in IPJ arthrodesis, advanced proximally or distally depending on side - vanore 2011
40
what is the name of the headless screw?
- herbert screw - developed for scaphoid fractures - threaded proximal and distal ends with different thread ptich and thread diameters - as screw is placed, greater pitch on the distal end will produce a larger linear displacement than the proximal end, causing compression in unthreaded shaft
41
what is the overdrill size for a 4.5 mm screw?
- overdrill used to prevent threads at proximal end of screw from purchasing proximal cortex - 4.5 mm
42
How many angiosomes in the foot?
(taylor defined angiosome) (attinger in foot and ankle in 2006) - angiosome = three dimensional section of tissue supplied by blood from a single artery - six total 1. calcaneal branch of posterior tibial --\> medial heel 2. medial plantar a of posterior tibial --\> medial plantar foot and hallux 3. lateral plantar a --\> lateral foot and plantar toes 4. anterior tibial --\> dorsum of foot 5. anterior perforating branch of peroneal --\> anterolateral ankle 6. calcaneal branch of peroneal a --\> lateral heel
43
what is the name of arteries connecting two angiosomes?
'choke vessels' allow anastomosis b/w angiosomes
44
what is tissue oxygen saturation foot-mapping?
imaging using near-infrared oximeter monitoring to provide a non-invasive image of the foot with ischemic areas directly visible
45
What is the Allgower-Donati suture?
- Advantages: grasps a relatively broad amount of tissue (spreading tension force over a large area) while not disrupting as much of the vertical blood flow as a truly horizontal mattress. It’s useful wherever there are flaps or parts of an incision that appear less vascularized than others. Also results in cosmetically acceptable scars
46
What is the d-test ?
- microbiological assay used to determine inducible clindamycin resistance in strep resistant to erythromycin
- done when isolate demonstrates resistance to erthyromycin but susceptibility to clindamycin
- plasmid contains resistance to both
- d shaped zone of inhibition arund clinda disc --\> resistance
47
What are the stewart classifications?
I: extra articular fracture b/w metatarsal base and diaphysis
II: intra articular fracture of metatarsal base
III: avulsion fracture of metatarsal base
IV: comminuted fracture with intra-articular extension
V: partial avulsion of metatarsal base w/ or w/o fracture
48
What are the Torg (1984) classifications?
- used for stress type fractures of the 5th metatarsal proximal diaphysis where fracture is within 1.5 cm of tuberosity
- I: indicative of early union. no intramedullary sclerosis. sharp fracture lineiwth no widening. Minimal cortical hypertrophy or periosteal reaction
- II: indicative of delayed union. fracture line involving both cortices adn periosteal reaction and widened fracture line. some intramedullarly sclerosis
- III: indicative of non-union. wide fracture line with periosteal new bone and total sclerosis of intramedullary canal at the fracture site.
49
DIAL A PIMP science
- Berndt and Hardy originally determined that osteochondral lesions of talar dome were most coommonly located posteromedially 57% adn anterolaterally 43% on x-rays
- dorsiflexion inversion anterolateral
- plantarflexion inversion posterolmedial
50
clinical signs and symptoms of OCD lesion
- persistent pain in ankle with limited range of motin
- edema and lockign or giving way 4-5 weeks after an injury
- made worse with weight bearing
51
What is the range of values for the angle between the ATFL and the CFL?
(Taser 2006)
- average angle is 132 with a range between 118 and 145
(stoller 2004)
- 70- 140 using MRI
52
What are the numbers associated with the talar tilt test?
- evaluates CFL for injury
- foot held in neutral position and inverted
- normal: 5-23 degrees
- abnormal: comparison to contralateral greater than 10 degrees
53
what are the clinical measurements of the anterior drawer test?
- used to evaluated ATFL for laxity or injury
- one hand on posterior heel and other on tibia superior to abkel joint
- anterior force applied to foot
- greater than 10 mm displacement or excessive movement in comparison to contalateral side is abnormal
54
what is the cobb procedure?
- split ATTT used to treat stage II flexible flatfoot.
- split the AT tendon and pass it through the medial cuneiform, then attach it to remaining PT stymp
55
what are the johnson and strom PTTD classification?
56
what is the golden hour in trauma?
- attributed to cowley
- patients have a better chance of survival when treated within an hour of the injury
- not based in science (Lerner 2001)
57
when should you provide tetanus prophylaxis?
Tetanus prophylaxis is dependent on the patient’s previous toxoid dosing and the cleanliness of the wound. Patients with unknown status or \<3 doses receive toxoid in clean and minor wounds, and toxoid and IgG in other wounds. Patients with \>2 doses receive toxoid in clean wounds only if the last dose was \>10 year ago. They receive toxoid in all other wounds if their last dose was \>5 years ago, and do not receive IgG in any situation.
58
what are signs of tetanus toxicity?
Classic signs of tetanus are trismus (or lockjaw), risus sardonicus, and dysphagia. Patients may also experience fevers, tremors, and tonic muscle spasms. Salvation, sweats, and fevers appear to come from dysregulation of the autonomic nerve system at spinal column level. The ‘spatula test’ can be used for suspected cases. This involves touching the posterior pharyngeal wall with a wooden spatula. A positive result shows a reflex spasm of the masseter muscles and has high specificity and sensitivity for tetanus.
59
What is the seiberg index?
- difference between horton index (distance b/w dorsal aspect of 1st and 2nd met at the neck) and the distance between the dorsal aspect of the 1st and 2nd met measured 15 mm from the 1st met base on a lateral WB view x-ray
- increased in hallux rigidus and metatarsus primus elevatus
- (usuelli 2011)
60
what is the hubscher maneuver?
- dorsiflexion of the hallux at MPJ in RCSP
- flexible flatfoot increases medial arch height
- (Halstead 2006)
61
What is helbing's sign?
- curvature of achilles tendon when observed from behind in RCSP
- observed due to excessive rearfoot varus
62
what is the first screw placed in an anti-glide application called?
trick screw
63
what is the lock pin technique?
- Yu 1999
- stabilize k-wire when wire is applied for fixation of osteotomy
- drive wire dorsal proximal to plantar distal into the capital fragment with the distal portion of the wire remaining in the subchondral bone of the capital fragment
- distal protion cut, twisted over the bone and pressed into the dorsal cortex
- bends wire to put compression on osteotomy and secures teh wire such that the wire will not translate during healing
64
what are the toxicities associated with aminoglycosides?
nephrotoxicity, ototoxicity, and neuromuscular blockade
- nephrotoxicity due to membrane binding of durg in renal tubules
- otoxicity moa?
- neuromuscular blockade from blockage of voltage gated calcium channels in nerves
65
what are some common k-wire sizes in mm?
.028” (0.7mm)
.035” (0.9mm)
.045” (1.1mm)
.062” (1.6mm)
66
what volumes of irrigation are used for different gustillo-anderson classifications?
(Cross 2008)
- 3L class I, 6 L all other classes reported in literature, but not evaluated?
67
Age/sex differences of distal tibial growth plate fusion?
- females fuse earlier than males (early as 12 yo)
- males fuse 14-19 yo
- in males only, ethnicity affects fusion age: hispanic/african american 14 and caucasian 16
68
what is a transitional fracture?
- named due to transitional status of distal tibial epiphysis as it closes
- fractures can sometimes be seen as salter-harris on plain xpray
- as growth plate closes, it changes teh geometry of the fractures present
- CT imagins should be done to rule out triplanar and juvenile tillaux fractures
(rosenbaum 2012)
69
who described a technique to reduce ankle fractures by suspending the leg?
Quigley 1959
- abduction external rotation injuries
- Quigley's traction consists of suspending the injured leg in a tubular fabric sling to allow gradual relaxation of deforming muscle forces and eventual reduction of a displaced ankle. For those displaced ankle fractures that are not amenable to reduction by direct manipulation, Quigley's traction applied after hematoma block may allow successful reduction. Improvised Quigley's traction can be built in a wilderness setting using available clothing
70
what % of syndesmotic repairs are malreduced?
(Gardner 2015)
- variability in the rate of malreduction from 16 - 52%
- most important portion of repair is lenght and position of distal fibula
- clamping lateral malleolar ridge of the fibula to the center of the AP width of the tibia resulted in most consistent and accurate reduction of syndesmosis
71
What is the name of syndesmotic injury hook test?
cotton or hook test
- The Hook or Cotton test is more reliable than the exorotation stress test
72
what is ligamentotaxis?
- theory in reduction of fractures that distraction of the ligaments surrounding a fracture will place tension indirectly on the fracture fragments, which will in turn guide fragments back to anatomic position
73
What is the bucket handle technique?
- crossed k-wires inserted to fixate a hallux IPJ fusion
- ends of wires exiting the distal hallux are trimmed and bent so that they overlap each other, and are then taped together to prevent additional movement of the wire
74
what are the principles of arthrodesis?
(4)
1. Removal of all material which could prevent bone to bone contact
2. Close and accurate fitting of both sides of the joint to be fused
3. Correct positioning of the joint
4. Maintenance of the position until fusion is complete
75
bone primary and secondary fusion
76
MRSA antibiotics
vancomycin IV
cubicin IV
synercid IV
bactrim PO
clindamycin PO
zyvox IV/PO
77
where do you make the evans calcaneal osteotomy?
1 - 1.5 cm proximal to CCJ
78
how much lengthening in an evans?
8-12 mm
79
why is the FDL used for transfer in PTTD?
- its cross sectional area is only 1/3 of the PTT but it is similar in size to the PB so it is suited to oppose the function of the PB
80
strayer vs. baumann
- strayer = distal GT
- baumann - deep GSR
- strayer is more invasice and difficult procedure compared with baumann and leaves the gastroc with less propulsion power and has more potential to cause nerve damage
81
Who described 2-3 mm graft resorption for an evans?
- evans calcaneal osteotomy is used for repair of a calcaneovalgus deformity
- works by lengthening the lateral column of foot
- use locking plates to help preserve correction
- Dayton and Feilmeier 2013
82
Who described the 9 compartments of the foot?
- Manoli describes 9 compartments in the foot
- Intermetatarsal x 4 (interossei)
- Medial compartment (abductor hallucis)
- Lateral Compartment (Abductor digiti minimi)
- Superficial central compartment (FDB)
- deep central compartment (adductor hallucis)
- calcaneal compartment (Quadratus Plantae and lateral plantar a)
- dorsal compartment (EHB and EDB)
83
What angles would you use in evaluating a bunion?
* Met Adductus Angle
* bissection of lesser tarsus and 2nd met
* Normal 0-15
* IMA
* Normal 8-12
* TSP
* Normal 1-3
* HAA
* Normal 10-15
* HIA
* Normal 0-10
* PASA
* representation of effective cartilage in relation to shaft of metatarsal
* less than 7.5
* DASA
* effective cartilage at the base of the proximal phalanx
* Met Protrusion Distance
* +/- 2 mm
84
what is the seiberg's index?
- difference between the horton index (perpendicular distance from the dorsal aspect of the second met shaft to the dorsal aspect of first met shaft at met neck level) and the perpendicular distance b/w the first and second metatarsal shaft
- measured 15 mm from the first metatarsal base
85
how much motion remains after subtalar joint fusion?
* TNJ is key joint to consider when performing triple arthrodesis
* TN has greates ROM out of 3 and fusion essentially eliminates motion of CC and STJ to 8-9% of its previous ROM
* Arthrodesis of STJ resulted in decrease in ROM of TNJ (26%) and in CCJ (56%)
* Arthrodesis of CCJ had little effect of ROM of either TN (67%) or STJ (92%)
(Astion 1997)
86
Name of splaying of toes from Morton's neuroma
sullivan sign
87
Whats the antimicrobial aspect of xerofoam called?
3% bismuth tribromophenate
88
IMA correction after 1st MPJ fusion
- mean preoperative IMA was 13.74 and the mean postoperative IMA was 9.38, for a mean change in the IMA of 4.36
(Dayton 2014)
89
what is the plantar plate made of?
type 1 collagen and fibrocartilage
90
why do you fenestrate bone during a fusion?
want to penetrate the subchondral plate and bring out the GFs and promote bleeding
91
what is the LRINEC score?
* used for diagnosing necrotizing fasciitis
* LRINEC laboratory risk indicator for necrotizing fasciitis
* score greater than 6 = necrotizing fasciitis suspicion
* score greater than 8 = strongly predictive (92%)
92
what is the eagle effect for clindamycin?
* eagle effect aka paradoxical zone phenomenon
* reduced antibacterial effect of penicillin at high doses. clindaymcin worked better in animal models.
* why? Penicillin is a bactericidal antibiotic that works by inhibiting cell wall synthesis but this synthesis only occurs when bacteria are actively replicating. In cases of extremely high bacterial burden (such as with G.A.S.), bacteria may be in the stationary phase of growth. In this instance since no bacteria are actively replicating penicillin has no activity. This is why adding an antibiotic like clindamycin, which acts ribosomally, kills some of the bacterial and returns them to the log phase of growth
93
what are the gas producing bacteria?
strep
staph aureus
clostridium
94
when would you close an infected wound?
WBC drops and cultures are negative
95
what are you looking for on x-ray with OM?
cortical erosion, periosteal reaction, trabecular destruction
96
complications of transfusions?
- volume overload (give lasix and monitor ins/outs)
- rash (give benadryl)
97
what's the difference between using a bone cutter and a saw on a bone for amputation?
The saw causes thermal necrosis which is beneficial because hypertrophic bone will not form or be less prone to form
98
what muscle in the thigh acts like extensus capsularis?
articularis genu
99
when do you do blood transfusions for a patient?
Hb less than 7 indefinitely
Hb less than 8 if symptomatic
100
what can you do to fix a dog ear?
extend your incision
101
what causes discoloration to the pretibial region?
hemosiderin deposits from venous stasis or pooling
102
How do Herbert and Reese screws work?
* Herbert headless screw
* leading threads have increased pitch so it draws in teh trailing heads
* Reese screws
* designed for IPJ fusion
* right and left handed pitch with same thread diameters
* screw driver on either side
103
eponym for 1st MPJ fusion
McKeever
self-titled 1952
104
What percentage of sydnesmotic ankle injuries are malreduced?
33%
| (VanHeest 2014)
105
what can you do for a white toe?
* try spinning k-wire
* pull wire post op
* place foot in dependent position
* warm compress
* vasodilatroy medications (topical amitriptyline and local anethetic)
106
define septic shock
refractory hypotension defines as systolic blood pressure less than 90 or a reduction of blood pressure less than 40 from baseline in absence of other causes of hypotension and with adequate volume resuscitation
107
what is MODS?
* multiple organ dysfunction score helps to quantify symptoms of organ dysfunction
* respiratory: PaO2/fiO2
* renal: serum creatinine
* hepatic: serum bilirubin
* cardio: CVP/MAP
* heme: platelet count
* neuro: glascow coma scale
108
most common cuase of lactic acidosis
* sepsis
* septic patients with lactic acidosis have a higher mortality rate
* caused by imparied clearance of lactate or increased production of lactate
* using sodium bicarb to treat can be helpful
109
Explain the probe to bone tests
* Grayson 1995: probe to bone is positive predictive value of 89% in a population of hospitalized patients
* Lavery 2007: probe to bone is negative predictive value of 98%
110
what is a bone island?
* aka enostosis
* benign bone tumor mostly encountered as an incidental and asymptomatic finding
* round, small intramedullary condensation composed of lamellar cortical bone
* aka intramedullary displacement of complact lamellar bone
* ddx: sclerotic metastatic lesions, osteoid osteoma, sclerotic osteosarcoma, calcififed enchondroma and boen infart
