Trauma 12/23/13 4:25 PM-Trauma Work-up:

1) Primary Survey (ABCDE)o Airway look for any obstructiono Breathing labored vs. non-labored breath soundso Circulation asses all 4 extremities

Start 2 large bore (18 gauge) needle if fluids needed o Deficits

AVPU (Alert, Verbal stim, Painful stim, Unresponsive) Glasgow (Eye opening, Verbal response, Motor reponse)

13(+) good prognosis < 8 intubate

o Exposure complete exposure to asses all damage2) Secondary Survey

o Clear C-spine (Miami-J, Philly, Malibu) Palpate down spine, the 4 neck motions

o Detailed HPI, PMHo Comprehensive physical exam

3) History o PMH, FH, SH, Allergies, Meds, Socialo Estimated blood loss & Initial treatment

4) Tetanus o Cause Clostridium tetani G (+) bacilluso Tetanus prone wound :

6 hrs old, infected, deep, devitalized tissue, MOIo Symptoms trismus, risus sardonicus, aphagiao Algorithm :

Complete tetanus status (booster w/in 5 yrs) Hold Toxoid & TIG regardless of wound

Incomplete tetanus status (No booster w/in 5 yrs) Clean Toxoid (0.5 ml IM in deltoid) Tetanus prone Toxoid + TIG (250 u IM)

5) NPO Status o Nothing by mouth after midnight night before elective surgery o Nothing by mouth w/in 6-8 hrs of any type of surgery

6) Physical o Vitals, Vasc, Neuro, Derm, Musculoskeletal

7) Local Wound care o Cleanse and irrigate with betadineo Explore for further damage or retained foreign bodieso Stop bleeders surgicel or hand-tieso Take deep cultures (aerobic, anaerobic, acid-fast, fungal)

8) Decision planning for wound closure o If at all questionable pulse lavage and pack open o DPC in 5 days

-Podiatric Emergences: (CONG) Compartment syndrome Open fracture/dislocation Necrotizing fasciitis Gas gangrene

-Mangled Extremity Severity Score (MESS) Criteria (LASS)

o Limb ischemia, Age, Skeletal/soft tissue injury, Shock Score (1-11)

o 7 (+) high risk for amputation

-Open fractures Don’t close until devitalized tissue has demarcated, but no always Gustilo Anderson

o I) Clean wound < 1 cm Abx Ancef (2g on admission then 1g q8 for 72 hrs)

o 2) Wound 1-5 cm w/ “minimal” soft tissue damage Abx Ancef + Clindamycin (600 mg q8)

o 3) Wound > 5 cm w/ “extensive” soft tissue damage A- adequate soft tissue B- soft tissue damage w/ periosteal stripping & massive

contamination C- arterial damage requiring primary repair “amputate” Abx Ancef, Clindamycin, Aminoglycoside (1.5 mg/kg)

-Fracture Blister Located in “Subepidermal” layer similar to 2nd degree burn Types :

o Clear fluid very tense (most common)o Hemorrhagic flaccid roof (most severe)

Treatment :o Never incise thru due to risk of open fracture underneath o Wait until re-epithelization

-Shock Symptoms tachycardia, tachypnea, delayed CFT, mental status

change, hypotensive, decreased urinary & H&H Types :

o Hypovolemic acute loss of circulating blood

o Septic secondary to infection Treatment :

o Aggressive fluid replacement

-Puncture wounds Only remove if :

o Contaminated object, local infection, pain, intra-articular Puncture wound bugs :

o Most common Staph aureus & Beta-hemolytic strepo Thru shoe Pseudomonao Farming Clostridium

Classifications :o Resnick

1 Superficial visible w/ no infection 2 SubQ or articular w/ no infection 3A SubQ or articular w/ signs of infection 3B Bone penetration w/ no infection 4 Bone penetration w/ OM

o Patzakis Zone 1 Toe to Met head (50% incidence of OM) Zone 2 Midfoot (17% incidence of OM)

Zone 3 Calcaneus (33% incidence of OM) Treatment:

o Tetanus Antibiotics Aggressive I&D w/ copious lavage

-Compartment syndrome Definition interstitial pressure exceeds capillary hydrostatic

pressure (microcirculation shuts down) Symptoms (7 P’s)

o **Pain out prop, Pain w/ toe dorsiflexion, Paresthesia, Pallor, Pulselessness, Pressure, Paralysis

Diagnosis Intracompartmental pressure > 30 mmHg Treatment :

o Remove all cast or dressingo Do NOT elevate (cause more ischemia)o Hydration (prevents effects of myoglobinuria associated with

rhabdomyolysis “muscle destruction”) Myoglobinuria brown urine

o Fasciotomy (should be made w/in 8 hrs of injury) Dual dorsal incision made over 2nd and 4th mets One medial inferior to 1st met and across Lateral leg anterior & lateral compartments Medial leg superficial & deep posterior compartments

Complications: o Volkmans contracture ischemia causing muscle necrosis

leading to scar formation/contracture

o Irreversible damage if left untreated for > 12 hrs Both motor & sensory damage

o Kidney Failure- secondary to myoglobinuria

-Pilon Fracture Definition result of direct impact of talar trochlea against the

distial tibia articular surface Classifications:

o Ruedi & Allgower 1 mild displacement w/ NO comminution or disruption 2 moderate dispacement w/ significant dislocation 3 “explosion fx” severe communition & dislcation

o AO-ASIF Type A (Extra-articular)

1) simple 2) wedge 3) complex Type B (Partial-articular)

1) split 2) split-depression 3) multi-frag Type C (Complete-articular)

1) simple 2) multi-frag 3) explodedo Ovadia-Beals

Type 1 intra-artic w/ no displcement Type 2 minimal displacemt

Type 3 displaced + severe large fragment Type 4 displaced + multiple fragments Type 5 severe comminution

Treatment o Roy Sanders, MD , 9/21/2000 at Loyola University

1) Plate fibula2) External fixation “Delta frame” 10-21 days

Maintains skeletal architecure Allows stable environment for soft tissue enevelope to

heal 3) Fixate tibia

o AO ORIF reduction order (FABB)1) Fibular reconstruction2) Articular surface of tibia recon3) Bone graft in metaphyseal deficit4) Buttress plate the tibia

Lisfranc Trauma 12/23/13 4:25 PM-Introduction

Definition Any subluxation, dislocation, or fracture dislocation of TMTJ complex

o Misdiagnosed in 20% of cases History

o Dr. Jacques Lisfranc served under Napoleon’s army where he was a trauma surgeon in 1820’s

Anatomy o TMTJ

-9 bones, 13 joints, 7 dorsal lig, 7 plantar lig Stronger plantar ligaments

-Keystone- recessed 8 mm creating “mortise”o Columns (Myerson) & Motion “sagittal plane” (Shereff)

Medial 1st met & MC (4 mm motion) Central 2nd & 3rd, IC, LC (1 mm motion) Lateral 4th & 5th, Cuboid (10 mm motion)

-Mechanism of injury Indirect

o Twisting “abduction” of FF on lesser tarsus Nutcracker injury 2nd met + cuboid fx

o Axial Loading axial compression on “plantarflex” foot Parachute jumper

Direct

o Crush excessive weight forced plantar or dorsal -Diagnosis

Clinical o Midfoot tenderness worse w/ pronation or abductiono Plantar ecchymosis Mondur’s sign o Inability to rise on toeso Palpable tenderness to cuboid Nutcracker injury o MUST RULE OUT COMPARTMENT SYNDROME

Plain film o AP view

Diastasis gapping b/w 1st & 2nd bases >2-3mm Fleck sign avulsion fx of 1st IM space (90% cases) Medial border 2nd met lines up w/ IC

o MO view Medial border 4th met continuous w/ medial cuboid Lateral border 3rd met continuous w/ lateral LC

o Lateral view Nutcracker fx compression fx of cuboid Sagittal plane displacement

o CT Scan More sensitive for detecting minor displacement &

fractures

-Classification Quenu & Kuss (1902) A) homolateral B) Isolateral C) Divergent Hardcastle (1982) A) Total incongruity B) Partial C) Divergent Myerson’s modification (1986)

o Type A Total incongruity May be sagittal, coronal or combined

o Type B Partial incongruity B1- incongruity of 1st met (medial direction) B2- incongruity of lesser mets (lateral direction)

o Type C Divergent pattern C1- Partial (only 1st & 2nd mets involved) C2- Total (all mets involved

-Treatment Literature

o Strongly suggests ORIF w/ displacement >2 mm between 1st and 2nd met bases

o Ly & Coetzee primary arthrodesis of medial 2 or 3 rays is better than ORIF in "Purley ligamentous injury”

Non-operative o When plain films show no displacement o NWB SLC for 6 weeks w/ films every 2 weeks

Operative

o Goals : Reduction & stabilization of medial column Reduce but do NOT fix lateral column cuz of excess

motion because of pronating mobile adapter o Incisions

1st webspace access to 1st, 2nd, 3rd and cuneiforms 4th webspace 4th & 5th mets and cuboid

o Fixation Order :

OCPM : MC-2nd met 1st met-MC IC Lateral mets

Kelkikian : Medial column LFL Lateral rays Hardware :

PerQ cross K-wires PerQ k-wires (rays 4 & 5) & ORIF of rays 1-3 ORIF w/ screws or plates External fixation Partial or full arthrodesis

Lateral column : K-wires from 4th or 5th met to cuboid Nutcracker fx H-plate or external fixation

o Post-operative Jones compression w/ splint 2 weeks NWB SLC for 6-8 weeks Transitioned into PWB SLC for 4 weeks High impact activity not till 6 months

o Complications Arthritis, DJD, CRPS, Compartment syndrome, Cuboid

syndrome, Additional surgery/fusion

Ankle Fractures 12/23/13 4:25 PMIntroduction

Anatomy o Ligaments :

-Lateral ATFL (weakest) , CFL (extracapsular), PTFL (strongest) 105 angle between CFL & ATFL

o -Medial Superficial

Calcaneotibial strongest “Superficial”posterior Talotibial taut in DF Tibonavicular weakest

Deep Anterior Talotibial taut when PF

Makes up medial gutter of ankle “Deep”-posterior Talotibial taut when DF

o -Syndesmotic AITFL & PITFL additional stability Transverse TF forms part of ankle mortise Interosseous TF prevents talus from wedging

-Classification Lauge-Hansen “position then direction”

o SAD (suppination-adduction)1) fibular fx or lateral collateral ligament tear2) vertical medial malleolar fx

o SER (supination-ext rotational)1) ATFL rupture 2) Spiral fibular fx (post spike)3) PTFL rupture 4) Med malleolar fx/deltoid rupture

o PAB (pronation-abduction)1) Med mall fx/deltoid rupture2) ATFL rupture3) Short oblique fibular fx (transverse on lateral)

o PER (pronation-ext rotational)1) Med mall fx/deltoid rupture 2) ATFL rupture3) High spiral fib fx 4) PTFL rupture

Daniis-Weber/AO o A) Infra-sydnesmotic

1) Unifocal2) Bifocal3) Circumferential

B) Trans-sydnesmotic1) Isolated lateral 2) Lateral & Medial

3) Later, Medial & PosteriorC) Supra-sydnesmotic

1) Simple diaphyseal 2) Multifragmentary3) Proximal

Mueller A) avulsion B) transverse @ mortise C) oblique D) vertical

Additional Names: o Tillaux-chaput ATFL avulsion from AL Tibiao Volkman PTFL avulsion from PL Tibiao Wagstaff ATFL avulsion from AM Fibulao Bosworth PTFL avulsion from PM Fibulao Dupuytrens Bimall w/ talus wedged bw/ fib & tibo Pott’s Bimall fx o Destot’s trimall fx

-Clinical Diagnosis Palpate :

1) Proximal & distal filbua2) Medial & Lateral gutters (deltoid & collaterals)3) Calcaneus & Achilles

4) Styloid process of 5th met (P. brevis avulsion)5) Sinus tarsi (EDB avulsion)6) Lisfranc & TMTJs

Tests 1) Anterior draw ATFL rupture (> 5mm)2) Stress inversion CFL rupture (> 10 compared contralateral)

-Radiographic Diagnosis Fracture pattern (look at all 3 views)

o Get more proximal views for suspicious SER Fibula out length (MO view)

o Ramsey & Hamilton- 42% decrease in TT contact with 1 mm lateral talus displacement 1) Medial clear space should be < 5 mm2) TF overlap should be > 10 mm3) Talar tilt should be < 10 mm alone4) Shenton line continuous line from lateral talar shoulder5) Dime sign continuous curve distal to fibula

Rule out OCD’s o Medial deep cup “more stable (inversion & PF)o Lateral wafer “less stable” (inversion & DF)

Plafond cartilage o Order CT scan to evaluate

o Allows better visualization of posterior malleolar fx-Treatment

Closed reduction o Hematoma block vs. IV conscious sedation per ED (etimodate,

versed, etc..)o Exaggerate distract reverseo Post-reduction filmso Posterior splint w/ sugar tong strap

Fracture Blisters Place in Posterior Splint for 1-2 weeks, RESPECT Soft tissue.!! Want good skin quality and turgor by POSITIVE WRINKLE TEST

Surgical technique (Follow Vassal’s principle)o Soft tissue dissection down to peroneal muscleso Curette hematoma out of fractureo Reduce fracture (k-wires, point-to-points, etc..)o Plates :

Neutralization plate takes the strain rather than the fracture (protects interfrag screw)

Buttress/Anti-glide prevents motion, applies force at 90 degrees to the axis of rotation deformity

Bridging strictly for comminuted fractures to hold fragments together “Relative stabilization”

DCP allows eccentric drilling and axial compression across fracture site

Tension band placed on tension side to convert tensile force to compressive forces at fx site

o Fibula fixation : 6 cortices above & as many as possible below Lag screw (3.5mm) to fracture

Non-locking cortical “Proximal” to fracture Non-locking cortical “Distal” to fracture Fill the rest in with locking or non-locking

o Medial malleolar: PerQ vs. Open approach 4.0 cancellous, plates, tension band wiring

o Posterior malleolar : Only if > 25-30% of joint space 4.5 cannulated screw (posterior to anterior)

o Syndesmotic : Fibular fractures above 5cm of Ankle mortise require

syndesmotic fixation (SER type) Stress exams (intra-op):

Cotton (lateral-hook) pull the fibula laterally, and If everything moves its NEGATIVE

External rotation of foot see if fibula displaces lateral and posterior

Fixation (rules of 3) *Leave a hole open on plate for fixation At least 3 cm proximal “parallel” to mortise 30 anterior Screw should be 3.5 mm diameter

Cortical screw vs. Tightrope

Tri vs. Quad cortical

Calcaneal fracture 12/23/13 4:25 PM-Introduction:

Etiology: o Men from 30-60 yrs oldo 75% of all calc fractures at INTRA-articularo 60% of all tarsal injuries

Mechanism of Injury o Direct axial load (fall from height)o Vertical shear force

Rules of 10: o 10% Lumbar Spine Fracture (L1 & L2)o 10% Bilateral o 10% Chance of Compartment Syndrome

-Clinical diagnosis: Pain w/ palpation to heel Mondur’s sign ecchymosis to plantar medial foot Hoffa’s sign less taut achilles tendon on involved side Fracture blister (usually on medial side due shear force)

-Radiographic diagnosis: Lateral View

o Bohler (25 – 40) DECREASEDo Angle of Gissane (125 - 140) INCREASEDo Joint depression w/ loss of calcaneal height

Lateral Oblique o Evaluate anterior process of calcaneuso Asses CC joint involvement

Harris-beath Posterior facet Isherwood “3 oblique” view that highlights all facets Broden “2 oblique” view for Middle & Posterior facts

o Show the congruence of the subtalar joint.o Taken at 30°, 50°and 70° to the horizontal

Calcaneal axial o Evaluates calcaneal widening & varus/valgus position

CT Scan o Gold standard for evaluation and surgical planningo Coronal view basis for Sander’s classification o MUST ORDER SAGITTAL RECONSTRUCTIONo Look for:

Sustentaculum tali stays in position! Lateral wall blowout (peroneal injury/sural) Calcaneal tuber tips to varus

Posterior facet is DEPRESSED

-Classifications: Sanders (widest view of posterior facet on semi-coronal CT)

o A/B/C lateral to medial o Type 1 non-displaced articular fx

Tx- conservativeo Type 2 2 part posterior facet fx

Tx- ORIF (86%)o Type 3 3 part posterior facet fx

Tx- ORIF (60%)o Type 4 4 part posterior facet

Tx- Primary arthrodesis Rowe

o Type 1 A) Med tubercle B) Sustentaculum C) Ant process

o Type 2 A) PS calc process B) PS calc w/ achilles involvment

o Type 3 EXTRA-articular thru calc bodyo Type 4 INTRA-articular thru calc bodyo Type 5 INTRA-articular thru calc body w/ comminution &

joint depression

Essex-Lopresti (Rowe 4 & 5)o Primary fx line in both superior to inferior from angle of

gissane to plantar calcaneal body o Type A (tongue type)

Force vertical directed Secondary fx line extends posterior thru tuberosity

o Type B (joint depression) Force anterior directed “lateral talus acts like wedge” Secondary fx line extends to behind posterior facet

-Treatment Options Non-op, ORIF, Ex-fix, STJ arthrodesis

o NO rush to fix fracture Usually delayed 8-14 days MAX delay- 3 weeks

o Wait for (+) wrinkle test Literature :

o Patient’s w/ better surgical outcome (Buckley- JBJS, 2002) Women, Young male, NOT receiving WC, Increased

Bohlers, Lighter workload at job, Simple fractureo Op vs. Non-op displaced calc fx (Stockholm- JBJS, Aug, 2013)

1 yr f/u comparable results 8 yr f/u slightly better VAS score in Op group

o More & more popular to not fix because of the high rate of patients that will eventually go into a fusion

Reduction Goals (AARRD)o Align post facet, Align RF, Restore height/length/width of

calcaneus, Reduce CCJ, Decompress lateral wall Reduction order (MPPLA)

o Med wall Primary fx line Post facet Lateral wall Anterior process fracture

o Constant fragment- fragment of fracture at medial side including sustentaculum where reconstruction is built on

o Preliminary reduction achieved by multiple k-wires fixation in a stepwise reduction

Incisions o Lateral extensile (modified Ollier)

Good visualization of posterior facet & CC joint Full thickness flap including the periosteum K-wires to drill into fibula and Talus to retract flap

o Medial (McReynolds) Easy reduction of sustentacular fragment

Technique o Joy-stick use of Steinman pin to help reduction fracture

fragments then use k-wires to temporary holdo Stryker balloon reduction (+) bone cemento Test reduction of articular facets by taking thru ROM in OR

Hardware o Plate & bunch of screwo AO website

Closing

o Place drain (due to vascularity of Calcaneus)o Remove drain 24-48 hours or when there is less than 25mL in

8 hour shifto Interrupted Allgower-donati stitch

Complications o Wound dehiscence, Arthritis, Nerve damage, RSD, DJDo Malunion (Stephens & Sanders)

Type 1 large lateral exostosis w/ or w/out extremely lateral arthrosis of STJ

Type 2 lateral exostosis combined w/ major arthrosis across the width of the STJ

Type 3 lateral exostosis, severe arthrosis of STJ and malunion of calcaneal body w/ RF in varus/valgus

Post-op o The ankle and subtalar joint are put through range-of-motion

exercises as soon as possible, usually by 2-5 days.o Weight bearing is delayed until 8-12 weeks, depending upon

the degree of comminution and the adequacy of the fixation.o Radiographic views is obtained at 6,12 and 26 weeks.

Lateral Ankle Stabilization 12/23/13 4:25 PM

-Introduction: Anatomy :

o ATFL (intracapsular) “WEAKEST” Flat & quadrilateral shaped Restricts internal rotation of talus

o CFL (extracapsular) Cord-like that blends w/ peroneal tendon sheath Restricts adduction Brostrom (1966) cfl rupture is rarely ruptured “only 2

of 60 cases”o PTFL (intracapsular) “STRONGEST”

Trapezoid shapedo Cervical

Restricts external rotation of talus Guides STJ “inversion” Highly innervated & attached to lateral talus

Etiology :o Inversion ankle sprains (athletes)

Inadequate treatment of original injury leads to scarred or elongated ligamentous structures

DDX :o Peroneal subluxation

Low-lying muscle belly Overcrowded w/in SPR (P. Quartus)

o Sinus Tarsi syndrome Caused by chronic ligament damage Pain with Plantarflexion & Inversion

o Others OCD, Syndesmotic injury, Cuboid fracture, Lateral talar process fx, ankle fx, 5th met avlusion fx

-Clinical Diagnosis: History of ankle giving way Anterior draw > 5 mm (+) in ATFL rupture Talar tilt > 10 (+) CFL rupture “sucking sign” Peroneal sublux test ankle in circles “feel for popping”

-Radiographic diagnosis: AP, Lateral and Ankle mortise Arthrogram for ATFL (since its intra-capsular) Tenogram for CFL (since it extra-capsular)

-Classifications: Anatomic

o Grade I ATFL sprain

o Grade II ATFL & CFL spraino Grade III ATFL, CFL, PTFL sprain

AMA standard nomenclature system o Grade 1 ligament stretchedo Grade 2 ligament partially torn o Grade 3 ligament completely torn

Eckert & Davis o Grade I SPR separated from fibrocartilageo Grade II fibrous lip of fibula avulsedo Grade III avulsion fx w/ retinaculum o Grade IV SPR elevated from calcaneus

Sobel (P. brevis tears)o Grade 1 splayedo Grade 2 partial thickness split (< 1 cm)o Grade 3 full-thickness split (1-2 cm)o Grade 4 full-thickness split (> 2 cm )

-Treatment Conservative

o RICE for all severities o Mild lace-up brace & NSAIDs

o Severe NWB, BK cast, Jones compression, NSAIDs Surgical

o Tendon reinforcement Bostrom imbrication of ATFL & CFL “pants-over-vest”

Gould - imbrication of IER to reinforce further Athroscopic repair manual debridement

o Tendon rerouting Watson Jones P. brevis thru distal fib & neck of talus Ellis-Jones lateral strip of achilles Lee P. brevis thru distal fib and sutured on itself Evans P. brevis thru distal fib and sutured to post. Fib Chirstman snook split P. brevis restores both CF & ATF

by rerouting thru talus, fib and calcaneus Kelikian & Kelikian Plantaris rerouted thru calcaneus,

distal fib and talus then sutured onto itself 15% of people have plantaris

o Bone block Kelly posteriorly rotated distal fib and fixated Duvries rectangle piece of distal fib slide posterior

o Groove deepening Changs method

Create several holes in posterior ridge of fibula Sutures are passed thru SPR then suture thru

holes under the leading edge w/ fiber wire Post-op

o NWB BK cast 4-6 weekso WB BK cast 3 weekso Physical therapy w/ strengthening following cast removal

Gout 12/23/13 4:25 PM

-Introduction Metabolic disorder secondary to the build-up of monosodium urate

crystals and supersaturated hyperuricemic extracellular fluids in and around joints and tendons causing red, hot and swollen joint

Decreased solubility of sodium urate at lower temperatures of peripheral structures likes toes & ears

Differential Diagnosis :o Pseudogout, Septic arthritis, RA, OA Cellultis, Trauma,

Infection, Sesamoiditis, Seronegative athropathy

-Classification Primary

o Overproduction (metabolic gout) Excessive amount of acid excreted Dx: Uric acid > 600 mg in 24 hr urine collection

o Underproduction (renal gout) Deficit in renal excretion of uric acid 90% of patients

Secondary o Minor clinical feature secondary to genetic or acquired person

Stages o Asymptomatico Acute gouty arthritis soft tissue swelling onlyo Intercritical gout periarticular calcification & erosions

o Chronic tophaceous gout large intra/extra-articular destruction of proximal phalangeal bases > 5 mm

Attacks are less frequent, but always chronic pain

-Radiology Increased soft tissue density Periosteal reaction Round osseous erosions w/ a scerlotic margin “Punched-out” Joint spaces preserved till late in course of disease Martel’s sign expansile lesion w/ overhanging margin

-Labs Joint aspirate

o “Negative birefringent crystals when view under polarizing light microscope

o Blue when & yellow when =o Pseduogout is opposite w/ “positive” crystals

Serum Uric acid > 7.5 mg/dl (non-diagnostic) Synovial fluid analysis elevated leukocytes w/ + neutrophils ESR elevated at time of attack

-Treatment:

Acute: o *Indomethacin 25 mg b.i.d. or t.i.d (MAX- 200mg)

o Naproxen 500 mg PO initially, then 250 mg PO q6-8hro Celebrex 400 mg PO initially, then 200 mg PRNo Medrol Dose pack (4 mg)

6 day course staring w/ 6 pills on day 1 then tapering to only 1 pill on day 6

o Colchine Take 0.5 mg × 1 dose, followed by 0.3 mg 1 hour later; at least 3 days must elapse before this dose is repeated

Chronic: o Allopurinol Inhibition of xanthine oxidase, the enzyme that

synthesizes uric acid from hypoxanthine 100 mg/day initially; increase weekly to 500 mg PO

qDayo Probenicid increasing net renal excretion of uric acid

through inhibition of tubular reabsorption 250 mg PO twice daily for 1 week; increase weekly to

500 mg PO twice daily Diet changes

o Avoid seafood, beer, red meat, asparagaus, sugar drinkso New diet low-fat dairy foods, complex carbohydrates,

coffee, and fruits, especially citrus fruits You should get 12 to 16 cups of fluid daily.

Surgery o I&D washouto Arthroplastyo Arthodesis

Charcot Neuroathropathy 12/23/13 4:25 PM-Introduction

History o Musgrave (1703) first to report neuropathic osteoathropathy o Jean Marie Charcot (1868) french neurologist who linked

syphilis to neuroathropathy Pathogenesis:

o Neurovascular (French theory) Trophic centers in the anterior horn of spinal cord

maintain nutrition to joint, and damage to these centers causes increases blood flow & osteoclastic activity

o Neurotraumatic (German “Virchow” theory) Repeated trauma to an insensate foot

o **Primary deforming force ankle joint equinus Etiology (ANYTHING THAT CAUSES NEUROPATHY)

o Most common Dm, Syringomyelia, Tabes dorsaliso Others Alcoholics, Polio, Tumors, CMT, CPo Drugs Indomethacin, Intra-artic steroid, Phenylbutazone

DDX: o OM, AVN, Inflammatory & Septic arthritis, Neoplasm

-Clinical diagnosis: Like any infection Red, hot, swollen, +/- painful BOUNDING pulses

-Classification Eichenholtz (based on plain film radiographs)

o Stage 0 (High risk pre-charcot) Radio maybe increased soft tissue density

Uptake in all 3 phases of Tc-99 scan Clinical sudden onset of non-pitting edema,

erythema, bounding pulses, +/- pain, instrinsic muscle atrophy

o Stage 1 (Acute/Developmental) Radio capsular distension, fragmentation, subluxation Clinical red, hot, swollen w/ joint laxity

o Stage 2 (Coalescence) Radio sclerosis, resorption of debris, fusion Clinical decreased red, hot and swollen

o Stage 3 (Reconstruction) Radio decreased sclerosis (+ vasc) & remodeling Clinical increased stability

Brodsky (based on location of deformity)o Type 1 lisfranc (27-60%)o Type 2 chopart (30-35%)o Type 3 A) ankle B) posterior calcaneuso Type 4 multiple combinationso Type 5 forefoot

Schon (Based on location & severity)o Lisfranc pattern - (A C w/ increasing deformity to “medial”

rockerbottom & ulceration)o NC pattern - (A C w/ increasing deformity to “lateral”

rockerbottom & ulceration)o Perninavicular pattern - (A C w/ lateral rockerbottom, talar

AVN and ulceration) o Transverse tarsal pattern - (A C w/ increasing deformity to

central rockerbottom and ulceration)

-Charcot vs. OM Osteomyelitis

o Leucocytosis and a left shift is present o Sed rates are usually higher than 70mm

Charcot o Involves multiple bones o Elevated alkaline phosphatase levels

Gold standard Bone Biopsy “if infected then OM” Plain films

o Charcot fragmentation & progressive resorptiono OM NO progressive resorption seen

Certec scano Charcot not hoto OM will be hot

-Treatment: Conservative If no ulcers & foot is plantar grade

o Resolution of edema w/ compression, elevation and rest; total immobilization of the limb by TCC

o As the disease progresses move from a cast to bracing such as a Charcot restraint orthotic walker (CROW)

o Long term AFO bracing; extra depth shoes or other types of accommodative foot wear

Surgical o Eichenholtz (1996) “early” stage I or “late” stage IIo Johnson (1998) stage III, and after conservative care has

been exhaustedo Myerson (1999) stage II or III

Acute phase of skin necrosis from pressure ulcer Dislocation of foot is likely to cause further issues

o Simon (2000) first to publish paper of success in stage I Operated on 14 patients in the acute phase of the

disease with good anatomical reduction & results Believe that early arthrodesis should be considered in

patients with early stage I charcoto Technique

Goal Make foot stable & plantar grade Pantalar, TTC, or TCN arthrodesis for deformity about

the ankle and rearfoot Triple arthrodesis for deformity correction about the

rearfoot Extended medial or lateral column arthrodesis for

deformity about the midfoot.o Ilizarov frame

Advantages :

Contributes to osseous healing Promotes revascularization Optimizes cellular environment Reduces infection

Principles (DARN) Distraction, Axial compression, Rotation,

Neutralization Technique :

Wires should cross at 60 Wires are then tensioned

12/23/13 4:25 PM