Forefoot

Nail

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?
  1. edge nail avulsion (slant back, wedge resection)
  2. partial nail matrixectomy
  3. partial chemical nail matrixectomy
  4. complete nail matrixectomy
20.What materials do you need for a partial nail matrixectomy?
  • English anvil
  • or beaver blade
  • spatula
  • tourniquet
  • gauze 4×4
  • curette
  • Kelly forceps
  • phenol solution
  • alcohol irrigation
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? 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.

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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
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?
  • lateral collateral lig
  • lateral phalangeal-metatarsal lig
  • fibular sesamoid lig
  • adductor halluces
  • flexor hallucis brevis tendon
  • deep transverse metatarsal lig
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?
  1. Medial capsulotomy
  2. Exostectomy – Medial eminence
  3. Section off DTML
  4. Release conjoined Adductor tendon
  5. Sesamodiectomy
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
What causes Hallux Varus?
  1. Steaking the metatarsal head
  2. Aggressive capsulotomy
  3. Fibular sesamoidectomy
  4. Down’s syndrome
 Treatments for Hallux Varus? first, try Soft tissue balance -> if fail try tightrope -> if all fails, do Arthrodesis (salvage procedure)
Akin: When to use it? screw size? Post-op?
  •  HAIA, rectus HAA
  • Screws 2.7, 2.0, stables
  • Post-op: WB boot or post op shoe
Austin: When to use it? screw size? Post-op?
  • ↑IMA, ↑↑ HAA
  • 60° angle cut, chevron
  • Screw 3.0, 3.5, or K-wire fixation
  • WB CAM boot or post-op shoe
Lapidus: When to use it? screw size? Post-op?
  •  ↑↑IMA, hypermobile
  • “2 screws + homerun screw”
  • Screw 3.4, 4.0 cannulated *lag by design
  • NWB!! 6-8 weeks, 3 weeks CAM boot
 Hallux limitus/Rigidus etiology?
  • Biomechanics: hypermobile 1st Ray, pronation, raised hallux
  • Traumatic: dislocation, fracture sesamoid
  • Imbalance: Weak peroneus longus, overpower anterior tibial tendon
  • Structural: dorsiflex 1st metatarsal, long phalanx
  • Iatrogenic: 2nd to previous bunion surgery!
Radiographic findings of HL/HR? Dorsal osteophyte, met. primus elavatus, eburnation, joint space narrowing, met. head flattening, subchondral sclerosis
Walk me through a Kalish osteotomy, pretend you are on the phone dictating:
  1. #15 incision dorsal medial to EHL
  2. Double/single prong skin hooks
  3. Blunt dissection with MAYO scissors
  4. Lateral release of adductor hallucis, sesamoid ligament, DMT
  5. Capsulotomy: H, L, T, or linear cut
  6. Reflect met. head
  7. Saw off medial eminence, then saline flush foot
  8. K-wire
  9. Saw, use Reece guide for Kalish angle
  10. Shift capital fragment
  11. Add screw (3.5 fully threaded)
    • Overdrill 3.5
    • Under drill 2.5
    • Countersink
    • Measure
    • Tap
    • Screw “2 fingers tightened”
  12. Medial overhang saw off
  13. Capsularaphy: 3.0 Vicryl
  14. Subcutaneous: 4.0 Vicryl, tapered needle
  15. Skin: Proline or Nylon 4.0

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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?
  • use Mini-Rail
  • Distract 1.0mm a day
  • wait 7-14 days after surgery to start
  • can walk immediately post-op
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
  1.  Kelikian Push up test during each step
  2. Long extensor hood resection
  3. Long extensor tenotomy
  4. PIPJ capsulotomy with arthroplasty or arthrodesis
  5. MTPJ capsulotomy
  6. MTPJ flexor plate release(McGlamry elevator)
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
What is a tailor’s bunion? the dorsal lateral prominence of the 5th metatarsal head
What is the classification system for tailor’s bunion?  Fallat & Buckholtz

  1. enlarged 5th met head
  2. lateral bowing of shaft
  3. increase IMA angle
Symptoms of tailor’s bunion? pain dorsolateral, bony prominence, bursa, hyperkeratotic. Rule out lister’s corn
 Treatment for tailor’s bunion? A wider toe box, NSAIDS, padding, RICE, surgery (distal osteotomy, etc.)
 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.
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

What are surgical treatments? 4.5 mm malleolar screw, plate & screws, Radial hook plate, tension-band wire
Name the neuromas of the foot and location:
  • Joplin’s neuroma – medial Hallux
  • Houser’s – 1st interspace
  • Heuter’s – 2nd interspace
  • Morton’s – 3rd interspace
  • Islen’s – 4th interspace
What is Morton’s Neuroma? not a true neuroma but a thickening (callus) of the nerve in between the 3rd and 4th digit interspace .
 Clinical signs of Morton’s Neuroma?
  • Mulder’s click
  • dorsal percussion (Tinel/Valleix sign)
  • Metatarsal head squeeze
  • does it feel like a stone pebble?
  • worse in wearing heels
 Treatment for Morton’s Neuroma?
  • Metatarsal Pad to splay toes
  • custom FFO orthotics
  • cortisone steroid injection
  • Sclerosing alcohol injection (x4 shots)
  • Cryogenic neuroblation (-50C)
  • Surgery: Neuroectomy (20% return rate)
Types of toe deformities? Claw toe, mallet toe, hammer toe
Etiology of hammertoes? Flexor stabilization, Extensor substitution, Flerox substitution
 Describe flexor stabilization: During the stance phase of walking, in a pronated foot type, the flexors will overpower the interossei muscles. (most common)
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.
 Describe Flexor substitution: During stance phase, in a pes cavus foot, the deep muscles (FHL, FDL) overpower the interossei muscles. (Least common)
How do you get 4th and/or 5th digit adductor varus formation? weak or cut QP muscle
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

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Classification

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
Stage 4 – ankylosis
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 Jahss classification used for? for 1st metatarsal 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
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 5th metatarsal fracture classifications?  Stewart, Torg, and Chapman
13.What are associated published articles with 5th met base fractures? 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.Stewart Classification system? 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)