Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
85 Cards in this Set
- Front
- Back
|
what is a major player in blindness from DM retinopathy and renal disease
|
DM
|
|
|
what other factors increase RF for non traumatic LEA
|
foot ulcers
smoking protienuria duration of DM neuropathy retinopathy men |
|
|
high the amputation level the higher the what
|
energy expenditure, higher cardiac expenditure
10-40% transtibial 41-75% transfemoral |
|
|
what is the risk for death with amputation
|
1/2 die within 2 years with PVD and DM pre-existing
only 50-65% ambulate after BKA 10-30% with AKA |
|
|
what is the chances of contralateral LEA after 5 years
|
50-70%
|
|
|
what are the 3 types of neuropathy
|
autonomic, sensory, motor - all contribute to ulceration
|
|
|
with DM neuropathy and they cannot feel the repetitive trauma, what do they feel with infection
|
will have feelings of infection
|
|
|
what type of neuropathy:
a. intrinsic muscle imbalance and deformity - hammertoe - pressure points |
motor
|
|
|
which type of neuropathy
skint temp and sweating - dry and stiff AV shunting cause hyperemia and ulceration |
autonomic
|
|
|
this is a type of neuropathy - has long history, its a rapid onset of painless but sever joint destruction associated with fractures and dislocation - erythema and swelling that is not infectious
|
charcot neuroathropathy
|
|
|
what are some diff diagnoses for charcot
|
cellulitits
osteomyelitits gout |
|
|
what will you see on exam and labs for charcot
|
absent fever
ulcer absent pain absent Swelling - will subside with elevation all labs WNL normal glucose |
|
|
what diagnostic testing is used for charcot
|
xray
bone scan will not be accurate, it will light up with osteocyte production so it does not mean infection - MRI better |
|
|
with charcot and all diagnostic tests are inconclusive what is the gold standard test
|
bone biopsy
|
|
|
what is the goal for charcot
|
makea shoeable, plantagrade and stable foot and ankle
will take months |
|
|
what medications are used for charcot treatment
|
biphosphonates - obtain kidney function first
|
|
|
what is the standard treatment if there is an ulcer present with charcot
|
total contact cast is gold standard
6-12 months in midfoot and 12-18 months with insoles will need braces in shoes for life, good to get braces before fragments noted on MRI, recheck with repeat MRIs |
|
|
when is surgery necessary for charcot
|
bony deformity and recurrent ulcers or infection
|
|
|
why do DM patients respond poorly to foot infections
|
blood sugar high
neutrophil function, chemotaxis and phagocytosis is impaired 70% of benign ulcerations have underlying osteomyelitits |
|
|
what on exam will you see with a foot infection compared to charcot
|
erythema
foul odor purulence exposed bone labs: high WBC, ESR, glucose fever and PAIN |
|
|
what is the treatment for foot infection and diagnostic tests
|
indium bone scan - not as good, will light up no matter what and then obligated to treat it
medullary scanning - uses sulfur and will pick up an infection parental abx if significant >2cm oral if smaller ulcer |
|
|
when would you debride an ulcer in foot infection
|
if it is chronic bone infection
if simple do IV abx for 4-6 weeks if chronic will need to debride and then IV abx must check vascular disease, because will not heal if you do not debride |
|
|
what organisms are common with DM foot infectons
|
#1 MRSA
strep pseudomonas enterococcus gram - and anaerobic more severe are poly |
|
|
when should you refer
|
for DM foot infections
start empiric augmentin, clindamycin or omnicef |
|
|
what are some history questions you should obtain with DM foot
|
controlled sugars
what meds they are on how long with DM smoking steriods sores that do not heal claudication or vascular insufficiency use shoegear, braces or current ulcers |
|
|
what on exam is important for DM foot
|
foot exam!
check skin, nails, muscle mass, sweating, and ulcers light touch, 2 point discrimination, pin prick - MONOFILAMENT best for sensory neuropathy vascular exam - manditory! pulses, ABI pallor in trendelemburg thickened nails loss of hair or thin skin pulse volume toe pressures |
|
|
what is the mortality of PAD not treated
|
60% in 5 years; neuropathic ulcer 45% in 5 years
|
|
|
what deformities are you looking for on exam
|
callouses - preulcerative because of pressure
hammer toe, clawtoe bunions, midfoot, sever cavus - high arch bony prominence look at shoes - too tight accomidative inserts in shoe? |
|
|
how much smaller should the wound be to not refer on the foot?
|
50% smaller in 4 weeks
|
|
|
what is the most injured joint in the body
|
ankle - inversion
|
|
|
what 3 ligaments are ankles supported by, which are the most commonly injured
|
medial
lateral interosseous LATERAL most commonly injured |
|
|
which of the lateral ligaments of the ankle are commonly injured
|
ATF - weakest then the PTF and CF is the strongest
|
|
|
what are the syndesmotic ligaments of the ankle and what is it considered
|
the anterior inferior tibiofinular ligament and posterior inferior tibiofibular ligament
considered high ankle sprain they stablize the tibiofibular articulation (ankle joint) and hold talus in place |
|
|
what are some history questions you should ask with ankle sprains
|
increased risk with previous injury, taller or heavier
heard pop or immediate swelling at injury - snapping or unable to walk on ankle described as stepping off curb, into hole, jumping, step on uneven ground HIGH ANKLE - if rotation involved - like turning and then internally rotate ankle. ask foot position with sprain |
|
|
medial ligaments of the ankle wind together and form what
|
deltoid ligament - large and strong - 4-6 total
|
|
|
what is diastasis in ankle sprain mean
|
when ligament tears and bone moves
|
|
|
what will you see on palpation and visiual exam of ankle sprain
|
swelling, ecchymosis
palpate tib/fib, anterior calcaneous, 5th metatarsal, post tibial tendon CF, ATF, PTF, and AITF |
|
|
what is the ROM of an ankle and what are special tests for ankle sprians
|
10 deg dorsiflexion and 45 degree plantarflexion
20-30 deg inversion and 10-20 deg elevation ant drawer - ATF <5mm Talar test (twist heel) - CF <4 deg Squeeze test - dyndesmotic injury - squeeze tib fib togetehr - shooting pain with ATF |
|
|
how is diagnosis made on ankle sprain
|
pain over ligaments - exam high fibula
swelling and ecchymosis unable to bear weight history of twisting or turning ankle must rule out bony pathology - xray history of sprain postive special test - ant drawer, talar twist or squeeze |
|
|
what diagnostic tests aid in eval of ankle sprain
|
x ray - AT LEAST TWO VIEWS
MRI - if chronic ankle sprains look for soft tissue tear |
|
|
what are differentials for ankle sprains
|
tendon injury - achilles, peroneal, post tibial
fractures - osteochondral lesion of talus styloid process, 5th metatarsal - same mechanism Jones fracture - under metatarsals hard to diagnose and treat - needs surgery tib or fib talus beak fracture - anterior calcaneous |
|
|
what are the 3 classifications for ankle sprains
|
grade I - stretching
grade II - partial tear grade III - complete |
|
|
what is the treatment for ankle sprains
|
early mobilization increases ROM and strength of ligaments
RICEN - unaboot with no medial or syndesmotic injury only protect CF cast and non weight bearing if severe instability, swelling and pain PT to strengthen and ROM ESPECIALLY ATHLETES |
|
|
what are some prevention measures for ankle sprain
|
bracing taping
high top shoes do this with athletes |
|
|
when would someone need surgery for an ankle sprain
|
only high peformance athletes, chronic sprainers
syndesmotic injuries associated tendon injuries or fractures if fracture present immobilize and refer out |
|
|
when do you refer for ankle sprains
|
any fracture
high ankle sprain - syndesmotic injury medial injury no progress after 4-6 weeks chronic sprains suspicious injuries - tendon or subluxation severe injury |
|
|
this is from repetitive stress, tears, fatigue, inflammation, and degeneration. Spur forms from tension and traction of the fascia - flexor digitorum brevis muscle
|
plantar fascitis
|
|
|
what are symptoms of plantar fascititis
|
45 year old female
history of weight gain and increased activity started work out program insidious onset worse with first few steps in morning or after sitting pain resolves during the day and is aggravated by prolonged standing or activity site: medial calcaneal tuberositity - proximal 1-2cm of plantar fascia does not radiate |
|
|
how is plantar fasciitis diagnosed
|
subjective diagnosis
can reproduce pain in medial calcaneal tuberositity and fascia must have tight heel cord compress heal to rule out fracture |
|
|
what tests can be done to diagnose plantar fascititis
|
lateral xray for spur, stress fracture, bone tubor
labs - rule out arthritis if not better then get MRI 90% by history and physical |
|
|
what are differentials for plantar fascititis
|
rupture of plantar fascia
fat pad atrophy stress fractor tumor of calcaneous nerve injury tarsal tunnel syndrome BAXTERS neuroma - radiation to abductor belt Labs - seropositive - RA and SLE Seronegative - Reiters, ankylosing spond, psoriasis |
|
|
what is the treatment for plantar fascititis
|
90% resond to conservative therapy
reduce inflammation - NSAIDS stretch improve foot gear STRETCH ACHILLES!!!! heel cup in shoes nigh splints to stretch PT US foot inserts for all heel pain do not go barefoot in home steroid injections if severe shock waves - extracorpial wave therapy cryoablasion - incision, RF necrosis below knee bearing cast |
|
|
when to refer for plantar fascititis
|
pain resistent to conservative measures
biomechanical foot abnormalitiy - flat foot or high arch pes planus or cavas suspect nerve entrapment seropositive or negative disease 8 weeks of treatment without relief |
|
|
what are s/sx of toe fractures
|
pain and swelling
history of trauma ecchymosis displacement look at nail trauma - if injured consider open fracture which is increased risk of infection REFER out |
|
|
what are differents for toe fractures
|
gout
RA cellulitis neuropathic joint |
|
|
what test should you do for toe fracture
|
xray - two pictures AP, lateral and oblique
|
|
|
what is the treatment for toe fracture
|
if not displaced - hard shoe and splint together
displaced - reduce it then splint RICE hard shoe for 3-4 weeks or when pain no longer surgery if not reducable - if open I and D watch for infection |
|
|
what hallux fracture if very significant
|
if intra articular
usueally a crushing injury if open fracure - can tell by nail bed injury |
|
|
what are s/sx of hallux fracture
|
same as digital fracture, nail bed lacs and pain
|
|
|
what is treatment for hallux fracture
|
hard shoe, BK cast if dont want them walking on it
splint sugery if nonreducible pinning if on growth plate - common in karate for kids sequale if left untreated |
|
|
what is the sequale of digital fractures
|
arthritis
stiffness loss of function bone spur or malalignment compartment syndrome persistent pain loss of digit |
|
|
when to refer for digital fracture
|
open fracture exp hallux
non reducible fracture significant trauam - nail bed damage intra articular fracture of hallux |
|
|
what are the most common fungal infections of the nail
|
trichophyton rubrum
T mentagrophytes epidermmorphyton floccosum |
|
|
what are s/sx of distal subfungal nail infections
|
yellow, lysis, subungual debris, nail and nail bed thickening, causing dystrophy
|
|
|
what are the s/sx of proximal subungual nail infections
|
nail plate infection
debris under the nail thickening T rubrum loosening of the nail |
|
|
what are s/sx of superfisial white nail infections
|
invasion of nail plate, soft and dry, powdery brittle nails
no thickening or lysis T mentagrophytes may have tinea pedis |
|
|
what are differentials for onychomycosis
|
onychogryphosis from shoe repetitive trauma
skin disease - eczema, psoriasis yellow naile syndrome clubbing carcinoma candidal infection staph or pseudo - green |
|
|
how do you make the diagnosis of onychomycosis
|
must culture
rule out melanoma under the nail DM may have several organisms may want to do bacterial culture as well |
|
|
what is the treatment for onchyomycosis
|
topical - Penlac
use for superfiscial white because topical does not penetrate well. Oral - Sporonox, lamisil, diflucan, give for 3 months check liver at baseline and at 6 weeks Lamisil best best to thin the nail then use pentac if oral not appropriate, if does not work then refer for surgery exicision |
|
|
when do you refer for onchymycosis
|
DM for routine care
if unable to trim nails significant nail conditions because of PVD or PAD neuropathy |
|
|
what types of HPV are most common for feet warts
|
1 2 4 - confined to epidermis and usually do not last longer than 2 years
Never break dermis, cancer types 16 and 18 |
|
|
what are s/sx of warts
|
young people
firm papules with warty surface may coalesce to form mosaic patches pinpoint bleeding when debride if have very wet feet baseline loss of skin lines pain with lateral compreesion may occur under nail and cause pain and dystrophy can be flesh colored or crusty |
|
|
what are differentials for warts
|
other benign or malignant lesions
intractable plantar keritosis molluscum pox virus coxsackie cutaneous keritin BIOPSY when in doubt |
|
|
what is the treatment for warts
|
variable - can watch and wait, make sure foot dry,
salicylic acid, MAA or TAA, candida antigen, cryotherapy - liquid nitrogen, CO2 - very painful should blister laser surgical curretage - painful in weight bearing area |
|
|
mortons neuroma involves which plantar nerve
|
4th - related to narrow shoes
|
|
|
what are s/sx of mortons neuroma
|
burning in 3-4th toes
focal paresthesia aggravated by certain shoes feeling of walking on marbles or lamp cord heels and narrow toe box aggravate it pain in webspace mulders click - when sqeeze hear click |
|
|
what diagnostic tests and exams should you do for mortons neuroma
|
xray to rule out stress fracture
examine all metatarsals MRI and US are used as adjunct diagnostic block in interspace - because if its a capsule it will nt numb up |
|
|
what are differentials for mortons neuroma
|
capsulitits - why get block
stress fracture prominent condyle of metatarsil volar plate rupture tumor or neuropathy intermetarsal bursitis MRI for neuroma - bursa forms in space, incrreased confined space, consistent hitting. |
|
|
what is the treatment for mortons neuroma
|
conservative - NSAIDS
shoes with padding or orthotics to off load nerve US for pain relief surgery for removal of nerve - will leave area numb |
|
|
when do you refer for mortons neuroma
|
continued pain
associated deformity when conservative measures fail recurrent symptoms do not do too many steriods because of atrophy - harm tendons and muscle |
|
|
what will you see with ingrown toe nails
|
red inflammed border with or without drainage or secondary infection
|
|
|
what are causes of paronychia
|
hypertrophic labia
subungual exostosis - bone spure cause nail to grow c- shaped congenital trauma fungal excessive tight shoe cutting nails too short |
|
|
what are treatments for paronychia
|
soaks and abx
partial excision perminent excision |
|
|
when do you refer for paronychia
|
chronic
do not resolve -could be squamous cancer perminant removal ingrown with cellulitis increased risk for osteo - 4 weeks IV abx |
|
|
if nail chronically inflammed in wound what should you do
|
punch biopsy
could be carcinoma |
