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104 Cards in this Set
- Front
- Back
pt presents with flexible pes valgus, what would you expect on clinical exam
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-everted heel
-abduction of FF on RF -collapse of medial column -foot functions maximally pronated through gait with little or no supination -equinus |
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what compensation occurs with equinus in pes valgus foot
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-early heel off
-STJ and midtarsal joint pronation -medial column sag -tarsometatarsal breech |
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describe the biomechnaical mechanism involved with compensation for equinus in pes valgus
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-ankle equinus prevents DF of talus, which maintains its posistion while the rest of the foot DF, abducts and everts from beneath it
-this leads to subluxatory collapse of the RF on FF |
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if transverse plane deformity predominates in pes valgus, what procedure would you do
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evans
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axis altering arthroeresis devices (STA peg) are used for flatfoot in what plane
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frontal plane
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what neural structures may be encountered when performing an evans
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sural
intermediate dorsal cutaneous |
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what position do you fuse te foot in for triple arthrodesis for flat foot
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- 15 degrees out toeing
-neutral ankle -slight heel valgus |
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when the STJ is pronated which muscles have less then optimal function
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PL and TP
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what calc osteotomies follow the arthroeresis principle
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Extra articular calc osteotomies
-chambers -selakovich -baker hill |
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calc osteotomy that uses a bone graft under the sinus tarsi to block translocation of the talus on the calc
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chambers
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calc osteot that shifts the posterior calc medially so it lies below the sus tali
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kouts
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flatfoot correction that includes nav-cune fusion
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Miller (nave - 1st cune)
Hoke (nav - 1st,2nd cune) |
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MC cause of peroneal spastic flatfoot
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tarsal coalition
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what joints are fused in a Miller
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-nav cune and cune-1st met
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Baker Hill
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-elevates the posterior facet by insertion of lateral bone graft beneath it
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lowman procedure for FF
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-TAL
-kidner -TN wedge fusion |
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where is the osteotomy and bone grafting for a selakovich procedure
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-sustentaculum tali
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who is an arthroesis genrally performed in
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-pt who hasnt reached skeletal maturity
-a felxible FF |
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some causes of congenital FF
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-congenital vertical talus
-tarsal coalitions -Z compensated met adductus -short achilles tendon |
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indications for RF fusion in flat foot
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-severe DJD
-paralytic deformity -rupture of TP tendon with collapse of foot and adaptive changes |
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list 2 problems with doing an isolated STJ fusion for flatfoot correction
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-DJD will occur at other joints
-no correction occurs in the Forefoot |
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describe the cyma line in flat foot
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anterior break
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Kites angle
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talo calc angle
N = 20 on AP |
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ligamentous laxity can occur do to a defect in collagen synthesis causing flat foot; list some dz
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-marfans
-ehlers danlos -osteogenesis imperfect |
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radiographic manifestations for sagital plane dominant flat foot
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-inc talar declination
-nav cune breach -inc talo calc angle on lateral -dec cal inc angle |
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name some abduction deformities of the LE that can lead to flexible pes valgus deformity
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-met adductus
-forefoot abductus -ext malleolar torsion -external tibial torsion -ext femoral torsion -tight lateral hamstrings |
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name the varus producing osteotomies performed in calc for flatfoot correction
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gleich - oblique oseot with anterior displacement
dwyer - lat closing wedge silver - lat opening wedge kouts |
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what foot deformity cant be present if an evans is performed
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-met adductus (you would basicaly inc the deformity)
-cause in toe gait and unmask the deformity |
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youngs procedure
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-reroute the TA to under the navi
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what muscle is encountered in an evans
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EDB
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instability of which column is more indicative of a pathological flatfoot
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lateral column
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during gait, the talus and the leg internally rotate and adduct to take up motion in what plane
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transverse
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dwyer osteot
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-opening wedge in lateral calc (MC)
-closing wedge in medial calc |
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how is congenital calcaneovalgus deformity easily distinguished from congenital convex pes valgus deformity on clinical exam
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congenital calcaneovalgus is flexible and allows for passive correction
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in tarsal coaltion, what happens with hubscher manuever
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-nothing
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what happens in normal hubscher maneuver
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-PF of 1st ray
-supination of RF -ext rotation of leg -inc in medial arch height |
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calc osteotomies are classified into three groups; list the groups and procedures in each group
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- extra articular: chambers, baker hill and selakovich
- anterior: evans -posterior osteotomies: gleich, dwyer, silver, kouts |
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axis of STJ
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- 42 from transverse plane
-16 from sagittal plane -this allows for equal amts of frontal and transverse plane motion |
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what is a kidner
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-resect an accessory navi
-transpose the insertion of the TP tendon underside of the navi |
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young procedure
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-reroute the TA through a slot in the navi without detaching the tendon from its insertion
-TP reattached beneath the navi |
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describe the midtarsal joint when the STJ is in its maximally pronated with the calc everted
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-TN and CC joints become divergent from each other with their axes more paralell allowing full independent motion of each of these joints and inc the ROM of the MTJ itself
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where is the osteotomy made for the evans
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1.5 cm proximal to the CC joint
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how is the evans cut directed
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-directed anteriorly to avoid the middle facet of the STJ
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Halluc abductus angle (HA)
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N <15
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IM angle
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N <8-12
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Met adductus angle (MA)
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N <15
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PASA
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N<8
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DASA
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N <8
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Hallux Abductus Interphalangeus Angle (HAI)
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N<10
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MPD (met protrusion distance)
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+/- 2 mm
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TSP (tibial ses position)
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N is 3 or less
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what is the relationship between the IM and MA angle
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-as the MA angle increases above 15, the IM angle becomes more significant at a lower angle
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what is the effective IM angle
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MA - 15 + IM angle
-in other words, every degree of MA angle over 15 is added to the IM angle |
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what does tracking of 1st MPJ mean
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-that the hallux wants to drift back into a uncorrected position after having been placed in corrected position and put through ROM
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what is the diff between positional deformity and structural deformity
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PASA+DASA = HA (structural)
Same, Structural PASA + DASA < HA (positional component) |
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how is met primus elevatus demonstrated on lateral WB view
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-by comparing dorsal cortical lines of 1st and 2nd met shafts
-the cortex of the 1st met will be seen to diverge from that of the 2nd |
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what structures are cut when excising a fibular sesamoid
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-lateral joint capsule
-fib ses lig -lateral head of FHB -lig between fib ses and prox phalanx -intersesamoid lig |
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what are the advantages of distal metaphyseal osteotomy
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-cancellous bone of metaphysis has better blood supply
-pt can WB post op -can be performed on a child with an open metaphysis, since the metaphysis is at the base |
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where would you aim you apical guide for an Austin to:
PF? DF? Shorten? Lengthen? |
PF (DorsoMed to PL)
DF (PlantarMed to DL) shorten (distal medial to proximal lateral) lengthen (prox med to distal lateral) |
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does an austin correct an abnormal IM angle
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-no, it corrects a relative IM angle
-to correct the actual IM angle, you have to move the shaft and the head closer to the 2nd met |
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green modification to a Reverdin
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-L exits behind the sesamoids
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Laird modification to a reverdin
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cuts all the way through to shift capital fragment laterally
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geode
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-a degenerative cyst seen in the medial eminence of a bunion
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when would you use a mitchell
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-a bunion with a long 1st met
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prox akin corrects for?
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inc DASA
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when should you use a distal akin
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inc hallux abductus interphalangeus (HAI)
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cheater akin
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-attempts to correct for hallux abductus when the DASA and HAI angle are normal
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MC complication of a keller
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-retraction of the hallux and lack of hallux purchase
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juvara
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oblique closing base wedge
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how is the screw placed, if a bas osteotomy is fixed with only one screw
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-placed halfway between the perpendicular to the long axis of shaft, and perpendicular to the osteotomy
-perpendicular to osteot would give the best compression, but not prevent axial movt -perpendicular to long axis of shaft prevents axial movt but not compression |
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mid diaphyseal ostetomies of 1st met
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-ludloff
-mau -scarf |
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common complication of mid diaphyseal osteotomies
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troughing
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trethowan
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-opening base wedge with medial eminence as a graft
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indications for lapidus
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-juv HAV with obliquity or hypermobility of 1st met-cune
-paralytic HAV -DJD -HAV > 18 -for correction of flat foot |
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incidence of non union in lapidus
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10%
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what precautions must be taken in lapidus dissection
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-avoid the MDC nerve, attachment of TA, TP and PL
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when is the crescentic a good choice for HAV
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-when the pt has a short met
(can be made more stable by crescentic shelf) |
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double osteot of 1st met
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logriscino
(reverdin and CBWO-loison balscecu) |
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when fusing the first MPJ, should the adductor be released
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-no, the adductor is no longer a deforming force and it actually gains mechanical advantagr and pulls the prox phalanx and 1st met closer to 2nd
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ideal position of MPJ fusion
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-15-20 abduction
no frontal plane rotation 10 dorsiflexion |
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regnauld
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mexican hat
-make a hemi implant from base of prox phalanx |
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kessel bonney
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-closing base wedge of prox pahlanx
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waterman
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dorsal closing wedge of met head
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what does the youngswick modification of austin do
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-shortening and plantarflexion
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engles angle
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-simplified met adductus measurement
-bisect the 2nd met and 2nd cuneiform |
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what % of adult pts with HAV deformity is a result of untreated juv HAV
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40%
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gender predisposition towards juv HAV
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-before age 14 it is found in males
-after age 14 it is 3 times more common in females |
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explain why a child with spastic CP gets HAV
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-scissor gait due to tight posterior muscles, including the triceps produces equinus force at the ankle
-the joints ditstally try to compensate and DF the foot via pronation throughout contact phase -the flexible pronated foot doesnt provide an effective lever for muscles to stabilize the 1st ray during propulsion |
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what other deformity often accompnaies juv HAV
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-met adductus
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what systemic dz has a high incidence of juv HAV
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-juv RA
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name the pedal factors that are implicated in causing the severity of juv HAV
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-round met head
-atavastic cuneiform -hypermobile 1st ray -hyperpronation -high IM angle |
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what are indications for sx on juv HAV pt before the close of the epiphysis
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-progressive deformity
-uncontrolable deforming forces -rigid met head adaptation -pain -severe deformity |
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when would you perform a lapidus on juv HAV
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-severe inc IM angle
(usually associated with NM or collagen disorders) |
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describe 2 techniques for performing epiphysiodesis in juv HAV
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-lateral stapling of growth plate (reversible)
-or insertion of bone graft into lateral aspect (irreversible) |
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MC complication of epiphydiodesis
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recurrence
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name 2 procedures for juv HAV that address the atavastic cune
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-lapidus
-fowler (open med wedge of med cune with bone graft) |
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name all types of fixation that are appropriate across a growth plate
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-smooth K wires (less likely to disrupt the growth plate)
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at what age does the 1st met epiphysis appear radiographically
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2 yrs
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when do the sesamoids ossify
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10-12 yrs
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what is the major diff between the ossification of lesser mets and the first met
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-the first met epiphysis is at the base, compared to the heads of the lesser mets
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the adductor tendon transfer is used an an adjunctive procedure to?
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relocated and maintain the corrected sesamoid position
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Hiss procedure
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transfer of the abductor tendon to the dorsomedial proximal phalanx of hallux
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is there a strong familial predilection for juv HAV
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yes 50-78% familial incidences
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what is the MC post op complication for CBWO
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elevatus
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