review - acfas surgical review book

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V ur era Review Booklet( & a f e w o t h e r f o r i m p o r t a n t i t e m s e x t e r n s h i p s ) O C p M ' s O f f i c e r s f ^ C f f l l ) o f 2 0 0 5

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All pictures came from class notes / handouts. Most of the pictures were referenced from Dr. Hetherington's book.

2

Tabliz of Contents: Topic ChartingSurgical Consult Pre-Op Note Post-Op Order Admission Order & Note Post-Op Note Post-Op Visit

Page #6 6 6 6 7 7

Layers of the Foot Key Lab Values Hospitalization Indications Post-Op Fever Etiologies SuturesTypes Selection Technique

8 8 9 910 11 11 12 13 14 15 16 17 18

Classification SystemsStewart, Salter-Harris Gustillo-Anderson, WatsonJones, Freiberg Berndt-Hardy, Hawkin Sneppen, Watson & Dobas, Kuwada Rowe, Sander's Hardcastle, Dias, Danis-Weber Lauge-Hansen

MRI Anesthesia Anesthetics Dosing Onset/Duration Increasing Comfort Ankle Block Hemostasis = Tourniquet Pressures3

19 20 20 20 21 21 21

Tablsz o j Contents (Continued): Topic Corticosteroid Injections Types Side Effects Cocktails Radiographic Data Joint Deformities Osteotomies Proximal Shaft Distal Internal Fixation Principles Rule of 2's K-Wires Steinmann Pins Monofilament Wire Tension Band Wiring Staples Screws Anatomy Types Fixation Technique Selection Soft Tissue Anchors Plates Page # 22 22 22 23 24 25-27 29-30 31-33 34 34 34 34 35 36 37 38-39 40-41 42-43 44 45 45-46

Table of Contents (Continued): Topic External Fixation Principles Complications Types Dynamics Care & Management Forefoot Pathologies / Surgical Procedures Hallux Limitus/Rigidus Hammertoes Etiologies for Contracted Digits 5th Digit Arthroplasty Rearfoot Surgery Plantar Fasciotomy Haglund's Deformity Keck & Kelly Osteotomies Tendon Transfers & Indications Adductor Hallucis Abductor Hallucis Extensor Hallucis Longus Jones Suspension Hibbs Tibialis Anterior STATT Cobb Tibialis Posterior Peroneus Longus Bunions based on Angles Other things to know... Pase # 47 48 48-49 50 50 51-52 53-56 57 58 59 59 60 60 60 60 60 61 61 61 62 62 63 67

CHARTING SURGICAL CONSULT

1. 2. 3. 4. 5. 6. 7.

Chief Complaint HPI (NLDOCAT) Allergies Medications Social History Medications Family History

8. Primary Care Dr 9. Hospitalizations 10. RoS > Vitals / Vascular / Neuro / Derm / Musculoskeletal 11. Ancillary (x-rays, labs, ect...)

PRE-OP NOTE

Surgeon Medications Pre-Op Dx Allergies Planned Procedure Diagnostic Data - Labs, x-rays, EKG, ect... Consent Form: Describe Procedure & Care / Complications / Alleviations / Expected Outcomes / Arrange Pre-Op Testing "Consent form was reviewed with patient, signed and placed in chart." "All risks, possible complication and alternative treatments have been discussed with the patient in detail. All patients' questions have been answered to satisfaction. No guarantees to the outcome have been made."POST-OPERATIVE ORDERS: ADMISSION O R D E R S & NOTE:

VANDIMAX Date/Time/Signature Vitals Activities Nursing Diet Ins/Outs Meds Ancillary X-ray

ADC - VAAN DILM A X Date/Time/Signature Admit to Dx Condition -

Vitals Activities Allergies Nursing Diet Ins/Outs Labs Meds Ancillary X-ray

6

P O S T - O P NOTE: S A P P A I T E M I F C 2 P 3

Findings Surgeon Hemostasis - type Pathology Assistants Estimated Blood Loss Prophylaxis Pre-Op Diagnosis Materials - sutures/hardware Post-Op Diagnosis Injectables - any post-incision Complications Condition Procedure Anesthesia - type / how much "Patient tolerated procedure and anesthesia well. Patient transported to recovery by anesthesia with vital signs stable and vascular status intact." Also may include.. Pathology - bone, ST; Condition - stable, guarded, fair, poor; Prophylaxis

P O S T - O P VISIT: S O A P

Subjective 1. POV# , PVD # 2. Procedure 3. N,V,C,F,SOB 4. Activity status 5. Pain / How controlled 6. Other Complaints Objective 1. How patient presents - walking, wheelchair 2. Vascular, Neuro, Derm, Musculoskeletal Assessment 1. Status Post-Op 2. Compliance Plan 1. Treatment 2. Dr & Residents7

L A Y E R OF T H E F O O T

1st Layer 1. Abductor Hallucis M. 2. Abductor Digiti Minimi M. 3. Flexor Digitorum Brevis M. 2nd Layer 1. Quadratus Plantae M. 2. Lumbricales M. 3rd Layer 1. Flexor Hallucis Brevis M. 2. Flexor Digiti Minimi M. 3. Adductor Hallucis M. 4th Layer 1. Dorsal Interossei M. (4) 2. Plantar Interossei M. (3)KEY LAB VALUES

(136-145mEq/L) (97-107mEq/L)

Chem 7 Na K

(5-20mg/dL)

CI CO

BUN / Glucose Cr(lcm in length Clean, minimal soft tissue necrosis Usually traverse or short oblon Type III Fracture with open wound >5cm in length Contamination and/or necrosis of skin, muscle, NV, & ST Comminuted > Type Ilia Adequate bone coverage > Type Illb Extensive soft tissue loss with periosteal stripping and bone exposure > Type IIIc " Arterial injury needing repairNAVICULAR FRACTURE - WATSON JONES

Type 1 Navicular tuberosity fracture Type II Avulsion fracture of dorsal lip Type III A: Transverse body fracture - Nondisplaced B: Transverse body fracture - Displaced Type IV Stress fractureF R E I B E R G CLASSIFICATION - A V N OF 2 N D M E T

Type I Type II Type III Type IV

No DJD Articular cartilage intact Peri-articular spurs Articular cartilage intact Severe DJD Loss of Articular Cartilage Epiphyseal dysplasia; multiple head involvement13

B E R N D T - H A R D Y CLASSIFICATION OF T A L A R D O M E L E S I O N S

Stage I Compression lesion or non-visible lesion Stage II Fragment attached Stage III Non-displaced fragment without attachment Stage IV Displaced fragmentT A L A R N E C K F R A C T U R E CLASSIFICATION - H A W K I N ' S

Type I Non-displaced talar neck Disrupts blood vessels entering dorsal talar neck and intra-osseous vessels 20% chance AVN Type II Displaced talar neck fracture with subluxed or dislocated STJ Disrupts dorsal neck arterial branches and branches entering from inferiorly from sinus tarsi & tarsal canal 40% chance AVN Type III Displaced talar neck fracture with dislocated STJ & ankle joint Disrupts all 3 major blood supplies 100% chance AVN Type IV Displaced talar neck fracture with complete dislocation of STJ Ankle joint + subluxation or dislocation of the talonavicular joint Disrupts all 3 major blood supplies 100% chance AVN14

SNEPPEX CLASSIFICATION OF T A L A R B O D Y LESIONS

Group I Transchondral / Compression fracture of the talar dome Group II Coronal/Sagital/Horizontal shearing fracture of the entire body Type I Coronal or Sagital A: Non-displaced B: Displacement of trochlear articular surface C: Displacement of trochlear articular surface with associated STJ dislocation D: Total dislocation of the talar body Type II Horizontal A: Non-displaced B: Displacement Group III Fracture of posterior tubercle of talus Group IV Fracture of lateral process of talus Group V Crush fracture of the talar bodyW A T S O N & D O B A S CLASSIFICATION POSTERIOR L A T E R A L T U B E R C L E OF T A L U S ( S H E P A R D ' S F R A C T U R E )

Stage Stage Stage Stage

I II III IV

Normal Lateral talar process with no clinical significance Enlarged posterior lateral tubercle of the talus (Steida's Proccss) Accessory bone / Os Trigonum that may be irritated by trauma Os Trigonum + cartilaginous/synchrondrotic union with talusK U W A D A CLASSIFICATION OF A C H I L L E S R U P T U R E

Type I Type II Type III Type IV

Partial rupture Complete rupture Complete rupture Complete rupture

6cm gap

15

R O W E CLASSIFICATION OF C A L C A N E A L F R A C T U R E S

Type

I

A B C A B

Medial Tuberosity fracture Sustentaculum Tali fracture Anterior Process fracture Posterior break fracture withow? Achilles involved Posterior break fracture with Achilles involvement Extra-articular body fracture Intra-articular body fracture without depression

Type

II

Type Type Type

III IV V A B

Comminuted, Intra-articular fracture with depression Comminuted fracture with severe joint depression

S A N D E R ' S C T CLASSIFICATION OF C A L C A N E A L F R A C T U R E S

* Fractures are classified according to the number of intra-articular fragments and location of fracture lines # of Fractures Type I Any non-displaced intra-articular fracture Type II 1 fracture through posterior facet creating 2 fragments Type III 2 fractures through the posterior facet creating 3 fragments Type IV 3~ intra-articular fracture lines Location of Fracture Lines:

16

LISFRANC'S F R A C T U R E CLASSIFICATION - H A R D C A S T L E

Type A: Total or Homolateral - Disruption of the entire Lisfranc joint - Transverse or Sagital plane - Most common type Type B: Partial B1 - Medial incongruity with the first met forced medially - Involves 1st met OR mets 2,3,4 but NOT 5 B2 - Lateral incongruity with lesser mets forced laterally Type C: Divergent CI - Partial divergence with the I s ' met medial and 2nd met laterally displaced C2 - Total divergence with the 1st met displaced medially and lesser mets displaced laterallyD I A S CLASSIFICATION OF L A T E R A L A N K L E L I G A M E N T INJURY

Grade Grade Grade Grade

I II III IV

> Partial rupture of CFL = > Complete rupture of ATFL = Complete rapture of ATFL, CFL, &/or PTFL = Complete rapture of all 3: ATFL, CFL, & PTFL = + Partial rupture of the Deltoid LigINVOLVED IN A N K L E F R A C T U R E S

D A N I S - W E B E R CLASSIFICATION OF F I B U L A R F R A C T U R E S

Type A Type B TypeC

Transverse avulsion fibular frac

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