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85 Cards in this Set

  • Front
  • Back
what is a major player in blindness from DM retinopathy and renal disease
what other factors increase RF for non traumatic LEA
foot ulcers
duration of DM
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
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
which type of neuropathy
skint temp and sweating - dry and stiff
AV shunting cause hyperemia and ulceration
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
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
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
foul odor
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
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
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

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
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
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
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

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
improve foot gear
heel cup in shoes
nigh splints to stretch
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
look at nail trauma - if injured consider open fracture which is increased risk of infection REFER out
what are differents for toe fractures
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
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
sugery if nonreducible
pinning if on growth plate - common in karate for kids
sequale if left untreated
what is the sequale of digital fractures
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
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
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
pox virus
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
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
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
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