Orthopedics - Many Topics

Front 1

Where is the sural nerve most vulnerable to entrapment?
What is the treatment?

Back 1

1.5 cm distal to tip of fibula with foot in equinus. Tx: Surgical Release.

Front 2

where does the sural nerve course:?

Back 2

Sural nerve is made of collateral branches off the common tibial and common fibular nerves (both from the sciatic division in the popliteal fossa)

Courses inferiorly between heads of gastroc, becomes superficial at middle of leg, descends with small saphenous vein, wraps inferiorly around lateral malleolus to lateral foot.

Front 3

course of the common fibular nerve

Back 3

Common Fibular Nerve branches off the Sciatic (divides away from Common Tibial) travels parallel to the biceps femoris to fibular head

Front 4

Function & Clinical Significance of Sural Nerve

Back 4

Purely sensory info from the posterior lateral corner of the leg, from the lateral foot and 5th toe (but not the tip which is lateral plantar).

good for nerve bx or donor graft.

Front 5

Medial Plantar Nerve Entrapment

Why, Where, Tx

Back 5

aka Jogger's Foot

Compression at Knot of Henry where FDL and FHL cross

MCC: Foot orthotics
Tx: dc orthoses

Front 6

Knot of Henry

Back 6

where FDL and FHL cross

most likely spot of Medial Plantar Nerve Entrapment (compression)

aka joggers foot

MCC: Foot orthotics
Tx: dc orthoses

Front 7

Lateral Plantar Nerve Entrapment

Back 7

Culprit is Baxter’s Nerve: 1st branch of LPN which innervates ADQ

compressed btw AHL & QP near calcaneus

Tx: surgical release of abductor halluces fascia

Front 8

Baxter's Nerve

Back 8

1st branch of LPN which innervates ADQ

Lateral plantar nerve entrapment caused when Baxter's nerve compressed btw AHL & QP near calcaneus

Tx: surgical release of abductor halluces fascia

Front 9

Superficial Peroneal Nerve Entrapment

Back 9

Paresthesia of dorsum worsened in plantarflexion/inversion

MCC: fascial defect ~12cm superior to lateral malleolus where it pierces fascia to become superficial, possibly from inversion injury

Tx: Non-Op: Observation; Op: Refractory/Elite Athletes

Front 10

Paresthesia of foot dorsum worsened in plantarflexion/inversion

Back 10

Superficial Peroneal Nerve Entrapment

MCC: fascial defect ~12cm superior to lateral malleolus where it pierces fascia to become superficial, possibly from inversion injury

Tx: Non-Op: Observation; Op: Refractory/Elite Athletes

Front 11

Plantar Sessamoid Bone Anatomy

Back 11

Two sessamoid bones within the Flexor Hallucis Brevis

Front 12

Tibialis Posterior Innervation & Insertion

Back 12

Tibial Nerve

Insertion:
Navicular & Medial Cuneiform

Front 13

Tibialis Anterior

Innervation, Insertion, Action

Back 13

Innervation: Deep Fibular Nerve
Insertion: medial cuneiform and first metatarsal
Action: Dorsiflexion and Inversion

Front 14

EHB

Innervation, Origin, Insertion

Back 14

Deep Fibular Nerve
Origin: Calcaneus
Insertion: Proximal Phalanx (1st)

Front 15

Fibularis Tertius

Innervation, Course, Action

Back 15

Deep Fibular Nerve
Dorsal Surface of Fibula to Dorsal Surface of 5th Metatarsal

Dorsiflexion & Eversion

Front 16

Dorsal interossei vs Plantar Interossei

Back 16

Both Innervated by Lateral Plantar Nerve

Dorsal interossei muscles are bipennate
Plantar interossei muscles are unipennate

Front 17

Flexor Hallucis Brevis

Innervation, Origin, Insertion

Back 17

Medial Plantar Nerve
Plantar Surface of Cuneiform to Medial and Lateral sessamoid bones

Front 18

Fibularis Longus

Nerve, Course, Action

Back 18

Superficial Fibular Nerve

Upper lateral fibular shaft to First Metatarsal, Medial Cuneiform

Plantarflexion, Eversion, Arch Support

Front 19

Flexor Digitorum Brevis

Nerve, Origin

Back 19

Medial Plantar Nerve
Calcaneus (Plantar aponeurosis)

Front 20

During Rehabilitation following ACL injury/repair: what strengthening exercises are possible without endangering the graft?

Back 20

Beynnon 1995 Am J Sports Med
Isometric Hamstrings contraction only at any angle
Isometric Quadrieps contraction after 60 degrees or greater
Or Active Knee motion between 35 degrees of motion or higher

Front 21

Strongest predictor of cutout in intertrochanteric fracture fixation with dynamic hip screw application?

Back 21

Trip-Apex distance >25mm
Baumgartner 1995 JBJS

Front 22

Exchange nailing

Back 22

Indicated for aspectic diaphyseal tibial and femoral non-unions in the absence of comminution, or segmental bone loss.
Hypertrophic non-unions have good biology and bad stability: treat with larger nail
Atrophic non-unions need better biology (bone graft, flap coverage, etc)
Brinker JBJS 2007
Zelle J Trauma 2004

Front 23

Preoperative factors associated with postoperative improvement in shoulder function following hemiarthroplasty

Back 23

Hetterich JBJS 2004
Most improvement: absence of glenoid erosion (pain and function)
No prior surgery, intact rotator cuff (function)
Osteonecrosis, DJD
Least Improvement: Rheumatoid Arthritis, Capsulorrhaphy arthropathy (arthropathy 2/2 overtightening of capsule following prior surgery)

Front 24

Blood Volume Estimation for Pediatric Patients

Back 24

Preme: 95mL/kg
Full Term Neonate: 85mL/kg
Infants: 80 mL/kg
Adult Men: 75
Adult Women: 65

Front 25

Flexor tendon damage zones:

Back 25

zone location affects healing and post-op course

Zone I: Phalanx Distal to FDS Insertion
Zone II: DIP to Distal Palmer Crease (“No Man’s Land”)
Zone III: Palm
Zone IV: Carpal Tunnel
Zone V: Wrist and forearm
Thumb: TII, TII, TII

Front 26

FDP vs FDS

Back 26

FDP
Origin: Ulna, Interosseus membrane
Insertion: P3
Innervation: Median & Ulnar
flexes DIP, assists with other flexion, common muscle belly

FDS
Origin: Medial Epicondyle
Insertion: P2
Innervation: Median
flexes PIP assists with MCP flexion, individualized muscle bellies (25% absence to 5th digit)

Front 27

where can you find the FPL in the carpal tunnel

Back 27

FPL: most radial strx in carpal tunnel

Front 28

most radial structure in the carpal tunnel

Back 28

FPL

Front 29

FCR

Back 29

Origin: common flexor tendon
inserts into 2nd metacarpal, most proximal to median nerve in carpal tunnel
Innervation: Median

Front 30

FCU

Back 30

origin: common flexor tendon
inserts on pisiform, hook of hamate, and base of 5th metacarpal
innervation: unlar nerve

Front 31

Phases of tendon healing:

Back 31

Inflammatory: Days 0-5, no strength
Fibroblastic: Days 5-28, increasing strength
Remodelling: Days >28, will tolerate active ROM

Front 32

Pulley system of the digits:

Back 32

A1 to A5 annular pullies and C1 to C3 cruciate pulleys
A2 (proxP1) and A4 (midP2) are the most important for preventing bowstringing
For thumb two annular (DIP & PIP) and one oblique pulley (P1)
Oblique is most important

Hint 32

Front 33

Vascular Supply to UE Flexor Tendons

Back 33

Diffusion through Synovial Sheath when Tendon is located inside sheath (see pic)
Diffusion is most important source proximal to MCP
Direct vascular supply nourishes tendons outside sheath

Hint 33

Front 34

Caring for Flexor Tendon Injuries

Back 34

Bishop J Trauma 1986: canine model demonstrates earl motion improved outcomes
McGeorge & Stillwell J Hand Surg Br. 1992: tendons lacerated by <60% need not be repaired

Front 35

Median nerve lies directly ulnar to what structure

Back 35

FCR

Front 36

Extensor compartments of the wrist

Back 36

1: AbPL, EPB
2: ECRL, ECRB
3: EPL
4: EIP, EDC (extensor indices proprius – ulnar to 1st EDC tendon, extensor digitorum communis)
5 EDM
6: ECU

Front 37

Extensor Zones

Back 37

I: over DIP
II: Middle Phalanx
III: over PIP
IV: Proximal Phalanx
V: over MCP
VI: dorsum of metacarpals
VII: extensor retinaculum (carpals)
VIII: proximal wrist

Front 38

Gold standard for determining adequate blood flow for an charco ulcer to heal:

Back 38

>30mmHg Transcutaneous O2 pressure TcpO2
-NB: ABI may be falsely elevated with calcified arteries

Front 39

Gold standard for relief of non-infected charcot plantar ulcerations

Back 39

Non-infected (no fever, erythema, exudate, CRP, ESR = absolute contra’d) with good arterial supply (relative contra) = Total Contact Casting.
Once active dz complete --> CROW Charcot Restraint Orthotic Walker, followed by custom shoe with fitted orthoses.
NB: ulcer recurrence most likely at 3-4 weeks

Front 40

Grading Diabetic Foot Ulcerations

Back 40

Wagner Classification
0: At Risk Foot --> shoe modification, serial exams
1: Superficial ulcer --> office debridement, contact casting
2: Deeper, full thickness ulcer --> operative debridement, contact casting
3: Deep Abscess or Osteomyelitis --> operative debridement, contact casting
4: Partial Gangrene of Forefoot --> Local vs Larger Amputation
5: Extensive Gangrene --> Amputation

Hint 40

Brodsky Depth-Ischemia Classification
0: At risk foot --> Education, accommodative footware, serial exams
1: superficial, noninfected ulcer --> Offload with Total Contact Cast, Walking Brace or Special Footwear
2: deep ulceration, exposing tendons or joints --> surgical debridement, wound care, off-loading, Cx specific Abx
3: Extensive ulceration or abscess --> debride or partial amputation, off-loading, Cx specific Abx
A: Non-ischemic
B: ischemia without Gangrene: non-invasive vasc testing, vasc recon c angioplasty/bypass
C: partial forefoot gangrene: vasc recon and partial foot amputation
D: complete gangrene: complete vasc eval and major extremity amputation