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ortho /biomechanics
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pediatrics
Developmental Landmarks
9 mos: Sits up
12 mos: Stands up
14 mos: Walks
18 mos: Talks
Ganley Splint
Met Adductus
Langer Brace
Torsional Abnormalities
Met. Adductu
Osteochondrosis
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Kenny’s reviews
Freidbergs Dz – 2nd Met head
Females, 10-18yo
Tx: Sx Shoe
Kohlers Dz – Navicular
Males, 3-6 yo
Self Limiting
Osgood-Schlatter – Tib-Tuberosity
Males, 10-15 yo
Self Limiting
Bowing of Legs
Males, 3-12yo
Females, Breech
Dislocates Post-Sup.
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Kenny’s reviews
Extended and adducted
Signs/Symptoms
(+) Trendelenberg
Limited Abduction
Waddling Gait
Tarsal Coalitions
Males>Females
Decrease ROM
Fusion Types
Syndesmosis: Fibrous
Synchondrosis: Cartilaginous
Synostosis: Osseous
Talocalcaneal Coalition
Radiographs
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Kenny’s reviews
Extra-Articular
8-12 yo
Tal-Nav Colalitions
Most asymptomatic
Met-Adductus
Etiology – unknown
Clinical Features
Males=Females
Windswept deformity
(High Arch)
Compensated = Skewfoot
(Flat Foot)
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Kenny’s reviews
Classifications
Lichtblau Test
Heel Stabalized
Medial pressure
At 1 year: 20 Degrees
At 4 y/o: 15 Degrees
Treatment
Inversion of heel
Thompson
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Berman/Gartland (BG)
Osteotomies 1-5
Clubfoot
FF-Adductus
RF-Varus
Ankle Equinus
*TN-subluxation
Etiology
SC Trauma, Post-CVA
Incidences
Polynesian>Black>White>Asian
Radiographs (Signs)
Talus
Reduced size
25
Kenny’s reviews
Lat: < 20 Degrees
Calcaneus
Normal Shape
Navicular
Normal Shap
Hypertrophic Tuberosity
Plantar/Med Subluxation
Treatment
Adduction
Equinus
Complications
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Met Adductus
Heel Varus
Surgical – NM disorders
Osseous Procedures
2-6 yo
Clinical Features
Males=Females
Usually B/L
Calcaneus is valgus/equines
STJ abnormal
Ant: Missing
Middle: hypoplastic
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Post: malformed
Etiology
Radiographs
Lateral
Negative/low CIA
Treatment
Conservative Tx
rarely successful
Surgery
Calcaneal Valgus
Clinical Features
Radiographs
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Treatment
P/F Foot
FF Adducted
RF neutral to Inv.
Post-Casting
Ganley Splints
Surgery
Soft Tissue
Osseus
Arthrodesis
Not Painful
Females
Maternal
Stages
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I – Slight Abduction
Irritation of Prominence
II – Moderate Abduction
“Tracking” Deformity
Rare
Surgery
30
Dermatology
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Dermatology Points
Koens Tumors
Tuberous Sclerosis
Hansen’s Dz (leprosy)
Scleroderma
Onychomycosis
T. rubrum
Tests
37
Kenny’s reviews
Seen in Bullus Diabeticorum
38
infectious diseases
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Kenny’s reviews
SE
Hypersensitivity Rxns
Thrombocytopenia
Diarrhea (amox)
CI
Methotrexate
Cephalosporins
SE
Diarrhea
CI - Probenecid (increase [ ])
Macrolides
SE
Hepatotoxicity
CI
Digoxin
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Kenny’s reviews
Coumaden (increase bleeding)
Statins
Aminoglycosides
SE
Nephrotoxic – reversible
Ototoxic – irreversible
CI
Quinolones
SE
Tendon Rupture
Diarrhea
Torsades de Pointe
Polymorphic Ventricular Tachycardia in pts with long QT interval.
CI Rapid irregular QRS complexes.
Diabetics (tequin)
Tetracyclines
CI
Vanco
SE
Nephrotoxic – reversible
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Kenny’s reviews
Ototoxic – reversible
Zyvoxx
SE - Thrombocytopenia
CI - SSRI’s
Imipenin
Bactrim
SE - Sulfa Allergy
CI
Clinda
SE - Pseudomembranous colitis
Metro
SE
Disulfiram rxn
Peripheral neuropathy
Pregnancy
Rifampin
SE
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Kenny’s reviews
Body Fluids turn orange
INH
SE
Peripheral neuropathy
Diarrhea
Dermatitis
Dementia
Diflucan
CI - pregnancy
Lamisel
SE
Taste disturbances
Green vision
Liver damage
Sporonox
Cimetidine
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Kenny’s reviews
Diabetes
Type
Gestational - self-limiting
Secondary Causes
Pancreatic Dz
Diagnosis
Hb1Ac
Every 1% = 30mg/dl of BS
Drugs
Rapid - Humalog/Novolog
Onset - 30 min
Pk - 3hrs
Duration - 5hrs
Onset - 2-4hrs
Pk - none
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Duration - 24hrs
Oral Meds
Metformin (glucophage)
Troglitazone
Diabetic Complications
Acute Conditions
Symptoms
Hyperventilation
Tachy/HOTN/Sycope
Acetone on breath
Labs
pH < 7.2
High K
Low Na
Tx
Fluids
Hypoglycemia (<50mg/dl)
Symptoms
Tremors/Siezures/Confusion
Syncope/Sweating
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Kenny’s reviews
Treatment
Accucheck in 20min
Lactose Acidosis
SE of Metformin
Tx - bicarb
Chronic Conditions
Pathogenesis of Hyperglycemia
Sorbitoln
Gwcosen
Reductase. Reductase Fructose
Decrease Na-K pump
,
$A
't
NADPH NADP NAD
't
DH
Decrease NCV
Polyneuropathy .
Can later lead to motor loss of intrinsic muscle – cavus foot, hammertoes
Autonomic Neuropathy
Systemic Manifestations
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CV - increase HR, HOTN
Amitriptyline
Neurotin
Lyrica
Topical capsacian
Radiograph features
Demineralization
Osteolysis
Vascular Dz
Nephropathy
Retinopathy
Diabetic Charcot
Neuro – decreased
Dermatology
Collagen inelasticity
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Grade
Stage
Stage A – clean
Stage B – infected
Stage C – ischemic
Complications
Chronic wounds
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Marelins Carcinoma
Work-up
Physical Exam
F/C/NS?
Lethargic?
Dermatological
Ulcer (D-DMB-DOC)
Diameter
Calor? - temp
Dolar? - painful
Labs
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Kenny’s reviews
C & S (anaerobic/aerobic)
Staph
Strep
E.coli
Enterococcis
Proteus
Pseudomonas
Bacteriodes
UA - r/o Urosepsis
CMP/BMP
Studies
X-rays
Dx - Cellulitis
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Dx - Cellulitis
Dx - OM
Tags WBC’s
Gallium
Ceretec Scan
MRI
T1 - decrease intensity
T2 - increase intensity
Osteomyelitis
Classification (Mader)
Medullary - infants/children
Localized - sequestra
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Get proximal margins
Etiology (Stept/Staph)
Acute Osteomyelitis
Osteolysis
Cortical erosions
Periosteal elevation/reaction
Neutrophils - day 1
T-cells - day 5
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Drainage - copious lavage
Treatment Goals
Wound Dressings
Regranex
Growth factors
Panafil
Debriding agent
Accuzyme
Silvadene
Antimicrobial
Xenoderm
Dakin's solution
Dilluted Bleach
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Silvasorb
Aquacel
Prevents maceration
H2O2
Bacitracin
SE - fungal super-infxn
Wound Irrigation
Minimum of 200cc
Strept A
Post-Op
Staph
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Necrotizing Fasciitis
Strept A
Gas Gangrene
C.Perfinges
Farm injuries
Vibrio species
Mycobacterium Avium
Fresh Water
Pseudomonas
Aeromonas
Puncture Wounds
Acinebactor
Lacerations
Burns
Staph
Gram (-)
E.coli
Kleb
Pseudomonas
Enterobacter
DM-Wounds
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Staph/Strept
Enterococuss
Gram (-)
E.coli
Pseudomonas
Proteus
Bacteriodes
Impetigo - Staph
Folliculitis
Staph
Erythrasma - Corneybacterium
Furuncle/Carbuncles - Staph
Abscesses
Staph
Bacteriodes
Strept A
Osteomyelitis
Staph
Staph/Strept
Pseudomonas
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Bites
Tick Bites
Animal Bite
ENT
Otitis/Sinusitis
Moraxella
H.Influenze
Pharyngitis - Stept
Staph/Strept
H.infleunza
Legionella
Actinomyces/Norcardia
Staph
Gram (-)
E.coli
Pseudomonas
Immuno-compromised Pneumonia
Myco-Avium/TB
Pneumocystis Carnii
GI
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Diarrhea
Gram (-)
Salmonella/Shigella
Camplyobacter
E.coli
Urogenitial
STD
Chlamydia
N.Gonnorhea
Treponema (Syphilis)
UTI
Gram (-)
E.coli
Kleb
Pseudomonas – nosicomial
CNS/CV
Endocarditis
Staph/Strept
Enteroccus
Strept
Meningitis
Strept
Listeria
N.meningitis
Sepsis
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Staph/Strept
Tuberculosis
Findings
F/C/NS
Weight loss
Tetanus
Findings
Trismus (lockjaw)
Muscle Spasm
Irritability
Dysphagia
50% mortality
DDx
Strychnine poisoning
Phenothiazines
Treatment
DTP
2, 4, 6, 15, 48 mos.
.
DT
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Tetanus-Ig (post-exposure)
Mycology
Superficial Mycosis
Sub-Q Mycosis
Sporotrichosis
Arthritis
Chromomycosis
Mostly in tropics
Etiology - Cladosporium
Weeping granulomas
Systemic Mycosis
Coccidioidomycosis
Blastomycosis
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Paracoccidiodomycosis
Seen in Brazil
Cryptococcosis
Opportunistic Fungi
Aspergillosis
Pneumocystic carinii
Parasitic Infections
Cutanea Larva migrans
Tx – topical thiabendazole
Viral Diseases
Vaccination available
Hepatitis B
STD
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(+) HBsAb = immunity
Type 1
Oral sores
Trigeminal Latency
Type 2
STD - genital lesions
Lumbar/Sacral Latency
Varicella/Zoster
Chickpox/Shingles
Epstein-Barr
Mono
CMV
Birth Defects
HIV pts
Papillomavirus (warts)
Pox Virus
Largest virus
Molluscum Contagiosum
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RNA Virus
Influenza
A - multilple host's
Paramyxoviruses
Mumps
Parotid glands
Measles (Rubella)
Encephalitis
Vaccine (live)
RSV
Resp infxn in peds <1yrs
Enteroviruses
Polio
CNS, Faccid paralysis
Coxackie
Mild Dz
Hepatitis A
No chronic state
Low fatality
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Retroviruses (HIV)
Skin Lesions
Kaposi’s Sarcoma
Eosinophilic Folliculitis
Molluscum contagiosum
Thrush
Psoraisis
Alopecia
Onychomycosis
Norwegian Scabies
Infection Complications
Meningitis – Cryptococcus
CMV retinitis
PCP – Bactrim Px
Flucanazole Px
M. Avium – Macrolide Px
Tuberculosis - Isoniazid Px
Rabies
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Animal bites
CNS/encephalitis
Vaccine (inactive)
Hepatitis
A - above
B - above
C - IV drug users
68
medicine
internal
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Anethesia
Patient Classification
Stages of Anesthesia
Stage 1
A – analgesia
A – sleep
B – sensory loss
D – intercostals paralysis
B – irreversible CV collapse
Halothane
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Kenny’s reviews
Iso,Sevo,Devoflurane
Nirtous Oxide
Diprivan (Propofol)
Sedatives
Diazepam (Valium)
Midazolam (Versed)
Amnesia Agents
Ketamine
SE – hallucinations
Side Effects
Morphine
Reduces GI motility
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Kenny’s reviews
Broncho-constricts
Demerol
Muscle Relaxors
Succinylcholine
SE – Hyper-K
Tubocurarine
Longer duration
Reversible by Neostigmine
Misc
Atropine
Reduces secretions
Bronchodilator
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Kenny’s reviews
Local Anesthetics
MoA
(-) Na-Channels
(-) Depolarization
1st Pain/Temp
Touch
Motor
Types
Esters
Amides
Metabolized in Liver
Marcaine
Most CV toxic
Epinephrine
Toxic Doses
Lidocaine (300mg)
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Kenny’s reviews
Lidocaine w/ epi (500mg)
Marcaine (175mg)
Indications
Contraindications
Preexisting neurological dz
Extremes in age
Septicemia
Shock
No post-op headache
Less HOTN
Spinal Advantages
Easier to perform
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Kenny’s reviews
Anesthesia Complications
Malignant Hyperthermia
Hypovolemic Shock
Intubation
Sore throat
Pneumothorax
Tissue necrosis
Thrombosis
Paralysis
Peds pts
Hypoglycemia
Hypothermia
NPO
High K – T-tent
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Kenny’s reviews
Arthropathies
Gout
Charcot
Rheumatoid
Juvenile RA
Osteoarthritis
Seronegative Arthropathies
Reiter’s
Psoriatic
Ankylosing spondylitis
Connective tissue Dz
SLE
Scleroderma
Joint Fluid
Non-inflammatory
Transparant, Straw
Viscous
Diagnosis
DJD, OCD
PVNS
SLE/Scleroderma
Inflammatory
Translucent, Yellow
Low viscosity
Crystal (gout)
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Kenny’s reviews
>50% PMN
2,000-75,000 WBC
Diagnosis
RA, Gout
Sero-neg's
SLE/Scleroderma
Ulcerative Colitis
Septic Joint
Opaque fluid
Viscosity variable
>75% PMN
>100,000 WBC's
Septic Arthritis
Pathogenesis
Findings
Types
Gonoccal (N.gonorrhea)
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Polyarticular --> Mono
Small rashes/vesicles
as bacterial is seldom
found in jt
Non-gonococcal
damage or immuno-
suppressed
H.infuenza in children
Pseudomonas - Ecthyma
gangrenosum
Viral Arthritis
Non-destructive
Poly-articular
Lymes Dz
Poly-articular artritis
mostly knee/ankle
Heart arrythmia's
Flu-symptoms
Tx - Doxy is DOC
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Kenny’s reviews
Gout
Clinical Signs
up or urate cyrstals
Asymmetrical, monoarticular
X-ray Findings
(Martels sign)
Types
10% of patients
Psuedogout
(rhomboid)
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Kenny’s reviews
Seen with Hyper-PTH and
Hypo-Thyroid
Labs
ESR – increased
Treatment
Acute Gout
Indomethacin (NSAID)
Colchicine
Beware of GI toxicity
it was gout
Chronic Gout
Allopurinol
For “overproducers”
Probenicid
For “undersecretors”
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Charcot
Pathogensis
Etiology
Diabetis
Alcoholism
Tertiary Syphillis/HIV
Theories
French (vascular)
vessels
resorption of bone
German (neuro)
sensation
Stages
Fragmentation
Coalescense – absorption of
Remoldling
Clinical Findings
Decrease sensation
Atrophy of Intrinsics
Anhydrosis
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Decrease in DTR’s
Treatment
Rheumatoid Arthritis
Clinical Findings
initial symptom
located in popliteal
X-ray findings
Arthritis mutilans
Diffuse osteopenia
Lab values
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Kenny’s reviews
ESR – increase
RA factor – increase
ANA – positive
Surgery considerations
1 – corticosteroid supplementation
(pre-op)
2 – ASA/NSAID discontinuation,
(very thin)
8 – DVT prophylaxis
Juvenille RA
Clinical Findings
Self-limiting
Labs
RA-factor negative
ANA - positive
Osteoarthritis
Clinical Signs
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Kenny’s reviews
Asymmetric
Joint enlargement
Crepitus
X-ray Findings
Subchondral sclerosis
Osteophytes
Lateral Column OA
Trauma
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Seronegative-Arthropathies
Reiter’s / Reactive Arthritis
Clinical Findings
Urethritis
Conjunctivitis
Arthritis (asymmetric)
Etiology
Camplyobacter
Idiopathic - woman/children
Other Findings
Keratodermas
Digital swelling
X-ray findings
Osteoporosis
Subluxations
Labs
HLA-B27 - positive
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Kenny’s reviews
Tx - self limiting
Psoriatic Arthritis
Clinical Findings
Middle age
5% of patients have
papalosquamos psoriasis
Asymmetric presentation
Digital swelling
X-rays
appearance” of distal
Lab values
ESR – increased
HLA-B27 - positive
Ankylosing Spondylitis
Aortic insufficency
X-ray Findings
Multiple ensopathies
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Kenny’s reviews
Labs
ESR - increase
HLA-B27 - positive
Clinical Findings
Young women
Butterfly rash
Photosensitivity
Nephritis
Pericarditis
Raynauds phenomenon
Lab Tests
ESR – increased
ANA – positive
Anti-dsDNA
RA-Factor
Scleroderma
CREST
Calcifications in skin
Raynauds
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Esophageal dysfunction
Sclerodactylyl
Telangiectasia
Lab Tests
ANA - positive
RA-Factor
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Hematology
RBC Disoders
Symptoms
Thalassemias
Macrocytic Anemias
Normal Anemias
Aplastic Anemia
BM Dz - pancytopenia
Auto-Ab
Malaria
Prosthetic valves
DIC
Liver dz
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Kenny’s reviews
Intrinsic Hemolytic Anemia
Hereditary Spherocytosis
Sickle Cell
Gallstone Dz
Salmonella, OM
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Kenny’s reviews
WBC Disorders
Lympho-Leukemia's
CLL
seen in adults
mature lymphocytes
ALL
seen in children
Myelogenous Leukemia's
CML
Basophilia, Neutrophilia
Splenomegaly
Philly chromosome
AML
Neutropenia
Splenomegaly
Thrombocytopenia
Lymphomas
Hodgkins (Eosinophilia)
Disorders of Coags
Platelet Dysfunction
Indomethacin
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Kenny’s reviews
Hereditary Disorders
Hemophilia A
Factor 8 def.
PTT abnormal
Factor 9 def.
Vit K Def
Malabsorption
Prolonged PT
DIC
other diseases
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Kenny’s reviews
Cardiology
Heart Sounds
S1 - AV valves closure
CHF
Valvular HD - stenosis
HTN
Treatment
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Kenny’s reviews
ACE (-) – reduces afterload via vasodilation
CAD
Risk Factors
Age - >50
Gender – males>females
LDL - <130mg/dl
HDL - >40mg/dl
Smoking, HTN, DM
Tx – nitrates, Beta/Ca-blockers
Clinical Findings
Crushing CP
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EKG Diagnosis
Transmural MI
Q-waves
Inverted T-waves
R-waves
Subendocardial Infarction
ST depression
Cardiac Enzymes
CK elevation at 6 hours
AST – at 12 hours
LDH – at 24 hours
Order 3 sets Q8
Location of MI
B-blockers
Statins
Ace (-)
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Kenny’s reviews
Aortic Stenosis
Mitral Stenosis
Aortic Regurg
Mitral Regurg
Tricuspid Regurg
Etiology - Congenital
Rheumatic HD
Dx - anti-streptolysin O-titers
Endocarditis
Located on palms/soles
Janeway Lesions
Located on palms/soles
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Kenny’s reviews
Syncope
Types
Orthostatic HOTN
Unconscousness – Brady
Treatment
Ammonia smells
Anaphylaxis
Pathogenesis
Urticaria, pruritus
Benadryl – 50mg
Anaphylactoid Rxn
Similar to anaphylaxis
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Kenny’s reviews
Direct release of mediators w/o prior exposure
HTN
Levels
Mild – DS 90-105
Mod – DS 105-115
Severe – DS >115
Treatment
Labetalol
Shock
Types
Tx w/ Fluids
Anaphylactic
Cardiogenic
Stages
1 – Compensated HOTN
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Ever taken PCN?
Ever eaten shellfish?
Are you allergic to latex?
FH
Anyone have DM, HTN, Stroke?
Parents still living? died? how?
SH
Smoke tobacco? Drink EtOH?
Use recreational drugs?
Who do you live with?
ROS
HEENT
Wear contact/eyeglasses?
Have blurry/double vision?
Ringing in ears/hearing loss?
Any dizzyness?
Have any running/nose bleeds?
Been coughing/sore throat?
Resp
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Been constipated?
Any blood in Stool?
GU
Any blood in urine?
Difficulty urinating?
Skin
Experience any itching/rashes?
Musculosketletal
Have any jt stiffness?
Any muscle weakness?
PE
Vitals - Temp, HR, RR, BP
General - NAD, AAOx3
Head - NCAT
Eyes - PERRLA, EOM intact
ENT - clear, (-) drainage, exudate
Neck
(-) JVD, (-) carotid bruits
NT/NP lymph nodes
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Kenny’s reviews
Pulses, CFT, (+) pedal hair
TG WNL b/l
Neuro
Sensation intact SWMF 5.07
Vibratory intact
Light touch/sharp/dull intact
Derm - "DDMBDOC"
Periwound edema/erythema?
Webspaces?
Toenails?
Ortho
Bony prominences?
MMT 5/5 for p/f, d/f, in/ev
Foot type?
Labs
CBC w/Diff
CMP, BMP
CRP, ESR
HbA1C
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Kenny’s reviews
Venous Dopplers
A/P
76 y/o DM male w/ sub-met 1 ulcer
- sharp debridement
- wound dressed WTD, DSD
- xrays, Cx pending
- continue IV Abx
- will continue to follow
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Kenny’s reviews
Labs : CBC, ESR, CRP, BMP, UA, Co-Ags
X-rays: Results/Pending
CXR/EKG: Results/Pending
PE: GEN: NAD, OAAx3
HEENT: NCAT, PERRLA, EOMI, Tympanic Membrane Intact, (-) drainage
Patent nares, Throat clear, (-) adenopathy
Neck: (-) JVD, (-) Carotid Bruits, NP-Lymphnodes
Resp: CTA B/L, (-) W / R / R
CV: RSR, (+) S1, S2, (-) M / R / G
GI: S/NT/ND, (+) BSx4
LEPE: Vasc: PT/DP Pulse (Palpable/Non-Palpable), CFT (Brisk/Sluggish),
(+/-) Pedal Hair, TG WNL
Neuro: Protective Sensation Intact SWMF 5.07. Sharp/Dull Sensation Intact
Ortho: No gross foot deformities. MMT intact.
Derm: Location, Size, Depth (Tracking/Probe to Bone), Base (Granular/
Fibrogranular/Fibrous/Fibronecrotic/Nectrotic), Drainage (Serous/
Serosanguous/Sanguous/Purulent), Wound Edges (Undermine/
Macerated/Necrotic/Healthy), Periwound (Erythema/Edema),
Maloder?, Flucutance?
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Condition
Vitals per protocal
Activity– WB Status, BRP
Nursing – ICE/Elevation, Accuchecks, Reinforce Bandages, Foley
Diet – Reg, 2000-ADA, 2g NA, 3g K
IVF - heplock
Labs
Meds: RISS – accucheck qac & qhs
150-200 – 2 units
201-250 – 4 units
251-300 – 6 units
301-350 – 8 units
351-400 – 10 units
< 65 or > 400 call MD
Ancillary - PT, noninvasive studies
X-rays
Sx Pre-op Note
HPI: (Age) y/o (Sex) w/ h/o (PMH) p/w (CC). Pt receiving IV (ABX) and LWC in the
form of (……). Due to (worsening/non-healing) condition of (CC), Sx intervention
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Dx Studies:
UPT: for Females
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- Hold ASA, Plavix, Lovenox, Pletal, Heparin, Coumadin, Oral Hypoglycemics
- Contact Dr.....for medicalclearance
- If Hb <10 order Type and Cross
- If Hb <8 transfuse, place PRBC on hold
- Order and pertinent labs/studies
“Pt tolerated procedure and anesthesia w/o complications and with vital signs
remaining stable throughout the procedure. Pt transported from OR to RR with
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vascular status intact to (R/L) LE, escorted by member of anesthesia dept and
podiatric sx resident”
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Studies:
PE: Location, Size, Depth (Tracking/Probe to Bone), Base (Granular/Fibrogranular/
Fibrous/Fibronecrotic/Nectrotic), Drainage (Serous/Serosanguous/Sanguous/
Purulent), Wound Edges (Undermine/Macerated/Necrotic/Healthy), Periwound
(Erythema/Edema), Maloder?, Flucutance?
AP: (CC)
Condition (improving/stable/worsening)
Bedside Debridement/Wound Cx’s Taken/LWC
Wound Cx/Bone Path/X-rays/Bone Scan/MRI results (Awaiting/Appreciated)
Vascular/Infectious Dz Note/Consult appreciated
Continue IV (ABX) (as per ID)
Will (d/w attending / follow closely / plan for possible OR / plan possible D/C)
Discharge Summary
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Pt’s name
Medical record #
Physician
Admit date
Discharge date
Date of Sx
Admitting Dx
Discharge Dx
Procedures
History, Physical Exam
Coarse of Tx
Discharge condition
Medications
D/C instructions
Follow-up
Labs
CBC w/diff
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Lymphocytosis: Viral, CLL, ALL, chronic infx
Lymphopenia: AIDS, hodgkins, acute infxns
Monocytosis: TB, Endocarditis, collagen dz
Neutrophilia
Right Shift (segs 50-65)
Chronic infxn
Liver Dz
Tumor, CML
Left Shift (bands 0-5)
Acute infxn
Neutropenia: Viral infxn, ALL, AML
Basophilia - CML
Eosinophilia: Hodgkins, Addisons, Parasitic infection
Hemoglobin (13-17)
Hematocrit (38-50)
RBC Indices
MCHC
High - Spherocytosis
Low - Fe-def., thalassemia
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von Willebrand Dz/DIC
ASA/NSAIDs/Plavix
PT/INR (3,7)
Vit K def.
Liver Dz
Coumadin
PTT (8,9,11,12) "Dec, 11th, 1998"
Hemophilia A,B
von Willebrans/DIC
Liver Dz
Heparin
Chem 7
Na (135-150)
High - Cushings, CHF
Low - Addisons
K (3-5)
High - Addisons, ARF, CRF
Low - Diuretics
Cl (95-110)
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Crt (0.5-1.5)
High - renal dz
Glu (60-120)
High - DM, Cushings, Pancreatitis
Low - Liver dz, Addisons
Ca (8.5-10)
High
Hyper-PTH, Hyper-Vit D
Multiple myeloma, Bone tumor
Immobilization
Low
Hypo-PTH, Vit D Def
Renal failure
PO3 (3-4.5)
High - Renal Dz, Hypo-PTH
Low - DM, Hyper-PTH
Alk-Phos (30-85)
High: Liver dz, bone dz, hyper-PTH
Low: Hypo-thyroid, scurvy
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High - DM, hypo-thyroid
MI Enzyme's
SGOT(AST) - 6-12 hrs
CPK - 12-24 hrs
LDH - 48 hrs
Uric Acid (1.5-7)
Renal dz, Gout, Leukemia, EtOH
Urinalysis
Sepcific Gravity - [ ] of urine
Increased in Diabetes Insipidus
Decreased in DM, Vol. Depletion
Color - Yellow, Clear
Ammonia smell
Sweet - DKA
Putrid - infxn
Maple Syrup
No gluc, ketones, blood, protein, NO3
Blood
RBC (hematuria)
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Muscle injury/dystrophies
Electric shock
Protien (albumin)
Nephritis/glomerulonephritis
Nephrosis
Polycystic Kidney
Hyperthyriodism
Bence Jones = multiple myloma
Urubillinogen
Hepatitis
Hemolytic/pernicious anemia
Casts
Hyaline - normal
RBC -glomerulonephritis
WBC – pyelonephritis (infxn of ureters Kidney)
Epithelial - tubular casts
Fatty - any nephritis
pH – 5-7.5
Acidic
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Inflammatory Labs
ESR/CRP
CRP is better test as it increases and decreases sooner
ANA/RA-factor positive
SLE/Scleroderma/Sjogrens
RA
Anti-ds DNA – SLE
HLA-B27
Ankylosing spondylitis
Psoriatic arthritis
Reiters syndrome
Infxn Dz Labs
Hb1AC – normal is less than 7
ELISA – HIV test
VDRL/RPR – syphilis
Vanco Peak and Trough
Pk - 20-40 (adjust dose)
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Flagyl 500 TID
Aug 500 (875) TID (BID)
Keflex (1st) 500 QID
Clinda 300 TID
Omnicef (3rd) 300 BID
Doxy 100 BID
Bactrim 800/160 BID
Zyvoxx 600 BID
Ancef (1st) 1g Q8
Primaxin 1g Q8
Vanco 1g Q12
Cefepime (4th) 1g Q12
Aztreonam 1g Q12
Invanz 1g Q24
Rocephin (3rd) 1g Q24
Dapto 4mg/kg Q24
Cipro 400 Q12
Clinda 600 Q8
Unasyn (1.5) 3g Q8
Antifungals
Sporonox
100mg BID
12 weeks
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CI – Lipid lowering agents
Lamisel
250mg QD
12 weeks
CI – TCA’s, SSRI & Rifampin
Gris-Peg (kills only dermatophytes)
750mg QD
24 weeks
Pain Meds
Demerol (mep) 50 Q4 IM
Dilaudid (hydro) 1mg Q4 IM
Percocet (oxy) 5/325 Q4-6 1-2(T)
Vicoden (hydro) 5/500 Q4-6 1-2(T)
Tyenol 3 (code) 30/300 Q4-6 1-2(T)
Darvocet (pro) 50/325 Q4-6 1-2(T)
Ultram (tram) 50/325 Q6-8
Toradal (nsaid) 30mg Q6 IV x3days
NSAIDS
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Celebrex 200 QD
Anticoagulants
Lovenox (LowMW-Hep)
40mg Daily (Prophylaxis)
1mg/kg (Therapeutic)
Moniter – nothing to monitor
Heparin Prophylaxis
5000u BID SQ
Intrinsic Pathway
Moniter - PTT
Heparin for DVT
10,000u(bolus) IV......then 1000u QH IV
Coumadin (warfarin)
5mg QD PO
Extrinsic Pathway
Moniter PT/INR
Plavix
75mg QD PO
Inhibits platelet aggregation
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Multiply % by 10 = __ mg/cc
Then multiply # cc’s injected
Ex: 15cc of 1% Lidocaine = 150mg
15cc of 0.5% Marcaine = 75mg
Lidocaine 1%
1cc = 10mg
Max = 300mg, or 30cc
Lidocaine 2%
1cc = 20mg
Max = 300mg, or 15cc
Marcaine 0.25%
1cc = 2.5mg
Max = 175mg, or 70cc
Marcaine 0.5%
1cc = 5mg
Max = 175mg, or 35cc
Sedatives
Xanax 0.5mg PO Short-life
Ativan 1mg PO Med-life
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Antiemetics
Zofran 4mg Q6
Tetanus Prophylaxis
Clean Wound:
Unknown Hx or No booster w/in 10 yrs or < 3 doses Tetanus Toxoid
Dirty Wound:
Unknown Hx or < 3 doses Tetanus Toxoid + Ig
No booster w/in 5 years Tetanus Toxoid
Emergency Meds
Nalaxone (1mg Q2 min IM/IV)
Give for narcotic overdoes
Can't give too much
Acetycysteine (70mg/kg Q4 PO)
Give for Tyenol overdose
Atropine (1mg IV)
Give for bradycardia
Ethanol
Give for antifreeze/methanol OD
Protamine Sulfate (1mg IV)
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Flumanzenil (0.2mg Qmin)
Give for Benzodiazepine OD
May induce seizures w/ pts taking TCA's
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Neurology
Back Pain
Cauda Equina: symptoms include urinary retention
Vertebral Mets: pain worse at night
Anatomy
Brachial Plexus Anatomy
Robert - roots
Taylor - trunks
Drinks - divisions
Cold - chords
Beer - branches
Blocks
Popliteal
7cm proximal to crease
1cm lateral
Saphenous (at knee)
Neurological Exam
Motor Exam
Grading (0-5)
5 – normal
4 - weakness
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3 – against gravity only
2 - gravity eliminated
1 – slight contractures, no ROM
Nerve Roots
L2,L3 – Adductors and Quads
L4 – TA
L5 – Extensors
S1 – Flexors and Peroneals
S2,S3 – Intrinsics
Spinal Lesions
L5,S1 - mimic shin splints
S1 - can't walk on toes
L5 - can't walk on heels
Sensory Exam
Anterior Tracts – Light touch
Post Columns – Propioception, Vibration
Lateral Tracts – Sharp/Dull
Reflex Exam (grading 0-4)
Patellar – L4
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Hyperreflexia
LMN
Dysfunctional motor unit nerves
Muscle atrophy, hyporeflexia
Neurological Dz’s
Siezures
Generalized (both hemispheres)
CF - sudden loss of consciousness
Grand mal - convulsive
Tx - Phenytoin
Abscence - minor twitching
Tx - Ethosuximide
*Valproic Acid for both types*
Partial (discrete areas of brain)
CF - impaired motor/sensory
Complex-partial
CF - impaired awareness/hallucination
Status Epilepticus
May involve both types
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Foods w/ nitrates
Stress
CMT (Peroneal M. Atrophy)
White Females
Cavus foot type
Steppage/Equinus Gait
PL > TA = p/f medial column
TP > PB > FDL > EDL= clawtoes
Peripheral neuropathy
Freidrichs Ataxia
Post/Lat Column dysfunction
Late childhood
Nystagmus
Ext/Peroneal muscle weakness
Peripheral neuropathy
Syringomyelia
Cavitation of SC
LMN, UMN (facial) symptoms
Cerebral Palsey
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Waddling, Equinus Gait
Becker’s – less severe form of Dz
Myasthenia Gravis
Ab's against Ach receptors on muscle
Young women
Thyoma, dysphagia/phalgia
Muscle weakness
Parkinson’s
Rigidity
Fenistrating Gait
Resting tremor
Bradykinesia (slow movements)
"pill rolling"
Multiple Sclerosis
Demyelinating disorder
Middle-age females
LE-spasticity
Ataxic Gait
Optic Neuritis - most common
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Flexion on neck causes pain to radiate down back
Also seen in RA, Ankylosing spondylitis
Guillain-Barre Syndrome
Preceded by infection
CMV, HIV, Hepatitis
C. jejuni, M. pneumoniae
Assoc. w/ SLE, Lymphomas
Steppage Gait
Motor/Sensory weakness distal to proximal, to total paralysis
Dx - elevated CSF protein
No DTRs
ALS
Degeneration of UMN and LMN
Spasticity of muscle groups (begins in hands)
Wasting and weakness
Peripheral Neuropathy
DM/Alcholic/HIV
Hypo-thyroid/B12 Deficiency
Guillian Barre/CMT/Freidrichs
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Can lead to muscle atrophy & loss of function
Stages
Stage I
Hot, red, swollen limb
Bone scan shows increase uptake in joints
Stage II
Cool, pale limb
X-rays show diffuse osteopenia (5-6 weeks to develop)
Stage III
Pain decreases somewhat
Tightly stretched skin
Treatment
Meds – Steroids, TCA’s
PT – massage, US, ROM, TENS
Nerve blocks
Beir block – local given into veins of tourniquet leg
Vit B12 Def
Demyelination, axonal degenerates
Post, Lat. SC Demyelination
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Kernigs Sign: Extension of knees w/ passive resistance
N. Meningitis: palpable pupura on lower legs
Nerve Injuries
Seddon Classification
Neuropraxia – bruised nerve
Axonotmesis – bruised axon (Wallerian degeneration)
Neurotmesis – severed nerve (irreversible)
Tarsal Tunnel
Etiology
Pes Planus
Varicosities
STM
Inflammation
Trauma
Laciate Ligment
Medial Planter N
Lateral Planter N
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Movement potentials should be roughly proportional
Denervation results in fasiculations at rest and w/ potentials increasing
in duration and amplitude, but decrease in freq.
NCV
Used to d/t myelin sheath or axonal disorder
Measures Latency of nerve
Normal > 40mq
Common Peroneal N. Palsy
Clinical Findings – Drop Foot
“Saturday Night Palsy”
Compression of Nerve from Bar Stool
Nueroma
Mortons
3rd interspace
Middle age females
Mulders Sign – silent palpable click
Joplins – involves medial plantar digital proper nerve
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Rx can't be called in (only fax’d)
No-refills
Class 3
Codiene, Hydrocodone
Refills x5 in 6 mos
Class 4
BZDP's, Darvon, Ultram
Rx required
Class 5
Over the counter meds
NSAID's
ASA
DOC - for RA
SE
CI
Coumadin
Celebrex
CI - Sulfa ALL
Hematological Agents
Pletal
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Dose - 100mg PO BID
Alteplace (tPA)
Activates plasmin
Steroids
Topical's
Potent - Topicort
Oral Steriods
Methylprednisone
Medrol Dosepack
10-100mg
Prednisone - 1mg/kg
Injectable's
Types
Celestone-Phos
Dex-Phos
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Acetates (long acting)
Kenalog
Celestone Soluspan
Joint Injections
Diuretics
MoA - Increase NaCl secretion
Tiazides's (HCTZ)
Hypo-K
Hyper-Uric Acid
Hypo-K
Hyper-Uric Acid
K-Sparer's (Spironolactone)
Weaker diuretic
MoA -
Increase Na secretion
Decrease BP
Tx - HTN, CHF
Ca-Channel Blockers
MoA
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(-) Ca in vascular SM
Coronary A. vasodilation
Tx - Angina, HTN
Drugs
Amiodipine (Norvasc)
Dilitiazem
Nifedipine
Verapamil
Misc
Lactulose
Stool softner
Polyethlene Glycol
Colace
Reglan
Metamucil
Milk of Magnesia
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Physical therapy
Heat
Whirlpool
Settings
45 Deg. C. (113 F)
15-30 minutes
Indications
Chronic post-trauma
Nerve Injuries
Stumps
DQ-Ulcers (w/ no bone)
Arthritis
Contrast Baths
Settings
Both hot and cold
Feet are placed alternately every 1 min
Always start cold, end cold
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Settings
Dip foot 6-10x for 5 seconds
Then wrap in plastic/and towel
Let sit for 20-30 minutes
Indications
Sprains/Strains
Arthritis
Ultrasound (Deep Heat)
Settings
Continuous–thermal/mechanical effects
Pulse – mechanical effects only
Goal - Alter cell permeability
Indications
Scar Tissue
Pain
Edema
CI
Areas w/ emboli
Anesthetized skin
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Pacemakers
Diathermy
EM radiation to heat tissues
Goal – heating of tissue w/ high water content
Indications
Muscle and Jt problems
E-Stim
TENS
Goal
High TENS - Blocks pain
Low TENS - endorphin release
Indications
Chronic Pain
Muscle Atrophy/Spasms
Edema
Peripheral Neuropathy
CI
Pacemakers
Pregnancy
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Anti-inflammatory’s
Muscle relaxants
Phophoresis
Goal
Delivering chem’s, non-invasive
Uses Ultrasound
Strengthening Exercises
Isometric Contraction – static
Isotonic Contraction – dynamic
Eccentric – muscle lengthens (resistance)
Concentric – muscle shortens (lifting)
Isokinetic Contraction
Constant velocity (machine)
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Pulmonology
Labs
<60mmhg PaO2 = hypoxemia
<35mmhg PaCO2 = resp alkalosis caused by hyperventilation
>45mmhg PaCO2 = resp acidosis caused by hypoventilation
COPD
Etiology
Tobacco (most common)
Pollution
Antitrypsin def
Chronic Bronchitis
Clinical Findings
Excessive mucus secretion in the bronchial tree
Productive cough for at least 3 mos, in 2 succesive yrs
Blue Bloaters - Cyanosis, edema, weight gain, chronic cough
VQ mismatch
Emphysema
Clinical Findings
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suppress hypoxic ventilatory drive
Asthma
Types
Allergic
Type I mediated
Seen in children
Intrinsic
Occurs in adults
No hypersensitivity rxn’s
Symptons
Coughing/SOB
Chest tightness, wheezing
Labs – low PaCO2
Treatment
Pleural Effusion Total protein > 2.9g/dl
Exudate Total LDH > 250mg/dl
Malignancy
Empyema
Infection
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Quick facts
Infectious Dz
Pen G – for any farm injury
Unasyn < Na than Zosyn/Timetim
Trauma
10 comparment of foot
- Med, Central, Lat x 3 layers
- Calcaneal
Surgery
Peak-a-Boo Sign
- peaking of medial aspect of heel from anterior view
- used to assess cavus deformity
Coleman Block Test - used to differientiate b/t rigid and flexible cavus
Wait at least 6 months before you take any hardware out
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Mnemonics
Codeine ALL – (STUDD)
- Staydal
- Toradal
- UItram
- Demoral
- Darvocet
Pt is having CP give (MONA)
- Morphine
- Oxygen
- Nitro
- ASA
PCN allergy drugs (CLAVE)
- Clinda
- Levaquin
- Aminglycosides
- Vanco
- Erythromycin
Anti-pseudomonal (FAT CIA)
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Tx Hyper-K (C BIG K Drop)
- Calcium gluconate
- Bicarb
- Insulin
- Glucose
- Kaexylate
- Dialysis
OCD of Talus (DIAL a PIMP)
-D/f & Inversion....Ant-Lat lesion
-P/f & Inversion..Med-Post lesion
Signs of Acute Artial Emboli (5 P's)
- Pain
- Pallor
- Parasethesia
- Paralysis
- Pulseless
DVT etiology (I AM CLOTTTED)
- Immobilzation
- A-Fib
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- Tumor
- Estrogen (BCP)
- DVT(previous)– most common
Scleroderma clinical signs (CREST)
- Calcifications in skin
- Raynauds
- Esophageal dysfunction
- Sclerodactyly
- Telangiectasia
Reiters Syndrome
- can't see (conjunctivitis)
- can't pee (urethritis)
- can't climb tree (arthritis)
Blood Transfusion Rxn give "BLT"
- Benadryl
- Lasix
- Tyenol
Percutaneous TAL - "LAMP"
- Lateral-
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S. Granulosum
S. Spinosum
S. Basale
Cranial Nerves
1 - Olfactory Oh Some
2 - Optic Oh Say
3 - Occulomotor Oh Marry
4 - Trochlear To Money
5 - Trigeminal Touch But
6 - Abducens And My
7 - Facial Feel Brother
8 - Vestibulo Virgin Says
9 - Glosso-P Girls Big
10 - Vagus Vagina's Boobs
11 - Accessory Ahhh Matter
12 - Hypo-P Hhhh More
Clinic
DDx for 1st MPJ pain
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bone grows in direction of bone growth
Ainhum
idiopathic vessel constriction of 5th toe resulting in amputation
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Vascular
Venous System
DVT
Virchows Triad (Etiology)
Statsis
Blood vessel trauma
Hypercoagulability
Pre-conditions (IAMCLOTTTED)
Immobilzation
A-Fib
MI (previous)
Coagability – Factor V Liden
Longevity – over age of 65
Obesity
Trauma
Tobacco
Tumor
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Diagnosis for DVT
Doppler – modality of choice
Venography – invasive test
DDx
Cellulitis
Compartment Syndrome
Venous Stasis
Diagnosis for PE
Blood Gas
CXR, EKG
V/Q scan
Pul. A-gram (gold standard)
Prophylaxis
Sub-Q Heparin
Pre-op – 5000u 2hrs before Sx
Post-op – 5000u q12
Compression Stockings
Early ambulation
Treatment
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Antidote: Protamine Sulfate
SubQ Heparin
DVT Prophylaxis
5000u BID
Coumadin (warfarin)
Peaks 3-5 days after use therefore start 2 days before d/c’ing heparin
Moniter PT/INR maintain 2-2.5x normal
Antidote = Vitamine K, Fresh Frozen Plasma (FFP)
Lovenox (Low MW Heparin)
40mg IM Daily (prophylaxis)
1mg/kg BID (treatment)
No need to moniter PTT
Superficial Thrombophlebitis
Clinical Signs
Palpable Chord
Pain, edema, eyrthema
Tx – heat, elevation, rest, NSAIDS
Venous Insufficiency
Etiology
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Antegrade flow from superficial veins into skin
Causes.....
Edema, Hemosiderin deposits
Causes Dermatitis, Vasculitis
Leads to ulceration, cellulitis
*Dx b/t Deep/Superficial Venous dysfuct. w/ Trendelenburg mvr*
1-Elevate leg
2-Place tourniquet on thigh
3-Have pt stand
4-Deep problem if veins fill
5-if they don't fill, Sup problem
Treatment
Rest, Elevation
Compression Stockings
Diuretics
Varicose Veins
Etiology
Dilated, tortuous superficial veins
Prolonged standing
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Elastic stockings
Sx excision/laser ablation
Lymphadema
Etiology
Obliteration of lymphatic tissue
Excision
Radiation
Infection
Malignant Mets to L.nodes (secondary lymphadema)
Clinical Sings
Non-pitting
Onset is explosive
Treatment - elevation, compression
Arterial System
PVD
Definitions
Arteriosclerosis: Thick, inelastic arteries
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Claudication
Pain on ambulation
Relief w/ 3-5min rest
DDx - Lumbar stenosis - requires 20min rest, worst downhill
Tx
Behavior modification - get pts to push through pain so that
muscles use O2 more efficiently
Medications - Pletol
Rest Pain
Pain at night
Relief brought on by putting leg in dependent position
If relief is brought on by walking then it’s a venous
Gangrene
Physical Exam
Derm
Color
Dependent rubor
Elevation pallor
Temp – decreased
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Cap Fill Time (>3secs)
Elevation pallor
Dependent rubor
Venous Fill Time (>20 secs)
Elevate leg...lower leg....how long for venous arch to fill
Diagnosis
Serial Pressures
>55mmHg needed in foot
>30mmHg needed in toes
ABI (ankle brachial index)
20mmHG, or 0.15 dec. down ipsilateral leg is considered normal
Values
>1.0……… calcified vessels
1.0 – 0.8 … normal
0.8 - 0.5….. claudication
< 0.5……... rest pain/ulcers
PVR (pulse volume recording)
Nomal – bi-triphasic pattern
PVD – monphasic pattern, Toes are always mono-P
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Thrombus – h/o claudication
Symptoms (Five P's)
Pain
Pallor
Parasethesia
Paralysis
Pulseless
Treatment
Keep extremity in horizontally
Embolism
<6 hrs – embolectomy
>12 hrs–Anticoag./embolectomy
Thrombus – Streptokinase
Raynaud’s Phenomenon
Vasospasm of digits causing local ischemia
Associated w/ SLE, Scleroderma
Females > Males
Buerger’s Dz (Thombolytis Obliterans)
Inflammatory changes to small & medium vessels caused by smoking
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Hyperhydrosis
Raynauds Phenomenon
HLA-B5
Treatement - Daily walking
Leriches Syndrome
Etiology - aortoioliac dz
Findings
Impotence
Buttock, back, calf pain
Livedo Reticularis
Etiology - vasospasm of arterioles
Findings - blue-red discolorations on the legs
Aneurysm's
Def - dilitation of wall of artery
Aorta 80% > Iliac's 20%
Peripheral (2%): Popliteal A. most common
Dx - ultrasound is gold standard
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radiology
Kenny’s reviews
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Arthropathies
Kenny’s reviews
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Arthropathies
Kenny’s reviews
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Skeletal Dysplasia
Kenny’s reviews
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Osteopenia
Kenny’s reviews
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Misc. Bone diseases
Kenny’s reviews
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Radiology Physics
Basics/Definitions
Filtration
Effects quantity/quality of x-rays
Types
Inherent – Glass
Added – Aluminum (wedged)
X-ray Absorption Factors
Atomic Number
Density
Terms
Compton Effect
Scatter radiation produced by action w/ outer electron shell
Detrimental to image
Causes less exposure to patient
Photelectric Effect
Absorbed radiation produced by action w/ inner electron shell
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Settings
Kvp – quality of x-rays (inversely related to contrast)
Decrease Kvp – reduce scatter rad
Decrease Kvp – increase photo-electric effect
Decrease Kvp – increase contrast
Increase Kvp - decrease contrast
Increase Kvp - increase penetration
Increase Kvp – reduce exposure to pt, but have lower quality of picture
mA – quantity (intensity) of x-rays (directly related to time)
Increase mA – 4 thick body parts
Increase mA – decrease exposure time
Increase mA – brighter xray
SID – source-image distance (directly related to sharpness, inversely related to
mag)
Increase SID – increase sharpness
Increase SID – decrease magnify
OID – object image distance (inversely related to sharpness, directly related to
mag)
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Decrease in OD = Underexposure
Directly proportional to mA
15% Rule
Increasing Kvp 15% = 2x mA
Want to decrease contrast so…..
You increase Kvp 15%.....
But this will double mA….
Which cause overexposure….
So that means you need to ½ the time of exposure….
Since mA = time
Decreasing Kvp 15% = 1/2 mA
Want to increase contrast so….
You decrease Kvp 15%.....
But this will ½ mA….
Which can cause underexposure
So that means you need to double the time of exposure
Since mA =time
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Increase mA (2x)
Decrease Kvp (15%)
Fiberglass Cast Viewing
Increase Kvp (10)
Increase mA (2x)
ANA – positive
Anti-dsDNA
RA-Factor - positive
Scleroderma
Clinical Findings
Middle age woman
Thickening and tightening of skin, beginning in hands/face
CREST
Calcifications in skin
Raynauds
Esophageal dysfunction
Sclerodactylyl
Telangiectasia
Lab Tests
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surgery
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Pre-op Orders
Stop ASA and smoking 1 week prior
CXR for pts over 60 (if they smoke then pts over 40)
Sx on dirty wounds
Inplants
Pre-existing infection
Blood transfusion
Meds
Ancef
Cancel Elective Sx
K<3
BUN > 50
Crt > 3
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Peri-operative
Tourniquet
Pre-op requirements
Anticoags/platelets
7 days prior - stop ASA
3 days prior - stop Coumadin
3 days prior - stop Plavix
1 day prior – stop Lovenox
6 hours prior - stop Heparin
RA pts - Get C-spine X-ray
NPO after midnite, or 8hrs b4 Sx
EKG for pts over 40, or any MI
CXR for pts over 60 (40 if smokes)
Previous MI - wait 6 mos
Pregnancy test – childbearing age
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Vanco:
PCN ALL
Implants
Amox: Endocarditis
Erythro: Endocarditis
Clinda: Endocarditis
DM Management
Keep BS b/t 140-240
NIDDM: Hold AM Dose of Oral ABX
IDDM
1/2 dose of Standing Insulin Orders
1/2 D5W/NS @ 70cc/hour
Steriod Patient (>7.5mg QD > 1mos) / (>20mg QD > 1wk)
Minor Sx: Reg. Dose w/ Surgery
Maintenance Dose after Sx
Major Sx: 100mg Pre-Op Q6
Reduce by 50% Daily (starting after Sx) until Maintenance Dose
Cancel Elective Sx
Hb < 10
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Peri-Operative Management
Tourniquet (100mmHg > Systolic-P)
Max Ankle – 250mmHg
Max Thigh – 500mmHg
Contraindications
I&D and Amputations
Sickle cell pts
Absolute Indications
Malignant tumors
Complications
Malignant hyperthermia
Susceptibility– EKG abnormality
Etiology – anesthetics/genetic
Symptons
Jaw clenching (1st sign)
Tachy (before temp rise)
Muscle spasm
Rising temp/sweating
Cyanosis at Sx Site
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Etiology - usually Ester's
Findings
CNS symptoms
restlessness, confusion
dizziness, tremors
convulsions
CV symptoms (higher doses)
tachy-->brady, HTN
Treatment
Valium (CNS)
Atropine/Epi (CV)
Post-op Complications
Post-op Fever (100.4)
Wind (0-12) - Atelectasis (90%)
Walk (12-24) - DVT
Water (24-48) - UTI
Wound (48-72) - Infxn
Wonder Drug (>72hrs)
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Sutures too tight
Hematoma
Treatment
Extravasation
Pop a stitch or two
Squeeze out blood
Aspiration – large bore needle
Steroid injection
Edema (due to dependent position)
Ischemia
White Toe
Etiology
Macro-emboli
Arterial insufficiency
Overstretching of NV-bundle
Tx
D/C ice and elevation
Place foot in dependent position
Loosen bandage
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Arterial insufficiency
Cold
Doesn’t blanch w/ pressure
Venous insufficiency
Warm
Blanch w/ pressure
Tansient vasospasm of vessels
SLE/Scleroderma/Raynauds/RA
Treatment
Arterial Insufficiency: Heat, vasodilators (lidocaine)
Venous Insufficiency: Avoid dependency
Sx Pre-op Note
Subjective
CC
PMH, PSH
Meds, ALL
SH, FH
Objective
Labs – BMP, CBC, Coags, UA
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3 – pt medically cleared for
procedure by Dr. _____
4 – procedure reviewed w/ pt
including risk, benefits and
complications
5 – all questions answered
6 – consent signed
7 – pt to be NPO after midnight
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“pt tolerated both procedure and anesthesia w/o apparent complications and with vital signs
remaining stable throughout the procedure. Pt transported from OR to RR with vascular
status intact to (R/L) LE, escorted by member of anesthesia dept and podiatric sx resident”
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X-rays
Discharge Summary
Pt’s name
Medical record #
Physician
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Admit date
Discharge date
Date of Sx
Admitting Dx
Discharge Dx
Procedures
History, Physical Exam
Coarse of Tx
Discharge condition
Medications
D/C instructions
Follow-up
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foot surgery
Types of Wound Healing
Primary Intention: initial closure of incision
Secondary Intention: healing by formation of
granulation tissue
Tertiary Intention: delayed primary closure
Wound Healing Phases
Substrate Phase (1-4 days)
Vasodilation
Hemostasis
Leukocyte response
Macrophages
Proliferative Phase (4-21 days)
Macrophages
Fibroblast lay down collagen
in random pattern
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Incisions improperly placed w/ RSTL
Traumatized Tissue
Failure to irrigate
Inadequate hemostasis
Desication of tissue
Prolonged dependency
Local Corticosteriods
Systemic Factors
Uncontrolled DM
Alcoholism
Vit C Def
Steroids
Hb<10
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Lipoma/Shwannoma
Pes Planus: Pronation
Exostosis
Venous Complex – usually B/L
Accessory Muscles
Os Trigonum Syndrome
Abductor H. hypertrophy
Myxedema: Synovial thickening
Symptoms
Shooting/Deep Trobbing pain
Worse at Night, prolong WB
Venous tourniquet test - causes symptoms to worsen
Dx
Nerve Condution Study
Dec. Latency/Amp
Dec. NCV
Get B/L Studies
R/O Common peroneal
(+) Tinels Sign – distal shooting
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Plantar Fibroma/Neurioloma
PVD/Claudication
Neuropathic Pain
Ganglion
Tenosynovitis
Tx
Surgery (External Neurolysis)
Release of laciniate lig.
15% recurrence
don’t reaproximate
NSAIDS/Steriods
Physical Therapy
Orthotics
Surgical Steps
Free up Base of Post-Tib N.
Free up Distal Tip of Tibia
Abductor Canal
Flexor Retinaculum
Neuroma Sx
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Ganglion Cyst
Neuritis
RA Nodule
Freiberg Infarction
Bursitis
Met Stress Fx
Pre-Dislocation Syndrome
Characteristics
Females Middle Aged
3rd Interspace most common
2nd Interspace 2nd most common
Sullivans Sign: splay of digits
Mulders Click
Joplans Neuroma
Involves medial plantar digital
Proper nerve
Diagnosis
T1-MRI
US (98% Sensitive)
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Dorsal Incision
Transects DTML
Avoid WB Scar
Web Space
Difficult Exposure
Avoid WB Scar
Plantar Incision
Excellent Visualization
Preserves DTML
Can transect nerve more prox.
Decreases hematoma formation
WB Scar
Best for “re-do” Neuroma
Neurectomy vs Epineurolysis
Neurectomy
Excision of nerve/branches
80% good results
Epinuerolysis
Freeing of surrounding tissues
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Complications
Hematoma
Stump Neuroma (neurectomy)
Recurrence (epineurolysis)
Hallux Varus
Etiology
Staking Met Head
Fib Sesamoid Excision
Overtightening Med. Capsule
Muscular Imbalance
Overcorrection of IM/PASA
Aggressive Splinting
Surgical
1) Soft Tissue Release
2) Medial Capsulotomy
3) Tibial Sesamoidectomy
4) EHL transfer laterally
5) Reverse Osteotomy
6) Arthoplasty/Implant/Fusion
Tendon Transfers
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Active ROM at 4 weeks
Ankle Fusion
Position of Fusion
Sagittal: 90 Degrees
Frontal: 0-5 Degrees Valgus
Leg: ER 5-10 Degrees
Posterior displacement of talus
Counter acts Achilles
Preserve heel prominence
Bone Healing
Definitions
Osteoblasts: derived from precursors located
In walls of blood vessels
Osteoclasts: multinucleated cutting cones
Osteoid: non-calcified matrix 95% collagen
Mineralization: osteoid deposited w/ Ca-PO3
Occurs 8-10 days after osteoid is formed
Occurs at 1um per day
Stages
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Lamellar bone
Remodeling (4 mos – 2 years)
Resorption of excessive bone
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Delayed Union
Healing that goes into the 4-6 months
Tx – requires strict NWB cast
Non-Union
Established when all reparative processes of healing have stopped
Usually around 8-9 months (medicare considers it at 3mos)
Diagnosis of Nonunion
X-ray – sclerotic borders, osseus void
Tc99 bone scan
Hypertrophic Nonunion
Persistent biphasic uptake pattern at Fx ends
Atrophic Nonunion
Low uptake on all phases
Tx – depends on type
Hypertrophic
Bone stimulator (3-6mos)
ORIF
Atrophic
Bone graft
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Decreases pO2
Enhances Ca-Deposition
Desensitize osteoclast to PTH
Indications
Nonunions, Delayed Unions
Congenital pseudoarthrosis
AVN
Contraindications
Uncontrolled motion
Synovial pseudoarthrosis
Fracture gap >1cm or ½ diameter of bone
Pregnancy
Active OM
Tumor
Bone Grafts
Indications
Delayed/Non-Unions
Arthrodesis
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Graft Healing
Vascular Ingrowth (1-2 weeks)
Takes a little longer in Allografts
Osteogenesis– forming new bone
Osteoinduction
Presence of bone morpheogenic Protein
Causes differentiation of mesenchymal cells into osteoblasts
Osteoconduction
"Scaffolding effect"
Acts as conduit for migration of cells
Creeping Substitution
Replacement of graft w/ viable bone
Graft Remodeling
Reformation of graft in response to biomechanical forces in accordance to
Wolfs law
Autograft vs Allograft
Autograft
Osteoinductive
Osteoconductive
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Cortical
Radiolucent when healing
Used to proved stability
Less blood supply
30-40% strength loss 6-8 wks
Takes 6 days to revasc
Cancellous
Radiodense when healing
Used to fill defects
Osteoconductive
Takes hours to revasc
Better for AVN
Allograft Types
Frozen: little reduction in antigenicity
Freeze-Dried: 95% of moisture removed
Reduction in antigenicity
Loss of torsional/bending strength
Decalcified: promotes osteoinduction
Reduction in antigenicity
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Low O2 favors cartilage
>6cm defect require BS transfer
Fixation
AO Goals
Anatomic reduction
Preservation of BS
Stable internal fixation
Early active Mobilization
Principles of Internal Fixation
Inter-Frag Compression
Static
Lag
Eccentric Loading Plate
Ex-Fix
Dynamic
Tension Band
Splintage
Internal
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Stress: pressure you put on material
Strain: measured deformation that results in a material after a
certain stress has been applied
Yield Pt: the point where the strain on material can’t return to original shape
Stress Shielding: stress absorbed by implanted material instead of the bone,
However can cause disuse and osteopenia
Tension: side opposite of the compression side where plates are placed
(creates neutral axis of bone)
Reasons to Fixate
Intra-articular Fx
Open Fx
Non-reducible Fx
Non-union
Early Mobilization
Pathological Fx (Tumor/Inf)
Multiple Trauma
Screw Anatomy
Shank – unthreaded portion
Run-out- junction b/t shank + threads
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2 –Overdrill (2.7mm)-near surface
3 – Countersink
4 – Measure
5 – Tap (2.7mm) – far surface
6 – Validate position of screw after insertion
Self-Tapping vs Non-Self Tapping
Self-Tapping Screws
Large pilot hole
Threads don’t penetrate as deep
Better in thin cancellous bone
Non-self-Tapping
Less heat is generated due to decreased resistance
Cortical vs Cancelous Screws
Cortical (DOCMTV)
Smaller pitch
Require bicortical penetrations
Only partially threaded
Cancellous (DCMTV)
Larger pitch
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Small Frag
3.5 Cortical
4.0 Cancellous (Partially/fullythreaded)
Standard Frag
4.5 Cortical
4.5 Malleolar - similar to partially threaded cortical
6.5 Cancellous - Partially/Fully threaded
Cannulated Screws
3.0mm, 4.0mm, 4.5mm sizes
Plates
Plate Sizes
Semi-Tubular: 4.5mm screws
1/3 Tubular: 3.5mm screws
Dynamic Compression Plate
Allows compression across Fx site as screws
Are tightened due to plate screw hole shape
Butrresing Plate: Used to maintain separation to protect bone graft
Neutralization Plate
Protects the lag screw
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Cross K-wires need to be crossed proximal to osteotomy site
When used with screw it provides rotational stability
Can cause tracting infections
Acute Angles use Trochar Tips
Absorble K-Wires (orthosorb)
Polydioxanone (PDS)
Degraded by hydrolysis
May cause inflammatory rxn
50% dec. holding power 4-6wks
Steinman Pins
Large K-wires
Cerclage Wire’s
24-30 guage wires
Used w/ small fragments or osteoporitic bones
Best compression of all hardware
Can cause irritation of overlying skin/tendon
Tension-band Wiring
Used in areas where soft tissue pulls on fx site
Staples
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Can be used w/ infection
Allows for post-op adjustments
Early ROM and WB
Terms
Dynamyzation: procedure by which
All the wires are loosened and pt allowed to WB,
before ex-fix is removed
Ligamentotaxis – pulling of fx frag’s into alignment
using distraction
Materials
Pins – greater diameter than wires
Divergent>Convergent>Parallel
Wires – stronger than wires
Classification (Pin Fixators)
Simple
Pro: easy, versatile
Con: prior reduction required
Modular
Pro: very versatile
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Preserve periosteum
1mm/day (0.25 qid)
Compress for 7 days prior to removal
Compression
Neutralization
Indications
Open Fx
Communition
Arthrodesis
Osteotomy Fixation
Soft Tissue Stabilization
Suture
Terms
Elasticity – return to original length
ei. Ethibond
Plasticity – elongation persists
ei. Prolene
Intermediate – possess both
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Nonabsorbable
Silk – skin, highest tissue reactivity
Nylon – skin, high tensile strength
Prolene – very inert, holds knots better
Ethibond (polyester)
Braided, used for tendons
Staples – least reactive
Point Config
Reverse Cutting: Skin
Conventional Cutting: Skin
Taper Cutting: Tendon
Taper Point: SQ / Fascia
Diameter
Smaller the #, the greater thewidth of suture mateial
Sub-Q - closes w/ 2-0, 3-0
Skin - closes w/ 4-0, 5-0
Techniques
Simple
Mattres - good eversion
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PDS – 4 weeks
Misc Sx Tools
Bone Paste
used to prevent bleading of bone
indicated for CN-bar and bunionectomy
Drains
Remove in 24-48hrs
Penrose & TLS (tiny little sucker)
Trephine
Allows for removal of screws by overdrilling
Classification
Autograft: same person
Isograft: same twin
Allograft: same species
Xenograft: different species
Types
Full Thickness
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211
Kenny’s reviews
Synthetic Grafts
212
Kenny’s reviews
Integra Graft
Resting Skin Tension Lines
Regular shaped furrow created upon pinching the skin. Usually perpendicular to muscle
bellies. Placing incisions parallel creates ideal scar
213
Non-Union
Kenny’s reviews
214
Nail Surgery
Kenny’s reviews
215
Skin Flap -Plastic
Kenny’s reviews
216
Bunion Evaluation
Kenny’s reviews
217
Head Bunionectomties
Kenny’s reviews
218
Neck Bunionectomties
Kenny’s reviews
219
Shaft Bunionectomties
Kenny’s reviews
220
Base Bunionectomties
Kenny’s reviews
221
Kenny’s reviews
222
Lesser Metatarsals Sx
Kenny’s reviews
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Kenny’s reviews
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Kenny’s reviews
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Kenny’s reviews
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Kenny’s reviews
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Kenny’s reviews
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Kenny’s reviews
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Haglund’s
Kenny’s reviews
230
Equinus
Kenny’s reviews
231
Triple Arthrodesis
Kenny’s reviews
232
Kenny’s reviews
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Kenny’s reviews
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Ankle scope
Kenny’s reviews
235
Amputations
Kenny’s reviews
236
Amputations
Kenny’s reviews
237
trauma
Kenny’s reviews
238
Kenny’s reviews
239
Watson Jones
Kenny’s reviews
240
Stewart
Kenny’s reviews
241
Sneppen
Kenny’s reviews
242
Sanders
Kenny’s reviews
243
Salter-Harris
Kenny’s reviews
244
Rowe’s
Kenny’s reviews
245
Jahss
Kenny’s reviews
246
Lis Franc Injury
Kenny’s reviews
247
Hawkins
Kenny’s reviews
248
Gustillo- Anderson
Kenny’s reviews
249
Essex-Loprosti
Kenny’s reviews
250
Eckert-Davis
Kenny’s reviews
251
Berndt-Hardy
Kenny’s reviews
252
Ankle Sprains
Kenny’s reviews
253
Ankle Fractures
Kenny’s reviews
254