Beginner’s guide to 1st Metatarsal Fractures

 

Terms to know:

  1. Jahss classification

 

Conservative treatment for 1st met fractures: NWB in SLC for 4-6 weeks

When should you do ORIF for met fractures?

  1. Extra-articular: >2-3 mm displacement and >10 degrees angulation
  2. Intra-articular: fracture involves >20% articular surface if

 

When should you do open surgery for Jahss?

  1. Jahss classification 1
  2. Order is ADI – adductor, DTML, intersesamoidal ligament

Beginner’s guide to Calcaneal Fractures

A crash course regarding calcaneal fractures.

 

Last edited: March 2016

Author: Rossi bad

The most fractured bone of all the tarsal bones is the calcaneus. They are mostly intra-articular and closed.

There are 3 common “types” of fractures as it relates to the calcaneus:

  1. Intra-articular: Primary fx line (oblique-shearing) results in two fx: superio-medial (constant fragment) and superolateral (posterior facet) fragments. Secondary fx line results in either tongue-type or joint depression.
  2. Extra-articular: gastroc-soleus avulsion fracture
  3. Anterior process fx: inversion/plantarflexion results bifurcate avulsion fx.

 

Common associated terms:

  1. Essex-Lopresti classification
  2. Rowe classification
  3. Sanders classification
  4. Degan classification
  5. Tongue type vs joint depression
  6. Gissane’s angle
  7. Bohler’s angle
  8. Constant fragment
  9. Harris view
  10. Broden view
  11. Shear fracture of Palmer
  12. Mondor’s sign

 

Pearls:

  1. Most commonly fractured tarsal bone? calcaneus
  2. Most important surgical concept in the surgical reduction of calcaneal fractures? elevate the posterior facet
  3. Rowe Class IV corresponds to Essex Lopresti

 

References

  1. http://www.orthobullets.com/trauma/1051/calcaneus-fractures

Everything about the NAVICULAR!

 

 

The navicular primary ossification center is the last to appear at 3 years.

 

There are classifications for the navicular, which include the Watson-Jones (tuberosity, dorsal lip, body, stress – TABS mneomonic fractures). Navicular body fractures have a classification called the Sangeorzan (3A-C).

 

PTTD pathological joint axis

Kidner

Os tibiale externum

Stress fx:

  1. hard to heal, high rate of non-union. 6-8 weeks NWB, then 4-6 weeks WB immob.
  2. most commonly occurs: middle third

 

Blood supply:

  1. dorsalis pedis artery: dorsal and medial
  2. medial plantar artery: plantar and lateral

Differentials: Osteomyelitis vs Charcot Neuroarthropathy Foot

Charcot neuroarthropathic (CN) foot and Diabetic foot Osteomyelitis (DFO) are two differential complications that occur due to diabetes. CN and DFO are notoriously  troublesome to differentiate at initial presentation. Therefore, podiatrists that are presented with a diabetic foot patient suspected of OM or CN, must be extremely vigilant in diagnosing these entities as treatment vastly differs– a wrong treatment can cost someone their limb, and their lives.

 

Submitted: March 2016

Authors: Rossi Bad

Title: A summary of the differences between Charcot Foot and Osteomyelitis.

 

Charcot Neuroarthropathic Foot Osteomyelitis (Acute)
Neuropathic/Biomechanical etiology Infective etiology
Elevated leg may reduce erythema Will not affect the localized erythema
Associated with long standing diabetic, and Leprosy History of diabetic foot ulcers, open fracture, and deep wounds (probe to bone)
MRI shows diffused bone edema particularly in multiple joints, and articular surfaces i.e. peri-articular and subchondral edema MRI would show localized bone edema
FDG PET is diffused and <2 i.e. lesser glucose uptake FDG is localized and >3 i.e greater glucose uptake
Affects midfoot Affects toes and forefoot
May appear grossly as a “deformed” foot. i.e. rockerbottom foot Foot shape may be normal
Pulses may be bounding Pulses may be normal to non-existent
ESR non-elevated ( in NON-ACUTE stage) ESR elevated ( 70 mm/hr)
Radiograph will show non-specific  changes: periosteal reaction, joint dislocation, fractures Radiograph will show focalized cortical destruction with involucrum, sequestrum, clocoae,
Bone biopsy to rule out osteomyelitis Bone biopsy is the gold standard, and can guide treatment plan

 

 

References:

 

  1. http://diabeticfootandankle.net/index.php/dfa/article/download/21855/pdf_1
  2. http://www.podiatrytoday.com/osteomyelitis-keys-diagnosis-and-treatment

Podiatry Pearls for Externships

Weil Osteotomy (plantar oblique 3mm displacement of met neck)

Who was the first to describe it? Baruke described it.

What happens if the displacement is greater than 3 mm (i.e. what is a complication)? Floating toe

What causes the floating toe in a Weil Osteotomy? Disadvantages the interossei

What modification avoids this? Maraska (1 mm section removed->reduces the vertical height increase from the weil)

What is the “Hat trick”? 1) plantar plate repair 2) PIPJ athrodesis 3) Parallel Weil (Maraska). It’s goal is to the restore the center of rotation of the 1st MTPJ.  3P’s is the hat-trick.

Medial Double Athrodesis

According, to Astion (1997), How much ROM is eliminated after a talo-navicular fusion in the CC and STJ joint? 90%. i.e. only 2 degrees of motion is available

What is the advantages of using a medial double athrodesis over a triple? Since it does not affect the CC joint, the lateral column length is preserved (no FF abduction). It can also be done with one medial incision.

 

Podiatry Classifications – Mnemonics, vignettes, easy ways to remember

The following is a table of common podiatry classifications. They do not describe the classification in detail, but serves    …..as a stepping stone. It is paramount that you first know what the system describes.

 

Classification
How to remember
Jahss  (1st MPJ dislocation) “JahSeS-amoid”
Watson-Jones (navicular) “Watsaw [the] navicular”
Rowe (calcaneus – extraarticular) “go out and Rowe [your boat] in the Essex river”

the calcaneus looks like a boat too! out = extraarticular, in = intraarticular.

Essex-Lopresti (calcaneus – intraarticular) “see above.”

Out of the types of calcaneal classifications (Rowe, Sanders, Essex-lopreseti) it has TWO words=> 2 types of essex-lopresti

Bernt-Hardy (talar dome lesions) “talar dome lesions are hard to see”

talar dome lesions are commonly missed on normal radiographs (50%)

Lauge-Hansen (ankle fx) “Large-hansen”

refers to ankle fractures! the ankle is large compared other classifications. you prob. should know this classification anyways.

Hardcastle (lis-franc) “queen lis-abeth [and king frank] lives in a castle. ”

if you remember the above, then you can associate QUENU (sounds like queen with this classification. recall that hardcastle elaborated on quenu)

the met's look like a castle's gate
the met’s look like a castle’s gate
Sanders (CT calcaneus) “FEEL THE BERN…from the CT machine”

CT would most likely be used for intra-articular fractures, so this is an intra-articular classification, for the calcaneus. Say it with me: Feel the bern of the coronal CT of the calcaneus –lol?

Danis-Weber (fibula fx) Danis-Weber goes with Salter-Harris. Remember the ABCDanis -Weber. Visualize three locations (A,B,C) with respect to the ankle mortise. Since the mortise involves the tibia, these fractures have to be wrt the FIBULA.
Salter-Harris (tibia fx) See above. S-same SalTEr- TIBIAL EPIPHYSEALradiopaedia.

How to dictate an Austin procedure

The following article was originally found at:

http://medical-transcription-sample-reports.blogspot.com/2011/12/austin-bunionectomy-medical.html

DATE OF OPERATION:  MM/DD/YYYY

PREOPERATIVE DIAGNOSIS:  Hallux abductovalgus deformity, left first metatarsal.

POSTOPERATIVE DIAGNOSIS:  Hallux abductovalgus deformity, left first metatarsal.

OPERATION PERFORMED:  Austin bunionectomy with internal fixation, left first metatarsal.

SURGEON:  John Doe, D.P.M.

HEMOSTASIS:  Pneumatic ankle tourniquet set at 250 mmHg.

ANESTHESIA:  MAC with local.

ESTIMATED BLOOD LOSS:  Minimal.

COMPLICATIONS: None.

PROPHYLAXIS: Ancef 1 gram 30 minutes prior to incision.

DESCRIPTION OF OPERATION:  The patient was placed on the operating room table in the supine position. Following adequate sedation, a Mayo block was performed utilizing 10 mL of 0.5% Marcaine plain around the first metatarsal. The pneumatic ankle tourniquet was then placed around a well-padded left ankle. The left lower extremity was then scrubbed, prepped, and draped in the usual sterile fashion. Attention was directed to the left and an Esmarch was then utilized for exsanguination. The pneumatic ankle tourniquet was then inflated on the left lower extremity to 250 mmHg. A 6 cm linear longitudinal incision was then made medial and parallel to the extensor hallucis longus involved with the contour deformity. The incision was then deepened through the subcutaneous tissues using sharp and blunt dissection. Care was taken to identify and retract all vital neurovascular structures. All bleeders were electrocauterized as necessary.

At this time, a linear capsulotomy was then performed over the dorsal aspect of the first metatarsophalangeal joint. The periosteal and capsular structures were then carefully dissected free of their osseous attachments and reflected medial and laterally exposing the head of the first metatarsal at the operative site. A sagittal bone saw was then utilized to resect all noted medial prominence. Attention was then directed to the first interspace by the original skin incision, where the extensor hallucis longus was observed and retracted out of the way, exposing the extensor hallucis brevis, which was identified and retracted out of the way. Dissection was then continued deep using blunt dissection down to the level of the fibular sesamoid, which was freed from its soft tissue attachments proximally, laterally, and distally. The conjoined tendon of the abductor hallucis muscle was then identified and resected at its attachment to the base of the proximal phalanx at the hallux. At this time, the level of the contracture present on the hallux was noted to be reduced and the sesamoid apparatus was noted to flow in a normal corrected position.

At this time, attention was directed to the medial aspect of the first metatarsal head at which time a 0.45 inch K-wire was then driven from the medial to lateral in a perpendicular fashion across the head of the first metatarsal, being perpendicular to the line of the second metatarsal with no dorsiflexion or plantarflexion noted. At this time, a V-type osteotomy was created in the metaphyseal region of the bone utilizing a sagittal bone saw. After this was created and placement of the guidewire, the apex of the deformity was pointed distally and the arms were approximated plantarly and proximal, dorsally. Upon completion of the osteotomy, the capital fragment was distracted and shifted laterally into a more corrected position impacted on the first metatarsal shaft. At this time, a 0.45 inch K-wire from the DePuy screw set was then driven from dorsal to plantar across the osteotomy site to serve as temporary fixation.

Following standard AO technique procedures, one 20 x 2.7 mm FRS DePuy bone screw was then inserted and placed across the osteotomy site with excellent compression noted. At this time, the K-wire was then removed and attention was then directed to the medial bone shelf, which was resected utilizing a sagittal saw and passed from the operative site. A power rasp was then utilized to smooth all bony prominences. Correction of the deformity was then reassessed at this time, both clinically and utilizing intraoperative fluoroscopy, and the position of the screw and correction of the deformity was noted to be excellent. The wound was then flushed with copious amounts of sterile normal saline and a medial capsulorrhaphy was then performed. The capsule and the periosteal structures were then reapproximated utilizing 4-0 Vicryl. The subcutaneous layer was then reapproximated utilizing 4-0 Vicryl and the skin was closed in a subcuticular stitch fashion using 4-0 Monocryl. Benzoin and Steri-Strips were then applied.

Upon completion of the procedure, the incisions were then dressed with dilute Betadine-soaked Adaptic covered with dilute Betadine-soaked gauze, Kling, Kerlix and Coban. The pneumatic ankle tourniquet on the left ankle was then rapidly deflated with a prompt hyperemic response noted to all digits of the left foot. A DonJoy ice dressing was then incorporated into the wound dressing, after initial dry sterile dressings. The patient tolerated the procedure and anesthesia well and was transferred to the recovery room in satisfactory condition with vital signs stable and vascular status intact to all digits bilaterally.

Residency interview questions

The following article is originally found at

http://forums.studentdoctor.net/threads/residency-interview-questions.277489/

 

“I want to start off by saying that as a GENERAL rule, if you’ve externed at a place or visited several times they will be easier on you and by being there you will discover what they like to ask.

The type of questions you get also varies on the amount of applicants applying to the program. For example, this year had a very low applicant pool and a much higher number of residency spots. So most of the interviews were social except for the top programs which always have academic interviews.

The typical academic interview goes through a case.
a) history
b) physical
c) diagnosis (labs, x-rays ect.)
d) treatment

Some “interesting” questions I heard were:

1) Dictate an Austin (for those of you who are not familiar with dictation, after every sx case the resident or the surgeon dictates a verbal recap of everything the happened in the sx. )

2) Another place didn’t ask any podiatry questions but asked every student internal medicine questions pertaining to the review of systems.

3) A student who didn’t visit the program once got a difficult gunshot case with the interviewers constantly interrupting her with ,”why didn’t you visit us? Why didn’t you visit us?”

The typical cases you will get asked are:

1) Red Hot swollen foot
2) Bunion
3) Lisfranc’s dislocation
4) Ankle fractures
5) Diabetic foot ulcer/infection

Some social questions I got were:

What is the last book you read?
Which clinician at your school do you dislike the most?
What can our program inprove upon?
Tell us about a journal article you read?

– 4th year student”