Trauma 6/30/2014 10:13:00 AM

-Trauma Work-up:
1) Primary Survey (ABCDE)
o Airway look for any obstruction
o Breathing labored vs. non-labored breath sounds
o Circulation asses all 4 extremities
Start 2 large bore (18 gauge) needle if fluids needed
o Deficits
AVPU (Alert, Verbal stim, Painful stim, Unresponsive)
Glasgow (Eye opening, Verbal response, Motor reponse)
13(+) good prognosis
< 8 intubate
o Exposure complete exposure to asses all damage
2) Secondary Survey
o Clear C-spine (Miami-J, Philly, Malibu)
Palpate down spine, the 4 neck motions
o Detailed HPI, PMH
o Comprehensive physical exam
3) History
o PMH, FH, SH, Allergies, Meds, Social
o Estimated blood loss & Initial treatment
4) Tetanus
o Cause Clostridium tetani G (+) bacillus
o Tetanus prone wound:
6 hrs old, infected, deep, devitalized tissue, MOI
o Symptoms trismus, risus sardonicus, aphagia
o Algorithm:
Complete tetanus status (booster w/in 5 yrs)
Hold Toxoid & TIG regardless of wound
Incomplete tetanus status (No booster w/in 5 yrs)
Clean Toxoid (0.5 ml IM in deltoid)
Tetanus prone Toxoid + TIG (250 u IM)
5) NPO Status
o Nothing by mouth after midnight night before elective surgery
o Nothing by mouth w/in 6-8 hrs of any type of surgery
6) Physical
o Vitals, Vasc, Neuro, Derm, Musculoskeletal
7) Local Wound care
o Cleanse and irrigate with betadine
o Explore for further damage or retained foreign bodies
o Stop bleeders surgicel or hand-ties
o Take deep cultures (aerobic, anaerobic, acid-fast, fungal)
8) Decision planning for wound closure
o If at all questionable pulse lavage and pack open
o DPC in 5 days

-Podiatric Emergences: (CONG)
Compartment syndrome
Open fracture/dislocation
Necrotizing fasciitis
Gas gangrene

-Mangled Extremity Severity Score (MESS)
Criteria (LASS)
o Limb ischemia, Age, Skeletal/soft tissue injury, Shock
Score (1-11)
o 7 (+) high risk for amputation

-Open fractures
Dont close until devitalized tissue has demarcated, but no always
Gustilo Anderson
o I) Clean wound < 1 cm
Abx Ancef (2g on admission then 1g q8 for 72 hrs)
o 2) Wound 1-5 cm w/ minimal soft tissue damage
Abx Ancef + Clindamycin (600 mg q8)
o 3) Wound > 5 cm w/ extensive soft tissue damage
A- adequate soft tissue
B- soft tissue damage w/ periosteal stripping & massive
contamination
C- arterial damage requiring primary repair amputate
Abx Ancef, Clindamycin, Aminoglycoside (1.5 mg/kg)

-Fracture Blister
Located in Subepidermal layer similar to 2
nd
degree burn
Types:
o Clear fluid very tense (most common)
o Hemorrhagic flaccid roof (most severe)
Treatment:
o Never incise thru due to risk of open fracture underneath
o Wait until re-epithelization

-Shock
Symptoms tachycardia, tachypnea, delayed CFT, mental status
change, hypotensive, decreased urinary & H&H
Types:
o Hypovolemic acute loss of circulating blood
o Septic secondary to infection
Treatment:
o Aggressive fluid replacement

-Puncture wounds
Only remove if:
o Contaminated object, local infection, pain, intra-articular
Puncture wound bugs:
o Most common Staph aureus & Beta-hemolytic strep
o Thru shoe Pseudomona
o Farming Clostridium
Classifications:
o Resnick
1 Superficial visible w/ no infection
2 SubQ or articular w/ no infection
3A SubQ or articular w/ signs of infection
3B Bone penetration w/ no infection
4 Bone penetration w/ OM
o Patzakis
Zone 1 Toe to Met head (50% incidence of OM)
Zone 2 Midfoot (17% incidence of OM)
Zone 3 Calcaneus (33% incidence of OM)
Treatment:
o Tetanus Antibiotics Aggressive I&D w/ copious lavage

-Compartment syndrome
Definition interstitial pressure exceeds capillary hydrostatic
pressure (microcirculation shuts down)
Symptoms (7 Ps)
o **Pain out prop, Pain w/ toe dorsiflexion, Paresthesia, Pallor,
Pulselessness, Pressure, Paralysis
Diagnosis Intracompartmental pressure > 30 mmHg
Treatment:
o Remove all cast or dressing
o Do NOT elevate (cause more ischemia)
o Hydration (prevents effects of myoglobinuria associated with
rhabdomyolysis muscle destruction)
Myoglobinuria brown urine
o Fasciotomy (should be made w/in 8 hrs of injury)
Dual dorsal incision made over 2
nd
and 4
th
mets
One medial inferior to 1
st
met and across
Lateral leg anterior & lateral compartments
Medial leg superficial & deep posterior compartments
Complications:
o Volkmans contracture ischemia causing muscle necrosis
leading to scar formation/contracture
o Irreversible damage if left untreated for > 12 hrs
Both motor & sensory damage
o Kidney Failure- secondary to myoglobinuria

-Pilon Fracture
Definition result of direct impact of talar trochlea against the
distial tibia articular surface
Classifications:
o Ruedi & Allgower
1 mild displacement w/ NO comminution or disruption
2 moderate dispacement w/ significant dislocation
3 explosion fx severe communition & dislcation
o AO-ASIF
Type A (Extra-articular)
1) simple 2) wedge 3) complex
Type B (Partial-articular)
1) split 2) split-depression 3) multi-frag
Type C (Complete-articular)
1) simple 2) multi-frag 3) exploded
o Ovadia-Beals
Type 1 intra-artic w/ no displcement
Type 2 minimal displacemt
Type 3 displaced + severe large fragment
Type 4 displaced + multiple fragments
Type 5 severe comminution
Treatment
o Roy Sanders, MD, 9/21/2000 at Loyola University
1) Plate fibula
2) External fixation Delta frame 10-21 days
Maintains skeletal architecure
Allows stable environment for soft tissue enevelope to
heal
3) Fixate tibia
o AO ORIF reduction order (FABB)
1) Fibular reconstruction
2) Articular surface of tibia recon
3) Bone graft in metaphyseal deficit
4) Buttress plate the tibia

Lisfranc Trauma 6/30/2014 10:13:00 AM
-Introduction
Definition Any subluxation, dislocation, or fracture dislocation of
TMTJ complex
o Misdiagnosed in 20% of cases
History
o Dr. Jacques Lisfranc served under Napoleons army where he
was a trauma surgeon in 1820s
Anatomy
o TMTJ
-9 bones, 13 joints, 7 dorsal lig, 7 plantar lig
Stronger plantar ligaments
-Keystone- recessed 8 mm creating mortise
o Columns (Myerson) & Motion sagittal plane (Shereff)
Medial 1
st
met & MC (4 mm motion)
Central 2
nd
& 3
rd
, IC, LC (1 mm motion)
Lateral 4
th
& 5
th
, Cuboid (10 mm motion)
-Mechanism of injury
Indirect
o Twisting abduction of FF on lesser tarsus
Nutcracker injury 2
nd
met + cuboid fx
o Axial Loading axial compression on plantarflex foot
Parachute jumper
Direct
o Crush excessive weight forced plantar or dorsal
-Diagnosis
Clinical
o Midfoot tenderness worse w/ pronation or abduction
o Plantar ecchymosis Mondurs sign
o Inability to rise on toes
o Palpable tenderness to cuboid Nutcracker injury
o MUST RULE OUT COMPARTMENT SYNDROME
Plain film
o AP view
Diastasis gapping b/w 1
st
& 2
nd
bases >2-3mm
Fleck sign avulsion fx of 1
st
IM space (90% cases)
Medial border 2
nd
met lines up w/ IC
o MO view
Medial border 4
th
met continuous w/ medial cuboid
Lateral border 3
rd
met continuous w/ lateral LC
o Lateral view
Nutcracker fx compression fx of cuboid
Sagittal plane displacement
o CT Scan
More sensitive for detecting minor displacement &
fractures

-Classification
Quenu & Kuss (1902) A) homolateral B) Isolateral C) Divergent
Hardcastle (1982) A) Total incongruity B) Partial C) Divergent
Myersons modification (1986)
o Type A Total incongruity
May be sagittal, coronal or combined
o Type B Partial incongruity
B1- incongruity of 1
st
met (medial direction)
B2- incongruity of lesser mets (lateral direction)
o Type C Divergent pattern
C1- Partial (only 1
st
& 2
nd
mets involved)
C2- Total (all mets involved
-Treatment
Literature
o Strongly suggests ORIF w/ displacement >2 mm between 1
st

and 2
nd
met bases
o Ly & Coetzee primary arthrodesis of medial 2 or 3 rays is
better than ORIF in "Purley ligamentous injury
Non-operative
o When plain films show no displacement
o NWB SLC for 6 weeks w/ films every 2 weeks
Operative
o Goals:
Reduction & stabilization of medial column
Reduce but do NOT fix lateral column cuz of excess
motion because of pronating mobile adapter
o Incisions
1
st
webspace access to 1
st
, 2
nd
, 3
rd
and cuneiforms
4
th
webspace 4
th
& 5
th
mets and cuboid
o Fixation
Order:
OCPM: MC-2
nd
met 1
st
met-MC IC Lateral
mets
Kelkikian: Medial column LFL Lateral rays
Hardware:
PerQ cross K-wires
PerQ k-wires (rays 4 & 5) & ORIF of rays 1-3
ORIF w/ screws or plates
External fixation
Partial or full arthrodesis
Lateral column:
K-wires from 4
th
or 5
th
met to cuboid
Nutcracker fx H-plate or external fixation
o Post-operative
Jones compression w/ splint 2 weeks
NWB SLC for 6-8 weeks
Transitioned into PWB SLC for 4 weeks
High impact activity not till 6 months
o Complications
Arthritis, DJD, CRPS, Compartment syndrome, Cuboid
syndrome, Additional surgery/fusion

Ankle Fractures 6/30/2014 10:13:00 AM
Introduction
Anatomy
o Ligaments:
-Lateral ATFL (weakest) , CFL (extracapsular), PTFL (strongest)
105 angle between CFL & ATFL
o -Medial
Superficial
Calcaneotibial strongest
Superficialposterior Talotibial taut in DF
Tibonavicular weakest
Deep
Anterior Talotibial taut when PF
Makes up medial gutter of ankle
Deep-posterior Talotibial taut when DF
o -Syndesmotic
AITFL & PITFL additional stability
Transverse TF forms part of ankle mortise
Interosseous TF prevents talus from wedging

-Classification
Lauge-Hansen position then direction
o SAD (suppination-adduction)
1) fibular fx or lateral collateral ligament tear
2) vertical medial malleolar fx
o SER (supination-ext rotational)
1) ATFL rupture 2) Spiral fibular fx (post spike)
3) PTFL rupture 4) Med malleolar fx/deltoid rupture
o PAB (pronation-abduction)
1) Med mall fx/deltoid rupture
2) ATFL rupture
3) Short oblique fibular fx (transverse on lateral)
o PER (pronation-ext rotational)
1) Med mall fx/deltoid rupture 2) ATFL rupture
3) High spiral fib fx 4) PTFL rupture
Daniis-Weber/AO
o A) Infra-sydnesmotic
1) Unifocal
2) Bifocal
3) Circumferential
B) Trans-sydnesmotic
1) Isolated lateral
2) Lateral & Medial
3) Later, Medial & Posterior
C) Supra-sydnesmotic
1) Simple diaphyseal
2) Multifragmentary
3) Proximal
Mueller
A) avulsion B) transverse @ mortise C) oblique D) vertical

Additional Names:
o Tillaux-chaput ATFL avulsion from AL Tibia
o Volkman PTFL avulsion from PL Tibia
o Wagstaff ATFL avulsion from AM Fibula
o Bosworth PTFL avulsion from PM Fibula
o Dupuytrens Bimall w/ talus wedged bw/ fib & tib
o Potts Bimall fx
o Destots trimall fx
-Clinical Diagnosis
Palpate:
1) Proximal & distal filbua
2) Medial & Lateral gutters (deltoid & collaterals)
3) Calcaneus & Achilles
4) Styloid process of 5
th
met (P. brevis avulsion)
5) Sinus tarsi (EDB avulsion)
6) Lisfranc & TMTJs
Tests
1) Anterior draw ATFL rupture (> 5mm)
2) Stress inversion CFL rupture (> 10 compared contralateral)
-Radiographic Diagnosis
Fracture pattern (look at all 3 views)
o Get more proximal views for suspicious SER
Fibula out length (MO view)
o Ramsey & Hamilton- 42% decrease in TT contact with 1
mm lateral talus displacement
1) Medial clear space should be < 5 mm
2) TF overlap should be > 10 mm
3) Talar tilt should be < 10 mm alone
4) Shenton line continuous line from lateral talar shoulder
5) Dime sign continuous curve distal to fibula
Rule out OCDs
o Medial deep cup more stable (inversion & PF)
o Lateral wafer less stable (inversion & DF)
Plafond cartilage
o Order CT scan to evaluate
o Allows better visualization of posterior malleolar fx
-Treatment
Closed reduction
o Hematoma block vs. IV conscious sedation per ED
(etimodate, versed, etc..)
o Exaggerate distract reverse
o Post-reduction films
o Posterior splint w/ sugar tong strap
Fracture Blisters Place in Posterior Splint for 1-2 weeks,
RESPECT Soft tissue.!! Want good skin quality and turgor by
POSITIVE WRINKLE TEST
Surgical technique (Follow Vassals principle)
o Soft tissue dissection down to peroneal muscles
o Curette hematoma out of fracture
o Reduce fracture (k-wires, point-to-points, etc..)
o Plates:
Neutralization plate takes the strain rather than the
fracture (protects interfrag screw)
Buttress/Anti-glide prevents motion, applies force at
90 degrees to the axis of rotation deformity
Bridging strictly for comminuted fractures to hold
fragments together Relative stabilization
DCP allows eccentric drilling and axial compression
across fracture site
Tension band placed on tension side to convert tensile
force to compressive forces at fx site
o Fibula fixation:
6 cortices above & as many as possible below
Lag screw (3.5mm) to fracture
Non-locking cortical Proximal to fracture
Non-locking cortical Distal to fracture
Fill the rest in with locking or non-locking
o Medial malleolar:
PerQ vs. Open approach
4.0 cancellous, plates, tension band wiring
o Posterior malleolar:
Only if > 25-30% of joint space
4.5 cannulated screw (posterior to anterior)
o Syndesmotic:
Fibular fractures above 5cm of Ankle mortise require
syndesmotic fixation (SER type)
Stress exams (intra-op):
Cotton (lateral-hook) pull the fibula laterally,
and If everything moves its NEGATIVE
External rotation of foot see if fibula
displaces lateral and posterior
Fixation (rules of 3)
*Leave a hole open on plate for fixation
At least 3 cm proximal parallel to mortise
30 anterior
Screw should be 3.5 mm diameter
Cortical screw vs. Tightrope

Tri vs. Quad cortical

Calcaneal fracture 6/30/2014 10:13:00 AM
-Introduction:
Etiology:
o Men from 30-60 yrs old
o 75% of all calc fractures at INTRA-articular
o 60% of all tarsal injuries
Mechanism of Injury
o Direct axial load (fall from height)
o Vertical shear force
Rules of 10:
o 10% Lumbar Spine Fracture (L1 & L2)
o 10% Bilateral
o 10% Chance of Compartment Syndrome

-Clinical diagnosis:
Pain w/ palpation to heel
Mondurs sign ecchymosis to plantar medial foot
Hoffas sign less taut achilles tendon on involved side
Fracture blister (usually on medial side due shear force)

-Radiographic diagnosis:
Lateral View
o Bohler (25 40) DECREASED
o Angle of Gissane (125 - 140) INCREASED
o Joint depression w/ loss of calcaneal height
Lateral Oblique
o Evaluate anterior process of calcaneus
o Asses CC joint involvement
Harris-beath Posterior facet
Isherwood 3 oblique view that highlights all facets
Broden 2 oblique view for Middle & Posterior facts
o Show the congruence of the subtalar joint.
o Taken at 30, 50and 70 to the horizontal
Calcaneal axial
o Evaluates calcaneal widening & varus/valgus position
CT Scan
o Gold standard for evaluation and surgical planning
o Coronal view basis for Sanders classification
o MUST ORDER SAGITTAL RECONSTRUCTION
o Look for:
Sustentaculum tali stays in position!
Lateral wall blowout (peroneal injury/sural)
Calcaneal tuber tips to varus
Posterior facet is DEPRESSED

-Classifications:
Sanders (widest view of posterior facet on semi-coronal CT)
o A/B/C lateral to medial
o Type 1 non-displaced articular fx
Tx- conservative
o Type 2 2 part posterior facet fx
Tx- ORIF (86%)
o Type 3 3 part posterior facet fx
Tx- ORIF (60%)
o Type 4 4 part posterior facet
Tx- Primary arthrodesis
Rowe
o Type 1
A) Med tubercle B) Sustentaculum C) Ant process
o Type 2
A) PS calc process B) PS calc w/ achilles involvment
o Type 3 EXTRA-articular thru calc body
o Type 4 INTRA-articular thru calc body
o Type 5 INTRA-articular thru calc body w/ comminution &
joint depression
Essex-Lopresti (Rowe 4 & 5)
o Primary fx line in both superior to inferior from angle of
gissane to plantar calcaneal body
o Type A (tongue type)
Force vertical directed
Secondary fx line extends posterior thru tuberosity
o Type B (joint depression)
Force anterior directed lateral talus acts like wedge
Secondary fx line extends to behind posterior facet

-Treatment
Options Non-op, ORIF, Ex-fix, STJ arthrodesis
o NO rush to fix fracture Usually delayed 8-14 days
MAX delay- 3 weeks
o Wait for (+) wrinkle test
Literature:
o Patients w/ better surgical outcome (Buckley- JBJS, 2002)
Women, Young male, NOT receiving WC, Increased
Bohlers, Lighter workload at job, Simple fracture
o Op vs. Non-op displaced calc fx (Stockholm- JBJS, Aug, 2013)
1 yr f/u comparable results
8 yr f/u slightly better VAS score in Op group
o More & more popular to not fix because of the high rate of
patients that will eventually go into a fusion
Reduction Goals (AARRD)
o Align post facet, Align RF, Restore height/length/width of
calcaneus, Reduce CCJ, Decompress lateral wall
Reduction order (MPPLA)
o Med wall Primary fx line Post facet Lateral wall
Anterior process fracture
o Constant fragment- fragment of fracture at medial side
including sustentaculum where reconstruction is built on
o Preliminary reduction achieved by multiple k-wires fixation in
a stepwise reduction
Incisions
o Lateral extensile (modified Ollier)
Good visualization of posterior facet & CC joint
Full thickness flap including the periosteum
K-wires to drill into fibula and Talus to retract flap
o Medial (McReynolds)
Easy reduction of sustentacular fragment
Technique
o Joy-stick use of Steinman pin to help reduction fracture
fragments then use k-wires to temporary hold
o Stryker balloon reduction (+) bone cement
o Test reduction of articular facets by taking thru ROM in OR
Hardware
o Plate & bunch of screw
o AO website
Closing
o Place drain (due to vascularity of Calcaneus)
o Remove drain 24-48 hours or when there is less than 25mL in
8 hour shift
o Interrupted Allgower-donati stitch
Complications
o Wound dehiscence, Arthritis, Nerve damage, RSD, DJD
o Malunion (Stephens & Sanders)
Type 1 large lateral exostosis w/ or w/out extremely
lateral arthrosis of STJ
Type 2 lateral exostosis combined w/ major arthrosis
across the width of the STJ
Type 3 lateral exostosis, severe arthrosis of STJ and
malunion of calcaneal body w/ RF in varus/valgus
Post-op
o The ankle and subtalar joint are put through range-of-motion
exercises as soon as possible, usually by 2-5 days.
o Weight bearing is delayed until 8-12 weeks, depending
upon the degree of comminution and the adequacy of the
fixation.
o Radiographic views is obtained at 6,12 and 26 weeks.
Lateral Ankle Stabilization 6/30/2014 10:13:00 AM

-Introduction:
Anatomy:
o ATFL (intracapsular) WEAKEST
Flat & quadrilateral shaped
Restricts internal rotation of talus
o CFL (extracapsular)
Cord-like that blends w/ peroneal tendon sheath
Restricts adduction
Brostrom (1966) cfl rupture is rarely ruptured only 2
of 60 cases
o PTFL (intracapsular) STRONGEST
Trapezoid shaped
o Cervical
Restricts external rotation of talus
Guides STJ inversion
Highly innervated & attached to lateral talus
Etiology:
o Inversion ankle sprains (athletes)
Inadequate treatment of original injury leads to scarred
or elongated ligamentous structures
DDX:
o Peroneal subluxation
Low-lying muscle belly
Overcrowded w/in SPR (P. Quartus)
o Sinus Tarsi syndrome
Caused by chronic ligament damage
Pain with Plantarflexion & Inversion
o Others OCD, Syndesmotic injury, Cuboid fracture, Lateral
talar process fx, ankle fx, 5
th
met avlusion fx

-Clinical Diagnosis:
History of ankle giving way
Anterior draw > 5 mm (+) in ATFL rupture
Talar tilt > 10 (+) CFL rupture sucking sign
Peroneal sublux test ankle in circles feel for popping

-Radiographic diagnosis:
AP, Lateral and Ankle mortise
Arthrogram for ATFL (since its intra-capsular)
Tenogram for CFL (since it extra-capsular)

-Classifications:
Anatomic
o Grade I ATFL sprain
o Grade II ATFL & CFL sprain
o Grade III ATFL, CFL, PTFL sprain
AMA standard nomenclature system
o Grade 1 ligament stretched
o Grade 2 ligament partially torn
o Grade 3 ligament completely torn
Eckert & Davis
o Grade I SPR separated from fibrocartilage
o Grade II fibrous lip of fibula avulsed
o Grade III avulsion fx w/ retinaculum
o Grade IV SPR elevated from calcaneus
Sobel (P. brevis tears)
o Grade 1 splayed
o Grade 2 partial thickness split (< 1 cm)
o Grade 3 full-thickness split (1-2 cm)
o Grade 4 full-thickness split (> 2 cm )

-Treatment
Conservative
o RICE for all severities
o Mild lace-up brace & NSAIDs
o Severe NWB, BK cast, Jones compression, NSAIDs
Surgical
o Tendon reinforcement
Bostrom imbrication of ATFL & CFL pants-over-vest
Gould- imbrication of IER to reinforce further
Athroscopic repair manual debridement

o Tendon rerouting
Watson Jones P. brevis thru distal fib & neck of talus
Ellis-Jones lateral strip of achilles
Lee P. brevis thru distal fib and sutured on itself
Evans P. brevis thru distal fib and sutured to post. Fib
Chirstman snook split P. brevis restores both CF &
ATF by rerouting thru talus, fib and calcaneus
Kelikian & Kelikian Plantaris rerouted thru calcaneus,
distal fib and talus then sutured onto itself
15% of people have plantaris

o Bone block
Kelly posteriorly rotated distal fib and fixated
Duvries rectangle piece of distal fib slide posterior

o Groove deepening
Changs method
Create several holes in posterior ridge of fibula
Sutures are passed thru SPR then suture thru
holes under the leading edge w/ fiber wire
Post-op
o NWB BK cast 4-6 weeks
o WB BK cast 3 weeks
o Physical therapy w/ strengthening following cast removal
Gout 6/30/2014 10:13:00 AM

-Introduction
Metabolic disorder secondary to the build-up of monosodium urate
crystals and supersaturated hyperuricemic extracellular fluids in and
around joints and tendons causing red, hot and swollen joint
Decreased solubility of sodium urate at lower temperatures of
peripheral structures likes toes & ears
Differential Diagnosis:
o Pseudogout, Septic arthritis, RA, OA Cellultis, Trauma,
Infection, Sesamoiditis, Seronegative athropathy

-Classification
Primary
o Overproduction (metabolic gout)
Excessive amount of acid excreted
Dx: Uric acid > 600 mg in 24 hr urine collection
o Underproduction (renal gout)
Deficit in renal excretion of uric acid
90% of patients
Secondary
o Minor clinical feature secondary to genetic or acquired person
Stages
o Asymptomatic
o Acute gouty arthritis soft tissue swelling only
o Intercritical gout periarticular calcification & erosions
o Chronic tophaceous gout large intra/extra-articular
destruction of proximal phalangeal bases > 5 mm
Attacks are less frequent, but always chronic pain

-Radiology
Increased soft tissue density
Periosteal reaction
Round osseous erosions w/ a scerlotic margin Punched-out
Joint spaces preserved till late in course of disease
Martels sign expansile lesion w/ overhanging margin

-Labs
Joint aspirate
o Negative birefringent crystals when view under polarizing
light microscope
o Blue when & yellow when =
o Pseduogout is opposite w/ positive crystals
Serum Uric acid > 7.5 mg/dl (non-diagnostic)
Synovial fluid analysis elevated leukocytes w/ + neutrophils
ESR elevated at time of attack

-Treatment:
Acute:
o *Indomethacin 25 mg b.i.d. or t.i.d (MAX- 200mg)
o Naproxen 500 mg PO initially, then 250 mg PO q6-8hr
o Celebrex 400 mg PO initially, then 200 mg PRN
o Medrol Dose pack (4 mg)
6 day course staring w/ 6 pills on day 1 then tapering to
only 1 pill on day 6
o Colchine Take 0.5 mg 1 dose, followed by 0.3 mg 1 hour
later; at least 3 days must elapse before this dose is repeated
Chronic:
o Allopurinol Inhibition of xanthine oxidase, the enzyme that
synthesizes uric acid from hypoxanthine
100 mg/day initially; increase weekly to 500 mg PO
qDay
o Probenicid increasing net renal excretion of uric acid
through inhibition of tubular reabsorption
250 mg PO twice daily for 1 week; increase weekly to
500 mg PO twice daily
Diet changes
o Avoid seafood, beer, red meat, asparagaus, sugar drinks
o New diet low-fat dairy foods, complex carbohydrates,
coffee, and fruits, especially citrus fruits
You should get 12 to 16 cups of fluid daily.
Surgery
o I&D washout
o Arthroplasty
o Arthodesis
Charcot Neuroathropathy 6/30/2014 10:13:00 AM
-Introduction
History
o Musgrave (1703) first to report neuropathic osteoathropathy
o Jean Marie Charcot (1868) french neurologist who linked
syphilis to neuroathropathy
Pathogenesis:
o Neurovascular (French theory)
Trophic centers in the anterior horn of spinal cord
maintain nutrition to joint, and damage to these centers
causes increases blood flow & osteoclastic activity
o Neurotraumatic (German Virchow theory)
Repeated trauma to an insensate foot
o **Primary deforming force ankle joint equinus
Etiology (ANYTHING THAT CAUSES NEUROPATHY)
o Most common Dm, Syringomyelia, Tabes dorsalis
o Others Alcoholics, Polio, Tumors, CMT, CP
o Drugs Indomethacin, Intra-artic steroid, Phenylbutazone
DDX:
o OM, AVN, Inflammatory & Septic arthritis, Neoplasm

-Clinical diagnosis:
Like any infection Red, hot, swollen, +/- painful
BOUNDING pulses

-Classification
Eichenholtz (based on plain film radiographs)
o Stage 0 (High risk pre-charcot)
Radio maybe increased soft tissue density
Uptake in all 3 phases of Tc-99 scan
Clinical sudden onset of non-pitting edema,
erythema, bounding pulses, +/- pain, instrinsic muscle
atrophy
o Stage 1 (Acute/Developmental)
Radio capsular distension, fragmentation, subluxation
Clinical red, hot, swollen w/ joint laxity
o Stage 2 (Coalescence)
Radio sclerosis, resorption of debris, fusion
Clinical decreased red, hot and swollen
o Stage 3 (Reconstruction)
Radio decreased sclerosis (+ vasc) & remodeling
Clinical increased stability
Brodsky (based on location of deformity)
o Type 1 lisfranc (27-60%)
o Type 2 chopart (30-35%)
o Type 3 A) ankle B) posterior calcaneus
o Type 4 multiple combinations
o Type 5 forefoot
Schon (Based on location & severity)
o Lisfranc pattern- (A C w/ increasing deformity to medial
rockerbottom & ulceration)
o NC pattern- (A C w/ increasing deformity to lateral
rockerbottom & ulceration)
o Perninavicular pattern- (A C w/ lateral rockerbottom, talar
AVN and ulceration)
o Transverse tarsal pattern- (A C w/ increasing deformity to
central rockerbottom and ulceration)

-Charcot vs. OM
Osteomyelitis
o Leucocytosis and a left shift is present
o Sed rates are usually higher than 70mm
Charcot
o Involves multiple bones
o Elevated alkaline phosphatase levels
Gold standard Bone Biopsy if infected then OM
Plain films
o Charcot fragmentation & progressive resorption
o OM NO progressive resorption seen
Certec scan
o Charcot not hot
o OM will be hot

-Treatment:
Conservative If no ulcers & foot is plantar grade
o Resolution of edema w/ compression, elevation and rest; total
immobilization of the limb by TCC
o As the disease progresses move from a cast to bracing such
as a Charcot restraint orthotic walker (CROW)
o Long term AFO bracing; extra depth shoes or other types of
accommodative foot wear
Surgical
o Eichenholtz (1996) early stage I or late stage II
o Johnson (1998) stage III, and after conservative care has
been exhausted
o Myerson (1999) stage II or III
Acute phase of skin necrosis from pressure ulcer
Dislocation of foot is likely to cause further issues
o Simon (2000) first to publish paper of success in stage I
Operated on 14 patients in the acute phase of the
disease with good anatomical reduction & results
Believe that early arthrodesis should be considered in
patients with early stage I charcot
o Technique
Goal Make foot stable & plantar grade
Pantalar, TTC, or TCN arthrodesis for deformity about
the ankle and rearfoot
Triple arthrodesis for deformity correction about the
rearfoot
Extended medial or lateral column arthrodesis for
deformity about the midfoot.
o Ilizarov frame
Advantages:
Contributes to osseous healing
Promotes revascularization
Optimizes cellular environment
Reduces infection
Principles (DARN)
Distraction, Axial compression, Rotation,
Neutralization
Technique:
Wires should cross at 60
Wires are then tensioned


6/30/2014 10:13:00 AM