Nails
1.Patient has nail fungus, what should you order with long-term use of Terbinafine? | liver panel test |
2.what is another term for a fungal nail? | onychomycosis or tinea unguium |
3.symptoms of a fungal nail? | thickening, yellow nail, discoloration, hand nails may also be affected |
4.what are risk factors for a fungal nail? | peripheral vascular disease (PVD), decreased immune function, athlete’s foot. |
5.differential diagnosis? | nail trauma, paronychia, dermatitis, psoriasis, melanoma |
6.nail anatomy? | matrix root, mantle, eponychium (proximal), lunula, nail bed, nail plate, hyponychium (distal) |
7.what organisms cause fungal nail? | trichophyton rubrum, trichophyton interdigitale, Epidermophton floccosum, microsporum gypseum, Candida albicans, Aspergilllus |
8.How do you diagnose with labs? | culture, histology exam, potassium hydroxide smear, PCR , periodic acid-Schiff stain |
9.Name topical treatments: | ciclopirox, amorolfine, efinaconazole |
10.Oral medication: | terfinafine, itraconazoe, fluconazole |
11.What are side effects of terbinafine? | nausea, diarrhea, rash, and elevated liver enzymes/ liver problems. |
12.Mechanism of action of terbinafine? | inhibits ergosterol synthesis by stoping squalene epoxidase. |
13.What is the recurrence rate of fungal nails? | 10-50% |
14.Why do we concern fungal nails in diabetic, AIDS, or leukemia patients? | it is opportunistic and can lead to more serious complications. (i.e. cellulitis, bone infection) |
15.What is another name for an ingrown nail? | onychocryptosis or unguis incarnates |
16.What is associated with an ingrown nail? | paronychium – inflammation of the skin. |
17.Symptoms of ingrown nail? | red, hot, swollen nails with light touch sensitivity. Possible us and discharge. Also maybe from thickening of the skin. |
18.What contributes to ingrown nails? | poor shoegear, tight toe box, damp or sweaty nails, genetics, nail bed, hallux bone formation, poor nail trimming. |
19.What are minor nail surgeries you can offer? |
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20.What materials do you need for a partial nail matrixectomy? |
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21.What is phenol? | toxic, colorless class of carbolic acid (C6H5OH) |
22.For the treatment of onychomycosis, Griseofulvin is not effective against? | Candida |
23.Why use alcohol after chemical matrixectomy? | alcohol flush serves as irrigation to remove phenol rather than neutralization agent. |
24.You are about to do a nail avulsion, you inject local lidocaine, the patient starts getting sweaty and is unable to breathe, what do you do? | He is having an allergic reaction. Maintain airway, administer valium for convulsions, and epinephrine for cardiac depression. Add toe tourniquet to localize anesthesia. |
1st Ray
1.Define bunion? | This can be a tough yet easy one to miss! Response: medial to medial-dorsal prominence of the 1st MTPJ. Can include callus, bursitis, or bony prominence. |
2.What causes hallux varus? | Over capsule tightening, staking of the head, removal of fibular sesamoid, Down syndrome |
3.What position do you fuse the first MTPJ? | 10 degrees dorsiflexion and 15 degrees abduction |
4.In a capsulotomy, what is involved in lateral release? |
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5.What do you use a McGlammry elevator for? | to raise the plantar plate |
6.What surgery do you perform in addition to a Jones Tenosuspension? | IPJ fusion of hallux |
7.When looking at an x-ray, what is one way to tell if a patient had a true McBride? | fibular sesamoid is removed |
8.Nerves in a Mayo block | 1. Saphenous n 2. Deep peroneal n 3. Medial dorsal cutaneous n 4. Medial plantar n |
9.Steps to a McBride? |
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10.In what layer is the neurovascular bundle located in the foot? | Superficial Fascia layer |
11.True or False: Can a patient immediately weight bear after a chevron osteotomy? | True, many Italian podiatrists do this as a post-op course. Most US podiatrists let 1-2 WB as tolerated instead. |
12.What is Morton’s extension used for? | Treats hallux limitus by dorsiflexing the big toe |
13.Name some bunion head procedures? | Austin Reverdin Reverdin-Green Reverdin-Laird Reverdin-Todd |
14.What is an Austin? What does it correct? |
Chevron Osteotomy – Head
60 degree cut. Corrects relative IM angle |
15.What is a Reverdin? What does it correct? | Head osteotomy Wedge resection with lateral apex intact Corrects PASA |
16.What is a Reverdin-Green? | Same as Reverdin but has Plantar cut to protect the sesamoids. Corrects PASA |
17.What is a Reverdin-Laird? | Like Reverdin-Green but through cut/no hinge to translocate the capital fragment Corrects PASA and mild IMA |
18.What is a Reverdin-Todd? | Reverdin-Green-Laird but a plantar wedge is created for sagittal correction Corrects PASA, mild IMA |
19.Name some bunion neck procedures | Hohmann and Wilson. Can cause shortening. |
20.Name some Shaft bunion procedures | Kalish
Scarf
Ludloff Mau |
21.What is a Kalish? | A long arm chevron osteotomy at 55 degrees angle, performed at shaft. Corrects IM angle |
22.What is a Scarf? | A “Z”- osteotomy. Corrects: IMA > 15, PASA. Can shorten/lengthen, plantarflex/elevate |
23.Where are the dorsal and plantar cuts made in a scarf? | Distal arm – Dorsal Proximal arm – Plantar |
24.Most common complication with scarf? | throughing |
25.Difference between Ludloof and Mau? | Ludloff-Oblique cut proximal dorsal to distal plantar. Mau-Oblique cute proximal plantar to distal dorsal |
26.Some base procedures? | Crescentic Juvara |
27.What is crescentrics? | Crescent shape blade, Treats IMA > 15. Minimal shortening but difficult to fixate. |
28.What is a Juvara? | A- “hinge-type”, cut obliquely across 1st met base at a 45-degree angle
B1-“hingeless”, cut through and through the met base B2- combination, first cut oblique and leave a hinge (Juvara A), add the screw. Then, cut the hinge portion to move the shaft in the sagittal plane to plantarflex or dorsiflex. |
32.Osteotomies for Hallux rigidus/Limitus? | Youngswick Watermann Green-Watermann Cheilectomy Kessell-Bonney Regnauld |
33.What is regnauld? | Mexican Hat Procedure Remove 1/3 base of proximal phalanx, fashion into hemi-plant, |
34.What is a Kessell-Bonney? | Dorsal closing wedge osteotomy at proximal phalanx Dorsiflexes distal hallux Treats hallux limitus |
35.What is a chielectomy? | Removes dorsal osteophytes |
36.What is a Kessell-Bonney? | Dorsal closing wedge osteotomy at proximal phalanx. Dorsiflexes distal hallux Treats hallux limitus |
37.What is a Watrmann? | Dorsal closing wedge osteotomy at the metatarsal head |
38.What is a Green-Watermann? | Watermann with the protection of sesamoid apparatus |
39.What is a Youngswick? | Decompression Austin osteotomy. Treats IMA 12-15 and plantarflexes met head. |
40.What is a Silver? | removes medial bump |
41.What is an Original McBride? | Silver + Fibular sesamoidectomy + lateral release |
42.A Modified McBride? | keep sesamoid |
43.T or F: A McBride corrects PASA | False, treats no angles |
44.What causes Hallux Varus? |
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45.Treatments for Hallux Varus? | first, try Soft tissue balance -> if fail try tightrope -> if all fails, do Arthrodesis (salvage procedure) |
46.Akin: When to use it? screw size? Post-op? |
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47.Austin: When to use it? screw size? Post-op? |
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48.Lapidus: When to use it? screw size? Post-op? |
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49.Hallux limitus/Rigidus etiology? |
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50.Radiographic findings of HL/HR? | Dorsal osteophyte, met. primus elavatus, eburnation, joint space narrowing, met. head flattening, subchondral sclerosis |
51.Walk me through a Kalish osteotomy, pretend you are on the phone dictating: |
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Lesser Digits
1.What is Freiberg’s infraction? | Freiberg’s Disease – infarction and fracture of metatarsal head |
2.What is demographics of Freiberg’s disease? | affects females more (4:1), patients age 13-18, most common in female athletes |
3.What metatarsal most affected? | most often seen in 2nd metatarsal |
4.Pathophysiology of Freiberg’s disease? | microtrauma and stress overload causes disruption of blood supply |
5.Symptoms of Freiberg’s? | swelling, stiffness, erythema, pain, worse weight bearing |
6.Classification system for Freiberg’s disease? | Smillie classification |
7.Radiographic signs are seen in Freiberg’s disease? | metatarsal head flattening |
8.Conservative treatment of Freiberg’s? | limit activity, immobilization, NSAIDS, a custom orthotic with MT bar or pad |
9.Surgical treatment of Freiberg’s? | metatarsophalangeal arthrotomy, dorsal closing wedge osteotomy, partial arthroplasty |
10.How do you treat brachy metatarsalgia? |
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11.True or False: in brachy metatarsalgia the vessels shortened but nerves are normal? | False, both nerves and vessels shortened |
12.Dorsal approach for neuroma, what do you need to resect? | Deep transverse metatarsal ligament |
13.How to avoid floating toe in Weil ostotomy? | plantarflex the digit |
14.Incision for adductovarus 5th toe deformity? | distal medial to proximal lateral |
15.Which Jahss classification grade are you able to close reduce? | Type 2A and 2B |
16.Lateral slip of plantar fascia inserts where? | 5th metatarsal base |
17.What is intra articular comminuted frx 5th met classification? | Stewart Type IV |
18.What is the type of hammertoe deformity in a cavus foot? | Extensor substitution |
19.What are several different ways that you could fix a 5th metatarsal fracture? | Interfrag screw, hook plate with screws, tension banding, cerclage, k-wires, etc. |
20.The steps to do a hammertoe reduction |
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21.A 22-year-old comes to your office complaining of pain when wearing tight shoes. A clinical image shows a severe bunion, tracking, and underlying the 2nd toe. Radiographs reveal a slight increase in IMA, no hypermobility noted. What procedure would you do? | Distal metatarsal osteotomy |
22.What nerves do you block in a mayo block 3rd digit? | Medial dorsal cutaneous, intermediate dorsal cutaneous, medial plantar nerve |
23.A mother brings her 5-year-old boy concern about his toe walking, what is the initial treatment? | Physical therapy and stretching |
24.What is a tailor’s bunion? | the dorsal lateral prominence of the 5th metatarsal head |
25.What is the classification system for tailor’s bunion? | Fallat & Buckholtz
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26.Symptoms of tailor’s bunion? | pain dorsolateral, bony prominence, bursa, hyperkeratotic. Rule out lister’s corn |
27.Treatment for tailor’s bunion? | A wider toe box, NSAIDS, padding, RICE, surgery (distal osteotomy, etc.) |
28.What is a True Jones Fracture? | Fracture of 5th metatarsal base at the watershed area of poor blood flow, at the metaphysis and diaphysis junction. At about 1.5 cm distal to tuberosity. Kwon for poor non-union results. |
29.What are the zones in a 5ht met base? | Zone 1 – Avulsion Tuberosity Fracture, the line extends into the metatarsal cuboid area
Zone 2 – Jones Fracture, the fracture in metaphysis-diaphyseal base and extends into 4th met articulation Zone 3 – Stress Fracture, proximal diaphyseal |
30.What are surgical treatments? | 4.5 mm malleolar screw, plate & screws, Radial hook plate, tension-band wire |
31.Name the neuromas of the foot and location: |
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32.What is Morton’s Neuroma? | not a true neuroma but a thickening (callus) of the nerve in between the 3rd and 4th digit interspace . |
33. Clinical signs of Morton’s Neuroma? |
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34.Treatment for Morton’s Neuroma? |
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35.Types of toe deformities? | Claw toe, mallet toe, hammer toe |
36.Etiology of hammertoes? | Flexor stabilization, Extensor substitution, Flerox substitution |
37.Describe flexor stabilization: | During the stance phase of walking, in a pronated foot type, the flexors will overpower the interossei muscles. (most common) |
38.Describe Extensor substitution: | During the swing phase (foot not touching ground), the extensor digitorum longus/ brevis muscles will be firing and overpowering the lumbrical muscles. Seen in cavus foot type and ankle equinus patients. |
39.Describe Flexor substitution: | During stance phase, in a pes cavus foot, the deep muscles (FHL, FDL) overpower the interossei muscles. (Least common) |
40.How do you get 4th and/or 5th digit adductor varus formation? | weak or cut QP muscle |
41.How do you make the incision for soft tissue balance on the adductor varus deformity? | over the 4th or 5th MTPJ, distal medial to proximal lateral incision |
1st MPJ Arthritis
1. What is the most common location of OA in the foot? | 1st MPJ |
2. What two medical conditions are commonly associated with this condition? | RA and Gout |
3. What nerve is commonly irritated by the osteophytes associated with this condition? | Medial dorsal cutaneous nerve |
4. What percentage of body weight does the 1st MPJ carry in gait? | Up to 120% |
5. What phase of gait is this pathology usually the worst? | toe off |
6. What are the intraarticular findings of OA? | joint space narrowing |
7. What are the extraarticular findings of OA? | osteophyte formation, cyst formation int eh metatarsal head, sclerosing of the bone |
8. What is the best imaging modality for bone assessment? | CT scan |
9. What grades of 1st MPJ OA indicate conservative treatment? | Grade 0 or 1 |
10. What is the Moberg procedure? | Dorsal closing wedge of the proximal phalanx |
11. What are the contraindications for 1st MPJ arthroplasty? | infection, insufficient bone stock, sesamoid arthritis |
12. What grades of 1st MPJ OA indicate a 1st MPJ arthrodesis? | grade 3 or 4 |
13. What is the average satisfaction rate for a 1st MPJ arthrodesis? | 95% |
14.What length of shortening of the 1st metatarsal, compared to the lesser metatarsal, indicates the need for a structural bone graft? | >5mm |
15. What is the mainstay orthotic treatment for 1st MPJ OA? | Morton’s extension |
16. What is the name of an osteophyte found in the joint space? | a joint mouse |
17. What is the maximum amount of metatarsal head resection that should be done for a cheilectomy? | 30% |
18. If more than 30% of the metatarsal head is resected, what complication can happen? | subluxation of the 1st MTPJ |
19. What is the major complication of a Keller? | Hallux hyperextensino and elevation |
20. What are the benefits of a hemi implant over a total joint replacement? | maintaining length, and easier conversion to an arthrodesis if necessary |
21. What is the material most commonly used for 1st MPJ implants? | Chromium cobalt |
22. What is the strongest construct for a 1st MPJ arthrodesis? | dorsal plate with a compressions crew |
23. What is the desired position of the hallux for a 1st MPJ arthrodesis? | about 10-15 degrees dorsiflexion, frontal plane neutral ( 0 degrees), parallel to the toe, and 15 degrees abduction |
24. What is functional hallux limitus? | the lack of motion in the 1st MPJ ONLY during gait |
25. What is structural hallux limitus? | the adaptions of the 1st MPJ that prevent motion in the joint |
26. What is the name of the modification of an Austin that removes a small wafer of bone from the first metatarsal? | Youngswick |
27. What stage of hallux limitus is a joint sparing procedure appropriate? | Grade 1 and 2 |
28. What osteotomy derotated the articular surface of the first metatarsal? | Watermann |
29. In addition to the MPJ, what is a second joint is affected by hallux limitus? | the sesamoid apparatus |
30. When an autograph is planned for 1st metatarsal joint preservation and restoration, where is the donor site for the graft? | the talar head |
classifications
1. Classification for hallux limitus? | • Regnauld classification • Drago, Olof, and Jacobs classification • Modified Regnauld/Oloff |
2. What is the Modified Regnauld/Oloff classification? | Stage 1 – functional hallux limitus Stage 2 – joint adaptation Stage 3 – joint deterioration |
3. What symptoms or radiographic changes do you see in Regnauld/Oloff classification? | Stage 1 – No degeneration, no pain on range of motion, limited dorsiflexion weight-bearing Stage 2 – Metatarsal head flattening, dorsal exostosis, pain at end range of motion Stage 3 – asymmetric joint space narrowing, osteophytes, subchondral cysts, and subchondral sclerosis Stage 4 – no real range of motion (<10 degrees dorsiflexion), joint destruction, self-fusion of joint, loose bodies |
4. What is the Jahss classification used for? | for first metatarsal phalangeal joint dislocation |
5. what are the stages of Jahss classification? | Type 1 – proximal phalanx & sesamoids are dislocated dorsally (intersesamoid ligament intact) Type 2A -same as type 1 but, intersesamoid ligament ruptured Type 2B – same as type 1 but, sesamoid fractured transversely, inter ligament intact |
6. How do you treat each Jahss classification? | Type 1 – required open reduction and internal fixation (ORIF) Type 2A – closed reduction w/ CAM boot Type 2B – closed reduction w/ post-op shoe or remove fractured sesamoid |
7. Nail injury classification? | Rosenthal classification |
8. What is each zone of the Rosenthal classification? | Zone I – distal to the tip of the phalanx bone Zone II – distal to the tip of the lunula Zone III – proximal to the lunula |
9. Treatment for Rosenthal classification? | Zone I – if >1cm loss, apply a skin graft Zone II – Atasoy type or Kutler biaxial (V-Y advancement) Zone III – nail bed irreparable, amputation performed |
10. Classification for Freiberg’s disease | Smilie classification |
11. Stages of Smilie Classification? | Stage 1 – fracture on MRI Stage 2 -radiograph shows the dorsal collapse Stage 3 – dorsal met head collapse, plantar aspect intact Stage 4 – dorsal and plantar collapse Stage 5 – joint space narrowing, arthritic changes |
12. What is the 5th metatarsal fracture classification? | Stewart, Torg, and Chapman |
13. What are associated published articles with the 5th metatarsal base fracture? | Lawrence (1993) – differentiate the difference between Jones fracture, diaphyseal stress fracture, and avulsion fracture. Shereff (1991) – Apophysis fuses at 9-12 years old. Blood supply to the 5th base is poor, the nutrient artery supplies medial 1/3 of metatarsal shaft. |
14. Steward classification? | Fracture of the base of the 5th metatarsal “EIEIO” Type I: Extra-articular fx at metaphyseal-diaphyseal junction (True Jones Fracture) Type II: Intra-articular avulsion fracture Type III: Extra-articular avulsion fracture Type IV: Intra-articular, Comminuted Type V: Extra-articular avulsion fractures of the epiphysis; only occur in children (Salter-Harris Type I fracture) |