Classifications
| Questions | Answers |
| 1.Describe the Rosenthal Classification? | Zone 1 – Injury to distal phalanx Zone 2 – Distal to nail lunula – treatment is Atasoy flap (plantar V to Y) or Kutler flap (biaxial V to Y) Zone 3 – Distal to DIPJ – treatment generally amputation |
| 2.What is the Jahss classification? | Dislocation of the hallux Type 1 – Dorsal dislocation of proximal phalanx and sesamoids with intact intersesamodial ligamentType 2 – Dorsal dislocation of proximal phalanx and sesamoids A – ruptured intersesamoid ligament B – fracture of sesamoid with ruptured intersesamodial ligament |
| 3.What is the Stewart 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) |
| 4.What is the Torg classification? | Non-union base of the 5th metatarsal Type 1 – Acute injuries Type 2 – Delayed union Type 3 – Non-union |
| 5.Hardcastle classification?
Give the Quenu and Kuss description. |
Type A: Total incongruity in any plane (QK – Homolateral)Type B: Partial incongruity (QK – Isolateral) B1 – 1st met goes medial B2 – Lesser mets go lateralType C: Divergent (QK – Divergent) C1 – Partial (only 1st and 2nd mets) C2 – Total (all mets involved) |
| 6.Classification system for Navicular trauma? | Watson-Jones Type 1 – Navicular tuberosity Type 2 – Dorsal Lip Avulsion Type 3 – Navicular Body Fractures A: Coronal plane fracture B: Dorso-lateral to plantar-medial fracture C: Comminution Type 4 – Stress Fracture of the Navicular |
| 7.Berndt and Harty classification? | Talar dome fractures Type 1: Chondral Depression. Type 2: Partial OCD fracture Type 3: Nondisplaced complete OCD Type 4: Displaced complete OCD |
| 8.Hawkins classification? | Talar Neck Fractures Type 1 – Non-displaced (13% AVN) Type 2 – Displaced fx with STJ dislocation (AVN 50%) Type 3 – Displaced fx with STJ and ankle dislocation (95% AVN) Type 4 – Displaced STJ, AJ, TNJ dislocation (> 95% AVN) |
| 9.(SAD) Supination Adduction ankle fractures? | Stage 1 – Lateral collateral ligament tear, avulsion fibular fracture (Weber A) Stage 2 – Vertical medial malleolar fracture (Mueller D) |
| 10.(PAB) Pronation Abduction ankle fractures? | Stage 1 – Transverse avulsion fx medial malleolus/ deltoid rupture (Mueller B) Stage 2 – AITFL syndesmotic rupture or avulsion of its insertion Stage 3 – Short, oblique lateral malleolus fracture (Weber B), transverse on lateral radiograph |
| 11.(SER) Supination External Rotation ankle fractures? | Stage 1 – AITFL syndesmotic rupture or avulsion of its insertion
Stage 2 – Spiral lateral malleolus fracture (Weber B), long, posterior spike on lateral radiograph Stage 3 – PITFL syndesmotic rupture or avulsion of its insertion Stage 4 – Transverse avulsion fx medial malleolus/ deltoid rupture (Mueller B) |
| 12.(PER) Pronation External Rotation ankle fractures? | Stage 1 – Transverse avulsion fx medial malleolus/ deltoid rupture (Mueller B)
Stage 2 – AITFL syndesmotic rupture or avulsion of its insertion Stage 3 – Oblique or spiral fibular fracture suprasyndesmotic (Weber C) Stage 4 – PITFL syndesmotic rupture or avulsion of its insertion |
| 13.Give the stages in Pronation Dorsiflexion ankle fractures. | Stage 1 – Deltoid rupture Stage 2 – Dorsal tibial lip fracture Stage 3 – High fibular fracture Stage 4 – Posterior avulusion/ fracture |
| 14.Sneppen classification? | Talar body fractures Type 1: Osteochondral fracture. Type 2: Sagittal, coronal, transverse body fracture. Type 3: Posterior tubercle fracture. Type 4: Lateral process fracture. Type 5: Crush fracture. |
| 15.Sanders classification system? |
Uses widest view of the posterior facet on semicoronal CT cut. Type 1: Non-displaced articular fx. A/B/C division – A is lateral, B central, and C medial to sustentaculum tali |
| 16.Rowe Classification for calcaneal fractures? | Type 1 A – Plantar tuberosity fractures B – Sus tali fracture C – Anterior process fractures Type 2 A – Extra-articular “beak” fracture of the posterior-superior calcaneal body B – Intra-articular “tongue-type” Achilles avulsion fracture Type 3 – Extra-articular calcaneal body fx Type 4 – Intra-articular comminuted fx Type 5 – Intra-articular Joint Depression |
| 17.Essex-Lopresti fracture classification? |
Tongue-type and Joint Depression fx
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| 18.What is Hawkins sign and when does it appear? | subchondral radiolucent band that occurs in the talar dome, appears 6-8 weeks |
| 19.Common mechanism of injury for a Lisfranc’s fracture? | Forced dorsiflexion on a plantarflexed foot |
| 20.What does the Lisfranc ligament connect? | base of the second met to the lateral side of the medial cuneiform |
| 21.What are some potential causes of dropfoot? | Trauma to fibula neck (deep peroneal nerve), Guillain-Barre, Charcot-Marie Tooth disease, compartment syndrome |
| 22.What is skin tenting? | when the bone elevates the skin and causes it to lose vascularity |
| 23.What type of anesthesia is most commonly used when you are trying to reduce an ankle fracture? | Hematoma block |
| 24.Where is Tillaux-Chaput fx located? | AITFL avulsion from the anterolateral tibia |
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25.Where is Wagstaff fx located?
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AITFL avulsion from the anteromedial fibula |
| 26.Where is the Volkmann fx located? | PITFL avulsion from the posterior-lateral tibia |
| 27.Where is the Bosworth fx located? | PITFL avulsion from the posterior-medial fibula |
| 28.What is the classification system for acute Achilles Tendon Rupture? | Kuwada Type 1 – Partial tear involving <50% of tendon Type 2 – Complete tear w/ 6cm deficit |
| 29.What is strain? | change in length over original length |
| 30.Time it takes for a stress fracture to appear on x-ray ? | 10-21 days because 30-50% of the cortex has been lost |
| 31.Weber and Cech classification for non union fractures? | 1) Hypertrophic – elephant foot, horse hoot, oligotorophic
2) Atrophic – torsion wedge, comminuted, defect, atrophic |
| 32.Muller Classification for medial malleolar fracture? |
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Open Fractures
| Questions | |
| 1.What are 5 podiatric surgical emergencies? | 1. Infection with emphysema (gas gangrene) 2. Open fracture/dislocation 3. Compartment syndrome 4. Necrotizing Fasciitis 5. Neurovascular compromise |
| 2.Treatment of open fractures? |
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| 3.What are the 6″P’s” of compartment syndrome? |
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| 4.How to diagnose compartment syndrome? | Diagnose when pressure reading is above 30-40mmHg |
| 5.What instrument do you use? | wicks catheder |
| 6.Gustilo-Anderson Classification System: | Type 1 – wound <1cm, no extensive soft tissue damage
Type 2 – >1cm no extensive soft tissue damage Type 3 – Wound >5cm w/ extensive soft tissue damage |
| 7. What antibiotics are recommended in the original Gustilo-Anderson article for Class I, II, and III open fractures? |
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| 8.Treatment for Gustilo-Anderson Classification of Open Fractures IIIB? | Extensive soft tissue damage with periosteal stripping and massive contamination. Cannot reapproximate soft tissue coverage
Abx choice: Ancef (or high dose PCN), Clindamycin and Aminoglycoside |
| 9.Gustilo-Anderson Classification of Open Fractures IIIC | Extensive soft tissue damage with periosteal stripping and massive contamination Cannot reapproximate soft tissue coverage Arterial damage requiring primary repair Abx choice: Ancef (or high dose PCN), Clindamycin and Aminoglycoside |
| 10.What is is a gun shot wound considered in the classification system? | automatically it is Gustilo-Anderson type III (3) |
| 11.What antibiotic do you need in the case of a soil-contaminated wound? | penicillin |
| Which Abx in open fractures? | Grade 1: 1st gen cephalosporin (Ancef) Grade 2/3: add gentamicin |
| ABCDE’s of Trauma? | Airway, Breathing, Circulation, Disability, Environment |
| Why are open fractures considered emergenyc? | bone sensitive to infection, significant forece damages blood vessels |
| A farm injury is considered what Gustilo classification? | Type 3 |
| MESS classification (1990) | mangled extremity severity score, a score of >7 increases likelihood of amputation |
| What are the basic principles in open fracture? |
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| What if you are allergic to Ancef? | Clindamycin 600mg QID |
| What if your open wound is exposed to water? | Ciprofloxacin 400-600mg BID |
| Antibiotic treatment for open fractures? |
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| When do you stop abx? | 3 days if no active infection and final closure |
| Tetanus toxoid protocol? | Tetanus toxoid (0.5mL) 3 injections given as infancy, 1 give 4-7 yo, 1 given 12-15 yo, and booster required every 10 years. |
| Tetanus Immunoglobulin protocol? | Tetanus immunoglobulin (250 units). If wound clean = none given. Dirty wound = give 250 units IM |
| How many liters of saline you give per Gustillo Anderson classification to irrigate wound? |
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| What do you clean wounds with? | Sterile saline (effective), lactated ringer, soap |
| What do you not want to use to clean wound? | betadine solurion, hydrogen peroxide, chlorohexidine is too caustic and damages soft tissue |
External fixation
| What are some advantages of Ex-Fix? | -good for closed or limited open surgery -achieves multilevel correction -gradual lengthening -postoperative adjustments -possible early WB -good wound surveilance |
| What are the disadvantages? |
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| What are the materials involved in an Ex-Fix? |
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| What are the types of Ex-Fix? |
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| What are Ex-Fix made of? | stainless steel/titanium |
| Describe a unilateral Ex-Fix? | half pins in a linear placement clamp to a fixator (i.e. mini rail) |
| When do you use a unilateral Ex-Fix? | lengthening, primary fusion, stability |
| What is a weakness of using a unilateral Ex-Fix? | No stability in the sagittal plane, so it can still move a lot. |
| What are the two types of circular Ex-Fix? | Ilizarov & Taylor Spatial Frame |
| What are the properties of an Ilizarov Ex-Fix? |
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| What is the mechanism of action for an Ilizarov? | It adds stabilization by the use of tension wires and half-pins are screwed to the bone. |
| What is the difference between Ilizarov and Taylor Spatial Frame? | Taylor Spatial Frame allows triplane reduction. Taylor Spatial Frame you need to reduce the deformity before adding on the ex-fix. |
| What is the mechanism of a Spatial Frame? | Stability is created using rings and tension wires. When the wires are placed under tension, there is an increase in bone stability. |
| What is a hybrid frame? | Combines one circular frame and at least one unilateral frame |
| When would you apply an Ex-Fix in an acute setting? |
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| What are the three segments of concern when applying an Ex-fix? |
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| What are we concerned at the neck of the fibula? | The common peroneal nerve |
| Where is the K wire inserted at the first segment? | Transfibular wires at this level must be inserted through the head of the fibula and away from the neck. |
| What are we concerned about at the ankle joint line? |
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| 44.What are indications for a pin to bar exfix? | -post trauma stabilization -arthrodesis -intraoperative tool |
| 45.What are 4 main types of EXFIXES? | -pin to bar (delta frame) -circular frame (Static or spatial) -monolateral (minirail) -hybrid (circular + delta) |
| 46.What is another name for the monolateral exfix? | minirail, for callus distrction in brachymeatarsia |
Pilon Fractures
| 1.What does CORA stand for? | Center of Rotation Axis |
| 2.What is the vassal principle? | Fixture/stabilization of the primary dislocation will cause the secondary dislocations to reduce. “Restore the keystone and the rest will follow” |
| 3.What is ligamento taxis? | ligaments help reduce secondary dislocations when the primary/keystone dislocation is stabilized and reduced. |
| 4.What are the three steps to closed reduction? Charle’s principles? |
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| 56.What are the three most popular narcotics used for analgesia during closed reductions? | -fentanyl -dilaudid -morphine |
| 57.What are the 4 most common sedatived used for closed reductions? | -propofol -ketamine -etomidate -midazolam |
| 48.Where are pilon fx? | at distal tibia and its articular surface |
| 49.What are the two main mechanism of action of pilon fx? |
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| Describe a pilon fx caused by axial loading. | -caused by high energy injury -articular comminution and impaction -metaphyseal comminution -major fragment displacement (widening) -soft tissue insult |
| What are three types of plates used to fix a tibia? |
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| 52.What are the stages of treatment for a high energy pilon fx? | 1) Exfix for traction and stability 2) CT for preop planning 3) Elevate and wait for swelling to go down 4) Reconstruction |
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