Hershey Manual Ch 24 Hav/ Ch 28 Lesser Met Sx

Front 1

list the ligaments of the 1st MPJ and tell whether they are extra or intracapsular

Back 1

1. medial collateral (met to phalanx) 2.lateral collateral (met to phalanx)3. medial and lateral met sesamoid suspensory 4. medial and lateral phalangeal sesamoidal 5. intersesamoidal 6. DTIL; all are intracapsular except the DTIL

Hint 1

Front 2

what is the capsularis actually a branch of

Back 2

TA

Front 3

what is the axis of the first ray and how does this dictate its motion

Back 3

medial/proximal/dorsal to plantar/lateral/distal. There is almost no transverse plane motion bc of the horizontal positioning of the axis. The first ray DF/inverts and PF/everts.

Front 4

what should you suspect as the cause of HAV in a 3-4 yo

Back 4

an anatomical anomaly or NM dz because you must have propulsion for HAV to form

Front 5

when the crista erode in Grade 4 HAV, how can you hold the sesamoids in the correct position

Back 5

transfer the adductor hallucis to the tibial sesamoid ligament

Front 6

If PASA + DASA = HAA; what type of deformity is this

Back 6

Structural, joint is congruent, PASA or DASA is abnormal

Front 7

If PASA + DASA < HAA; what type of deformity

Back 7

Positional deformity, joint is deviated or subluxed, PASA and DASA are normal

Front 8

If PASA + DASA > HAA; what type of deformity

Back 8

Combined deformity; joint is deviated or subluxed, PASA or DASA is abnormal

Front 9

If HAA = 35, DASA = 2, PASA = 6; what is the condition/position of the MPJ

Back 9

6+2< 35; DASA is abnormal, so MPJ is deviated or subluxed

Front 10

If HAA is 35, DASA is 8, PASA is 27; what is the position of the MPJ

Back 10

27+8 = 35, DASA is normal, MPJ is congruent

Front 11

If HAA is 35, DASA is 2, PASA is 17; what is the position of the MPJ

Back 11

19 < 35, but PASA is abnormal, MPJ deviated and deformity is combined

Front 12

define a structural deformity in HAV

Back 12

-this is a boney deformity in which there is osseous change in either PASA or DASA, the structural deformity has a congruent joint

Front 13

Define a positional deformity in HAV

Back 13

-this is a soft tissue deformity in which the PASA and DASA are normal and the joint is either deviated or subluxed

Front 14

what does PASA attempt to quantify

Back 14

the structural adaptation of the 1st MTPJ

Front 15

when should PASA be corrected

Back 15

when it is greater than the IM angle, so a PASA of 12 can be normal as long as the IM angle is >12. The PASA should be corrected by atleast the amount that it is larger than the IM angle.

Front 16

will a capsulotomy correct a structural deformity

Back 16

no, it is a boney deformity

Front 17

list the indications for a Keller

Back 17

-HAV with DJD, 2nd/3rd degree HR (loss of joint), geriatric bunion

Front 18

how much does a Keller reduce IM angle

Back 18

3-5 degrees

Front 19

list some disadvantages of Keller

Back 19

-short hallux, loss of purchase, sesamoid retraction, limited ROM, metatarsalgia, stress fx to 2/3rd met

Front 20

what does a true McBride entail

Back 20

-medial eminence removed, fibular sesamoid excision, adductor tendon transfer (its a capsule-tendon balancing procedure)

Front 21

what is a true silver

Back 21

-just remove the bump

Front 22

what is the final position of a McKeever

Back 22

5-10 degrees DF, slight abduction so its parallel to the 2nd toe or 10-15 on the transverse plane (no varus or valgus)

Front 23

appropriate fixation for a McKeever

Back 23

4.0 cancellous screw, 3.5 cortical lag screw, 2 crossed 0.45 wires, wire loops, herbert screw

Front 24

with a lapidus; how should the met be manipulated before fixation

Back 24

adducted and slightly plantarflexed

Front 25

what can correct a high DASA

Back 25

Proximal Akin

Front 26

what can correct a high HIA

Back 26

distal akin, HIA > 10, can be used when hallux is putting pressure on the 2nd toe

Front 27

what can be used to shorten a long proximal phalanx

Back 27

central akin

Front 28

dorsal wedge osteotomy of the base of the prox phalanx

Back 28

Kessel Bonney, used for HL

Front 29

when performing an Austin, how much will 1mm in lateral shift adjust the IM angle

Back 29

1mm of lateral shift will decrease the IM angle 1 degree (you can safely shift the met head laterally ⅓ of the width of the met, so if met is 21 mm wide, you can safely slide the bone 7 mm and get 7 degrees of correction)

Front 30

angle of Austin

Back 30

60 degrees

Front 31

what happens if the capital fragment hits the ground….

Back 31

place in a basin containing: 1 Liter saline, 1 cc neosporin G.U irrigant and 1;100,000 bacitracin for 5 minutes, then a new basin with same solution for 5 minutes, third basin for 1 minute with same solution; also ancef post op for 3 doses. Other lit states that a 30 min soak in 4% chlorhex gluconate, saline rinse, then triple abx solution as above, then saline rinse again is more effective.

Front 32

how can u use an Austin to correct PASA

Back 32

thicker cut is made after the intial cut; remova a dorsal medial trapezoid from met head

Front 33

what is the location of prox met osteotomies for HAV

Back 33

1-1.5 cm distal to the base

Front 34

which osteotomies can correct an increased PASA

Back 34

Austin with a dorsomedial wedge, All Reverdins, Peabody, Offset V, Keller, Mau

Front 35

which osteotomies can correct an increased DASA

Back 35

Proximal Akin, Central Akin, Keller

Front 36

What is the normal declination of the lesser metatarsals

Back 36

15 degrees

Front 37

What is the normal metatarsal parabola

Back 37

142

Front 38

Which sx should be performed? IPK’s under met heads, atrophy of plantar fat, ,met heads are palpable, DJD, contracted toes, RA, psoriatic arthritis

Back 38

pan met head resection –

Front 39

What adjunct procedure can be used with a pan met to add stability to the forefoot

Back 39

syndactyly the toes

Front 40

Disadvantages of a pan met head resection

Back 40

loss of propulsive gait, flail toes post op, incidence of hematoma, loss of digit stability

Front 41

Where is the apex of deformity with Met adductus

Back 41

lisfranc joint

Front 42

Why is the met adductus angle not always accurate

Back 42

because the lesser tarsal bones in the neonate are not measurable bc they are radiographically silent and in many cases the TC relationship is abnormal ( talo -2nd met angle; N=16)

Front 43

When is a Heyman, Herndon, Strong procedure indicated and what is it

Back 43

for flexible met adductus; usually in kids less than 5, deformity present at the lisfranc joint. Soft tissue procedure that releases the dorsal, interossei and plantar ligaments of the tarso-met and inter-met joints, manipulate the foot into abduction, K wire fix the first met cune joint and 5th met cuboid joint. LEAVE THE PLANTAR LATERAL LIGAMENTS INTACT

Front 44

What do you want to avoid damaging with a Heyman, Herndon, Strong ST release for met adductus

Back 44

avoid damage to the 1st met growth plate, do not confuse this with the met cuneiform joint

Front 45

What procedure would you use? Child 5-8 yo with a met adductus deformity

Back 45

cartilaginous procedure (Johnson Osteochondrotomy); Closing abductory BWO of 1st met, wedge resection of cartilage nad bone from the bases of the lesser mets, fixate with wire or staples.

Front 46

Which procedure would you use? Met adductus in a child older than 6-8 yo

Back 46

Osseous procedure (MA may be a residual deformity of tx TEV) Berman-Gartland Procedure; transverse or oblique closing abductory wedge of 1st met, similar osteotomies of lesser mets with medial cortical hinge; fix with wire, staples or screws or LEPIRD procedure

Front 47

Describe the Lepird procedure and when it is used

Back 47

Osseous procedure for MA in pts older than 6-8 yrs; usually residual MA from TEV treatment. Juvara of the 1st and 5th met, rotational osteotomy of lesser mets. Lesser met rotational osteotomies are dorsal distal to plantar proximal, 45 degrees from the WB surface, (Mau?) distal fragment is rotated laterally into a corrected position and fixed with screws.

Front 48

What is the general algorithm for met adductus treatment based on age

Back 48

Birth – 4 yo (stretching or casting), Less than 5 yo (Soft tissue procedures-HHS), 5-8 yo (cartilage procedure – Johnson),> 7 yo (Osseous – Berman Gartland or Lepird)

Front 49

Treatment for Freibergs

Back 49

Conservative: casting and cortisone, then orthotics. Surgical: implant arthroplasty/met head remodeling/bone graft to restore the head contour/rotational osteotomy to rotate the lower aspect of the met head dorsally/excision of loose bodies

Front 50

List etiologies of Tailors bunion

Back 50

1. Uncompensated varus FF or RF, congenital PF 5th ray deformity, dorsiflexed 5th ray deformity, lateral deviated or wide 5th met head

Front 51

When tailors bunion is present, what deformity should you also check for

Back 51

Splay foot (IM angle > 12 and 4th/5th IM angle > 8

Front 52

Radiographic findings of Tailors bunion

Back 52

IMA: >8, N=6, Lateral deviation angle: 8, N = 2.6, rotation of lateral plantar

Front 53

MC procedures for Tailors bunion

Back 53

-bumpectomy, reverse Wilson (oblique), Hohman (transverse osteot)

Front 54

What is a Skewfoot

Back 54

Met adductus with RF valgus

Front 55

What are the radiographic findings of skewfoot

Back 55

adducted FF with pronated RF, MA >21, cuboid abduction angle >5