Pocket Pod

ANATOMY
CHAPTER 1
ANATOMY
CALCANEUS, p l 4
CRANIAL NERVES, p2
LIGAMENTSIRETINACULUMS,p8
LOWER EXTREMITY-NERVES, p4
LOWER EXTREMITY-BLOODSUPPLY, p6
MUSCLES-EXTRINSIC, p17
MUSCLES-INTRINSIC, p20
SESAMOIDALATTACHMENTS, p13
TALUS, p16
TALUS-BLOOD SUPPLY, p3
TOE, p l 2
TOENAIL, p13
CHAPTER 1
ANATOMY
CHAPTER 1
NERVES
III
III
IV
V
VI
VII
Vlll
IX
X
XI
XII
.....
Optic
Occulomotor
Trochlear
Trigeminal
vision
eye muscles, accommodation
one eye muscle
sensation to faceloral,
mastication
one eye muscle
Abducens
Facial
taste, muscles of facial
expression, secretions of
lacrimal, mucosal, and some
saliva glands
Vestibulocochlear hearing, sense of equilibrium
(or auditory)
Glossophatyngeal sensation from pharynx, taste,
one pharyngeal muscle,
secretion of one saliva gland
Vagus
sensation from pharynx and
larynx, taste, muscles of
palate, pharynx, and larynx,
parasympathetic to thorax
and upper abdomen
two neck muscles
Accessory
tongue muscles
Hypoglossal
1n
Sensory
Motor
Motor
Both
Motor
Both
Sensory
Both
Both
Motor
Motor
ANATOMY
CHAPTER 1
BLOOD SUPPLY TO THE T A L U S

Posterior tubercle-the medial calcaneal artery anastomosis with a
branch from the peroneal artery to supply this area
Body-supplied by the artery of the sinus tarsi and the artery of the tarsal
canal and there anastomosis as well as the deltoid branches
Head/Neck-supplied by branches off the dorsalis pedis artery and the
anastomoses that the dorsalis pedis makes with the deltoid branches
and the artery of the sinus tarsi
Anterior Tibial a.
Deltoid a.
ANATOMY
NERVES TO THE
LOWER EXTREMITY
PLANTAR FOOT
CHAPTER 1
ANATOMY
CHAPTER 1
NERVES TO THE LOWER EXTREMITY

lnfrapatellar branch of the saphenous nerve
Saphenous nerve(L3, L4)
Tibial nerve
Lateral calcaneal nerve
Medial calcaneal nerve
Lateral branch of deep peroneal nerve
Medial branch of deep peroneal nerve
1st dorsal digital proper nerve
2nd-10th dorsal digital proper nerve
Lateral dorsal cutaneous nerve
Medial dorsal cutaneous nerve
Intermediate dorsal cutaneous nerve
Deep peroneal nerve
Sural nerve
Superficial peroneal nerve
Lateral sural cutaneous nerve
Peroneal communicating branch
Common peroneal nerve
Medial sural cutaneous nerve
1st-4th common dorsal digital nerve
Sciatic nerve(L4-S3)
y.
1 st-10 th Proper plantar digital nerve
z.
Medial plantar nerve
aa. lnfracalcaneal nerve (nerve to the abductor digiti minimi) -a.k.a.
Baxter's nerve
bb. Lateral plantar nerve
cc. Superficial branch of lateral plantar nerve
dd. Deep branch of lateral plantar nerve
ee. Communicating branch
gg. 1st-4th common plantar digital nerve
a.
b.
c.
d.
e.
f.
g.
i.
j.
I.
m.
n.
o.
p.
q.
r.
s.
t.
u.
v.
w.
ANATOMY
CHAPTER 1
ANATOMY
CHAPTER 1
ARTERIES OF THE LOWER EXTREMITY

A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
U
V
W
X
Z
BB
CC
DD
EE
FF
GG
HH
II
1st-4th Plantar metatarsal arteries

2nd and 3rd Common superficial plantar digital arteries
Medial or deep branch of the lateral plantar artery
(deep plantar arch)
Deep plantar artery
Superficial branch of medial plantar artery
Lateral plantar artery
Posterior tibial artery
Medial plantar artery
Deep branch of the medial plantar artery
Lateral branch of the deep branch of the medial plantar artery
Medial branch of the deep branch of the medial plantar artery
Lateral branch of the superficial branch of the medial plantar artery
1stCommon superficial plantar digital artery
Digital branch of the 1stplantar metatarsal artery
Lateral sural artery(an end artery)
Circumflex fibular artery
Anterior tibial artery
Peroneal artery
Perforating branch of peroneal artery
Anterior lateral malleolar artery
Dorsalis pedis artery
Arcuate artery
Superficial branch of the lateral plantar artery
1st- 1
O th Dorsal digital proper arteries
1st-4th Dorsal metatarsal arteries
Anterior medial malleolar artery
Medial calcaneal artery
Communicating branch of the peroneal artery
Anterior tibial recurrent artery
Medial sural artery (an end artery)
1st-4th plantar digital proper artery
Femoral artery
ANATOMY
CHAPTER 1
ANKLE LIGAMENTS
DELTOID LIGAMENT
-composed of 5 distinct
LATERAL ANKLE
Posterior talofibular lig.

(capsular)
Posterior tibiofibular lig.
Medial talocalcaneal li
Posterior talocalcaneal lig.
ANATOMY
CHAPTER 1
ARTERIES OF THE LOWER EXTREMITY

A
B
C
D
E
F
G
H
I
J
K
L
M
N
O
P
Q
R
S
T
U
V
W
X
Z
BB
CC
DD
EE
FF
GG
HH
II
1st-4th Plantar metatarsal arteries

2nd and 3rdCommon superficial plantar digital arteries
Medial or deep branch of the lateral plantar artery
(deep plantar arch)
Deep plantar artery
Superficial branch of medial plantar artery
Lateral plantar artery
Medial plantar artery
Deep branch of the medial plantar artery
Lateral branch of the deep branch of the medial plantar artery
Medial branch of the deep branch of the medial plantar artery
Lateral branch of the superficial branch of the medial plantar artery
1st Common superficial plantar digital artery
Digital branch of the 1st plantar metatarsal artery
Lateral sural artery(an end artery)
Circumflex fibular artery
Anterior tibial artery
Peroneal artery
Perforating branch of peroneal artery
Anterior lateral malleolar artery
Dorsalis pedis artery
Arcuate artery
Superficial branch of the lateral plantar artery
1st-1
Oth Dorsal digital proper arteries
1st-4th Dorsalmetatarsal arteries
Anterior medial malleolar artery
Medial calcaneal artery
Communicating branch of the peroneal artery
Anterior tibial recurrent artery
Medial sural artery (an end artery)
1st-4th plantar digital proper artery
Femoral artery
ANATOMY
10
l,u
CHAPTER 1
RETINACULUMS AND TENDON ORIENTATION

Peroneus b r e ~ i s - - ~
%Superior
Peroneus longus
extensor retinaculum
-Inferior extensor retinaculum
retinaculum
retinaculurn
LATERAL ANKLE
Tibialis posterior
Superior extensor
retinaculum
Inferior extensor
retinaculum
Flexor digitorurn longus

lexor hallucis longus
chilles tendon
MEDIAL ANKLE
Mnemonic-structures from anterior to posterior Tom, Dick, a d Harry
Tibialisposterior, flexor Digitorumlongus, Artery, Nerve, flexor Hallucis longus
ANATOMY
11
CHAPTER 1
Ligament
Peroneus tertius
Extensor digitorum
longus
DORSAL FOOT
Mnemonic-structures from medial to lateral A HAND P
Ant tib., ext. Hallucis longus, Artery, Nerve, extensor Dig. longus, Peroneus tertius
-
ANATOMY
12
CHAPTER 1
ANATOMY
13
CHAPTER 1
SESAMOIDAL ATTACHMENTS
LIGAMENTOUS ATTACHMENTS
lntersesamoid Ligament-(tibia1 & fibular)
Medial metatarsosesamoid Suspensory Ligament-(tibia/)
Lateral metatarsosesamoid Suspensory Ligament-(fibular)
Medial Sagittal Hood Ligament-(tibia/)
Lateral Sagittal Hood Ligament-(fibular)
Medial Sesamophalangeal Ligament-(tibia/)
Lateral Sesamophalangeal Ligament-(fibular)
TENDON ATTACHMENTS
Adductor Hallucis Conjoined Tendon-(fibular)
Abductor Hallucis Tendon-(tibial)
Flexor Hallucis Brevis Tendon(Medialhead)-(tibial)
Flexor Hallucis Brevis Tendon(Lateral head)-(fibular)
OTHER ATTACHMENTS
Plantar Fascia-(tibia1 & fibular)
Plantar Intermetatarsal Ligament-(fibular)
Plantar Plate-(tibia1 & fibular)
TOENAILS
Lunula
\
Ungual labia
(med. nail fold)
lrnail
~$;J
Eponychium(cuticle
,-Nail plate
'-Hyponychium
(distal nail groove)
ANATOMY
14
CHAPTER 1
CALCANEUS
al and intermediate
Middle facet for talu
.-6
DORSAL VIEW OF CALCANEUS
Articular
surface
for cuboid
PLANTAR VIEW OF CALCANEUS
ANATOMY
15
Posterior articular
facet
Middle articular
CHAPTER 1
Tubercle for
calcaneofibular
ligament
Superior horizontal line
Achilles attachmenit
Inferior horizontal line
Peroneal tubercl
~;oove for
peroneous longus
6
Iy
5.=
I3
LATERAL VIEW OF CALCANEUS
3u
0 5
5,
5, E
g
:g
+
POSTERIOR SURFACE
SURFACE Attachment of the medial
Middlefacet for the talus calcaneal subtalar ligament
E ?i
e0
.g
Attachment of the
Talocalcaneonavicular
MEDIAL SURFACE
Groove for flexor digitorum longus
tendon and attachment of the
Calcaneotibial lig.
INFERIOR SURFACE
Groove for the flexor
hallucus longus tendon
STRUCTURES AROUND THE

SUSTENTACULUM TALI
ANATOMY
16
CHAPTER 1
T A L U S - 3 1 5 of talus is covered by cartilage
Cervicis(attachmentsite
of the cervical ligament)
Comma-shaped facet
for medial malleolus
Posterior
Trochlea surface
Medial tubercle
Groove for FHL
DORSAL VlEW OF THE RIGHT TALUS
iculation with the navicular

Articulation with the
anteriorfacet of the
calcaneus
Sulcus tali-forms the
roof of the Sinus tarsi
the middle facet
of the calcaneus
Medial tubercle
Groove for FHL
ANTERIOR VlEW OF THE RIGHT TALUS

Modified from Anatomy of the Lower Extremity, Draves. Williams and Wilkins, 1986
ANATOMY
17
CHAPTER 1
LEG MUSCLES
TIlBIALIS ANTERIOR MUSCLE
Origin: lateral condyle of the tibia, the proximal lateral 112 of the tibial
shaft, the interosseous membrane, and the deep surface of the fascia
cruris
Insertion: plantar surface of the medial cuneiform and base of the 1st
metatarsal
Action: dorsiflexes ankle, inverts foot
Innervation: deep peroneal nerve(L4, L5, S1)
Arterial Suppy: anterior tibial artery
EXTENSOR HALLUCIS LONGUS MUSCLE

O r i g i n :anterior
:
surface of the interosseous membrane and from the
middle two-fourths of the medial surface of the fibula
Insertion: dorsal base of the distal phalanx
Action: extension of the hallux, dorsiflexion of the ankle
Innervation: deep peroneal artery(L4, L5, S1)
Arterial Supply: anterior tibial artery
NOTE: Extensor hallucis capsularis is an extra slip from the
medial side of the EHL tendon present in 80-90% of patients which
inserts into the dorsomedial capsule of the 1st MPJ. It's function is
believed to be to reinforce the joint and take the slack out of the joint
upon dorsiflexion.
EXTENSOR DIGITORUM LONGUS MUSCLE

O r i g i n:lateral
:
condyle of the tibia, the upper two-thirds of the medial surface of the shaft of the fibula, the upper part of the interosseous membrane, the fascia cruris, and the intermuscular septum
Insertion: dorsal base of the middle and distal phalanx of digits 2-5
Action: extend digits 2-5, dorsiflex the ankle
Innervation: deep peroneal nerve(L4,L5, S1)
Arterial Supply: anterior tibial artery
PERONEUS TERTIUS MUSCLE
m:lower one-quarter of the medial surface of the fibula and the

adjacent surface of the interosseous membrane
Insertion: dorsal base and shaft of the 5th metatarsal
Action: dorsiflex the ankle, evert the foot
Innervation: deep peroneal nerve(L5, S1)
Arterial Supply:anteriortibial artery
NOTE: abscent in 8-9% of population
ANATOMY
18
CHAPTER 1
PERONEUSLONGUSMUSCLE
m
: head and upper one-half of the lateral fibula
Insertion: plantar lateral surface of the 1st cuneiform and base of the 1st
metatarsal
Action: evert foot, plantarflex ankle, support the longitudinal and transverse arch of the foot
Innervation: superficial peroneal nerve(L5, S1, S2)
Arterial Supply: anterior tibial and peroneal artery
PERONEUS BREVIS MUSCLE

-most efficient pronator of the subtalar joint
inferior two-thirds of the lateral side of the fibula
Insertion: styloid process of the 5th metatarsal
Action: evert the foot, plantarflex the ankle
Innervation: superficial peroneal nerve(L5, S1)
Arterial Supply: peroneal artery
m:
GASTROCNEMIUS MUSCLE
m
: medial and lateral condyles of the femur
Insertion: middle one-third of the posterior aspect of the calcaneus
Action: plantarflex ankle, flex knee
Innervation: tibial nerve(S1, S2)
Arterial Supply: sural artery(an end artery)
SOLEUS MUSCLE
m
: posterior head and upper one-third of the fibula, and soleus line
of the tibia
Insertion: middle one-third of the posterior aspect of the calcaneus
Action: plantarflex ankle
Arterial Supply: posterior tibial artery
PLANTARIS MUSCLE
m
: lateral condyles of the femur
Insertion: medial one-third of the posterior calcaneus
Action: plantarflex ankle, flex knee
Innervation: tibial nerve(L5, S1, S2)
Arterial Supply: sural artery
NOTE: abscent in 7% of population
ANATOMY
19
CHAPTER 1
POPLITEUS MUSCLE
Qjgin: lateral condyle of the femur
Insertion: superior posterior surface of the tibia
Action: flexes the knee, medially rotates the knee
Innervation: tibial nerve(L4, L5, S1)
Arterial Supply:medial inferior genicular artery and the posterior tibial
artery
FLEXOR DIGITORUM LONGUS
m:
the posteromedial aspect of the middle third of the tibial shaft

Insertion: plantar surface of the base of phalanges 2-5
Action: flexes the DIPJ, PIPJ, MPJ of digits 2-5, and plantarflexes the
ankle
Arterial Supply:posterior tibial artery
TIBIALIS POSTERIOR MUSCLE
m:posterior two thirds of the interosseous membrane and the adja-
cent tibia and fibula

Insertion: plantarly on the navicular(major insertion site), medial and
intermediate cuneiform, and base of the second, third, and fourth
metatarsal
Action: invert the foot, adduct foot, plantarflex ankle
Innervation: tibial nerve(L4, L5)
Arterial Supply: sural, peroneal, and posterior tibial arteries
FLEXOR HALLUCIS LONGUS

Qjgin: Most of the inferior two-thirds of the posterior surface of the
fibular and the lower part of the interosseous membrane
Insertion: plantar surface of the base of the distal phalanx of the hallux
Action: flexes the IPJ, 1st MPJ, plantarflex ankle
Arterial Supply:peroneal, and posterior tibial arteries
ANATOMY
CHAPTER 1
20
INTRINSIC MUSCLES OF THE FOOT

EXTENSOR DIGITORUM BREVIS
m:Superolateral aspect of the calcaneus,
just anterior to the sinus tarsi

Insertion: Dorsal base of the 1st-4th
proximal phalanx
Action: Extension of the 1st-4th MPJ
Innervation: Lateral terminal branch
of the deep peroneal nerve(S1, S2)
Arterial Supply:Dorsalis pedis
w:
Medial process of the calcaneal

tuberosity
lnsertion: The tendons of abductor
hallucis and the medial head of the flexor hallucis brevis insert together on the
medial side of the plantar aspect of the
base of the proximal phalanx. Some
fibers also attach to the medial
sesamoid.
Abduct the hallux.
Innervation: Medial plantar nerve(L5, S1,
a:
-
S2)
Arterial Supply:Medial plantar artery.
Modified from Anatomy of the Lower Extremity, Draves, Williams and Wilkins, 1986
ANATOMY
21
CHAPTER 1
FLEXOR DIGITORUM BREVIS
m:Plantar aponeurosis, medial
intermuscular septa, lateral intermuscular

septa, and the medial process of the
calcaneal tuberosity.
Insertion: Inserts by two tendinous
slips on to each side of the shaft of
the 2nd-5th middle phalanx.
Action: Flexion of the 2nd-5th PIPJ,
with continued contraction flexion
of the 2nd-5th MPJ.
Innervation: Medial plantar nerve
(L5, S1, S2)
Arterial Supply: Medial plantar artery.
ABDUCTOR DIGIT1 MINIMI

QUINTI
m:
Lateral process of the calcaneal

tuberosity.
Insertion: Lateral side of the plantar
aspect of the base of the 5th proximal
phalanx.
Abduct the 5th toe and assist
with flexion.
Innervation: Lateral plantar nerve S1, S2
Arterial Supply: Lateral plantar nerve.
m:
Modified from Anatomy of the Lower Extremity, Draves, Willlams and Wilkins, 1986
ANATOMY
22
CHAPTER 1
LUMBRICALES
m:Tendon of the flexor digitorum longus after its separation into 4

slips
Insertion: Medial aspect of the extensor expansion, slightly more
dorsally than plantarly
Action: Flex the 2nd-5th MPJ and extend the lPJs of these same toes
Innervation: The 1st(medial) lumbrical
is innervated by the medial plantar
nerve L5, S1. The lateral 3
lumbricales are innervated by
the deep branch of the lateral
plantar nerve S1, S2
Arterial Supply:Plantar metatarsal
arteries
QUADRATUS PLANTAE
m:Arises from two heads
of origin which are separated

from one another by the calcaneal
attachment of the long plantar
ligament. The medial head
originates from the medial plantar
surface of the calcaneus. The
lateral head originates from the
lateral plantar surface of the
calcaneus.
Insertion: Tendon of the flexor digitorum longus.
Action:Aids the flexor digitorum longus in the flexion of t
2nd-5th toes by straightening the line of pull to the tendon.
Innervation: Lateral plantar nerve S2, S3
Arterial Suoppy:Lateral plantar artery
N0TE:This muscle is also called FLEXOR DIGITORUM ACCESSORIUM
Modified from Anatomy of the Lower Extremity, Draves, Williams and Wilkins, 1986
ANATOMY
23
CHAPTER 1
FLEXOR HALLUCIS BREVIS

Oriqin: Plantar surface of the cuboid
and lateral cuneiform
Insertion: The medial(larger) head
inserts on the medial side of the plantar
aspect of the base of the proximal
phalanx, the medial sesamoid, and
the medial aspect of the plantar pad
of the hallux. The lateral(smaller)
head inserts on the lateral side of
the plantar aspect of the base of the
proximal phalanx, the lateral sesamoid,
and the lateral aspect of the plantar
pad of the hallux.
Flex the first MPJ
Innervation: Medial plantar nerve L5, S1
Arterial Supply: The first plantar
metatarsal artery
Flexor
hallucis
brevis
m:
ADDUCTOR HALLUCIS
m:
The oblique head originates from the
bases of the plantar-medial aspects of the
second, third, and fourth metatarsals, and
from the mid-portion of the tendinous sheath
of the peroneus longus tendon. The transverse head originates from the plantar plates
and the plantar metatarsophalangeal
ligaments of the third, fourth, and fifth toes
and from the deep transverse metatarsal ligament.
Insertion: The two heads come together and
insert proximally along with the lateral head of
the flexor hallucis brevis on the lateral, plantar
area of the proximal phalanx. The tendons
enclose the lateral sesamoid.
Action: The oblique head functions to adduct
and help flex the hallux. The transverse head
acts to adduct the hallux and bring the
metatarsals closer together and maintain the
transverse arch of the foot.
Innervation: Deep branch of the lateral
plantar nerve S1, S2, (S3)
Arterial Supply: First plantar metatarsal artery.
Modifled from Anatomy of the Lower Extremity,Draves. Williams and Wilkins, 1986
ANATOMY
24
CHAPTER 1
FLEXOR DIGITI MINIM1

Oriain Base of the fifth metatarsal
on its medial-plantar surface, the
sheath of the tendon of the peroneus
longus, and the plantar aponeurosis
Insertion: Lateral side of the plantar
aspect of the base of the 5th proximal
phalanx
Action: Flex and help abduct the 5th
digit
Innervation: Superficial branch of the
lateral plantar nerve S1, S2, (S3)
Arterial Supply: Lateral plantar artery
zgz
digiti
PLANTAR INTER0
w:Medial side of the bases of the
Plan
inter
3rd, 4th, and 5th metatarsal bones

Insertion: Medial side of the bases of the
proximal phalanges, the metatarsophalangeal joint capsules, and the extensor
expansion of the same digit on which
they originate.
Action: Adduct the third, fourth, and fifth
toes toward the midline of the foot.
Innervation: The 1st and 2nd are
innervated by the deep branch of the
lateral plantar nerve, The 3rd is
innervated by the superficial branch of
the lateral plantar nerve.
Arterial Supply: 2nd, 3rd, and 4th plantar
metatarsal arteries.
NOTE: Mnemonic-PAD, PlantarADduction
Modified from Anatomy of the Lower Extremity, Draves, Willlams and Wilkins. 1986
ANATOMY
25
CHAPTER 1
DORSAL INTEROSSEI
m:Originate from adjacent sides

of adjacent metatarsal bones.
Insertion: The base of the proximal
phalanx and the extensor expansion.
Action:Abduct the toes away from
the midline of the foot(the second toe)
Innervation: 1st-Deep branch of the
lateral plantar nerve and an extra
branch, the medial branch of the deep
peroneal nerve. 2nd-Deep branch of
the lateral plantar nerve and an extra
branch, the lateral branch of the deep
peroneal nerve. 3rd-Deep branch of
the lateral plantar nerve. 4th-Superficial
branch of the lateal plantar nerve.
Arterial Supply: Dorsal metatarsal artery
NOTE: Mnemonic-DAB, Dorsal-Abduction
PLANTAR LAYERS OF THE FOOT

First Layer(superficial)
1. Abductor Hallucis Muscle
2. Flexor Digitorum Brevis Muscle
3. Abductor Digiti Minimi(quinti)
Second Layer
1. Quadratus Plantae Muscle
2. Lumbricales
3. Flexor Hallucis Longus Tendon
4. Flexor Digitorum Longus Tendon
Third Laver
1. Adductor Hallucis Brevis Muscle
2. Flexor Hallucis Brevis Muscle
3. Flexor Digiti Minimi Brevis Muscle
Fourth Layer(deep)
1. Plantar lnterossei
2. Dorsal lnterossei
3. Tibialis Posterior Tendon
4. Peroneus Longus Tendon
Modified from Anatomy of the Lower Extremity, Draves, Williamsand Wilkins, 1986
ANATOMY
26
TYPES OF JOINTS
Enarthrodial(ball and socket)
examples: hip, shoulder
Condyloid(ellipsoid or saddle)
examples: wrist, calcaneocuboid joint
Ginglymus(hinge)
examples: interphalangeal joints
Trochoid(ring and pivot)
examples: C1-C2, there are none in the low extremity
Arthrodial(gliding)
examples: lisfranc's joint
CHAPTER 1
PHARMACOLOGY
27
CHAPTER 2
CHAPTER 2
PHARMACOLOGY
,
ANALGESICS - NARCOTIC, p34 '

ANALGESICS-NONNARCOTIC, p37
ANESTHESIA-GENERAL, p57
ANESTHETICS-LOCAL, p55
ANESTHETICS-TOPICAL, p55
ANGIOTENSIN II ANTAGONISTS. p 6 3
ANGIOTENSIN CONVERTING ENZYME(ACE) INHIBITORS, p63
ANTIADRENERGIC AGENTS-CENTRALACTING, p63
ANTIADRENERGIC AGENTS-PERIPHERALLY ACTING, p64
ANTIBIOTICS, p43
ANTICOAGULANTS, p41
ANTICONVULSANTS. p 6 7
ANTIDEPRESSANTS; p59
ANTIDIARRHEALS, 71
ANTIDOTES, p73
ANTIEMETICS, p69
ANTIFUNGALS(TOPICAL), p28
ANTIFUNGALS(ORAL/IV),p 3 0
REDUCTASE INHIBITORS, p65
ANTI-HYPERTENSION COMBINATIONS, p65
ANTIMICROBIALS-TOPICAL.p
. . 42
ANTIPERSPIRANTS. p 3 1
p60
BETA BLOCKERS, 66
CALCIUM CHANNEL BLOCKERS, 66
CONTROLLED SUBSTANCE ACT, p34
CORTICOSTEROIDS-TOPICAL, p51
DIABETIC MEDICATION-ORAL, p70
DIURETICS, p58
agents), p32
FIBROLYTICS. 31
p53
INSULIN, p70
KERATOLYTICS-TOPICAL, p31
LAXATIVES, p71
MUSCLE RELAXANTS.. .p 6 7
NSAIDs. p 3 8
SEDATIVE/HYPNOTICS, p 6 1
STEROIDS-INJECTABLE, p54
TETANUS PROPHYLAXIS, p73
THROMBOLYTIC AGENTS, p42
WART MEDICATIONS, p75
PHARMACOLOGY
28
CHAPTER 2
FORMULATION
1%
solution, 1%
cream 1%
I solution. 1%
Mycelex
Presc
Presc strgth Desenex
05% Betarnethasone)
Spectazole
Econazole
Ketoconazole
Miconazole
Presc strgth Desenex
powder, 1%
spray powder, 1
spra liquid, 1%
deo erant powder,
cream, 1%
cream,
cream, 1%
cream, 1%
1%
cream.
cream, 1%
cream, 1%
spray
2%
spray
spray owder, 2%
, 2%
spray l i q u i d2%
spray deoder powder, 2%
BID
powder, 2%
cream, 1%
Oxiconazole
Exelderm
BID
BID
BID
cream, 1
cream,
1%
BID
CHAPTER 2
29
PHARMACOLOGY
X X X X X X X X X X X X X X X X X X X X X X
ggggggoooog ~
.5
I --3%
15
i
a
-n
111
Z k
.'V
z0,
~ ~8 p
mmmmmmmmmmm mmmUmmmmmmmmmmmmmmmmOmmm
PHARMACOLOGY
30
CHAPTER 2
~tracona~0~e(~poranox)-100rng
PO bid x12 weeks for fungal toenails
or x6 weeks for fungal finger nails. "Pulse dosingn-200mg PO bid x l
week then 3weeks off, 3 pulses for toenails and 2 pulses for fingernails
[loo]
-imidazole derivative
-active against dermatophytes, and Candida
-contraindicated with; Astemizole, Terfenadine, Cisapride
-possible hepatotoxicity, monitor hepatic function before
treatment and at one month
Ketoc0na~0Ie(~izoral)-200-400mg
PO qd [200]
-imidazole derivative
-active against dermatophytes, Candida, some G+, and has
also shown to have some antiviral properties
-can cause hepatotoxicity
-contraindicated with; Cisapride, Terfenadine
Amphotericin B ( ~ b e l c e tAmphotec)-test
,
dose 1-5mg IV over 1530min, then wait 30 minutes. If no reaction infuse 3-5mglkg qd IV at a
rate of 1-2mglkglhr
-antibiotic antifungal
-active against fungus and Candida, does not affect bacteria
or dermatophytes
-not effective orally
-can cause renal toxicity
Terbinafine H C L ( ~ a m i s i 1 ) - 2 5 0PO
m ~ qd x6 weeks for fingernails,
x l 2 weeks for toenails
-allyamhe derivative
F ~ ~ ~ ~ n a ~ ~ l e ( ~ i f l u c a n ) - c a n200
d i dIV/PO
i a s i sfirst
: day, then 100200mg qd. Cryptococcal meningitis: 400mg IV first day, then 200-400mg
qd. Vaginal candidiasis: 150mg PO single
dose. [tabs 50, 100, 150,200, susp 10 & 40mg/ml]
-1midazole derivative
-active against dermatophytes, some Candida, but has no
antibacterial properties
-can cause renal toxicity
G r i s e o f u I v i n ( ~ u l v i c i n ,Grifulvin, Grisactin, Gris-PEG)-375mglg(750mg for onychomycosis) PO qd in divided doses x 4 months fingernails, x 6 months for nails. [tabs 125, 250, 500, susp 125mg/5ml]
-active against dermatophytes, does not kill Candida
-pts should be monitored for renal and hepatic function
PHARMACOLOGY
31
CHAPTER 2
Gentian Violet
-topically BID x 3days
-active against dermatophytes, Candida, and G+(color is due
to crystal violet, hence G+ activity)
-not recommended for dermatophyte infections because it's
not that effective and has local irritant and staining properties
-solution .5%, I%, 2%
-drying properties, so use on macerated infections
PEDAL ANTIPERSPIRANTS
Ostiderm roll-on
-QD [30z bottle]
Xerac AC
-QD at bedtime[35cc, 60cc Dab-0-Matic bottle]
Drysol
-QD at bedtime[37,5cc bottle, 35cc, 60cc Dab-0-Matic bottle]
Bromi-Lotion
-QD[4oz bottle]
Dr. Scholl's Antiperspirant Spray

-BlD[3.50z]
TOPICAL KERATOLYTICS
Salicylic
A c i d ( ~ u o f i l mDuoplant)
,
-topically QD
-used for scaling dermatosis and localized hyperkeratosis
-also used for Seborrheic Dermatitis, Psoriasis and dandruff
-12%-17.6%
U r e a ( ~ r e a c i nCarmol,
,
Vanamide)
-topically QD-TID
-cream/lotion 5%-40%
S ~ I f u r ( ~ u l f o r c iSulfron)
n,
-cream/lotion/ointrnent2%-5%
Hyaluronidase(wydase)
-used as an adjuvant to increase the dispersion and
absorption of parenteral fluids
-also used to break up scar tissue
-contraindicated in infection and cancer because it could
facilitate spreading
PHARMACOLOGY
32
CHAPTER 2
E M O L L I E N T S ( s o f t e n i n g agents)
A q ~ a p h ~ r ( o i n t m e n t ) - a p pBID
l y [ I ,7502 tube, 3.25, or 16oz jar]
Calamine(~otion)-applyBID
Cetaphil(cream, lotion)-apply BID
Eucerin(cream, lotion)-apply BID [4, 8, 1602 jars]
Lac-Hydrin 12%(cream, lotion)-apply BID
-Ammonium Lactate
Lanolin(cream)-apply BID
Moisturel(cream, lotion)-apply BID
PHARMACOLOGY
When
pa:; from
33
CHAPTER 2
EE1
BIOFREEZEa is available in 160z., 32 oz., and gallon

pump bottles for clinical use and personal size tubes
& roll-ons for use at home between office visits.
For more information and your free trial product please call:
1-800-BIOFREEZE 1-800-(246-3733) FAX: 1-724-733-4266
e-MAIL: heaIth@biofreeze.com
BIOFREEZE
Pain relief fhaf works
rcrto~
PHARMACOLOGY
34
CHAPTER 2
CONTROLLED SUBSTANCE ACT

Schedule I(C1)
-high abuse potential
-no accepted therapeutic use
4.e. heroin, LSD
Schedule II(CII)
-high abuse potential
-most potent opiates, intermediate acting barbituates,
methaquinalone, cocaine, amphetamines
-non-refillable, Rx can't be called in
Schedule III(CIII)
-moderate abuse potential
-preparations of codeine, some barbituates
-refillable a maximum of 5 times within 6 months
Schedule IV(CIV)
-low abuse potential
-i.e. diazepam, d-propoxyphene
Schedule V(CV)
-Rx not required
NARCOTIC ANALGESICS
-side effects-hypotension,respiratory depression, nausea,
urinary retention, and constipation
-low dose narcotics suppress the cough reflex
-contraindicatedin head trauma, opioids caused an increase
in intracranial pressure
Alfentani~(~lfenta)-8-2op~lk~
IV increments, CII
Buprenorphine(~uprenex)-0.3mg
lVllM q6h, CV
6utorphan0l(Stadol)-1mg IV or 1-4mg IM q3-4h. Nasal spray(Stado1
NS)-1spray q3-4h. [ I mglspray]
Codeine-o.smg/kg up to I5-6omg POllM q4-6h [I 5, 30,601 CII
-Low dose suppresses a cough
De~0~ine(Dalgan)-2.5-1om~
IV q2-4h or 5-10mg q3-6h
F?Iltany~(Sublirnaze)- itr rated IV increments of 2-3pglkg up to 50pg.
Transdermal(Duragesic) one 2.5mg patch q3 days. [patches 2.5, 5, 7.5,
lOmg] Transmucosal lollipops(Fentanyl 0ralet)-5-15pg/kg,max 400
pg [200, 300, 400pg1 CII
Hydrocodone(Hycodan)-5mlpo q4-6h [5] Clll
PHARMACOLOGY
35
CHAPTER 2
Hydromorphone(Dilaudid)-1-2mgIMlSC/IV q4-6h. 2mg PO q4-6h.

3mg PR q6-8h. [tabs 1, 2, 3, 4, suppositories 31 CII
Le~0rphan01(Levo-Dromoran)-2mgPO/SC q6h. [2] CII
~ e ~ e r i d i n e ( ~ e m e r o l ) - 2increments
5m~
IV. I-1.8mg/kg up to 150mg
IM/PO q3-4h. [tabs 50, 100, syrup 50mg/5ml] CII
Methadone(Do1ophine)-2.5-10mg PO/IM/SC q3-4h. [tabs 5, 10, solution 5 & lOmg/5ml] CII
-primarily used for detoxification of heroin addicts
Morphine sulfate-o.lmg/kg up to 2-4mg increments IV. 0.10.2mglkg up to 15mg IM q4h. Sustained release tabs(MS Contin)-3Omg
PO q8-12h. [30, 601 Elixir(Roxanol)-10-3-mg PO q4h. [20mg/5mg] CII
Nalbuphine(Nubain)-10mg IV/IM/SC q3-6h
O~y~0d0ne(~oxicodone)-5m
PO
g q6h. Controlled
release(0xyContin)- 10-40mg PO q12h. [tab 5, syrup 5mg/5ml, controlled release OxyContin 10, 20, 40, 80, 160mgl CII
Oxymorphine(~umorphan)-1-1.5mg
IM/SC q4-6h, CII
Pentaz~cine(~alwin)-30mg
IV/IM q3-4h. Oral form(Ta1win NX,
pentaxocine 50mg + naloxone 0.5mg)-1 PO q3-4h, CIV
Propoxyphene(~arvon)-65mg
PO q4h. 132, 651 CIV
Sufentalil(sufenta)-10-25pg IV increments, CII
NARCOTIC ANALGESICS(COMBINATI0NS)
A~ex~~a(~cetarninophen1Hydrocodone
50015)-1-2 tabs PO q4-6h.
Anexia(65017.5)-I tab PO q4-6h, CHI
Damason-P(~~drocodonel~~A/caffeine
51224132)-1 tab PO q4-6h
~ a ~ ~ 0 ~ e t ( ~ r o p o x ~ ~ h e n e / ~ c e t a m i n o ~ h e n ) - ~ -25tabs
0 = 5PO
01325,
q4h. N-100=1001650,1 tab PO q4h, CIV
Darvon C ~ m p ~ ~ n d ( ~ r o p o x ~ p h e n e l ~ ~ A651389132.4mg)/~affeine
1 PO q4h, CIV
Empirin with C o d e i n e ( ~ 325mg
~A
+ Codeine 30mg [#3],
60mg[#4])-1-2 tabs PO q4h, Clll
Fioricet with C~deine(Acetaminophen325mg + Butalbital 50mg +
Caffeine 40mg + Codeine 30mg)-1-2 tabs PO q4h, Clll
Fiorinal with C o d e i n e ( A s A 325mg + Butalbital 50mg + Caffeine
40mg + Codeine 30mg)-1-2 tabs PO q4h, Clll
PHARMACOLOGY
36
CHAPTER 2
L ~ ~ ~ ~ t ( ~ y d r o c o d o n e l ~ c e t a m i 51500)-1-2
n o p h e n tabs PO q4-6h, and
Lorcet(7.51650, 101650)-1 tab PO q4-6h, Clll
L~~ab(~ydrocodone/~cetaminophen
2.5/500, 51500, 7,51500)-1-2 tabs
PO q4-6h. Elixir(2.51167 per 5 ml)-15ml PO q4-6h, Clll
Mepergan Fortis(Meperidine1Phenergan 50125)-1 tab PO q4-6h, CII
-Phenergan is an antiemetic and potentiates Demerol
Norc~(HydrocodonelOmg + Acetaminophen 325mg)-1 tab PO q4-6h
PRN pain, not to exceed 6 tabslday
Panlor DC(Acetaminophen 356.4mg + Caffeine 30mg +
Dihydrocodeine Bitartrate 16mg)-1 tab q4-6h PRN pain, no more than
lolday, Clll
Panlor SS(~cetamino~hen
712.8mg + Caffeine 60mg +
Dihydrocodeine Bitartrate 32mg)-1 tab q4-6h PRN pain, no more than
Slday, Clll
Pe~~~~et(Oxycodone/~cetaminophen
2.5mg/325mg, 5mg/325mg,
7.5mg/500mg, 10mgl650mg)-1 tab PO q6h, CII
Percodan(0xycodone 5mg + ASA 325mg)-1 tab PO q6h, CII
Soma Compounds with Codeine(~arisoprodol200mg+ ASA
325mg + Codeine 16mg)-1-2 tabs PO qid, Clll
Ta~aCe~(~entazocine/~cetarninophen
251650)-1 tab PO q4h, CIV
Talwin C ~ m p ~ ~ n d ( ~ e n t a z o12.5mg
c i n e + ASA 325mg)-2 tabs PO
tidlqid, CIV
Talwin NX(~entazocine50mg + Naloxone 0.5mg)-1 tab PO q3-4h
-does not produce euphoria, agonist to both Mu and Kappa
receptors
-if combined with antihistamines produces euphoria, so
tablets contain .5mg Naloxone to reduce abuse potential
Tylenol with Codeine
Tylenol #l(Acetaminophen 300mg + Codeine 7.5mg) -1-2 tabs PO q4h.

Tylenol #2(Acetaminophen 300mg + Codeine 15mg) -1-2 tabs PO q4h.
Tylenol #3(Acetaminophen 300mg + Codeine 30mg) -1-2 tabs PO q4h.
Tylenol #4(Acetaminophen300mg + Codeine 60mg) -1-2 tabs PO q4h.
Peds Elixir(Acetaminophen 120mg + Codeine 12mg15ml)-3-6yrs:5ml(l
tsp) q3-4 day; 7-12yrs: lOmI(2 tsp) q3-4 day, CV
Tyl~~(~xycodo
5mg
n e + Acetaminophen 500mg)-1 tab PO q6h, CII
UltraCet(Tramadol + Acetaminophen) -2 tabs PO q4-6h
V i ~ ~ d i n ( ~ y d r o c o d o n e / ~ c e t a m i n o51500)-1-2
phen
tabs PO q4-6h, Clll
V i c o d i n ES(~ydrocodone/~cetaminophen
7.5/750)-1 tab PO q4-6h, Clll
PHARMACOLOGY
37
CHAPTER 2
V i c o d i n HP(~ydrocodone1Acetaminophen101660)-1 tab PO q4-6h, Clll

Vicopr~fen(~ydrocodone/lbuprofen
7.51200)-1 tab PO q4-6h, CHI
W ~ g e ~ ~ ~ ( ~ r o p o x ~ p h e n e 1 A c e t a m 651650mg)-1
i n o ~ h e n tab PO q4h, CIV
~~d~ne(~ydrocodone/~cetamino
51400,
p h e n7.51400, 101400)-1 tab
PO q4-6h, Clll
NONNARCOTIC ANALGESICS
Acetaminophen(TylenoI, Panadol, Tempra)-65Omg POIPR q4h.
Peds 15mg/kg/dose. [chewable tabs 80, tabs 160, 325, 500, suppositories 120, 325, 650, elixir 160mg/5ml, drops 80mg10.8ml dropperful]
-has analgesic and antipyretic properties but no
anti-inflammatory action
A s c r i p t i n ( A S A 325mg + MgIAI Hydroxide buffers)-2 tabs PO q4h.
Anacin(ASAfCaffeine 400132)-1-2 tabs PO q4h
E~gi~(~cetaminophen/Butalbital/Caffeine
325150140mg)-1-2 tabs PO
q4h.
Fi~ri~et(Acetarninophenl~utalbitall~affeine
325150140mg)-1-2 tabs PO
q4h.
Fiorinal(ASN~utalbital/Caffeine325150140mg)-1-2 tabs PO q4h.
Methotrimeprazine(~evoprome)-lo-2omg
q4-6h IM
Phenazopyridine(~yridium)-200mg
PO tid x 2 days. [loo, 2001
Used most commonly for urinary tract pain(from Sx or infection)
N ~ r g e ~ i ~ ( O r p h e n a d r i n e l A ~ ~ / ~ 501385130mg)-1-2
affeine
PO tidlqid.
R o b a x i ~ a l ( ~ e t h o c a r b a m400mg
ol
+ ASA 325mg)-2 tabs PO qid.
Soma C ~ m p ~ u ~ d ( ~ a r i s o p r2001325rng)-1-2
o d o ~ l ~ ~ ~tabs PO qid.
Tramadol(~1tram)-50-1oomg
PO q4-6h, max 400mglday. [50]
PHARMACOLOGY
38
CHAPTER 2
NSAlDs
-action: anti-inflammatory, antipyretic, analgesia
-blocks production of prostaglandins by inhibiting cyclo-oxygenase
-ASA-irreversibly inhibits cyclo-oxygenase all other NSAID's reversibly
inhibit cyclo-oxygenase
-major side affect is increased bleeding tendency, contraindicated in
patients with stomach ulcers
-may be taken with food to reduce GI irritation
-may precipitate asthmatic attack by diverting the arachidonic acid pathway to produce bronchoconstrictor mediators(leukotrienes)
ARACHIDONIC AClD CASCADE

PHOSPHOLIPID
NSAIDS block
Steroids block
ARACHIDONIC ACID
-1ipoxygenase
cyclooxygenase'
(COX- 1, COX-2)
LEUKOTRIENES
-ana h laxsis/allergic
res gnle
-br8nchoconstriction
PROSTAGLANDINS
-1nf1ammatoryresponse
-increases ain sensitwit
-pyrogenlc&duce,s fevery
-pr.otect stomach(~ncreaseb~carb& mucin levels)
-stlmulates uterine contractions
-maintain patency of ductus arteriosus
THROMBOXANES,
-platelet a gregatlon
-platelet r8eaae
-a vasoconstr~ctor
,
- -------------- --
---
'There are two distinct isoforms of the Cycloox enase enzyme(C0X-1

and COX-2 both catalyze the same react~on.%x-1 is required for
synthesis 01prostaglandins involved in physiolog~cprocesses stomach
protection, b ood clotting). COX-2 is triggered in response to \issue
st~mulationin'ury, inflammatory stimuli and other forms of cellular stress.
are aimed at block~ngonly COX-2.
Newer N S A I ~ S S
PHARMACOLOGY
39
CHAPTER 2
Aspirin(6ayer, Ecotrin, Empirin)-analgesia-325mg-lgqd, antiinflammatory-3-6g(9-18 325mg tabs) qd [tabs 81, 325, 500, 650, 975, supp
120, 200, 300, 6001
-prolongs bleeding time(irreversib1y inhibits cyclooxygenase)
-increased incident of Reye's syndrome in children when used
for febrile viral infections
-drug of choice for RA
-contraindications: gout(inhibits excretion of uric acid),
asthmatic, and patients taking Coumadin
Choline magnesium trisalicylate(~rilisate)-1-1.59
BID
-Salicylic acid derivative
Diclofenac(voltaren, Cataflam)-50mg PO bidltid. [25, 50, 751
(Arthrotec)-50mg or 75mg bidltid. [501200, 7512001
-Arthrotec tablets are combined with 200pg Misoprostol which
is a GI protector making it safer for patients with sensative
stomachs
Diflunisal(~olobid)-1000mg
initially, then 500mg PO bid. [250, 5001
-very low incidence of GI irritation
-very little antipyretic activity
Et0d0la~(~odine)-200-400mg
PO tidlqid. [200, 3001
Fen0pr0fen(~alfon)-200-600mgPO tidlqid. [ ~ o o300,
,
6001
Flurbiprofen(~nsaid)-200-300mglday
PO divided bidltidlqid. [50, 1001
I b u p r o f e n ( ~ o t r i nAdvil,
,
Nuprin, Rufen, Midol 200, Medipren)-300800mg PO qid. A minimum of 1,800mg and a maximum dose of
2,400mg qd is best for inflammatory conditions [ZOO, 300, 400, 600,
8001. Pediatric formulation(Children's Motrin)-5-lOmg1kgPO q6h.
[ I 00mg/5ml]
Indomethacin(lndocin)-25-50mgtid. [tabs 25, 50, supp 50, susp
25mgI5mll. lndocin SR-75mg PO qdlbid. [75]
-often used to treat inflammation caused by gout
Ketoprofen(0rudis)-50-75mg PO tid. [25, 50, 751. Sustained
release(0ruvail)-200mg PO qd. [200]
Ketorolac Tromethamine(~oradol)-30mg
IVIIM q6h. First IM
dose may be 60mg. 1Omg PO q4-6h. [ l o ]
-indicated for short term(less than 5 days) management of
mederatelsevere post-op pain when opioid level analgesia is
desired
Meclofenamate(~eclomen)-5omg
PO tidlqid. [50, 1001
Mefenamic acid(~onste1)-250mgPO qid. [250]
Nab~met0ne(~e1afen)-1000-2000ms/day
PO divided qdhid. [500, 7501
PHARMACOLOGY
40
CHAPTER 2
Naproxen(~aprosyn,Aleve, Anaprox)-250-500mgPO bid. [200, 250,

375, 500, susp 125 mg/5ml]. Naproxen sodium(Anaprox)-275-550mg
PO bid. [275, 5501. Delayed release(EC-Naprosyn)-375-500mgPO bid.
[375, 5001
Oxaprozin(~aypro)-i2oomg
PO qd. [600]
Piroxicarn(~e~dene)-20mg
PO qd. [I 0, 201
-advantage of qd dosing
Salsalate(~alflex,Disalcid)-3000mg/day in divided doses
S ~ l i n d a ~ ( ~ 1 i n o r i 1 ) - 1 5 0 - 2 PO
00m
bid.
g [150, 2001
-very low incidence of GI irritation
ToImetin(~olectin)-200-600mg
PO tid. [200, 400, 6001
-only NSAlD besides ASA that is approved for children
TriIisate(sa~icy~ate
combination)-1 tab PO q4-8h. [tabs 500, 750,
1000, liquid 500mg/5ml]
NSAID'S COX-2 INHIBITORS

R ~ f e ~ ~ ~ i b ( ~ i o x x ) - ~ s t e o a 12.5-25mg
r t h r i t i s qd, for pain 50mg
qd[l2.5, 25mg, susp 12.5mg/5mL, 25mg/5mL]
-not contraindiated in patients with stomach problems or
patients on anticoagulants
Celecoxib(celebrex)-OA: 200mg PO QD or 100mg PO BID. RA:
100-200mg BID [ I OOmg, 200mgl
-not contraindicated in patients with stomach problems or
patients on anticoagulants
-contraindicatedin patients that are allergic to sulfa drugs
V a l d e c o ~ i b ( ~ e x t r a ) - O&ARA:lOmg PO QD. Primary dysmenorrhea:
20mg PO BID [lomg, 20mgl
-contraindicatedin patients that are allergic to sulfa drugs
OTHER ANTIINFLAMMATORIES
Hydrochloroquine(~1a~ueni1)-3io-465mg1day
PO initially, may
increase after 5-10 days until optimal effect, then decrease dose to 50%
to maintenance dose of 155-310mg
-used to treat malaria, severe RA, and SLE
-mechanism unknown
Gold Sodium Thiomalate(~yochrysine)-10mgIM test dose, then
25mg first week, then 50mg weekly for 14-20 doses; if improvement,
then 50mg q2 weeks for 4 doses, then q3 weeks for 4 doses, then
monthly as maintainence dose
-mechanism unknown, retards destruction of bone and joint
-used to treat progressive RA
-side effects: GI disturbances, thrombocytopenia, dermatitis
PHARMACOLOGY
41
CHAPTER 2
ANTICOAGULANTS
Heparin
Full dose(treatment for DVT)
IV ADMINISTRATION
-get baseline PTT
-5,000-10,000~IV bolus, then 750-1,500uIhr IV
-monitor PTT q8h(maintain PTT at 1%-2 above control)
SubQ ADMINISTRATION
-get baseline P l 7
-5,000~IV bolus and 10,000-20,000~subQ, then 8,000-10,000~
subQ q8h or 15,000-20,000~subQ BID
-monitor PTT q8h(maintain PTT at 1%-2 above control)
Mini dose(prophylaxis for DVT)
-5,000~subQ bid
-surgical patients-give 1 hour pre-op followed by bid dose until
ambulatory
Warfarin(Coumadin, Panwarfin)
loading dose lOmg PO qd x2-4 days
maintenance dose 2-7.5mg PO qd
maintain PT about 2-2.5 times normal
treat 1st DVT episode for 3 months
-Coumadin requires 16-48hrs to cause a measurable change in the PT,
therefore begin Tx 2 days before discontinuing Heparin
OTHER HEMATOLOGICAL AGENTS

Pentoxifylline(~rental)-400mg
TID with meals [400]
-decreases blood viscosity by increasing flexibility of RBCs
-indicated in intermittent claudication related to chronic
occlusive vascular disease
-therapeutic response may take 2-4 weeks
C i l ~ ~ t a Z ~ l ( ~ l e tOOmg
al)-1
po bid [ I OOmg]
-indicated in intermittent claudication
-works by causing vasodilation increasing circulation to
the legs
PHARMACOLOGY
42
CHAPTER 2
THROMBOLYTIC AGENTS
-convert Plasminogen to Plasmin(the enzyme that dissolves
clots)
-not selective for breaking down good or bad clots and so can
cause bleeding(stroke)
-all are administered IV
-all are short acting
Streptokinase
-antigenic(foreign protein)
Urokinase
-natural enzyme found in endothelial cells
f PA(Altep1ace)
-tPA, tissue plasminogen activator
-natural enzyme found in endothelial cells
-shortest 1/2 life
APSAC(~ntistrep~ase)
-antigenic(foreign protein)
-longest % life
TOPICAL ANTIMICROBIALS
B a c i t r a c i n ( ~ o l ~ s ~ o Neosporin,
rin,
Campho-Phenique)
-topically QD-TID
-active against G+(including Erythrasma) and some G-may cause superinfection of fungus
Chloramphenicol(~hloromycetin)
-topically TID-QID
-active against G+ and G- anaerobes
-systemically-Grey Baby Syndrome
-cream 1%
Erythromycin(~rycette)
-topically BID
-active against most aerobic and anaerobic G+ and a few G-not active against Pseudomonas
M~pirocin(Bactroban)
-topically TID
-2% creamlointment
-good Staph. aureus coverage most notably impetigo
N e o m y c i n ( ~ e o s p o r i n ,Polysporin)
-active against many aerobic G- and some G+
P o l y m y x i n ( ~ o l y s p o r i nNeosporin)
,
-active against many G-, inactive against G+
PHARMACOLOGY
43
CHAPTER 2
ANTIBIOTICS
-all abx can decrease activity of BCP's
Aminoalvcosides
-used for G(-) and pseudomonas
-poorly absorbed orally
-nephrotoxic and ototoxic
-require oxygen for uptake into bacteria therefore they do not
kill anaerobes
-infuse IV over 30-60 minutes to avoid neuromuscular blockage
-necessary to monitor serum conc.(Peaks & Trough)
-peaks-taken 60 minutes after an IM injection or 30 minutes
after the end of a 30 minute IV infusion
-troughs-taken 30 minutes before dose infused
-adjust dosage based on peaks, adjust intervals based on
troughs
Amikacin(~mikin)-15mgIkg
up to 1,500mglday IMIIV divided q8-12h.
Peak 20-35mcglm1, trough mcglml. Alternative 15mglkg IV q24h
-use for organisms resistant to other aminoglycosides
GentamiCirl(Garamycin)-Adults: 3-5mglkglday lMllV divided q8h.
Peak 5-lOmcg/ml, trough <2mcg/ml. Alternatively 5-7mglkg IV q24h.
Peds: 2-2.5mglkg q8h
S t r e p t o m y c i n - i s r n g l k g up to l g IM qd. Peds: 20-40mgIkg up to l g
IM qd. Adultslpeds: 25-30mglkg up to 1.5mg IM 2-3 timeslwk
-limited use due to resistance
-use to treat plague, tularemia, and TB
T o b r a m y c i n ( ~ e b c i n T0BI)-Adults:
,
3-5mglkglday IMIIV divided q8h.
Peak 5-10-mcg/ml,trough <2mcg/ml. Alternatively 5-7mglkg IV q24h.
Peds: 2-2.5mglkg q8h. TOBl for Cystic Fibrosis: 300mg neb bid 28days,
then stop for 28days.
KanamyCin(~antrex)-15mg/kg/dayIVIIM divided q8-12h. l g PO q4h
-usually limited to topical or oral use due to toxicity
-used for irrigation
Ne0my~itl(~ycifradin)-300mg
IM q6h. l g PO q4h. (tab 500, solution
125mgl5ml)
-usually limited to topical or oral use due to toxicity
-commonly found in topical antibiotics
Spectin~mycin(~robicin)-2g
IM single dose for gonorrhea. Peds
40mglkg
PHARMACOLOGY
44
CHAPTER 2
Antiprotozoal
P e n t a m i d i n e ( ~ e b u ~ e nPentam
t,
300)-4mglkg IV over 1-2h qd for
14-21d; monitor glucose
-Tx of pneumonia due to Pneumocystic carinii
Carbapenam
-may be used as drug choice in severellimb threatening
diabetic
-broadest spectrum abx(covers G(+), G(-) including
Pseudomonas and anaerobes)
-not effective against MRSA
-extremely potentlvery expensive abx
-cilastatin prevents renal inactivation of lmipenem
-cross sensitivity with PCN
-only antibiotic that can be used alone in a diabetic foot
infection
Ertapenem(1nvanz)-1g IVIIM q24h
Imi penem/Cilastatin(~rimaxin)-250-1000mg IV/IM q6-8h
Meropenem(~errem
IV)-lg IV qsh. Peds: 20-40 mg/kg up to 29 IV
q8h
Cephalosporins
-5-10% of pt's allergic to PCN are allergic to Ceph's
-not effective for MRSA or enterococci
1ST GENERATION
-good against most G(+)
-limited G(-) coverage-PECK(Proteus mirabilis, E. coli,
Klebsiella pneumonia)
-Enterococcus and Pseudomonas are resistant
C e f a d r o x i l ( ~ u r i c e f Ultracef)-1-2glday
,
divided qdlbid. Ped
30mg/kg/day divided bid. [tab 500, 1000, susp 125, 250, 500mg/5ml]
C e f a z o l i n ( ~ n c e f ,~efzo1)-0.5-2gIMIIV q6-8h. Ped 25-ioomg~kg~day
divided q6-8h
-Most common Ceph. for Sx. prophylaxis
Cephalexin
Keflex(Cepha1exin monohydrate)-250-500mg PO qid. Peds
25-100mglkg/day divided qid. [caps 250, 500, liq. 125 & 250
mg/5ml]
Keftab(Cepha1exinhydrochloride)-500mg bid [500]
PHARMACOLOGY
45
CHAPTER 2
Cephalothin(~eflin)-0.5-29
IVIIM q4-6h
Cephapirin(cefadYl)-0.5-2g
IVIIM q4-6h
Cephradine(ve1osef)-lg IMIlV q6h. 1-2glday PO divided bidlqid.
Peds 75-100mgIkglday divided bidlqid. [tabs 250, 500, susp 125 & 250
mg/5ml]
2ND GENERATION
-extended G(-) coverage compared to 1st gen. Cephs
-G(-) coverage-HENPECK( H. flu, Enterobacter, Neisseria,
PECK)
Cefa~10r(ceclor)-250mgPO tid. Peds 20-4-mglkglday divided tid.
[tabs 250, 500, elixir 125, 187, 250, & 350mg/5ml]
Cefamandole(~ando~)-0.5-1s
IMIIV q4-ah. Peds 50-100mg/kg/day
divided q4-8h. Clotting impairment
Cefmetazole(zefazone)-2gIV q6-12h
Cefonicid(~onicid)-0.5-2s
IMIIV q12-24h
Ceforanide(~recef)-0.5-1s
IMIlV q12h. Peds 20-40mglkglday
divided q12h
Cefotetan(cef0tan)-1-29 IMIIV q12h
Cefoxitin(Mefoxin)-1-29 IMIIV q6-8h
C e f p ~ d ~ ~ i n e ( ~ a n t i n ) - 1 0 0 - 4 0PO
0 mbid.
g PedslOmglkgIday divided
bid [tabs 100,200, susp 50 & 100mg/5ml]
Cefpr~Zil(Cefzil)-250-500mgPO qd or divided bid [tabs 250, 500,
susp 125 & 250mg/5ml]
C e f u r o x i m e ( ~ i n a c e f Ceftin)-750-1500mg
,
IV q8h. 250-500mg PO
bid. [125, 250, 5001 Peds 50-100mg/kglday IV divided q6-ah,
meningitis 200-240mglkglday
L0racarbef(Lorabid)-200-400m~PO bid. Peds 15-30mglkglday
divided bid. [tabs 200, susp 100mg/5ml]
3RD GENERATION
-somewhat reduced activity against G+, but greater G(-)
coverage including Pseudomonas
Cefdinir(0mnicef)-14mglkglday up to 600mglday PO divided qdlbid.
[300mg,
susp 125mgl5ml]
Cefditoren(Spectracef)-200-400mg PO bid with food [200mg]
Cefixime(Suprax)-400mg PO qd or 200mg bid. Peds 8mglkglday
divided qdlbid. [200, 400, susp 100mg/5ml]
PHARMACOLOGY
46
CHAPTER 2
Cefoperazone(~efobid)-2-4s
IV q12h. Clotting impairment
Cefotaxirne(c~aforan)-1-29
IV q4-8h. Peds 50-100mg/kg/day divided
q4-6h IV. Meningitis may require higher doses
Cefpodoxi~e(~antin)-100-400mg
PO bid. Peds: 1Omg/kg/day divided bid [loo, 200mg, susp 50, 100mg/5ml]
C e f t a z i d i r n e ( ~ o r t a zFortaz,
,
Tazidime, Tazicef)-lg IMIIV or 29 IV q812h. Peds: 30-50mg/kg IV q8h
-good Pseudomonas coverage
-does not kill anaerobes
Cefti~oxime(cefizox)-1-2g
IV q8-12h. Peds 50mglkglday IV q6-8h
-good anaerobic coverage
Ceftriaxone(~oce~hin)-1-2~
IVllM q24h. Gonorrhea single dose
250mg IM. Peds 50-75mg/kg/day(max 29) divided q12-24h
-one of the more popular 3rd generations due to its long half
life (qd)
-does not kill anaerobes
M~xalactarn(~amoxactam
Latamoxef,
,
Moxam)-24glday divided q8h
4TH GENERATION
-increased activity over 3rd gen Cephs. to
Enterobacteriaceae, and Pseudomonas
Cefepime(~axipime)-I-2gIMIIV q12h
C e f p i r o m e - I -29 IV q12h
G(+),
Quinolones
-have been known to cause tendon rupture, specifically
Achilles tendon rupture
C i p r o f l o x a c i n ( c i p r o , Ci1oxan)-200-400mgIV q12h. 250-75omg PO
bid. [250, 500, 7501

-good G(-) and Pseudomonas coverage
-contraindicated in children(carti1age degeneration)
-caution in asthmatics(can increase Theophylline)
-combine with Clindamycin or Metronidazole to Tx diabetic
foot infections
Enoxacin(~enetrex)-200-400mgPO bid [200, 4001
L e ~ 0 f ~ 0 ~ a ~ ~ n ( ~ e v a ~ u i n ) - 5 0 0POIIV
- 7 5 0qd[250mg,
mg
500mg, 750mgl
-a good substitute for Cipro
-better Staph/Strep coverage that Cipro
PHARMACOLOGY
47
CHAPTER 2
L0mef~oxa~in(Maxa~uin)-400mg
PO qd
Moxifloxacin(~velox)-400mg
PO qd I4001
N o r f l o x a c i n ( ~ o r o x i n )400mg PO bid [400]
Ofloxacin(~loxin)-200-400mg
IV q12h, each dose over 1h 200400mg PO bid [200, 300, 4001
Macrolides
Azithromycin(zithromax, Z-pak)-500mg PO first day, then 250mg
PO qd x 4 days. lOOOmg PO single dose for Chlamydia. 500mg IV qd.
C l a r i t h r o m y c i n ( ~ i a x i nBiaxin
,
XL)-250-500mg PO bid. 7.5mglkg
PO bid. Biaxin XL: 1000mg PO qd with food [250, 5001
Erythromycin
-good G(+) coverage
-used in PCN allergic patients
-better absorbed on an empty stomach(inactivated by
stomach acid)
a) Erythromycin Base(ERYC, E-mycin)-250-500mgPO qid, 333mg PO tid,
or 500mg PO bid [250,333,500]
b) Erythromycin Estolate(llosone)-Peds 30-50mglkgldayPO divided tidlqid
[tabs 250, 500, elixir 125 & 250mg/5ml] Peds only hepatotoxicity in adults
-a pro-drug, more resistant to stomach acids
c) Erythromycin Ethylsuccinate(EES, Eryped)400mg PO qid peds 3050mglkglday divided qid [tabs 200, 400, elixir 200 & 400mg/5ml]
d) Erythromycin Lactobionate(Erythrocin IV)-15-20mg/kglday(max 49) IV
divided q6h
e) Erythromycin Stearate(Eramycin)-250-500mgPO qid
Dirithromycin(Dynabac)-500mgPO qd with food [250]
Monobactam
Aztreonam(~zactarn)-0.5-2mg
lMllV q6-12h
-No cross reactivity with PCN or Cephs
-good G(-) and Pseudomonas coverage
P e n i c i l l i n s ( 1 s GENERATION
~
)
-narrow spectrum
-good G(+) coverage
-used mainly for strep.
PHARMACOLOGY
48
CHAPTER 2
Penicillin G-12-24 million unitsld IV divided q4-6h. Procaine(Wycillion)0.6-1.2million units IM, duration 24h. Benzathine(Bicillin L-A) 1.2 million
units IM, duration 2-4weeks. Bicillin CR-combination of procaine and benzathine in mixes 1501150, 3001300, 6001600, 3001900
-not effective orally
Penicillin V(Pen-vee K, Veetids)-250-500mg PO qid. Peds 2550mglkglday divided qid. [125, 250, 500, elixir 125 & 250mg/5ml]
-oral form of Pen G
Penicillins: Pencillinase-Resistant(2ndGENERATION)
-narrow spectrum
-not susceptible to P-lactamases(penicillinases)
C l o x a c i l l i n ( ~ l o x a p e n ,Tegopen)-250-500mgPO qid. [250, 500, liq
125 rngl5mll
Dicloxacillin(~ynapen)-125-500mg
PO qid. Peds 12-25mglkglday
divided qid. [tabs 125, 250, 500, elixir 62.5mgI5mll
Methi~illin(~taphci11in)-l-2g
IMIIV q4-6h
Nafcillin(Nafcil, Unipen)-1-2g lMllV q4h. 250-500mg PO q4-6h. Peds
50mg/kglday, divided q4-6h. [250, 500, susp 250mg/5ml]
O x a c i l l i n - l a g IVIlM q4h. 500rng PO q4-6h. [tabs 250,500, susp
250mgl5ml]
Penicillins:
A m i n o p e n i c i l l i n s ( 3 GENERATION
~~
)
-wider spectrum than Pen G
-active against anaerobes
A m o x i c i l l i n ( ~ m o x i l Polymox,
,
Trimox)-250-500mg PO tid. Peds
4Ornglkglday divided tid [tabs 125, 250, 500, elixir 125 & 250 mgI5rnll
-used pre-op to prophylax against endocarditis
~moxici~~in/~~avulanate(~ugmentin)-250-500mg
PO tid, or
875mg bid. Peds 40mglkglday divided tid [tabs 125, 250, 500, 875
elixir 125 & 250mg/5ml]
-good oral abx for dog and cat bites
A m p i c i l l i n ( ~ r i n c i p e n Omnipen)-1-29
,
IMIIV q4-6h. 250-500mg PO
qid. Peds 50-200mglkglday divided qid. [250, 500, elixir 125 &
250mg/5ml]
Ampicillin/Sulbactam(unasyn)-1.5-39IV q6h
-addition of Sulbactam enhances resistance to P-lactamase
PHARMACOLOGY
49
CHAPTER 2
Penicillins:
E x t e n d e d - S p e c t r u m ( 4 ~GENERATION
~
)
-aka Anti-Pseudomonal penicillins
-Greater activity against G(-) including Pseudomonas, and
anaerobes
Carbenicillin(Geocillin)-382-376mg PO qid
Mezlocillin(~ezlin)-3-4s
IVIIM q4-6h
Piperacillin(~ipraci1)-3-49
IVIIM q4-6h
Piperacillinfrazobactam(zosyn)-3.375sIV q4-6h
-Tazobactam is a p-lactamase inhibitor
T i c a r c i l l i n ( ~ i c a r ) - 3 - 4 IVllM
s
Q3-6H. Peds 200-300mglkglday divided
-clavulanic acid inactivates the p-kctamase enzyme
Sulfonamides
-broad spectrum G(+) and many G(-)
-commonlv used for UTls and nocardiosis
-sulfonamides are structurally similar to p-aminobensoic acid
and compete for the dihydropteroate synthetase enzyme in
the folic acid metabolic cycle of bacteria
C O - t r i m ~ ~ a ~ ~ l e ( ~ a Septra,
c t r i mCotrin,
,
Sulfatrin) Trimethoprimlsulfamethoxazole-5mglkg IV q6h. One tab PO bid, single strength (801400) or
DS(1601800). Peds 5ml elixir per 10kg per dose PO bid. (401200per 5ml)
-trimethoprim inhibits dihydrofolate reductase and when used
with sulfonamides there is a sequential blockage of the folic
acid metabolic cycle
S u l f a ~ e t a m i d e ( ~ k - s u l fBleph
a,
10, Cetamide, Ocu-Sul)-1 drop
ql-6h [lo, 15, 30%]-used to treat ocular infections
Sulfadiazine-500-looomg P o qid
-Sliver sulfadiazine(Silvadene, SSD)-topical antimicrobial used
qd-bid, commonly used for 2nd and 3rd degree burns
Sulfamethizole-500-1000mg
tid to qid
Sulfamethoxazole(~antanol)-1
OOOmg PO tid. [500, susp
500mg/5ml]
Sulfa~alazine(~zuIfidine)-3-4glday
divided tid-qid. Peds 406Omglkglday divided into 3-6 doses
~ ~ ~ f i ~ o ~ a ~ o ~ e ( G a n t r i s i n ) - 5 0 0 -PO
1 0 0qid
0 r n[500,
g syrup
PHARMACOLOGY
50
CHAPTER 2
Tetracyclines
1st choice drug for
-because of resistance and toxicity
relatively few infections including rickettsia, M. pneumoniae,
chlamydia
-take on empty stomach, some foods specifically dairy
products and antacids impair absorption
-contraindicatedduring pregnancy, infancy, and childhood up
to age 8 years due to permanent staining of teeth(yellow,
gray, or brown)
~ernec~ocyc~ine(~eclorn~cin)-150mg
PO qid or 300mg bid. [150,
3001
D o x y ~ y ~ l i n e ( ~ i b r a m ~Monodox)-200mg
cin,
IVIPO initially, then 50lOOmg q12h [tabs 50,100, syrup 25 & 50 mg/5ml]
Methacycline(~ondomycin)-150mgPO qid or 300mg bid. [ I 50, 3001
M i n o c y c I i n e ( ~ i n o c i n Dynacin)POOmg
,
IVIPO initially then loomg
q12h. [tabs 50, 100, susp 50mgl5ml]
Oxytetracycline(~erram~cin)-250-50omg
PO qid [250]
Tetracycline(Achromycin,Tetracyn, Sumycin) 250-500mg POIIVIIM
qid. 1250, 500, susp 125mg/5ml]
-used for Lyme's dz, Rocky Mountain Spotted Fever, and
H. pylori
-contraindicatedin pregnanvnursing women-brown teeth
Miscellaneous
ChloramphenicoI(ch1oromycetin)-50-1oomg1kg/day IVIPO divided
q6h. 50-100mglkglday for pediatric meningitis. [250, syrup 150mg/5ml]
-good G(-) coverage including anaerobes
-side affects-Gray Baby Syndrome, bone marrow
suppression(aplasticanemia)
-due to its many side effects chloramphenicol is not usually a
first choice antibiotic
Clindamycin(cieocin, Dalacin C)-300-900mg IV q6h. 150-450mg
PO qid. Peds 8-40mglkglday divided qid.
-use in PCN allergic
-side affects-Pseudomembranouscolitis (superinfection
of Clostridium)
PHARMACOLOGY
51
CHAPTER 2
Dapsone-50-loomg PO qd [25, l o o ]
-drug of choice for Leprosy
M e t r ~ n i d a ~ ~ l e ( ~ l a g y l ) -lLgoora d15mglkg IV, maintenance 500mg
or 7.5mglkg q6h, each dose over 1H. 250-750mg PO qid.
-contraindicated during pregnancy-teratogenic potential
-drug of choice for to Tx Pseudomembranous colitis
Nitrofuranfoin(~uradantin,
Macrodantin, Macrobid)-50-100mg divided q6h. Peds 5-7mglkglday divided q6h
Rifampin(flimactane, Rifadin, Rofact)-Meningococcalcarriers: 1020mglkg up to 600mg PO qd for 4 days [150, 3001
-good G(+), Legionella, and TB coverage
-an anti-TB agent
-stains body fluids(tears, sputum, sweat, urine) red-orange
-rarely used alone-resistance develops rapidly
-penetrates bone
Spectinomycin(~robicin)-IM
29, Peds 40mglkg
Vancomycin(vancocin, Vancoled)-500mg IV q6h each dose over 1H
500mg PO qid. Peds 40mglkglday. For prophylaxis during implant Sx
dosage is l g m over 60-90 minutes. [ I 25, 2501
-good G(+) and MRSA coverage
-use in PCN allergic
-Infuse slowly to prevent "Red Man Syndrome"
-only used orally to Tx Pseudomembranous colitis
-best drug for implant Sx because it covers Staphyloroccus
epidermis
Linezolid(~r/ox)-400-600mgPOIIV BID. Infuse over 30-120 minutes
[400, 6001
-oxaziolidinoneclass antibiotic
-indicated for Vancomycin Resistant Enterococcus faecium
-can cause thrombocytopenia
Quinupristin and Dalfopristin(synercid)-150/350(Synercid)7.5mglkg q8h
-Indicated for VRE
TOPICAL CORTICOSTEROIDS
Side effects:
Striae, Atrophy, Acne, Rosacea, Periorbital dermatitis,

Pigmentation abnormalites, Glaucoma,
Systemic absorption
PHARMACOLOGY
52
CHAPTER 2
TOPICAL CORTICOSTEROIDS
w
ll Cyclocort
Diprdene AF
Elocon
Florone
Halog
Lidex
Amcinonide
Beiami?Ihasonediprophae
Mometasone furoate
Diflorasone diacetate
Halcinonide
Fluocinonide
Lidex-E
Fluocinonide
gel, 0.05%
15% 509
ointment, 0.1%
cream, 0.0556
ointment, 0.1 %
ointment, 0.05%
cream, 0.1%
cream, 0.05%
gel, 0.05%
15g,30g,60g
159,509
159, 459
159, 309, 60g
159, 3Og,6Og,24Og
159, 309, 609, 1209
cream, 0.25%
gel, 0.05%
ointment, 0.25%
159, 60g, 1209

159,609
159, 60g
--
cream, 0.1%
lotion, 0.1%
ointment, 0.1%
solution, 0.1%
15~1,3Og,6Og
20ml, 60ml
159, 309, 60g, 2409
20m1,60ml
ointment, 2.5%
309
and Pramoxine HCL 1 % cream 2.5%

lotion, 1 .O%
lotion, 2.5%
ointment, 1.0%
ointment, 2.5%
30g,60g
2oz,4oz, 802
202, 402
309
309
~p~
PHARMACOLOGY
53
CHAPTER 2
GLUCOCORTICOSTEROIDS
Betamethasone(celestone)-0.5-9.omgIMIPO qd [0.6, 0.6mg/5ml]
C0rti~0ne(Cortone)-25-300mg PO qd [5, 10, 251
Dexamethasone(~ecadron)-0.75-9mgldayPOIIVIIM, divided q6h
[0.5, 0.75, 1.0, 1.5, 2, 4, 6, liq 0.5mg/5rnl],
-soft tissueljoint-inject -1-2 mlll~gramin the foot
H y d r o c o r t i s o n e ( c o r t e f , Solu-Cortef)-100-500mgIVIIM q2-6h PRN,
20-240mglday PO divided dose [5, 10, 20, susp lOmg/5ml]
Methylprednisolone-parenteral(~olu-~edrol)-l0-125mg
IVIIM.
oral(Medro1)-4-48mg PO qd, peds-1-2mglkg POIIVIIM [2, 4, 8, 16, 24,
321 (Medrol Dosepack)-starts at 24mg and reduced to Omg at the end of
7 days. IM/Joints(Depo-Medro1)-4-120mg
Prednisolone-5-6omg POllVIlM qd [5, liq 5, 15mgl5ml]
P r e d n i s o n e ( ~ e l t a s o n eOrasone,
,
Liquid Pred)-1-2mglkg or 5-60mg
PO qd [ I , 2.5, 5, 10, 20, 50, liq 5mg/5ml]. Tapering dose
packs(Sterapred Unipak)-5mg in a 21 tablet tapered dose dispensing
pack(Sterapred 12 day Unipak) -5mg in a 48 tablet 12 day tapered dose
dispensing pack
(Sterapred DS Unipak) -10mg in a 21 tablet tapered dose dispensing
pack(Sterapred DS 12 day Unipak) -1 Omg in a 48 tablet tapered dose
dispensing pack
T r i a m c i n o l o n e ( ~ e n a c o r t ,Kenalog-lo, Kenalog-40)-4-48mgPOIIM
qd [1, 2, 4, 8, syrup 4mg15mlI
( HYPOTHALAMIGPITUITARYNEGATIVE FEEDBACK
( -
Steroids exert a negative-feedback control over their own

secretion. Therefore, when
administering steroids the patient
must be weaned off of them to
prevent Addison's like symptoms.
ACTH
Effector Cells
53
PHARMACOLOGY
54
CHAPTER 2
CUSHING DISEASE
-Due to chronic exposure to excessive corticosteroids. Signs/symptoms
include: hyperglycemia, polycythemia, protein wasting, decreased cellular immunity, "moon" faces, "buffalo hump", increased Na+ and BP, and
decreased K+.
ADDISON'S DISEASE
-Due to decreased adrenocortical function. Signslsymptoms include:
hyperpigmentation, hypoglycemia, anemia, decreased Na+ and BP, and
increased K+.
INJECTABLE STEROIDS
-side affects are infrecluent but may include hy~opiamentation

of the skin
., . over the injection site and soft tiss6e atrophy
INTRAARTICULAR INJECTIONS
-amount injected is arbitrary, but as a general guideline
knee, ankle, and shoulder
20-40mg
wrist, elbow
10-20mg
small joints of the foot
5-15mg
-use caution with acetates, they leave a precipitate which can damage
the joint. lntraarticular acetate injections should be resewed for damaged joints(moderate to severe DJD)
-a local anesthetic can be mixed in a single syringe with the
glucocorticosteroids to promote immediate relief
-injectable glucocorticosteroids come in two forms:
Phosuhates
Acetates
-short acting
-long acting
-Hz0 soluble
-Hz0 insoluble(shake vial prior to use)
-injectable anywhere -shouldn't be injected in a jt, superficially,
-clear
or in an infection
-cloudy, forms a precipitate
Triamcinolone(~enalo~)
-an acetate
-Kenalog-1O(1Omglml), Kenalog-40(40mg/ml)
Betamethasone(celestone)
Celestone Phosphate
-a phosphate(3mglml)
-can be used anywhere
Celestone Soluspan
-an acetate and a phosphate
-(3mglml Betamethasone sodium phosphate and 3mg/ml
Betamethasone acetate)
D e x a m e t h a s o n e ( ~ e c a d r o n Dexon)
,
-prepared in both acetate or phosphate forms
-4-8mglml
PHARMACOLOGY
55
CHAPTER 2
TOPICAL ANESTHETICS
-produce only superficial anesthesia

-clinical use IS limited to some superficial laser procedures,
curettage of molluscum contagiosum, and numbing skin before injections
EMLA cream
-2.5% Lidocaine and 2.5% Prilocaine

-requires 1 hr application under occlusion
-most effective topical anesthetic for the skin
Cr oanesthesia(Ethyl chloride, tetrafluoroethane)
-&st acting, very short duration
-Ethyl chloride is flammable and should not be used for
electrosurgery
TAC(tetracaine, adrenaline, cocaine)
-the only topical anesthesia that causes vasoconstriction
-not effective on intact skin and it's main use is on mucous
membrane in dentistry
Topical Lidocaine(2% jelly, 2% viscous, 4% solution, 5% ointment,
10% spray)-indicated for use on mucosal surfaces
Topical Benzocaine(Hurricaine Spray, Cetacaine Spray)
-not effective on intact skin, used for painful skin abrations
INJECTABLE
LOCAL ANESTHETICS
N
-Lidocaine mav be mixed with sterile bicarbonate in a 1:10 dilution
decreasing the pain during injection by balancing the pH. Lidocaine/
bicarbonate mixtures are only good for 1-2 weeks with refrigeration and
so can't be prepared far in advance.
-local anesthetics effects are reduced in an infected area because bacteria cause a drop in pH. Local anesthetics are ineffective in an acid
environment
-systemic effects from local anesthetics may include: anxiety,
anaphylaxis, overdose toxicity, or allergic reaction
-Epinephrine mixed with local anesthesia(in a concentration of
1 :200,000-1:400,000) results in vasoconstriction resulting in:
1) decreases bleeding
2) reduces absorption of anesthesia, increasing duration of block
-the use of Marcaine in children under 12 years of age is contraindicted
due to it's effects in growth plates
-Diphenhydramine(Benadryl) may be used as a local anesthetic when
patients are allergic to both amines and esters. Not used much any
more because it occasionally causes skin necrosis
/ CONVERSION OF
TO MG \
STEP 1: Multiply the concentration(%) by 10

STEP 2: Change % to mg/cc
STEP 3: Multiply by the # of cc's injected
EXAMPLE: l0cc's of .25% Marcaine is how many mg?
.25% x 10 = 2.5mg/cc x 10cc
PHARMACOLOGY
56
CHAPTER 2
INJECTABLE LOCAL ANESTHETICS

--
GENERIC
T- ----^r--I BRAND NAME
I CONCENTRATION(%) POTENCY
MAXIMUM DOSE
L- 1 W/O EPI
---
W/ EPI
1
j
L
Y --I
-
PHARMACOLOGY
57
CHAPTER 2
GENERAL ANESTHESIA
Atropine
-from Belladona plant, used as beauty aid to dilate pupils
-decreases secretions(tears, saliva, sweat)
Fentanyl(~ublimaze)
-opioid
-used for induction of anesthesia
-has the advantage of no cardiac effects
Ketamine(~eta1ar)
-produces "dissociative anesthesia", patient cooperates but
with analgesia and amnesia
-often used with BDZ due to "emergence reaction", adverse
hallucinations
Midazolam(versed)
-shortest acting IV BDZ
Propofol(Diprivan)
-white IV liquid
-used to initiate and maintain anesthesia
Thiopental
-used for induction of anesthesia
-a barbiturate
-also used as an anticonvulsant
-does not raise intracranial pressure
-contraindicated in porphyria
Succinyl Choline
-blocks nicotinic receptors
-muscle relaxant used in anesthesia
-not attached by Ach-ase
-irriversable by drug
-short duration
-may cause fasciculations
Tubocurarine
-blocks nicotinic receptors
-muscle relaxant used in anesthesia
-not attached by Ach-ase
-reversible by Neostigmine(better due to lack of CNS
penetration) or Physostigmine
-longer duration
-does not cause fasciculations
-used by Indians for poison on their spears
PHARMACOLOGY
58
CHAPTER 2
Halothane(~luothane)
-used for induction and maintenance of general anesthesia
-an inhalation anesthesia
-hepatotoxic
lsoflurane
-decreases BP by vasodilation only, no cardiodepressant
activity
Methoxyflurane
Enflurane
-decreases BP by vasodilation and cardiodepression
-may cause seizures, especially if the patient has been
hyperventilated
Nitrous Oxide
-MAC is greater than 100%-not very potent
-least effects on cardiovascular system
-chronic exposure(denta1office staff) may lead to pernicious
anemia
DIURETICS
-water pills
-generally used for CHF, HTN, and edema
-their primary effect is excretion of salt from the body to
facilitate water loss
LOOP DIURETICS
-inhibits active NaCl resorption on the thick ascending limb of
the loop of Henle
-"high ceiling" diuretics-strong
may cause increased serum uric acid or hypokalemia
Burnetanide(~umex)-0.5-2mg1dayPO qd [0.5, 1, 21. 0.5-lmg IV/IM
Ethacrynic a~id(Edecrin)-25-l00m~
PO qd [25,501. 0.5-lmglkg up
to 50mg IV
~urosemide(~asix)-20-80mg
PO qdlbid [20, 40, 80, solution 10,
40mg/5ml]. 1 mg/kg up to 20-40mg IV
Torsemide(~emadex)-5-20mgPOIIV qd [5, l o , 20, loo]
PHARMACOLOGY
59
CHAPTER 2
POTASSIUM SPARING DIURETICS

-interferes with K+ secretion and Na+ resorption in the cortical
collecting tubules
-weak diuretic-usually used in combination with other diuretics
-may cause hyperkalemia, dietary K+ should be reduced
A m i l o r i d e ( ~ i d a m o r ) - 5 -0mg
1
PO qd [5]
Spir0n0~actone(~ldactone)-25-50mg
PO qdlbid [25, 50, loo]
Triamterene(Dyrenium)-5-20mg IVIPO qd [5, 10, 20, 1001
THlAZlDE DIURETICS
-inhibits active resorption of NaCl in ascending loop on Henle
and distal convoluted tubules resulting in excretion of Na+
and water
-may cause hypokalemia
Chlorothiazide(Diuril)-250-500mgPO qdlbid [250, 500, susp
250mg/5ml]
Chlorthalidone(~ygroton)-25-100mg
PO qd [15, 25, 50, loo]
Hydrochlorothiazide(~c~z,
Esidrix, HydroDIURIL, Oretic,
Microzide)-12.5-50mg PO qd [12.5, 25, 50, 100, solution 50mgl5ml]
Indapamide(~o~o1)-1.25-5mg
PO qd [I .25, 2.51
MethycIothiazide(~quatensen)-2.5-1Omg
PO qd
M e t o l a z o n e ( ~ i u l oMykrox,
,
Zaroxolyn)-5-20mg qd as extended tabs.
0.5-1mg as prompt tab. Zaroxolyn and Diulo are extended tablets,
Mykrox is a prompt tablet
ANTIDEPRESSANTS
Tricyclics
-function by increasing the levels of norepinephrine(NE)
andlor serotonin(5-HT) by reducing their reuptake in the
prejuctional nerve endings
-therapeutic response may take several weeks to develop
TERTIARY AMINES
A m i t r i p t y l i n e ( ~ l a v i 1Endep)-start
,
25-75mg po qhs, or 20-30mg IM
qhslbid. Average effective dose: depression 150-300mglday
peripheral neuropathy 10-1 00mgIday
Cl~mipramine(~nafranil)-start
25-75mg po qhs. Average effective
dose 150-250mg/day,maximum 250mglday [25, 50, 751
PHARMACOLOGY
60
CHAPTER 2
Doxepin(Adapin, Sinequan)-start 25-75mg po qhs. Average effective

dose 150-300mglday [lo, 25, 50, 75, 100, 150, liq lOmg/ml]
Imipramine(~ofranil,Janimine)-start 25-75mg po qhs. Average effective dose 150-300mglday [lo, 25, 501
Trimipramine(~urmontil)-start
25-75mg po qhs. Average effective
dose 150-300mglday [ I0, 25, 501
SECONDARY AMINES
De~ipramine(~orpramin)-start
25-75mg po qam or in divided doses.
Average effective dose 150-300mglday [lo, 25, 50, 75, 100, 1501
N o r t r i p t y l i n e ( ~ v e n t ~Pamelor)-start
l,
25-50mg po qhs. Average
effective dose 50-150mglday [lo, 25, 50, 75, solution 10mg/5ml]
ProtriptyIine(~ivacti~)-15mg
po qam. Average effective dose 156OmgIday
SEROTONIN R E U P T A K E INHIBITORS
FI~oxetine(~rozac)-start
20mg po qam, average effective dose 2040mglday, maximum 80mglday 110, 20, liq 20mg/5ml]
FIu~~xamine(~uvox)-start
50mg po qhs, average effective dose 100300mglday divided bid, maximum 300mglday. OCD in children 8-17yIo
start 25mg po qhs average effective dose 50-200mglday divided bid,
maximum 50mglday [25, 50 1001
Paroxetine(~axil)-start20mg po qd, average effective dose 2050mg/day, maximum 50mglday [lo, 20, 30, 401
SeTtraline(~oloft)-start
50mg po qd, average effective dose 50200mg/day, maximum 200mglday [25, 50 1001
ANTIPSYCHOTICS(NEUR0LEPTICS)
-side effects include Parkinsonian syndrome and Tardive dyskinesia
ChlOrpromazine(~horazine)-start
10-50mg POIIM bidltid, average
effective dose 300-800mglday [lo, 25, 50, 100, 200, supp 25, 100,
syrup 1Omg/5ml]
ClO~apine(~lozaril)-start
25mg PO qd [25, 1001, does not cause
Tardive dyskinesia, may cause agranulocytosis
Haloperidol(~aldol)-2-5mg
IVIIM, start 1-5mg PO tid, average effective dose 6-20mg/day, therapeutic window 2-15nglm1, drug of choice for
Tourette syndrome
Thorida~ine(~el~aril)-start
50-1Oomg PO tid, average effective dose
200-700mg/day, side effects include pigmentation in the retina and
atropine like symptoms
PHARMACOLOGY
61
CHAPTER 2
SEDATIVEIHYPNOTICS
BENZODIAZEPINES
-all are CIV
Alprazolarn(xanax)-0.25-0.5mgpo tid [0.25, 0.5, 1, 21 Short Half-life

Chl~rdiazep~~ide(~ibrium)-5-25mg
po tidlqid [5, 10, 251 Long half-life
-used to treat EtOH withdrawals
C ~ o n a z e p a m ( ~ l o n o ~ istart
n ) - 0.25mg bid and elevate to target dose
of 1 mg bid after 3 days, [0.5, 1, 21 Long half-life
-also used for absence seizures; start 0.5mg po tid, increase
0.5-1mg every 3 days until seizures are controlled, maximum 20mglday
Clora~epate(~ranxene)-7.5-15mg
po qhslbid [3.75, 7.5, 151Long halflife
Dia~epam(Valium)-2.5-5mg
increments IV up to 0.2mglkg. 2-10mg
po tidlqid [2, 5, 10, sol'n 5rng/5ml] Long half-life
-drug of choice for status epilepticus(raises convulsion
thresholds)
-used as a muscle relaxant in patients with CP
E s t a z O l a m ( ~ r o s o m ) -rng
1 po qhs [ I , 21 Medium half-life
FIurazepam(~almane)-15-30rng
po qhs [15, 301 Long half-life
-used for insomnia to sustain sleep
Hala~epam(Paxipam)-20-40mg
po tidlqid [20, 401 Long half-life
Lorazepam(Ativan)-0.5-2mg
IVIIMIPO q6-8h [0.5, 1, 21 Medium half-life
-also used as an anticonvulsant
M i d a Z ~ l a m ( ~ e r s e d ) - p r e 70-80mcglkg
op
IM 1hr before Sx. Induction
of anesthesia 150-350 rncglkg, give additional doses on increments of
25% of initial dose up to 600mcglkg
Oxazepam(Serax)-10-15mg po tidlqid [lo, 15, 301 Short Half-life
Prazepam(Centrax)-10mg po tid [5, 10, 201 Long half-life
Temazepam(~estoril)-15-30mg
po qhs [15, 301 Medium half-life
-used for insomnia to sustain sleep
Triaz0lam(Halcion)-0.125-0.5mg po qhs [0.125, 0.251 Short Half-life
-used for insomnia to initiate sleep
Quazepam(~roa1)-15mg
po qhs [7.5, 151 Long half-life
PHARMACOLOGY
62
CHAPTER 2
BARBITURATES
-no hypnotic(increasetendency to sleep) activity
Butabarbital(~utisol)-15-30mg
po tidlqid [15, 30, 50, 100, liq
30mg/5ml]
Mephobarbital(Mebara1)-32-100mg
po tid [32, 50, loo] Long Half-life
Pentobarbital(~embutal)-30-150mgPOIIVIIMIPR tidlqid
Secobarbital(Seconal)-100mgpo or 100-20omg IM [I 001
OTHER
Buspirone(Bu~par)-start
7.5 po bid, then after 1 week increase to
15mg po bid, average effective dose 40-60mg/day, maximum 6Omglday
[5, 10, 151
-no additive effects when taken with EtOH
-therapeutic response may take several weeks to develop
Chloral hydrate(~octec)-anxietylsedation250mg tid, peds
25mglkglday divided doses. Insomnia 500-1000mg hs, peds
50mglkglday divided doses [250, 500, syrup 250, 500mg/5ml, supp 324,
500, 6481
-used primarily to treat children
-used to be used as a "Mickey finn"
Diphenhydramine(~enadr~l)-25-50mg
IVIIMIPO q6h. Peds
5mglkglday divided q6h [25, 50, liq 6.25, 12.5mg/5ml]
-many other uses including; antihistamine, antiemetic(motion
sickness), injectable local anesthetic
Hydroxyzine(Atarax, Vistari1)-50-lOOmg IMIpo qd-qid (25, 50, 100,
liq 10, 25mg/5ml]
-often used as an antipruritic
Zolpidem(Ambien)-5-10mg po qhs [5, l o ]
PHARMACOLOGY
63
CHAPTER 2
CARDIOVASCULAR DRUGS
ANGlOTENSlN CONVERTING ENZYME(ACE)

INHIBITORS
-used to treat HTN(BP of 140/90 or higher), and CHF
-blocks conversion of Angiotensin I to Angiotensin II
Benazepril(~0tensin)
RENIN-ANGIOTENSIN MECHANISM
Captopril(Capoten)
Enalapril(vasotec)
Angiotensinogen
Ren~n
(kidneys)
Fosinopril(Monopril)
L i s i n o p r i l ( ~ r i n i v iZestril)
~,
Moexipril(univasc)
Quinapril(Accupril)
Ramipril(A1tace)
Trandolpril(Mavik)
ANGlOTENSlN II
ANTAGONISTS
losartan(Cozaar)
VaIsartan(~atapres-TTS)
Angiotensin I
I
AngmAngm
Converting enzyme
(lungs)
Aldosterone
Vasoconstriction
\/
Na'and water retension
decreased BP
ANTIADRENERGIC AGENTS-CENTRAL
ACTING
-used to treat HTN
-activate (alpha-adrenoceptorsin the CNS reducing sympathetic
outflow
-decreases total peripheral resistance
-tricyclic antidepressants(i.e. Elavil) may block the
antihypertensive effects
Clonidine(catapres)
Guanabenz(wytensin)
Guanfacine(~enex)
Methyldopa(~1domet)
PHARMACOLOGY
64
CHAPTER 2
ANTIADRENERGIC AGENTSPERIPHERALLY ACTING

-used to treat HTN
-blocks release of norepinephrine from peripheral sympathetic
nerve terminals
-reduces cardiac output and total peripheral vascular
resistance
-tricyclic antidepressants(i.e. Elavil) may block the
antihypertensive effects
D~xazosin(~ardura)
Guanadrel(~y1orel)
Guanethidine(lsme1in)
Prazosin(Minipress)
Reserpine(serpasi1)
Terazosin(Hytrin)
ANTI-DYSRHYTHMICS/CARDlAC ARREST
Adenosine(~den0card)
Amiodarone(Cordarone)
Bretylium(~retylol)
D i g o x i n ( ~ a n o x i nLanoxicaps)
,
Digoxin-immume Fab(~igiblind)
Disopyramide(~orpace)
Flecainide(~ambocor)
Ibutilide(Corvert)
Isoproterenol(lsupreI)
Magnesium sulfate
Mexiletine(~exiti1)
Moricizine(~thmozine)
P r o c a i n a m i d e ( ~ r o c a nSR, Pronestyl-SR, Prornine, Rhythmin)
-may cause drug induced Lupus erythematosus
Propafenone(Rythmo1)
Q u i n i d i n e ( ~ u i n a g ~ u tQuinalan,
e,
Quinidex, Quinora, Cin-Quin)
-may cause cinchonism
S~talol(~etapace)
Tocainide(~onocard)
PHARMACOLOGY
65
CHAPTER 2
ANTI-HYPERLIPIDEMIC AGENTS-HMG-COA
REDUCTASE INHIBITORS
-used to treat hypercholesterolemia
-function as competitive inhibitors of
3-hydroxy-3-methylglutaryl-coenzyme A
reductase(HMG-CoAR), which is the rate limiting enzyme in
cholesterol biosynthesis
Atorvastatin(~ipitor)
Fluvastitin(~escol)
Lovastatin(~evacor)
Pravastatin(~ravachol)
Simvastatin(zocor)
ANTI-HYPERTENSION COMBINATIONS
Aldactazide(~C~~/spironolactone)
Apre~azide(h~dralazine/~~~~)
Capozide(captopriI1HCTZ)
C~mbipre~(clonidine/chlorthalidone)
C~rzide(nadolol/bendroflumethiazide)
Dyazide(~~~Z/triamterene)
Hyzaar(iosartan1HCTZ)
lnderide LA(propranolol/HCT~)
Le~~el(enalapri11felodipine)
Lopressor H C T ( m e t o p r o l o l 1 ~ ~ ~ ~ )
Lotensin HCT(benazepri11HcT~)
L~trel(amlodipine/benazepril)
Maxide(HCTZ/triamterene)
Minizide(prazosin1polythiazide)
M o d u r e t i c ( ~ c T zamiloride)
/
Prinzide(lisinopriI1HCTZ)
Tarka(trandolapriI/verapamil)
Teczem(enalapriI/diItiazem)
Ten~retic(atenolol/chrorthalidone)
Timolide(timolollHCTZ)
Vaseretic(enalapril1HCTZ)
Zestoretic(lisinopriIIHCTZ)
Zia~(bisoprolol/HCTZ)
PHARMACOLOGY
66
CHAPTER 2
BETA BLOCKERS
-used to treat tachyarrhythmias
-acts to prolong A-V conduction, decrease heart rate,
contractility, and decrease BP
-act as antagonists on (P-adrenoceptors, thus reducing
sympathetic stimulation
Acebutolol(sectra~)
Atenolol(~enormin)
Betazolol(~erlone)
Bisoprolol(~ebeta)
Carteolol(Cartrol)
Carvedilol(coreg)
E~m010I(~revibloc)
LabetaloI(Trandate, Normodyne)
Metoprolol(Lopressor)
Nadolol(Corgard)
Penbutolol(Levato~)
Pindolol(~isken)
Propranolol(lnderal)
Sotalol(6etapace)
Timolol(Blocadren)
CALCIUM CHANNEL BLOCKERS

-used to treat angina and management of HTN
-causes coronary vasodilation by inhibiting calcium
transport into vascular smooth muscle
Aml~dipine(~owasc)
Bepridil(vascor)
Diltiazem(cardizern)
Felodipine(~lendi1)
Isradipine(~ynacirc)
Nicardipine(cardene)
Nifedipine(cardene)
Nisoldipine(su1ar)
Verapamil(lsoptin, Calan)
PHARMACOLOGY
67
CHAPTER 2
MUSCLE RELAXANTS
B a ~ l ~ f e n ( ~ i o r e s a l ) - s 5mg
t a r t tid, maximum 80mglday [lo, 201
C a r i s o p r o d o l ( s o m a , Rela)-350mg po tidlqid 13501
Cyclobenzaprine(~lexeriI)-start
1Omg po tid, maximum 60mglday 1101
Dantrotene(~antrium)-spasticity
start with 25mg/day, then increase,
maximum 400mglday bidlqid [25, 50, 1001
-treatment for Malignant Hyperthermia-continuous rapid IV
push of lmglkg and continue until symptoms subside or until
a maximum of 1 Omglkg is reached
Metaxalone(Skelaxin)-800mg po tidlqid [400]
Methocarbamol(~obaxin)-1000-1500mg
po qid [500, 7501
Orphenadrine(~orf~ex)-60mg
IVIIM bid. lOOmg bid [loo]
Quinine-260-3oomg po qhs [200,260,300,325]
-also classified as an antimalarial agent
-may be used to treat leg cramps
-can cause cinchonism
-function by preventing the spread of excitation from a focus
Carbamazine(~egret01)-200-600mg
po bid [loo, 200, susp
100mg/5ml]
(Tegretol XR)-extended release 200mg po bid 1100, 200, 4001
-also used for chronic pain(trigemina1neuralgia, peripheral
neuropathy)
-carbamazine is a tricyclic but has no antidepressive action
Clona~epam(~lonopin)-start
0.5mg po tid, maximum 20lday 10.125,
0.25, 0.5, 1, 21.
E t h 0 ~ ~ ~ i m 1 d e ( ~ a r o n t i n ) - 2 5po
0 mqd
g if 3-6y/o, 500mg po qd if
>6y/o [250, liq 250mgl5ml]
-drug of choice for absence seizures
-may cause bone marrow suppression
Felbamate(~elbatol)-start
400mg po tid, maximum 3600mgJday.
Peds-start 15 mglkglday, maximum 45mglkglday [400, 600, susp
600mg/5ml]
F ~ ~ p h e n y t ~ i n ( C e r e b y x )dosing
- a l l in "phenytoin equivalent" milligrams. Load 15-20mg/kg(1000mgfor a typical adult) lMllV no faster
than 100-150.mglmin. OK in either NS or D5W
Gabapent~n(~eurontin)-start
300mg po qhs and increase over a few
days to 300-600mg po tid, maximum 3600mglday [loo, 300, 4001
PHARMACOLOGY
68
CHAPTER 2
Lamotrigine(~amictal)-start
50mg qd x 14days, then 50mg bid x
14days, then maintain 150-250 bid
Mephenyt~in(~esantoin)-1OOmg
po bidltidlqid [loo]
Methsuximide(celontin)-300mgpo qd [I~o, 3001
Phenobarbital(~umina1)-load
15-20mg/kg up to 300-800mg IV at 2550mglmin. Maintenance 60mg po bidltid, peds 3-6mglkglday [15,16,30,
60, 100, liq 15, 20mg/5ml]
Phensuximide(~i1ontin)-500-1000mg
po bidhid [500]
-used most often on infants
Phenyt~in(~ilantin)-load
15-20mg/kg(1000 typical adult) IV no faster
than 50mglmin. Mix in NS, precipitates in D5W. Oral load 400mg po
initially followed by 300mg in 2h and 4h. Maintenance 5mgIkg or 300mg
po qd or divided tid [30, 100, chewtabs 50, susp 30 and 125 mg/5ml]
-drug of choice for Grand Mal seizures
Primidone(~yso1ine)-start
loo-125mg po qhs, increase over 10days
to 250mg tidlqid [50, 250, liq 250mg15ml]
-metabolized to phenobarbital
Topiramate(Topamax)-start50mg po qhs, increase weekly by
50mglday to effective dose of 200 bid 125, 100, 2001
V a l p r o i c acid(Depakene, Depakotepstart 15mglkglday po qdlbid,
maximum 60mglkglday [125, 250, 500, syrup 250mg/5ml]
(Depacon)-parenteraldivided oral daily dose q6h, each dose (20mg/min IV
-used to treat absence seizures, but is the drug of choice on
patients with both Grand Mal and Petite Mal(absence)
seizures
ANTIGOUT MEDICINES
Indomethacin(lndocin)-25-5Omg
- tid [25, 50, SUPP
. . 50, susp
25mg/5ml] (Indocin SR)-75mg PO qdlbid
-strong NSAlD
A l l o p u r i n o I ( ~ y l o p r i m ,Purino1)-200-300mgPO qdlbid [loo, 3001
-inhibits xanthine oxidase(a major enzyme in uric acid
synthesis)
C o l c h i c i n e - P O l m g initially, .5mg ql-2h until nausea/vomiting or
diarrhea occur to a maximum dose of 7-8mg[0.5, 0.61, IV 2mg initially,
then .5mg q6h to a maximum dose of 4mg
-acts by interfering with WBCs ability to phagocytize urate
crystals thus reducing inflammation
-very effective for acute attacks, but side effects often out
weigh the advantages
-can be used as a diagnostic tool for acute gout, if symptoms
are relieved, it was gout
-
PHARMACOLOGY
69
CHAPTER 2
Probenecid(~enemid)-250mg
PO bid x7 days, then 500 bid [500]
-inhibits the reabsorption of uric acid in the proximal tubules
Su~finpyrazone(~n~urane)-100-200m~
PO bid [loo, 2001
ANTIEMETICS
-indicated for N N associated with motion sickness
DronabinoI(~arinol)-2.5mg
PO bid before lunch and dinner
-indicated for N N associated with chemotherapy
Granisetron(~ytn)-1Omcg/kg
IV 30 min before chemo, 1mg PO bid [ I ]
O n d a n ~ e t r ~ n ( ~ o f r a n ) - s i n32mg(infused
gle
over 15 minutes) or three
0.15mglkg IV doses, 8-10mg PO bid [4, 8, solution 4mg/5ml]
Prochlorpera~ine(~ompazine)-5-10mg
POIIM tidlqid, 2.5-10mg
slow(5mglmin) IV, single dose not to exceed IOmg, supp 25mg bid,
maximum daily dose 40mg [lo, 15, 301
-also effective for short term treatment of non-psychotic
anxiety
Pr0metha~ine(~henergan)-25-50mg
PO/IM/PR q4-6h, Peds 0.250.5mglkg POIIMIPR q4-6h [12.5, 25, 50, syrup 6.25, 25mg/5ml, supp
12.5, 25, 501
-indicated for post-op N N associated with anesthesia,
motion sickness, as an adjuct to analgesics for control of
post-op pain(potentiates Demerol), also effective for allergic
conditions
S ~ ~ p ~ ~ a m ~ n e ( ~ r a n s d e r m ~ circular
c o p ) - patch
o n e is applied in the
postauricular area
-takes 4 hrs to become effective and lasts for 3 days
-indicated for N N associated with motion sickness
-wash hands after handing-causes dilation of pupils and
blurred vision if chemicals come in contact with the eyes
Thiethylperazine(~orecan,
Norzine)-10-30mg qd-tid, 2ml IM qd-tid
Trimethobenzamide(Tigan)-250mgPO tidlqid, Peds 100mg PO

tidlqid, supp 200mg tidlqid, Peds 100mg tidlqid
PHARMACOLOGY
70
CHAPTER 2
ORAL DIABETIC MEDICATION

/Hvpoulvcemics)
-all act to lower blood glucose levels
Chlorpropamide(~iabinese)-start
100-250mg PO qd, rnax
750mglday [ I00, 2501
-1st Gen. Sulfonylurea
Glimepiride(Amary1)-1-4mgPO qd [I, 2, 41
-2nd Gen. Sulfonylurea
G I i p i z i d e ( ~ l u c o t r oGlucotrol
~,
XL)-varies, 5-30mg PO qdlbid [5, l o ]
G l y b u r i d e ( ~ i a ~ e tGlynase,
a,
Micronase)-1.25-5mgPO qam with 1st meal
M e t f ~ ~ ~ ~ ~ ( ~ l u c o ~ h a ~ e500-1000mg
) - v a r i e sPO
, bid or 850mg PO
qd-qid [500, 8501
Miglitol(~lyset)-start25mg PO tid with meal, maintenance 50-100mg
tid 125, 50, 1001
ToIa~amide(~olinase)-start
100-250mg PO qd [loo, 250, 5001
T0lb~tamide(0rinase)-250-3000mg PO qd or divided bid [500]
Tr0g1ita~one(~ezulin)-start
200mg PO qd with food, maintenance
usually 400-600mg/day, max 6OOmglday [200, 4001
INSULIN
TYPES
Rapid
-Regular(Humulin R)
-Semilente
Intermediate
-NPH(Humulin N)
-Lente(Humulin L)
Long Acting
-Protarnine zinc(PZ1)
-Ultralente(Humulin U)
ONSET
10-30min
0.5-1hr
0.5-2hr
1-4hrs
1-4hrs
4-8hrs
4-8hrs
DURATION ROUTE
PHARMACOLOGY
71
CHAPTER 2
ANTIDOTES
Poison
Antidote
Acetaminophen
Anticholinesterase
Benzodiazepine
Digoxin, Digitoxin
Methanol
Heparin
l ron
Lead
Methotrexate
Narcotics, Heroin
Tricyclic Antidepressants
Warfarin
Acetylcysteine
~tropineor Pralidoxine
Flumazenil(Romazicon)
Digoxin immune Fab '
Ethanol
Protamine sulfate
Deferoxamine
Succimer
Leucovorin calcium
Naloxone
Physostigmine
Phytonadione(Vit K)
Botulinum toxin A(Botox)

-derived from the neurotoxin of Clostridium botulunum
Uses:
A. Plastic surgery to decrease wrinkling by paralyzing facial muscles
B. IM injections for spastic muscles, most notably the calves
C. SubQ injections for hyperhydrosis
TETANUWTETANUS PROPHYLAXIS
GENERAL
The causative organism is Clostridium tetani(anaerobic, G(+), slender,
motile rods) which is ubiquitous in soil and stool. The sporulated form
has a characteristic drumstick or tennis racket shape. This bacteria
produces an exotoxin called tetanospasmin. Any injury that violates the
integrity of the skin, including burns, is at risk for developing tetanus.
Incubation period is 2-54 days(ave.12-14 days) and mortality rate is
-50%. Natural infection does not result in immunity against future
infections
SYMPTOMS
-trismus(lock jaw)
-muscle spasm
-irritability
-dysphagia
-neck stiffness
note: strychnine poisoning and the use of phenothiazines may produce
similar symptoms
PHARMACOLOGY
72
CHAPTER 2
Magnesium H y d r o x i d e ( ~ oMilk
~ , of Magnesia)-15-40ml PO
-also an antacid
-osmotically draws water into the gut
Fleet Enema
-osmotically draws water into the gut
LactuIose(Cephulac, Cholac, Chronulac, Constilac)-10-20mg(l530ml) PO qd, hepatic encephalopathy 20-30mg(30-45ml) PO tidlqid
-also used to reduce ammonia levels in the blood
Polyethylene Glyc~I(Colovage,CoLyte, NuLytely, OCL, PEG-ES,
GoLytely)-4liters PO q4h
-used for bowel cleansing in preparation for GI exam
S a l t s ( ~ ~ s osalt,
m MgS04, KP04, NaP04)
-gut becomes hypertonic and causes water to move into the
gut by osmosis
STIMULANT L A X A T I V E S
-promote peristalsis
Castor 0il(~urge)-15-30m1PO qhs, Peds 5-15m1

-works in 1-6hrs
-active ingredient, ricinoleate
Phenolphalein(~x- ax, Modane)-30-270mg qdlbid, peds 6-11yrs
30-60mg qdlbid, 2-5yrs 15-30mg qdlbid
B i ~ a ~ o d y l ( ~ u l c o Defico1)-lOmg
lax,
POIPR, 5mg if 6-12yIo [5, supp 101
Cascara 325mg PO qhs 13251
LUBRICANTS
Mineral O i l ( ~ l e eMineral
t
Oil, Milkinol, Nujol)-5-45ml PO qhs, Peds 520ml PO qhs
-coats surface of stool and intestine with a lubricant film
PHARMACOLOGY
73
CHAPTER 2
ANTIDOTES
Poison
Antidote
Acetaminophen
Anticholinesterase
Benzodiazepine
Digoxin, Digitoxin
Methanol
Heparin
l ron
Lead
Methotrexate
Narcotics, Heroin
Tricyclic Antidepressants
Warfarin
Acetylcysteine
~tropineor Pralidoxine
Flumazenil(Romazicon)
Digoxin immune Fab '
Ethanol
Protamine sulfate
Deferoxamine
Succimer
Leucovorin calcium
Naloxone
Physostigmine
Phytonadione(Vit K)
Botulinum toxin A(Botox)

-derived from the neurotoxin of Clostridium botulunum
Uses:
A. Plastic surgery to decrease wrinkling by paralyzing facial muscles
B. IM injections for spastic muscles, most notably the calves
C. SubQ injections for hyperhydrosis
TETANUWTETANUS PROPHYLAXIS
GENERAL
The causative organism is Clostridium tetani(anaerobic, G(+), slender,
motile rods) which is ubiquitous in soil and stool. The sporulated form
has a characteristic drumstick or tennis racket shape. This bacteria
produces an exotoxin called tetanospasmin. Any injury that violates the
integrity of the skin, including burns, is at risk for developing tetanus.
Incubation period is 2-54 days(ave.12-14 days) and mortality rate is
-50%. Natural infection does not result in immunity against future
infections
SYMPTOMS
-trismus(lock jaw)
-muscle spasm
-irritability
-dysphagia
-neck stiffness
note: strychnine poisoning and the use of phenothiazines may produce
similar symptoms
PHARMACOLOGY
74
CHAPTER 2
IMMUNIZATION
for immunization)
TETANUS
tetanus, pertussis)
-part of the standard primary immunization given to children at 2
months, 4 months, 6 months, 15 months, and 4-6 years. Thereafter,
a booster of Td is necessary every 10 years
-used in patients less than seven years of age unless history of
hypersensitivity to Pertussis, then use DT
tetanus)
-same dosage as
-used in patients less seven years old
dose, tetanus)
-contains 25% less diphtheria toxoid than DTP and DT to reduce
side effects
-used in adults and children greater than 7 years of age
-dosage for boosters and for immunization series is the same
TETANUS
postexposure to neutralize the toxin)
immune
-given postexposure
-dose 250U
tetanus antitoxin)
-used when TIG is not available
-no longer used due to possible horse serum allergy
-usual dose is
IV or
HISTORY
Unknown or
less than 3 doses
YES
At least 3 doses
'NO
YES
YES
'Yes if it has been greater than 10 years since last dose

if it has been greater than 5 years since last dose
tetanus toxoid
would be the beginning of a series of 3
1-2 months
shots to immunize the patient. 2 doses 0.5 cc given
apart followed by a third shot at 6-12 months.
EXAMPLES OF TREATING FOR TETANUS
Patient present with wound and has a history of tetanus immunization
and his last booster was 12 years ago
-Give 0.5 cc of tetanus toxoid
Patient present with wound and doesn't remember if he's been
immunized or if he's had a booster
-Give 0.5 cc of tetanus toxoid
-And give 250 U of tetanus immunoglobin
If toxoid and immunoglobin are both administered they should be given
in separate arms in case of allergic reaction
PHARMACOLOGY
75
CHAPTER 2
VARIOUS TREATMENTS FOR WARTS

Regardless of treatment, when using topical modalities everything works
better if you first pare the wart down to the bleeding point
Salicylic acid(Duofilm, Duoplant, Occlusal-HP, Viranol, Compound-W)
-concentrations greater than 6% are destructive to tissue
-some formulations contain lactic acid for additional keratolytic
effects
II Mono-, Di-, Trichloroacetic acids
-80% monochloroacetic acid penetrates the skin causing blister
formation
-50-80% dichloroacetic acid or trichloroacetic acid are less
powerful but still effective therapies
Ill Cantharidin
-due to a lack of controlled studies this product is no longer
commercially available in the U.S. However, some pharmacies
still make it available by compounding it from its ingredients
-Cantharidin requires occlusion for anywhere from 1-24hrs.
depending on thickness of skin.
IV Cryotherapy
-mainstay in most dermatologist offices
-freezing destroys the cells that harbor the virus
-retreatment is usually at 2-4 week intervals
V Electrodesiccation and Curettage
-creats plume and can leave a scar
-requires local anesthesia
VI Laser(C0,)
-creats plume and can be technically difficult
VII Excision with Suturing
-leaves a scar
-requires local anesthesia
Vlll Podophyllun
-an antimitotic agent by preventing the formation of mitotic
spindles
-Podofilox 0.5% solution is a pure form of Podophyllin applied to
the warts BID for 3 days, followed by a rest for 4 days, and the
cycle repeated until resolution
-problem is the shelf life is only 6 months
IX lmiquimod
-an immune response modifier applied topically BID causing the
patient's cells to produce interferon
X Bleomycin
-Injected into wart, usually takes several injections
-extremely painful and causes local tissue necrosis
PHARMACOLOGY
76
CHAPTER 2
XI Cimentidine
-Generally accepted to be of placebo value only
-The bulk of evidence shows that it does not work affectively for
treating wart
XI1 Benzalkonium
-antiseptic agent is also used as a 25% solution to treat warts
Xlll 5-fluorouracil
-a pyrimidine analogue that inhibits thymidylic synthetase, thereby
preventing the conversion of deoxyuridylic acid to thymidylic acid
and inhibiting DNA synthesis
MICROBIOLOGY
77
CHAPTER 3
MICROBIOLOGY
BACTERIA FLOW SHEET, p78

ANTIMICROBIALAGENTS FOR SPECIFIC ANTIGENS, p80
VIROLOGY, p92
SUPERFICIAL MYCOSES, p97
SUBCUTANEOUS MYCOSES, p97
SYSTEMIC MYCOSES, p98
OPPORTUNISTIC FUNGI, p98
MICROBIOLOGY
78
CHAPTER 3
MICROBIOLOGY
79
CHAPTER 3
MICROBIOLOGY
80
CHAPTER 3
PREFERRED ANTIMICROBIAL AGENTS FOR SPECIFIC PATHOGENS

ORGANISM
USUAL DISEASE
PREFERREDAGENT ALTERMATIVE
Achromobacter
xylosoxidans
Meningitis, septicemia
lmipenem
Acinetobacter calcoacetcus
var antitratus(Herellea
vaginicola); var
/woffi(Mimapolymorpha)
Actinobacillus
actinomycetemcomitans
Sepsis(esp. line sepsis,

pneumonia
Imipenem,
fluoroquinolone +
ceftazidine or amikacin
Actinomycosis
Penicillin
Endocarditis
Penicillin +
aminoglycoside
Penicillin G
Actinomyces israaaelii(also)
Actinomyces naeslundii,
Actinomyces viscosus,
Actinomyces odontolyticus,
and Arachnia propionica
Aeromonas hydrophilia
Bacillus anthracis
Bacillus cereus
Bacillus species
Actinomycosis
Diarrhea Bacteremia
Ceflazidime, trimethiprimsulfamethoxazole(TMP-SMX),
antipseudomonad penicillin, ticarcillinclavulanate, doxycycline
Fluoroquinolone, tetracyclines, TMP-SMX
Clindamycin, tetracyclines, erythromycin,

cephalosporins
Cephalosporin + aminoglycoside
Clindamycin, tetracycline, erythromycin
Fluoroquinolone,TMP- Tetracyclines TMS-SMX

SMX
Cellulitis, mycosis,
Ciprofloxacin
Aminoglycosides, tetracyclines, irnipenem,
osteomyelitis
aztreonam, amoxicillian-clavulanate,
ticarcillin-clavulanate
Anthrax
Penicillin G
Erythromycin, tetracyclines,
chloramphenicol.fluoroquinolone
Food poisoning
Not treated
Septicemia(compromisedhost) Vancomycin
Irnipenem, aminoglycosides
MICROBIOLOGY
81
CHAPTER 3
MICROBIOLOGY
82
CHAPTER 3

ORGANISM
USUAL DISEASE
Calymmatobacterium
granulomatis
Campylobacter fetus
Campylobacter jejuni
Capnocytophaga
ochraceus
Cardiobacterium species
Chlamydia pneumoniae
(TWAR agent)
Chlamydia psittaci
Chlamydia trachomatis
Granuloma inguinale
Tetracycline
Septicemia, vascular
infections, meningitis
Diarrhea
lrnipenem
Periodontal disease,
bacteremia in neutropenic
host, tonsillitis(?)
Bacteremia, endocarditis
Pneumonia
Psittacosis
Urehritis, endocervicitis
pelvic inflammatory
disease, epididymitis,
urethral syndrome
Trachoma
Erythromycin,
fluoroquinolone
Clindamycin,
erythromycin
Penicillin +
arninoglycoside
Tetracycline,
erythromycin
Tetracycline,
Tetracycline,
azithromycin
Citrobacter diversus
Urinary tract infections,

pneumonia
Citrobacter freundii
Urina
Clostridium difficile
tract infection,
infection,
Arnoxicillin-clavulanate,imipenem,
cefoxitin, cephalosporins(3rd gen.),
ciprofloxacin, tetracyclines
Cephalosporin + arninoglycoside
Chlorarnphenicol
Erythromycin, ofloxacin, sulfisoxazole
Tetracycline(topical
Sulfonamide(topical
Tetracycline
Erythromycin(topical
+ oral)
Aminoglycoside,
cephalosporin(2nd and
3rd aen.) TMP-SMX
Erythromycin
Sulfonamide
+ oral)
Lymphogranuloma venereum
Inclusion conjunctivitis
TMP-SMX, erythromycin(pregnancy),
gentamicin, chlorarnphenical
Chlorarnphenicol, erythromycin,
clindamycin, tetracyclines
Tetracyclines, furazolidone
+ oral)
Tetracyclines, fluoroquinolone, irnipenem,

piperacillin
aminoglycoside
Tetracyclines, cephafosporins(3rd gen

antipseudomonad
Vancomycin(oral).
metronidazole(oral)
Bacitracin(oral), cholestyramine,
rifampin
lactobacilli,
MICROBIOLOGY
Clostridium species
Corynebacterium
diphtheriae
83
Gas gangrene, sepsis,

tetanus,botulism, crepitant
cellulitis
Diphtheria
Corynebacterium JK strain
Corynebacterium ulcerans
Coxiella burnetii
Septicemia
Pharyngitis
Q fever
Dysgonic fermenter type 2

(DF-2)
Edwardsiella tarda
Septicemia(dog bite),
wound infection
Gastroenteritis(usuaIlynot
treated), wound infection,
bacteremia, liver abscess
Ehrlichiosis
Oral infections, bite wounds
wound
Sepsis, pneumonia, wound
infection
Ehrlichia species
Eikenella corrodens
Enterobacter aerogenes
and E. cloacae
Urinary tract infection
Enterococcus faecalis

Wound infection,
intraabdominal sepsis
Endocarditis
CHAPTER 3
Chloramphenicol, metronidazole,
erythromycin, antipseudomonad
penicillin, clindamycin
Penicillin or
erythromycin +
antitoxin
Vancomycin
Erythromycin
Tetracycline
Penicillins
Ampicillin
Fluoroquinolone
Chloramphenicol, ciprofloxacin, rifampin,
erythromycin
Cephalosporins, imipenem, vancomycin,
fluoroquinolone, erythromycin
Tetracyclines, cephalosporins,
aminoglycosides, chloramphenicol
Tetracycline
Chloramphenicol
Ampicillin-amoxicillin, Tetracyclines, eryromycin, amoxicillinclavulanate, cephalosporins, imipenem
penicillin G
Aminoglycoside, TMP- Aztreonam, antipseudomonad
SMX, ciprofloxacin,
penicillin, cephalosporins (3rd gen.)
imipenem
TMP-SMX,
Antipseudomonad penicillin,
cephalosporin (3rd gen .)aminoglycoside, ciprofloxacinnitrofurantoin, imipenem
Penicillin+aminoglycoside, nitrofurantoin,
fluoroquinolone
Ampicillin
Penicillin + aminoglycoside,imipenem, (E.
faecalis), vancomycin
Penicillin G-ampicillin Vancomycin + gentamicin or streptomycin
+ gentamicin or
streptomycin
MICROBIOLOGY
84
CHAPTER 3

ORGANISM
USUAL DISEASE
Enterococcus faecium,
vancomycin resistant
Erwinia herbicola
Erysipelothrix
rhusiopathiae
Escherichia coli
Steptogramin
Urinary tract infections,
bacteremia, pneumonia
Localized cutaneous
erysipelas
Disseminated endocarditis
Septicemia, intraabdominal
sepis, wound infection
Flavobacterium
meningosepticum
Francisella tularensis
Sepsis
Tularemia
Fusobacteriurn species
Oral, dental, pulmonary

infections, liver abscess
Gardnerella vaginalis
Haemophilus aphrophilus
Haemophilus ducreyi
Vaginitis
Sepsis, endocarditis
Chancroid
Aminoglycosides
Penicillin
Penicillin
Aminoglycoside,
cephalosporin,
ampicillin (if sensitive)
Ampicillin (if sensitive),
tetracycline,TMP-SMX,
aminoglycoside,
cephalosporin,
antipseudomonad
penicillin
Vancomycin
Streptomycin,
gentamicin
Penicillin G,
metronidazole,
clindamycin
Metronidazole
Penicillin G +
Ceftriaxone,
erythromycin
azithromycin
Chloramphenicol, tetracyclines,
fluoroquinolone
Fluoroquinolone, chloramphenicol,
cephalosporin
Erythromycin
Cephalosporins
TMP-SMX, imipenem, aztreonam,
fluoroquinolone
Imipenem, aztreonam, sulfonamide,
fluoroquinolone
TMP-SMX, clindamycin, imipenem,

fluoroquinolone
Tetracycline(?), chloramphenicol(?)
Cefoxitin-cefotetan, chloramphenicol,
imipenem
Clindamycin
Cephalosporin(3rdgen.) + aminoglycoside
Amoxicillin-clavulanate, ciprofloxacin
CHAPTER 3
85
MICROBIOLOGY
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MICROBIOLOGY
86
CHAPTER 3

ORGANISM
USUAL DISEASE
PREFERREDAGENT
ALTERMATIVE
Leptorrichia buccalis
Leptospirosis
Tetracycline
Leptorrichia buccalis
Listeria monocytogenes
Orodental infectious
Meningitis, septicemia
Moraella species
Ocualar infection, bacteremia
Moraxella catarrhalis(see
Branhamella catarrhalis)
Morganella morganii
Penicillin G or
ampicillin
Penicillin G
Ampicillin or penicillin
+gentamicin (systemic
and intrathecal)
Aminoglycoside,
penicillins, TMP-SMX,
cephalosporins(2nd
and 3rd gen.)
Bacteremia, UTI,
pneumonia, wound infection
Aminoglycoside.
fluoroquinolone
Mycobacterium
aviumintracellulare
Pulmonary infection
Disseminated infection
Clarithromycin+
ethambutol+ rifampin
Mycobacterium chelonae
Pulmonary, cutaneous
Clarithromycin
Mycobacterium fortuitum
Soft tissue and wound

infections
Pulmonary infection
Amikacin+ cefoxitin
Mycobacterium kansasii
Mycobacterium leprae
Leprosy, paucibacillary
multibacillary
Isoniazid + rifampin +
ethambutol or
streptomycin
Dapsone + rifampin
Clofazimine + rifampin
+ dapsone
Tetracycline, clindamycin
TMP-SMX, erythromycin, vancomycin(?)
Cephalosporin(3rd gen.), imipenem,

ciprofloxacin, antipseudomonad penicillin,
erythromycin, clarithromycin
Imipenem, cephalosporin(3rd generation),

TMP-SMX, aztreonam, antipseudomonad
penicillin, ticarcillin-clavulanate, ammoxicillinclavulanate
Capreomycin, ethionamide, amikacin,
imipenem, cycloserine, ofloxacin,
ciprofloxacin, azithromycin
Amikacin + cefoxitin, clofazimine, or c
clarithromycin
Rifampin, erythromycin, sulfonamide,
cefoxitin, doxycycline, ciprofloxacin
Ethionamide, cycloserine, streptomycin,
amikacin, TMP-SMX
Minocycline or ofloxacin
Clarithromycin, protionamide
MICROBIOLOGY
87
Mycobacterium marinum
Soft tissue infection
Mycobacterium tuberculosis
Tuberculosis
Mycoplasmapneumoniae
Pneumonia
Neisseria gonorrhoeae
Urethritis, salpingitis,
Neisseria meningitidis
Meningitis, bacteremia,
pericarditis, pneumonia
Nocardia asteroides
Norcardiosis: pulmonary
infection; abscesses of skin
lung, brain
Animal bite wound
Pasteurella multocida
Peptostreptococcus
Plesiomonas shigelloides
Septicemia, septic arthritis,

osteomyelitis
Oral, dental, or pulmonary
infection; intraabdominal
sepsis; gynecologic infection
Diarrhea(usually not treated)
Extraintestinal infection
CHAPTER 3
Rifampin + ethambutol, Erythromycin, ciprofloxacin

TMP-SMX, tetracycline
Isoniazid + rifampin + Cycloserine, ciprofloxacin, ofloxacin,
ethambutol, ethionamide, kanamycin,
pyrazinamide
capreomycin, aminosalicylic acid
Erythromycin,
Carithromycin, azithromycin,
tetracycline
fluoroquinolones
Ceftriaxone, cefixine,
Spectinomycin, cefuroxime axetil,
TMP-SMX
Penicillin G
Ampicillin, chloramphencol, TMP-SMX,
cephalosporin-cefotaxime,ceftizoxime,
ceftriazone, cefuroxime
Sulfonamide(usually
Minocycline + sulfonamide, arnikacin +
sulfadiazine) or TMP
imipenem, ceftriaxone, cefurozime,
imipenem + cefotaxirne or TMP-SMX
SMX
Tetracycline, cephalosporins, amoxicilinPenicillin G
clavulanate
Penicillin G
Cephalosporins, ampicuillin-subactam,
cholramphencol
Penicillin G, ampicillin- Clindamycin, metronidazole, cephalosporin
amoxicillin
chloramphenicol, erythromycin
vancomycin, irnipenem
Fluoroquinolone, TMP- Tetracycline
SMX
Cephalosporin(3rd
TMP-SMX, imipenem, fluoroquinolone
generation),
aminoglycoside
MICROBIOLOGY
88
CHAPTER 3

ORGANISM
USUAL DISEASE
Prevotella melaninogenica
(Bacteroides
melaninogenicus)group
Propionibacterium acnes
Proteus mirabilis
Proteus vulgaris
Providencia rettgeri
Providencia stuartii
Pseudomonas aeruginosa
Pseudomonas mallei
Pseudomonas pseudomallei
Pseudomonasputida
Rickettsia species
Oral-dental, pulmonary,
female genital tract infection
Metronidazole,
clindamycin, cefoxitin
Chloramphenicol, ampicillin-sulbactam,
amoxicillin-clavulanate, ticarcillinclavulanate, imipenem, cefotetan,
cefmetazole
Tetracycline
Clindamycin(topical)
Acne
Septicemia, UTI,
Ampicillin,
Aminoglycosides, cephalosporins, TMPintraabdominal sepsis, wound cephalosporins(lst, 2nd,SMX, antipseudomonad penicillin,
infection
3rd gen)
aztreonam, imipenem, fluoroquinolone
Septicemia, UTI
Cephalosporin(3rd
TMP-SMX, antipseudomonad penicillin,
generation),
aztreonam, amoxicillin-clavulanate,
aminoglycoside,
ticarcillin-clavulanate, fluoroquinolone
imipenem
Cephalosporin(3rd
Antipseudomonad penicillin, TMP-SMX,
Septicemia, UTI
generation), imipenem imipenem, aztreonam, fluoroquinolone
Septicemia, UTI
Aminoglycoside,
Antipseudomonad penicillin, TMP-SMX,
cephalosporin(3rd gen) imipenem, aztreonam, fluoroquinolone
Septicemia, pneumonia,
Aminoglycoside
Aminoglycoside + cefoperazone,
intraabdominal sepsis
(tobramycin) +
imipene, cefazidime or aztreonam,
antipseudomonad
ciprofloxacin
penicillin
Glanders
Streptomycin +
Chloramphenicol + Streptomycin
tetracycline
Ceftazidime
Tetracycline + chloramphenicol: imipenem,
Melioidosis
TMP-SMX, amoxicillin-clavulanate
Septicemia, pneumonia, UTI
Aminoglycoside,
fluoroquinolone
Chloramphenicol, fluoroquinolone
Rocky Mountain spotted fever, Tetracycline(>8years)
Q fever, tick fever, murine
typhus, scrub typhus, typhus,
trench fever
MICROBIOLOGY
Salmonella typhi
Salmonella species
(nontyphoid)
Serratia marcescens
Shigella flexneri
Spirillum minus
Staphylococcusaureus,
methicillin resistant
Staphylococcusaureus,
methicillin sensitive
Staphylococcus epiderrnidis
Staphylococcus
saprophyticus
89
CHAPTER 3
Ceftriaxone,
Chlorarnphenicol, TMP-SMX, ampicillinfluoroquinolone
amoxicillin, cefotaxime, cefoperazone
Fluoroquinolone,
Chlorarnphenicol, ampicillin, TMP-SMX
Enteric fever, mycotic
cefotaxirne,
aneurysm
cefoperazone,
ceftriaxone
Cephalosporin(3rdgen) Antipseudomonad penicillin + gentamicin
Septicemia, UTI, pneumonia
or amikacin, aztreonarn
+ gentamicin or
amikacin +
fluoroquinolone,
imipenem
Ampicillin, tetracyclines, ceftriaxone,
TMP-SMX,
Colitis
fluoroquinolone
cefixirne
Tetracyclines, streptomycin
Penicillin G
Rat-bite fever
Vancomycin + rifarnpin TMP-SMX, fluoroquinolone(if sensitive),
or gentamicin
minocycline
wound infection
Penicillinase-resistant Erythromycin, clindamycin, vancomycin,
amoxicillin-clavulanate, ticarcillinpenicillin + rifampin
wound infection
or gentamicin,
clavulanate, imipenem, ciprofloxacin,
cephalosporins (1st
ampicillin-sulbactam, TMP-SMX,
generation),
ciprofloxacin
cefuroxime-cefamandole,
vancomycin + rifampin
or gentamicim
TMP-SMX, penicillinase-resistantpenicillin,
Septicemia, infected prosthetic Vancornycin
cephalosporin, fluoroquinolone
devices
TMP-SMX, ampicillin- Cephalosporins, tetracyclines
UTI
amoxicillinn,
fluoroquinolone
Typhoid fever
MICROBIOLOGY
90
CHAPTER 3

ORGANISM
USUAL DISEASE
Stenotrophomonas (formerlv Septicemia
xanthbmonas) maltophilia
Streptobacillus moniliformis Rat-bite fever,
Haverhill fever
Pharyngitis, soft tissue
Streptococcus group A, B,
infection, pneumonia,
C, G ; S. bovis, S. milleri,
viridans, anaerobic(Pepto- abscesses
streptococcus) and penicillin-sensitive strains of S.
pneumoniae
Endocarditis
TMP-SMX
Ticarcillin-clavulanate
Penicillin G
Tetracyclines, streptomycin
Penicillin G
Cephalosporin, (1st generation), cefuroxime,

cefotaxime, ceftriaxone, clindamycin,
vancomycin, erythromycin, clarithromycin,
azithromycin
Penicillin G
Cephalosporin, vancomycin
+ streptomycin
Streptococcus pneumoniae,
penicillin resistant
Pneumonia, septicemia,
septic arthritis
Meningitis
Jreponema carateum
Treponema
pallidum
Treponema pallidum
subsp. endemicus
Jreponema pallidum
subsp. pertenue
Pinta
Syphilis
Bejel
or gentamicin
Penicillin G,
Chloramphenicol, vancomycin + rifampin
cefotaxime, ceftriaxone
Ampicillin-amoxicillin
Penicillin + aminoglycoside, vancomycin,
nitrofurantoin, ciprofloxacin-norfloxacin
Ampicillin-amoxicillin
Vancomycin, penicillin + aminoglycoside,
intraabodominal sepsis imipenem(not for E. faecium)
Penicillin G-ampicillin Vancomycin + gentamicin or streptomycin
+ gentamicin or
streptomycin
Fluoroquinolones, cefotaxirne, ceftriaxone,
Vancomycin +
cefpodoxime, clindamycin, macrolide
Vancomycin +
cefotaxime or
ceftiaxone + rifampin
Penicillin G
Tetracyclines
Penicillin G
Tetracyclines, ceftriaxone
Penicillin
Yaws
Penicillin G
Meningitis
Streptococcus group D,
Enterococcus faecalis and
E. faecium
UTI
Wound infection,
Endocarditis
Tetracyclines
MICROBIOLOGY
91
Trepheryma whippelii
Whipple's disease
Ureaplasma urealyticum
Urethritis, endocervicitis,
pelvic inflammatory disease(?)
Cholera
Tetracycline
Vibrio Cholerae
Vibrio vulnificus
Yersinia enterocolitica
Septicemia, wound infection

Enterocolitis(usuallynot
treated), mesenteric
adenitis(usually not treated)
Septicemia
Yersinia pestis
plague
Yersinia Psuedotuberculosis
Mesenteric adenitis(usually
not treated), septicemia
TMP-SMX(2doublestrength/d x 1 yr)
Erythromycin
Teytracycline
TMP-SMX
CHAPTER 3
Tetracycline, penicillin V
Tetracyclines, claithromycin
Ampicillin, TMP-SMX, furazolidone,
fluoroquinolone, erythromycin
Chloramphenicol, penicillin G
Cephalosporin(3rd generation),
fluoroquinolone
Aminoglycoside
(gentamicin)
Streptomycin
Chloroamphenicol, cephalosporin(3rd
generation), TMP-SMX
Chloramphenicol, tetracyclines, gentamicin
Aminoglycoside,
TMP-SMX, tetracyclines
Adapted from Bartlett JG: 1996 Pocketbook of Infections Disease Therapy. Baltimore, Williams & Wilkins, 1996, pp 20-40.
MICROBIOLOGY
92
CHAPTER 3
VIROLOGY
DNA VIRUSES
A d e n o v i r i d a e ( d s , Icosahedral, nonenveloped)
Human Adenoviruses
-Found in 50-80% of normal humans adenoid tissue(tonsils)
-Respiratory and conjunctival infections
-Vaccine, Live attenuated
-High incident in military
H e p a d n a v i r i d a e ( d s , Icosahedral, nonenveloped)
Hepatitis B
-Parentera1route, STD
-Acute and chronic states
-Vaccine, purified HBsAg
-Incubation 4-1 2wks
-HBsAg is found on the surface of the viral particles, and it's
presence indicates that the patient has been infected with the
hepatitis B virus
-HBsAb is the Hepatitis B antibody and it's presence
indicates that the patient is now immune from the disease
and noninfectious
H e r p e t o v i r i d a e ( d s , Icosahedral, enveloped)
Type I, Herpes simplex-1
-Oral herpes(cold sores, fever blisters)
-Trigeminal ganglion cells(latency)
Type II,Herpes simplex-2
-STD
-Genital herpes
-Lumbar/sacral ganglion cells(latency)
-Intranuclear inclusion bodies
Type IIIl,Varicella-Zoster
-Varicella(chickenpox)/skin
-Zoster(Shingles)/Dorsalroot ganglion
-Multinucleated giant cells
Type IV, Epstein-Barr
-African Burkitt's Lymphoma/B-Lymphoidcells
-Nasopharyngeal carcinoma
-Infectious Mononucleosis
Type V, Cytomegalovirus(CMV)
-Birth defects
-Serious inf. in immunocomprornised
MICROBIOLOGY
93
CHAPTER 3
P a p o v a v i r i d a e ( d s , Icosahedral, nonenveloped)
Papilloma
-Common warts(verrucae)
-Genital warts(Condyloma acuminatum)
-Associated with benign and malignant tumors
Polyoma
-Found in 70% of normal adults
-Less significant in humans/initiates tumors in mice
Simian Vacuolating(SV40)
-Monkey virus that can initiate tumors in mice
Parvoviridae(ss, Icosahedral, nonenveloped)

Parvoviruses
-Transient aplastic crisis(TAC)in people with hemolytic
(smallest virus) anemia i.e. Sickle Cell Anemia
-Canine Parvo
Dependoviruses
-Adeno-associated viruses
-Needs helper virus to replicate
Poxviridae(ds, complex, enveloped)-largest virus
Variola
-Smallpox/skin
-Resp route
-Eliminated 1977
-Guarnieri Inclusion Bodies in cytoplasm
-Vaccine, Living attenuated
Molluscum Contagiosum
-Benign, wart-like epidermal tumor
-Spread by direct(STD) or indirect(towels, Jacuzzi) contact
RNA VIRUSES
Filoviridae(ss, helical, enveloped)
Filovirus
-Ebola virus
-Acute hemorrhagic fever
MICROBIOLOGY
94
CHAPTER 3
Orthomvxoviridae(ss,
helical, enveloped)
lnfluenza A
-Humans, animals, birds
-Epidemic 2-3yrs, Pandemic 10-llyrs
-Vaccine, Killed virus(short term immunity)
lnfluenza B
-Humans only
-Epidemic 4-6yrs
-Vaccine, Killed virus(short term immunity)
-Less severe than lnfluenza A
lnfluenza C
-Humans only
-No epidemics
-Less severe than lnfluenza B
Paramvxoviridae(ss,
Icosahelical, enveloped)
Parainfluenza
-Common respiratory infections
Mumps
-Respiratory route
-Infected parotid glands
-Complications, orchitis, encephalomyelitis
-Vaccine, Living attenuated virus(MMR)
Measles(Rubeola)
-Resp secretionslvery contagious
-Complications, encephalitis
-Vaccine, Attenuated virus(MMR)
Respiratory Syncytial Virus(RSV)
-Most important cause on lower resp infection in infants
under 1yr
P i c o r n a v i r i d a e ( s s , Icosahelical, nonenveloped)
ENTEROVIRUSES(fecaloral route)
Polio
-Target cells CNS/flaccid paralysis-Man is the only known
host and it's highly contageous
-Tends to attack the anterior horn of the spinal cord
-Vaccine, Salk-inactivated virus particles Sabin-live
attenuated
MICROBIOLOGY
95
CHAPTER 3
Coxackie Mild/asymptomatic dz
-Some dz associated with this virus are: Hand/foot/mouth dz,
Paralysis, Neonatal dz, Colds, Myocardiopathy, Conjunctivitis,
Diabetes
ECHO (Enteric-Cytopathogenic virus Human-Orphans)
-No dz associated with this
Hepatitis A
-Incubation period 2-4weeks
-low fatality
-No chronic(carrier) state
RHINOVIRUS
Common Cold
-Air droplets
-Upper resp infection
R e o v i r i d a e ( d s , Icosahelical, nonenveloped)
ARBOVIRUSES
Orbivirus
Colorado Tick Fever
-Rocky Mountains
-Vector, Wood tick
-More common April-July
R e t r o v i r i d a e ( s s , Icosahelical, enveloped)
ONCOVlRlNAE
-Tumor viruses(Leukemias, sarcomas, lymphomas)
LENTIVIRINAE
HIV
-AIDS
Simian and feline immunodeficiency viruses(SIV, FIV)
-AIDS like dz in monkeys and cats
Spumavirinae
-Cause "foamy" degeneration of inoculated cell
R h a b d o v i r i d a e ( s s , Icosahelical, enveloped)
Rabies
-Bite of rabid animal
-CNS/encephalitis
-Negri bodies(inclusion bodies) in cytoplasm
-Vaccine, Inactivated virus
-Incubation 10 days-1yr
MICROBIOLOGY
96
CHAPTER 3
Togaviridae(ss, Icosahelical, enveloped)

ARBOVIRUSES(Arthropod born)
Alphavirus
-Vector, Mosquito
-Encephalitis, febrile illnesses
Flavivirus
-Vector, Mosquito
-Dengue Fever
-Yellow Fever(hemorrhagic fever)
-Vaccine, Live attenuated virus
Pestivirus
Rubvirus
-Rubella(German Measles)
-Exception, not arthropod borne
-Vaccine, Living attenuated virus(MMR)
F l a v i v i r i d a e ( s s , Icosahelical, enveloped)
Hepatitis C
-Non-A, Non-B
-Parenteral route also labeled as Togavirus-group
-Acute and chronic state
-Most common cause of post transfusional hepatitis
-Incubation 8wks
H e p a d n a v i r i d a e ( d s , Icosahelical, nonenveloped)
Hepatitis D
-Requires obligatory helper function of hep B virus because
there is no outer protein coat
-Transmitted same as hep B
-Incubation 2-12wks
C a l i c i v i r i d a e ( s s , Icosahelical, nonenveloped)
Hepatitis E
-Fecal oral route/water borne
Norwalk
-Winter vomitting dz
MICROBIOLOGY
97
CHAPTER 3
MYCOLOGY
Cutanoeus Mycosis(Dermatophytes)
SEE DERMATOLOGY CHAPTER
Superficial Mycosis
-Superficial mycoses are found on the outer layers of the stratum
corneum or on the hair.
-These fungi do not elicit an immune response and do not become systemic.
1 Skin
Skin
DESCRIPTION
-Superficial brownishred scaling areas
-Usually on the trunk
Fluoresce under UV
light
Exophilia wernickii Light brown to black
macules on the palms
and soles, no scaling
-Tx: Keratolytics
-Hard black nodules
(primarily found in
form on the hairs of the
scalp & beard
the tropics)
Trichosporon beigeli -Soft white/light brown
nodules form on axilla,
pubic, beard, and scalp
hair
Tinea Versicolor Malassezia furfur
Tinea nigra
Subcutaneous Mycosis
-Saprophytic fungi which can affect the skin, fascia, subcutaneous
tissue, and sometimes bone and muscle. Infection is usually by way of
a thorn producing a localized abscesses and granulomata. Usually- the
infection is chronic and self limiting, but it canbecome svstemic.
DISEASE
1 ETIOLOGY
1 DESCRIPTION
Sporotrichosis Sporothrix Schenckii-Lesions develop along
Eumycotic
mycetoma
(madura foot)
Phialophora sp.
Fonsecaea sp.
Cladosporium sp.
Petriellidium boydii
warty, tumor like lesions

Draining sinuses
"Grains" of colonies
MICROBIOLOGY
98
CHAPTER 3
Systemic Mycosis
Most infections begin in the lungs by inhalation of spores. Symptoms
(San Joaquin Valley Fever)
More common in dark
common east of
-Single bud off mother cell
Opportunistic Fungi
These are not pathogenic in healthy humans.
DISEASE
ETIOLOGY
Canidia albicans
Candidiasis
(Thrush)
Aspergillosis
Aspergillus fumigatus
Zygomycosis
Mucor sp.
Pneumocystic
carinii pneumonia
Rhizopus sp.
Pneumocystic carinii
DESCRIPTION
-Oral candidiasis
-Vulvovaginal
candidiasis
-Caused by
inhalation of spores
-Causesed by
-Caused by
-Most common oppor
tunistic infection in AIDS
VASCULAR
99
CHAPTER 4
CHAPTER 4
PERIPHERAL VASCULAR DISEASE

ACUTE ARTERIAL OCCLUSION, p106
ARTERIAL EMBOLISM, p106
ACUTE ARTERIAL THROMBOSIS, p106
ARTERIAL INSUFFICIENCY, p104
ARTERIOSCLEROSIS OBLITERANS, p104
THROMBOANGIITSOBLITERANS, p104
MONCHEBER'S DZ, p105
ANEURYSM, p105
NONINVASIVE VASCULAR STUDIES, p100
SERIAL PRESSURES, p102
ANKLE/ARM INDEX, p101
DOPPLER. p101
ELEVATION-DEPENDENCY TEST, P101
EXERCISE TEST, p101
5-MINUTE REACTIVE HYPEREMICTEST, p102
PERTHES TEST, p102
TRENDELENBERG'S MANEUVER, p102
STAGES OF ARTERIAL OCCLUSION, p100
VENOUS DZ
VARICOSE VEINS, p107
THROMBOPHLEBITIS(SUPERFICIAL), p108
VENOUS INSUFFICIENCY, p108
DEEP VENOUS THROMBOSIS(DVT), p 1 1 0
LYMPHEDEMA, p l l l
LYMPHANGIITS, p l l l
LYMPHADENITIS,p l l l
VENOUS VS. ARTERIAL ULCERS, p103
VIRCHOW'S TRIAD, p100
REYNAUD'S PHENOMENON, p103
100
VIRCHOW'S TRIAD
Three factors that are commonly associated with the formation of
thrombi
1. Stasis(Arrhythmias,
MI, CHF, heart failure, Immobilization, obesity,
varicose veins, dehydration)
2. Blood vessel iniury(trauma, Fx, IV)
3. Hvpercoaaulability(Neoplasm, oral contraceptives, pregnancy, Sx,
polycythemia)
STAGES OF ARTERIAL OCCLUSION

Intermittent Claudication
BIL pain, usually in the calf, that occurs after the patient walks a distance. The pain is relieved by rest and reoccurs if the patient resumes
activity. The pain is due to the arteries inability to meet the metabolic
demands of the exercising muscle.
Rest Pain
As occlusion worsens, the blood supply is not sufficient to supply the
demands of even the resting muscle and pain develops. Pain is constant but usually worse at night when other distracting stimuli are at a
minimum. Night pain may lessen if the legs are allowed to dangle off
the bed(allowing more blood to enter the extremity). Night pain relieved
by walking indicates a venous problem.
Gangrene
Death of tissue, associated with loss of vascular supply. Dry gangreneoccurs gradually as a result of occlusion of blood supply and is not usually associate with bacterial infection. Wet gangrene-result of sudden
stoppage of blood(burns, freezing, embolism) with subsequent bacterial
infection.
NONINVASIVE VASCULAR STUDIES

SERIAL PRESSURES
What toe pressure in diabetics are associated with healing wounds?
>55 mmHg
Healing
range of uncertainty
45-55 rnmHg
<45 mmHg
No wound healing
-at least 3OmmHg required for healing of a wound on the digits
101
ANKLE/ARM INDEX(AKA Ankle/Brachial Index, Ischemic Index)

Determine brachial systolic pressure
Determine ankle systolic pressure
-Place BP cuff just above ankle and elevate until no arterial
pulsation can be heard through Doppler over PT artery
-The point at which arterial sound returns is the systolic pressure of
the artery
-Repeat on the DP and peroneal artery
-The highest of the three values is used as the ankle systolic
pressure
Divide ankle systolic by arm systolic
Normal is 1, values greater than 1 indicates calcified vessels, 0.5-0.8 is
associated whith intermittent claudication, and less than 0.5 is
associated with rest pain and ulcers
DOPPLER
The Doppler uses ultrasound with an audible output which the physician
uses for interpretation of the velocity and flow pattern.
Normal arteries-Sharp, high pitched sound, bi or triphasic. The
second sound represents backward flow. Small digital arteries may
be monophasic because they are too small and blood flow at this
level is too smooth for backward flow.
Abnormal arteries-Monophasic lower pitched longer "swishing"
sound. This indicates an occluded vessel or collateral flow.
ELEVATION-DEPENDENCY TEST
In an ischemic foot, elevation of the foot produces pallor, while
having the foot in the dependent position produces erythema.
Be careful not to note color change due to venous blood which
will produce a false positive. Patients with severe ischemia may
not have erythema on dependency due to occlusion.
EXERCISE TEST
Record pedal blood pressure with foot at heart level, then elevate leg to
30". Against slight resistance, dorsiflex and plantarflex foot for 1
minute(-1cycle/sec). Return leg to heart level and record pedal BPS
again every 30 seconds for 2 minutes.
Results:
If ankle pressure drops more than 20% and does not return to normal
within 2 minutes, there is arterial occlusion.
Explanation:
The reason for the drop in pressure is because the blood going into the
foot is diverted to the exercising calf muscles where there is less
resistance to flow.
102
5 MINUTE REACTIVE
TEST
-Pt lies supine with legs raised 30" and foot is dorsiflexed and
plantarflexed several times to empty venous blood from it
-Apply ankle cuff, inflate to 100mmHg above ankle systolic pressure
-Place foot at heart level
-After 5 minutes quickly deflate cuff
-Time the interval between cuff let down and color return to foot
Results:
Normal-Color returns almost instantaneously with maximum erythema
occurring at approximately 1 minute. Foot should be uniformly erythematous.
Vasospasticdz-Return of color is uniform, but slightly delayed especially
in toes(5-8sec). Maximum erythema takes approximately 2 minutes and
may be markedly erythematous.
Oraanic Occlusive dz- Return of color is not uniform and requires at
least 15 sec to reach toes. Maximum erythema exceeds 2 minutes and
the amount of erythema is less than normal
PERTHES TEST
Used to detect deep vein valvular incompetence.
-A tourniquet is placed around the elevated leg(-30-60mmHg to occlude
superficial venous flow) at midthigh or proximal calf level to obstruct
superficial veins.
-The patient is asked to walk(The purpose of walking is to assess
muscle pumping function on the deep veins which may help to evacuate
blood, or, with incompetent valves, may accentuate the abnormal flow
through perforators into the varicosities).
Results:
-With valvular incompetence blood will reflux from deep veins through
incompetent communicators to the superficial venous system and superficial veins will enlarge below the tourniquet.
-If patient feels pain on walking, this could mean deep venous
claudication meaning that the secondary varicose veins are critical
collateral channels and should not be interrupted or removed.
TRENDELENBURG'SMANEUVER
Used to differentiate deep and superficial venous incompetence.
-Elevate leg to empty venous blood
-Place tourniquet around upper thigh -30-60mmHg to occlude
superficial venous flow.
-Have patient stand.
103
CHAPTER.4
Results:
If varicosities fill within 20-30 seconds, deep and perforation dz is
present.
If varicosities do not fill after about 30 seconds, release tourniquet.
If the varicosities promptly return, the source of reflux is the superficial
system.
VENOUS VS. ARTERIAL ULCERS
RAYNAUD'S PHENOMENON
-paroxysmal vasospasm of the digits in response to cold or emotionally
stress resulting in digital ischemia
-associated with: primary thromboangiits obliterans, cryoglobulinemia,
occupational trauma, collagen vascular disease(e.g., lupus,
polyarteritis), frostbite, sympathetic hyperactivity, and thoracic outlet
syndrome
VASCULAR
104
CHAPTER 4
ARTERIAL INSUFFICIENCY
ARTERIOSCLEROSIS
OBLITERANS(Arteriosclerotic
Occlusive Dz)
DESCRIPTION
Arteriosclerosis in which proliferation of the intima of small vessels
has caused complete obliteration of the lumen causing an insidious
development of tissue ischemia.
SIGNS/SYMPTOMS
-Foot is painful, cold, and numb
-Skin is dry and scaly with dystrophic nails and poor hair growth
-Atrophy of muscle and soft tissue
-Edema is usually absent
-Initial symptom is Intermittent Claudication(pain, usually B/L in the
calf, after pt walks awhile. Pain is relieved by rest)
-Rest Pain may occur as dz advances. Severe unrelenting pain
which wakes pts up at night. Elevation increases pain and hanging
foot off bed (dependent position) relieves pain
-Ischemic feet may have ulcers which develop especially after
local trauma. Ulcers are usually on toes or heel and occasionally
the legs.
-Severely ischemic feet develop gangrene
DIAGNOSIS
Rest pain(ankle/arm index .25),
-Claudication(ankle/arm index .7),
gangrene(ankle/arm index .1)
-Dependent rubor and blanchina on elevation
TREATMENT
-Daily walking to build up, collateral circulation. Pt walks until

claudication pain occurs', at which time they rest for 3 minutes then
walk again. This should be done at least 8 times a day.
THROMBOANGIITIS OBLlTERANS(Buerger's DZ)

DESCRIPTION
An obliterative dz characterized by inflammatory changes in
small and medium sized arteries and veins. Caused by some sort
of hypersensitivity to tobacco. Occurs more in males(20:1),
between 20-40yrs who smoke. Gradual onset beginning in the
most distal vessels and progressing proximally, causing gangrene.
Episodic with quiescent periods of weeks, months, yrs. As
compared to Atherosclerosis Obliterans, the condition tends to be
more drastic and less progressive. Very similar to Arteriosclerosis
Obliterans and some feel that it is not a distinct clinical entity.
Thrombosis of the superficial veins may also occur.
105
SIGNSISYMPTOMS
-Signs/symptoms are those of arterial ischemia and superficial
phlebitis.
-Raynaud's phenomenon is common.
-Intermittent Claudication pain may occur, usually in the arch
of the foot. Later, rest pain may occur
-Frequently sympathetic nerve overactivity may occur; coldness,
hyperhidrosis, cyanosis.
-<pulses
-Inflammatory occlusions tend to be in the more distal arteries,
resulting in circulatory insufficiency of the toes and fingers
-There is a Hx/finding of small red, tender cords usually in the
saphenous tributaries rather than the main vessel. These findings
are a migratory superficial segmental thrombophlebitis
-Pt often have increased HLA-A9, HLA-B5
TREATMENT
-Same as with Atherosclerosis Obliterans
-Stop smoking
MONCHEBERG'S DZ
A benign arteriosclerosis resulting in extensive deposits of calcium
in the media layer of medium size arteries. This is a sclerotic,
but not an occlusive disorder, and is usually an incidental finding
of x-ray. It does not decrease blood flow but may decrease pulses
due to lack of distensibility.
ANEURYSM(aortic, femoral, & popliteal)
DESCRIPTION
A sack formed by the dilatation of the wall of an artery, most
exhibit arteriosclerosis. 80% occur in the infrarenal aorta, 20%
in the iliac arteries, 2% in the femoral and popliteal arteries
SIGNSISYMPTOMS
-Asymptomatic
-With expansion they may be associated with back pain or flank pain
-Abdominal aneurysms may be recognized as painless pulsatile
masses during routine physical exam
DIAGNOSIS
-Ultrasonography is the most efficacious manner to screen for
these lesions.
106
ACUTE ARTERIAL OCCLUSION

ARTERIAL EMBOLISM
DESCRIPTION
Acute ischemia caused by an emboli thrown from somewhere
else in the body. Usually large emboli come from the heart,
usually a history of heart disease is present(MI, rheumatic heart dz).
40% of embolic obstructions are in the femoral artery and 20%
are in the popliteal artery. Emboli from arteries(vs. the heart) are
usually small and give rise to transient symptoms in the toes and
brain. Atheroembolism is an important form of embolism.
Dislodged debris from aneurysms or extensive occlusive lesions
become entrapped in small distal arteries. This may cause pain and
focal cutaneous infarction.
SIGNS/SYMPTOMS
-5 "p's" (Pain, Pallor, Paresthesia, Paralysis, Pulseless extremity)
-Sudden onset of severe pain, coldness, numbness and pallor
-Pulses are absent distal to the obstruction
DIAGNOSIS
-Angiography is valuable(or MRI angiography)
-Fogarty catheter
TREATMENT
-Extremity is kept at or below horizontal plane.
-Immediate embolectomy is Tx of choice, best if performed
within 4-6 hrs after embolic episode.
-Delayed embolectomy(12 hrs or more after occlusion) when there
is ischemia or necrosis(mottled cyanosis, muscular rigidity,
anesthesia, elevated CK) involves a high risk of acute resp.
distress syndrome or acute renal failure. Anticoagulation rather
than Sx is indicated accepting urgent or elective amputation as
the necessary lifesaving procedure.
ACUTE ARTERIAL THROMBOSIS

DESCRIPTION
-Generally occurs in an arteriosclerotic artery. Blood flowing
through such a narrow, irregular or ulcerative lumen may clot
leading to sudden complete occlusion. Incomplete arterial flow
usually results in some collateral flow, so when the occlusion
develops blood is shunted, however, until additional
collateralization develops the limb may be threatened.
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CHAPTER 4
SIGNS/SYMPTOMS
-Same as described in arterial embolism. differentiation made bv hx.
Hx of occlusive arterial dz(absent pulses ntermittent claudication,
dystrophic skin and soft tissue changes) think thrombosis. With
embolism these symptoms may or may not be present and there
is more often a history of heart dz(MI, rheumatic heart dz)
TREATMENT
-Sx is not indicated because:
1) removing embolism from an already sclerotic artery is
difficult
2)The extremity is likely to survive due to collateral
circulation
3) The segment of occlusion may be quite long
-Tx: Thrombolysis using streptokinase, Urokinase, or tissue
plasminogen activator(tPA)
VENOUS DZ
VARICOSE VEINS
DESCRIPTION
Dilated, tortuous superficial veins in the lower extremity, more
common in women. Caused by periods of increased venous
pressure due to prolonged standing, heavy lifting, or pregnancy.
The long saphenous vein and its tributaries are most commonly
involved, but the short saphenous may also be affected.
Thrombophlebitis may develop in the varicosities, especially
in post-op pts, pregnant or post partum women, or those taking
oral contraceptives. A second type subcutaneous varicose veins
(Sunburst varices) exist. These are dilations of subcutaneous
venous plexuses that have a spider-like arrangement and an
unsightly purple color. Although they are cosmetically
displeasing, they are otherwise asymptomatic.
SIGNS/SYMPTOMS
-Itching from an associated eczematoid dermatitis may occur
-May be asymptomatic or associated with fatigue, aching,
discomfort, fullness, or pain
-Edema, pigmentation, and ulceration of the skin may develop
TREATMENT
-Elastic stockings
-Sx excision
-Cramps may occur at night that are relieved by elevation.
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CHAPTER 4
THROMBOPHLEBITIS OF THE SUPERFICIAL VEINS

DESCRIPTION
Inflammation of a superficial vein associated with thrombus
formation presents as a palpable linear indurated cord possibly
with variable inflammatory reaction manifested as pain,
tenderness, erythema, and warmth. There may be a Hx of recent
IV or trauma which could be the etiology. Indicates occult
deep venous thrombosis in 20% of cases. Pulmonary embolism
is rare.
SIGNS/SYMPTOMS
-Contributing factors include those of Virchow's Triad(epithelial
injury, hypercoagulability, stasis)
-No significant swelling of extremity
-Long Saphenous vein is most often involved
-Symptoms arise over a period of hours to 1-2 days.
-Self limiting and lasts 1-2 weeks
-The inflammatory reaction generally subsides in 1-2 weeks,
but a firm cord may remain for a much longer period
-Edema and deep calf tenderness are absent(unless deep
thrombophlebitis has developed)
-The linear rather than circular nature of the lesion and the
course along a vein serve to differentiate it from cellulitis
-Lymphangitis is also a differential dx.
TREATMENT
-Local heat
-Bed rest with elevation
-NSAIDS
VENOUS INSUFFICIENCY
DESCRIPTION
This disorder usually results from deep venous thrombophlebitis
with destruction of valves in the deep venous system and reversal
of normal superficial to deep flow of blood in the perforating veins.
The muscular action of the calf becomes ineffective and blood
flows to the superficial veins. Valves in the superficial(Saphenous)
system become incompetent resulting in antegrade venous flow,
increased pressure resulting in edema, fibrosis, pigmentation
(hemosiderin deposits), and later dermatitis, cellulitis, and ulceration.
Hemosiderin deposits are caused by venous hypertension which
distends local capillaries allowing RBC's to leak into tissue.
Hemoglobin from these cells is metabolized and results in a brawny
appearance in the skin. CHF and chronic renal dz also have B/L
edema of the LE, but generally there are other clinical and laboratory
VASCULAR
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CHAPTER 4
findings of heart and kidney dz. Dilation of superficial veins mav

occur leading to varicosities. Venous insufficiency due to deep '
thrombophlebitis is also called postphlebitic syndrome

SIGNS/SYMPTOMS
-First sign is progressive edema of the leg and is followed by 2"
changes in the skin and subcutaneous tissues
-Usually symptoms are itching and a dull discomfort made worse
by periods of standing
-Skin is usually thin, shiny, atrophic and cyanotic, and brownish
pigmentation(hemosiderin deposits), develops
-Eczema may be present, with superficial weeping dermatitis
-Subcutaneous tissue becomes thick and fibrous
-Recurrent ulceration may occur usually just above the medial
malleolus(these are usually not as painful as an ischemic ulcer)
-Lymphedema is associated with a brawny thickening in the
subcutaneous tissue also, but it does not respond well to
elevation and varicosities are absent
-Pitting edema is a sign of chronic venous obstruction or of an
acute inflammatory process
-Pt may complain of fullness, aching, tiredness in leg or have no
discomfort. This occurs by standing or walking and is relieved
by rest and elevation
-Night pain is relieved by getting out of bed and walking
TREATMENT
-Bed rest with legs elevated
-Support hose
-Weeping ulcers: Wet compresses for 1 hr, 4 times a day of
solution containing boric acid, Burow's solution, or saline
-Compresses are followed by local corticosteroid such as .5%
hydrocortisone cream in a water soluble base(Topical Abx may
be incorporated)
-Use wet to dry dressings for ulcers with normal saline change
BID. Necrotic tissue and other debris will be removed when the
dry dressing is removed. This tx is appropriate early in ulcer
management when there is substantial exudate and debris to
remove. Later the dressing can be moistened before removal to
avoid damage to delicate healing tissue. When an ulcer is clean
or shallow a hydrocolloid dressing(i.e. Duoderm) or Unna
Boot may be appropriate.
-Resolution of edema is important to ulcer management:
elevation, compression hose, diuretics
-If an ulcer fails to heal, skin grafting may be required along with
venous stripping and ligation
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DEEP VENOUS THROMBOSIS(DVT)

DESCRIPTION
Partial or complete occlusion of a vein by thrombus with secondary
inflammatory reaction in the wall of the vein. Arises approximately
80% of the time in the deep veins of the calf. Contributing factors
include those of Virchow's Triad such as: CHF, MI, stroke,
malignancy, Sx, trauma, immobilization, previous thromboembolic
dz, obesity, pregnancy, oral contraceptives, and advanced age.
The typical patient is a woman over 30 yrs old, on BCP's who
smokes. There is a danger of pulmonary embolism in these patients.
DVT usually results in destruction of the venous valves resulting
in veins that are incompetent resulting in postphlebitic syndrome
(venous insufficiency).
SIGNS/SYMPTOMS
-Symptoms arise over a period of hours to 1-2 days.
-Self limiting and lasts 1-2 weeks
-Distention of superficial venous collaterals, and slight fever and
tachycardia may develop.
-Physical exam is normal in 50% of pts
-Painful swollen leg with dilated superficial veins and a palpable
cord
-(+)Homan's sign-dorsiflexion of foot causes deep pain in calf
-Pulses are usually present
DIAGNOSIS
-Difficult to diagnose by Hx and PE
-Venography remains the gold standard
TREATMENT
-Leg should be elevated -15-2O0, trunk should be kept horizontal
-Bedrest until local tenderness and swelling disappears
-Heparin(bolus of 5,000-10,000 units IV followed by a continuous
IV infusion of 500 units/kg every 24hrs).
-PTT should be checked 4-6hrs after initial therapy and then at least
every 24hrs. PTT levels should be maintained at 2-3 times the
control value
-Monitor ABGs
-Pt should later be started on long term anticoags(Coumadin)
loading dose of 1 0mg is given each day until PT increases.
Then a smaller dose (5-7.5mg) is given to maintain PT -1.3-1.5
above the control value. Pts should be Tx for 3 months for the 1st
episode.
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CHAPTER 4
LYMPHEDEMA
DESCRIPTION
-Accumulation of excessive lymph fluid and swelling of
subcutaneous tissue due to obstruction, destruction, or hypoplasia
of lymph vessels
-May result from infection or obliteration of lymphatic tissue by
excision or radiation therapy
SIGNS/SYMPTOMS
-Nonpitting edema is a sign of lymphatic obstruction
-Onset is explosive, with chills, high fever, toxicity, and a red hot
swollen leg
-Lymphangitic streaks may be seen in the skin, and lymph nodes
in the groin are usually enlarged and tender
TREATMENT
-Swelling is Tx with elevation and compression occasionally
diuretics may be helpful
-Inflammation of a lymphatic vessel or vessels, usually caused

by bacterial infection
-Manifested by painful subcutaneous red streaks along the course
of the vessel and painful palpable regional lymph nodes
-Often associated with fever and chills followed by nausea and
malaise
-Often there is a portal of entry(i.e. ulcer, Sx)
-Inflammation of one or more lymph nodes, usually caused by a

primary infection elsewhere in the body
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NEUROLOGY
113
CHAPTER 5
CHAPTER 5
NEUROLOGY
CLASSIFICATIONS, p114
CUTANEOUS INNERVATION, p117
DERNATOMES, p116
ENTRAPMENT NEUROPATHY
-MORTON'S NEUROMA, PI18
-JOPLINIS NEUROMA, PI19
-TARSAL TUNNEL, p120
INNERVATION OF INTRINSICS, p118
NCV/EMG, p127
NERVE BLOCKS, p114
NEUROLOGICAL CONDITIONS-MISCELANEOUS
-MULTIPLE SCLEROSIS, PI21
-ALS, PI22
-GUILLIAN-BARRE SYNDROME, p122
-CMT, PI23
-CHARCOT JOINT, p124
-FRIEDREICH'SATAXIA, p124
-REFLEX SYMPTOMATIC DYSTROPHY, p124
NEUROPATHIES, p128
TREATMENT OF PERIPHERAL NEUROPATHIES, p155
NERVE SCLEROSING INJECTION p155
NEUROLOGY
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CHAPTER 5
CLASSIFICATIONS
Seddon Classification
Neurapraxia-bruised nerve. Results in numbness that is reversable
Axonotmesis-injury to axon that results in Wallerian degeneration. Will
regenerate over several months as long as gap is not too big
Neurotmesis-complete severance of the nerve resulting in irreversible
numbness
Sunderland's Classification
First dearee-a conduction deficit without axonal destruction
Second dearee-axon is severed without reaching the neural tube.
Wallerian degeneration with regeneration. Regeneration is likely
(axonotmesis)
Third dearee-degeneration of axon with destruction of fascicle with
irregular regeneration
Fourth dearee-destruction of axon and fascicle and no destruction of
nerve trunk, but a neuroma-in-continuity exists
Fifth dearee-complete loss, neuroma is likely and spontaneous recovery
is rare
NERVE BLOCKS
FIELD BLOCKS
ANKLE BLOCK
Tibial nerve
Saphenous nerve
Deep peroneal nerve
Intermediate dorsal cutaneous nerve
Sural nerve
DIGITAL BLOCK (e.g. 3rd)
5th & 6th dorsal digital proper nerve
5th & 6th plantar digital proper nerve
HALLUX BLOCK
1st dorsal digital proper nerve
Deep peroneal nerve
1st plantar digital proper nerve
2nd plantar digital proper nerve
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CHAPTER 5
MAY0 BLOCK(for bunions)

Saphenous nerve
Deep peroneal nerve
Medial plantar nerve
MINI-MAY0 BLOCK(for tailor's bunion)
Lateral dorsal cutaneous nerve
4th common dorsal digital nerve
Superficial br. of the lateral plantar nerve
4th common plantar digital nerve
POPLITEAL BLOCK
Sciatic nerve(injection is given at the posterior knee -7cm proximal
and -1cm lateral to the transverse popliteal crease. At this level it
shares an epineurial sheath with the common peroneal nerve)
For a complete leg block the Saphenous nerve is also injected just
distal and anterior to the medial chondyle of the tibia.
LOCAL INFILTRATION
A localized area is flooded with anesthesia without regards to location of
specific nerves. Used more commonly for ulcers, warts, and biopsies.
BIER
BLOCK(Intravenous
regional anesthesia)
Veins, arteries, and nerves run together so by injecting anesthetic into a
vein it diffuses out into the surrounding nerves. A tourniquet is placed
around the patients calf. An intravenous cannula is then inserted as distally as possible. The leg is then elevated for 3 to 4 minutes or an
Esmarch bandage is used to exsanguinate the extremity. The tourniquet
is then inflated. The local anesthesia(usually Lidocaine, plain) is then
injected. The intravenous cannula is removed prior to preparation for
operation. The block will persist as long as the cuff is inflated and disappears shortly following deflation.
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DERMATOMES OF THE LOWER EXTREMITY
NEUROLOGY
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CHAPTER 5
CUTANEOUS INNERVATION OF THE

LOWER EXTREMITY
Genitofemoral n. L1, L2
Anterior Femoral
Cutaneous n. L2, L3
Posterior Femoral
Cutaneous n. S1, S2, S3
Superficial Peroneal n.
Saphenous n. L3, L4
Deep Peroneal n. L4, L5
Lateral Plantar n. L4, L 5
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I N N E R V A T I O N OF INTRINSIC MUSCLES
Medial plantar nerve:
Abductor hallucis muscle
Flexor digitorum brevis
1st Lumbrical
Flexor hallucis brevis
Lateral plantar nerve:

Abductor Digiti Minimi
Quadratus Plantae
2nd Lumbrical
3rd Lumbrical
4th Lumbrical
Deep br. of the lateral plantar nerve:

Adductor Hallucis muscle(both heads)
1st Dorsal lnterosseous muscle
2nd Dorsal lnterosseous muscle
3rd Dorsal lnterosseous muscle
1st Plantar lnterosseous muscle
2nd Plantar lnterosseous muscle
Superficial br. of the lateral plantar nerve:

Flexor Digiti Minimi Quinti
4th Dorsal lnterosseous muscle
3rd Plantar lnterosseous muscle
Lateral terminal br. of the deep peroneal nerve:

Extensor Digitorum Brevis
ENTRAPMENT NEUROPATHIES
MORTON'S NEUROMA
A painful benign fibrotic enlargement of one of the common digital
nerves caused by shearing forces of adjacent metatarsal heads. This
process most commonly affects the 3rd common digital nerve and less
commonly the 2nd. The 3rd common digital nerve is located between
and often distal to the third and fourth metatarsal head, plantar to the
intermetatarsal ligament.
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CHAPTER 5
SIGNSISYMPTOMS
-more common in females, possibly due to shoe gear
-most common in the 4th-6th decade of life
-pain is described as burning, cramping, or sharp and frequently radiates to the toes. Pt may also have pain radiating proximally and may
notice numbness or tingling.
-patient may feel as though they are walking on a wrinkle in their
sock
-Sullivan's Sign-toes adjacent to affected IS splay apart on weight
bearing
-pain is worse in shoes and upon dorsiflexion of MPJ's(high heels)
-lateral squeeze test(point tenderness upon palpation of the plantar
aspect between the metatarsal heads while squeezing the
metatarsal heads together)
-Mulderls sign-silent palpable click
-pain relieved by removing shoe and massaging affected area
TREATMENT
-modification of shoe gear
-orthotics, strapping, padding
-corticosteroid injections
-oral anti-inflammatory agents
-cold therapy, stretching and other PT modalities
-Sx, neurectomy, EDIN
JOPLIN'S NEUROMA
-a benign enlargement of the medial plantar digital proper nerve located
on the plantar medial aspect of the first MPJ of the hallux
-signs and symptoms are similar to those of other distal focal neuropathies; paresthesia and burning with pain at the point if compression
or entrapment
-cause is usually biomechanical(excessive pronation, hallux limitus)
TREATMENT
-off-weight nerve
-orthotics
-injections
-NSAIDs
-Local anesthesia
-Neurectomy
NEUROLOGY
TARSAL
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TUNNEL SYNDROME
-an entrapment or compression neuropathy within the tarsal tunnel

beneath the flexor retinaculum(Laciniate ligament)
-the tibial nerve divides into three branches beneath the flexor retinaculum, medial plantar nerve, lateral plantar nerve, and the medial calcaneal nerve
-tarsal tunnel syndrome is analogous to carpal tunnel syndrome in the wrist
TARSAL TUNNEL BORDERS
Flexor retinaculum(laciniateligament)
-MEDIALLY and POSTERIORLY
Calcaneus and posterior aspect of talus -LATERALLY
Distal tibia and medial malleolus
-ANTERIORLY
CAUSE
-trauma(fracture, sprain, dislocation)
-Inflammatory conditions(RA, tendonitis, synovitis, diabetes)
-space occupying lesions(ganglion, varicosities, lipoma, neurilemoma,
edema)
-biomechanical(excessive pronation-results in stretching of the tibial
nerve)
SlGNSlSYMPTOMS
-pins-and-needles, numbness, burning, or shooting pains over the entire
plantar foot
-symptoms are usually exacerbated by activity such as prolonged weight
bearing, walking, or running
-forced eversion of the foot may produce symptoms because this motion
essentially stretches the nerve and compresses the content of the tarsal
tunnel
-intrinsic muscle atrophy with hammertoe formation is a late manifestation
-possibly a (+) Tinel's sign
-possibly a (+) Valleix's sign
-possibly a (+) Turks test
TREATMENT
-NSAIDS
-local PT nerve blocks with infiltration of corticosteroids
-control pronation(arch supports, orthotics)
NEUROLOGY
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CHAPTER 5
SURGICAL TREATMENT
-involves a longitudinal incision of the flexor retinaculum
-any space occupying lesions are excised
-care must be taken not to damage the medial calcaneal branch of the
tibialnerve as it penetrates the flexor retinaculum to provide sensory
innervation to the medial heel
-a tourniquet may or may not be used, however, with a vascular etiology
such as varicosities, a tourniquet may hide the cause
-the flexor retinaculum should not be sutured back after surgery to
prevent constriction of the nerve
MISCELLANEOUS NEUROLOGICAL
CONDITIONS
MULTIPLE SCLEROSIS
-a chronic inflammatory disease characterized by patchy demyelination
of the CNS
-the incident rises steadily from the teens to age 35, and declines gradually thereafter
-the clinical course is highly variable and unpredictable, but generally
follows one of relapsing and remitting
-male to female ratio is 1 :2
CAUSE
-thought to be autoimmune
SIGNS AND SYMPTOMS
-initially patients have discrete motor, sensory, cerebellar or visual
attacks that come on over a 1-2 week period and resolve over a 4-8
week period
-there may be only partial recovery or no recovery from an attack
-other symptoms include: ocular palsy, fatigability/weakness, clumsiness,
bladder dysfunctions, spasticity
-Charcot's triad-nystagmus, intention tremor, scanning speech(syllables
are separated by pauses)
-excess heat may accentuate symptoms(avoid hot baths and jacuzzis)
NEUROLOGY
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DIAGNOSIS
-MRI
-spinal tap
-increased DTR's and (+) Babinski
TREATMENT
-symptomatic(corticosteroid)
AMYOTROPHIC LATERAL SCLEROSIS(ALS,

LOU GEHRIG'S DZ)
-a devastating progressive degenerative disease of UMN's and LMN's
-usually occurs when patients are in their 40's
-male to female ratio is 2:1
-usually fatal within 2-5 years of onset
SIGNSISYMPTOMS
-wasting, weakness, cramps, stiffness, muscle twitching, spasticity of
muscle groups, unexplained weight loss, or slurred speech
-musculoskeletal symptoms often beginning in the hands and spreading
to the arms and legs
-increased DTR's
-mental status is usually preserved
DIAGNOSIS
-diagnosis is difficult but there may be an abnormal EMG or mildly
elevated serum CK
CAUSE
-unknown
TREATMENT
-none
GUILLIAN-BARRE SYNDROME(LANDRYIS
PARALYSIS)
-an acutely progressive but self-limiting, acquired, inflammatory,
demyelinating polyneuropathy resulting in rapid weakness and paralysis
-the weakness spreads within several days and in some cases may
cause life-threatening breathing difficulty
-most commonly affects those between 30-50 years of age
-spontaneous recovery begins 1-3 weeks after onset and complete
recovery usually takes place within 3-6 months; in more severe forms
permanent residual paralysis may occur, most notably foot drop
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CHAPTER 5
CAUSE
-cause is unknown(autoimmune)
-there is often a precipitating factor such as a viral infection, vaccination,
or recent surgery
SIGNSISYMPTOMS
-symmetrical muscle weakness usually beginning in the legs and progressing to the arms
-although sensory involvement may occur, motor weakness is always
more prominent
-decreased DTR's
TREATMENT
-respiratory function must be monitored, even mild weakness may
progress to life-threatening respiratory failure within hours
-physical therapy to prevent contractures
CHARCOT-MARIE-TOOTH DISEASE(CMT,
PERONEAL MUSCULAR ATROPHY)
-named for the 3 physicians who first recognized the disease
-a hereditary, demyelinating, hypertrophic neuropathy of the peripheral
nervous system
-characterized by slow progressive distal muscle atrophy(esp. peroneals) resulting in foot drop
-there may or may not be sensory changes, but these are less severe
than muscle atrophy
-when autosomal-recessive, the disease manifests at around age 8
years of age, when dominant, the disease manifests at around age 30
years old
-the earlier the onset, the poorer the prognosis
CAUSE
-hereditary
SIGNSISYMPTOMS
-weakness in the peroneal muscles
-pes cavus
-"stork legu-skinny legs due to peroneal atrophy
-inverted Champagne bottle legs
-foot drop(slapping gait)
-unsteady gait/tending to trip easily
-stocking-glove sensory loss
-decrease ankle DTR's
-later in the disease the hallux becomes fixed and rigidly plantarflexed
and the hands may become involved
NEUROLOGY
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CHAPTER 5
TREATMENT
-symptomatic
-AFO for foot drop
CHARCOT'S JOINT
-a destructive arthropathy resulting from impaired painperception and
increased bone blood flow from reflex vasodilation
-with increased bone blood flow the bones become washed out and
weak, and with impaired deep pain sensation and proprioception small
periarticular fractures go unnoticed until the entire joint is destroyed
-this is a separate and distinct entity from CMT
-any condition resulting in neuropathy can cause a charcot joint most
notably diabetes
FRIEDREICH'S ATAXIA
-a spinal form of the hereditary sclerosis
-onset in childhood or adolescence(5-15 years)
-decreased DTRs, ataxia, pes cavus, and scoliosis are common
-Life expectancy is limited
RSD(Reflex Sympathetic Dystrophy)

-a disease characterized by persistent severe burning pain associated
with trophic and vasomotor changes
-bilateral in 10-20% of patients
-causalgia is often used interchangeably with RSD, however, it should
be resewed for painful burning and hyperpathia over the area of a specific nerve
-Sudek's atrophy-post traumatic painful osteoporosis
-occurring most commonly following trauma(possibly minor) or disease
-the interval between injury and onset may vary from several days to
years, 35% of patients have no history of trauma
-the pain is initially localized to the site of injury or the distribution of the
affected nerve, but with time it spreads to involve the entire extremity
-the pain is usually continuous and may be so severe that even moving
or touching the limb is unbearable, the pain may also be exacerbated by
emotional stress
-untreated, the condition can lead to muscle atrophy, fixation of joint,
and a useless extremity
-more common in middle age, and those with psychiatric
problems(depression)
NEUROLOGY
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CHAPTER 5
CAUSE
-the exact pathophysiology is unknown
-sympathetic nervous system plays an important role in both the pain
and the autonomic symptoms
-one popular theory by Livingston is chronic irritation of a peripheral sensory nerve secondary to trauma causing abnormal firing in a closed selfsustained loop in the dorsal horn of the spinal cord
STAGES
Stage 1-Acute
-days to weeks
-constant burning pain, allodynia, hyperalgesia, hyperesthesia, hyperpathia
-localized edema
-joint stiffness, limitation of motion
-initially the skin is warm, red, and dry, but near the end of this stage it
becomes cyanotic, cold, and sweaty
-bone scans with technetium(99mTC) show increased uptake by the
small joints
-radiographs are usually normal, changes take 5-6 weeks to develop
Stage 2-Dystrophic
-3-6 months
-continuous burning, aching pain, allodynia, hyperalgesia, hyperpathia
-indurated edema
-skin takes on a cool, pale, discolored, and frequently mottled or
cyanotic appearance
-dystrophic changes occur, hair growth is decreased and nails are brittle,
cracked, and ridged
-radiographs may show spotty/diffuse osteopenia(Sudeck's atrophy)
-joints become thickened/contracted and muscle wasting may be present
-this stage is still capable of improvement
Stage 3-Atrophic
-greater than 6 months
-pain, allodynia, and hyperpathia extend proximally to involve the entire
extremity, however, the pain may become less severe
-more advanced atrophic skin, nail, and soft tissue changes
-skin becomes tightly stretched, smooth, pale, waxy, and cyanotic
-marked muscle atrophy, particularly the interossei
-contractures and ankylosing joints
-radiograph show marked spotty or diffuse periarticular demineralization
-at this stage prognosis is very poor
NEUROLOGY
126
CHAPTER 5
DIAGNOSIS
-history and physical
-thermography-decrease in temperature in either the early or late stages
of the disease, possibly increased temperature localized around joints
-bone scans-diffuse increased uptake in the affected area using a 3
phase Technetium bone scan
-radiographs-spotty or diffuse osteopenia(Sudeck's atrophy), takes 5-6
weeks to develop
-doppler may be helpful in evaluating vasomotor changes
-sympathetic block-relief of symptoms
TREATMENT
-early diagnosis and treatment are crucial for a good prognosis
-prompt diagnosis and treatment can result in remission of symptoms
and complete recovery
-medications:
steroids
tricyclic antidepresants
beta-blockers
antiseizure medications
-physical therapy:
massage
ROM exercises
US
splinting
contrast baths
-interference with nerve transmission:
TENS
acupuncture
sympathectomy
-blocks:
peripheral blocks
Bier block-Reserpine
-psychotherapy:
NEUROLOGY
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CHAPTER 5
ELECTROMYOGRAPHYCEMG) AND NERVE

CONDUCTION VELOCITY[NCV) STUDIES
-used for electrodiagnosis of neuromuscular disorders
EMG-Electromyography
Assesses the electrical activity generated by muscle fibers at rest and
with activity.
RESULTS
Normal
-At rest the electrical signal should be silent and with
voluntary movement unit potentials are roughly
proportional to effort.
Denervation -In denervated muscles there are fasciculations at rest.
With voluntary movement the number of motor units
under voluntary control are decreased, and the duration
and amplitude of the individual potentials are increased.
The increase is due to collateral sprouting of axonal
processes from surviving axons.
NCV-Nerve conduction velocity

Used to distinguish conditions involving the myelin sheath from those
affecting the axon. They are also helpful in determining the distribution
of a nerve lesion, including areas of focal nerve compression(tarsal tunnel). NCVs measure the latency of motor nerve conduction, which is the
time from stimulation of a nerve to the evoked muscle response. The
test is performed by stimulating one point on a nerve and measuring the
time taken before the muscle responds. The test is then repeated at a
second site closer to the muscle. By subtracting one time from the
other, it is possible to determine the time taken for the impulse to cover
the measurable distance between the two sites of stimulation. The
result is a rate of meters per second(mps). Normal values vary but are
almost always greater than 40mps.
PERIPHERAL NEUROPATHY
The following chart was reproduced with permission from The
NeuropathyAssociation: 60 E. 42nd St. Ste. 942. New York. NY 10165
~hone
(800) 247-6968 ~ h Neuropathy
e
~ssociationis a ndnprofit, charitable, patient based organization that provides support, education, and
promotes research into the cause and treatment of peripheral neuropathy.
-
- -
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NEUROLOGY
130
CHAPTER 5
NEUROLOGY
131
CHAPTER 5
NEUROLOGY
132
CHAPTER 5
NEUROLOGY
133
CHAPTER 5
NEUROLOGY
134
CHAPTER 5
NEUROLOGY
135
CHAPTER 5
NEUROLOGY
136
CHAPTER 5
NEUROLOGY
137
CHAPTER 5
NEUROLOGY
138
CHAPTER 5
NEUROLOGY
139
CHAPTER 5
NEUROLOGY
140
CHAPTER 5
NEUROLOGY
141
CHAPTER 5
NEUROLOGY
142
CHAPTER 5
NEUROLOGY
143
CHAPTER 5
NEUROLOGY
144
CHAPTER 5
NEUROLOGY
145
CHAPTER 5
NEUROLOGY
146
CHAPTER 5
NEUROLOGY
147
CHAPTER 5
NEUROLOGY
148
CHAPTER 5
NEUROLOGY
149
CHAPTER 5
NEUROLOGY
150
CHAPTER 5
NEUROLOGY
151
CHAPTER 5
NEUROLOGY
152
CHAPTER 5
NEUROLOGY
153
CHAPTER 5
NEUROLOGY
154
CHAPTER 5
NEUROLOGY
155
CHAPTER 5
TREATMENT FOR PERIPHERAL NEUROPATHY

Narcotic and Nonnarcotic Analgesics(i.e.,Codeine, Acetaminophen, ASA)
Antidepressants(i.e., Amitryptilline-Elavil, Desipramine, Imipramine,
Doxepin, Nortryptiline, Trazodone, Bupropion)
Anticonvulsants(i.e., Carbanazepine, Phenytoin, Clonazepam,
Gabapentin-Neurontin)
Local Anesthetics(i.e., Lidocaine)
Aldose Reductase Inhibitors(i.e., Epalrestat, Ponalresat, Alrestatin)
Topical Agents(i.e., Capsaicin, Zostrix)
Vitamins(i.e., Vitamin 812, Biotin)
Antiarrhythmics(i.e., Mexiletine)
Antipsychotic-phenothiazines(i.e.,Prolixin)
Selective Serotonin Reuptake 1nhibitordi.e.. Paroxetine, Fluoxetine.
Sertraline)
NERVE SCLEROSING INJECTIONS

-used as an alternative to surgery for Morton's neuroma
-causes chemical neurolysis via Wallerian degeneration
-alcohol has a high affinity for neural tissue and causes Wallerian nerve
degeneration by dehydrating the nerve
- 0 . 5oc c f 4 % alcohol sclerosing agent are injected
-administer 3-7 injections one week appart
Preparing solution: Aspirate 2cc's from a 50ml vial of 0.5%
Bupivacaine HCL with epi. Next introduce 2ml of absolute dehydrated
alcohol into the same vial. This yields 50cc's of 4% sclerosing solution
This solution is good for about 1 month.
NEUROLOGY
156
CHAPTER 5
CARDIOLOGY
157
CHAPTER 6
CHAPTER 6
CARDIOLOGY
ANATOMY, p158
BLOOD FLOW THROUGH HEART, 158
CARDIAC RHYTHMS, p164
HEART SOUNDS, p159
MURMURS, p159
READING EKGs, p162
CARDIOLOGY
ANATOMY
158
CHAPTER 6
Ligamentum arteriosum
(former Ductus arteriosus)
Superior vena cava
Left pulmonary artery
Right pulmonary artery
Sinoatrial nod
eft bundle branch
Inferior vena cava
Rlght bundle branch
BLOOD FLOW THROUGH HEART

-superior and inferior vena cava
-right atrium
-tricuspid valve
-right ventricle
-pulmonic valve
-pulmonary artery
-lungs
-pulmonary veins
-left atriuma
-mitral valve(bicuspid valve)
-left ventricle
-aortic valve
-aorta
-systemic circulation
CARDIOLOGY
159
CHAPTER 6
HEART SOUNDS
I
S1
-due to closure of the atrioventricular valves(tricuspid and mitral)

-heard loudest at mitral and tricuspid areas
-use diaphragm of stethoscope
S2 -due to closure of the semilunar valves(aortic and pulmonic)

-heard loudest at aortic and pulmonic areas
-use diaphragm of stethoscope
S3
-caused by rapid ventricular filling

-heard loudest at mitral area
-may be normal in young people or due to CHF or mitral
regurgitation
-use bell of stethoscope
S4 -caused by forceful atrial ejection into a distended ventricle

-heard loudest at mitral area
-may be normal(children, well-trained athletes) or due to HTN or
aortic stenosis
-use bell of stethoscope
MURMURS
-use the diaphragm for high-pitched murmurs
-use the bell for low-pitched murmurs
-loudness of murmur is not proportional to severity of dz
-the term "regurgitation", "incompetence", and "insufficiency" are used
interchangeably
CARDIOLOGY
160
CHAPTER 6
INNOCENT VS. PATHOLOGICAL MURMUR

innocent
~ h o l o g i c a l
systollc
d~astolic
not max~mallyat aort~carea orlglnates In heart Itself
Grade 3 or &ss
can be any grade
Variat~onw~th can vary greatly
usually constant
resp~rat~on (louder on ~nsplrat~on)
Evidence of
no
cardiac dz
all ages
Age
more common in
childrenlyoung adults
Timing
MURMUR LOUDNESS SCALE

I
II
Ill
IV
V
barely audible
faint, clearly audible
moderately loud with no palpable thrills
loud with palpable thrill likely
very loud, may be audible with stethoscope partly off chest. Palpable
thrill likely
VI very loud, may be audible with stethoscope off chest. Associated
with palpable thrills
*thrills-low frequency cutaneous vibrations associated with loud heart

murmurs. The vibration can often be felt with the hand placed on the
chest.
MURMUR TYPES
Aortic Stenosis
-loudest at aortic area
-mid-systolic murmur
SI
-radiates to carotids and sometimes apex
-crescendo-decrescendo
-loud, harsh, medium pitched
-ejection click and S4 often heard at apex
S
"
5%
S
-5% SI
D
CARDIOLOGY
161
Aortic Regurgitation
-location varies-aotic area
-left lower sternal border
-3rd intercostal space left
-early-diastolic murmur
-decrescendo
-holosystolic
-blowing, high-pitched
-louder sitting forward and after
exhalation
CHAPTER 6
S,
SI
s2
SI
Pulmonic Stenosis
-loudest at pulmonic area
-mid-systolic murmur
-crescendo-decrescendo
-harsh, medium pitch
-louder on inspiration
-click often heard
Pulmonic Regurgitation

s
-diastolic murmur
-low pitched
s,
decrescendo or crescendo-decrescendo
-louder on inspiration
Mitral Stenosis
-
Is,
S2
111111111s,11111
D
E~
SP
1 . " . , .s,?~,.
1DIIIIIIII~IIIIIII~~~~
. ,. . .
-heard loudest at apex(mitra1area)

-mid-diastolic murmur
S,
-opening snap
-low pitch, rumbling(use the bell)
-decrescendo
-accentuated by-exercise
-left lateral decubitus position
SI
Mitral Regurgitation
sometimes the aortic area
-holosystolic murmur
-radiates to left axilla
-high-pitched, blowing murmur
s,
"
Is,
s 2 D A S T 0 L E
CARDIOLOGY
162
CHAPTER 6
Rhvthm
regular-a pulse with no irregualarities
regularly irregular-a pulse having an irregularity that occurs in a
regular pattern
irregularly irregular-an irregular pulse with no pattern
Components
P
=depolarization of the atria
QRS =depolarization of the ventricles
T
=repolarization of the ventricles
a) PR interval
-beginning of the P wave to the
beginning of the QRS complex
-normal interval is between
0.1 2-0.21 seconds
-if longer than 0.21 sec-heart block
-if shorter than 0.12 sec-Wolf-Parkinson-White Q
'T
-and Lown-Ganong-Levine syndrome
b) QRS interval
-beginning of Q wave to end of S wave
-normal is less than 0.12 seconds
-lengthening can occur with:
beats initiated in the ventricles(i.e. PVC, VT, AIVR)
bundle branch blocks
pacemakers
c) Q wave
-hallmark of infarction
-Q wave will appear or enlarge following an MI
-most Q waves are permanent and offer valuable information when
pre-oping a patient(no Sx if patient had an MI in past 6 months)
important to get old EKG for comparison
d) ST segment
-between end of QRS and beginning of T wave
-elevated ST is the hallmark of myocardial injury
e) T wave
-inverted T wave may indicate ischemia
-tall, peaked T waves indicate hyperkalemia
f) U wave
-sometimes seen following T waves
-associated with electrolyte disturbances(hypokalemiaand hypomagnesemia)
CARDIOLOGY
163
CHAPTER 6
Tricuspid Regurgitation
-loudest at tricuspid area
-blowing, high pitched
-holosystolic murmur
-increases with inspiration
SI
S,
SI
SI
a ' " ' u . ' "
"
S 2 0 1 A s T 0s,L E
Atrial Septal Defect

-systolic murmur
~A
2C q
Ventricular Septal Defect

-loudest at tricuspid area
-high-pitched, harsh
-holosystolic with mid-systolic peak
Sl
'
S 2 D ' A S T 0Sl
L E
Patent Ductus Arteriosus

-loudest at left 2nd intercostal
mace below left clavicle
-continuous, "machine murmur"
..
,
s8"
.
-
"
""S1
READING EKGs
EKG paper
-little 1mm box
-big 5mm box
-distance between slashes at top of page
= 0.04 seconds
= 0.20 seconds
= 3 seconds
Determining Heart Rate

measure the distance between two consecutive QRS complexes
1 big box =300bpm
2 big boxes =150bpm
Divide 300 by the number of big boxes
3 big boxes =100bpm
between two consecutive QRS complexes
4 big boxes =75bpm
5 big boxes =60bpm
6 big boxes =50bpm
Alternately, if the rate is slow or rhythm is irrregular
-count the number of QRS complexes between 2 three second slash
marks at the top of the page(30 big boxes) and multiply by 10
CARDIOLOGY
164
2 Second degree heart block
CHAPTER 6
ype
not all atrial impulses reach the ventricles
P-R interval progressively lengthens until a QRS complex is dropped,
then the cycle repeats
not all atrial impulses reach the
CARDIOLOGY
165
CHAPTER 6
3) Third degree heart block

-none of the atrial impulses reach the ventricles
-atrium and ventricles beat independently at their own regular rates
(atrial rate 60-100bpm, ventricular rate 40bpm)
-no correlation between P's and QRST's
4) Sinus Arrhythmia
-NSR with varying rate depending on respiration
-rate increases with inspiration, rate decreases with expiration
in a prolonged pause
CARDIOLOGY
166
CHAPTER 6
7) Sinus tachycardia
8) Premature atrial
-a focus in the
than the SA node) depolarizes prematurely
wave appears early and abnormally shaped or it may be lost in the
previous T wave
-causes: stimulants-coffee, tobacco,
heart disease, CHF, meds, hypoxia
low
levels
CARDIOLOGY
167
CHAPTER 6
9) Paroxysmal atrial tachycardia(PAT) or Paroxysmal

supraventricular tachycardia(PSVT)
-a focus in the atrium(other than the SA node) depolarizes, giving rise to
a series of rapid beats at a regular rate between 150-250lminute
-begins and ends suddenly(paroxysmal)
10) Atrial flutter

-rapid firing of an ectopic atrial focusMsawtooth"pattern
-only some beats pass to the AV node
11) Atrial fibrillation
-multiple atrial foci depolarizing in a chaotic manner

-a small number pass through th AV node
CARDIOLOGY
168
CHAPTER 6
12) Premature ventricular contraction(PVC)

-ectopic depolarization in any portion of the ventricular myocardium
-PVC's are of little concern if they arise from the same foci or if there
are less than 5/minute
-If they arise from more than one foci or there are greater than
5/minute, can lead to V-fib
13) Ventricular tachycardia

-ectopic depolarization of ventricles usually at a rate of 150-250/minute
-can degenerate to V-fib
14) Ventricular fibrillation

-rapid, irregular, disorganized ventricular rhythm
-results in lack of cardiac output, no pulse, no BP
CARDIOLOGY
169
CHAPTER 6
15) Normal sinus rhythm
16) Wolff-Parkinson-White Syndrome(WPW)
-an electrical bridge exists between the atrium and ventricles causing a
conduction bvoass of the AV node
17) Junctional Rhythm

-heart beat originating in the AV junctional tissue as a safety mechanism
when the higher pacemaker site(SA node) is not functioning or if the
impulses are not getting through
-inverted P wave
-the AV junct~onaltissue beats at 40-60bpm
CARDIOLOGY
170
CHAPTER 6
PHYSICAL THERAPY
171
CHAPTER 7
CHAPTER 7
PHYSICALTHERAPY
THERAPEUTIC HEAT, p172
SUPERFICIAL HEAT, p172
Whirlpool, p172
Contrast baths, p 172
Paraffin wax, p173
DEEP HEAT, p173
Ultrasound, p173
Phonophoresis, p175
Shortwave Diathermy, p174
Microwave Diathermy, p174
THERAPEUTIC COLD, p174
Ice pack, p174
ELECTRICAL STIMULATION, p175
TENS, p175
lontophoresis, p175
Phonophoresis, p175
STRENGTHENING EXERCISES, p175
WALKING AIDS, p176
Crutches, p176
Canes, p176
PHYSICAL THERAPY
172
CHAPTER 7
THERAPEUTIC HEAT
Phvsioloaical effects
Uses
I-vasodilation
-increases local tissue metabolism
-increases capillary permeability
-increases collagen extensibility
-decreases joint stiffness
-arthritis
-stiff ioints
-muscle spasms
-inflammation
-pain
-trauma*
*Heat can be used on subacute and chronic stages of injury, do not use
heat during the first 48hrs following injury or while active swelling is
occuring
SUPERFICIAL HEAT
-with most heat modalities where the temperature can be
controlled(whirlpool, contrast baths, paraffin) the heat source should be
set at around 45C and treatment should run about 15-30 minutes
Indications
Contraindications
-chronic post-traumatic conditions

-nerve injuries
-painful stumps
-decubitus ulcers
-post-surgical rehab
-arthritis
-photosensitivity
Whirlpool
-mechinical agitation which relaxes and massages muscles
-kinetic whirlpool-combine with ROM exercises
-can be used with ulcers that don't involve bone, Abx may be added to
the water
-indications: chronic post-traumatic conditions, nerve injuries, painful
stumps, decubitus ulcers, post surgical rehabilitation, arthritis
Contrast baths
-although it involves both hot and cold, the effects are that of a heat
modality
-two baths: 1 with hot water, 1 with cold(ice water)
-feet are placed alternately in each for -1 minute
-always start and end with cold
-effectiveness is due to reflex hyperemia(Hunting effect or response)
-particularly good for stimulating circulation, reducing muscle fatigue,
edema, and is useful in treating RSD
PHYSICAL THERAPY
173
CHAPTER 7
Paraffin wax
-dip foot 6-10 times for several seconds
-wrap in plastic and a towel and let sit for 20-30 minutes
-good for sprains, strains, and arthritic conditions
DEEP HEAT
Indications
Contraindications
-chronic post-traumatic conditions

-nerve injuries
-painful stumps
-decubitusulcers
-post-surgical rehab
-arthritis
-metal implants
-pacemakers
Ultrasound
-therapeutic ultrasound is a deep heating modality that uses a mechanical vibration in the form of a longitudinal sound wave causing not only a
thermal but mechanical effect on tissue
-the mechanical effects of US have a therapeutic physiological effect
-increased diffusion rates across cell membranes
-altered cell permeability
-streaming effect-movement of molecules along the path of sound
transmission
-break up adhesions/scars
Indications
Contraindications
-edema
-pain
-adhesions/scar tissue
-areas with embolism

-anesthetized skin
-epiphyseal areas in children
-bony prominences
-vascular dz(DVT, atherosclerosis,
hemorrages)
-acute infection
-around implants, malignancies
-patients with pacemakers
Application
-Ultrasound does not propagate through air so a coupling medium is
required. It must have a low attenuation coefficient, meaning it does not
absorb sound(US gel or water)
-ultrasound machines have an option of continuous or pulsed sound
waves; continuous
PHYSICAL THERAPY
174
CHAPTER 7
produces both thermal and mechanical effects and pulsed produces only
mechanical effects(does not heat tissue)
1 Direct couolina
-requires gel
-US head is olaced directlv on the skin and moved around in smooth
circles over the affected area
2) Water immersion coupling
-ideal when direct contact with skin is not possible due to pain or
uneven surface(around toes)
-place the foot and sound head in water and hold the sound head
directed at the area less that one inch from the skin with out actually
contacting the tissue
Shortwave Diathermy
-uses a high frequency alternating current to heat tissues
Microwave Diathermy
-a form of electromagnetic radiation used to heat tissues
-tissue containing a high water content is heated more than tissues with
a lower water content, thus it's is good tor muscle problems and joints
with soft tissue covering
THERAPEUTIC COLD
Phvsioloaical effects
Uses
-vasoconstriction
-swelling
-decrease cellualr metabolism(inflammation) -pain
-decrease muscle spasm
-muscle spasm
-analgesia(numbing effect)
-trauma'
-decrease swelling
-inflammation
*cold is used during the first 48 hours following injury during acute
swelling
Ice pack
-ice should be applied for the first 24-48 hours after an acute injury
-ice should be alternated 10 minutes on and then ten minutes off
-Ice should be acompanied by Rest, Compression and Elevation(RICE)
PHYSICAL THERAPY
175
CHAPTER 7
ELECTRICAL STIMULATION
TENS(transcutaneous electrical nerve stimulation)
-a pocket-size, battery-operated device that provides mild, continuous
electrical current through the skin by using 2 to 4 electrodes.
-TENS units can be used continuously or intermittently depending on the
disease process
-the intensity(output) knob is slowely turned until a slight tingling or
buzzing is felt on the skin
-a mild electrical current modifies and blocks the pain messages and
replaces them with a buzzing, tingling sensation and can also stimulate
the production of endorphins
-high TENS(100-500Hz) relieves pain by blocking pain fibers and is
used up to 24hrs/day because when the unit is turned off the pain cycle
often returns, low TENS(1-50Hz) relieves pain by endorphin release,
and due to the 4 hour 1/2life of endorphins need only be used 15-30
minutes at time
Indications
Contraindications
-chronic pain
-muscle atrophy
-muscle spasms/fatique
-edema
-peripheral neuropathy
-pacemakers
-pregnancy
lontophoresis
-a noninvasive way of delivering chemicals of like charge through the
skin using a direct current
-must use ionizable compounds
-usually used for such things as topical anesthetics, antiinflammatories,
and muscle relaxants
Phonophoresis
-a noninvasive way of delivering chemicals through the skin using ultrasound, the actual mechanism is probably via the thermal effect and
acoustical streaming of the ultrasound
-usually used for such things as topical anesthetics, antiinflammatories,
and muscle relaxants
STRENGTHENING EXERCISES
Isometriccontraction(static contraction)-muscle contraction that
is not associated with joint motion or change in muscle length. Can be
performed in a cast.
PHYSICAL THERAPY
176
CHAPTER 7
Isotonic contraction(dynamic contraction)- muscle contraction

with associated joint motion and change in muscle length, either eccentric
or concentric
Eccentric c o n t r a c t i o n -m u s c l e contraction in which the muscle
lengthens while contracting. Contraction force of the muscle is
against an overpowering weight resistance
Concentric
c o n t r a c t i o n -m u s c l e contraction in which the
muscle shortens as a result of the contraction. Where a weight is
lifted with the force of muscle contraction
lsokinetic contraction-contraction at a constant velocity at all
ranges of motion by using a machine with an accommodating resistance.
WALKING AIDS
Crutches
Sizing:
-adjust height of crutches to allow 2 fingers width between axilla and
axillary pad
-handpiece is adjusted to allow 30" of elbow flexion
Canes
Sizing:
-measure from ground to the greater trochanter for the length of the
cane
-elbow should be flexed about 30"
-cane is held in hand opposite affected foot
PLASTIC SURGERY
177
CHAPTER 8
CHAPTER 8
PLASTIC SURGERY
INCISIONS, p184
SKlN GRAFTS, p178
SKlN PLASTIES, p180
PLASTIC SURGERY
178
CHAPTER 8
SKIN GRAFTS
GENERAL
-skin taken from one part of the body and used to cover a wound in
another part of the body
the thinner the graft the better the 'take', the thicker the graft the better
the function
-a good "take" requires absence of infection, perfect hemostasis, a good
dressing and absence of motion
TYPES(Full-thickness vs. partial-thickness)
FULL-THICKNESS
PARTIAL-THICKNESSCSPLITGRAFTS
THICKNESS)GRAFTS '
eedidermisand all of the dermis
-epidermis and varyingamount
.
-"taken is not as good and infection of'the dermis
-the thinner the graft the more
rate is higher
likely it will "take" because a higher
grafts do not shrink and do not
number of blood vessels are
change color
transected and there is more
-hair follicles are preserved
opportunity for revascularization
-grafts tend to shrink(50%-70%) and
become hyperpigmented
MESHING
-meshing is a process by which multiple staggered rows of full-thickness
incisions are placed in a graft before application to the recipient site
DISADVANTAGES
ADVANTAGES
-expands tissue allowing a smaller -inferior aesthetic appearance
after healing
graft to cover a larger site
-graft becomes very delicate
-allows drainage of hematoma/
seroma through the graft
-easily torn
-allows the graft to drape extremely
well around irregular surfaces
PLASTIC SURGERY
179
CHAPTER 8
DONOR SITE
Full-thickness
Partial Thickness
Graft
(Split-thickness) Graft
-best donor sites are flexor surfaced -common donor sites include the
especially the groin
anterior or lateral thigh, upper inner
arm, gluteal region, or the dorsum
-the donor site is closed primarily
of the foot
leaving a linear scar
-length to width ratio of donor graft -grafts are harvested with an
should be at least 3:l for adequate instrument called a dermatome
closure
(Padgett, Humby, Gouiiain knife,
Stryker, Brown) which takes thin
slices of skin
-smaller grafts can be obtained
using a scalpel
-after the graft is removed,
minimalize bleeding with topical
thrombin and dilute epinephrine or
cautery and dress with Opsite or
Teaaderm
RECIPIENT SITE
-grafts require a vascular recipient site and cannot be place directly over
cortical bone or tendon
-control bleeding(topical thrombin, dilute epi. and cauterization)
-must be free of infection(bacterial count less than 105/mL)
-granulation tissue must be debrided
-graft is sutured into place leaving strategically placed long ties at various points around the graft sites for securing a stent dressing
Stent dressing
-a type of dressing designed especially for skin grafts that functions to
hold the graft in place, apply pressure, and absorb fluids
-consist of a semipermeable nonadherent dressing(Adaptic, Owen's
Silk), several layers of moist saline soaked gauze, and fluffs held in
place by the tie-over sutures left in place during securing of the graft.
Alternately in the case of the lower extremity a circumferential wrap may
be used
PLASTIC SURGERY
180
CHAPTER 8
POST-OP
-dressing remains on for 5-7 days(2 days if unmeshed) during which
time the extremity is elevated until venous circulation is established
-important to eliminate movement/shearing so graft can "take" this may
require NWB, casting/splinting
-any fluid that accumulates under graft must be aspirated because it creates a barrier against revascularization
REASONS FOR GRAFT FAILURE

hematoma-blood develops under graft(most common)
seroma-serosanguineous fluid develops under graft
infection(second most common)
shearing forces between graft and recipient site
improper preparation of recipient site
SKIN PLASTIES
Transpositional Flap
Rotational Flap
PLASTIC SURGERY
181
CHAPTER 8
Bilobed Flap
I
I
\
Flap
,
Kutler-Type Bi-axial V-Y
(Advancement Flap)
Atasoy-Type Plantar V-Y

(Advancement Flap)
PLASTIC SURGERY
182
CHAPTER 8
Z-Plasty
-angles permissible for Z-plasties are 45-60(60 gives
the greatest
lengthening)
-angles less than 45 results in impaired blood flow to the flaps and
angles greater than 60 results in severe tension
-particularly useful in treating linear scar contractures
V-Y Plasty
-skin lengthening technique
-the apex of the "V" can point distally or proximally
Derotational Skin Plasty for 5th Digits

-done in conjunction with an arthroplasty
-acts to correct for the varus(frontal) and hammering(sagittal)of the digit
-incision made from distal, medial to proximal, lateral
PLASTIC SURGERY
183
CHAPTER 8
Desyndactyly Procedure
-place needles from dorsal to plantar to line up apices
Tsuge's "inch worm" plastic reduction procedure

-fishmouth incision made around toe just dorsal to phalange
-dorsal skin is retracted allowing proximal skin to buckle
-tip of toe excised, nail may be reduced in width if desired
-6 to 8 wks later dorsal redundant skin is excised
PLASTIC SURGERY
184
CHAPTER 8
INCISIONS
Ollier's lncision
DeVries lncision
Cincinatti lncision
Lateral Extensile lncision

-full thickness incision down to bone
-designed to outline the distribution of the peroneal artery,
also protects the sural n., and peroneal tendons
ARTHRITIS
185
CHAPTER 9
CHAPTER 9
ARTHRITIS
SPONDYLITIS, p190
CROHN'S DISEASE AND ULCERATIVE COLITIS, p201
DERMATOMYOSITIS/POLYMYOSITIS,p199
FUNGAL ARTHRITIS, p195
GOUT, p196
JOINT ASPIRATION TECHNIQUE, p186
JUVENILE RHEUMATOID ARTHRITIS, p188
LYME DZ, p195
OSTEOARTHRITIS, p189
PSEUDOGOUT, p197
PSORIATIC ARTHRITIS, p192
REITER'S SYNDROME, p191
RHEUMATOID ARTHRITIS, p187
SCLERODERMA, p199
SEPTIC JOINT, p193
SJBGREN'S SYNDROME, p200
SYNOVIAL JOINT FLUID ANALYSIS, p187
SYSTEMIC FEATURES OF VARIOUS ARTHROPATHIES, p186
SYSTEMIC LUPUS ERYTHEMATOSUS, p198
TUBERCULOSIS ARTHRITIS, p195
VIRAL ARTHRITIS, p 1 9 5
ARTHRITIS
186
CHAPTER 9
SYSTEMIC FEATURES OF ARTHROPATHIES

DISEASE
-FEATION
EFEM
Psor~atlcarthr~t~s
Re~ter'ssyndrome
I Keratoderma blennorrhaglca
1 Rash
ISe~t~
arthr~t~s
c
(esp N. gonorrhoeae) !
Lyme arthr~t~s
Erythema chronlcum mlgrans
SLE
Butterfly rash, photosens~t~vlty
JOINT ASPIRATION TECHNIQUE

-clean aspiration site with povidoneliodine solution
-local infiltration with 1% Lidocaine may be used for anesthesia, but caution must be used to assure it is does not enter the joint(Lidocaine is
bacteriocidal)
-aspirate with a large bore needle(20 gauge)
-for ankles place the foot perpendicular to the leg and approach either
medially(immediately medial to the extensor hallucis longus tendon) or
laterally(just distal to the fibula)
-for the small digital joints in the foot, enter the joint dorsally just
medially or laterally to the extensor tendons
-in some instances saline may first be injected to the joint to increase
aspirate yield
ARTHRITIS
187
CHAPTER 9
CLOT
WBC
VISCOSITY
Friable
High
200-2,000
2,000-75,000
High
Low
DDX OF
DJD
Trauma
Osteochondritis dissecans
Neuropathic arthropathies
synovitis
Pigmented
SLE
Scleroderma
NT FLUID ANALYSIS
INFLAMMATORY
SEPSIS
A
Bacterial Infection
Scleroderma
Gout
Pseudogout
Reiter's Syndrome
Ankylosis Spondylitis
SLE
Psoriatic Arthritis
Ulcerative Colitis
RHEUMATOID ARTHRITIS
DESCRIPTION
Begins as a chronic symmetric peripheral polysynovitis with insidious
aching and morning stiffness. Caused by an autoimmune response that
progresses to destruction of articular and periarticular structures.
SIGNS AND SYMPTOMS
-symmetrical inflammatory polyarthritis
-pain and swelling worse in the morning and after
better
with motion)
-Gel phenomenon-after rest the pts jt stiffens and becomes painful to move
-female to male
-onset is 20-50 yrs of age
-affects small jts in hands and
wrists,
and PIPJ)
-Possible low grade fever, fatigue, weight loss, and malaise
-Rheumatoid nodules-benign subcutaneous painless masses found at
sites usually subject to trauma
-Boutonniere deformity-flexion of the PIPJ of the finger with
hyperextension of the DlPJ
-Swan neck deformity-hyperextension of the
of the finger with
flexion of the DlPJ
ARTHRITIS
188
CHAPTER 9
-Baker's Cyst(poplitea1cyst)-a synovial fluid filled cyst which develops

in the popliteal fossa. When ruptured symptoms mimic a DVT
-Feltyls Syndrome-rheumatoid arthritis with associated splenomegalia.
Patient presents with pigmented spots on the lower extremity
-Pannus transformation-the synovium develops into a vasculature
granulation tissue that produces inflammatory agents and
immunoglobin-producing lymphoreticular-like elements that destroy
the articular cartilage
DIAGNOSIS
W - i n c r e a s e d Sed rate
-(+)RA factor
-normocytic MCV
m - f i b u l a r / u l n a r deviation of phalanges
-marginal erosions, ulnar styloid process shows early erosions
-increased soft tissue density
-early increase in joint space(from pannus formation), later
decreased joint space which can lead to ankylosis
-juxta-articular osteopenia(metatarsa1heads are washed out while
the shafts may be relatively normal)
TREATMENT
-rest(splints) during flare-ups, ROM exercise during remission
-anti-inflammatory drugs-especially ASA
-corticosteroids(prednisone)
-Antimalarial drugs(Hydroxychloroquine)
-Gold salts, Methotrexate
JUVENILE RHEUMATOID ARTHRITIS

-RA factor is usually negative, however ANA is usually positive
-not a life long disorder(fades with age)
-onset is usually before age 16yrs
-females to males(4:l)
-usually involves the knees, elbows, ankles or neck
-in addition to arthritis JRA is often associated with fever and skin rash
and fusions of the cervical spine(especial1y C2-C4)
-JRA is divided into three types
1) polyarticular(40%)
2) pauciarticular(40%)
-associated with iridocyolitis
3) Still's disease(20%)
-associated with systemic manifestations(splenomegaly, generalized
adenopathy)
-treatment is largely the same as with RA, including ASA and other
antiinflammatory modalites
ARTHRITIS
189
CHAPTER 9
OSTEOARTHRlTlS(~egenerative
Joint Dz)
DESCRIPTION
Osteoarthritis is the most common arthritis and occurs as a result of
wear and tear on joints. The cartilage that cushions the impact on the
joint gradually deteriorates. As the cartilage wears down, subchondral
bone is exposed which becomes sclerotic, the surface becomes worn
and polished in a process called eburnation. Over time, the ends of the
bones also are affected, with bone growing along the sides producing
lumps. There is usually a predisposing factor such as trauma or prior
inflammatory arthritis.
SIGNS AND SYMPTOMS
-asymmetrical noninflammatory arthritis
-pain worse at end of day(after use)
-pain in joint before a change in weather
-loss of flexibility
-Heberdenls nodes(bony protuberances at the margins and dorsal
surface of the DIPJs)
-Bouchard's nodes(bony protuberances at the margins and dorsal
surface of the PIPJs)
-joints most commonly affected(neck, back, knees, hips, shoulder,
1st MPJ and the 1st radiocarpal jt)
DIAGNOSIS
X-ray-subchondral sclerosis
-loose bodies($ mice)
-asymmetrical jt space loss
-soft tissue is normal
TREATMENT
-ROM exercises for stiffness
-Joint replacements
-Synovial fluid viscosupplements-Injected into joints to cushions and
lubricate joint space
SYNVISC(Hylan G-F 20)
-an elastoviscous fluid containing hylan polymers
-indicated in OA
-supplied in 2.25mL syringe containing 2mL
-intra-articular injections once a week for a total of 3 injections
HYALAGAN(SodiumHyaluronate)
-a viscous solution consisting of high molecular weight fraction of
purified sodium hyaluronate
-indicated in OA
-2mL vials or 2mL pre-filled syringes
-intra-articular injections once a week for a total of 5 injections
ARTHRITIS
190
RHEUMATOID ARTHRITIS
Inflammatory
Symmetrical
Pain worse in
or after rest
Osteopenia
Increased soft tissue densitv
CHAPTER 9
Noniflammatory
Asymmetrical
Pain worse at the end of the day
Sclerosis
Soft tissue is normal
(-)RA factor
SERONEGATIVE SPONDYLOARTHROPATHIES
ANKYLOSING SPONDY
DESCRIPTION
A chronic inflammatory arthritis that affects the sacroiliac joint and to a
lesser extent the rest of the spine. Pain and stiffness are early signs,
stiff, inflexible backbone) is
but in advanced cases a poker
common.
AND SYMPTOMS
-onset is 15-35 yrs
-male to female
-lower back
-Recurrent acute iritis in
DIAGNOSIS
-increased sed rate
of pts
Test
-X-ray
-abnormalities at the sacroiliac jt
-bamboo spine
TREATMENT
-PT
ARTHRITIS
191
CHAPTER 9
REITER'S SYNDROME
DESCRIPTION
-a syndrome consisting of the tetrad:
1) arthritis
2) urethritis(nonbacteria1)
3) conjunctivitis
4) mucocutaneous lesions
-most signs of the disease disappear in days to weeks, the arthritis may
persist for months or years
TYPES
Sexually transmitted
Typical patlent Ma&s(20-40y~s)~~
Females and children
Salmonella
_ _
Cam lobacter
Enteritis(di~hea1
SIGNS AND SYMPTOMS

-asymmetrical arthritis that usually follows within 1 month of
urethritis or enteritis
-much more common in males
-Tetrad: arthritis, urethritis(nonbacterial),conjunctivitis, and
mucocutaneous lesions
-dysenteric form results in diarrhea
-usually attacks large WB jts of LE: sacroiliac jt, knees, and ankles
-back pain may occur with more severe dz
-Inflammation of tendinous insertions("Sausage" toes, plantar fasciitis)
-heel pain(Loverls heel) associated with a fluffy or woolly heel spur
-Small mucocutaneous painless lesions including; stomatitis and
balanitis, and keratoderma blennorrhagica(skin lesion)
-Self-limiting, most resolve in less than a year
DIAGNOSIS
-increased sed rate
-(+)HLA-B27
ARTHRITIS
192
CHAPTER 9
-
PSORIATIC ARTHRITIS
DESCRIPTION
An inflammatory arthritis seen in approximately 7% of patients with dermatological psoriasis. Usually peripheral joints are involved, but there
may be associated back pain. The skin disease typically precedes the
joint disease, however arthritis can occasionally precede the psoriasis
by months to years.
SIGNS AND SYMPTOMS
-asymmetrical arthritis of large and small(especially the DIPJs) joints,
including the sacroiliac and the spine
-male=female
-peak age -40yrs
-associated psoriatic skin and nail lesions(pitting)
DIAGNOSIS
-(+)HLA-B27
-radiographic- "Pencil in cup" deformity
"whittling" of the distal tufts of the phalanges
TREATMENT
-NSAIDS
SEPTIC ARTHRITIS
-infection of a joint by a microbe
-usually reaches joint hematogenously, however direct traumatic
inoculation is possible
-symptoms and the severity of the condition vary depending on the pathogen
-most often occurs in the knee followed by the shoulder, wrist, hip,
phalanges, and the elbow
Long Bone Vasculature-Possibility of Septic Joint via

INFANTILE(0-1year)
vessels penetrate the
growth plate
-joint sepsis possible
I CHILDHOOD(1-16years)l ADULT(over 16 years)
I vessels don't penetrate I vessels penetrate the

growth plate, joint
the growth plate,
-joint sepsis not possible -sepsis not possible
Resnick, Bone and Joint Imaging, PA,
W.B. Sauders Co., 1989, pg. 731
ARTHRITIS
193
CHAPTER 9
ACUTE BACTERIAL ARTHRITIS

-acute bacterial arthritis is a medical emergency requiring admittance
to the hospital
-usual presentation is with fever and an acute monoarticular arthritis
-onset is acute with fever, severe pain, and limitation of movement,
the joint is swollen and tender and the overlying skin is red and hot
-prognosis is good if diagnosed within 3-4 days
-etiologic bacterias are generally divided into gonococcal vs. non
gonococcal disease
' NONGONOCOCCAL
GONOCOCCAL
Accounts for Yi of all septic Tends to occur in patients wtth previous
arthritis rn othetwise healthy
. .joint damaqe or immunocompromised
sexually active young adults . p a t i e n t s
1 Neisseria gonorrhoeae
Staphylococcus aureus(70%)
Streptococcus species
Gram (-) seen in IV drug abuse,
neutropenia, UTls, and post-ops
In children under 2 years, the most

common pathogen is Staphylococcus
aureus followed by Hemophilus
Gonococcal arthritis(other distinguishing characteristics)
-usually presents as a migratory polyarticular arthritis involving
several joints in rapid succession and then settles in one or two
-there is typically a rash associated with this type of arthritis which
develops on the extremities as small, mildly painful pustules on an
erythematous base, which may break down and ulcerate during
healing
-N. gonorrhoeae is seldom isolated from the synovial fluid, so
all mucous membranes should be cultured(throat, urethra, vagina,
and rectum)
DIAGNOSIS
-joint aspiration(gram stain, culture)
-blood cultures should also be obtained
ARTHRITIS
194
CHAPTER 9
TREATMENT
-for acute joint sepsis admit pt. Begin early and prompt IV
antibiotic, see below*
-arthrocenteses-performedqd-bid. Arthrocentesis is beneficial for
many reasons:
1. monitor response of therapy
2. removes destructive inflammatory mediators
3. reduces intra-articular pressure which promotes antibiotic
penetration
4. surgical drainage may be required if the joint does not
respond in 5-7 days of therapy
*Antibiotic Tx for acute septic joint
ORGANISM
DRUG OF CHOICE
Staphylococcus Nafcillin or Oxacillin
aureus
150rnglkgld IV divided
q4h
Neisseria
gonorrhoeae
Penicillin G
150,00Ounits/kg/d IV
ALTERNATIVE DRUG
Vancomycin
30mglkgld IV divided q6h
Cephalothin
Cephalothin
divided q4h
Cephalothin
Streptococci or Penicillin G
150,00Ounitslkg/d IV
pneumococci
divided q4h
An aminoglycoside plus
Pseudomonas Tobramycin
5-6mgks/d IM/IV divided Piperacillin, Mezlocillin, or
aeruginosa
q8h and Ticarcillin
Ceftazidine in full doses
may be used if resistance
encountered
MRSA
Vancomycin
30rns/ks/d IV divided q6h
Other facultative Gentamicin
Tobramycin, Netilmcin,
gram(-) bacilli 5-6mglkgld lMllV divided Amikacin plus. A 3rd gen.
qq8h plus broad-spectrum Ceph, Pipercillin, or
PCN(Mezlocillin or
Mezlocillin. Each in doses
Pipercillin) or a 3rd gen. for life-threatening infection
Ceph(Cefotaxime, Ceftizoxime, or Ceftazidine)
in doses for lifethreatening infections
ARTHRITIS
195
CHAPTER 9
VIRAL ARTHRITIS
-presents as a self-limiting mild inflammatory nondestructive arthritis that
lacks suppuration
-usually begins as a migrating polyarthralgia
-rarely lasts for more than 6 weeks
-may be caused by: hep B(most common), mono, rubella, or rubella
vaccination, mumps, infectious mono, and parvovirus
-respond well to conservative regimen of rest and NSAlDs
TUBERCULOSIS ARTHRITIS
-presents as a chronic, inflammatory, slowly destructive arthritis with few
if any systemic signs
-only 50% of CXR are positive
-synovial biopsies are diagnostic-joint cultures may or may not be positive for the organism
-treatment is with antituberculosis drugs(i.e. Rifampin)
FUNGAL ARTHRITIS
-presents as a chronic monoarticular arthritis(simi1ar to TB)
-Sporothrix schenckii is the most common pathogen
LYME DZ
-presents as a migratory polyarthritis and tendonitis associated with an
expanding skin rash(erythema chronicum migrans)
-the arthritis usually settles in the knee or ankle
-caused by the spirochete Borrelia burgdorferi
-transmitted by a dear tick(1xodes dammin~)
-any or some of the following symptoms may be present
muscle acheslpains
fatiguellethargy
feverlchills
stiff neck with headache
backache
nauseaJvomiting
sore throat
enlarged spleen or lymph nodes
enlarged heart and heart-rhythm disturbances
-specific Ab tests can be diagnostic
-Tx: Doxycylcine lOOmg bid, Tetracycline 250mg qid, or Amoxicillin
500mg tid given po x 3wks
ARTHRITIS
196
CHAPTER 9
CRYSTALINE-INDUCEDARTHRITIS
GOUT
DESCRIPTION
A recurrent acute arthritis that affects peripheral joints, most notably the
1st MPJ. The arthritis stems from a build up of monosodium urate crystals in and around joints and tendons. Supersaturated hyperuricemic
body fluids crystalize causing a severe red hot swollen joint. The arthritis may become chronic and deforming. Not all hyperuricemic persons
develop gout. A build up of uric acid crystals in the joint may be from
excessive breakdown or over production of purines. Gout classically
begins in the evening or early morning and tends to occur in previously
damaged joints.
SIGNS AND SYMPTOMS
-asymmetrical monoarticular arthritis
-sudden onset, red hot swollen joint
-low grade fever is sometimes present
-more common in men(20:l)
-joint sparing(chronic gout may be joint destructive)
-most commonly first attacks the 1st MPJ(called Podagra), followed
by Lisfranc's and then the heel
-crunchy tophi felt in ears, olecranon bursa, and Achilles tendon.
NOTE: Formalin dissolves gouty tophi
DIAGNOSIS
X-ray
-rat bites
-cloud sign
-punched out lesions
-Martel's sign-overhanging margins
Aspiration
-negatively birefringent yellow needle shaped crystals, when parallel
to axis of the lens and blue when perpendicular.
Blood work
-Hyperuricemia(>7.5mg/dl ) not conclusively diagnostic for gout
TREATMENT
For effective Tx determination must be made as to whether the pt. is an
over producer of uric acid(metabo1ic gout) or an under excreter(rena1
gout).
ARTHRITIS
197
CHAPTER 9
'
Name
I
I
OVERPRODUCER
I
OF URIC ACID
1
-metabol~cgout
1
-uric a c ~ dlevel above
1 600mg In a 24 hr urine
sample
1R-ETCX
UNDER
OF URIC ACID
-renal gout(more
-uric acid level
in a 24 hr urine sample
Cause
-tumor
-.
Treatment
Allopurinol
-xanthine oxidase
inhib~tor
-300mg QD
2" kidney problem

-lead poisoning
-excessive ac~ds(lactic
acid, ASA)
Probenec~d
-competes with uric acid for
reabsorption from kidneys
-250mg BIDxlwk, then
double the dose, then
Increase by 500mglday
every 4wks(not to exceed
2gIday)
-
-Avoid foods and medications that exacerbate gout

-organ meat(liver sweetbread, kidney, heart, brains)
-lard
-anchovies and sardines
-ETOH especially red wine
-diuretics(increases osmolarity)
PSEUDOGOUT
(Chondrocalcinosis, Calcium pyrophosphate dihydrate, CPPD)
DESCRIPTION
-associated with acute or chronic inflammatory arthritis
-caused by deposition of calcium pyrophosphate dihydrate(CPPD)
crystals in the joint
-symptoms are similar to those of gout but it tends to run a longer
course(reaches maximum severity at 1-3 days, and resolves in 1
week or longer)
-the knee is most oflen involved(50%) followed by the ankle, wrist,
and shoulder
-risk increases with age, trauma, patients hospitalized for other
medical conditions and those with metabolic dz(hypothyroidism,
hyperthyroidism, gout, amyloidosis)
-associated with high grade fever
ARTHRITIS
198
CHAPTER 9
DIAGNOSIS
-microscopic examination of joint aspiration reveals rhomboid crystals
-radiographically-calcifications of the articular cartilage or meniscus
TREATMENT
-immobilization, NSAID, analgesics
CONNECTIVE TISSUE DZ
DEFINITION
A chronic, remitting, relapsing, inflammatory, and often febrile, multisystemic disorder of connective tissue, acute or insidious in onset.
Drug induced lupus may be caused by: Procainamide, Hydralazine,
Chlorpromazine, Isoniazid, Penicillamine, Griseofulvin
SIGNSISYMPTOMS
-age of onset 15-35 yrs

-joint pain in 90% of patients(an early manifestation)
-primarily small joints of the hands and feet
-mainly in young women(l0:l)
-more common in blacks
-fever(gO% of patients)
-abdominal pains
-butterfly rash
-skin lesions in sun exposed areas(photosensitivity)
-fatigue, weight loss, and anorexia
-Raynaudls phenomenon
-alopecia
-vision problems
-proximal nail fold telangiectasis
-renal, cardiac, splenic, and pulmonary problems
DIAGNOSIS
-increased sed rate
-(+)ANA(antinuclear antibody test)
-antibodies to double-stranded DNA
-decreased hemoglobin, WBC, and platelets
TREATMENT
-symptomatic
steroids
antimalarials(chloroquine)
immunosuppressants
avoid sunlight
ARTHRITIS
199
CHAPTER 9
SCLERODERMA(PROGRESSIVE SYSTEMIC SCLEROSIS)

DEFINITION
A systemic disorder of the connective tissue characterized by induration,
thickening, and tightening of the skin. Beginning in the hands, then face,
and then other areas. There is also associated fibrotic degenerative
changes in various organs especially the lungs, heart, and GI.
SIGNS/SYMPTOMS
-CREST(Calcinosis cutis-calcifications in the skin, Raynaud's
phenomenon, Esophageal dysfunction, Sclerodactyly-localized
scleroderma of the digits, and Telangiectasia)
-may be confined to face and hands
-onset 30's-40's
-woman 4:l
-hyper/hypopigmentation
-dysphagia
-migratory polyarthritis
-constipation, diarrhea, abdominal bloating
-weight loss
-mask facies
-thick, hard leathery skin
-nails grow clawlike over shortened distal phalanges
-matlike telangiectasia
-mouse like appearance, due to skin around mouth having many
furrows radiating outward
DIAGNOSIS
-clinically
-(+)ANA
TREATMENT
-symptomatic
DERMATOMYOSITIS/POLYMYOSlTlS
DEFINITION
Polymyositis is a chronic progressive inflammatory disease of skeletal
muscle characterized by symmetrical weakness of the limb girdles,
neck, and pharynx, usually associated with pain and tenderness. If
associated with skin lesions it is termed Dermatomyositis. These skin
manifestations include violaceous(heliotrope) inflammatory changes of
the eyelids and periorbital area, erythema of the face, neck, and upper
trunk.
ARTHRITIS
200
CHAPTER 9
SIGNSISYMPTOMS
-females(2:1)
-Gotiron's sign-flat-topped violaceous papules over the dorsal aspect
of the knuckles
-reddish-purplish(heliotrope) facial lesions
-polyarthritis occurs in 113 of pts
-proximal muscle weakness
-proximal nail fold telangiectasis
DIAGNOSIS
-elevated serum CPK(Creatine Phosphokinase)
-muscle biopsy
-abnormal EMG
-elevated creatine(z2OOmg) in a 24hr urine specimen
TREATMENT
-steroids
SJOGREN'S SYNDROME
DEFINITION
A chronic autoimmune inflammatory disorder of the exocrine glands.
Resulting in decreased secretions in many areas of the body.
Histologically there is a lymphocytic infiltration of the secretory glands.
SIGNSISYMPTOMS
-women(g:l)
-age 40's-60's
-often associated with rheumatic dz
-keratoconjunctivitis sicca(dry eyes)-felt as burning or itchy
-xerostomia(dry mouth)
-dry vagina
-possible loss of taste or smell
-dysphagia
-dry skin may be the only cutaneous manifestation
-parotid gland enlargement
DIAGNOSIS
-mild anemia, leukopenia
-(+)RA factor in 70%
-Schirmer test-measures quantity of tears. Litmus paper is placed in
the eye for 5 minutes, if < 5mm of wetness, the test is(+).
-biopsy saliva gland
TREATMENT
Symptomatic
ARTHRITIS
201
CHAPTER 9
ARTHRITIS ASSOCIATED WITH INFLAMMATORY BOWEL DISEASE
CROHN'S DISEASE AND ULCERATIVE COLITIS

-rheumatologic manifestations seen in about 15-20% of patients
-asymmetric, nondestructive, transient arthritis
-arthritis flares tends to parallel flares of the underlying bowel diesease
-commonly involes the knees, ankles, elbows, and wrists
ARTHRITIS
202
CHAPTER 9
BIOMECHANICS
203
CHAPTER 10
CHAPTER 10
BIOMECHANICS
BIOMECHANICS, P214
BONE ANGLES, p205
GAIT ANAYSIS, p212
GAIT PATTERNS, p218
JOINT ROM , p204
SHOE ANATOMY, p210
Frontal Plane or
Coronal Plane
BIOMECHANICS
204
CHAPTER 10
JOINT RANGE OF MOTION

Hip
Rotation
adults
20"-25"
Flex
Ext
straight knee
flexed knees
abduction
adduction
36")
Knee
Flexion
Extension
vertical)
extension is called genu
when knee is semiflexed
med rotation
rotation
40"
During the last
of knee extension of gait the tibia rotates
laterally, with a more rapid rotation occuring the final
of knee
extension. When the knee is fully extended no rotation is possible
birth
2-4yrs
4-6yrs
14+
knee)
genu varum
straight
genu valgum
straight
genu valgum
straight
BIOMECHANICS
205
CHAPTER 10
Ankle
Dorsi/Plantarflexion
dorsiflexion
10"-2O0(past perpendicular)
20"-40"
plantarflexion
-birth 75", 3 yrs 20, 10 yrs 15", 15 yrs 10"-20"
-for normal ambulation 10" dorsiflexion and 20" plantarflexion is
required
-less that 10" dorsiflexion is equinus
-ankle joint is most stable in the maximally dorsiflexed position
STJ
-axis 42" from sagittal, 16" from transverse
-neutral position is 213 the distance from the most supinated
position
-the average ROM is 25"-3O0(reportedvalues are highly varied)
and a minimum of 12" is required for normal ambulation
MPJ
Flex/Extension
flexion
extension
30"-40"
50"-60"
Lesser MPJs
1st MPJ
45"
70"-90"
-angles are measured from the long axis of the metatarsal not
the ground
BONY ANGLES
Femur
Anale of inclination
:I::
-long axis of the neck with long axis of the shan

-COXA VARA, an angle greater than normal
-COXA VALGA, an angle less than normal
birth
140"
lyr
146"
4yrs
137"
14yrs
132"
adults
120"-13O0(ave127")
BIOMECHANICS
206
CHAPTER 10
Anule of declination(antetorsion)
aka-angle of femoral torsion
-long axis of the neck with the
dicondylar coronal plane
39"
lyr
10yrs
24"
2lvrs
16"
adht
6.
Anule of anteversion
-long axis
birth
adult
neck
60"
10"-1
Tibia
Tibial torsion
-lateral twist of the long axis of the tibia
-tibia1 torsion is measured clinically by malleolar position(angle
between knee axis and the two malleoli)
-malleolar position is about 5" less
than tibial torsion
tibia1
malleolar
age
tors~on
birth
lyr
6"
O"
position
3"-4"
0"
2yrs
6yrs
adults
12"
6"-8'
22"
13-180
18"-23"(ave20")
VarumNalaum
-long axis of distal 113 of leg with perpendicular line to the ground
5"-10" varum
birth
> 2 yrs
2"-3" varum
BIOMECHANICS
207
CHAPTER 10
Talus
Talar neck anale
-long axis of the talar body and the talar neck
two sets of values depending on which angle
is measure
ANGLE A
ANGLE B
birth 35"-40"
birth 130"-140"
adult 150"-155"
adult 10"-20"
Talar torsion(angle of declination of the talus)

-lateral rotation or torsion of the talar head
-increases with age, brings the
supinated embryonic foot to it's
pronated adult position
-normal is 25-30"
normal 21"
Metatarsal length
longest 2-3-5-4-1
shortest
Metatarsal distal protrusion

longest 2-3-1-4-5
shortest
BIOMECHANICS
208
CHAPTER 10
Bohlers Angle
-normal value is 20"-40"
-average -30-35
-decreases in calcaneal fracture
Gissane's Angle
-normal is
-increases in calcaneal fracture
Critical angle, Crucial angle
Fowler-Philip Angle
-normal
-pathology
Total Angle
Inclination Angle Fowler-Philips Angle
-greater than 90" may be observed in a Hagland's deformity
Parallel Pitch Lines

(a) draw a line along the plantar
surface of the calcaneous
(b) perpendicular line passing
through the posterior aspect of the
posterior facet of the STJ
the point it passes through the
posterior facet, draw another
perpendicular line, parallel to the CIA
(d) if the posterior tubercle extends
i nd i ca i t e a b o v e of 2nd
pa ra lle l line it's d e f o r m i t y
BIOMECHANICS
209
Meary's Angle
-straight line through the mid axis of the talus
and mid axis of the 1st metatarsal
-normal 0"
-1-15" mild flatfoot
- >15" severe flatfoot
Calcaneal Inclination Angle

-average 20-25"
-value does not change with
pronation and supination
-decreased pes planus
-increased in pes cavus
Angle of Hibbs
-long axis of 1st metatarsal and long
axis of the calcaneous on a lateral view
-less than 150" is a cavus foot
-normal 135-140"
Kites Angle
-long axis of talus and long axis of calcaneus
-normal range is 20"-40"
-increased in pronation, decreased in supination
CHAPTER 10
BIOMECHANICS
210
CHAPTER 10
SHOE ANATOMY
4)
5)
6)
7)
8)
9)
The upper rim at

the opening of the shoe
HEEL
HEEL COUNTER
The ort ti on of the umer that
surrdunds the heel. 'Acts to reinforce the
heel portion of the upper and help provide stability to calcaneus
INSOLE
The top layer of the sole that comes in direct contact with the
foot. Provides traction and is made of durable material.
LACE STAYS
Part of the upper on the dorsum of the shoe, often reinforced with
leather and contains holes for shoe laces
MIDSOLE
Located between the insole and outersole. This layer is usually
responsible for absorption of the shoe
OUTSOLE
Bottom layer of the sole that comes in contact with the ground.
Provides traction and is molded of durable material. Determines
the flexibility of the shoe
QUARTER
The posterior portion of the upper
SHANK
Often made of steel. Located between the insole and outsole, the
shank runs from the heel center to the ball of the shoe and acts to
give support to the longitudinal arch and prevent colapse of the
shoe. The shank is the section of the shoe's sole in this area.
BIOMECHANICS
211
CHAPTER 10
10) THROAT
The area where the vamp and quarter and vamp and tongue meet
11) TOE BOX(toe cap)
The most anterior portion of the upper which covers the toes and
acts to protect the toes and help maintain the shape of the upper
in the toe
12) TONGUE
Piece of material continuous with the vamp and covers the dorsum
of the foot under the lace stays
13) UPPER
The section of the shoe that covers the dorsum of the foot and
attaches to the sole of the shoe. The upper includes; the vamp,
quarter, lace stays, tongue, throat, heel counter, and toe box
14) VAMP
The anterior portion of the upper covering the forefoot and toes
LAST
A last is a 3-D model of the shape and cubical content of a shoe that
the shoe is built around.
inflare last
straight last
outflare last
BIOMECHANICS
212
CHAPTER 10
BIOMECHANICS
213
CHAPTER 10
BIOMECHANICS
214
CHAPTER 10
BIOMECHANICS
LLD(limb length discrepancy)
-a true LLD requires a 5mm discrepancy or more to cause significant
functional and structural problems
-children typically walk with a shoulder drop
-during stance the foot of the longer leg is usually pronated and the
shorter leg is supinated
-by age 13-14 years compensatory scoliosis may develop
-with a difference of ?h" or more, will have some change in their shoulders
Open kinetic chain

Describes the movement of a body part that is NWB. Open kinetic
chain pronation can be described as abduction, evertion, and dorsiflexion of the foot.
Closed kinetic chain

Describes the movement of a bone around a joint in a body part that is WB.
Closed kinetic chain pronation can be described as talar plantarflexion and
adduction in the ankle joint, and calcaneal evertion.
Flexor Stabilization
Occurs in flat feet with excessive pronation. STJ pronation allows
hypermobility and unlocking of the midtarsal joint leading to hypermobility
of the forefoot. The flexors fire earlier and longer than normal in an
attempt to stabilize the forefoot. The flexors overpower the interosseous
muscles and cause digital hammering or clawing. There is also an possible associated adductovarus of the fourth and fifth toes because the
quadratus plantae loses its mechanical advantage.
Flexor Substitution
Occurs with weak triceps surae, the deep posterior leg and lateral leg
muscles try to compensate for lack of plantarflexion. i n doing so, they
create a hiah arched supinated foot and contract the diaits. There is
usually no adductovarus deformity of the digits.
Extensor Substitution
Extensor muscles normally contract to dorsiflex the ankle to allow the
foot to clear the ground during swing phase. With extensor substitution
the extensors gain a mechanical advantage over the lumbricles and the
extensors will contract the MPJs. There is normally no adductovarus
deformity. Causes include anything that will give the extensors a
mechanical advantage over the lumbricles.
BIOMECHANICS
215
CHAPTER 10
Windlass mechanism
-As the
is dorsiflexed the plantar fascia is pulled under the head
of the metatarsal. This brings the calcaneus toward the head of the 1st
metatarsal, thereby creating an elevated medial longitudinal arch.
Posting
-used to increase support of the heel seat of an
and tilt the
contoured plate against the foot
posts can be used as wedges and usually have an angle
Lateral flare
-used for lateral instability and
frequent inversion sprains
-can be put on the
or a shoe
Thomas heel
-an anteromedial extension made to the heel to provide additional support to the longitudinal arch and limit late midstance pronation
-a reverse Thomas heel is an anterolateral extention made to the heel to
support a weak lateral longitudinal arch-rarely indicated
BIOMECHANICS
216
Triplane wedge
-a heel wedge thickest at it's anteromedial
edge
-used to supinate the foot
SACH heel
CHAPTER 10
114 "
thick
-a modification made to the heel of a shoe to round off the heel in a

rocketbottom fashion
-allows a more cushioned fluid motion through the heel contact phase of
Cobra pad
-a prefabricated type of orthotic providing
arch support and off-weighting the heel
-usually constructed out of felt it is easily
fitted into dress shoes
Metatarsal bar
- a pad placed just behind the metatarsal

heads to reduce pressure on the 2nd,
3rd, and 4th metatarsal heads -metatarsal
bars can be incorporated into an orthotic,
insole, or taped directly on the foot
3rd,
Denver bar
-placed under the metatarsal bones to support the transverse arch
extending from the metatarsal heads to the tarsometatarsal joint
BIOMECHANICS
217
CHAPTER 10
Heel lifts
-used to treat haglund's deformity, apophysitis, LLD, and equinus
Dancer's pad
-used to off-weight the 1st metatarsal
-indications are sesamoiditis or
fractured sesamoid
Low-Dye Strap
-a straping technique achieved with tape that alleviates the strain
associated with pronation particularly plantar fasciits
Step 1
-apply 1-3 strips of 1" adhesive tape in a Heel Lock fashion
-the heel lock is applied by placing
the adhesive tape on the lateral
side of the foot just proximal to the
5th metatarsal head and extending
around the posterior aspect of the
foot to just distal to the st
metatarsal head
-hold the foot in the adducted
(supinated) position during taping
Step 2
-over the heel lock place a Plantar Rest Strap using 3-4 strips of
adhesive tape
-the plantar rest strap is applied
by placing the first strip on the
lateral aspect of the foot just below
the malleoli across the plantar
surface and up the medial foot to
the navicular
-apply an additional 2 or 3 strips
distal and slightly overlapping the first
BIOMECHANICS
218
CHAPTER 10
GAIT PATTERNS
Spastic gait
Manifested by internal rotation and adduction of the entire limb with
hiplkneelankle in marked flexion. Seen with CP, familial spastic diplegia,
paraplegia, and hemiplegia
Dyskinetic gait
Aconstant movement abnormality with a high degree of variability from
patient to patient and gait cycle to gait cycle. It is characterized by
motion involving considerable effort, often with deliberated almost concentrated steps. Seen with CP, Huntington's chorea, and dystonia muscular deformities
Ataxic gait
Characterized by a marked instability during single limb stance with an
alternating widelnarrow base during double support. During swing
phase the limb will swing widely and cross the midline. Seen with MS,
tabes dorsalis, diabetic polyneuropathy, Fredrich's ataxia
Waddling gait
A laboring gait exhibiting difficulty with balance proximal pelvic instability
leading to a lumbar lordosis. May see an associated equinovarus foot
type. Seen with muscular dystrophies, spinal muscular atrophy, and
congenital dislocated hip
Steppage gait
Gait exhibits a swing phase drop foot. Seen with Charcot-Marie-Tooth,
polio, Guillain-Barre syndrome, CVA, paralytic drop foot, and fascioscapulohumeral dystrophy
Vaulting gait
Gait changes include a high step rate, increased lateral trunk movement, scissoring and instability from step to step suggesting a loss of
balance. Seen with myotonic dystrophy
Equinus gait
Gait exhibiting a swing phase ankle plantarflexion with no heel contact.
Seen with CP, CMT, MD, spinal muscular atrophy, schizophrenia,
osseous block of the ankle, and habitual toe walking
BIOMECHANICS
219
CHAPTER 10
Fenistrating gait
Shuffling gait with loss of reciprocal arm swing, decreased velocity,
decreased stride length, and increased step rate. Seen with Parkinson's
disease
Trendelenberg gait
Stance phase of each step leads to a contralateral tilt of the pelvis with a
deviation of the spine to the affected side. Seen with dislocated hip or
weakness of the gluteus medius muscle
Antalgic gait
Counteracting or avoiding pain, walking with a limp to lessen pain.
BIOMECHANICS
220
CHAPTER 10
RADIOLOGY AND IMAGING
221
CHAPTER 11
CHAPTER 11

ACCESSORY BONES, p229
BONE SCAN, p232
CAT SCAN, p232
FLUOROSCOPY, p235
MRI, p232
OSSIFICATION CENTERS, p230
ULTRASOUND, p235
XERORADIOGRAPHY, p235
X-RAY VIEWS, p223
X-rays should be taken:
222
CHAPTER 11
WB
ANGLE AND BASE OF GAIT
-feet abducted 15"
-medial malleoli 2" apart
STANDARD FOOT X-RAYS

NP, Lat, MO
EXPOSURE
FACTORS
Kilovolts(kVp)-Kilovoltscontrol the contrast of a film. lncreasing the kilo

volts produces a more penetrating x-ray but poor contrast.
lncreasing the kVp results in less exposure to the patient but
a lower quality picture.
Milliamperaae(mA)-Milliamperagecontrols the intensity of the x-rays
emitted from the x-ray tube and is the most important
component controlling density. lncreasing mA produces a
brighter radiograph but little change in overall contrast. To
reduce radiation exposure decrease mA.
Distance-To achieve maximum fidelity(true sizelshape of original object)
the distance of the object to the film must be kept to a
minimum. A small focal spot gives better detail.
RADIOGRAPHIC TERMINOLGY
Compton effect-The compton effect is the scatter radiation caused by interaction with the outer shell electron. It causes less radiation exposer to the
patient and is detrimental to the image.
Grid-Composed of alternating strips of lead and aluminum spacers to
control, by absorbing, scatter radiation.
Collimators-A light beam that shows where the x-ray beam will project.
Photoelectric effect-The photoelectric effect is the absorbed radiation involving interaction with the inner electron shell. It is beneficial to the image and
increases the exposure to the patient. The photoelectric effect increases at
lower kVp.
Orthoposer-The elevated lead lined base of the x-ray unit which the
patient stands on during the x-ray.
Hard x-ravs-Hard x-rays are produced by increased kVp. They have a
short wavelength, high frequency, increased penetration, and are less
dangerous to the patient.
Soft x-ravs-Soft x-rays are produced by decreased kVp. They have a
long wavelength, low frequency, low penetration, and are more dangerous to the patient.
223
CHAPTER 11
SLOW VS. FAST SPEED FILM

The larger the size of the AgBr crystals and the thicker the emulsion
layer, the faster the film. The faster the film=the darker the image
X-RAY MACHINE REQUIREMENTS

-dead-man type exposure switch with a 6ft cord
-machines <70kVp don't need l o or 2" barriers or special lead lined
rooms(the majority of podiatric x-rays are taken below 70
kilovoltages)
-lead aprons, gloves, and goggles are 0.25 mm thick
gonadal shields are 0.5 mm thick
RELATIVE DENSITIES OF DIFFERENT MATERIALS
Cortex - Cancellous - Muscle - Nerve -Tendon - Ligament - SubQ - Fat -Air

highest density-------->--------->------------->>- - - - - - ,,westdensity
PODlATRlC X-RAY VIEWS

DORSOPLANTAR(DP) OR ANT
-central ray aimed at lateral portion of
navicular
-15" from vertical
-central ray directed at navicular
-when examining the foot for a foreign
body this view may be taken
perpendicular for better spatial location
LATERAL
-medial side of foot against film
-central ray aimed at cuboid
-tube is angled 90" from vertical
224
CHAPTER 11
MEDIAL OBLIQUE(M0)
-angle unit 45" from vertical
LATERAL OBLIQUE(L0)
I
-angle unit 45" from vertical

-central ray aimed at navicular
STRESS LATERAL OR
STRESS DORSIFLEXION
-position patient for a lateral but then
have patient flex knees and maximally
dorsiflex ankle
-demonstrates any anterior ankle
impingement(osseous equinus)
PLANTAR AXIAL
-head angled at 90" to the vertical
-aimed at the plantar aspect of the sesamoids
-good view of sesamoids and plantar aspect of
metatarsal heads
-toes dorsiflexed against film and then
raise heel
-positioning device may aid in taking
this projection
225
CHAPTER 11
HARRIS-BEATH(SK1-JUMP)
-good for posterior and middle STJ
coalitions
-angle unit 45"
-patient stands on film with knees
and ankles flexed 15-20"
-first take a scout lateral film
and determine the declination
I
angle of posterior facet of STJ.
Then take 3 views; one at the angle determined by the lateral film,
one 10" above and one 10" below
-some advocate 3 arbitrary views at 35", 40, and 45"
AXIAL CALCANEUS
-central ray aimed at posterior aspect
of calcaneus
-angle unit at 45"
-examines the calcaneus for Fx,
abnormalities in shape, or internal
fixation in major tarsal fusions
ISHERWOOD(3 positions to fully visualize the STJ)

Lateral obliaue axial view
-foot at 45"
-demonstrates the posterior facet of the calcaneous
-demonstrates anterior facet of STJ
-central ray directed vertically to a point 1 inch
anterior to the lateral malleoli
Medial obliaue axial view

-foot at 30"
-maximally dorsiflex and invert the foot
using a sling
-middle facet
-central ray directed at 1 inch distal and 1
inch anterior to the lateral malleolus at an
angle of 10" cephalad from vertical
226
CHAPTER 11
Lateral obliaue
-foot at 30"
-posterior joint in profile
-foot held in maximally dorsiflexed and
everted position with a sling
-central ray 1 inch distal to the medial
malleoli at an angle of 10" cephalad
from vertical
STRESS NVERSION(TALAR TILT)

-patient supine or sitting in chair, internally rdtate foot 150from 9Oo(to
bring malleoli parallel to film. Stabilize leg with one hand and maximally
invert foot with other hand)
-examiner wears lead gloves
-stabilize lower leg with one
hand while forcefully inverting
foot with other hand
-central ray at ankle joint
-performed following ankle
inversion sprains, may need to
anesthetize foot(common
peroneal block) for pain relief
and to relax foot
-assess lateral ligamentous injury
-(+) test is a talar tilt greater than 4" of
inversion
ANTERIOR DRAWER OR PUSH-PULL STRESS

-patient supine or sitting with leg in lateral position. Stabilize leg with
one hand and place an anterior dislocating force on the foot with the
other hand
-taken following ankle trauma
-place hand against anterior
aspect of leg other hand behind
heel and attempt to pull the talus
forward out of the ankle mortise
-central ray at medial malleoli
-good visualization of the tibia1
plafond and medial space between
the medial malleolus and body of the talu
-lateral space between the lateral
malleolus and talus can not be visualized
-(+) is greater than 2mm excursion o
ankle mortise
227
ANKLE-AP
-beam parallel to the floor
-foot straight ahead
-central beam between malleoli
-good visualization of the tibia1 plafond
and medial space between the medial
rnalleolus and the body of the talus
-lateral space between the lateral
rnalleolus and talus can not be visualized
ANKLE-LATERAL
-good for trochlear surface of talus
and it's articulation with the
tibia and fibula
ANKLE-MEDIAL OBLIQUE
-leg internally rotated 45"
-good view of tibiofibular syndesmosis
ANKLE-LATERAL OBLIQUE
-leg externally rotated 45"
CHAPTER 11
228
CHAPTER 11
MORTISE VlEW
-leg internally rotated
(placing
on a plane parallel to the film)
-better tibiofibular articulation view
-x-ray head set at 90" from the vertical
-aimed at center of the ankle joint
-articular relationship between trochlea
plafond
of talus and the
-space between the lateral
and the talus
VlEW
-same as the
view but the foot is fully
plantarflexed and pronated
-this view provides a good view of the
talar neck for fractures in this area
BRODEN I VlEW
-allows visualization of the middle and
posterior STJ facet, useful in comminuted
fractures of the ankle i s at 90" and the foot is
adducted
-4 cephalad views at
intervals off the
perpendicular
-the 40" projection shows the anterior portion
of the posterior facet, the
projection shows
posterior facet,
the posterior portion of
and the middle facet can usually best be seen at one of the intermediate
projections
BRODEN
VlEW
-allows visualization of depressions in

the posterior facet of the STJ
-x-ray beam is tilted
caudally
-3 projections taken at
intervals
-this view allow visualization of
depressions in the posterior facet of the STJ
229
CHAPTER 11
ACCESSORY BONES
0 s Vesalianum
9. 0 s lntercuneiform
0 s Trigonum
10. 0 s lntermetatarsum I
0 s Peroneum
11. 0 s Talonavicular Dorsale
0 s Sustentaculum Tali
12. Fabella-sesqmoiod bone in the
0 s Calcaneus Secondaris
astrocnem~usmuscle found
0 s Tibiale Externum
%ehindthe knee(not shown)
7. Dorsal 112 of bipartite medial cuneiform
8. Plantar 112 of bipartite medial cuneiform
1.
2.
3.
4.
5.
6.
--
-- - ---
Great Tarsal Jt, -------- ----------Medial Tarsometatarsal Jt..............................

Lateral Tarsometatarsal Jt.- - . .
230
CHAPTER 11
N0TE:AII 0 s Coxa secondary ossification centers fuse at about age 25 years.

fill Ferner secondary ossification centers fuse at about age 15 vears. All
Tibia & Fibular secondary ossification centers fuse at about age 17 years.
All Metatarsal secondary ossification centers fuse at about age 18 years
231
CHAPTER 11
READING AN
Facility where
MRI was taken
was taken
'This value is in the 100's for T2 images, and around 25-30 in
images
232
CHAPTER 11
MAGNETIC RESONANCE IMAGING

-patient is placed inside a magnetic field where all the hydrogen nuclei
in the body becomes capable of producing radiofrequency signals.
Different tissues resonate at different frequencies. The resulting
radiofrequency signals are picked up by a computer and analyzed and
an image is generated
-noninvasive, no ionizing radiation is used and no contrast agents are
required
-excellent visualization of soft tissue
-TI weighted image-fat lights up(bone marrow, nerves, lipomas)
-T2 weighted image-water lights up(blood, inflammation, edema, tumors)
CAT SCAN(Computer Axial Tomography)

-computer-controlled radiological examination that renders a
reconstructed cross sectional image
-high radiation exposure
-used frequently to visualize ankle joint or STJ(coa1itions)
BONE SCANS(Scinti
-radioactive compounds(radiopharmaceuticals)are slowly injected into
the patient and localize in specific organs.
-a scintillation probe or detector is positioned over the target and emitted
gamma photons are converted to visible light and counted.
-hot spot-area of high radiopharmaceutical uptake
-cold spot-area of low radiopharmaceutical uptake
-identifies areas of increased bone turnover or osteoblastic activity(i.e.
fx's, bone tumors)
-bone scanning allows early diagnosis of a stress fracture(7 hours SIP)
Podiatric Indications
-OM
-trauma/inflammatory arthritis
-stress fracture-as early as 7 hrs after insult
-tumors
-nonspecific pain
233
CHAPTER 11
TECHNETIUM-99(TC-99M)
-usually combined with an appropriate bone-imaging agent:
Tc-99MDP (methylene diphosphate)
Tc-99MAA (macroaggregated albumin)
-highly selective for bone metabolism(osteoblastic activity)
-normal uptake seen at: tendon insertion, normal bone growth in children, epiphyseal plates, areas of constant stress or osseous remodeling
-will pick up in any areas of focal inflammation or bone turn over
-used to identify fracture, tumor, infections
Tc-99m methylene diphosphate (Tc-99MDP)

-used to identify areas of increased bone metabolism(i.e. fx's) and
increased blood flow
-normal uptake:
-tendon insertions
-epiphyseal plates
-areas of constant stresses or osseous remodeling
-images obtained at 2-4hrs
-osteoblastic-mediated chemo-absorption onto the surface of hydroxyapetite crystals
-physical % life of 6hrs
-useful 140-keV gamma photon
-50% is excreted by the kidney so adequate hydrationlvoiding is important to reduce the radiation exposure to bladder wall
-a positive scan will show up 7hrs following a stress fracture
4-phase bone scan(uses Tc-99MDP)

1ST PHASE-RADIONUCLIDE ANGIOGRAM(BLO0D FLOW PHASE)
-images taken 1-3 seconds apart immediately following injection
-dynamic visualization of blood flow
-provides information about the relative blood supply to the extremity
2ND PHASE-BLOOD POOLING IMAGES
-imaging taken 5-10 minutes following injection
-quantifies relative hyperemia or ischemia
3RD PHASE-DELAYED IMAGE(B0NE-IMAGING PHASE)
-imaging at 3-4hrs following injection
-visualizes regional rates of bone metabolism
-this phase is useful to determine cellulitis vs. OM
-by the 3rd phase with cellulitis there should be a flushing and cleaning
returning toward normal density. With OM Tc-99 will incorporate into the
bone and show increased density
234
CHAPTER 11
4TH PHASE
-used in the diagnosis if OM
-shows greater bone activity and less soft tissue activity
-Images are taken at 24hrs. If the ratio at 24hrs is increased more than
one whole number compared to the 3-4 hour image(3rd phase), it's
positive for OM. If the ratio at 24hrs is decreased more than one whole
number compared to the 3-4 hour image(3rd phase), it's negative for
OM. If the ratio at 24hrs is less than a whole number different
compared to at 3-4 hours hours(3rd phase), it's inconclusive.
TC-99m
albumin (Tc-99MAA)
-assess capillary bed perfusion in diabetics
-assess healing potential in ischemic ulcers
- Gallium binds to WBC, plasma proteins, siderophores, and iron-binding

proteins(transferrins, ferritin, lactoferrin)
-identifies neoplasms and inflammatory disorders
-imaging performed at 6-24hrs for infections
-imaging performed at 24-72hrs for tumors
-excreted by the kidneys
-112 life is 78hrs thus radiation dose is high
-used for leukocyte-mediated pathology

-binds to cytoplasmic components of the WBC membrane
-spleen and liver light up because of WBC destruction at these locations
-used for inflammatory disorders
-Imaging at 18-24hrs
-more accurate at assessing acute infection, while Ga-67 is more sensitive for subacute and chronic infection
-half life 67hrs
-rather than simply injecting the radiopharmaceutical, In-111 bone scans
involve drawing blood from the patient isolating WBCs labeling
them(with In-111) and then reintroducing them back into the blood
stream
-more accurate at assessing infection if Gallium studies are inconclusive
THALLIUM-201(Ti-201)
-used to assess foot perfusion
235
CHAPTER 11
COMBINED Tc and Ga BONE SCAN

-combining technetium(bone imaging radionuclide) and gallium(inflammatory imaging nuclide) gives more information than either scan alone
-technetium should be given first, because it has a shorter % life, followed in 24-48hrs by gallium
-when they talk about the Tc being (+) or (-) they are referring to phase
3(bone-imaging phase)
-Tc tells us if bone is involved and Ga tells us if WBCs are involved
Results
Ga(+) Tc(+)
1
I
Diagnosis
OM
cellulitis
Ga(+) Tc(-)
I
Ga(-) Tc(+)
Explanation
I Ga(+) indicates that infection is

I present and Tc(+)
. . indicates that
I
osteoarthropathy
Stress fraction
Chronic OM
bone is involved
Ga(+) indicates that soft tissue
infection is present and Tc(-)
indicates that bone is not
involved
Ga(-) indicates that there is no
infection and Tc(+) indicates
that bone is involved
FLUOROSCOPY
-a mobile C-arm unit that can be used intraoperatively
-used to assess joint motion, internal fixation, or to locate foreign bodies
-used to see something dynamic in motion while it's happening
-high amount of radiation exposure
-some units have hard copy capability
XERORADIOGRAPH
-superior to x-ray for visualizating bone trabeculation and certain foreign
body such as wood or glass
-uses cassettes with charged selinium plates rather than x-ray film
-processing develops charge and transfers to blue Xerox powder coated paper
-a machine called a conditioner recharges the plate
DIAGNOSTIC ULTRASONOGRAPHY
-Used in the office to diagnose such things as: Cysts, neuromas, tendinitis, Achilles injuries, plantar fasciitis, fibromas, ligament injuries, foreign
bodies, capsulitis, stress fractures and arthritis
236
CHAPTER 11
THE WISE CHOICE I N

PODIATRIC ULTRASOUND
The full line o f high quality ultrasound systems from Esaote is perfectly
suited for podiatric scanning.The systems feature body markers specific t o
podiatry that make scanning easier and more convenient. And the compact,
ergonomic design and full digital capabilities make Esaote systems the wise
choice for affordable, practical ultrasound solutions. For more information
contact your Esaote sales representative.
BONE TUMORS
237
CHAPTER 11
CHAPTER 12
BONE TUMORS
ANEURYSMAL BONE CYST, p247
CHONDROBLASTOMA, p245
CHONDROMA, p244
CHONDROMYXOIDFIBROMA, p245
CHONDROSARCOMA, p245
ECCHONDROMAS, p244
ENCHONDROMA, p244
ENCHONDROMATOSIS, p244
ENOSTOSIS, p248
EWINGS SARCOMA, p254
FIBROSARCOMA, p246
GENERALREPRESENTATIONOFM E LOCATION OF BONE TUMORS, p247
GIANT CELL TUMOR, p246
INTEROSSEOUSLIPOMA, p247
MALIGNANT VS. BENIGN AND AGE DISTRIBUTION, p240
MAFFUCCIS SYNDROME, p244
NONOSSIFYING FIBROMA, p246
OSSIFYING FIBROMA, p243
OSTEOBLASTOMA, p242
OSTEOCHONDROMA, p245
OSTEOID OSTEOMA, p242
OSTEOMA, p242
OSTEOSARCOMA, p243
PATTERNS OF BONE DESTRUCTION, p238
TYPES OF PERIOSTEALRESPONSE, p238
UNICAMERAL BONE CYST, p247
BONE TUMORS
238
CHAPTER 11
BONE TUMORS
-bone tumors are either primary or metastatic
-primary bone tumors can be either benign or malignant
-definitive diagnosis requires a biopsy
-radioisotope scans(99 Tc MDP) can estimate the local intramedullary
extent of the tumor and screen for other skeletal areas of involvement
-sclerosis of the surrounding normal bone indicates a slow growing
lesion
TYPES OF PERIOSTEAL RESPONSE

periostitis)
-slow growing tumor presses against the periosteum and thickens the
cortex
CODMAN'S TRIANGLE
-a triangle elevation of the periosteum
seen in osteogenic sarcoma and other
condition
SUNBURST
-delicate rays of periosteum bone formation
separated by spaces containing blood
vessels
-seen with hemangioma, Ewing's sarcoma,
and osteogenic sarcoma
ONION SKIN
-multiple layers of new periosteal bone
-seen in Ewing's sarcoma, eosinophilic
granuloma, lymphoma of bone
ON END
-similar to sunburst pattern but rays are
all parallel
-indicated in most malignant tumors
-rays of periosteal bone project in a
perpendicular direction to the underlying
sarcoma)
PATTERN OF BONE DESTRUCTION

defined margins with a short
zone of transitionfrom normal to
abnormal bone
-indicative of a slow growing
benign lesion
BONE TUMORS
239
CHAPTER 11
MOTHEATEN
well defined lesion margins
and a longer zone of transition
between normal and abnormal bone
-more aggressive pattern than
geographic and indicates a faster
growing lesion
-indicative of malignant tumors and OM
PERMEATIVE
-poorly defined lesion margins
with a long zone of transition, the
lesions boundaries are not easily
discerned from normal bone
-aggressive, rapidly growing lesion
indicative of malignant bone tumors
THE MOST COMMON SOURCES OF METASTATICTUMORS

breast, lung, prostate, kidney, and multiple myeloma
MOST COMMON BENIGN PRIMARY BONE TUMOR

Osteochondroma
MOST COMMON MALIGNANT PRIMARY BONE TUMOR

Multiple myeloma
MALIGNANT vs. BENIGN TUMORS

MALIGNANT
Osteosarcoma
Chondrosarcoma
Fibrosarcoma
Ewing's sarcoma
Multiple myeloma
BENIGN
Osteoma
Osteochondroma
Enchondroma
Chondroblastoma
Chondromyxoid fibroma
Osteoid osteoma
Osteoblastoma
Nonossifying fibroma
lntraosseous lipoma
Giant cell
malignant)
Unicameral bone cyst
Enostosis
Ossifying fibroma
Aneu smal bone cyst
BONE TUMORS
240
CHAPTER 11
MALIGNANT VS. BENIGN AND AGE DISTRIBUTION

B E N I G N TUMORSMALIGNANT TUMORS
Aneurysmal bone cyst
Osteold osteoma
Osteosarcoma
Un~cameralbone cyst E w i n g s sarcoma
Nonosslfying fibroma
I
I Chondroblastoma
I
Osteochondroma
Enchondroma
Enostosis
Chondromyxoldfibroma
Osslfylng fibroma
pIioma
- - L
Ages 20-50 years old Aneurysmal bone
Osteoblastoma
Osteoma
Glant cell tumor
Enchondroma
Enostosls
Chondromyxoid flbroma
Ossifying f~broma
AGE
t--
Chondrosarcoma
ppplp-
BONE TUMORS
241
CHAPTER 11
GENERAL REPRESENTATION OF THE LOCATION OF

BONE TUMORS
BONE TUMORS
242
CHAPTER 11
OSTEOMA
-benign bone forming tumor
-occurs in the 4th and 5th decade of life
-males are more often affected than females
-Occurs in bone that is formed from the periosteum(membranous bone)
-Although more common in the skull(specifically the sinuses) they also
arise in the tubular bones of the extremities
-lesions are usually asymptomatic
-radiographic appearance: homogenous radiodense bony protrusion
from the surface of bone. Similar to an osteochondroma without the
cartilaginous cap
Multiple
osteomas may be seen in Gardner's Syndrome (familial polyposis of the large bowels, supernumerary teeth, fibrous dysplasia of the
skull and epithelial cysts)
OSTEOID OSTEOMA
-occurs in the 1st and 2nd decade of life
-M>F
-occurs in the diaphysis of long bones(esp. tibia and femur) and may be
located in the cortex, medullary canal, or parosteally. Occurs in the foot
5-8% of the time and the talus and calcaneus are most commonly
involved
-symptoms are pain, worse at night, relieved bv a s i r i n
-radiographic appearance: oval or round radiolucent area, measuring
< l c m in diameter surrounded by a zone of uniform bone sclerosis
ENOSTOSIS(bone island)
-occurs in all age groups
-most commonly seen in the proximal femur, pelvis, and ribs, but any
osseous site can be involved
-radiographic appearance: intramedullary sclerotic area with discrete
margins and radiating spicules. Lesions do not distort the shape of the
bone or protrude from the cortical surface
O S T E O B L A S T O M A ( g i a n t osteoid osteoma, osteogenic fibroma)
-rapidly growing benign bone forming tumor that can become malignant
-occurs in the 2nd and 3rd decade of life
-M>F
BONE TUMORS
243
CHAPTER 11
-most commonly seen in the spine, skull and the diaphysis of long
bones
-mild pain worse at night not relieved by aspirin
-radiographic appearance: well circumscribed, expansile, osteolytic
lesion(> lcm) with areas of calcifications and cortical thinning.
Resembles and was once considered a large osteoid osteoma
OSSIFYING FIBROMA
-benign bone forming tumor closely related to fibrous dysplasia
-occurs during the 2nd, 3rd, and 4th decade when found in the face, and
the 1st and 2nd decade of life when found in the legs
-the most common site of these lesions is the mandible
-lesions in the leg are usually in the tibia and located in the distal anterior diaphysis of the cortex and may lead to enlargement and bowing of
the bones
-radiographic appearance: intracortical osteolytic lesion with a ground
glass appearance that may be a single confluent region or a multiple
elongated bubbly area clearly delineated by a band of sclerosis
OSTEOSARCOMA(osteogenic sarcoma)
-malignant bone forming tumor
-most common malignant bone tumor with exception of Multiple Myloma
-age 10-25yrs, and >40yrs
-male to female distribution is equal
-most commonly found in the metaphyseal region around the knee(dista1
femur or proximal tibia)
-usually occurs in teenagers during rapid growth spurts or in patients
over 40 who have a preexisting condition most notably Paget's dz
-Symptoms: Pain, swelling, and fever(R/0 OM), the osteoid producing
nature of the tumor often yield an elevated alkaline phosphatase level
-radiographic appearance: appearance is variable depending on osteolytic or sclerotic nature of lesion. Penetration of cortical bone usually
occurs with a Codman's triangle or "Sunburst" appearance
-prognosis is poor
BONE TUMORS
244
CHAPTER
11
3RD EDITION
BONE TUMOR
CHONDROMAS
-tumors composed of hyaline cartilage
-many different subtypes depending on location or associated
findings(see below)
a. ENCHONDROMA
-chondroma arising within the medullary canal of bone
-benign cartilage forming tumor
-occurs in 3rd and 4th decade of life
-mostly found in the metaphysis and diaphysis of the tubular bones in
the hands, also can be found in the pelvis where it may become
malignant.
-while mostly found in the hand it is one of the more common benign
pedal tumors and is usually found in the proximal phalanges
-painless swelling is often the only symptom
-radiographic appearance:Well defined medullary lesion with some calcification, a lobular contour, and endosteal erosion. Possibly cortical
expansion and pathologic fx
~O~~~~I
b. E C C H O N D R O M A S ( P ~ ~Chondroma)
-chondroma arising on the surface of bone(just beneath the periosteum)
-may occur in any age group but mostly during the 2nd decade of life
-humerus and femur are usually affected and to a lesser extent the
hands and feet
-symptoms may include swelling and mild pain
-radiographic appearance: soft tissue mass with erosion of the adjacent
cortex
c. ENCHONDROMATOSIS(OII~~~'s
dz)
-multiple chondromas(dispersed asymmetrically around the skeleton)
-occurs during the 1st decade of life
-may become malignant
-most commonly seen in the hands
d. MAFFUCCIS SYNDROME
-multiple chondromas associated with soft tissue hemangiomas
-1st decade
-may become malignant
-most commonly seen in the hands
BONE TUMORS
245
CHAPTER 11
CHONDROBLASTOMA
-occurs during the 2nd and 3rd decade of life
-M>F
-located in the epiphysis of long tubular bones(esp. femur, tibia, and
humerus) when found in the foot it's usually in the talus or calcaneus
-symptoms include pain, swelling, and tenderness
-radio~raphicappearance: well defined round or oval osteolytic lesion,
eccen~ricallyor'centrally located that may have a thin sclerotic border.
Secondary changes such as hemorrhagic foci and cystic blood spaces
may mimic an aneurysmal bone cyst
CHONDROMYXOID FIBROMA
-occurs during the 2nd and 3rd decade of life
-M>F
-occurs in the metaphysis of long tubular bones(esp. tibia)
-symptoms include slowly progressing pain, tenderness, and swelling
-radiographic appearance: radiolucent lesions, some appearing lobulated or bubbly with well-developed sclerotic borders
OSTEOCHONDROMA
-benign cartilage covered osseous protuberance
-occurs during the lst, 2nd, and 3rd decade of life
- M>F
-occurs in the metaphysis of long tubular bones(esp. femur, humerus,
and tibia)
-radiographic appearance: cartilage covered osseous protuberance with
normal trabeculation pointing away from the joint. Most commonly seen
subungually in the foot
-symptoms include a painless slowly growing mass
-most common benign tumor
CHONDROSARCOMA
-malignant cartilage forming tumor
-occurs during the 3rd, 4th, 5th, and 6th decade of life
-males are affected more often than females
-lesions can occur almost anywhere, the most commonly affected bone
being the femur.
In long bones it is generally found in the metaphysis. Chondrosarcomas
arising near the surface of the bone(periphera1chondrosarcomas) usually arise from preexisting osteochondroma
-symptoms include a slowly progressing pain
-radiographic appearance: varies but is generally appears aggressive
and involves calcifications
BONE TUMORS
246
CHAPTER 11
NONOSSIFYING FIBROMA
-benign connective tissue tumors
-occurs during the Ist and 2nd decade of life
-affects the metaphysis of long tubular often around the knee(dista1
femur proximal tibia)
-radiographic appearance: expansive, elongated, radiolucent, rnultiloculated lesions with cortical thinning
-possibly due to an unrecognized traumatic insult to the periosteum,
hence their propensity to occur at sites of muscle insertions, where tendons are pulling
-self limiting, heals over time being replaced by normal bone
FIBROSARCOMA
-malignant connective tissue tumors
-occurs during the 3rd, 4th, 5th, and 6th decade of life
-distribution of males to females is equal
-usually found in the metaphysis of long tubular bones(esp. femur, tibia)
-symptoms can include pain, swelling, and limited motion with possible
pathologic fx
-radiographic appearance: osteolytic foci with a geographic, motheaten
or permeative pattern of bone destruction. There is usually no associated periostitis
-occurs de nova or secondary to Paget's dz, osteonecrosis, chronic OM,
radiation or other undifferentiated neoplast(chondrosarcoma)
-aggressive tumor that has a tendency to reoccur
GIANT CELL TUMOR

-benign fibrohistocytic tumors composed of connective tissue, stromal
cells and giant cells
-occurs during the 3rd and 4th decade of life
-usually originates in the metaphysis but quickly extends into the epiphysis and subchondral bone
-seen in long tubular bones especially around the knee(dista1 femur or
proximal tibia)
-symptoms include pain, with possible swelling and limitation of motion
-may be associated with Paget's dz
-radiographic appearance: eccentric osteolytic lesion extending to the
subchondral bone. Large extensive periostitis is generally not present
-Have a tendency to reoccur
BONE TUMORS
247
CHAPTER 11
UNICAMERAL BONE CYST(So~itarybone cyst, Simple bone cyst)

-benign tumors of unknown origin
-occurs during the 1st and 2nd decade of life
-males are more often affected then females
-lesions in patients less than 20yrs of age generally occur in the metaphysis of tubular bones(esp. proximal humerus and the femur)
-lesions in patients over 20yrs of age generally occur in the pelvis or calcaneus
-usually asymptomatic unless associated with a pathologic fx
-radiographic appearance: centrally located radiolucent possibly multilocular lesion with cortical thinning and mild osseous expansion.
Calcaneal lesions are well-defined, radiolucent lesions usually occurring
at the neutral triangle
-fallen fragment sign-with a pathologic fx a bone fragment falls into the
cyst and migrates to the dependent position(this is because cysts are
filled with fluid)
-Recurrence rate is high in children
ANEURYSMAL BONE CYST

-benign blood filled cyst
-occurs during the lst, 2nd, 3rd decade of life
-F>M
-unusual in that it is a rapidly growing painful lesion yet it is benign
-lesions are usually located in the metaphysis of long tubular bones and
the spine
-symptoms include pain and swelling, possible pathologic fx
-radiographic evaluation: an eccentric, osteolytic(possibly trabeculated)
expansive lesion which may extend out into the soft tissue
-trauma is a possible etiology
-benign tumors of fatty tissue

-can affect all ages and is distributed equally between male and female
-usually found in long tubular bone most notably the fibula, femur and
tibia. 15% of cases however are found in the calcaneous
-can be asymptomatic but the majority experience pain and soft tissue
swelling
-radiographic evaluation: osteolytic lesion surrounded by a thin, welldefined sclerotic border. Internal osseous ridges are frequently present
and bone expansion may be seen. When the calcaneous is involved
lesions are usually in the neutral triangle(as with simple bone cysts) and
there is often a central calcified nidus
BONE TUMORS
248
CHAPTER 11
EWINGS SARCOMA
-malignant tumors of miscellaneous/unknown origin
-usually occurs between the ages of 7-20yrs
-M>F
-Metadiaphysis, metaphysis
-most commonly located in the metaphysis or metadiaphysis of the
femur, pelvic bones, tibia, and humerus
-symptoms include pain, swelling, fever, weight loss, and leukocytosis
-radiographic evaluation: looks very aggressive, permeative or motheaten, osteolytic lesion with cortical erosions, periostitis(onion-skin pattern)
and a soft tissue mass
-almost exclusively found in Caucasians
-prognosis is poor
BONE HEALING
249
CHAPTER 13
CHAPTER 13
BONE HEALING
AUTOGRAFTS VS. ALLOGRAFTS, p254
BONE GRAFT HARVESTING SITES, p255
BONE GRAFTS, p254
BONE HEALING COMPLICATIONS, p251
BONE HEALING STAGES, p250
BONE STIMULATORS, p253
CALCANEAL AUTOGENOUS BONE GRAFT, p255
CORTICAL VS. CANCELLOUS, p254
DELAYED UNION, p251
GRAFT HEALING, p255
NONUNION CLASSlFlCATION(WEBERAND CECH), p252
PRIMARY(MEMBRAN0US) VS. SECONDARY(ENCHONDRAL),p250
BONE HEALING
250
CHAPTER 13
BONE HEALING
-requires immobilization(fixation) and compression(optimalis 12-181bs/in2)
-bone can regenerate back to 100% of its strength following a fracture
-the body has a difficult time healing bone ends that are greater than 1
cm apart or fractures when the gap is greater in width that the radius of
the bone at that level
-osteoblasts deposits bone and osteoclasts absorb bone
FOUR OVERLAPPING STAGES OF BONE HEALING
Inflammation
-peaks at 48hrs and subsides at about a week
-inflammation(in addition to its normal role) also acts as an
immobilizer by causing:
Pain-patient protects area
Edema-acts as a hydrostatic splint
Soft callus
-begins several days after injury and persists for about 1-2 months
-fibrous and cartilagenous tissue develops at each end of the fracture
-if the soft callus fails to unite the two sides of the fracture(as with an
amputation) it will cease to grow and be resorbed
Hard callus
-if a soft callus is successful in connecting the fracture it begins to
ossify
-occurs at around 3-4 months
Remodeling
-lasts for several years
-excessive callus is resorbed
-final bone morphology is determined by Wolff's law
TWO TYPES OF BONE HEALING
PRIMARY(MEMBRAN0US) SECONDARY(ENCH0NDRAL)
-haversian remodelina(consistsof I -involves the formation of cartilaaenous
simultaneous remodeling
and fibrous tissue intermediates that
and direct formation of new
are later replaced by bone
-involves a callus formation(irritati0n
bone)
-little or no callus formation
callus)
-occurs when there is good
-occurs when there is motion at the
opposition and no motion at fracture/osteotomy site replaced
the fracture/osteotomy site
by bone
-desirable method of healing -less desirable method of healing
BONE HEALING
251
CHAPTER 13
BONE HEALING COMPLICATIONS

rate
for the location and type of fracture/osteotomy
-tme frame can not be arb~trar~ly
set, but most
doctors cons~dera delayed unlon at about
UNION
-of
heallng have stopped
-tme frame can not be arbltrarlly set, but most
doctors cons~dera nonunlon at about 8-9 months
(Medicare cons~dersa nonunlon at 90 days)
-generally, only lntervent~onby a bone

st~mulatoror operat~vemeans will heal
a nonunlon
-atrophic nonunlons usually requlre
a bone graft
-end stage of a nonunlon

surface develops at the
bone fracture s ~ t eand a jolnt space develops
-operatwe ~ n t e r v ISzthe only yellable

method of galnlng union
Treatment
-delayed unlons can often be healed
by str~ct~mmob~l~zat~on(NWB)
alone
- -
Note: a malunion is a fracture that heals in an anatomically incorrect position
BONE HEALING
252
NONUNION
CHAPTER 13
and Cech)
ELEPHANT FOOT
HORSE HOOF
-hypertrophic
-mildly hypertrophic -not hypertrophic
-large callus
-poor callus
-no callus
-greatest chance
of healing
Hypertrophic nonunions can often be treated by stable fixation alone
TORSION
WEDGE
COMMINUTED DEFECT
-intermediate
-intermediate
fraament that has
fraament that has
to one of the become necrotic
main fragments but
not the
-characterizedby
the loss of a
fragment such that
the two ends are
too far apart to
unite
ATROPHIC
-end result of a
defect nonunion,
ends of the
fragments become
osteoporotic an
atrophic
Atrophic nonunions require decortication and bone grafts to heal
BONE HEALING
253
CHAPTER 13
Local contributing factors t o nonunions

-infection
-poor fixation
-immobilization for an insufficient amount of time
-fracture with impaired blood supply (open fractures/comrninuted
fractures)
-distracted fracture(either by traction or fixation)
ELECTRICAL STIMULATION
-application of electrical current of 5-20pA(rnicroampers) has been
shown to stimulate bone formation at the cathode
-bone stimulators require approximately 3-6 months for bone healing
Theory
-living bone exhibits electronegativity over active areas of growth and
repair therefore electronegative charge stimulates bone growth
Bone Stimulators(success rate is similar with all three methods)
1) invasive
-requires a surgical procedure in which the cathode is placed
into the fracture site, the anode is placed on the skin
2) semi-invasive
-requires the percutaneous insertion of a cathode into the
fracture site
3) noninvasive
conductive
inductive coupling
a) Pulsating Electromagnetic Field(PEMF)
-uses an external apparatus over the fracture site
-used 10-12 hourslday
-position the flexible coil over the nonunion site treat
10 hourslday
b) Capacitive Coupling
-place the windows on each side of the fracture(ie plantarly
and dorsally)
-more portable than the inductive devices
-used 24 hourslday
Contraindications
synovial pseudarthrosis
large gap at the fracture site
-gaps larger than '/2 the diameter of the involved bone
-gaps that are greater than 1 cm apart
BONE HEALING
254
CHAPTER 13
BONE GRAFTS
FUNCTION/INDICATION
-0steogenesis
-immobilization
-replacement
GRAFT TYPE
Autoaraft-from one's own body or identical twin
-short term storage of graft-closed container covered with a
moistened saline sponge, without immersion
-storage in saline solution is detrimental to the graft
Alloaraft(homograft)-deadbone from same species
-usually freeze dried(lyophi1ized) bone bank bone
-some brands require reconstitution with an IV sterile saline
infusion before use
Xenoaraft(heter0graft)-bonefrom different species
Svnthetic arafts
-hydroxyapatite, tricalcium phosphate, type I collagen, marine coral
AUTOGRAFT VS. ALLOGRAFT

ALLOGRAFT(LY0PHILIZED)
Freeze driedldevoid of water
Noncellular bony matrix
No osteoinductive properties
Allows creeping substitution
Unlimited amount
Slower healing
Bonebankbone
1
1
AUTOGRAFT
Fresh water is present
Cellular bony matrix
Osteoinductive properties
Allows creeping substitution
Limited amount
Faster healing
Requires a donor site
CORTICAL VS. CANCELLOUS GRAFT

CORTICAL BONE
1
-dense
-used to provide stabilii(canbe fixated)
-few viable cells
-incorporation is slow
-does not revascularize
-does not facilitate osteogenesis
-allows creeping substitution
-not completely replaced by new bone
-radiolucent when healing
-haversion system
-graft is weakest at 8 weeks
CANCELLOUS BONE
-porous
-used to fill defects
-many viable cells
-incorporation is faster
-does revascularize
-facilitates osteogenesis
-allows creeping substitution
-completely replaced by new bone
-radiodense when healing
-no haversion system
-graft becomes stronger each week
BONE HEALING
255
CHAPTER 13
HARVESTING SITES FOR AUTOGRAFT

Iliac crest
-best source of cancellous bone
-proximal anteromedial tibia
Fibula
-the middle third to half of the bone may be
removed without any ill effects
-rarely the entire proximal 3/4 may be removed
-the distal % should always be left to maintain
ankle joint integrity
-the fibula graft is removed by a Henry's approach
-good source of cortical bone
Calcaneus
Proximal tibia
Distal tibia
Greater trochanter
Rib
HARVESTING A CALCANEAL AUTOGENOUS BONE

GRAFT
-lateral incision over the calcaneus(avoid: the neutral triangle, the sural
nerve. and the calcaneofibular liaament attachment)
-drill holes to outline a cortical wyndow and cut window with a power saw
-the cortical window is then pried from its bed
-curette out cancellous bone as needed through the window
-if cortical bone is not needed, replace the window after packing the
defect with lyophilized bone
-keep NWB until signs of healing are present
GRAFT HEALING
Osteoaenesis
-the formation of bone
Cree~inaSubstitution
-the process by which most cellular elements in grafts die and are
slowly replaced by viable bone
-transplanted bone is invaded by vascular granulation tissue, causing
the old bone to be resorbed and subsequently replaced by the host
with new bone
Osteoconduction
-the scaffolding effect of the bone graft that acts as a conduit for
migration of viable cells
-the matrix that allows creeping substitution to occur
Osteoinduction
-the presence of a bone morpheogenic protein inductor substance
that causes nonosseous tissue to become osteogenic. The process
of inducing pluripotential primitive mesenchymal cells to differentiate
into osteoblasts
BONE HEALING
256
CHAPTER 13
DERMATOLOGY
257
CHAPTER 14
CHAPTER 14
DERMATOLOGY
ACANTHOSIS NIGRICANS, p293
ATOPIC DERMATITIS, p264
BASAL CELL CARCINOMA, p285
BLUE NEVI, p280
BULLOUS DIABETICORUM, p290
CAFE AU LAIT SPOTS, p295
CALLUS/CORNS, p294
CARBUNCLE, p272
CELLULITIS, p270
CHICKENPOX, p276
CONTACT DERMATITIS, p263
DERMATOFIBROMA, p282
DERMATOPHYTOSIS, p272
DIABETIC DERMOPATHY, p290
DYSHIDROTICECZEMATOUS
P267
ERYTHRASMA, p270
FOLLICULITIS, p271
FURUNCLE, p271
GLOMUS TUMOR, p284
GRANULOMAANNULARE, p293
HEMANGIOMA-CAPILLARY
(STRAWBERRY MARK), p281
HEMANGIOMA(CAVERN0US)
p282
HERPES SIMPLEX, p274
HERPES ZOSTER, p275
IMPETIGO, p268
KAPOSI'S SARCOMA, p284
KELOID, p283
LICHEN PLANUS, p278
LICHEN SIMPLEX CHRONICUM
p266
MELANOMA, p287
p279
MOLLUSCUM CONTAGIOSUM
p274
NECROBIlOSIS
DIABETICORUM, p289
NUMMULAR ECZEMA, p265
PITTED KERATOLYSIS, p269
ROSEA, p278
POROKERATOSIS PLANTARIS
DISCRETA, p294
PORT-WINE STAIN
(NEVUS FLAMMEUS), p281
PSORIASIS, p277
PYODERMA GANGRENOSUM
p268
PYOGENIC GRANULOMA, p282
ROSACEA, p292
SCABIES, p290
SEBORRHEIC DERMATITIS, p267
SKIN TAG, p280
SPIDER ANGIOMA , p281
SQUAMOUS CELL CARCINOMA
p286
STASIS DERMATITIS, p266
SYPHILIS, p291
TESTS, p261
TlNEA PEDIS, P272
VERRUCA, p273
XANTHOMA DIABETICORUM
p289
DERMATOLOGY
LAYERS
258
CHAPTER 14
hair
STRATUM
LAYER)
-the outer most layer of the epidermis
-composed of dry, flattened, anuclear, dead, keratinized cells that
ultimately flake from the body
STRATUM
-a clear translucent layer of the epidermis
GRANULOSUM LAYER
-cytoplasm contains keratohyalin granules
-several cell layers thick
STRATUM
bridges give the cells a spiny appearance
-several cell layers thick
BASEMENT
GERMINATIVUM, BASAL LAYER)
-deepest layer of the epidermis
-composed of a single layer of rapidly proliferating cells that slowly
migrate upward to ultimately become the stratum corneum
-it takes 4 weeks for basal cells to reach the surface and be shed
DERMATOLOGY
259
CHAPTER 14
DERMIS(about 0.5mm thick)

-the dense connective tissue stroma forming the bulk of the skin
-connected to the dermis by finger like projections called dermal
papillae
-contains blood vessels, lymphatics, nerve ending, and hair follicles
PAPILLARY LAYER
-upper 113 of the dermis
-contains Meissner's corpuscles
RETICULAR LAYER
-lower 213 of the dermis
-contains Pacinian corpuscles
SUBCUTANEOUS TISSUE(PANICULUS, HYPODERMIS)

-composed of fatty connective tissue
ADDITIONAL CELLS
MELANOCYTES
-intermingled amongst the basal cells
-melanocytes produce melanin which absorbs ultraviolet light and
protects the tissue
-ultraviolet radiation activates melanocytes(tanning)
LANGERHAN CELLS
-found throughout the epidermis
-involved in the immune system(functioning as macrophages)
GLANDS
ECCRINE GLANDS
-sweat glands
-produce a watery substance(odor free)
-abundant in the axillae, palms, and soles
-controlled by the sympathetic nervous system
APOCRINE GLANDS
-sweat glands found in close association with the hair follicles
-produce a viscous sticky substance(odorous)
-reach maturity at puberty and are abundant in the axillae, areola,
pubis, and perineum
-adrenergic mediated
SEBACEOUSGLANDS
-a holocrine gland
-found surrounding the hair follicles
-discharge sebum which lubricates the hair follicle and spreads on to the skin
-become active at puberty and controlled by androgens
DERMATOLOGY
260
CHAPTER 14
DERMATOLOGICAL LESIONS
PRIMARY LESIONS
Macule-flat circumscribed lesions measuring up to l c m in diameter.
Cannot be felt, but can be seen
m - f l a t lesion measuring over l c m in diameter
Papule-circumscribed solid elevated lesions measuring up to l c m in
diameter
Plaaue-circumscribed, thickened elevated lesion over 1 cm in diameter
Nodule-circumscribed solid elevated lesion measuring up to l c m in
diameter. Differs from a papule in that it has the added dimension
of depth in the underlying tissue
Tm-circumscribed solid elevated lesion measuring greater than
Icm in diameter. Differs from a papule in that it has the added
dimension of depth in the underlying tissue
Vesicle-fluid-filled elevated lesions less than 0.5cm in diameter
Bulla- fluid-filled elevated lesions over 0.5cm in diameter
m-noninfected, deep-set collection of material surrounded by a
histologically definable wall
Burrow-an intraepidermal tunnel usually caused by insects or para
sites
-(Hives)-a well circumscribed, elevated, lesion that appears and
disappears rapidly(minutesto hours)
Pustule-a vesicle or bulla containing pus
SECONDARY
due to evolution of the primary
lesion)
--an
exfoliative condition marked by flaking laminations of the
epidermis
Excoriation-scratch marks usuallv seen where there is oruritis
~ichenification-thickening
of the skin with exaggeration'of skin lines
givina a leathew appearance-often associated with
hyperpigmentation: 'May be due to excessive scratching or rubbing
Erosion-deep excoriations in the epidermis, but the dermis is not
breached, leave no scars
--deep
epidermal defects in which the dermis or deeper tissues
are exposed, may leave scars
--dried
masses of serum, pus, or blood, generally mixed with
debris-"scabs"
Fissure-linear, deep, epidermal cracks, commonly found in areas of
dry or thick skin that may extend into the dermis
Scar-"cicatrix",the formation of fibrous connective tissue which has
replaced dermis or deeper layer, lost as a result of trauma or
disease
m - l o s s of the epidermis and a portion of the dermis
Maceration-epidermisbecomes overly hydrated and turns white
DERMATOLOGY
261
CHAPTER 14
DERMATOLOGICAL TESTS
Auspitz Sign
Pinpoint bleeding that occurs when the scales of a psoriatic lesion are
removed
D i a s c o p y ( g ~ a s sslide test)
Press a clear glass slide against the lesion and look for blanching.
Dilated capillaries(erythema) will blanch, hemorrhagic lesions(purpura)
will not.
Fungal Culture
Dermatophyte Test Medium(DTM) is used to grow dermatophyte cultures. Cultures require about 10 days to grow, medium will turn red if
dermatophytes are present. If the DTM turns red it is diagnostic for dermatophytes, however a false (+) may be seen with saprophytes, so the
colonies must be examined. Dermatophytes have powdery white
colonies. Saprophytes have shiny colonies which may be white, brown,
black, or green in color.
KOH Test
A KOH test can be performed on hair, skin, or nail.
Technique:
-scrape the scales from a lesion onto a slide with a blade.
-apply a drop of 10-2096 potassium hydroxide(K0H). KOH dissolves
keratin so that the skin, nail, or hair shaft becomes clear.
-KOH will dissolve keratin alone, but the process may be speeded up by
adding gentle heat or DMSO.
-examine under microscope for the presence of fungus, if present the
septated fungal hyphae can be seen growing through the epithelial cells.
Nikolsky Sign
An epidermal detachment produced by lack of skin cohesion, seen in
Bullous Diabeticorum
Shave Biopsy
-particularly suited to lesions confined to the epidermis such as seborrheic keratoses or molluscum contagiosum
DERMATOLOGY
262
CHAPTER 14
Punch Biopsy
-method of choice for most inflammatory or infiltrative diseases
-produces a full-thickness specimen of the skin
Technique
-prep biopsy site with alcohol, Betadine, or Hibiclens
-a sterile drape may be used but is optional for solitary punches
-infiltrate area with local with epinephrine
-when possible spread the skin perpendicular to skin tension lines.
This will allow the wound, circular under tension, to revert to an oval
shape when relaxed for easier closure
-with gentle downward pressure the bunch is rapidly rotated back and
forth allowing it to drill a core like specimen
-the punch is then removed, and the specimen remains in the center
of the site
-downward pressure around the punch site often elevates the speci
men above the surounding skin level
-gently pick up the specimen and cut the base as low as possible with
sharp scissors
-2 mm punch biopsies or smaller can be left to heal without suturing
Excisional Biopsy
-method of choice for diagnosis and removal of dermal and
subcutaneous cysts and tumors(epiderma1cysts and lipomas)
-also the method of choice for malignant melanoma
-can be used for lesions to big to punch biopsy(genera1ly greater than
8mm in diameter)
Tzanck Test
-used to diagnose viral disease(herpes simplex, herpes zoster, and
molluscum contagiosum)
-Technique
-scrape fluid and base of vesicle/bullae onto a glass slide
-fix with methanol and stain with Wright's stain
-the presence of multinucleate giant cells suggests herpes infection
Wood's Light Examination

-a black light with a 360nm wavelength(UV) filtered through glass used
to diagnose certain infections by causing different colors to fluoresce
Erythrasma(Corynebacteriumminutissimum)-coral red
Tinea capitis(M. canis)-Light, bright green
Pseudomonas aeruginosa-green
Tinea versicolor-yellow gold
Ash leaf macule(tuberous sclerosis)-accentuated hypopigmentation
DERMATOLOGY
263
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Contact Dermatitis
-dermatitis caused by contact with certain substances found in the environment causing inflammation of the epidermis and dermis
-the most common and classic example of this is poison ivy
-another common cause is nickel which is widely used in jewelry and in
metal clasps on women's underclothes. In podiatry contact dermatitis is
commonly due to the rubber found in the toe box of most shoes or the
cement used to bind shoes together
CLASSIFICATION
a) Irritation contact dermatitis
mechanisms
-a single exposure causes
a reaction
detergents, fiberglass
b) Allergic contact dermatitis
-acquired immunologic
response
-first contact causes no
reaction, but the exposure
sensitizes the skin to future
exposures
poison ivy
PRESENTATION
-irregular poorly demarcated patches of erythema and edema on
which are superimposed closely spaced vesicles, punctate erosions
exuding serum and crust.
-may be seen with a subchronic or chronic lesion lichenification
TREATMENT
-avoid contact with the offending agent
-increase aeration: avoid shoes with plastic uppers, wear cotton or
wool socks instead of synthetic ones, apply drying powders
-topical hydrocortisone cream for pruritis
-in moderate to severe cases treat pruritis with oral
Atarax, Vistaril)
-astringent
solution, Epsom salt) will decrease
inflammation and reduce weeping
-moisturizing lotions may also be soothing and help with
lichenification and fissuring
-topical Abx for secondary bacterial infections
DERMATOLOGY
264
CHAPTER 14
Atopic Dermatitis
-dermatitis resulting from a hereditary predisposition to a lowered
cutaneous threshold to pruritis. This leads to scratching and rubbing
which turn into eczematous lesion
-there is usually a positive
familyhistory of allergic
rhinitis, hay fever, asthma,
or migraine headaches
-often exacerbated by
sudden changes in
temperature, humidity,
stress/anxiety, and females
may have eruptioniust
befbre their menstrual
period
CLASSIFICATION
a) Infantile atopic
dermatitis
-usually starts at about
2-6 months
-mostly commonly seen on the face
-in about 1/2 the infants it clears up by age 2 and never returns;
in the other half, it clears up and then reappears in late childhood or
early teens(chi1dhood atopic dermatitis)
b) Childhood atopic dermatitis
-starts in late childhoodlearly teens
-most commonly seen on the antecubital and popliteal fossae
-in about % of these individuals the condition clears up in
adolescence; in the remaining half it persists into adulthood(Adult
atopic dermatitis)
c) Adult atopic dermatitis
-as the person grows older the rash usually seems to shrink and
become localized
-can be found anywhere but has a predilection for the flexures, front
and sides of the neck eyelids, forehead, face, wrists, and dorsum of
the hands and feet
PRESENTATION
-irregular poorly demarcated patches of erythema and edema on
which are superimposed closely spaced vesicles, punctate erosions
exuding serum and crust.
-with a subchronic or chronic lesion lichenification may be seen
-often symmetrical
DERMATOLOGY
265
CHAPTER 14
TREATMENT
-increase aeration: avoid shoes with plastic uppers, wear cotton or
wool socks instead of synthetic ones, apply drying powders
-topical hydrocortisonecream for pruritis
-in moderate to severe cases treat pruritis with oral
Atarax, Vistaril)
-astringent
solution, Epsom salt) will decrease inflam
and reduce weeping
-moisturizing lotions may also be soothing and help with
lichenification and fissuring
-topical Abx for secondary bacterial infections
Urticaria
-an allergic reaction resulting in
transient puritic wheals or small
erythematouspapules that erupt in
minutes to hours and disappear
usually within
or less
-patients often have a history of
atopic dermatitis
-in severe reactions, anaphylaxis
may occur
CAUSES
eggs, shellfish, nuts)
-parasites
TREATMENT
terfenadine)
Eczema
-pruritic dermatitis occurring In the
form of coin-shaped plaques

composed of grouped small
on an erythematous
base
-especially common on the lower
legs of older males during the winter
often have as associated
bacterial infection and treatment
should include oral dicloxacillin or
erythromycinin addition to topical
corticosteroids
Gary L.
Atlas of Foot
and Mary E. Crawford, Color

Ankle Dermatology, PA
Publishers, 1999, p. 20
DERMATOLOGY
266
CHAPTER 14
Lichen Simplex Chronicum

-a circumscribedarea of
resulting from
repeated physical
>
C
Dermatitis
-dermatitis of the lower leg related to PVD
present
DERMATOLOGY
267
CHAPTER 14
-in the crusted stage there are golden-yellow crusts that appear "stuck
on" an erythematous base
Impetigo-which presents as scattered thin-walled
arising
in normal skin and containing clear yellow fluid without later becoming
crusted
TREATMENT
-curable in 7-10 days
ointment
-oral PCN or Erythromycin
Pitted Keratolvsis
-superficial pitting in the stratur
corneum on the soles of the
feet giving rise to a "moth-eate
appearance
-result of a
enzymes
from bacteria
-often associated with
and bromhidrosis
TREATMENT
oral
-measuresshould
be taken to reduce foot
DERMATOLOGY
268
CHAPTER 14
Ewthrasma
-a bacterial infection affecting the intertriginous areas of the body
(between toes, groin, and axillae)
-there is a higher incidence in warm, humid climates and in diabetics
-often a secondary infection as a result of tinea
CAUSE
-Corynebacterium minutissimum
DIAGNOSIS
-Wood's lamp will cause the area to fluoresce "coral-red"
PRESENTATION
-lesions are scaling, fissuring, and slightly macerated
-resembles tinea
-in the feet it most commonly occurs between the 8 and 4Ihtoe
TREATMENT
-oral rythromycin or Tetracycline

relapses are common within 6-12 months
DERMATOLOGY
269
CHAPTER 14
LOCATION OF LESIONS
-most common on the lower leg
-Erysipelas-acute supedicial form of cellulitis involving the dermal lymphatics
PRESENTATION
-sudden onset of tender, edematous, erythema in an area of the skin
that is warm to the touch as compared to the contralateral side
-can spread rapidly
-hyperemia, edema, pain, increased local temperature, and decreased function
-red streaking may be seen from the cellulitis towards the heart
-swollen lymph glands nearest the cellulitis
-fever/chills
-may lead to sepsis and become life threatening
TREATMENT
-oral antibiotics
-warm water soaks to relieve painlinflammation and hasten healing
-elevation and restricted movement of affected area
Folliculitis
-a superficial contagious bacterial
infection of a hair folliculitis
-usually caused by Staphylococcus
aureus
-most common on the neck, face,
buttocks, and breast
-treatment involves applying moist
heat to allow the lesion to come to
a head and drain.
maul u uu#uatalrl,rracrrar uarrrraturvyy,
Mosby, 1997, p. 76, fig. 7-6
Furuncle
-a contagious deep bacterial infection of a hair follicle
-folliculitis eventually develops into a
furuncle which is a deep-seated, red, hot,
very tender, inflammatory nodules
-also known as a boil
-most common on the neck, face, buttocks,
and breast
-treatment involves applying moist heat to
allow the lesion to come to a head and
drain. Incision and drainage is often required
-usually caused by Staph. aureus
-lymphadenopathy may be present
..
.Gary L. Dockel , ,,lorAtlas of I
-oral antibiotics may be required
Ankle ~errnatof y Llppincott-Raven,
., ..
1999, p143, fig.%
DERMATOLOGY
270
CHAPTER 14
Carbuncle
-a cluster of furuncles that coalesce when the infection spreads through
small tunnels underneath the skin
-usually caused by Staph. aureus
-most common on the neck, face, buttocks, and breast
-treatment involves applying moist heat to allow the lesion to come to a
head and drain.
-incision and drainage may be required
-lymphadenopathy is often present
-if associated with cellulitis or fever, systemic antibiotics are required
FUNGAL INFECTION
Dermatophytosis(Cutaneous Mycoses)
-responsible for most cases of
-other areas of infection are:
-Tinea pedis-athletes foot
-Tinea corporis-skin
-Tinea barbae-beard hair
-Tinea capitis-scalp hair
-Tinea cruris-groin
-only live on dead cells
-they do not become systemic,
but they do elicit an immune
response
-there are three main genus
a) Microsporum
Microsporum canis
-animal source
audouini -human source
gypseum -soil source
-infects skin and hair
-Responsible for childhood Tinea capitus. Rarely cause Tinea
pedis.
-Microsporum species fluoresce green under UV light.
b)
Epidermophyton
Epidermophyton floccosum
-3"j most common cause of T. pedis(5-10%)
-infects skin and nail
C)
Trichophyton
-Responsible for most Tinea pedis, and Tinea capitis
Trichophyton mentagrophytes
-Pdmost common cause of T. pedis(45%)
-most acute type
DERMATOLOGY
271
CHAPTER 14
DIAGNOSIS
fluid from one of the vesicles)
TREATMENT
or topical)
Herpes Zoster
-an acute CNS infection involvina
the dorsal root ganglia
-also know as Shingles
-triggered by systemic disease,
particularlyHodgkin's disease or
immunosuppressive therapy
at any age but most
common after age 50 years
-reoccurrenceis rare 4%
Hunt's
involving the face and
auditory nerve. Involves pain in
the ear and facial paralysis
CAUSES
virus
-the same virus that causes chickenpox
-arises from a reactivation of the virus that has lain dormant in the sensory root ganglia for many years
PRFSENTATION
symptoms occur 3-4 days before and outbreak and include
chills, fever, malaise, GI disturbances
-presents as crops of clear fluid filled vesicles on an
base
erupt along the cutaneous area supplied by a peripheral sensory nerve
-after several days the blisters rupture and leave painful, shallow ulcers
that heal in 2-4 weeks
neuralgic pain in the cutaneous area supplied by a
peripheral sensory nerve may linger long after skin lesions are gone
fluid from one of the vesicles)
DERMATOLOGY
272
CHAPTER 14
TREATMENT
-locally applied wet compresses are soothing
-pain meds
-acyclovir
1 Herpes Simplex
1
(Common name1 cold sores, genital herpes /
1 Causative agent HSV-1, HSV-2
Presentation
single or multiple vesicles
Location
mouth, eyes, genitalia
Prodrome
itching and tingling in area
of eruption
Pain
moderatelsevere
common
Herpes Zoster
shingles
varicella-zoster virus
crops of vesicles
along dermatomes
chills, fever, malaise,
GI problems
severe
rare
Varicella!Chicken pox)
-highly contageous primary
infection caused by varicella
-zoster virus
-90% in children under 10
years of age
-transmitted by airborne
droplets as well as direct
contact
-patients are contageous
from several days before
vesicles appear until the last
crop of vesicles; crusts are
not infectious
-incubation period is 2 weeks
SIGNSISYMPTOMS
-successive crops of pruritic vesicle,
, , progress to pustules crusts
and sometimes scar
-mild headache, fever, and malaise may be present
DIAGNOSIS
-Tzanck test
TREATMENT
-symptoms in children are usually mild and antiviral treatment is not indicated, in adults oral acyclovir 1,000mg q6h x5days
-vaccination is available
..,
DERMATOLOGY
273
CHAPTER 14
Dvshidrotic Eczematous
-a special vesicular type of hand and foot eczema associated with
pruritis
-predilection for the sides of the fingers,
palms and soles of the feet
-small vesicles deep seated (appearing
like "tapioca") in clusters occasionally
Later stages present with scaling,
lichenification,painful fissuresand erosions
-despite the name, sweating plays no
role in the pathogenesis
-the
form is called pompholyx
-emotional stress and ingestion of
certain
cobalt, or
chromium) have been suggested as
possible precipitating factors
TREATMENT.
-vesicular stage-saline or Burrow's wet
-eczematous stage-topical cotticosteroids
Seborrheic Dermatitis
-a common chronic inflammatory
redness
-usually worse in the winter
-it does not cause hair loss
PRESENTATION
-flaking, white, scales over
erythematous patches
commonly seen in
those 20-50 years, in children
it's called "cradle cap"
LOCATION OF LESIONS
-scalp, eyebrows,
area,
folds, retroauricular
creases, beard, presternal
area, and central back
-less commonly seen in the
and umbilicus
by scaling and
of
and
Dermatology, 2nd Ed ,
lnc , 1992, p 55
DERMATOLOGY
274
CHAPTER 14
TREATMENT
-antiseborrheicshampoos are the standard therapy for the scalp 1%
selenium sulfate suspension(Selsun Blue) zinc pyrithione(Headand
Shoulders, Sebulon) tar derivatives(T1Gell)
-hydrocortisone creams and lotions
Pvoderma Ganarenosum
-a rare disease frequently
associated with GI diseases
(ulcerative colitis, Crohn's dz.)
-consists of large ulcers with
characteristic purple overhanging
edges which develop rapidly frorr
pustules and tender nodules
- o c c u r particularly on lower legs,
abdominal, and face
-exact etiology is unknown
-responds to systemic steroids
BACTERIAL INFECT
lm~etiao
-a common contagious
superficial skin infection
-seen in preschool children
and young adults
CAUSE
-usually Staphylococcus aureus
LOCATION OF LESIONS
-most often presents on the face,
arms, legs, or buttock
PRESENTATION
-initially presents as a red rash
with many small blisters, the
blisters later break forming a
crusted stage
DERMATOLOGY
275
CHAPTER 14
-inflammation with vesicles or bullae

-occurs on the plantar skin and may resolve into a keratosis
-there is an also intertriginous form which is most common
-occurs at the IS especially the 3rd and 4th
-characterized by maceration, scaling, and fissuring with pruritus
and malodor
Trichophyton rubrum
-Most common cause of T. pedis(50%)
.-infects skin, nail, or hair
-Squamous form
-moccasin distribution-affects the plantar surface and sides if the foot
-may be accompanied by keratosis
-may co-exist with intertriginous form
Trichophyfon tonsurans and Trichophyton schoenleini
-Most common causes of T. capitus
VIRAL INFECTIONS
Verruca!plantar wart)
-plantar warts are common contagious benign tumors caused by a virus
-more common in older children
-caused by human papillomavirus
-must be distinguished from a
callus(see table below)
-only painful when on WB surfaces
TREATMENT
-surgical excision, liquid nitrogen,
various topical acids, laser, oral
ranitidine (See p. 74)
-spontaneous remission occurs in
-60% of cases with or without
treatment, may reoccur at the same
or a different site
-WB or NWB surfaces

-pain on lateral pressure
-WB surfaces
-pain on direct pressure
DERMATOLOGY
276
CHAPTER 14
Molluscum Contaaiosum
-contaaious viral infection of the skin
-common in children. in adults it's often sexuallv transmitted
CAUSE
-poxvirus
PRESENTATION
-discrete, round, smooth,
umbilicated, pearl-white or skin
colored papules
-usually measuring 1-3mm in
diameter
-lesions are asymptomatic
unless secondarilv infected
-lesions may be akingle
isolated lesion or multiple
scattered lesions
-often disappear
s~ontaneouslvwithin 1-2 vears
TREATMENT*
-liquid nitrogen
Thomas
!patric .
lor Atlas ant
H e r ~ e sSim~lex
Synopsis of Clinical Dermatology, 2nd Ed.,

McGraw-Hill Inc., 1992, p. 69
-the virus remains dormant in the nerve ganglia

-recurrent herpetic eruptions can occur due to over exposure to the sun,
febrile illnesses, physical or emotional stress, immunosuppressive
..
drugs, or menstruation
-incubation is 2-20 days(average
6 days)
-Herpetic whitlow-a painful herpetic
eruption that occurs on the distal
phalanx through a cutaneous break
CAUSE
-HSV-1(herpes simplex virus-1)
-found on the mouth, on the lips,
conjunctiva or cornea
-HSV-2(herpes simplex virus-2)
-found on the genitalia(STD)
PRESENTATION
-usually associated with a prodrom
itching in the area where the eruption will occur
-initially presents as single or multiple clusters of small vesicles, filled
with clear fluid on an erythematous base
-after several days the blisters rupture and leave painful, shallow ulcers
that heal in 2-4 weeks
DERMATOLOGY
277
CHAPTER 14
SCALING PAPULAR DISEASE

Psoriasis
-a common, chronic,
inflammatory, dermatitis
-affects 2% of the
population, whites blacks
-onset is usually between
10-40 yrs
-usually a positive family
history
-typical course is chronic
remission and recurrence
-mostly a cosmetic problem
unless associated with joint
arthritis)
-severity increases during
cold weather
LOCATION OF LESIONS
-usually involves the scalp, extensor surfaces of the
. .
knees and elbows), the back and the buttock
PRESENTATION
are well circumscribed, erythematous "salmon
. ,
plaques covered with silvery shinyscales
-lesions are not pruritic and heal without scaring
phenomenon-removal of silvery scales results in pinpoint
bleeding
-pitting of the finger and toenails seen in 25% of
-topical corticosteroids
-exposure to sunlight generally
helps heal lesions, however
occasionally sunburn can
exacerbate the condition
is used to treat
severe resistant cases
or
DERMATOLOGY
278
CHAPTER 14
Pitvriasis Rosea
lesions
-occur most often in young adults
(between age 10-35 years)
-spontaneous remission usually
occurs in 1-4 months,
recurrences are rare
CAUSE
-unknown, probably by all
infectious agent
PRESENTATION
-lesions are round or oval.
slightly erythematous
with fine scales, and have
a slightly raised border
-a "herald" or "mother" patch
ostll U.
rrslrz,~rr,urrrr,cravrvyy.
found on the trunk usually
Mosby, 1997, p. 177, fig. 14-13
precedes the generalized eruption
by 5-10 days and is usually larger than the rest of the lesions
-the generalized eruption consists of many lesions 2-5 cm in diameter
and continues to develop for weeks
-on the back, their long axes parallel the lines of cleavage, typically
radiating from the spinal column in a "Christmas tree" pattern
-pruritis may or may not be present
TREATMENT
-usually none is needed
-pruritis may be controlled symptomatically
uvmurtrt~~,
Lichen
-a recurrent, benign, pruritic, inflammatory eruption of the skin,
associated with oral lesions in about half of patients
-most common in people over 40 years of age
-lesions may disappear in weeks or persist for years
-10% of patients develop pterygium
-may result in sudden hair loss in patches on the head
-moderatelsevere pruritis in common
CAUSE
-unknown, may be caused by certain drugs
-stress can precipitate an attack
DERMATOLOGY
279
CHAPTER 14
LOCATION OF LESIONS
-seen symmetrical in the flexor surfaces of the wrists, forearm, lower
abdomen, back, and mucous membrane
PRESENTATION
Skin
-flat topped, violaceous, shiny,
polygonal shaped papules
measuring 2-4mm in diameter
with a network of fine white
striae)
Mucous
mucosa, tongue, lips)
-milky-white papules with a
fine white
striae)
-on rare occasion, long standing
oral lesions may develop
carcinoma
TREATMENT
-consists of topical corticosteroids
with occlusion
-erosions usually resolve in weeks
to months, however lesions may
on the
persist for years
shins or in the mouth
of Dr
M
Dermatology. TJ ane
BENIGN TUMORS
nevi
Junctional nevi
-flat and hyperpigmented
-nevus cells are found at
the dermoepidermal
junction above the
basement membrane
DERMATOLOGY
280
Comaound nevi
-raised and hyperpigmented
-combination of the histologic
factors of the junctional and
dermal moles
-cells are found both at the
dermo-epidermal junction and
also in the dermis
Blue nevi
dermo-epidermal junction
-the melanocytes are found in the lower
dermis and the refraction of light at this
level gives rise to the blue color
-they are benign
sKin taq
-common soft, small. flesh-colored
or hyperpigmented pedunculated
lesion
-may occur anywhere, but most
common at intertriginous sites
-asymptomatic and only a cosmetic
concern, more common in obese
people
-tend to become longer and more
numerous over time
-removed most often for cosmetic
reasons(liquidnitrogen or excision)
CHAPTER 14
lntradermal or dermal nevi

-raised and flesh colored
(sometimes pigmented)
-nevus cells are entirely
within the dermis
-common on the face, rarely
malignant
DERMATOLOGY
281
CHAPTER 14
VASCULAR TUMORS
Anaioma/Hemanaioma
Capillary Hemangioma
(strawberry mark)
-soft, bright-red, vascular
nodule-plaques that develop
at birth or soon after birth
-disappears spontaneously
by age 5 years old
-treatment is rarely necessary
Beth G Goldstein, Practical Dermatology,
Mosby, 1997, p. 278,20-13
'ort-Wine Stain(Nevus Flammeus)

-an irregularly shaped red or violaceous macular vascular formation
which is present at birth and does not
disappear spontaneously
-treatment may be with skin colored
dyes or copper vapor laser
-occationally associated with two
syndromes: Sturge-Weber Syndrome
and Klippel-Trenaunay-Weber
Syndrome
S~iderAnaioma
-a focal telangiectatic network of
dilated capillaries radiating from a
central papular punctum
-associated with pregnancy or
hepatic disease
DERMATOLOGY
282
CHAPTER 14
:avernous Hemanaioma
-an edematous vascular lesion
characterized by soft compressible
tissue
-may be associated with surface
varicosities or nevus flammeus-like
changes
-lesions are not apparent at birth but
become visible during childhood
-Maffuccils syndrome-a variant of
cavernous hemangioma
associated with dyschondroplasia
and hard nodules on the finaers
or
"
Thomas B. Fitzpatrick, Color Atlas and

Synopsis of Clinics, Dermatology, 2nd Ed.,
~ c ~ r a w - HInc.,
~ I I 1992, p. 163
-lesions are asymptomatic except

from cosmesis
Pvoaenic Granuloma
-a benign skin lesion composed of small blood vessels
-usually occurs in children or persons <30 years, increased incidence
during pregnancy
PRESENTATION
-rapidly developing bright-red or
violaceous or brown-black nodule
-the base is slightly c:onstri
-lesions bleed easily when
slightly touched
-lesions generally do not hurt or itch
LOCATION OF LESIONS
-commonly occurs at nail mars
and grooves, especially in
conjunction with ingrown toeni
TREATMENT
-excise lesion
-1
Dermatofibroma
-vew common button-like dermal fibroma usuallv occurina on the

extremities, most commonly the leg
DIAGNOSIS
-Dimple sign-lateral compression with thumb and index finger yields a
depression or "dimple"
DERMATOLOGY
283
CHAPTER 14
PRESENTATION
can be skin color pink tan or brown
are firm papules or nodules usually between 3-10 mm
LOCATION OF LESIONS
-the extremities, most commonly the leg
TREATMENT
are benign and require no treatment unless they pose a
cosmetic
or are subiect to
trauma
Richard
Skin Surgery,
Mosby, 1998, p. 147
Keloid
-a hypertrophic scar that extends
beyond the site of
often with
claw-like extensions
-familial and more common in blacks
TREATMENT
-is controversial but may include
surgical excision and steroid injections
Thomas
ColorAtlas and
Synopsis of ClinicalDermatology,
Ed..
McGraw-Hill
1992, p. 175
DERMATOLOGY
284
CHAPTER 14
Glomus Tumor
-a benign, extremely painful, vascular tumor usually found subungual
-arise from glomus bodies in the nail bed
glomus bodies function in blood shunting as an aid to temperature
regulation in the nail bed
CAUSE
-unknown
PRESENTATION
-blue-red, moderately firm painful
in diameter
papule usually
-rarely ulcerative or bleed
-characterizedby paroxysmal pain
LOCATION OF LESIONS
-commonly found subungual
TREATMENT
-surgical excision is curative
L.
Dermatology,
6.56
Color Atlas of Foot Ankle

1999,
fig.
Sarcoma
-a multicentric systemic vascular tumor characterized by violaceous
nodules and by edema secondary to lymphatic obstruction
-prior to HIV was uncommon and seen in greatest frequency in Eastern
Europe and Jewish and Italian immigrants over 60 years of age
-now occurs mainly in homosexual
males with HIV
PRESENTATION
-bluish-red, purple to violaceous
or dark brown macules, nodules,
and patches that spread and may
coalesce to form large plaques or
nodules
-often associated with edema
-most lesions are asymptomatic
DERMATOLOGY
285
CHAPTER 14
LOCATION OF LESIONS
-most frequently found on the feet or legs
TREATMENT
-in HIV patients treatment is not often indicated since infection usually
dominates the clinical cause
MALIGNANT TUMORS
Basal Cell Carcinoma
-sometimes called a rodent ulcer
-most common type of skin cancer
-more common in fair skinned
individuals
-metastasis is rare
CAUSES
-include excessive sunlight or
radiation exposure
LOCATION OF LESIONS
-occurs on sun exposed areas,
especially the face
PRESENTATION
-the clinical presentation is highly variable
are usually asymptomatic
commonly begin as a small smooth hemispherical translucent,
shiny papule with a pearly border
-later dilated blood vessels and occasionally specks of brown or black
pigment can be seen
-the lesion gradually enlarges into a mass of pearly nodules or a papular
plaque that maybe darkly pigmented.
-later still it may develop into an ulcerated crusted or bleeding lesion
surrounded by a nodular
ulcer)
TREATMENT
-excision, curettage,
or cryotherapy, and in severe cases
radiation therapy
DERMATOLOGY
286
CHAPTER 14
Sauamous Cell Carcinoma

-a malignant tumor of epithelial keratinocytes(skinand mucous
membrane)
-high incident of metastasis
-Bowen's disease-a superficial variant of squamous cell carcinoma that
resembles a localized patch of psoriasis, dermatitis, or tinea
-Sauamous cell carcinoma is the carcinoma most freauentlv
,
, associated
with chronic venous ulcers
CAUSE
-exogenous carcinogens(i.e. sunlight
exposure, ingestion of arsenic,
radiation, smoking)
-more common on fair skinned
persons
-usually occurs in people over
55 years old
-males are more affected that
females, however on the legs
females predominate
LOCATION OF LESIONS
-usually found on the face or back
of the hands
-occur on sun exposed areas
-on the foot often arise in previous
damaged skin especially scars
PRESENTATION
-clinical presentation is highly variable
-superficial discrete hard lesions resembling a verruca arise from an
indurated elevated base, dull red color with telangiectasias
-begin as small erythematous hard scaly plaques
-begin as a small hard red nodule which may ulcerate
-may ulcerate
TREATMENT
-excision, curettage, cautery, or clyotherapy, and in severe cases
radiation therapy
DERMATOLOGY
287
CHAPTER 14
Melanoma
DESCRIPTION
-malignant tumor of the
-arising from pre-existing nevi or
de novo
-found primarily on sun exposed
areas of fair skinned individuals
-predilection for the backs of men
and the legs of women
-when it occurs in blacks it is often
found on the palms, soles, or nail
beds
-majority present between 30-60
years of age
-any pigmented skin lesion with
Oncology,
1982.
recent change in appearance
p 1131 Fig 31-9
should be suspect
TYPES
a) Superficial Spreadina Melanoma
-Most
-Occurs in younger patients
-Spreads radially before invading deep
-Pigmented
lesion with irregular borders
b) Nodular Melanoma
-15% of cases
-Worst
invasive early)
-Uniformly pigmented bizarrely colored nodule
-Commonly ulcerates
c) Lentiao Maliana
freckle)
-5% of Melanomas
-Slowest growing, least likely to metastasize
patch of mottled pigmentation
-Enlarged radially before spreading deep
-Occurs on sun exposed areas
-More common in older pts
d) Acral lentiainous Melanoma
-10% of Melanomas
-Aggressive, invades early
-Occurs chiefly on the palms and soles, often on the digits or sub
whitlow)
-Usually found on nonwhite individuals
DERMATOLOGY
288
CHAPTER 14
Amelanotic melanoma
-occurs when a melanoma arises from a melanocyte devoid of pigment
-may occur in any of the four clinico-pathological variants
-present as erythematous papules or nodules lacking significant
pigmentation
-often misdiagnosed as basal cell carcinoma, squamous cell
carcinoma and other non-pigmented skin tumors
SIGNS AND SYMPTOMS

a) ABCDE's
AsymmetricalBorders-irregular, notched
Eolor-multicolored (pink, white, purple. gray, tan, black, blue or
brown)
Diameter-greater than 6mm in diameter(-the diameter of a pencil
eraser)
Elevation-lesions are usually elevated
y
skin lesion with recent change in
b) ~ n pigmented
appearance should be suspect
c) Palpable regional lymph nodes(late manifestation)
d) Hutchinson's sign-Seen in subungual melanoma. Pigment changes
in the eponychium secondary to leaching of the pigment from a
subungual melanoma
PATHOLOGIC STAGING
Clark's Classification (depth of invation)
Stage l
-Limited to the epidermis
-No basement membrane involvement
Stage II
-Through basement membrane into papillary dermis
Stage Ill
-Filling the papillary dermis
Stage IV
-Into the reticular dermis
Stage V
-Into the subcutaneous fat
Breslow's Classification (thickness of tumor)
Depth of lesion in mm
S u ~ i v aRate
l
Q 10yrs
< 0.75
97%
0.76-1.50
87%
67%
1.51-3.99
>4.00
40%
TREATMENT
-Surgical excision
-amputation
DERMATOLOGY
289
CHAPTER 14
CUTANEOUS MANIFESTATIONS OF DIABETES

Necrobiosis Lipoidica Diabeticorurn
-may be an important clinical finding as it precedes the onset of diabetes
in 15-20% of patients
CAUSE
-caused by an obliterative endarteritis,
characteristic of diabetic
microangiopathy
PRESENTATION
-begins as a red or red-brown, flat, well
lesion that slowly expands
-the sharply demarcated active border
but the center
remains
appears atrophic, yellow, waxy, shiny
and telangiectatic as lipids are deposited
-dermal vessels become telangiectatic
and the subcutaneous
Marc A. Brenner:Management of the
Diabetic Foot,Williams Wilkins, 1987
become visible
-these lesions may persist for years and ulcerate from minor trauma
-lesions can be anywhere from
to 25cm in diameter
LOCATION OF LESIONS
-in 90% of patients it is localized to one or both shins
TREATMENT
-unless ulcerated lesions do not have to be treated
-a high potency topical corticosteroid applied to the active margin may
arrest the progression
-resolution
prognosis is not related to the patients glycemic
control
Xanthorna Diabeticorurn
-sudden onset of crops of
asymptomatic yellow papules
each with an erythematous rim
-located mostly over the extensor
elbows, back,
buttocks, and truck)
-most arise during the
hypertriglyceridemic phase of
uncontrolled diabetes
-spontaneously disappear over
several weeks after the serum lipid
level has returned to normal
DERMATOLOGY
290
CHAPTER 14
Bullous Diabeticorum
-occur as spontaneous atraumatic lesions
usually on the extremities, especially the feet
-blisters are sterile and filled with clear
fluid that range from a few millimeters to
several centimeters in diameter
-blisters start as tense lesions, but as it
enlarges it becomes flaccid-the exact
cause of the blisters is unknown
although photosensitivity has been
suggested as initiating factor
Thomas P. Habif Clin~calDermatology,
-blisters heal over a 6 week period
Mosby, 1990,p. all,flg. 16-4
without scarring
-lesions are asymptomatic and require no treatment, however the
blisters may be incised and drained if they are in a precarious position
Diabetic Dermomthy
-atrophic, hyperpigmented,
circumscribed skin lesions
-often found BIL on the shins or feet
-occur in 30-60% of diabetics
-pigmentation is due to hemosiderin
deposits
-lesions are asymptomatic and
require no treatment
MISCELLANEOUS
Scabies
-a contagious intensely pruritic parasitic infection
-scabies is the basis for the colloquial term "the seven year itchn as it
tends to occur in communities in a 7 vear cvcle
-impregnated female mites
tunnel into the stratum corneum
and deposit eggs along the
burrow. Larvae hatch within a
few days and congregate
around the hair follicle
-transmitted mostly by personto-person contact, also by towels,
cloths and bedding
-the m~tecan only suwive 2 days
off the skin
Thomas 8.Filz~atrtck.Color Atlas and

Synopsis of Clinical Dermatology, 2nd Ed.,
McGraw-Hill Inc., 1992,p. 133
DERMATOLOGY
291
CHAPTER 14
CAUSE
-a skin infestation by a mite, Sarcoptes scabiei
PRESENTATION
-characteristic initial lesions are gray or skin colored burrows seen as a
fine waxy dark line a few millimeters to 1 cm long with a minute papule
at the open end
LOCATION OF LESIONS
-lesions occur predominately on the finger and toe webs, the flexor
surfaces of the wrists, around the elbows and axillary folds, around the
areolae of the breasts in females and on the genitals in males, along the
belt line and on the lower buttocks
-scalp and face are usually spared
DIAGNOSIS
-diagnosis is confirmed by scrapings taken from the burrows which will
demonstrate the parasite
TREATMENT
-5% permethrin cream(cover entire body from neck down for a minimum
of 12 hrs)
-Single dose po ivermectin(StromectoI)
CAUSE
-spirochete, Treponema pallidurn
STAGES
Primary syphilis
-incubation period is 3 weeks
-painless ulcers or chancre develop at the site of inoculation
-there is often regional lymphadenopathy
Secondary syphilis
-appears 2-6months after

initial infection
-lesions are asymptomatic
round or oval brown red or
pink dry macules and papules
measuring 0.5-lcm in diameter
-lesions may be generalized
to the trunk or localized on
the head, neck, palms, or
soles
Beth G Goldstein Practical Dermatology,
-usually associated with a
Mosby, 1997, p. 197, fig. 15-6
flu-like syndrome(headache,
sore throat, generalized arthralgia, malaise, fever)
DERMATOLOGY
292
CHAPTER 14
Tertiary syphilis
begin as nodules that ulcerate resulting in "punched out
lesions called a
-25% of patients
have
neuropathy,
mental deterioration) or cardiovascularsyphilis
DIAGNOSIS
TREATMENT
Rosacea
-a chronic
inflammation of the
units of the
liquids)
heat stimuli in the
PRESENTATION
-patients have periodic reddening of the
with increase in
skin temperature
are characterizedby telangiectasias,erythema, papules and
pustules appearing especially in the central area of the face
last days to weeks
TREATMENT
-reduce stress level, eliminate food or drink that exacerbates condition
-topical
-oral tetracycline
are contraindicated,they have been known to worsen
the condition
DERMATOLOGY
293
CHAPTER 14
Acanthosis Niaricans
-may precede other symptoms of malignancy by 5 years
-must
an underlying endocrine disorder and malignancies
LOCATION OF LESIONS
are most common in the
and on the neck, also the groin,
antecubital fossa, knuckles, submammary, and umbilicus
-in the feet there may be
toes
PRESENTATION
-a diffuse velvety thickening an
hyperpigmentation of the skin
CLASSIFICATIONS
type 1-hereditary, benign
type 2-benign, associated with
endocrine
type 3-pseudo, complication of
obesity
type 4-drug induced
type 5-malignant
I Dermatology, 2nd Ed.,
-Hill Inc., 1992, p. 733
Granuloma
-benign
are usually asymptomatic and self limiting
-recurrencesare common
-possibly a higher incident in
diabetics
LOCATION OF LESIONS
-lesions are usually present
on the feet, legs, hands, or

fingers
PRESENTATION
-characterizedby confluent,
firm, pearly, white, papules or
nodules that spread peripherally
to form rings with normal skin in
their center
-may also present as a
subcutaneous nodule appearing
much like a rheumatoid nodule
75% of
disappear spontaneously in 2 yrs
of Clinical Dermatology, 2nd Ed.,
DERMATOLOGY
294
TREATMENT
triamcinolone acetonide injections
-topical corticosteroids with occlusion
PorokeratosisPlantaris Discreta
-benign lesion caused by hypertrophy of
the stratum corneum around the duct of
a sweat
sweat duct)
-slow growing, hyperkeratotic papules that
are exquisitely tender
-often misdiagnosed as a wart or callus
-generally a solitary lesion found on the
of me foot
interdigital callus
white and
macerated
-when found at the 4th IS
it's usually caused by
pressure from the head of
the proximal phalynx 5th
toe aaainst the base of the
phalynx 4th toe
CHAPTER 14
DERMATOLOGY
295
Cafe au lait s ~ o t s
-hyperpigmented macules on the
trunk and legs
-associated with neurofibromatosis
(von Recklinghausen's disease)
-10% of normal individuals have
one to three cafe au lait spots
-extensive cafe au lait macules
with a "coast of Maine," or irregular
edge
-the spots are due to heavily
pigmented melanocytes of neural
crest origin
CHAPTER 14
DERMATOLOGY
296
CHAPTER 14
WOUND HEALING/DIABETES
297
CHAPTER 15
CHAPTER 15
WOUND HEALING / DIABETES
FOOT, p305
COMPRESSION THERAPY, p311
DIABETES, p298
DIABETIC EDUCATION, p313
HYPERBARICS, p314
LABS, p302
OFF-LOADING ULCER, p312
OSTEOMYELITIS, p303
PHASES OF WOUND HEALING, p305
ULCER EXAM, p301
WOUND CLASSIFICATION, p300
WOUND DRESSING, p310
WOUND CLOSURE, p307
298
CHAPTER 15
DIABETES
-6% of Americans(12 million people) have diabetes
-glucose levels >200mg/dl
-when treating a diabetic with Insulin one should always error on the
side of hyperglycernia; hypoglycemia results in permanent neuron
destruction
SYMPTOMS
HYPERGLYCEMIA
-polyuria
-polydipsia
-polyphagia
-weight loss -fatique -blurred vision
HYPOGLYCEMIA
-diaphoresis/syncope
-tachycardia/palpitations
-hunger
-anxietylirritability
-tremors
-weakness
-mental confusion
-seizures
-headache
TYPE I vs. TYPE

TYPE
-IDDM
-juvenile onset
-prone to ketosis
-onset less than 30yrs. of age
-accounts for 10% of diabetics
-due to the pancreas not
making sufficient quantities
of insulin
-abrupt onset
-must take insulin
TYPE II
-NIDDM
-adult onset
-ketosis resistant
-onset usually over 40 yrs. of age
-accounts for 90% of diabetics
-caused by patient's body not
responding properly to it's
insulin
-slow onset and progression
-controlled with oral hypoglycemics,
diet, andlor insulin
-patients tend to be overweight
299
CHAPTER 15
Gestational D i a b e t e s ( ~ III~ diabetes)

~ e
-hyperglycemia that can occur during pregnancy
-occurs in 1-3% of women
-disappears in 97% of cases at the end of pregnancy
-higher incident in Hispanics and Blacks
INSULIN
TYPES
Rapid
-Regular(Humulin R)
-Semilente
Intermediate
-NPH(Humulin N)
-Lente(Humulin L)
Long Acting
-Protarnine zinc(PZ1)
-Ultralente(Humulin U)
ONSET
DURATION ROUTE
10-30min
0.5-1hr
0.5-2hr
1-4hrs
1-4hrs
4-8hrs
4-8hrs
FACTORS THAT PUT DIABETICS AT RISK FOR

FOOT ULCERS
lmmunocompromized
-defective PMN function resulting in an increase risk of infection
Angiopathy
-blood vessels in the diabetic are subject to accelerated
atherosclerosis and increased viscosity, clotting, and thrombosis
formation
Neuropathy
-caused by direct metabolic damage to nerves
SENSORY
-classically described with sock-glove distribution
-absent protective threshold
-loss of proprioception(loss of balance)
-sensory impairment typically precedes motor dysfunction
MOTOR
-motor deficit affects the intrinsic muscles of the foot leading to
clawinglhammering of the digits resulting in plantarflexed
metatarsal heads(cavus foot)
AUTONOMIC
-anhydrosis(resulting in dry scaly feet prone to fissuring)
-hot, hyperemic foot
-increased arteriovenous shunting
-reduced capillary flow
-bounding pulses
300
CHAPTER 15
WOUND CLASSIFICATIONS
Wagner's Diabetic Ulcer Classification
Grade 0
Grade 1
Grade 2
Grade 3
intact skin(cellulitis, erythema)

superficial ulcer involving the skin(no subQ involvement)
ulcer extending to tendon capsule or bone(through subQ)
more extensive ulcer with associated abscess, osteomyelitis,
or joint sepsis
Grade 4 local gangrene of the toes or forefoot
Grade 5 gangrene of entire foot
Knighton Classification
I
-I1
Ill
IV
V
VI
Partial thickness ulcer

-extends through the epidermis and into, but not through, the dermis
II
Full thickness ulcer
-ulcer extending to sub-cutaneous tissue only
-ulcer extending to tendon, ligament, joint, andlor bone
-level Ill ulcer with abscess andlor osteomyelitis
-level Ill ulcer with necrotic tissue in wound
-level Ill ulcer with gangrene
University of Texas Wound Classification System

(Wound Grade and Stage Classification)
GRADE
Grade 0 -pre or postulcerative site
Grade I -ulcers are superficial wound through the epidermis or
dermis
Grade II -wound penetrates to tendon or capsule
Grade Ill -wound penetrates to bone or into a joint
STAGE
Stage A -clean
Stage B -non-ischemic infected
Stage C -ischemic
Stage D -infected ischemic
301
CHAPTER 15
NPUAP Pressure Ulcer Staging System

STAGE
I
II
Ill
IV
DEFINITION
Nonblanchable erythema of intact skin,
Partial-Thickness-skin loss involving epidermis and/or dermis
Full-Thickness-skin loss involving damage or necrosis of
subcutaneous tissue that may extend down to but not
through, underlying fascia.
Full-Thickness skin loss with extensive destruction, tissue
necrosis or damage to muscle, bone, or supportive
structures
ULCER EXAM
Systemic Signs
-R/O sepsis
-fever/chills/sweats
-1ethargiclgeneral malaise
-vitals(elevated pulse)
Vascular
-establish adequate perfusion
Neurologic
-establish adequate protective threshold
Musculosketetal
-assess bony prominences which may be the cause of ulcers
Dermatological
ASSESSING ULCER
-depth(probe with Q-tip, to bone?)
-diameter(measure)
-base(necrotic, granular, beefy red, macerated, fibrotic)
-margins(keratolytic-usually neuropathic in origin)
-drainage(purulent, clear, red, brown)
-odor fecal smell-Anaerobes, fruit smell-Pseudomonas)
ASSESSING SURROUNDING T I S ~ U E
-tem erature(warm to touch)
-erytEema-notedistribution and rate of progresson(draw
margins of erythema directly on skin)
-edema-note pitting vs. nonpitting and extent
-R/O: Cellulitis and necrotizing fasciitis
-lymphangitis/lymphadenopathy
-red streaks up leg
-tender palpable regional lymph nodes
302
CHAPTER 15
LABS
Cultures
-gram stain-guide initial Abx treatment until cultures and C and S are
available
-mrobic and anaerobic
-.GmdS
-blood cultures(when sepsis is suspected)
must take three samples, each from a different location or from the
same spot 10 minutes apart. Best to obtain when the patient is
spiking a fever
-most diabetic foot ulcers are polymicrobial(usually2-5 mixed
aerobic-anaerobic bacteria)
-bacterial count of >105/gmof tissue in a healthy adult can cause
infection
-the most common organisms infecting superficial diabetic
wounds
Staphylococcus aureus
Staphylococcus epidermidis
Group A and B streptococci
Proteus spp.
Escherichia coli
Enterococcus
Klebsiella/Enterobacter spp.
Pseudomonas spp.
\ Bacteroidesand other anaerobes
Blood tests
CBC with diff
-WBC >10,000 indicates an infection
-an acute infection will show an increase in immature
leukocytes(leftshift)
determine anemia(often associated with diabetic infection)
FSR and C-reactive protein
-to follow progression and regression of infection
Hemoalobin A l C
-determine long term control of diabetes
Glucose
-hyperglycemiadespite using their normal dose of insulin may

indicate an infection
-values above 250mgldl have a negative effect on wound healing
303
CHAPTER 15
X-rays
-use as a baseline for osteomyelitis(presents as osteolysis)
-osteomyelitis takes about 2 weeks to show up on x-ray after there has
been a 50% loss of bone
-X-ray evaluation:
-look for osteolysis
-look for periosteal reationlcortical erosions
-look for soft tissue swelling
-look for gas in tissue
-look for foreign bodies
-look for sequesta formation
-look for grossly remodeled bone
Bone scans
-Tc-99 bone scan is (+) in all phases especially 3rd phase which is
highly sensative for osteomyelitis
-in most cases bone scans become(+) within 48-72hrs
OST ELITIS
-bone infection
-a definitive diagnosis requires a bone biopsy
-some authors(Grayson et al) say anytime there is exposed bone it is
considered clinical OM
Bone becomes infected by one of three ways:
Hematogenous
-enters bone via the blood stream
Contiguous
-spread from adjacent soft tissue
Direct inoculation -trauma or surgical
Acute osteomyelitis
-occurs from the time the bone becomes infected until portions of the
bone become necrotic
-the earliest radiographic signs of osteomyelitis are usually osteolysis,
cortical erosions, and periosteal reaction
Chronic osteomyelitis
-involves necrotic bone
-once a chronic osteomyelitis develops, antibiotics alone are rarely
effective and must be combined with surgical debridement of necrotic
bone
304
CHAPTER 15
Treatment
SURGICAL INTERVENTION
Situations requiring prompt surgical intervention include: plantar space
infection, gas in tissue, necrotizing fasciitis, infection with overt clinical signs
-vascular evaluation prior to surgery
-surgical debridement with excision of infected bone
-deep wound cultured in OR
-generally, diabetic foot infection are never primarily closed
-acute OM 7wks parenteral therapy
-one regimen for chronic OM is parenteral therapy until ESR is 112 the
initial value, then oral therapy for 4-6 months
-If you amputate for local tissue infection, then administer abx for 3-5
days parenterally
-antibiotic treatment for OM should continue for at least 6 weeks
Surgical Debridement for Osteomyelitis

-excise necrotic bone plus small portion of noninfected bone, pack open
or close primarily
-heat stable antibiotics(.ie. tobramycin, or gentamicin) can be mixed
with polymethylmethacrylate(PMMA)impregnated beads and used
locally to achieve 200 times the antibiotic concentration achieved with IV
administration. Traditionally Gentamicin is used, however
Cephalosporin, Tobrarnycin, Vancornycin, or Ticarcillin may also be
used. Beads are closed in wound primarily and remove 2-4 weeks later.
Sequestrum-a piece of necrotic bone separated from living bone by
granulation tissue, radiographically evident as a highly opaque,
smooth island of bone that is usually surrounded by area of
decreased bone density
Involucrum-a layer of living bone that has formed around the
dead(infected) bone
Cloaca-an opening in the involucrum that may form a sinus and drain
Brodie's Abscess-a chronic abscess in bone surrounded by dense
fibrous tissue and sclerotic bone, most commonly found in the
metaphysis
TYPES OF DEBRIDEMENT
Surgical Debridement-a sharp or surgical procedure that is mostly
selective, causing little or no damage to healthy tissue.
Mechanical Debridement-a nonselective procedure performed by
changing wet-to-dry gauze dressings or hydrotherapy
Enzymaticlchemical Debridement-a process requiring topical agents
capable of degrading eschar, protein and other nucleic
agents(Accuzyme, Santyl)
Autolytic Debridement-the bodies own phagoctic debridement which is
encouraged by a moist occlusive dressing such as Hydrogel
305
CHAPTER 15
PHASES OF WOUND HEALING

inflammatory phase(a.k.a., substrate phase, lag phase)
-1-7 days
-influx of platelets and leukocytes
-release of cytokines and mediators
-coagulation
Proliferative phase(a.k.a., fibroblastic phase, repair phase)

-5-20 days
-collagen fibers are produced and lend strength to wound
-reepithelialization(someauthors describe epithelialization as a separte
phase between Proliferation and Remodeling)
-angiogenesis
-fibroplasia
-wound contraction
Remodeling phase(a.k.a., maturation phase)
-3 weeks-2 years
-deposition of matrix materials
-collagen deposition/remodeling
-return to preinjury state
-as long as the scar or past ulcer site is erythematous, remodeling is
occuring
CHARCOT FOOT
GENERAL
-a destructive arthropathy resulting from im~airedpain ~erceotionand
increased bone blood flow from reflex vasodilation
-with increased bone blood flow the bone becomes washed out and
weak, and with impaired deep pain sensation on proprioception small
periarticular fractures go unnoticed until the entire joint is destroyed
-diabetes is the leading cause of charcot foot
-majority of charcot joint are the result of trauma and impaired sensation
caused by neuropathy
-male to female ratio is equal
-B/L 30% of cases
-painless swelling is the hallmark sign of charcot foot, however about
half of the patients present with a chief complaint of pain
-most feet with a charcot joint involve the midfoot
306
CHAPTER 15
CAUSE
diabetes, alcoholism, syphilis, Hansen's dz, syringomyelia, cerebral
palsy, hereditary insensativity to pain, myelodysplasia, poliomyelitis,
spina bifida, meningomyelocele, spinal or peripheral nerve injury
STAGES
Stage I (Fragmentation)
-acute inflammatory process
-foot is hyperemic, swollen, red, and hot
-dissolution, fragmentation, and dislocation
Stage II (Coalescence)
-beginning of the reparative process
-edema, warmth and redness begins to diminish
-radiographically there are signs of new bone formation
S t a g e I I I ( R emodeling)
-marked by bony consolidation and healing
-residual bony deformity is common most notably collapse of the
longitudinal arch resulting in the classic "rocker-bottom" foot
-bony protuberences are clinically important because they may
develop sites for future neuropathic pressure ulcers
TREATMENT
-rest, elevation, and cast immobilization to prevent further bone destruction
-once bony consolidation has begun and the foot has stabilized, a
custom molded accommodative insert is indicated or a pair of custom
molded shoes depending on the extent of the deformity
-surgery on the charcot foot is aimed at either removing bony prominences or arthrodesis to realign and stabilize the architecture of the foot
307
CHAPTER 15
TREATMENT(WOUND CARE)
-neurotrophic ulcers are offloaded and debrided weekly
-vascular ulcers-vascular consult to address revascularization and/or
begin the patient on blood thinners or other medications for
circulation(Pletal, Trental)
-once a wound is "clean" d/c cytotoxic agents such as
-Chlorhexidine(Hibicleans)
-full strength betadine
-Gentamicin sulfate
-hydrogen peroxide
-Dakinls solution
-Acetic acid
-EtOH
methiolate
-gentian violet
TYPES OF WOUND CLOSURE

Primary closure
Secondary closure
Delayed primary Closure
wound is immediately sutured; must

be a clean wound. Leaves a
pleasing linear scar
infected or dirty wounds are left open
and allowed to granulate in from the
bottom up; leaves a less pleasing
scar
infected or dirty wound is left open
until immediate threat of infection
has passed(days to weeks) and then
later the wound is closed primarily
with sutures
308
CHAPTER 15
309
CHAPTER 15
Type of Wound - pressure ulcer

Time Span - approximately
weeks
Patient presented with an injury to the medial

aspect of the first metatarsal. The injury
had persisted for three months (1-25-00).
The eschar and surrounding
were
were used for three weeks
prior to placement of OASISa Wound
Matrix (2-15-00). At that time, the ulcer
measured 2.5 x 1.7 cm x 0.2 cm deep.
Some granulated tissue was present,
although the extensor tendon remained
exposed. A
dressing covered
to help maintain a moist wound
environment. The saline-moistened gauze
The tendon was covered with granulated

tissue in two weeks, and the ulcer was
completely epithelialized in weeks.
Note: This case study demonstrates the

use of
on one patient. Individual
Case Closed
Two words that mean as much to the doctor as they do to the patient.
way to get it is with OASIS.
After all, everyone wants closure. And a
The secret is in the Small Intestinal Submucosa (SIS) technology that helps
the skin's
maintain an environment for wound management and
for epithelialization of partial- and full-thickness skin loss. Cells in
the viable tissue around the wound migrate across the matrix - building
tissue as
go - and before you know it, the patient is back on track.
-8223
of
of
is for
Care
310
CHAPTER 15
WOUND DRESSING
DRESSING TYPE
Films
Foam(high absorbant)
Foam(extra thin)
Hydrogels
Hydrocolloid
Alginates
Collagens
ABSORPTlVE CAPACITY
none
high
low
low
low to medium
medium to high
low
HYDRATING ABILITY
low to medium
low
low
medium to high
medium to high
medium
low
Hydrocolloid
Made from materials such as gelatin or pectin that contain hydrocolloid
granules or powder that when combined with water(exudate) forms a
soft gel mass. Available as free granules
or attached to a .polyurethane
.
foam or film backing
Comfeel, Duo-DERM, CGF Border, hydropad, Intact, Restore,
Tegasorb, Ultec, TRIAD. CarraSmart, Cutinova, DermaCol,
gnate ell, Exuderm, Hydrocol, NutraCol, OriDerm, Replicare,
SignaDRESS, Sorbex, 3M Tegasorb
Film
Provides a moist wound healing environment useful for minor burns,
simple injuries, and treatment of superficial pressure area. It is also
used to cover IV catheters and for post-op dressing.
ACU-derm, Bioclusive, Opraflex, OpSite, Polyskin, Tegaderm,
Transite, UniFlex, Preclude, Ensure, Dermafilm, Carra-Film,
BlisterFilm, CarraSmart Film, Cutifilm, DermaSite, EpiView,
Hyperion Film, Mefilm, OriFilm, ProCyte, Suresite, Transeal
Foam
Useful in both superficial and cavity type ulcers. In addition to maintaining a moist wound environment and raising the core temperature of a
wound, foams are also useful in absorbing exudative wounds.
Allevyn, Hydrosorb, Epilock, Lyofoam, PolyMem, Mitraflex, Flexzan,
Hydrosorb, Mitraflex, Curafoam, Biatain, CarraSmart, Curafoam,
Cutinova, Mepilex, Orifoam, Polyderm, Sof-foam, Reston, Tielle,
VigiFoam
Hydrogel
Hydrogels are indicated for dry wounds where rehydration of eschar is
desired. Also useful in deeper wound where structures such as tendons
need to be kept moist.
Aquasorb, Biolex, Curasol, Elasto-Gel, Hydron, lamin, Intrasite,
Nu-Gel, Vigilon, Carrington, Core Care, MPM, Carrasyn, Cutinova,
DiaB, DuoDERM, Hydroactive Gel, HyFil, Hypergel, lamin, IntraSite,
Macropro, Normlgel, NU-GEL, NutraVue, Phyto Derm, Purilon,
SAF-Gel, WOUN'DRES, Biolex, Curafil, Gentell, Hyperion,
311
CHAPTER 15
Restore, Skintegrity,
Aquaflo, Aquasorb,
Nu-Gel,
Elasto-Gel, Flexderm,
3M Tegagel,
Curagel,
Toe-Aid,
Alginate
Highly absorbant dressing made from seaweed that osmotically drys out
wounds. Used for highly exudative wounds and at donor sites as a
hemostat postsurgically and other bleeding areas.
Kaltostat, Alginate, Sorbsan, Dermacea, Curosorb,
Kaltocarb, Tegagen, Algosteril,
Cornfeel, Curasorb, Cutinova,
Hyperion, Kalginate, Kaltostat, Maxorb, Melgisorb,
Restore
Sorbsan, Tegagen,
Enzymatic debriders
Enzymatically
necrotic tissue from the wound.
Accuzyme
Panafil, Collagenase,
Growth Factors
Growth factors incorporated into gel
Procuren,
Bioengineered Dressings
graft,
Apligraf, Dermagraft,
-Norton's Scale is a
evaluation used to determine if a
patient is at risk for pressure ulcers
-Ischemia occurs after 2-6hrs of unrelieved pressure and necrosis
of continuous pressure
occurs after
-Normal digital blood pressure varies greatly but generally ranges
between 70-1
COMPRESSION THERAPY
in patients with an ABI of less than 0.8
TED, Sigvarus)
TYPE OF STOCKING
PRESSURE
Antiembolism stockings
16-1
Low
18-24mmHg
stockings
Low to Moderate
25-35mmHg
compression stockings
Moderate compression
stocking
High compression stocking 40-50mmHg
USES
DVT prophylaxis
nonambulatory
patients
edema secondary to
venous insufficiency
edema with or
without ulcer
lymphedema
312
CHAPTER 15
Four-Layer Bandage(Profore)
Provides a graduated sustained compression using four layers of bandage. If applied correctly the bandages start with 40mmHg at the ankle
and decrease to 17mmHg at the calf.
Compression Pump
A programmable leg sleeve is periodically inflated and "milks" edema
from the leg
OFF-LOADING ULCER SITE

-extra depth shoe with custom multidensity insole-accomodate for
bony prominence
-custom molded shoe with custom molded insole-for severe deformities such as partial amputation and charcot foot
-rocker bottom soles-may be added to either shoe type to provide
additional offloading of forefoot
-NWB-best method, very poor patient compliance
-partial weightbearing with crutches/walker may be used in combination
with protective foot wear to stabilize and assist in off-weighting
Protective Footwear
-flat surgical shoe-usually requires additional padding. May be modified by cutting holes in shoe or padding to offload ulcer
-orthowedge shoe-wedge in sole to relieve forefoot pressure. Make
sure the patient is stable
-Ipos post-op shoe-a half-shoe with a wedge. Nothing touches forefoot. A walker is recommended to assist in stability for this shoe
-Ipos heel relief-a half-shoe to offload plantar heel. Requires a walker
-multipodus/l'nard splint-a BK boot for relief of posterior heel ulcers in bed
-Carville healing sandle-custom molded plastizote sandle. Good for
Charcot foot-type
-DH walker bootlshoe-has small octagonal ulcer cushions that may be
removed form the sole of the shoe to offload the ulcer
-total contact cast-technically difficult to apply, but one of the best
methods for offloading
-total contact casts redistribute body weight over a larger surface area of
the foot with the use of a cast, in an effort to alleviate pressure off an
ulcer
-orthotics should not be rigid, instead should be accommodating with
adequate padding to relieve overloaded joints
313
CHAPTER 15
DIABETIC EDUCATION
-wear soft moldable uppers(always with socks)
-break new shoes in slowly by wearing only 2 hrs at a time initialliy
-buy shoes at the end of the day when feet are most swollen
-avoid socks with mends and seams
-feel inside shoes for seams or folds
-avoid pads or devices not custom made
-avoid constrictive bandages
-never place bandaged foot in closed shoe
-proper nail care
-nightly inspection of feet including between toes
-inspect inside of shoe for sharps
-never go barefoot
-avoid open toed or open backed shoes
-never trim callus
-beware of tapes, adhesives on risk areas
-check bath temperature with elbow
-protect feet from sunburn
-beware of hard floors
-beware of corn remedies
-never use OTC corn remedies
-dry feet completely especially between toes
-buy shoes with a good fit(excessive width or length can lead to friction,
causing blistering and ulceration)
-high toe box and a rounded toe(to accomodate HT's, orthotics, and HM's)
-rigid counter to support heel
-wide toe box with extra-depth
-rigid shank to support arch
-soft insert to accomodate any plantar lesions
-no cracks or breaks in the inserts or seams
-apply a light water-based lotion daily without moistening between the toes
-refrain from applying adhesive tape or chemical agents for removing
cornslcallus
-patients with impared vision should have a family member inspect their
feet daily
-professional nail care with regular follow-ups
314
CHAPTER 15
Hyperbaric oxygen treatment(HB0) has shown to be effective treatment

in hypoxic ulcers(i.e. ulcers due to diabetes or arterial insufficiency).
Repeated dives in the chamber over a period of time increases the oxygen concentration in the blood. As a result angiogenesis and fibroblast
production occurs, which help collagen synthesis and epithelial closure.
During the HBO treatment and for 3-4 hours after treatment, the 0 2 is
dissolved in the plasma to help oxygenate the hypoxic area. This elevates the 0 2 levels surrounding the ulcer site to speed the healing time.
Patients that will benefit from hyperbarics must have a serious problem
with their oxygen gradient in the tissue around the ulcer which is measured by their TCOMs(transcutaneous oxygen monitoring). If the TCOM
reading is less than 30-40, the patient has a problem involving oxygen
transport that is serious enough to consider hyperbaric oxygen therapy.
A trial treatment at 2.4 atmospheres of 100% oxygen in the chamber is
performed and the TCOMs are measured in the hyperbaric oxygen environment. If hyperbaric therapy is going to help, the hyperbaric oxygen
should increase the reading from less than 30-40 to over 200.
Patients are typically placed in the hyperbaric chambers between 2-2.4
atmospheres of 100% oxygen for 90 minutes. Treatment does not generally exceed 90 minutes because 100% oxygen can cause convulsions
and oxygen toxicity. The peak effects of hyperbarics is between 18-23
dives at which time TCOMs should improve as a result of angiogenesis.
Other indications for hyperbaric oxygen treatment include chronic refractory osteomyelitis, necrotizing infections, burns, crush injuries, compromised or failed flaps, and soft tissue radionecrosis.
NAILS
315
CHAPTER 16
NAILS
CHEMICAL MATRIXECTOMY, p319
NAILANATOMY, p316
NAILPATHOLOGY, p316
SUBUNGUAL EXOSTOSIS, p323
SURGICAL MATRIXECTOMIES, p320
CHAPTER 16
NAILS
316
CHAPTER 16
Ungual Labia
(medial nail fold)
I
Eponychium(cuticle,
posterior nail fold)
Medial nail groove
Hyponychium
(distal nail groove)
Nail Bed
NAI L
PATHOLOGY
Anonvchia-Absence of nail. Describes a nail that has failed to develop.

Beau's lines-Horizontal depression across a nail plate caused by transient arrest of nail growth. Causes could include any stressful event
such as MI, PE, or high fever.
Blue nails-Causes include: antimalarial drugs, minocycline(a tetracycline), emochromatosis(an iron metabolism disorder), Wilson's Dz.,
ochronosis(a metabolic disorder), and exposure to silver nitrate.
Brown nail-Occurs in Addison's Dz. hemochromatosis, gold therapy,
arsenic intoxication, malignant melanoma, and Nelson's syndrome.
Dystrophic nail-A nail disorder due to faulty nutrition.
Gray nail or gray lunula-Occur in argyria(prolonged ingestion, injection,
or mucosal absorption of silver nitrate).
Green nail-Pseudomonas infection.
Hapalonychia-A rubbery and pliable nail plate usually caused by hyperhidrosis or endocrine disorders.
Herpetic Whitlow-Usually severely painful herpetic(viral) infection of the
distal phalanx. Erythematous streaking of the extremity and enlarged
lymph nodes may be noted.
Hippocratic nails(clubbing)-Positive clubbing is noted when the
Lovibond's angle, between the nail plate and proximal nail fold is 2180".
Occurs in cardiac dz.(cyanotic heart dz, bacterial endocarditis), pulmonary dz.(primary and metastatic cancer, bronchiectasis, lung
abscess, mesothelioma), or GI dz.(enteritis, ulcerative colitis, and
hepatic cirrhosis).
lntraungual hematoma-Hematoma within the body of the nail, due to
trauma to the proximal nail fold. May take several weeks to develop
because the nail must grow out.
NAILS
317
CHAPTER 16
PHENOL
ELIMINATE
AND
RESIDUAL
The main disadvantage
t o both the NaOH and
phenol procedures is the
creation of a chemical
injury that denatures
proteins. AmeriGel"
Wound Dressing
proliferates proteins to
the wound site and
promotes granulation
tissue development
t h a t enhances t h e
healing process.
"I have done thousands of
these since writing the
original paper on NaOH
matrixectomies in 1980.
I personally have had great
results with
use
after these procedures and it
is my standard at this time,
eliminating the need for
soaking 2 times a day."
Gerald
times by
Provide an
antimicrobial barrier
Reduce potential
complications in
healing
Broad range
antimicrobial1
antifungal
Requires only daily
dressing changes
Generates profit t o
your practice
DPM
Colorado Springs, C O
AMERX HEALTH CARE
CLEVELAND STREET, SUITE
CLEARWATER, FL 33755
800-448-9599
NAILS
318
CHAPTER 16
Koilonychia(spoon nail)-Seen in long standing iron deficiency anemia

or Plummer-Vinson syndrome(a combination of koilonychia, dysphagia,
and glossitis primarily seen in middle-age women). aka Plummer's nails.
Leukonychia-Nails exibiting white spots(punctata) and/or striata.
Lindsay's nail(half and half nails)-The distal half is pink or brown and
is sharply demarcated from the proximal half which is dull and white and
obliterates the lunula. Seen in liver Dz. and azotemia(uremia).
Macronychia-Abnormally large nail.
Mee's lines-Single transverse white band associated with arsenic poisoning. A variation of Beau's lines it can also be seen following stressful
events.
Melanonychia-Pigmented longitudinal bands in the nails. Normal variant usually seen in darker skinned individuals.
Micronychia-Abnormally small nail
Muehrcke's nails-Paired narrow horizontal white bands, separated by
normal color, that remain immobile as the nail grows. Seen in hypoalbuminemia associated with nephrotic syndrome.
Onychatrophia-Atrophy of the nail.
Onychauxic-Hypertrophy of the nail(thick nail).
Onychia-Inflammation of the matrix of the nail.
Onychoclasis-Breaking of a nail.
Onychocryptosis-Ingrown nail.
Onychogenic-Producing nail substance.
Onychogryphosis-A type of onychauxia(rams horn).
Onychoheterotopia-Abnormallyplaced nail on the digit as a result of
displaced matrix material.
Onycholysis-Separation of the nail from the nail bed. Begins distally
and progresses proximally. Usually associated with mild inflammatory
processes such as psoriasis.
Onychomadesis(defluvium unguium, onychoptosis)-Separation of the
nail from the nail bed beginning proximally and progressing distally.
Onychomalacia-Softening of the nail.
Onychomycosis-Fungal nail.
Onychophagia-Nail biting.
Onychophosis-A callus in the nail groove.
Onychopuntata-Pitting of the nails. Seen in psoriasis, alopecia areata,
lichen planus.
Onychorrhexia-Abnormal brittle nails <16% water in nail. Normal nail
hydration is between 16 and 30%.
Onychoschizia-Splitting or lamination of the nail plate into layers that
flake off.
NAILS
319
CHAPTER 16
Onychotillomania-Neurotic picking or tearing at the nail.

Paronychia-Inflammation involving the folds of tissue around the nail.
Pterygium-The overgrowth of cuticle. May be normal variant or caused
by lichen planus, dermatomyositis, or scleroderma.
Raquet nail-A short fat nail.
Red lunula-Right sided CHF.
Splinter hemorrhages-Seen in subacute bacterial endocarditis and
trichinosis, which is a disease from eating inadequately cooked meet
infected with Trichinella spiralis. Pt. will also have diarrhea, nausea/vomiting, and fever).
Subungual hematoma-Associated with acute trauma(dropping something on the toe). Hematoma develops instantly beneath the nail plate.
Often there is severe pain from the pressure of the blood beneath the
nail plate which can lead to increased necrosis of tissue. Drilling a hole
in the nail or avulsing the nail may be necessary to relieve pressure.
Telangiectatic posterior nail folds-Proximal nail fold becomes tortuous
and dilated. Indicative of connective tissue dz.(lupus and dermatomyositis).
Terry's nails-Proximal 2/3 of the nail plate is white, whereas the distal
113 shows the red color of the nail bed. Seen in hypoalbuminemia associated with hepatic cirrhosis.
Yellow nail syndrome-Nails grow slow, thick and with increased longitudinal curvature with some onycholysis. Usually associated with pulmonary disease and lymphedema.
CHEMICAL MATRIXECTOMY(P & A)

-Standard foot prep and digital block are performed.
-Tourniquet is applied(phenol must be applied to a bloodless field)
-A 2-3 mm strip of nail is removed from the offending border.
-3 thirty second applications of 89% phenol are applied to the nail matrix
with an applicator.
-Next using a small curette, scrape the matrix epithelium to further the
destructive process.
-With the curettage complete, the entire field is lavaged with 70%
isopropyl alcohol to flush the remaining phenol from the tissue.
NAILS
320
CHAPTER 16
SURGICAL MATRIXECTOMIES
PARTIAL MATRIXECTOMIES
Frost
-An inverted "L" incision is made through the long axis of the nail and
carried about 1/16 of an inch beyond the proximal and distal ends of the
nail, being vertical in nature, and carried down to the periosteum. The
base of the "L" is an incision just through the dermis down to, but not
into, the nail root.
-The base of the "L" becomes a skin flap which is dissected free of the
nail matrix and reflected.
-The next incision is parallel to the first incision beneath the skin flap
and becomes semi-elliptical distally to join the first incision.
-The tissue sliver is dissected free of the periosteum and dissected
proximally back onto the base of the phalanx until this portion of the nail
root is freed.
-The flap at the base is now reapproximated.
When
the Frost technique was first described no sutures were advised
because it was thought to compromise blood flow.
Modified Frost
-The procedure is basically the same as a Frost except it involves altering the "L" flap to a curved incision.
NAILS
321
CHAPTER 16
Plastic Lip
-Involves excision of a p i eshaped wedge of tissue taken from the side
of the toe. Useful only in cases of hypertrophy of the ungualabia.
Winograd
-A longitudinal incision is made through the nail and nail bed -4mm from
the affected margin, then through the skin over the nail matrix and the
matrix itself, extending l c m proximal to the eponychium.
-A second incision is made in the skin at the nail fold, completing an
ellipse with the first incision.
-A wedge of tissue is then removed down to the periosteum and the
wound is curetted.
-The edges are reapproximated and sutured.
TOTAL MATRIXECTOMIES
Kaplin
-This is a modification of the Zadik.
-Nail plate is avulsed.
-Two incisions are made from the corners of the eponychium extending
each nail groove proximally forming a tissue flap(as in the Zadik).
-The leading edge of the eponychium is trimmed.
-The entire matrix is excised along with the entire nail bed, down to the
periosteum of the phalanx.
-The incisions into the eponychium are sutured, but the exposed phalanx is left open and allowed to granulate in by secondary intention.
NAILS
322
CHAPTER 16
Suppan(techniaue #2)
Nail
is avulskd.
-Using a blade the entire matrix is excised down to periosteum in toto
from under the eponychium without any skin incisions.
-The posterior nail fold is then sutured to the proximal nail bed.
..
Svmes (Lapidus
-An elliptical incisonis made around the entire nail and nail bed(the
wroximal curve of the incision should be distal to the IPJ and the distal
curve in a fishmouth incision carried around the sides and across the tip
of the toe).
-The distal half of the distal phalanx is then cut so that the nail, nail bed,
and the terminal half of the proximal phalanx are removed as a single
unit.
-The plantar flap is then pulled up over the remaining phalanx and
sutured to the dorsal skin.
-----_
Whitney
Nail is avu sed.

-Frost type incisions are made in the eponychium.
-The flaps are undercut and retracted.
-Leading edge of the eponychium is trimmed.
-The central eponychium skin flap should now be freed and retracted
proximally to expose the entire matrix.
-A circumferential, transverse incision carried down to bone encompassing the lunula and the entire matrix is made at this time.
-This tissue is then freed of it's attachments and removed.
-The three skin flaps are then reapproximated and sutured, the epony-
NAILS
323
CHAPTER 16
Zadik
-Nail plate is
-Two incisions are made from the corners of the eponychium extending
each nail groove proximally forming a tissue flap.
-The leading edge of the eponychium is trimmed.
-A strip of tissue is excised from just distal to the
laterally into the
nail folds and proximal -3-5mm under the proximal nail fold. The tissue
to be excised should extend down to periosteum and care should be
taken to include the under surface of the proximal nail fold.
-The proximal nail fold is then advanced distally where it meets the proximal end of the nail bed and is sutured.
-If the lateral nail furrows are deep, Zadik advises excising the lateral
nail folds and suturing them to the nail bed.
A benign bony lesion which protrudes from the dorsal surface of the distal phalanx. Most commonly seen in the
this condition is usually
painful and causes the nail to become deformed. Radiographs are often
unhelpful as the protuberance may have a cartilagenous cap which will
not show on x-ray. Treatment of choice is excision of the lesion.
NAILS
324
CHAPTER 16
HEEL CONDITIONS
325
CHAPTER 17
HEEL CONDITIONS
BAXTER'S NEURITIS,
CALCANEAL BURSITIS,
HAGLAND'S DEFORMITY,
INFRACALCANEAL HEEL SPUR, p327
PLANTAR FASCIITIS,
CHAPTER 17
HEEL CONDITIONS
326
CHAPTER 17
PLANTAR FASCIITIS, "Heel Spur Syndrome"

DESCRIPTION
Pain at the weightbearing surface of the foot usually
Achilles Tendon
caused by a biomechanical imbalance resulting in
tension along the plantar fascia. Although pain
may occur along the entire course of the
plantar fascia, it is usually
Nerve to the Abductor
limited to the inferior
aspect of the
Quadratus Plantae
calcaneus, at
~~~~l~
the medial process
of the calcaneal
tubercle.
Patients often
Plantar Fascia
describe pain
Heel Spur
Plantar Heel
in the heel
Fat Pad
on taking the first several
steps in the morning, with symptoms lessening as walking continues.
Patients believe the condition to be the result of a stone bruise or a
recent increase in daily activity. A heel spur may or may not be present
and is rarely the source of the pain, it is actually located in the flexor digitorum brevis muscle which originates above the plantar fascia.
CAUSE
Causes include poor foot mechanics due to pes planus or cavus foot
type, obesity, inappropriate footwear, tight triceps surae, fat-pad atrophy,
and repetitive microtrauma.
SIGNSISYMPTOMS
-women>men
-B/L in 10% of cases
-75% are female
-described as a deep aching pain
-direct palpation of the medial calcaneal tubercle often causes severe pain
-pain is deep and aching in nature and tends to be more pin-point vs.
diffuse on palpation
-pain is typically on or near the medial process of the calcaneal tuberosity
-pain may be elicited by evoking the "windlass mechanism" with passive
dorsiflexion of the MPJ's
HEEL CONDITIONS
327
CHAPTER 17
TREATMENT
Conservative(SO%of cases improve with nonsurgical treatment)
-NSAIDS
-Low-dye strap
-prefabricated orthotics
-avoid barefoot walking
-decrease activity level
-daily tendoachilles and plantar fascia1 stretching
-ice
-night splints
-corticosteroid injection
-custom orthotics
-ultrasound
-short leg walking cast x4 weeks
Surgical
-plantar fasciotomy
-spur excision
-orthotripsy
INFRACALCANEAL HEEL SPUR

SHARP WELL DEFINED HEEL SPUR
-RA
-normal variant
-DISH
-Reiter's syndrome
-Acromegaly
FLUFFY ILL DEFINED HEEL SPUR
-psoriatic arthritis
-hyperparathyroidism
-RA
-Reiter's syndrome
-ankylosing spondylitis
HEEL CONDITIONS
328
CHAPTER 17
CALCANEAL BURSITIS
TYPES
Subcutaneous calcaneal
bursa)
in the subcutaneous layer between the Achilles tendon and the
skin
-a
bursa can often be palpated just below the skin over the
Achilles tendon
Albert's disease,
Subtendinous calcaneal
caneal bursitis, anterior Achilles bursitis)
-between the Achilles tendon and the calcaneous
-with discrete palpation medially and laterally just superior to the
insertion of the Achilles tendon, one can feel fluid within the sub
tendinous bursa
CAUSE
trauma
poorly fitting shoes
arthritis
sports
TREATMENT
-RICE
-pads
injection
-heel lifts
Baxter's Neuritis
Often misdiagnosed as plantar fasciitis the
Baxter's neuritis is an entrapment neuropathy
of the first branch of the lateral plantar nerve.
Also called the nerve to the abductor digiti
quinti muscle. As compared to plantar fasciitis,
there is usually pain after activity vs. first step
pain. Conservative treatment is much the same
as with plantar fasciits, but if surgery is
considered the procedure of choice is neurolysis.
Through a medial incision bluntly dissect down to
the superficial and deep fascia of the abductor
muscle, and perform a vertical incision
through these structures and remove a segment
of these tissues. Follow the nerve plantarly and
ressect a portion of the plantar fascia. If a spur is
present ressect it. The nerve is just superior to the spur.
USC E
L
HEEL CONDITIONS
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CHAPTER 17
HAGLAND'S DEFORMITY(Pump Bump)

A painful bony prominence and bursitis of the lateral posterior superior
aspect of the calcaneus above the insertion of the Achiles tendon.
Usually involving the retrocalcaneal bursa between the calcaneus and
the Achilles tendon, an adventitious bursa between the tendon and the
skin may also develop. The most common cause is a compensated
rearfoot varus, a compensated forefoot varus, a compensated forefoot
valgus, or a plantarflexed 1st ray.
SIGNS AND SYMPTOMS
-more common in females
-prominence of the posterior, superior, lateral aspect of the calcaneus
-pain(worse in shoes) and tenderness
-Fowler-Philip Angle >75O
-Total Angle(CIA + Fowler-Philips Angle >90)
-(+)Parallel Pitch Lines
TREATMENT
Conservative
-heel lifts, to elevate the prominence above shoe counter
-RICE
-NSAIDS
-steroid injections, use caution around tendon
-orthotics, to control rearfoot motion to prevent friction against shoes
-bursa1 aspiration
Surgical
-involves removing inflamed bursa and resection of the bony
prominence, may necessitate detaching a portion of the Achilles
tendon
-Keck & Kelly, A procedure involving a dorsal wedge osteotomy may
also be indicated if there is enlargement of the entire posterior aspect
of the calcaneus, where simple resection of the bone will be
inadequate. Postoperative care includes a BK cast for 6-7 weeks and
Keck & Kelly
HEEL CONDITIONS
330
CHAPTER 17
SOFT TISSUE MASSES
331
CHAPTER 18
CHAPTER 18
SOFT TISSUE MASSES

Lymphoid tissue origin, p332
Malignant Lymphoma, p332
Fibrous tissue origin, p332
Fibroma, p332
Giant cell tumor of tendon sheath, p332
Dermatofibrosarcoma protuberans(Darier's tumor), p333
Fibrosarcoma, p333
Plantar fibromatosis, p333
Nodular Fasciitis(Nodular Pseudosarcomatous Fasciitis), p333
Smooth muscle origin, p334
Leiomyoma, p334
Leiomyosarcoma, p334
Skeletal muscle origin, p335
Rhabdomyoma, p335
Adipose tissue origin, p335
Lipoma, p335
Liposarcoma, p335
Piezogenic papule, p336
Nerve tissue origin, p336
Schwannoma, p336
Neurofibroma, p336
Neurilemmoma, p336
Cysts, p337
Ganglionic cyst, p337
Epidermal inclusion cyst, p337
Synovial joints conditions, p337
Pigmented Villonodular Synovitis, p337
Synovial Sarcoma, p338
SOFT TISSUE MASSES
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CHAPTER 18
LYMPHOID TISSUE ORIGIN

Malignant Lymphoma
-rarely occurs without coexisting involvement of the lymphoid organs
and there is usually a known history of leukemia or other
lymphoid organ disease
-it may also appear in the skin as Mycosis Fungoides
-presents as a painless soft mass in the tissue; enlargement of lymph
nodes or the spleen may also be reported
-treatment includes surgical excision, irradiation, and chemotherapy
FIBROUS TISSUE ORIGIN

Fibroma
-benign, self-limiting, tumor
-presents as a painless, fairly well-demarcated, slow growing, firm,
encapsulated tumor
-usually found in connection with the skin, subcutaneous tissue, fascia,
or tendon
-surfer's knob-fibromas on the dorsum of the feet as a result of repeated
l p h y s i c a l trauma from surfboard
-may be fixed to overlying skin if superficial
-usually not painful unless affecting local function
-once excised with a clinically normal tissue border, recurrence is rare
Giant Cell Tumor of Tendon Sheath

-well circumscribed benign nodule or mass that may be, but not
always painful
-these lesions are usually red-brown in color due to the amount of
hemosiderin found in the tissue
-older lesions tend to become more xanthomatous and fibrotic and
may be called xanthofibromas
-rarely become malignant
-average age is 40 years and males are more often affected than females
-not necessarily adherent to overlying skin, but skin may be stretched
taut giving the impression of fixation
-these lesions occasionally become malignant and treatment is excision
with surrounding normal skin, to prevent metastasis
-even when benign these lesions can be pseudometastatic, if cut, they
can reseed locally
SOFT TISSUE MASSES
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CHAPTER 18
Dermatofibrosarcoma protuberans(Darierrstumor)
-tumor of intermediate malignancy(can become metastatic)
-slow growing subcutaneous mass
-usually present as a slow growing, somewhat elevated, slightly
protruding structure that is fixed to the skin and may have
hyperpigmented and somewhat violaceous overlying skin
-usually seen in patients 30-50 years old, males are affected more
that females
-treatment is excision for small lesions with surrounding tissue, frozen
sections may be necessary, low grade malignancy that can reoccur if
not completely excised
Fibrosarcoma
-a fully malignant, infiltrative, metastatic tumor of fibroblastic origin
-present as a slow growing, lobulated, rubbery, firm, mass with or without ulceration(depending on depth)
-pain may be present depending on involvement
-they tend to metastasize to regional lymph nodes
-have a very high rate of recurrence
-most often seen between ages 40-60 years
-treatment includes wide excision with surrounding normal tissue,
chemotherapy, and irradiation
-survival depends on the histologic grade of the neoplasm
Plantar Fibromatosis
-a benign and reactive lesion of fibrous tissue
-usually present as a firm, single or multiple, lobular nodules, involving
the medial and central bands of the plantar fascia of the foot
-associated factors include hereditary, long standing epilepsy, diabetes,
thyroid disorders, EtOH, cirrhosis, Dupuytren's contracture(shortening,
thickening, and fibrosis of the palmer fascia, producing a flexion deformity of the fingers especially the 4th and 5th digit), Peyronies disease
(induration of the corpora cavernosa of the penis)
-padding, injection(corticosteroids), Sx excision
Nodular Fasciitis(Pseudosarcomatous Fascitis)

-rapidly growing, benign, self-limiting, fibroblastic proliferation
-lesions are firm, nodular, freely moveable under the skin and plaquelike but not fixed to the skin
-most common site is the forearm, lower extremity involvement is
relatively uncommon
-wide surgical excision to prevent reoccurrence is advised
SOFT TISSUE MASSES
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-occurs predominantly in patients 20-40 years old

-symptoms are nonspecific and it may be difficult to differentiate from a
fibrosarcoma
SMOOTH MUSCLE O
RIGI
Leiomyoma
-benign smooth muscle tumors
-found almost exclusively in adults
-smooth muscle tumors are far more frequent in organ systems such as
the gastrointestinal tract and female genital system
-when found in the soft tissue, leiomyomas are confined to the
superficial subcutaneous tissue and skin
-treatment is usually excision with surrounding normal tissue
-two basic types:
-angioleiomyoma: -arises in the smooth muscle of the blood vessel walls
-usually are solitary venous lesions
-may be painful during temperature change due to
contraction of vascular smooth muscle
-pilar leiomyoma: -occurs in arrector pili muscles that are attached to
(Leiomyoma cutis) each hair, therefore, they only occur where there is
hair-not found on the plantar surface of foot
-occurs singly or in groups of as many as dozens of
firm, usually pea-sized nodules which are often
tender or painful
-may be painful in any situation when the hair on
the feet "stand on end"
Leiomyosarcoma
-vary rare malignant smooth muscle tumor
-smooth muscle tumors are far more frequent in organ systems such as
the gastrointestinal tract and female genital system
-when found in the soft tissue, leiomyosarcoma are confined to the
superficial subcutaneous tissue and skin and are more common on the
dorsum vs, plantar of the foot
-presents as a large painful or tender nodule with possible skin
discoloration and ulceration
-may arise from pilar or venous smooth muscle
-most frequent in persons 35-50 years
-treatment is excision with a large margin of clinically normal
surrounding tissue, amputation may be necessary, chemotherapy, irradiation
-metastatic spread is common-prognosis is poor
SOFT TISSUE MASSES
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SKELETAL MUSCLE ORIGIN

Rhabdomyoma
-extremely rare benign skeletal muscle tumor usually occuring in the
tongue, neck muscles, larynx uvula, nasal cavity, axilla, vulva, and heart
ADIPOSE TISSUE ORIGIN

Lipoma
-benign usually painless tumor derived from fat cells
-presents as soft(doughy), freely moveable, lobulated masses that
usually arises superficially in the subcutaneous tissue
-occurs most commonly in 50-60 year old patients
-soft, movable, subcutaneous nodules
-more common in women
-can occur anywhere, although neck, shoulder, arms, and trunk are most
common; rarely found in foot
-rarely symptomatic and very rarely become malignant
-if painful or bothersome, they can be surgically excised or removed by
liposuction
-very rarely transform to liposarcoma
-have been shown to be associated with Gardner's svndrome and
neurofibromatosis
hibernoma-rare fat tumor composed of brown fat
Liposarcoma
-slow growing malignant tumor of adipose tissue
-usually arising from deep in the subcutaneous tissue or between the
fascial planes of major muscle groups
-most commonly seen in the upper thigh, buttocks, or back
-most common between 40-60 year
-with few exceptions they are not derived from pre-existing lipoma
-compared to lipomas, liposarcomas tend to be somewhat more firm,
less compressible, less freely moveable, and are found deeper in the
tissue than benign lipomas
-treatment may include amputation, chemotherapy, irradiation; check for
metastasis
-one of the most common soft tissue sarcomas in adults, however it's
still about 100 times less common then a benign lipoma
SOFT TISSUE MASSES
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Piezogenic papule
-benign herniation of subcutaneous fat into the dermal connective tissue
-seen most frequently on the lateral and medial aspect of the weight
bearing heel
-more common in obese persons due to pressure
-can be painful and may become necrotic
-these lesions may give "cobblestone" appearance
-heel-cupping orthoses and weight reduction are treatment of choice
NERVE TISSUE ORIGIN

Schwannoma
-benign neoplastic lesion that arises from Schwann cells
-the schwannoma tumor group includes; neurilemmomas and
neurofibromas
Neurofibroma
-a type of schwannoma
-when multiple cutaneous lesions are noted with cafe au lait spots, the
condition is called von Recklinghausen's disease
-In von Recklinghausen's disease the skin lesions may produce
protuberant, saggy, disfiguring masses
-more prone to become malignant as compared to neurilemmoma
-feel rubbery
-family history can be helpful in diagnosis
-solitary neurofibromas are usually small, superficial nodules that are
asymptomatic
-occur around 20-30 years of age
-due to its central location, in the peripheral nerve, the entire nerve is
usually removed with the tumor during excision
Neurilemoma
-a type of schwannoma
-present as a solitary, painless, fusiform, round, or oval mass that is
sharply circumscribed and encapsulated
-tumors may fluctuate due to cystic changes
-develops along the coarse of a digital nerves
-tend to favor the flexor surfaces of the extremity
-malignant transformation is extremely rare
-most occur in the 20-50 year age group
-due to its eccentric location the nerve of origin is rarely damaged during
excision
-recurrence is rare and rarely becomes malignant
SOFT TISSUE MASSES
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CYSTS
Ganglionic Cyst(Tendosynovial cyst, Synovial cyst)
-common lesion in the foot produced from an out pouching or herniation
of joint or synovial tissue allowing synovial fluid to escape and form an
encapsulated cyst
-pain may be present due to pressure from shoes or pressure on local
tissues
-although the skin is freely moveable over the ganglion, the ganglion
itself is usually firmly tied to its structure of origin so that it can not be
mobilized over the underlying bones and joints
-ganglions are thin walled fluctuant cysts that readily transmit light and a
pen light placed on the side of the ganglion will cause the whole cyst to
glow(transilluminate)
-a Baker's cyst is a ganglionic cyst in the popliteal fossa
-treatment includes aspiration with injection of corticosteroids(high reoccurrence rate -70%)
-local excision of the entire cyst with pedicle is curative
Epidermal Inclusion Cyst

-common skin cyst that occurs secondary to traumatic implantation of
the epidermis into the dermis, the epidermal cells continue to grow and
accumulate keratin within the cyst
-presents as a slow growing, round, firm, elevated subcutaneous lesion
-a sinus tract may develop exuding a pasty foul smelling cheese like
material
-one of the most common lesions found in the foot
-the content is usually foul smelling
-most commonly found on the plantar aspect of the foot
-Vamp's disease is an epidermal inclusion cyst at the MPJ caused by
trauma from the vamp portion of the shoe
-treatment usually consists of surgical excision
SYNOVIAL JOINTS
Pigmented Villonodular Synovitis
-same basic histologic process as Giant cell tumor of the tendon sheath
-symptoms usually have been present for a few years and include pain,
joint effusion, and hemarthrosis(thus hemosiderin pigment), limited ROM
-the synovium will appear red-brown in color due to the hemosiderin
found in the tissue
SOFT TISSUE MASSES
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CHAPTER 18
Synovial Sarcoma(TendosynovialSarcoma, Malignant

Synovioma)
-highly malignant tumor arising from undifferentiated mesenchymal cells
in tendons, tendon sheaths, or joint capsule
-symptoms are highly variable: there is sometimes pain, sometimes not,
there is sometimes a mass, sometimes not, there may be a long standing mass, or a rapidly growing mass, vague arthritic symptoms may be
present
-the masses are usually extra- and para-articular
-people in their 20's are most commonly affected
-due to its vague symptoms it should be in the differential diagnosis for
all deep pedal pain, especially in young adults
-treatment is often amputation; these lesions, should never be locally
excised unless a large tumor free area can be taken with it;
chemotherapy, irradiation
-these patients should be evaluated for metastatic lesions
-most common malignant soft tissue lesion in the foot
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CHARTING
ADMIT ORDERS(ADC VANDILMAX), p343

ADMITTING A PATIENT, p343
H&P, p351
IN-PATIENT PROGRESS NOTE, p341
LOWER EXTREMITY EXAM, p345
POST-OP CHECWPROGRESS NOTE, p340
POST-OP NOTE(0P NOTE), p342
POST-OP ORDERS(VANDILMAX), p343
PREOP CHECK(NOTE), p341
SAMPLE DICTATIONS, p346
CHAPTER 19
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CHAPTER 19
POST-OP CHECK/PROGRESS NOTE

DATE/TlME
S Patient seen @ bedside, resting comfortably, NAD
-if sleeping, were they easily aroused?
Number of hours s/p(name of procedure)
-If IV sedation with local is used, visit pt 1-2 hours post-op
-If general anesthesia is used, visit pt 2-3 hours post-op
Questions to ask: (if yes, you must do an HPI for the problem)
1. pain at surgical site
6. groin pain on side of surgery
7. calf pain on side of surgery
2. headache
3. chest pain
8. appetite
9. unable to void (urination)
4. shortness of breath
5. nausea or vomiting
10. bowel movement
0 Vitals: (document the most recent set taken by the nurse, and note
time)
General appearance and mental status of pt:
COR:(coronary) no abnormalities
Lungs: clear, no cough
ABD: soft, no pain or masses. + bowel signs
LEPE: Describe the dressing (dry and intact, or spotted with blood)
Describe position of K-wire if present
Position and function of drains if present
Vasc: SPVPFT, pulses
Neuro: sensation returned or absent
Labs or post-op x-rays
A 1. number of hours s/p(name of procedure), doing well or complications

2. any other problems the pt. had or developed since surgery and status
P Anything and everything you are doing for the above problems
-discharge to home
-X-ray
-gait or crutch training by physical therapy
-meds to continue or discontinue
-pt. education
Signature, degree
Resident, degree
Attending, degree
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IN-PATIENT PROGRESS NOTE

DATE/TIME
S Patient visited at bedside, awake, alert and oriented. Patient without
complaints. Patient denies fever/chills, nausea/vomitting, calf/thigh
pain, chest pain and SOB. Good appetite, + void, +BM
0 Tmax:
Tpresent:
BP:
P:
R:
Lungs: clear B/L
L foot: NVS intact
wound edges appear healthy, viable and well approximated
with sutures.
No drainage or erythema noted. Mild localized edema.
Labs: C & S
x-rays: - OM
A SIP bunionectomy with infection
wound status improving. Low grade fever-Vanco day #5 IDDM blood
glu well controlled
P I)dressing change performed
2) continue daily wound care
3) increase Vanco 750mg q12h IV, check Vanco levels
4) Repeat CBC and wound cultures in am
PREOP CHECK(N0TE)
DATE/TIME
SURGEON:
PREOP DIAGNOSIS:
PLANNED PROCEDURE:
CONSENT: signed and in chart
ANESTHESIA: MAC(monitored anesthesia care)
PATIENT confirms npo since midnight
HISTORY AND PHYSICAL by
, no
contraindications to surgery:
PMH:
Allergies
Medications
Illnesses
LABS:
Creat
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CHAPTER 19
color
turbidit
ketones
glucose
bilirubin
RBC
Epi
Bac
EKG: NSR(normal sinus rhythm)

CXR:
Patient presented for
surgery. No contraindications to surgery
noted, no guarantees given or implied.
SIGNATURE
POST-OP NOTE(OP NOTE)(SAPPPPA HEMI)

DATE/TIME
Operation start time
SURGEON:
Operation end time
ASSISTANTS:
PREOPERATIVE DIAGNOSIS:
POSTOPERATIVE DIAGNOSIS:
PROCEDURE:
PATHOLOGY: specimens taken, including type and analysis ordered.
Pertinent intraop findings i.e. DJD
ANESTHESIA: MAC or IV sedation with local(amount)
HEMOSTASIS: RIL pneumatic ankleithigh cuff @
mmHg(time
inflated and deflated)
EBL:
MATERIALS: anything left in the body
INJECTABLESback table meds
DRESSINGS: anything left on the body
COMPLICATIONS:
GENERAL STATEMENT: The patient tolerated anesthesia and
procedure well, left the OR for recovery with VSS(Vitalsigns stable)
and normal vascular status intact to the R/L foot as noted by
immediate hyperemia to digits 1-5 RIL foot upon deflation of the ankle
cuff.
SIGNATURE, DEGREE
RESIDENT, DEGREE
ATTENDING, DEGREE
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ADMIT O R D E R S ( A D C VANDILMAX)
POST-OP ORDERS(VANDILMAX)
DATE/TIME:
ADMIT TO:
DX: SIP Austin Bunionectomy
CONDITION: Good, Stable, Fair, Poor
VITALS: q8d
ACTIVITIES: CBR(complete bed rest) with bathroom privileges
NURSING: Elevate foot of bed, dressing change qd
DIET: Regular, House, ADA Diet
110's: IVs, Foley Cath.
LABS: med levels, ABGl02: If COPD pt
MEDS: PRN for pain or nausea
ANCILLARY:
X-RAY: Post-op x-rays
SIGNATURE:
HOW TO ADMIT A PATIENT

HAVE PATIENT GO TO ADMITTING OR THE
Have the patient go to admitting or the patient may be admitted via the
E R Admitting by way of ER may be desirable if one is unclear as to
whether the patient's condition warrants admission or if you want to
"pass the buck" and have someone else be the admitting doctor. The
ER doctor will generally admit the patient to their primary doctor or a
PCP doctor on call.
Once the patient has been assigned a room-
WRITE ADMIT ORDERS(ADCVANDILMAX)

Include
-IV antibiotics
-x-rays(baseline, R/O OM and gas gangrene)
-temp Q-shift
-Labs(C&S, gram stain, anaerobiclaerobic cultures, blood cultures)
-Consults (primary care for H&Pand evai, I&D)
WRITE A PROGRESS NOTE

Thereafter-
WRITE A PROGRESS NOTE BID

Patient is ready to go home-
WRITE A DISCHARGE SUMMARY
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DISCHARGE SUMMARY
Patient's name:
Medical Record #:
Physican:
Admition date:
Discharge date:
Date of Surgery:
Admitting Diagnosis: Infected 1st metatarsal lefi foot following bunion
surgery
Discharge Diagnosis: SIP foot infection
Procedures: I & D 1st metatarsal head with bone biopsy
History, Physical Exam: Pertinent admission H & P and lab tests
Coarse: Summary of the treatment and progress during hospital stay
Discharge Condition: Good, stable, fair, guarded, critical, etc.
Medications: discharge meds with dosage, administration, refills
D/C Instructions: The patient was discharged home with the following
instructions:
1. keep the feet elevated during periods of rest
2. wear surgical shoe during all periods of ambulation and avoid
excessive ambulation
3. keep dressing dry and intact
4. contact Dr.
for all follow-up care and if any problems arise.
The patient was given written and oral instructions on wound care
before discharge. Prior to discharge the patient was noted to be
afebrile, all vitals were stable, and helshe was ambulating well in postop shoe. All the patient's questions were answered and the patient was
discharged in apparent satisfactory condition.
Follow-up: Follow-up appointment, emergency phone numbers, etc.
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LOWER EXTREMITY EXAM

Name:
Age:
CC:
HPI:
PMH: previous sx
Meds:
All:
ROS: DM, HTN, lungs, heart, GI, Kidney
Family/social Hx:EtOH, smoke
Vitals: BPPulseRespVascular:
Dorsalis Pedis pulse
Posterior T i b i a lpulse
SPVPFT(normal3 seconds)
Edema(pitting/nonpitting)
O=not present, 1+=minimal, 2+=moderate, 3+=severe
Hair growth/varicosities/skin Temp
Neuroloaical:
Light Touch
Vibratory
Proprioception
Sharp/dull
Temperature
Protective threshold(Semmes Wienstein monofilament)
If the patient cannot feel a 5.07 monofilament this means they have
lost protective sensation at that location and are at risk for developing
an ulcer
Deep Tendon Reflexes
(0 absent, l+decreased, 2+normal, 3+increased, 4+hyperactive)
Patellar(L-2, L-3, L-4)
Achilles(L-5, S-1, S-2)
Superficial Reflexes
Babinski-The outer surface of the sole of the foot is vigorously stroked
with a blunt instrument from the heel toward the small toe. Normal
response; flexion of the toes, in upper motor neuron lesion;
dorsiflexion of the hallux and fanning of the toes.
Chaddock-An instrument similar to that used for the Babinski is used to
stimulate the lateral aspect of the foot below the malleolus from the
heel forward to the small toe. A positive test results in dorsiflexion of
the toes
Clonus-The foot is forcibly and quickly dorsiflexed and slight pressure is
maintained on the foot. If the test is positive, a rhythmic flexion and
extension of the foot continues.
Gordon sign-Dorsiflexion of the great toe or all the toes when the calf
muscles are squeezed. A positive sign is dorsiflexion of the hallux.
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Oppenheim-Heavy pressure with the thumb applied to the anteromedial

tibia and stroking down from the infrapatellor region to the ankle. The
response is a slow one and usually occurs at the end of stimulation.
A positive sign is dorsiflexion of the hallux.
Dermatoloaical
Skin(turgor, texture, temperature)
Nails(elongated, mycotic, incurved)
Callus(HDs, HMs, IPKs)
Tinea
Musculoskeletal
Bunions, Hammertoes(reducible/nonreducible)
Joint ROM/Crepitus
Muscle strength
(0-No contraction, 1-Trace, 2-Poor, movement with gravity eliminated,
3-Fair, movement against gravity, but not against resistance, 4-Good,
movement against gravity and some resistance, 5-Normal)
Gait
SAMPLE DICTATIONS
OPERATIVE REPORT
PT NAME: Spell it
PT MEDICAL RECORD #:
DATE:
PREOPERATIVE DIAGNOSIS:
POSTOPERATIVE DIAGNOSIS: same
NAME OF OPERATION:
SURGEON:
ASSISTANT:
ANESTHESIA: Local with monitored anesthesia care.
HEMOSTASIS: Pneumatic ankle tourniquet.
ESTIMATED BLOOD LOSS: Minimal
PROCEDURE IN DETAIL: Under mild sedation the patient was brought
into the operating room and placed on the operating table in the
supine position. A pneumatic ankle tourniquet was then placed about
the patient's R/L ankle. Following IV sedation, local anesthesia was
of a 1:1mixture of 1%
obtained about the R/L ankle utilizing -cc's
Lidocaine plain and .5% Marcaine plain. The foot was then scrubbed,
prepped, and draped in the usual aseptic manner. An Esmarch
bandage was utilized to exsanguinate the patient's R/L foot and
the pneumatic ankle tourniquet was inflated.
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BUNIONECTOMY:
Attention was directed to the dorsal aspect of the first metatarsal
head R/L foot where a 6 cm linear longitudinal incision was made
medial and parallel to the tendon of the extensor hallucis longus and
involved the contour of the deformity. The incision was deepened
through the subcutaneous tissues using sharp and blunt dissection.
Care was taken to identify and retract all vital neural and vascular
structures. All bleeders were ligated and cauterized as necessary.
At this time an inverted L-type capsulotomy was performed over the
dorsal aspect of the first metatarsal phalangeal joint. The periosteal
and capsular structures were then carefully dissected free of their
osseous attachments and reflected medially and laterally thus
exposing the head of the first metatarsal at the operative site.
Next, utilizing an oscillating bone saw, the dorsal and medial
prominences were resected and passed from the operative field. All
rough edges were then smoothed with the bone rasp.
Attention was then directed to the first interspace via the original skin
incision where the tendon of the extensor hallucis brevis was initially
identified and tenectonized. The dissection was continued deep
using blunt dissection down to the level of the fibular sesamoid which
was freed of it's soft tissue attachments proximally, laterally, and
distally. The conjoint tendon of the adductor hallucis muscle was then
identified and transected at it's attachment to the base of the proximal
phalanx of the hallux. At this time the lateral contracture present on
the hallux was noted to be reduced and the sesamoid apparatus was
noted to float into a more corrected medial position.
At this time the hip was externally rotated and the knee was flexed to
bring the medial surface of the foot superior to allow better access to
the medial aspect of the metatarsal head for the osteotomy cuts.
Attention was then redirected to the medial aspect of the first
metatarsal head where a through and through V-type osteotomy was
created in the metaphysial region of this bone utilizing an oscillating
bone saw. The apex of this osteotomy pointed distally with the arms
pointing proximo-plantarly and proximo-dorsally. The dorsal arm was
made longer to accommodate internal fixation. Upon completion of
the osteotomy the capital fragment was distracted and shifted laterally
into a more corrected position and impacted upon the first metatarsal
shaft.
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At this time three 0.045 inch K-wires were driven from dorsal to
plantar across the osteotomy site to serve as temporary fixation.
Following sequential removal of two of the 0.045 inch K-wires and
following standard A 0 principles and techniques, a 2.7 x m
m and
a 2.0 x m
m cortical bone screw were inserted in their place across
the osteotomy site with excellent compression noted. At this time the
remaining 0.045 inch K-wire was removed.
Attention was then directed to the remaining medial bone shelf which
was resected utilizing the oscillating bone saw and passed from the
operative site. Correction of the deformity was assessed at this time
and noted to be excellent.
The wound was then flushed with copious amounts of sterile normal
saline. The periosteal and capsular structures were reapproximated
and coapted utilizing 3-0 Vicryl. Redundant capsular tissue was
resected as necessary. The subcuticular tissues were then reapproximated and coapted utilizing a 3-0 Vicryl, and the skin was
reapproximated and coapted utilizing a 5-0 Nylon in a continuous
running interlocking suture technique.
HAMMERTOE
REPAIR:
Attention was then directed to the
digit RIL foot where 2
converging 2 cm semi-elliptical longitudinal incisions were made over
the dorsal aspect of this digit. The incisions were centered over the
PIPJ and encompassed a dorsal callus present at the PIPJ. The
incisions were deepened through the subcutaneous tissues, with
care being taken to identify and retract all vital neural and vascular
structures. The ellipse of skin was removed in toto using sharp
dissection. All bleeders were cauterized and ligated as necessary.
ARTHROPLASTY:
At this time, a transverse tenotomy and capsulotomy was performed
to the proximal interphalangeal joint of the digit R/L foot. The head
of the proximal phalanx was then freed of its capsular and
ligamentous attachments. Next utilizing the oscillating bone saw, the
head of the proximal phalanx was resected and passed from the
operative site. The wound was then flushed with copious amounts of
sterile normal saline. The extensor tendon was reapproximated and
coapted utilizing 3-0 Vicryl and the skin was reapproximated and
coapted utilizing 5-0 Nylon using simple interrupted and horizontal
mattress suture techniques.
CHARTING
349
CHAPTER 19
ARTHRODESIS:
Attention was then directed to the base of the middle phalanx where
the base was freed of its soft tissue attachments. The articular
cartilage was then resected utilizing an oscillating bone saw, and
passed from the operative site. At this time a ,045 K-wire was driven
through the proximal aspect of the base of the middle phalanx exiting
the distal aspect if t h e d i g i t . The K-wire was then retrograded
proximally through the remaining aspect of the proximal phalanx and
into t h e metatarsal head. Correction of the deformity was
assessed at this time and noted to be excellent. The wound was then
flushed with copious amounts of sterile normal saline. The extensor
tendon was reapproximated and coapted utilizing 3-0 Vicryl and the
skin was reapproximated and coapted utilizing 5-0 Nylon using
simple interrupted and horizontal mattress suture techniques.
MPJ RELEASE:
Attention was then directed to the M P J were a dorsal
linea/ltransverse stab incisionwas made over this joint. Using blunt
dissection, the incision was continued down to the long and short
extensor tendons and capsular tissues. Utilizing a 15 blade, a
tenotomy and capsulotomy were performed on the dorsal aspect of
MPJ. Upon completion of the tenotomy and capsulotomy, the
the
dorsal contractures were assessed and noted to be reduced.
NEUROMA:
Attention was then directed to the i n t e r s p a c e of the
foot
where a 3cm linear longitudinal incision was made beginning distally
at the web space of the intermetatarsal area and extending proximally.
The incision was deepened through the subcutaneous tissues being
careful to identify and retract all vital neural and vascular structures,
and all bleeders were cauterized and ligated as necessary. At this
time, dissection was then continued down into the-interspace using
blunt dissection until the glistening soft white neural tissue mass of
common plantar nerve was initially identified beneath the
the
intermetatarsal ligament.
After initial identification, the hypertrophied soft tissue neural mass
was followed distally to the point of it's bifurcation into the proper
plantar digital nerves. The proper plantar digital nerves were tracked
as far distally as possible and severed. The neural mass was then
dissected as far proximally as possible, separated from it's soft tissue
surroundings and severed. At this time the entire soft tissue neural
mass was resected and passed from the operative field in toto. The
wound was inspected for any remaining hypertrophied neural tissue
and it should be noted that none was found.
CHARTING
350
CHAPTER 19
The wound was then flushed with copious amounts of sterile normal
saline. The subcutaneous tissues were then reapproximated and
coapted utilizing a 3-0 Vicryl, and the skin was reapproximated and
coapted utilizing a 5-0 Nylon in a continuous running interlocking
suture technique.
AFTER THE PROCEDURE(S):

Upon completion of the procedure, a total of one cc of Decadron
phosphate was infiltrated about the incision site. A postoperative
block consisting of c c ' s of .5% Marcaine plain was also injected.
The incision was dressed with Betadine soaked Adaptic/Xeriform and
covered with sterile compressive dressing consisting of 4 x 4 ' s and
Kling. The pneumatic ankle tourniquet was then deflated and a
prompt hyperemic response was noted to all digits of the R/L foot. A
posterior splint, Ace wrap, and post-op shoe were then applied.
The patient tolerated the procedure and anesthesia well. He/She was
transferred to the recovery room with vital signs stable and vascular
status intact to all toes of the R/L foot. Following a period of
postoperative monitoring, the patient will be discharged home on the
following written and oral postoperative instructions.
1. Keep dressing dry and intact.
2. Avoid excessive ambulation.
3. Ice and elevate RIL foot when at rest.
4. Wear surgical shoe at all times when ambulating.
5. Contact Dr. f o r all postoperative follow-up care
and if any problems arise.
6. Prescriptions were written for:
CHARTING
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CHAPTER 19
H&P
INTRODUCTION:
Name: Age:
Race:
Sex:
Occupation:
CHIEF COMPLAINT: In patients own words.
HISTORY OF PRESENT ILLNESS: Onset, duration, type of pain,
trauma, radiating, provokes, relieves, quality, previous episodes,
severity, previous tx.
PAST MEDICAL HISTORY: (OMAHI)
Operations
Medications
Allergies
Hospitalizations
Illnesses
Childhood Diseases(Chicken Pox, Rheumatic Fever, Scarlet Fever,
Measles, Mumps, Polio). Chronic Disease and Systemic
Disorders(Hepatitis, TB, Diabetes, Cancer, Arthritis, Stroke, HTN,
Ulcers, Seizures, Heart, Lung, or Kidney Disease)
SOCIAL HISTORY: Tobacco, EtOH, Recreational Drugs, Type of work,
Marital status, Children.
FAMILY HISTORY: Diabetes, HTN, Cancer, etc.
REVIEW OF SYSTEMS:
General: General health, weight change, fever, fatigue.
Skin: Pt denies hx of changes in pigmentation, texture, eruptions,
pruritus, bruising, hair loss, jaundice, and change in nails.
Lymph Nodes: Pt denies hx of enlargement, pain and drainage.
Ears:Pt denies changes in hearing, tinnitus, vertigo, discharge,
recurrent infections, and pain.
Nose and Sinuses: Pt denies hx of sinus infection, rhinitis, epistaxis,
obstruction, drainage or discharge.
Mouth and Teeth: Pt denies hx of sores of mouth or tongue, bleeding
gums, dentures, dental problems or jaw pain.
Throat:Pt denies hoarseness and sore throat.
Neck: No history of goiter or enlarged nodes.
Breasts: No history of masses, lumps, pain, or discharge.
Respiration: Pt denies SOB, wheezing, dyspnea, cough, hemoptysis,
pleurisy, bronchitis, TB or asthma.
Cardiovascular: Pt denies hx of palpitations, tachycardia, heart
murmurs, irregular rhythm, chest pain, intermittent claudication,
phlebitis, and cold extremities.
Gastrointestinal: Pt denies change in appetite and bowel habits. Pt
denies nausea, vomiting, abdominal pain, ulcers, hematochezia,
melena, diarrhea, constipation, and hemorrhoids.
CHARTING
352
CHAPTER 19
Genitourinary: Pt denies dysuria, hematuria, oliguria, frequency,

incontinence, stones, discharge, and UTls. Male-Pt denies sores,
discharge, testicular masses or tenderness. Pt denies STDs.
Female-Menarche, length/flow of menses, or menopause. Pt
denies dysmenorrhea, intermenstrual bleeding, dyspareunia, discharge, sores, pain, and STDs.
Hematopoietic: No hx of bleeding disorders or anemia.
Endocrine: Pt denies hx of goiter, polyuria, polyphagia, dryness of
skin or hair.
Musculoskeletal: Pt denies hx of arthritis, jt pain, aches, loss of
strength, gout, and RA.
Neuroloaical: Pt denies stroke, vertigo, syncope, sensory disturbance,
numbness, tremors, paralysis, muscle weakness, and convulsions.
Psvchiatric: Pt denies anxiety, nervousness, mood changes,
depression, and hallucinations.
PHYSICAL EXAM
Vital Sians: Temp: Pulse: Resp: BP: Height: Weight:
General Appearance: The pt is a well developed, well nourished-yr
o l d
who is alert, oriented, cooperative, and in no apparent
distress.
Skin: Warm, dry, good color, turgor, and pigmentation with no lesions
scars or signs of cyanosis.
Head: Head is normocephalic with normal hair texture and
distribution. Scalp shows no evidence of masses, scars, rashes or
scaling. Face is symmetrical with no signs of scars or edema.
Eyes
Visual acuity using the near card is 20120, visual field is full B/L,
EOMI, PERRLA, and the cornea and lens are clear. Sclera clear,
no conjunctival injection. Lashes and eyebrows show normal
amount of hair with normal texture. Palpebral fissures symmetrical.
Ears:Auricula have normal size, shape, symmetry and location with
no tenderness or tophi. External canals are patent and without
erythema or exudates. Tympanic membranes are intact with good
color and position. Weber midline, Rinne neg B/L.
Nose and Sinus: Septum is midline, mucous membrane pink and
moist without erythema or exudates, airways fully patent. No
drainage noted, sinus are not tender to palpation.
Mouth and Throat: Gums are pink and moist, no bleeding is present.
Tongue has normal color, good motility and is in midline. No noted
swelling, erythema, exudate or ulcerations. Uvula midline and
elevates normally, gag reflex intact.
CHARTING
353
CHAPTER 19
Neck: Neck is symmetrical and supple with no neck vein distention

and full ROM, trachea midline and freely moveable. Thyroid is
smooth, not enlarged and without nodules. There is no cervical
lymphadenopathy. Palpation of the carotids reveals good upstroke.
No carotid bruits were auscultated.
Lvmehatics: No anterior, posterior, occipital, cervical, submaxillary,
supraclavicular, axillary, epitrochlear, or inguinal lymphadenopathy.
Chest and Lunas: AP/transverse diameter (1:2). Breathing is unlabored. Thorax is symmetrical. Breath sounds are bilaterally clear
to auscultation with no adventitious sounds, roles, rhonchi,
wheezes, pleural friction rubs or stridor. Respiratory excursion(35cm).
Cardiovascular: Regular rate with no murmurs, gallops, rubs, or clicks
appreciated. No S3/S4 noted. There are no heaves or other visible
precordial movements. Apical impulse is palpable in the fifth left
interspace in the midclavicular line. No neck veinous distention at
30". Pulses: Carotid, radial and femoral pulses are palpable, of
good quality and equal B/L at 314. The posterior tibialand dorsalis
pedis are palpable 314.
Abdomen: Nontender and nondistended without scar or hernias
present. Symmetric abdomen without aortic pulsations. Positive
bowel sounds in all four quadrants. Percussion reveals normal
variation between dullness and tympany. Palpation reveals no
guarding or masses felt on superficial and deep palpation. Liver
size percussed at cms. Spleen was unpalpable.
Extremities: There is no lower or upper extremity edema, ulcerations,
tenderness, varicosities, erythema, tremor or deformity. Toe and
fingernails have good color and shape with no clubbing.
Breast: No discharge, retraction, asymmetry, tenderness, or masses
noted.
Genitalia: No urethral discharge. B/L hernia exam was negative.
Male-the penis islis not circumcised. Testicles descended with no
apparent atrophy. No masses or tenderness on palpation. No
thickening or tenderness of epididymis. Female-External genitalia
are without lesions, discharge or erythema. Uterus and ovaries
normal size and consistency.
Rectal: Good sphincter tone present with no pain on insertion of
finger. No masses palpable and hemoccult was negative. Prostate
without nodules or masses palpated.
Musculoskeletal: The patient ambulates without assistance. There is
normal cervical, thoracic, and lumbar spine ROM. No scoliosis, lor
dosis or kyphosis noted. No paravertebral muscular tenderness.
CHARTING
354
CHAPTER 19
Neuroloaical: Pt's behavior, level of consciousness, and emotional

status appear normal. Cranial nerves II-XIIare intact. Muscle size,
tone, and strength are normal and no involuntary movements are
noted. Coordination is adequate. Sensory function appear intact.
Reflexes are present and symmetrical.
LABORATORY TESTS
355
CHAPTER 20
CHAPTER 20
LABORATORY TESTS
URINALYSIS,
Specific gravity,
Color,
Appearance,
Smell,
Blood,
Glucose,
Leukocyte esterase,
Nitrite,
Protein,
Urobilinogen,
Epithelial cells,
Crystals,
Casts,
CBC
DIFFERENTIAL,
WBC,
Differential,
RBC,
Indices,
Count,
COAGULATION STUDIES,
Bleeding Time,
Platelet Count,
Prothrombin Time,
Partial Thromboplastin
Activated Partial Thromboplastin
Coagulation Cascade,
BLOOD CHEMISTRY,
Albumin,
Alkaline Phosphatase,
Bilirubin,
BUN,
Calcium,
Chloride,
Cholesterol,
Creatine Phosphokinase,
Creatinine,
Lactate Dehydrogenase,
Potassium,
Protein,
Sodium,
Uric Acid,
MISCELLANEOUS TESTS,
Erythrocyte Sedimentation,
Sed rate),
C-reactive protein,
2-hour Postprandial Blood
PPBS),
Oral Glucose Tolerance,
Glycosylated Hemoglobin
LDH Isoenzymes,
ELISA,
VDRL,
RPR,
ANA,
Anti-ds-DNAAntibody Test,
RA factor,
HLA-B27, P375
LABORATORY TESTS
356
CHAPTER 20
URINALYSIS
Generally divided into two parts
a) General
-includes macroscopic evaluation, specific gravity, and a dipstick
segment
b) Microscopic evaluation
-quantitative assessment of cellular component
Specific gravity
Normal value: 1.003-1.035
-measures the kidney's ability to concentrate urine, the higher the value
the more concentrated the urine
INCREASED IN
DECREASED IN
-diabetes mellitus
-diabetes insipidus
-volume depletion
dehydration
fever
vomiting
diarrhea
COLOR Normal: yellow, straw-colored, amber

-in addition to the following many medications and foods can alter urine
color
BLUEIGREEN OR BLACK
RED
ORANGE
-hemoglobinuria -restricted fluid intake -lysol poisoning
-hematuria
-concentrated urine
-melanin
-myoglobinuria -urobilin
-bilirubin
-porphyrins
-fever
-methemoglobin
-menstral
-porphyrin
-Pseudomonas toxemia
contamination
Appearance
~ o r m a lclear
:
CLOUDY
-UTI
LABORATORY TESTS
357
CHAPTER 20
Smell
-fresh urine from most healthy persons has an aromatic ammonia smell
SWEET SMELL
Smell of acetone on diabetic ketosis
PUTRID SMELL
Presence of bacteria
MAPLE SYRUP SMELL
Due to a genetic disorder called Maple sugar urine disease. An
enzymatic defect(branched-chain keto acid decarboxylase) renders
these children unable to break down branched chain amino acids
and they accumulate in the urine.
pH
Normal value: 4.6-8.0

ACIDIC
-high-protein(meat) diet
-starvation
-diabetes
-COPD
BASIC
-UTI
-vomiting
-old urine specimen
Blood
Normal value: 0 to trace amounts
-a positive test has 3 possible implications because the reagent is
sensitive to RBC's, free Hb, and myoglobin
HEMATURIA
HEMOGLOBINURIA MYOGLOBINURIA
(RBC's)
(free Hb)
(a muscle protein)
-UTI
-burns
-traumatic muscle injury
-Lupus
-crush injury
-electric shock
-Polyarteritis nodosa -transfusion reaction -muscular dystrophies
-malignant hypertension -febrile intoxication
-subacute bacterial
-Malaria
-glornerulonephritis
endocarditis
-trauma
-heavy smoker
Glucose
GLUCOSURIA
-diabetes mellitus
-brain injuries
-severe stress
-drugs(ASA, epinephrine)
LABORATORY TESTS
358
CHAPTER 20
Ketones(acetone)
-children are particularly prone to develop ketonuria
-ketone bodies appear in the urine before there is any significant
increase in the blood
KETONURIA
-uncontrolled diabetes
-starvation
-fever
-prolonged vomiting
-diarrhea
Leukocyte esterase
-positive results indicate pyuria(pus in the urine)
INCREASED IN
-UTlls
Nitrite
-bacteria convert nitrates to nitrites
-false negatives are not uncommon as not all bacteria convert nitrates to
NITRITURIA(greater than trace amounts in urine)
-UTl1s
Protein
-generally refers to the albumin levels since albumin represents the bulk
of blood protein
-the term albuminemia is often used interchangeably with proteinuria
-electrophoresis or turbidimetric methods can be used to demonstrate
Bence-Jones protein which is specific for multiple myeloma
PROTEINURIA(greater than trace amounts in urine)
Usually indicates some form of renal disease
-nephritis/glomerulonephritis
-nephrosis
-polycystic kidney
-CA of the kidney
-pyelonephritis
Other nonrenal causes include:
-fever
-trauma
LABORATORY TESTS
359
CHAPTER 20
-severe anemia and leukemia

-toxemia, pre-eclampsia of pregnancy
-intestinal obstruction
-abdominal tumors
-convulsive disorders
-hyperthyroidism
-liver disease
-acute infection
Transient proteinuria may be associated with:
-severe exercise
-severe emotional stress
-cold baths
Urobilinogen
Normal values: 0 to trace amounts
-Urobilinogen is metabolized in the liver and excreted in bile, if the liver
is unable to metabolize urobilinogen, either due of problems with the
liver or excessive amounts of urobilinogen it ends up in the urine
INCREASED IN
-hepatitis(infectious or toxic)
-hemolytic anemia
-pernicious anemia
-malaria
RBC's
<3 cellslhpf
INCREASED IN
-trauma
-cystitis
-UTI
-tumors
-stones
-prostatitis
-Lupus
-Polyarteritis nodosa
-malignant hypertension
-subacute bacterial endocarditis
-glomerulonephritis
-pyelonephritis
-heavy smoker
LABORATORY TESTS
360
CHAPTER 20
WBC's
<5 cellslhpf
INCREASED IN
-UTl1s
-pyelonephritis
-most renal disorders
Epithelial cells
<2 cellslhpf
INCREASED IN
-acute tubular damage
Crystals
-presence of crystals is a normal finding
-the type and number vary according to the pH
Casts
-general indicator of kidney disorders
-named because their shape represents the cylindrical shape of the kidney tubular lumen
-different types of casts are so-named for the cells or cellular components they contain
HYALINE CASTS
-empty cast containing no cellular components
-normal unless numerous-low urine flow
RBC CASTS
-glomerulonephritis
WBC CASTS
-pyelonephritis
EPITHELIAL CASTS
-tubular damage
GRANULAR CASTS
-cellular casts(e.g. RBC casts, WBC casts) break down to granular
casts
-nonspecific, associated with any form of nephritis
WAXY CASTS
-end stage of granular casts
FATTY CASTS
-any form of nephritis, esp. nephrotic syndrome and Fabry's dz
LABORATORY TESTS
361
CHAPTER 20
CBC WITH DIFFERENTIAL

WBC
Normal value: 5,000-10,00O/pI

-measures the total number of circulating leukocytes
LEUKOPENIA
LEUKOCYTOSIS
(<4,ooo/pl)
(>1o,ooo/pl)
-overwhelming infection
-bacterial infection
-viral infection
-inflammatory process
-hypersplenism
-tissue necrosis(M1, burns)
-bone-marrow depression
-physical stress
Differential
-a differential determines the relative amounts of each of the 5 types of
WBC's which is more diagnostically valuable than just the total number of
WBC's alone
Leukocvtes
Agranulocytes
Granulocytes
Monocvtes
Neutrophlls(PMN1s)
Eosinoohils
~asophlls
v.
t
Lymphocytes
TYPES
WFMALVALUES SIGNIFICANCESOF INCREASE
Neutrophis(totai) 50-70%
Bacterial infections
(2,500-7,000/~1)
Segments
50-65%
Rlght shW-l~ver
dz, some types of anemla
(2,500-6,500lpl)
Bands
045%
Left sh~ft*-acutebacter~al~nfect~on
0-5001~1)
E O S I ~ O ~ ~ O A
Allerglc and paras~tcd~seases
I Lymphocytes
Source of h~stamlnes~nflammat~onlallerq~es
Vlral ~nfect~on,
TB, parasltlc d~seases,
subacute bacter~alendocarditls,
monocytlc leukernla, collaqen dz
V~ral~nfect~on,
lymphocytlc leukem~a
25-359.6
(1,700-3,50O/pl) I
*Normally most circulating neutrophils are in their mature form which the
laboratory identifies by its segmented nucleus(segmented neutrophils). In
contrast, the nucleus of less mature neutrophils are not yet segmented but
still seen as a band(band neutrophils).
When lab. reports were written by hand, the bands were written first on
!he left side of the page and the segments to the right, hence the terms
left shift" and "right shift".
LABORATORY TESTS
362
CHAPTER 20
RBC
Normal value: (average) 4,600,0001pl (higher in males)
-average lifespan of a RBC is 120 days
-decreased in anemia(for more specific diagnosis evaluate Hct, Hb, and
indices)
-increase in RBC's is termed polycythemia and is associated with many
factors which cause over production of RBC's or decrease in plasma
-dehydration
-acute poisoning
-severe diarrhea
-pulmonary fibrosis
Hematocrit(Hct)
-Average value is 45% (higher in males)
-Hct is the % volume of RBCs in a sample of anticoagulated whole
blood
-Hct decreases in anemia and blood loss
-useful when evaluating bleeding or blood loss. The body reacts to
blood loss by dumping more fluids into the vascular system to maintain
BP. This excess fluid does not contain RBCs and Hct decreases
Hemoglobin(Hgb, Hg, Hb)

- N o r m a l value: (average) male 16, female 14
-Decreased in anemia, increased in polycythemia
I ~ ~ ~ c ~ s (Indices)
R B c
-provides information about the size and hemoglobin content of red
blood cells
-useful aid in differentiating anemias
MCHC(Mean Corpuscular Hemoglobin Concentration)
-measures the proportion of each cell occupied by hemoglobin
HYPERCHROMIA
HYPOCHROMIA
(abnormal increase in the
(abnormal decrease in the
Hb content of RBC's)
Hb content of RBC's)
-spherocytosis
-iron deficiency anemia
dhalassemia
LABORATORY TESTS
363
CHAPTER 20
MCH(Mean Corpuscular Hemoglobin)

-measures the average amount of hemoglobin in the RBC's
MCV(Mean Corpuscular Volume)
-measures the average volume occupied by a single RBC
MlCROCYTlC
NORMOCYTIC
MACROCYTIC
ANEMIA
ANEMIA
ANEMIA
MCV<80)
(MCV80-100)
(MCV>100)
-iron deficiency
-chronic dz
-folate acid deficiency
-thalassemia
-bone marrow failure -vitamine 812 deficiency
-blood loss
-hemolysis
-liver disease
-lead poisoning
-drugs:
phenytoin
cytotoxic meds
Reticulocyte Count
-Normal value: (average) .5-1.5%
-% of immature RBCs
-a reticulocyte is a young, immature, nonnucleated RBC formed in the
bone marrow and therefore a reflection on bone marrow function
-can be useful in determining whether an anemia is caused by bone
marrow failure or by hemorrhageihemolysis
-also useful in evaluating treatment of anemia
COAGULATION STUDIES
Bleeding Time
-Normal value: 2-9 minutes
-measures the primary phase of hemostasis, the interaction of the
platelets with the blood vessel wall and the formation of a hemostatic
plug
-the test consists of a forearm scratch that is timed until a clot forms
INCREASED IN:
-von Willebrand's dz
-thrombocytopenia
-DIC
-platelet dysfunction
-ASA or NSAlD therapy
INR(lnternationa1Normalized Ratio)
-Normal value: 3-4
-INR was developed to calibrate all the different labs and give a more
standardized value for the PT
LABORATORY TESTS
364
CHAPTER 20
Platelet Count
-Normal value: 150,000-300,000
-Spontaneous bleeding occurs below 25,000-50,000
-Thrombocytopenia-decrease in the number of platelets
-Thrombocytosis-increase in the number of platelets
Factors requiring Vitamin K

Extrinsic pathway factors
Intrinsic pathway factors
11, Vll, IX, X

Ill, VII
Vlll, IX, XI, Xll,
Prothrombin Time(PT, Pro time)

-Normal value: 11-1 6sec(varies according to lab)
-measures the extrinsic pathway
INCREASED IN:
-Vitamin K deficiency
-biliary obstruction
-liver dz
-Coumadin Tx
-deficiencies in Extrinsic or common pathway factors(Mnemonic PET)
Partial Thromboplastin Time(PTT)

-Normal value: 25-35sec(varies according to lab)
-measures the intrinsic pathway
INCREASED IN:
-Hemophilia A(factor Vlll deficiency)
-Hemophilia B, "Christmas dz" (factor IX deficiency)
-von Willebrand's dz
-DIC
-deficiencies in Intrinsic or common pathway factors(Mnemonic PITT)
-liver dz
-Heparin Tx
Activated Partial Thromboplastin Time(APTT)

-Normal value: 20-35sec(varies according to lab)
-a modified PTT that is frequently used to monitor Heparin therapy
because it is a more sensitive test than PTT
LABORATORY TESTS
365
CHAPTER 20
COAGULATION CASCADE
tissue damage
blood vessel damage

(exposed collagen)
VII,
Prothrombin
Fibrinogen
FACTOR
II
V
X
XI
NAME
Prothrombin
Tissue Thromboplastin
Calcium
Proaccelerin
Proconvertin
Antihemophiliac Factor
Christmas Factor
Stuart Factor
Plasma Thromboplastin Antecedent
Factor
Transglutaminase
FIBRIN CLOT
=activated
LABORATORY TESTS
366
CHAPTER 20
BLOOD CHEMISTRY(SMA, SMAC)

-Used to screen for Cardiac, Renal, Hepatic, Bone & Parathyroid, and
Metabolic dz
Albumin
-Normal value: 3.5-5.5gldl
-makes up more than half of plasma protein
-produced in the liver
-albumin is used to transport many substances(medications) in their
inactive state(abx, ASA, many sed-hypnotics) and so medications may
reach toxic levels if albumin levels are low
INCREASED IN:
DECREASED IN:
-dehydration
-liver dz
-malnutrition/malabsorption
-eclampsia
-nephrosis
-severe burns
Alkaline Phosphatase
-Normal value: 30-85mUlml
-This enzyme is found mainly in the liver and bone and to a lesser
degree in the intestine, kidneys and placenta
INCREASED IN:
DECREASED IN:
-liver dz
-hypothyroidism
-bone dz
-malnutrition
-healing fxibone growth
-scurvy
-pernicious anemia
-obstructive biliary dz
-placental insufficiency
Bilirubin
-Normal value: .2-1 .3mg0h
-bilirubin is a break down product of hemoglobin
-a rise in bilirubin will occur if there is an excessive destruction of RBC's
or if the liver is unable to excrete the normal amount produced
-bilirubin can be divided into conjugated(direct) and unconjugated(indirect) and separate lab. values may be given for each. An increase in
conjugated(direct) bilirubin usually indicates obstructive jaundice and
unconjugated(indirect) usually indicates destruction of RBC's(hemolysis)
-jaundice is apparent when the serum bilirubin rises over 3mg0/i
LABORATORY TESTS
INCREASED IN:
-bile duct obstruction
-hemolytic anemia
-hepatocellular damage
367
CHAPTER 20
DECREASED IN:
-meds:PCN
sulfonamides
barbituates
B U N ( B I O OUrea
~
Nitrogen)
-Normal value: 10-20s
-BUN is a measure of urea produced in the liver as a product of protein
catabolism and excreted by the kidneys, thus it is a measure of liver
function and kidney excretion
-BUN alone is not considered to be as reliable an indicator of renal function because it is depends on many extrarenal factors(age, gender, lean
body mass), BUN and creatinine together is a much more reliable indicator of renal function
INCREASED IN:
DECREASED IN:
-renal dz
-liver failure
-dehydration
-malnutrition
-high-protein diet
-pregnancy
-diabetes mellitus
Calcium
-Normal value: 8.5-11mg%
-98%-99% of the body's calcium is stored in the skeleton and teeth
which acts a huge reservoir for maintaining blood levels needed for
muscular contractions, cardiac function, transmission of nerve impulses
and blood clotting
-any condition causing bone demineralization or atrophy will increase
calcium serum levels
-serum calcium deficiency causes neuromuscular excitability, tetany,
muscle twitching, and eventually convulsions
-increased serum calcium causes drowsiness, nausea, and cardiac
arrhythmias
INCREASED IN:
DECREASED IN:
-bone neoplasm
-hypoparathyroidism
-malabsorption
-immobilization
-vitamin D deficiency
-multiple myeloma
-renal failure
-hypervitaminosis D
-milk-alkali syndrome
LABORATORY TESTS
368
CHAPTER 20
Chloride
-Normal value: 98-109mEqIL
-chloride is the primary extracellular anion and plays a major role in
water balance, acid-base balance, and osmolarity of body fluids
-chlorides are depleted any time there is a massive loss of
gastrointestinal fluids or urine
INCREASED IN:
DECREASED IN:
-dehydration
-vomiting
-diarrhea
-eclampsia
-excessive IV saline
-ulcerative colitis
-severe burns
-heat exhaustion
Cholesterol
-Normal value: c200mg%
-cholesterol is synthesized in all body tissues, but in extremely high
amounts within the liver
-as the blood levels rise the risk of atherosclerosis and heart dz increases
-INCREASED IN:
-DECREASED IN:
-hypercholesterolemia
-malabsorption
-biliary obstruction
-anemias
-hypothyroidism
-nephrosis
-diabetes mellitus
Creatine Phosphokinase(CK, CPK)

-Normal value: 6-30UlmI
-elevated CPK may predispose a patient for malignant hyperthermia
-any time there is damage to muscle or CNS the CPK can be elevated
-CPK can be fractioned into different isoenzymes(BB, MB, and MM) for
a more specific diagnosis
-CPK is elevated 4-8 hours after an MI, peaks at 12-24 hours, and
returns to normal 4-6 days later. SGOT is elevated 6-12 hours after an
MI and returns to normal 5-7 days later, LDH is elevated 48 hours after
an MI and returns to normal 9 days later
CPK-BB
CPK-MB
CPK-MM
(cardiac muscle)
(skeletal muscle)
(CNS)
-muscular dystrophy
-CVA
-MI
-angina
-crush injury
-brain injury
-cardiac defibrilation
-IM injection
-heart surgery
LABORATORY TESTS
369
CHAPTER 20
Creatinine
-Normal value: .7-1.4mg%
-creatinine is a by-product of muscle catabolism, it's derived from the
breakdown of muscle creatine and creatine phosphate
-serum creatinine is used as an indicator of renal function and is more
sensitive an indicator than BUN
INCREASED IN:
-renal dz
-nephritis
Glucose: Fasting Blood Sugar(FBS)

-Normal(fasting) 65-11 OmgOh
-used as an initial screening for diabetes
-for borderline or slightly elevated blood glucose levels a postprandial
and/or a glucose tolerance test may be ordered
-glucose spills over into the urine(glucosuria) at about 180mg% or
higher
ELEVATED IN:
DECREASED IN:
-diabetes(most common)
-excessive insulin administration
-Gushing's syndrome
-liver dz
-acute pancreatitis
-adrenal hypoactivity
-adrenal hyperactivity(stress, shock)
-infection
Lactate Dehydrogenase(LDH, LD)

-Normal 90-200mU/ml
-LDH is an intracellular enzyme widely distributed in many tissues of the
body particularly the kidneys, heart, skeletal muscle, brain, liver, lungs,
and RBC's
-LDH is relatively nonspecific, but may be used to confirm MI or
pulmonary infarction when viewed w ~ t hother tests
-LDH is elevated 12-24hrs after an MI, peaks at 2-5 days, and returns to
normal at 6-1 2 davs
-LDH can be fractioned into isoenzymes for more specific diagnosis
ELEVATED IN:
-MI
-pulmonary infarction
-CVA
-hepatitis
-CA
-hemolytic anemia
-skeletal muscle necrosis
LABORATORY TESTS
370
CHAPTER 20
Phosphate(P)/lnorganic Phosphorus(P04)
-Normal 3-4.5mgldL
-phosphorous is the principal intracellular anion
-absorbed through the intestines and stored mainly in the bony skeleton
-about 85% of the body's total phosphorous is combined with calcium
and stored in the bone
-phosphate levels are always evaluated in relation to calcium levels
because there is an inverse relationship between the two, as one goes
up the other goes down
INCREASED IN:
DECREASED IN:
-renal dz
-hypoparathyroidism
-diabetes
Potassium
-Normal 3.5-5.5mEqlL
-potassium is the primary intracellular cation and is found in small
amounts in the blood
-low blood potassium(Hypokalemia) causes depression of the myocardial contractability and can lead to arrhythmias(EKG signs include:
depressed T wave and a peaking P wave)
-high blood potassium(Hyperkalemia) causes cardiac excitabitiy and can
lead to fibrilations and death(EKG signs include: elevated T wave and
f l a t t e n e d P wave)
-treatment for hyperkalemia may include; administering calcium, administering sodium bicarbonate, or administering a combination of insulin
and glucose)
-in addition to cardiac problems, Potassium deficiency causes leg
cramps and weakness
INCREASED IN:
DECREASED IN:
(HYPERKALEMIA)
(HYPOKALEMIA)
-tissue trauma(hernolysis)
-vomiting/diarrhea
-burns
-diuretics
-renal failure
-starvation
-Addison's dz
LABORATORY TESTS
371
CHAPTER 20
Protein
-Normal 6-8mgldL
-albumin is a protein formed in the liver that helps maintain normal distribution of water in the body(colloidal osmotic pressure), it also helps to
transport many blood constituents and drugs
-when referring to total blood protein it mostly refers to albumin levels
since blood protein is 50-60h albumin
-the non albumin portion of blood protein consists of globulins and the
albumin to globulin ratio, or N G ratio, is sometimes beneficial in diagnosing certain conditions such as Multiple Myeloma(0ence-Jones protein is a lobulin)
I N C R ~ A S E DIN:
DECREASED IN:
HYPERPROTEINEMIA(rare)
HYPOPROTEINEMIA
-dehydration
-chronic liver dz
-vomiting/diarrhea
-malnutrition/sta~ation
-Multiple Myeloma
-severe burns
-malignancies
SGOT or AST
-Normal 10-50mUlml
-found in high concentrations in the heart and liver and in moderate
amounts in skeletal muscle
-when ever there is heart or liver damage SGOT spills into the blood
and the amount in the blood is directly related to the number of
damaged cells
-SGOT is more specific for cardiac necrosis and less specific for liver
necrosis relative to SGPT
ELEVATED IN:
DECREASED IN:
-MI
-pregnancy
-liver dz
-uncontrolled diabetes
-skeletal muscle necrosis
-beriberi
SGPT or ALT
-Normal 10-50mUlml
-concentrations in descending order are found in; liver, kidneys, heart,
and skeletal muscle
-shows less marked elevation in MI than SGOT but is more elevated in
cases of liver necrosis
ELEVATED IN:
-same as SGOT, but will show very high elevation in acute(vira1)
hepatitis and hepatic necrosis
LABORATORY TESTS
372
CHAPTER 20
Sodium
-Normal
-sodium is the most abundant cation in the blood and its primary functions are; maintaining osmotic pressure, acid-base balance, and transmitting nerve impulses
usually reflects a relative excess of body water rather
than a low total body sodium
(increased levels)
-severe burns
(decreased levels)
-dehydration
dz
-excess
-Addison's dz
Uric Acid
-Normal
-uric acid is a breakdown product of purines
-uric acid levels are used most commonly to evaluate renal failure, gout,
and leukemia
(elevated)
-renal failure
- gout
-leukemia
-alcoholism
poisoning
MISCELLANEOUS TESTS
Erythrocyte Sedimentation
Sed rate)
Normal values: varies by sex, age, and method

-the test measures the rate at which
settle out of unclotted blood
-nonspecific test to follow the progression of disease
Rate increases with infections, inflammation, and malignancy
C-reactive protein
Normal value:
-similar to ESR in that it is a nonspecific indicator of inflammation and
tissue trauma
-this protein is virtually absent in healthy persons
-may be more valuable than ESR because it becomes elevated
hrs after tissue trauma) and returns to normal sooner once
the inflammatory process stops
LABORATORY TESTS
373
CHAPTER 20
2-hour Postprandial Blood Sugar(2-hr PPBS)

-Normal values: <120mg/dl
-this is a blood test taken 2 hours after eating a meal to screen for diabetes
-for best results eat a high carbohydrate meal
-a 2-hr PPBS greater than 200mVdl is consistent with a diagnosis with diabetes
Glucose Tolerance Test-Oral(0GTT)

-Normal values:
Time:
glucose level(mg/dL):
-Fasting
-65-110
-0.5hrs
-<I60
-1hr
-<I70
-2hrs
-<I25
-3hrs
-Fasting level
-the patient is given a very sweet commercially available 1009 bottle of
glucose to drink and blood is drawn just before(fasting), and at 0.5hrs,
1hr, 2hrs, and 3hrs after drinking. The test can be extended up to 6hrs
-indicated when there is sugar in the urine or when the FBS or 2hrPPBS is more than slightly elevated
-blood sugar levels for this test should peak around 0.5-1hr and return to
normal at 3hrs
Glycosylated Hemoglobin(HbA1c, Alc)

-normal (nondiabetic) value: 4.0%-7.0%
-index of long term glucose control
-reflects the average blood sugar level for the 2- to 3- month period
before the test
-better method of monitoring a patient's diabetic control, blood sugar levels alone are subject to instantaneous fluctuation
LDH lsoenzymes
-LDH can be fractioned into five isoenzymes by electrophoresis
-various diseases reveal abnormal patterns of isoenzymes
ISOENZYME
SIGNIFICANCE
LDH-1
MI*
LDH-2
I
LDH -3
Pulmonary ~nfarctLDH-4
Liver dz
W
5
L
*there is usually a prevalence of LDH-2 over LDH-1 however, after an
MI there is an LDH "flip" and LDH-1 predominates
LABORATORY TESTS
374
CHAPTER 20
immunoabsorbent assay)
Normal value: negative, nonreactive
-used to test for HIV
Disease Research Laboratory)
-test for syphilis
Plasma Reagin)
-test for syphilis
Antibody)
-Normal value.
-used to detect connective tissue dz
are present in some apparent normal individuals
CONDITION
% TESTING
Lupus
POSITIVE
99
Anti-ds-DNA Antibody Test

-used to test for Systemic Lupus Erythematosus
RA
Factor)
-absence of RA factor does not exclude the diagnosis of Rheumatoid

arthritis
POSITIVE IN:
-Rheumatoid arthritis
-Systemic Lupus Erythematosus
-Scleroderma
-Dermatomyositis
-Sjogrens syndrome
-Syphilis
-Sarcoidosis
-Liver dz
LABORATORY TESTS
375
CHAPTER 20
HLA-B27
-normals are not applicable. Requires clinical correlation.
-human leukocyte antigens (HLA) are a major histocompatibility antigen
found on all nucleated cells and play a major role in histocompatibility
between a donors and recipients for organ transplants.
-HLAs are also used as part of a complete diagnosis for certain rheumatoid diseases, seronegative spondyloarthropathies in particular.
ankylosing spondylitis
Reiter's dz.
psoriatic arthritis
ulcerative colitis
regional enteritis
-lOoh of normal individual test false positive, HLA-B27 testing is best
used as an adjunct to diagnosis and should not be regarded as diagnostic by itself.
LABORATORY TESTS
376
CHAPTER 20
PRE/PERI/POST-OPERATIVE
377
CHAPTER 21
CHAPTER 21
PRE-/PERI-/POST-OPERATIVE
PREOPERATIVE MANAGEMENT, p378

PERIOPERATIVE MANAGEMENT, p380
POST-OP MANAGEMENTICOMPLICATIONS, p383
378
CHAPTER 21
PREOPERATIVE
-pre-op lab work varies according to hospital protocol but may include:
SMA 6, CBC, UA, PT/PTT, EKG, Preg test, and CXR
-stop ASA and smoking 1 week prior to surgery
-NPO after midnight, or a minimum of 6 hours prior to surgery.
Children(more prone to dehydration) may have clear liquids up to 4
hours before surgery
American Societv of Anesthesioloaists Suraical Risk

Classification
CLASS
I
II
III
IV
V
IV
DESCRIPTION
Healthy patient
Patient with mild systemic disease(i.e. essential HTN, NIDDM)
Patient with severe systemic disease that limits activity
(i.e. angina, COPD)
Patient with incapacitating systemic disease that is a constant
threat to life
Moribund patient not expected to survive 24 hours with or
without surgery
Patient declared legally brain dead and awaiting organ
harvesting
w h e n to cancel elective suraerv
(general guidelines)
TEST
CANCEL ELECTIVE SURGERY
Hemoglobin
Hematocrit
10 gm/dl or less
30% or less
values < 2400/mm3 or > 16,000/mm3
1000/mm or less
less than 50,000 to 100,000 cells/mm3
WBC
Neutropenia
Platelets
Potassium
Glucose
BUN
Creatinine
gjreatine
lnase
3 meq/l or less(important cardiac electrolyte)

200 or more(may adjust with sliding scale)
50 or greater(R/0 renal insufficiency)
3.0 or greater (R/O renal insufficiency)
Increased levels may indicate a threat of
developing mal~gnanthypertherm~a
379
CHAPTER 21
UA
-used to RIO infection, renal dz(proteinurea), and diabetes
Coaaulation Studies
-important if patient is on Coumadin
EKG
-recommended for patients over 40 years
-useful for identifying recent Mi's, frequent premature ventricular
contractures(PVC's)
-a poor indicator of ischemic heart disease
CXR
-recommended for all patients over 60 years of age or patients over 40
with a positive hx of lung or heart dz and smokers
Antibiotic Prophylaxis
-given prior to surgeries that are higher risk for infection: surgery on dirty
wounds, patient's with preexisting valvular heart Dz,surgery longer than
2 hours, blood transfusion, pre-existing infection, or inplants
-1V Abx should be given about 30 minutes before the cuff is inflated
CEFAZOLIN(Ancef) a first generation cephalosporin
-used for prophylaxis against wound infections during surgery
-Ancef is a popular choice because it provides good coverage
against Staphylococcus aureus and Streptococcus, both of which
are likely pathogens of infection whenever the skin is broken. This
drug also has an appropriately long half-life
-dosage 1g IV pre-op
VANCOMYCIN
-used for prophylaxis against wound infections during surgery in
Pen. allergic patients
-best choice for implant surgery because it covers Staphylococcus
epidermis which is a common pathogen in implant Sx
-dosage l g IV(note because this drug must be administered slowly
to prevent Red Man's Syndrome it should be administered sooner
than 30 minutes prior to Sx)
380
CHAPTER 21
AMOXlClLLlN
-used for prophylaxis against bacterial endocarditis
-dosage 39 PO before and 1.5g PO 6 hours after the procedure or
2g IV 30 minutes before and l g IV 6 hours after the procedure
ERYTHROMYCIN
-used for prophylaxis against bacterial endocarditis in Pen allergic patients
-dose depends on the preparation
CLlNDAMYClN
-used for prophylaxis against bacterial endocarditis in Pen allergic patients
-dosage 300mg PO before and 150mg PO 6 hrs after the
procedure or 300mg IV 30 minutes before and 150mg IV 6 hrs after
the procedure
Preanancv Test
-all female patients of childbearing age
-all elective surgery should be postponed on pregnant women
Pituitarv-Adrenal Suppresion
-patients on 7.5 mg of corticosteroids a day or more should be tested for
endogenous cortisol suppression
-low plasma concentrations of cortisol and ACTH indicate suppression
-even if exogenous corticosteroids are D/Ced the pituitary-adrenal
negative feedback can take up to a year to recover
-Adrenal-Pituitary axis suppression leaves patients unable to produce
extra steroids in response to the stress of surgery
-patients on steroids often require increased dosing peri- and post-operatively
-steroids delay the wound healing process. This may be counteracted
with the use of topical Vitamin A. Usual dose is 1,000U applied TID to
the open wound bed for 7-10 days.
-plasma cortisol and ACTH levels will be decreased in patients with
Pituitary-Adrenal Suppresion
TOURNIQUET
-inflate tourniquet 100-120mm Hg above systolic blood pressure
-maximum tourniquet pressure for the ankle is 250mm Hg and 500mm
Hg for the thigh
-tourniquet must be deflated after 2 hours for at least 15-20 minutes
before reinflating
381
CHAPTER 21
DIABETIC
-given early morning surgical preference
-hyperglycemia(>200mgldL) impairs wound healing but hypoglycemia
causes organic brain damage and death. Therefore, hypoglycemia is a
more hazardous condition than hyperglycemia "better sweet than sour"
-there is no standarized protocol for diabetic glucose control during the
day of surgery while the patient is NPO but a few general guide lines
are:
GLUCOSE CONTROL THE DAY OF SURGERY WHILE PATIENT IS NPO
1. plasma glucose levels should be maintained between 150-250mgldL
2. if surgery is delayed or patient expected to be NPO for many hours
start IV D5W to avoid hypoglycemia and check glucose q2-3h
3. for NlDDM patients they should not take their diabetic medication
the day of surgery if they are NPO
4. have IDDM patients check their sugar the morning of surgery before
they arive at the hospital and if it is very high(>300mg/dL) have
them take half their normal morning dose and check again once
they reach the hospital
5. once the patient has reached the hospital elevated glucose levels
can be controlled with a sliding scale
6. exact values for insulin sliding scales vary depending on the doctor
or hospital
INSULIN SLIDING SCALE
el 50
0 units
151 -200
2 units
4 units
201-250
251-300
6 units
301-350
8 units
10 units
351-400
>400
12 units
PATIENTS ON ANTICOAGULANTS
-when possible discontinue anticoagulants 3-6 days prior to surgery and
resume 24 hours post-op
-If anticoagulants can not be discontinued, stop Coumadin 3 days prior
to surgery and start on heparin drip and stop that 2-4 hours prior to surgery
RHEUMATOID PATIENT
-do cervical spine x-ray pre-op(predisposed to atlaslaxis dislocation)
-more prone to infection due to immunosuppressive medications
382
CHAPTER 21
SICKLE CELL PATIENTS(a.k.a. Hemoglobin S disease)

A mutation in the p-chain gene that results in a change in amino acid
number 6 from glutamic acid to valine. On deoxygenation, hemoglobin
S becomes relatively insoluble and aggregates into long strands or
fibers giving the RBC its distinctive "sickle" shape. This sickle cell can
no longer deform in shape to fit through the small capillaries and they
clog the small blood vessels and result in ischemia. In addition to
ischemia there is an anemia problem from the spleen destroying all the
abnormal RBCs which results in splenomegaly. Found almost exclusively in blacks. Hemoglobin SC is the heterozygous condition in which
usually the patient has fewer symptoms.
DIAGNOSIS
Hemoglobin electrophoresis shows the presence of hemoglobin S.
Peripheral smear will show the characteristic sickle cells
SIGNSISYMPTOMS
-long bone pain(e.g. pretibial) and hand and foot pain
-arthritis with fever
-avascular necrosis of the femoral head
-chronic punched out lesions around the ankles
-abdominal pain with vomiting
ASSOCIATED CRISES
aplastic crisis-During acute infections(especially viral) production of
marrow RBCs slows
painful crises-Episodes of severe abdominal pain with vomiting that are
usually associated with back and joint pain
SURGICAL CONSIDERATIONS
-a high index of suspicion should be maintained for sepsis postoperatively
-Salmonella is the most common organism isolated from sickle cell
patients with osteomyelitis
-these patients are prone to hypoxia due to the decreased oxygen carrying capacity of the hemoglobin
-local anesthesia is preferred to prevent hypoxia
-due to the threat of hypoxia, avoid using a tourniquet if possible
-increased post-op complications
-with general anesthesia extra precaution must be taken to avoid
volume depletion and hypoxia
383
CHAPTER 21
CARDIAC PATIENTS
Top factors that lead to post-op cardiac complications
-manifested by S3 gallop or jugular venous distention
1) CHF
2) Rhythm
-PAC's, or greater than 5 PVC'sImin
3) age
-over 70 years
4) Coronary dz -MI within past 6 months
-elective surgery should be postponed until at least 6 months after an MI
-endocarditis prophylaxis should be given for patients with
-valvular heart dz
-rheumatic murmur
-prosthetic valves
-best prophylaxis is IV PCN or 1st generation cephalosporin(Ancef). If
PCN allergic, Clindamycin 300mg pre-op and 150mg post-op
-HTN(diastolic pressure of = 110) increases the chances of intraoperative and postoperative MI or stroke
-patients on diuretics-check K+
-most heart medications should be continued up to and through the day
of surgery
POST-OP MANAGEMENTICOMPLICATIONS
FEVER
Intraouerative
-transfusion reaction
-malignant hyperthermia
-pre-existing sepsis
Post-OD
0-6 hours
-pain
-rebound from cold operating room
-anesthesia reaction
-endocrine cause(thyroid crisis, adrenal insufficiency)
24-48 hours
-atelectasis
-aspiration pneumonia(after general)
-dehydration
-constipation
72 hours or greater
-infection(3-7 days)
-DVT
-thrombophlebitis from IV
-UTl(especially if catheterized)
-drug allergy
384
CHAPTER 21
Five "W"s
(mnemonic for remembering cause of post-op fever)
Wind-atelectasis, aspiration pneumonia, PE

Wound-infection, thrombophlebitis(lV site), pain
m - U T I , dehydration, constipation
Wal king-DVT
Wonder druas- virtually any drug can cause fever(pt appears less ill
than fever suggests)
ISCHEMIC TOE CONDITIONS

White toe(arteria1 problem)
-place foot in dependent position
-loosen bandages
-twist the K-wire
-apply heat to small of back
-PT block
-remove K-wire
-remove dressing, consider opening wound
Blue
Toe(venous problems)
-elevate foot
-loosen bandage
-twist K-wire
-remove K-wire
-remove dressing, consider opening wound
DVT
Surgical patients have additional risk factors for DVT's
-bed rest
-tourniquet
-surgical trauma
-infection
-dehydration(due to NPO status)
-change in medication(ie d/c ASA)
Post-Op Infection
Occurs 3-7 davs post-o~(GroupA Strep may occur earlier)
symptoms
-increased throbbing pain
-edema
-drainage
-dehydration
-erythema
-fever
-if systemic symptoms are present(fever/chills) consider admitting to
hospital
385
CHAPTER 21
Factors increasina the chances of a suraical infection

-surgery longer than 2 hours
-blood transfusion
-pre-existing infection
-implants
Pain
-post-op pain unresponsive to narcotic analgesics usually indicates one
of 3 things: infection, hematoma, or dressing pressure
severe pain within 48 hours post-op
-sutures too tight
-dressing too tight
-hematoma
-edema(foot in dependent position)
-vasospasm(from K-wire)
-compartment syndrome
Hematoma
-collection of blood within a closed tissue space
-can lead to infection
-may result in long term swelling and disability
-intense pain and inflammation can often mimic an infection but it
occurs sooner than one would expect an infection to occur(within the
1st 24hrs after surgery)
ETIOLOGY
caused by any process whereby fluid(blood) is allowed to pool in a
tissue space
-traumid surgical disection
-poor hemostasis
-creating a dead space(use a drain)
-exposed cancellous bone
-anticoagulants
-hypertension
-improper bandaging
FATE OF AN UNTREATED H E M A T W
1) a hematoma that has walled itself off from surounding tissue from
pressure will ultimately clot and undergo fibroplasia into a dense
scar
2) a hematoma that is more diffusely located within the tissue will
tend to resorb itself
386
CHAPTER 21
TREATMENT
EARLY(before all the hematoma has clotted)
Extravasation-pop a stitch or two and squeeze out the fluid
Aspiration-aspirate the hematoma using a large-bore needle(20
gauge)
Steroid injection-decrease inflammation, pain, and interfere with
fibroplasia and clotting
Wound re-entry-the patient is taken back to the OR and the wound is
reopened, drained, irrigated, ligate bleeders, and insert a drain
LATE
Gentle heat-in an attempt to accelerate enzymatic degredation of the
hernatorna
Physical therapy-exercise, ROM, massage, and ultrasound. All serve
to break up the hematoma and encourage resorption
INSTRUMENTS
387
CHAPTER 22
INSTRUMENTS
BLADES,
INSTRUMENTS,
CHAPTER 22
INSTRUMENTS
388
Bard Parker Blade Handle

(for blades 9-15 , 17)
Blade Handle
(for blades 20-25)
CHAPTER 22
INSTRUMENTS
389
Beaver Handle
CHAPTER 22
INSTRUMENTS
390
CHAPTER 22
INSTRUMENTS
391
CHAPTER 22
Dressing Forceps, Tissue Forceps,

Atraumatic Forceps One-Two's
Brun (Spratt)
Curette
Volkmann
Curette
Brown
Forceps
Nail Curette
INSTRUMENTS
392
CHAPTER 22
Mosquito,
Hemostat
Kelly Forceps
Clamps
Ochsner,
Kocker
Needle holder
INSTRUMENTS
393
CHAPTER 22
INSTRUMENTS
Metzenbaum
Scissors
Suture Removal
Scissors
394
CHAPTER 22
Mayo Scissors
INSTRUMENTS
395
CHAPTER 22
Osteotome
Key Elevator
Trephine
Spatula & Packer
INSTRUMENTS
396
CHAPTER 22
Bone Rasp
SUTURE
397
CHAPTER 23
CHAPTER 23
SUTURE
ABSORBABLE SUTURE TENSILE STRENGTH&ABSORBABLETIME,
HAND TIES,
KNOTS,
NEEDLE SHAPE,
POCKET LABEL INFORMATION,
TYPES OF SUTURE. P399
SUTURE
398
CHAPTER 23
NEEDLESHAPE
I
Keith
needle)
POINT CONFIGURATION
Reverse
Conventional
-skin
-skin
Cutting
Taper Cuttinq
-calcified tissue
3"
er Point
(noncutting)
-subcutaneous tissue
Blunt Point
tissue
SUTURE
399
CHAPTER 23
SUTURE
NONABSORBABLE-NATURAL
SYNTHETIC
NONABSORBABLE
BRAIDED
Silk- SOFSILK(USSC)
SURGICAL SILK(USSC)
PERMA-HAND(Ethicon)
MONOFILAMENT
STEEL(Ethicon)
BRAIDEDABSORBABLE
MONOFILAMENT
Polyester fiber- TEVDEK II(Davis&Geck) Polypropylene'COTTONY' I I DACRON

(Deknatel)
TI-CRON Davis&Geck)
Stainless steelMERSILENE(Ethicon)
SURGIDAC(USSC)
DACRON(Ethicon)
GortexETHIBOND(Ethicon)
NylonNylon- SURGILON(Davis&Geck)
BRALON(USSC)
NUROLON(Ethicon)
ABSORBABLE
SURGIPRO(USSC)
PROLENE(Ethicon)
SURGILENE(Davis&Geck)
STEEL(USSC)
FLEXON(Davis&Geck)
SURGICAL STEEL(Ethicon)
GORE-TEX(Gore)
DERMALON(Davis&Geck)
MONOSOF(USSC)
ETHILON(Ethicon)
Polybutester- NOVAFIL(Davis&Geck)
Polyethylene- DERMALENE(Davis&Geck)
Polyester fiber- SURGIDAC(USSC)
MERSILENE(Ethicon)
MONOFILAMENT
Polydioxanone- PDS II(Ethicon)

Polyglyconate- MAXON(USSC)
Poliglecaprone 25- MONOCRYL(Ethicon)
Glycomer 631- BIOSYN(USSC)
MONOFILAMENT
Chromic gut- SURGIGUT(Ethicon)

Plain gut- SURGIGUT(Ethicon)
BRAIDED
Polyglactin 910- VICRYL(Ethicon)

POLYSORB(USSC)
DEXON''S'', DEXON PLUS, DEXON II(Davis&Geck)
PANACRYL(Ethicon)
?,
SUTURE
400
CHAPTER 23
PACKET LABEL INFORMATION

Length of material
Product number
Guaranteed sterility
Meets standard established
by U.S. Pharmacopeia
Needle description
Absorbed by body
Generic name
Manufacturer's needlc
Suture construction(braided,
monofilament, twisted)
Davis + Geck Inc.

anati. P.R. W701 U.S.A.
Length of needle
Name of Manufacturer
Needle count
\'
Needle cutting pattern
Silhouette of needle
SUTURE
401
CHAPTER 23
ABSORBABLE SUTURE: TENSILE

STRENGTH AND ABSORPTION TIME
SUTURE
GUT
CHROMIC GUT
MONOCRYL
MAXON
BIOSYN
VICRYL
POLYSORB
DEXON ll
PDS I I
PANACRYL
50% TENSILE
STRENGTH
7-1Odays
21 -28days
2wks
3wks
3wks
3wks
3wks
3wks
4wks
4months
COMPLETELY
ABSORBED
70days
9Odays
90-1 20days
90-120days
90-110days
56-70days
56-70days
56-70days
180-21 0days
1-1.5yrs
SUTURE SIZES
Suture is sized by diameter stated as a number of zero's. The more
zero's the smaller the suture(i.e. 5-0 suture is smaller than 2-0 suture)
SUTURE "TRACKS"
may result from sutures being too tight or from sutures being left in too
long
GUT vs. CHROMIC GUT
Chromic gut is soaked in chromium salts which causes it to be resistant
to breakdown and less irritating to tissue
POP-OFF, CONTROL RELEASE, and D'TACH
all terms used to describe needle-suture combinations. The needle is
released with a straight tug of the needle holder without cutting the
suture.
SWAGGED
A term to describe the technique a suture strand is mounted on a needle. The suture is inserted into the hollowed out proximal end of the
needle and then closed or "swagged" around the suture.
SUTURE
402
KNOTS
Vertical mattress
-far-far, near-near
-used for difficult to approximate
skin edges
-everts tissue well
Horizontal
mattress
-good for everting skin edges
Subcutaneous stitch
-a stitch, usually running, placed
in the dermis
-often used in conjunction with
steri-strips for a more pleasing scar
CHAPTER 23
SUTURE
403
CHAPTER 23
Purse string Suture

-often used to interpose soft tissue between two bones (i.e. Keller)
Retention stitch
-far-near, near-far
Buried knot
SUTURE
404
Two Hand Tie

-may be used to tie off small vessels
CHAPTER 23
SUTURE
405
CHAPTER 23
SUTURE
406
CHAPTER 23
FIXATION
407
CHAPTER 24
FIXATION
ABSORBABLES, p411
BONE PLATES, p412
EXTERNAL FIXATORS, p418
PINS, p410
SCREWS, p408
STAPLES, 412
SUTURE ANCHORS, p413
WIRES, p410
CHAPTER 24
FIXATION
408
CHAPTER 24
SCREWS
HEAD
Hexagonal allows for the most
efficient translation of torque
and reduce CAM-OUT (lifting
out of the screw driver from the
screw head)
LAND
Undersurface of the head of the

screw which comes in contact
with bone
SHANK
Only present in
cancellous screws
RUN OUT
weakest point In screw
RAKE ANGLE
Thread to
angle
2.7 millimeter thread diameter)
INSTRUMENT SIZES FOR RESPECTIVE SCREWS

Screw
(mm)
Thread hole
(mm)
Glide hole
(mm)
tap
Surgical
(mm) set
1.5 Cortical
2.0 Cortical
2.7 Cortical
3.5 Cortical
4 0 Cancellous
1.1
1.5
2.0
2.5
2 0 or 2 5
1.5
2.0
27
3.5
none
15
2.0
2.7
35
35
2
3.2
3.2
4.5
none
none
4.5
-partially threaded
-full threaded
4.5 Cortical
4.5 Malleolar
6.5 Cancellous
(4.0 in hard bone)
45
6.5
M i nfrag
i
Small frag
Standard frag
FIXATION
409
CHAPTER 24
LAG TECHNIQUE
-allows compression across a fracture or osteotomy site
Example-inserting a 2.7mm cortical bone screw
1) drill thread hole(2.0 mm drill bit)-near and far cortex
2) drill glide hole(2.7 mm drill bit)-near cortex
3) counter sink
4) measure
5 ) tap(2.7 mm tap)
6) flush
7) insert 2.7mm screw(2 fingers tightness)
COMPRESSIVE SCREWS
Reese Arthrodesis Screw
-Reese: Peoria, AZ (602) 933-137
-headless screw
-right handed threads at its
leading edge and left handed threads at it's trailing end
-this screw is no longer manufactured
Acutrak Plus
-Acumed: Beaverton. OR (888) 627-9957
-headless, fully threaded screw
with a decreasing pitch from
head to tail for comoression
-cannulated self tappingwith cutting flutes at both proximal and distal end
Bold Screw
-Newdeal(Wright Medical)Arlington, TN (800) 238-7188
-headless screw, cannulated
-double threaded for
greater purchase
Herbert Screw
-Zimmer: Warsaw, IN (800) 613-6131
-headless screw
-threaded at both ends-trailing
pitch is greater than leading
threads for compression
-traditionally these screws are not cannulated, however there is now a
larger 4.5mm and 6.5mm that are cannulated
HerberWhipple Screw
-Zimrner: Warsaw, IN (800) 613-61 31
-these screws are very similar to the
Herbert screw but are cannulated
FIXATION
410
CHAPTER 24
PINS
Trochar
Diamond
Kirschner wires(K-wires)
-sizes(inches) 0.028, 0.035, 0.045, 0.062
-smooth/threaded
Steinmann pin
-larger than K-wires(usually used for rearfoot)
-sizes(inches) 5/64, 3/32, 7/64, 1/8, 9/64, 5/32, 3/16
-smooth/threaded
Snap fixation pin

Sgarlato Labs: Los Gates, CA, (800) 421-5303
-size ,062
-partially threaded pin
-bury all threaded portion of the pin and break "snap" off the remaining
portion
WIRES
Cerclage wire(monofilament wire)
-sizes, for podiatric forefoot cases usually
26gr 28 gauge is used
-wire passing technique
Tension band fixation

-used when there is eccentric distraction of a
fracture or osteotomy site due to muscle or
ligamentous pull
-tension banding converts distractive forces
into compressive forces
-the cerclage wire placed on the tension side
of an osteotomy/fracture will prevent
distraction on that side while also causing a
corresponding compression on the opposite side
-common lower extremity uses include; patellar,
malleolar, and styloid process fractures
FIXATION
411
CHAPTER 24
Tension Band System

-Acumed: Beverton, OR (800) 627-9957
-incorporated an eye hole into the pin for cerclage wire passage
-the tail end of the wire is broken off after insertion
ABSORBABLE MATERIALS
-nonradiopaque so their placement is difficult to evaluate by
postoperative radiographs
-tend to splinter if cut with wire or bone cutters, use oscillating saw, bovi,
or scalpel
PGA(polyglycolic acid)
-absorbed quickly(strength loss 4 weeks, mass loss 6-12 months)
-can be reactive, especially in older patients
-more suitable for use in children
PLLA(poly-L-lactic acid)
-absorbed slowly(stength for months, mass present for several years)
-less reactive than PGA
-more suitable for use in adults
Poly-p-dioxanone
-made of the same meterial as PDS suture
-significant strength loss over 3-6 weeks, mass loss over 6-12 months
ABSORBABLE SCREWS
Endo-Fix Interference Screw
-Dyonics: Andover, MA (800) 343-8386
-conical, headless, cannulated screw
-made of 213 polyglycolic acid(PGA) and 113 trimethylcarbonate
-completely absorbed in 1 year
Reunite
-Biomet: Warsaw, IN (800) 348-9500
-made of Lactosorb 82% PLLA and 18% PGA
-unique 'twist-off' hex. drive mechanism
-3.5 mm and diameter and larger, screws available cannulated
Smart Screw(Biofix Screw)

-Bionx: Blue Bell, PA (800) 259-2580
-available in either: Self reinforced poly-L-lactic acid(SR-PLLA)
Self reinforced polyglycolic acid(SR-PGA)-discontinued
FIXATION
412
CHAPTER 24
ABSORBABLE PINS
Orthosorb
-Johnson and Johnson: Raynham, MA (800) 526-2459
-made of poly-p-dioxanone
-Sizes: 1.3, 1.3 tapered, and 2.0 mm diameters
Reunite
-made of LactoSorb 82% PLLA and 1 8 %PGA
-Sizes: 1.5, 2.0, 2.4, and 3.2 mm diameters
Biofix
-Bionx: Blue Bell, PA (800) 259-2580
-available in either: Self reinforced poly-L-lactic acid(SR-PLLA)
Self reinforced polyglycolic acid(SR-PGA)
-Sizes: 1.1, 1.5, 2.0, 3.2, and 4.5 mrn diameters
BONE PLATES
Dynamic Compressive Plate
-allows compression across a fx/osteotomy site as screws are tightened
due to plate screw hole shape
Neutralization Plate
-allows stress to be transmitted through the plate so as to avoid the
fx/osteotomy site
Buttressing Plate
-used to maintain separation of bone to protect a bone graft from being
crushed
Tension-Band Plate
-as with tension-band wiring it takes advantage of asymmetrical
biomechanical forces across a fx/osteotomy site
-the plate is placed on the tension side of a fx/osteotomy will prevent
distraction on that side, while causing a corresponding compression on
the other side
STAPLES
-frequently used for fixation of the large cancellous bones of the midfoot
and rearfoot
-staples come on a variety of sizes and shapes
-staples may be inserted manually with a staple driver and mallet or with
a staple gun called the Staplizer[Orthopedic Products DivisionIBM St.
Paul, MN (800) 992-9999]
-0SStaple-The dorsal side of the staple is warmed with the Warmsystem
electrode causing the prongs of the staple to compress the osteotomy
site-BioMedical Enterprises, San Antonio TX (800) 880-6528
FIXATION
413
CHAPTER 24
SUTURE ANCHORS
Harpoon Anchor
Arthrotek
Warsaw, IN (800) 348-9500
-no pre-drilling required
-the anchor is tapped through the
cortex with a mallet
Mitek
Mitek
Westwood, MA (800) 382-4682
-requires pre-drilling
Mitek Anchor
Mitek SuperAnchor
-4 prongs
Mitek Panalok Anchor
Mitek Panalok RC
-absorbable(polylactic acid)
-absorbable(polylactic acid)
FIXATION
414
CHAPTER 24
Ogden Anchor
Orthofix
Richardson, TX (800) 527-0404
-requires pre-drilling, self tapping
-multiple suture strands can be
attached to a single anchor
Anchorlok
Wright Medical
Arlington, TN
(800) 238-7188
-no tapping required
-no pre-drilling required
Statak
Zimmer
Statak Anchor
-self drilling and self tapping
Bio-Statak Anchor
-resorbable(L-lactic acid)
-requires pre-drilling and
tapping
FIXATION
415
CHAPTER 24
Acumed Suture Anchor

Acumed
Beverton, OR (888) 627-9957
-self drilling and self tapping
I_-
OBL Anchor
(Orthopaedic Biosystems Ltd ,
I n c Scottsdale, AZ (800) 487-9128
-double h e l l ~hi-lo threads
-preloaded with 2 sutures
-self drllling and self tapping
ROC EZ
-Innovasive Devices
Marlborough, MA (800) 435-6001
-after insertion the distal portion
of the anchor is pulled proximally
into the proximal portion which
then expands
-BioROC EZ also available,
made of PLA
requires predrilling
$,-
FIXATION
416
ROC XS
-Innovasive Devices
Marlborough, MA (800) 435-6001
-requires pre-drilling
Corkscrew
-Arthrex Inc. (800) 934-4404
-BioCorkscrew also available, made of PLDLA
-no predrilling, and no tap required
FASTak
-Arthrex Inc. (800) 934-4404
BioFASTak also available, made of PLDLA
-no predrilling, and no tap required
CHAPTER 24
FIXATION
417
CHAPTER 24
HAMMERTOE ARTHRODESIS IMPLANTS

Stayfuse Implant
-drill proximal and intermediate phalanx screw in each component
and snap together
-Pioneer(Zimmer): Warsaw, IN (800) 348-2759
Weil-Carver Hammertoe Implant

-Absorbable(82% L-Lactic acid, 18% Glycolic acid)
-drill and tap proximal phalanx and screw in threaded half of implant,
drill distal phalanx and press fit the barbed portion of the implant
FIXATION
418
CHAPTER 24
EXTERNAL FIXATORS
Acumed Small Bone Fixator
-Acumed: Beaverton, OR (888) 627-9957
-utilizes standard K-wires(0.035-0.078) which eliminates the need for
predrilling and installing custom pins
Pennig Minifixator and Minirale

-0rthofix: Richardson, TX (800) 445-1923
-available with compression-distraction capabilities
Synthes Fixator
-Synthes: Paoli, PA (800) 523-0322
EBI Minifixator
-EBI: (800) 222-3244
llizarov
A technique to heal nonunions involving an external fixation device.
Through variations of this technique the bone can also be elongated by
as much as I mm/day through slow distraction.
IMPLANTS
419
CHAPTER 25
CHAPTER 25
IMPLANTS
FIRST METATARSOPHALANGEALJOINT IMPLANTS, p424
Hemi-Implants, p420
Swanson Hemi-Implants, p420
BioPro Hemi Implant, p420
Metal Hemi-Toe Implant, p420
LPT Great Toe Implant, p421
K2 Hemi Implant, p421
Total One Piece Hinged Implant, p421
Swanson Flexible Toe Implant, p421
La Porta Implant, p422
Lawrence Total Implant, p422
Primus, p423
GAIT, p423
Two Component Implants, p423
Total Toe System(Koenig), p423
Bio-Action Great Toe Implant, p424
Acumed Great Toe System, p424
The Kinetik Great Toe Implant, p424
Reflexion Toe Implant, p425
LESSER METATARSOPHALANGEALIMPLANTS, p425
Swanson Double Stemmed Hinged Implant, p425
Lesser Toe MetatarsophalangealJoint Implant(SgarlatoDesign),p425
DIGITAL IMPLANTS(PIPJ's), p425
Swanson Flexible Toe Implant, p425
Weil Type Swanson Design Hammertoe Implant, p426
Sgarlato Design Hammertoe Implant, p426
SHIP. p426
SHIP-ShawRodHammertoe Implant, p426
Flexible Digital Implants(FDI), p426
InterPhlex Implant, p427
IMPLANTS
420
CHAPTER 25
IMPLANTS
-the primary pathogen in infected implant surgery is Staphylococcus epidermis
-patients undergoing implant surgery should be prophylaxed with
Vancomycin
A) First Metatarsophalangeal Joint Implants
1) Hemi-Implants
-Used to replace the base of the proximal phalanx
-Necessitates adequate articular surface of 1st metatarsal head
-Concave surface for articulation with head of 1st metatarsal
Contraindicated by uncontrollable pronation
Swanson Titanium Hemi-lmplants

-Titanium
-5 sizes
-Rectangular stem
-Interchangeable right and left foot
-previously available in silicone
-Wright Medical: Arlington,
TN (800) 238-7188
BioPro Hemi Implant

-Cobalt Chromium
-3 sizes
-diamond shaped stem
-thinner articular head which
requires less bone resection
-interchangeable right and left
-BioPro: Port Huron, MI (800) 252-7707
M e t a l Hemi-Toe Implant
-cobalt chrom with a titanium plasma
sprayed stem
-15" angle between the articular surface
and the stem in the sagittal plane to
accommodate for the metatarsal declination
angle
-stem becomes thicker going from the tip
towards the base to better conform to the
shape of the medullary canal of the proximal phalanx
-implant are interchangeable between right and left foot
-Futura: San Diego, CA (800) 835-8480
IMPLANTS
421
CHAPTER 25
LPT Great Toe Implant(low

-Titanium
-Cruciate stem
-2 perforating holes to secure
-Angles version has a third hole,
placed medially to prevent lateral
subluxation
-Available in regular and angled to accommodate an increased
PASA(size 1 18", slze 2 16'
-Wright Medical: Arlington, TN (800) 238-7188
K2 Hemi Implant
-Cobalt chrome with titanium
plasma coated stem
-4 sizes
-Perforating hole plantarly to
secure FHL to the base of the phalanx
and implant preventing a hallux hammertoe
-Kineticos: San Diego, CA (800) 546-3845
2) Total One Piece Hinged Implant
Swanson Flexible Toe Implant

-Silicone
-Eight sizes
-Proximal stem is longer
-Stem sizes(standard and small)
-Interchangeable right and left foot
-Midsection of the implantis U-shaoed.
\
opening of "U" can be directed dorsally
grommet
or plantarly
-The two stems are in the same plane
and perpendicular to the hinge
-Stems are rectangular in cross-section
-Often used with a grommet(a titanium
shield contoured to fit over the base of
the stems and designed to protect the
implant from shearing forces and sharp bone edges)
-Sizes 0-5 are available with grommets
-Wright Medical: Arlington, TN (800) 238-71 88
IMPLANTS
422
CHAPTER 25
La Porta Implant
-Silicone
-Four sizes
-The hinge is designed with a 60"
dorsiflexion available
-Broad collars on both sides of the hinge
to prevent osteophyte development
-10" angulation of the metatarsal
stem in the transverse plane to
accommodate for the natural hallux abductus position
-Also available with a 15" angulation in the sagittal plane to
accommodate for normal metatarsal declination
-Interchangeable right and left foot except the model with both
sagittal and transverse angulation
Lawrence Total Implant

-Silicone
-5 sizes
-Hinge designed with 85" ROM
available
-Stem rectangular in cross-section
-Broad collar on both sides of the
hinge to prevent osteophytic development
-Distal collar angled 30" from proximal collar in a plantar proximal to
dorsal distal direction to preserve the insertion of the flexor hallucis
brevis tendon
-Distal stem is perpendicular to proximal collar
-Proximal stem angled 15" in the sagittal plane to accommodate for
the metatarsal declination angle
-Preserves weight bearing capacity of the 1st metatarsal head
because sesamoids don't retract due to FHB preservation, therefore
contraindicated in patients with degenerative changes in the
sesamoids
IMPLANTS
423
CHAPTER 25
The Primus Flexible Great Toe Im

-Silicone
-6 sizes
-Basically the same as the
Lawrence with some minor changes
-shorter distal stem that is trapezoidal
-Hinge designed with greater ROM (95")
-available with grommets
GAIT(Great toe Arthroplasty Implant Technique)

-Silicone
-Three sizes(small, medium, large)
-U-shaped hinge, opening of "U" can be
directed dorsally or plantarly
-The two stems are in the same plane
and perpendicular to the hinge
-Proximal collar and stem are larger than distal collar and stem
-Sgarlato: Los Gatos, CA (800) 421-5303
3) Two Component Implants
-Preserve the attachment of the flexor hallucis brevis
-Maintain full weight bearing capacity of the 1st ray
Total Toe System(Koenig)

-Metatarsal component made of
titanium alloy
-Phalangeal component available
as total polyethylene or metal
backed polyethylene
-Three sizes
-Any size metatarsal component can
be used with any size
phalangeal component
-Metatarsal component extends plantarly for sesamoid articulation
-Arthrotec(a division of Biomet): Warsaw, IN (800) 348-9500
IMPLANTS
424
CHAPTER 25
Bio-Action Great Toe Implant

-Metatarsal component made
of cobalt chromium
-2 sizes(small, and large)
-Phalangeal component is made
of titanium backed polyethylene
-Phalangeal component articulates
with dorsal bone of the first metatarsal
upon maximum dorsiflexion
-The metatarsal component is available in right, left, and neutral
geometry
-The phalangeal component is available in neutral or modified
geometry
-MicroAire: Charlottesville, VA (804) 975-8000
Acumed Great Toe System

of cobalt chromium
-Phalangeal component is made
of titanium backed polyethylene
-Three metatarsal sizes, two
phalangeal sizes
-Metatarsal component has an
extended dorsal curvature for implant
articulation upon maximum dorsiflexion
-Any size phalangeal component will fit any metatarsal component
-Acumed:Beverton, OR, (888) 627-9957
The Kinetik Great Toe Implant

of cobalt chromium
-Phalangeal component made of
titanium backed polyethylene
-Notched stem for more secure fit
-Metatarsal component has flattened surface to avoid sesamoid disruption
-3 Metatarsal component sizes, 4 phalangeal component sizes
-Metatarsal stem angled 10" in the sagittal plane
-Metatarsal component has an extended dorsal curvature for implant
articulation upon maximum dorsiflexion
IMPLANTS
425
CHAPTER 25
Reflexion Toe
-Osteomed: Addison, TX (800) 456-7779
-Three piece implant-the metatarsal component is actually
composed of two pieces. The head is applied after the stem is
inserted.
-Proximal stem is angled 17"
-Phalangeal component made o
titanium backed polyethylene
of titanium with cobalt chromium head
B) Lesser Metatarsophalangeal Implants

2) One Piece Double Stemmed Implants
Swanson Double Stemmed Hinged Implant

-6 sizes
-one stem size
-smaller version
-of the Swanson 1st MPJ implant
-not available with grommets
Lesser Toe Metatarsophalangeal Joint

Implant(Sgarlato Design)
-Silicone
-Three sizes
-Proximal stem extends into
out midsection to fit over metatarsal neck
-No hinge, relies on the flexibility of the stems for motion
C) Digital Implants
-Restricted to PlPJ
-All made of silicone
Swanson Flexible Toe Implant

-6 sizes
-one stem size
-smaller version
-of the Swanson 1st MPJ implant
-not available with grommets
IMPLANTS
426
CHAPTER 25
Weil Type Swanson Design Hammertoe lmplant

-Seven sizes
-No hinge
-Cylindrical mid section
-Cylindrical stems
-2 stem sizes, 6 collar lengths,
2 collar diameters
TN (800) 238-7188
Sgarlato Design Hammertoe lmplant

-Dacron mesh impregnated through
-4 sizes
-Stems rectangular on cross-section
TN (800) 238-71 88
SHIP(Sgarlato Hammertoe Implant Prosthesis)

-3 sizes(small, medium, large)
-Stem rectangular in cross-section
-Cylindrical tapered midsection
(narrow end goes distally)
-No hinge
SHIP-ShawRod Hammertoe lmplant

-silicone
-can be used at the PlPJ or
the DIPJ
-provides a flexible stable joint
and maintains length
-available in 3 shaft sizes(2.0mm-flexible, 2.3mm-regular, 2.5mm-stiff)
Flexible Digital Implants(FD1)

-designed for the PlPJ if digits 2-5
-silicone
-proximal stem is square, distal
stem is cylindrical
-midsection of the implant is
U-shaped, opening of "U" is to be directed dorsally
IMPLANTS
427
InterPhlex
-Indicated for both MPJ's and
IPJ's of the 2nd-5th t oes
-Made of Silicone
-Cylindrical stem with a spherical spacer
-4 sizes(2 for the MPJ's, and 2 for IPJ's)
-OsteoMed (800) 456-7779
CHAPTER 25
IMPLANTS
428
CHAPTER 25
TENDONS & TENDON TRANSFERS
429
CHAPTER 26
CHAPTER 26

FIXATION OF TENDON, p431
TENDON ANATOMY, p430
TENDON LENGTHENING PROCEDURES, p433
TENDON TRANSFERS, p434
430
CHAPTER 26
TENDON ANATOMY
1. E p i t e n o n - t h e outer covering of a tendon within its sheath.
Most important structure in the tendon repair process
2. E n d o t e n o n - a loose acellular tissue carrying
blood vessels that surrounds small
bundles of collagen fibers through
out the tendon
3. P a r a t e n o n -t h e loose elastic
areolar tissue surrounding the entire
tendon which allows the tendon to
slide. It supplies the blood supply to
the tendon and should be
reapproximated after tendon
surgery. Supplies the majority
of a tendons blood supply
4. M e s o t e n o n - a delicate
connective tissue sheath
attaching a tendon to its
fibrous sheath. A part of
the paratenon that attaches the
paratenon to the epitenon
which can stretch several
centimeters and allows
a blood supply to be
transferred from the
paratenon to the
tendon. The point at
which it attaches to the epitenon is called the hilus.
5. P e r i t e n o n - a l l the connective tissues associated with a
tendon(epitenon, endotenon, paratenon, mesotenon)
6 Farcicleca group of collagen fibers bundled together and
surounded by an endotenon
7 . Collagen Fibers-Formed from a polymer of tropocollagen, which
is the basic molecular unit of a tendon
431
CHAPTER 26
FIXATION OF TENDONS
End to end anastomosis
Bunnell Stitch
Kessler Stitch
Krackow Stitch
-strongest
Trephine plug
-a round cortical plug is
removed with a trephine, the
tendon is inserted and the
plug is replaced
Three-hole suture
-the tendon IS anchored to a plece of suture,
the tendon IS then inserted In a hole In the
bone and the two suture ends exit the bone
through two addltional holes and are tied
432
CHAPTER 26
Buttress and Button Anchor

-the tendon is anchored to a piece of suture, the tendon is then inserted
in a hole in the bone and the suture ends continue through the bone and
exit the skin on the other side of the foot and is fixated with a button
Tunnel with sling

-a hole is drilled through the
entire bone, the tendon is then passed
through the bone and sutured back on itself
Tendon with bony insertion

-a portion of bone is removed with the tendon and reinserted into a preformed hole of similar size and shape
Mason-Allen Stitch
-tendon to bone technique often
used in rotator-cuff repair
Screw and washer
433
CHAPTER 26
Bone Anchor
Chinese Finger Trap(Krachow and Cohn Technique)

-used to draw a tendon through a drill hole
-two sutures are criss-crossed, out of phase, about the distal end of the
tendon
TENDON LENGTHENING PROCEDURES
Accordion type lengthening

-cuts are made no less than 51% of the way through the tendon and the
tendon ends are distracted away from one another allowing the central
fibers to slide past one another
434
CHAPTER 26
TENDON TRANSFERS
-duringtendon transposition the paratenon should be preserved to allow
blood supply
gliding of the tendon' and
-with tendon transfers the involved muscle loses 1 grade of strength
-to qualify for a tendon transfer, a muscle must be of grade 4 or higher
-CVA patients should not have tendon transfers for at least 6 months following the CVA
PHASE CONVERSION
-muscles are divided into two phases depending on their use, swing
phase or stance phase
-a muscle transferred from one phase to be used in the other phase is
said to be transferred out of phase
-it is easier to retrain a muscle transferred within the same phase
-muscles transferred out of phase often never regain their activity but
can still be beneficial by acting as a sling and eliminating the need for
bracing
STANCE PHASE MUSCLES
SWING PHASE MUSCLES
Gastrocnemius
Anterior tibialis
Soleus
EHL
FHL
EDL
Peroneus Tertius
FDL
Peroneus Longus
Peroneus Brevis
All intrinsics
TENDON HEALING AND POST-OP CARE

-after a tendon has been transferred the patient should be casted, NWB
for 4 weeks
-gentle passive ROM and/or isometric exercises inside the cast may be
started at 3 weeks to prevent adhesions
-at 4 weeks active mobilization should begin but maximum contracture
should be postponed for several more weeks
435
CHAPTER 26
TYPES OF TRANSFERS
ADDUCTOR TENDON TRANSFER
-the adductor tendon is transected at its attachment to the lateral
sesamoid and the lateral base of the proximal phalanx and rerouted
over the metatarsal head and attached to the medial capsule
-performed with hallux abductovalgus surgery to help realign the
sesamoid apparatus under the metatarsal head
FLEXOR TENDON TRANSFER

-the flexor digitorum longus tendon is transected close to its insertion on
the distal phalanx, split longitudinally to the base of the proximal phalanx
wrapped around the proximal phalanx and sutured together
-AKA: Girdlestone Procedure
436
CHAPTER 26
JONES TENOSUSPENSION
-EHL tendon is transected and rerouted medial to lateral through the
head of the 1st metatarsal and sewed back on itself. Kirk modificationpass tendon from top to bottom(dorsal to plantar), this technique
requires less tendon
-the distal stump of the EHL is then attached to the EHB to maintain
some extensor function of the hallux
-arthrodesis the 1st IPJ to prevent overpowering of the EHL and hammering
-performed for pressure problems under the 1st metatarsal head
-Indications: flexible cavus foot, flexible plantarflexed 1st ray
437
CHAPTER 26
HIBBS TENOSUSPENSION
-the EDL tendon slips are detached from their insertion combined and
reattached to the 3rd cuneiform or the base of the 3rd metatarsal
-the EDB tendon are transected and reattached to the stump of the corresponding EDL tendon, the 4th and 5th longus slips are both attached
to the 4th EDB slip
-releases the buckling force at the MPJ's and elevates the forefoot
-Indications: eauinus with or without clawtoes
438
CHAPTER 26
SPLIT TIBIALIS ANTERIOR TENDON

TRANSFER(STATT)
-tibialis anterior is split from it's insertion up just proximal to the superior
extensor retinaculum
-the lateral fibers are passed through the peroneus tertius sheath and
sutured to the tendon or attached to the cuboid
-the procedure increases dorsiflexion of the foot and balances the force laterally
-Indications: flexible rearfoot varus, excessive supination, dorsiflexoryweakness
PERONEUS LONGUS TENDON TRANSFER

-Peroneus longus is released at the level of the cuboid and transfered
through the intermuscular septum down the EDL sheath and inserted
into the lesser tarsus or base of the 3rd
metatarsal
HEYMANPROCEDURE
-transfer of all long extensor tendons to their respective metatarsal

heads
439
CHAPTER 26
TIBIALIS ANTERIOR TENDON TRANSFER(TATT)

-tibialis anterior tendon is transferred to the 3rd cuneiform through the
EDL tendon sheath
-acts to reduce supination and increase dorsiflexion
-Indications: drop foot, recurrent clubfoot, flexible forefoot equius
TIBIALIS POSTERIOR
TENDON TRANSFER
-the tibialis posterior tendon is transferred
through the interosseus membrane and
fixated to the 3rd cuneiform
-this is an out of phase tendon transfer
-Indication: drop foot, recurrent clubfoot
440
CHAPTER 26
FIRST RAY SURGERY
441
CHAPTER 27
FIRST RAY SURGERY

BUNION EVALUATION, p442
BUNIONECTOMIES, p444
CAPSULOTOMIES, p452
HALLUX LIMITUS AND HALLUX RIGIDUS, p454
HALLUX VARUS, p456
METATARSUS PRIMUS ELEVATUS, p456
CHAPTER 27
FIRST RAY SURGERY
442
CHAPTER 27
BUNION EVALUATION
Stage I
Stage II
Stage I I I
Stage IV
-Subclinlcal subluxation of the flrst metatarsal joint

-Development of clinical hallux abduction deformity
-Development of metatarsus primus adductus deformity
-Clinical subluxation/dislocationof the flrst MPJ
METATARSUS
ADDUCTUS ANGLE
-normal 15"
-less than 15" IS a rectus foot
-MTA angle at birth IS -30, at
1 year(begin walking) it's -20,
by 4 years it's at the adult
normal of -15
INTERMETATARSALANGLE
(Metatarsus Primus Adductus angle)
-normal IS 8-12' In a rectus foot
and 8-10 In an adductus foot
-an IM greater than 16 a base wedge
osteotomy IS lndicated
HALLUX ABDUCTUS ANGLE

-normal 0-1 5
FIRST RAY SURGERY
443
CHAPTER 27
PASA(Proxlmal
Artrcular Set Angle)
-normal 7.5-12
thicular Set
HALLUX ABDUCTUS
INTERPHALANGEUS ANGLE
-normal 10
TIBIAL SESAMOID POSITION

-normal 1-3
,,
FIRST RAY SURGERY
444
HEADPROCEDURES
AUSTIN
-corrects IM
-chevron osteotomy with a 60 angle
-can incorporate wedge(bicorrectional)
to correct PASA
YOUNGSWICK-modification
-shortens and plantarflexes
-indicated in metatarsus elevatus
REVERDIN
-corrects PASA
-lateral cortex remains intact
REVERDIN-GREEN
-corrects PASA
-"L-shaped" cut preserves the integrity
of the sesamoid articulation
lateral ortex remains intact
REVERDIN-LAIRD
-corrects PASA and IM
-same as Reverdin-Green with completion
of the osteotomy through the lateral
cortex to allow IM correction
CHAPTER 27
FIRST RAY SURGERY
445
REVERDIN-TODD
-corrects PASA and IM, and allows
plantarflexes metatarsal head
-same as Reverdin-Laird with penetration
of the plantar cortex to allow sagittal
plane correction
WATERMANN
-indicated in hallux limitus
-plantar cortex is left intact
GREEN-WATERMANN
-preserves the sesmoidal articulation
NECK PROCEDURES
PEABODY
-same as Reverdin except osteotomy
is made more proximal to avoid the
sesamoids
HOHMANN
-correct IM(capital fragment shifted lateraly)
-corrects PASA(medial wedge resected)
-corrects metatarsus elevatus
(capital fragment plantarflexed)
CHAPTER 27
FIRST RAY SURGERY
446
WILSON
-shortens and lateral displaces head
DRATO(Derotational Abductory
Transpositional Osteotomy)
-metatarsal head can be manipulated
at any angle in any plane
-wedge resection can be incorporated
-very unstable osteotomy
MITCHELL
-corrects IM angle
-procedure shortens metatarsal so
metatarsal head is plantarflexed to
compensate
SHAFT PROCEDURES
KALISH
-modified(long arm) Austin
SCARF
-corrects IM angle
CHAPTER 27
FIRST RAY SURGERY
447
LUDLOFF
-corrects IM angle
MAU
-corrects IM angle
LAMBRINUDI
-corrects metatarsus primus elevatus
BASE PROCEDURES
CRESCENTIC
-corrects IM angle
-may be fixated slightly dorsi- or plantarflexed
-advantage is that it does not shorten the metatarsal
CHAPTER 27
FIRST RAY SURGERY
448
CHAPTER 27
JUVARA
Juvara type A
-wedge removed, medial cortex preserved(transverse correction)
Juvara type B
-wedge removed, medial cortex not preserved
Juvara type B1
-transverse and sagittal correction
Juvara type B2
-transverse and sagittal correcton and
corrrects for long or short metatarsal
Juvara type C
-no wedge resected
Juvara type C1
-sagittal correction only
\
Juvara type C2
-sagittal correction and corrects for long or short metatarsal
LOISON-BALACESCU
LOGROSCINO
-this is a Reverdin plus a Loison-Balacescu
-corrrects IM and PASA
-an opening Logroscino may be performed by taking the wedge from the
Reverdin and inserting it into an opening abductory wedge at the base
FIRST RAY SURGERY
449
CHAPTER 27
ARTHROPLASTIES
-indicated in older patients with hallux rigidus/limitus and severe DJD
-capsular tissue is sutured across the joint space(purse string) to prevent bone contact
-usually performed with an extensor hallucis longus lengthening
STONE
-metatarsal head resection
ARTHRODESIS
LAPIDUS
-fusion of first metatarsal-cuneiform joint
-indicated for increased IM and pain
at the first metatarsal-cuneiform joint
FIRST RAY SURGERY
450
CHAPTER 27
MCKEEVER
-fusion of the first MPJ
-performed with 15-20' extension in
males and up to 40 in females
depending on type of shoes worn
-fixation techniques vary but generally involve spearing the head of the
metatarsal into the base of the proximal phalanx
Other special 1st MPJ fixation devices are available:
Truncated Cone Reamer System
-alignment instruments allow a
peg-in-hole to be fashioned at a
specific angle
-Biomet; Warsaw, IN (800) 348-9500
Congruent Great Toe Fusion Plate
-Acumed; Beaverton, OR (888)
MISCELLANEOUS
SILVER
-medial bumpectomy
CHEILECTOMY
-dorsal bumpectomy
indicated in hallux limitus
KESSELL-BONNEY
FIRST RAY SURGERY
451
CHAPTER 27
MCBRIDE
-similar to a Silver but may be performed with an adductor tendon transfer and a fibular sesamoid excision
AKIN
-proximal Akin corrects DASA
-distal Akin corrects IPJ
HISS
-same as McBride bunionectomy with dorsal transfer and advancement
of the abductor hallucis tendon was performed in an attempt to
reestablish joint medial balance
REGNAULD(Mexical-hat
-similar to a peg-in-hole procedure
COTTON
-medial cuneiform opening wedge
-medial eminence and/or autogenous
bone graft are inserted into the medial
aspect of the cuneiform
FIRST RAY SURGERY
452
CAPSULOTOMIES
MEDIAL "U"
-transverse plane correction
-good exposure of medial aspect of the 1st metatarsal head
-enables removal of redundant medial capsule
MEDIAL "H"
MEDIAL T
CHAPTER 27
FIRST RAY SURGERY
453
CHAPTER 27
INVERTED "L"
LENTICULAR
-allows both transverse and frontal plane correction
WASHINGTON MONUMENT
-allows both transverse and frontal plane correction
-strengthens the medial capsule
FIRST RAY SURGERY
454
CHAPTER 27
HALLUX LIMITUSIHALLUX RIGIDUS

-a condition where the first MPJ has a decreased ROM or absent ROM
-radiographically there is joint narrowing, flattening of the first metatarsal
head with subchondral s c l e r o s i sand
, loose bodies
Hallux limitus
-decreased ROM at the 1st MPJ
-approximately 50-60of dorsiflexion are necessary for normal
functional gait
Hallux rigidus
-absence of ROM at the 1st MPJ
-the end result of hallux limitus
CLASSIFICATION
Grade I -functorial limitus
-no DJD
-pain at end of ROM
-hyperextension of the IPJ
-ROM WNL
Grade II -joint adaptation
-pain at end of ROM
-flattening of metatarsal head
-passive ROM limited
-small dorsal exostosis and periarticualar lipping
Grade III -joint destruction/arthiritis
-continued DJD and osteophytic formation
-crepitus on ROM
-pain on full ROM
Grade IV -ankylosis
-less than 1 0 ROM
-obliteration of joint space
-loss of majority of articular cartilage
CAUSE
-metatarsus primus elevatus
-hypermobile 1st ray
-immobile 1st ray
-long I st ray
-DJD
-neoplasm
-trauma
-septic joint
-iatrogenic
-neuromuscular dz
-arthritis(RA, psoriatic, gout)
FIRST RAY SURGERY
455
CHAPTER 27
FUNCTIONAL VS. STRUCTURAL

functional hallux limitus
-hallux dorsiflexion decreases only when the forefoot is loaded
-responds well to orthotics by keeping the foot in neutral position and
allowing the hallux to dorsiflex
Structural hallux limitus
-hallux dorsiflexion decreases whether forefoot is loaded or unloaded
-orthotics do not help this condition
SIGNS/SYMPTOMS
-gradual onset pain and decreased ROM
-pain tends to be on the dorsal aspect of the 1st MPJ
-dorsal bony prominence
-plantar callus at the IPJ due to hyperextention of the IPJ
-hallux tends to be rectus with possible spastic EHL
-joint narrowing
-flattening of the 1st metarsal head with subchondral sclerosis
-osteophytic proliferation on the 1st metatarsal head and base of the
proximal phalanx
-loose bodies
-painful hallux nail
TREATMENT
CONSERVATIVE
-shoe with a stiff sole
-rocker bottom shoe
-intraarticular corticosteroid injections
SURGICAL
-bunionectomy
-removal osteophytic proliferation and loose body excision(clean up
joint)
-shorten and/or plantarflex the Ist metatarsal
-CPM or early passive ROM exercises
FIRST RAY SURGERY
456
CHAPTER 27
HALLUX VARUS
-an adductus and/or varus deviation of the hallux at the 1st MPJ
CAUSE
-iatrogenic(failed bunionectomy)
-resection of fibular sesamoid
-trauma
-congenital
TREATMENT
Conservative
strapping, splinting
Surgical(step-wise approach)
1. total soft tissue release of the 1st MPJ
2. medial capsulotomy
3. tibial sesamoidectomy(if 30-50% of the tibial sesamoid is exposed
medially)
4. release EHL and transfer it to the plantar lateral aspect of the
proximal phalanx(lPJ must be fused)
5. osteotomy(if IM is negative do a reverse Austin)
6. joint destructive procedure(arthroplasty or implant)
7. arthrodesis(McKeever)
METATARSUS PRIMUS ELEVATUS

-the middle of the sagittal ROM of the 1st ray is above the lesser
metatarsal head plane
-normal ROM is 1Omm
CAUSES
-congential
-pronated foot
-iatrogenic(failed base wedge osteotomy)
SYMPTOMS
-IPK sub 2nd metatarsal head
-hallux limitus/hallux rigidus
TAILOR'S BUNION / BUNIONETTE
457
CHAPTER 28
CHAPTER 28
TAILORS BUNION (BUNIONETTE)
DESCRIPTION, p458
EVALUATION, p458
CLASSIFICATION, p459
CAUSES, p459
TREATMENT, p459
458
CHAPTER 28
TAILOR'S BUNION(BUNI0NETTE)
DESCRIPTION
-enlargement of, or prominence of, the 5th metatarsal head
EVALUATION
IM angle
TWO METHODS
1) Traditional method
The angle between the bisection of the 4th
metatarsal and the bisection of the 5th
metatarsal
-average normal value is 7, higher
values(8-10) indicate an abnormality
2) Fallat and Buckholz
The angle between the bisection of the 4th
metatarsal and the medial cortical margin of
the proximal portion of the 5th metatarsal
-average normal value is 7O, higher
values(8-10) indicate an abnormality
Lateral Deviation Angle

-bisection of the 5th metatarsal head and
neck in relation to the medial cortical margin
of the proximal portion of shaft
-average normal value is 3O, higher
values(8) indicate an abnormality
459
CHAPTER 28
CLASSIFICATION
Type
Enlarged head
Type II
Lateral bowing
Type III
Enlarged 4-5th IM angle
CAUSES
-enlarged 5th metatarsal head or hypertrophied plantar chondyles
-lateral bowing of the 5th metatarsal shaft
-increased 4 thIM angle
-biomechanical
cavus foot
uncompensated rearfoot varus
uncompensated forefoot varus
splay foot
metatarsus adductus
forefoot valgus
TREATMENT
Conservative treatment
-padding
-wider shoes
-NSAIDs
-steroid injections
-reduce callus
Surgical treatment
460
CHAPTER 28
EXOSTOSES
Davis
-removal of the lateral eminence
(reverse Silver)
Dickson and Dively

-same as a Davis but includes
removal of an inflammed bursa
-technically it is the removal of the lateral

metatarsal is often rotated
I plantar chondyle is often
tructure thus making the
procedure the same as the Davis
Amberry
-same as Davis plus removal
of the laterally prominent
base of the proximal phalynx
461
CHAPTER 28
ARTHROPLASTIES
Head resection
-to prevent a callus beneath the stump of the metata
make the cut oblique from distal/medial/dorsal to
proximal/lateral/lplantar
-toe retraction makes the 5th toe appear shorter
MODIFICATIONS-to prevent toe retraction
Addonte and
Petrich and Dull
-recommended silastic interpositional sphere(CalnanNicole implant) to prevent retraction
-force vectors in this joint make stemmed implants
unsuccessful
Klikian
-recommended syndactylizing the 5th metatarsal
to the 4th toe toe prevent retraction
1/2-2/3
of the 5th metatarsal
Brown
-resection of the entire 5th ray and toe
OSTEOTOMIES
462
CHAPTER 28
463
CHAPTER 28
-reverse Reverdin
-subcapital osteotomy that corrects
displaced articular face
distal third of the metatarsal
464
Throchmorton and Bradless or

Campbell or Johnson
-reverse Austin
Leach and lgou

-reverse Mitchell
CHAPTER 28
465
CHAPTER 28
-metatarsal head is staked on the shaft
Diebold and Bejjani

-proximal Austin
-fixated to the 4th metatarsal with Steinmenn pins
-opening base wedge osteotomy
466
CHAPTER 28
PEDIATRICS
467
CHAPTER 29
PEDIATRICS
APGAR, p468
BRACHYMETATARSALGIA, p503
CALCANEOVALGUS, p504
CAVUS FOOT, p490
CEREBRAL PALSY, p505
CLUBFOOT, p480
COALITION, p494
DEVELOPMENTAL LANDMARKS, p468
DISLOCATED HIP, p476
IMMUNIZATION, p468
MACRODACTYLY, p502
METATARSUS ADDUCTUS, p496
MUSCULAR DYSTROPHY, p505
OSTEOCHONDROSIS, p473
PES PLANUS, p484
POLYDACTYLY, p501
SKEWFOOT, p489
SPLINTS/BRACES, p469
SYNDACTYLY, p502
VERTICAL TALUS, p483
CHAPTER 29
PEDIATRICS
468
CHAPTER 29
APGAR
-scoring system to evaluate perinatal asphyxia
-not an indicator of long term outcome, but rather an indicator of
immediate needs
-the score is the sum of points gained on assessment of the following 5
Score: add the scores from

0-2
3-4
5-7
8-10
all 5 signs to assess infant

Serious asphyxia
Moderate asphyxia
Mild asphyxia
Normal
DEVELOPMENTAL LANDMARKS
3 months
6 months
9 months
12 months
14 months
15-18 months
18-21 months
21-24 months
36 months
Lifts head up when prone

Rolls over
Sits up
Stands/Cruises
Walks
Uses words
Combines words
Three word sentences
Child develops a propulsive gait
CHILDHOOD IMMUNIZATION SCHEDULE
'Previously unimmunlzed preadolesents/adolescents should begin immunization

'Those who have not had a documented case of chickenpox or have not been immunized should
begin immunlzat~on
PEDIATRICS
469
CHAPTER 29
SPLINTS AND BRACES

-use between 3 months-3 years
-when sizing a splint with a bar measure from one ASlS to the other plus
one inch
-splints used to abduct the foot are best used with triplanar varus wedge
to prevent subluxation of MTJ
-best used on positional abnormalities which are soft tissue problems(ie.
internal and external femoral rotation) as opposed to bony abnormalities
or torsional problems(ie tibialtorsion)
-splints and braces should be worn as much as possible at night, during
naps and as much as tolerated during the day
-if splints follow serial plaster immobilization wear splint for twice as long
as total casting time
-with braces that have a rigid bar connecting the feet, a 15" to 20varus
bend should be placed in the bar to prevent subluxation of STJ or MTJ
GANLEY SPLINT
-first splint to treat combination foot and leg disord
-same indications as Denis-Browne Bar but
also allows FF to RF control
-If treating internal rotational problems
torque bar is placed between the rearfoot
plates and if treating an external rotational
problem the torque bar is placed between
the two forefoot plates
-adjustment are made by simply
bending the aluminum bars
DENIS-BROWNE BAR
-has been used to treat metatarsus adductus, convex pes planovalgus,
and positional abnormalities of the leg
-originally designed to
treat clubfoot
-the bar is screwed
or riveted on the
child's shoes
PEDIATRICS
470
CHAPTER 29
FILLAUER BAR
-same as Denis-Browne Bar except it clamps to
soles of patient's shoes
-requires rigid soled shoes for clamp to stay on
UNIBAR
-same as the Denis-Browne Bar except it has a ball and socket joint
beneath each foot which can be tightened into a varus position(preventing STJ and MTJ subluxation) eliminating the need to bend the bar
COUNTER ROTATION SYSTEM(LANGER)

-designed to correct torsional abnormalities of the leg
-functionally the same as t
Denis-Browne Bar but
several hinges allow
greater freedom of motion
-best tolerated splint,
allows unencumbered
crawling
BEBAX SHOE
used to Treat FF to RF abnormalltes
(metatarsus adductus)
-recommended for use after serial casting
of MA, but not for primary correction
-also available IS the Clubax- a device
designed for rearfoot or leg deformities
speclflcally clubfoot
PEDIATRICS
471
CHAPTER 29
STANDARD AFO
-ankle set at 90"
-used in various neuromuscular disorders which
may cause equinus(CP, muscular dystrophy)
-also used to treat drop-foot
HEATON BRACE
-used for metatarsus adductus
-designed as an alternative to serial casting for
metatarsus adductus
-similar in appearance to an AFO with a medial flare
to abduct the forefoot
WHEATON BRACE SYSTEM

-this additional AK piece is designed to lock
into the BK component
-the knee is fixed at 90preventing twisting
of the femur or hip and allowing isolated
unilateral treatment of tibialtorsion
PEDIATRICS
472
CHAPTER 29
TWISTER CABLES
-belt(around waste) cables(inside pant leg
course down to shoe)
-controls the degree of abduction at heel contact
-used to treat scissors gait of CP patients
FRIEDMAN COUNTER
SPLINT OR
FLEXOSPLINT
-a dynamic splint consisting of a
belt around the posterior heels
allowing motion in all planes
except internal rotation
IPOS SHOE
-Anti-adductus Orthosis Type 2
indicated
for metatarsus adductus
-functions by the use of varied
correctional elastic tension bands
(formerly springs were used)
PEDIATRICS
473
CHAPTER 29
ISCHEMIC NECROSIS)
A disease of the growth or ossification center in children, which
begins as a degeneration or necrosis and is followed by
regeneration or recalcification.
Blount's Disease
-osteochondrosis of the medial portion of the proximal epiphyseal
ossification center in the tibia causing bowing of the leg or legs
-symptoms-limping and lateral bowing of the leg
-radiographic evaluation-sclerotic medial cortex with spurring
Infantile tvpe
occurs before age 6 yrs
caused by early walking and obesity
Adolescent type
occurs at 8-15yrs
caused by trauma and infection
Freiberg's Infraction
-osteochondrosis of the metatarsal head
-the second metatarsal head is most frequently involved followed by the
3rd, 4th, and then 5th
-more common in girls
-usually occurs between ages 10-18yrs, but can occur during adult life
-radiographic eval-sclerosis and fragmentation of the metatarsal head
with flattening of the articular surface
Svmptoms
-pain on ROM of the affected MPJ
- local tenderness and swelling
-generalized thickening at the MPJ
Treatment
-conservative-metatarsal pads, short leg casts, stiff post-op shoe
-surgical-aimed at removing any bony lipping from the perimeter of the
metatarsal head, when DJD is severe an implant may be indicated
PEDIATRICS
474
CHAPTER 29
Kohler Disease
-osteochondrosis of the navicular(tarsal scaphoid)
-more common in boys
-occurs between ages 3-6yrs
Svmptoms
-often asymptomatic
-pain and swelling
-navicular becomes sclerotic and flatlened(coin on edge, or silver dollar sign)
-self-limiting, recovery usually takes from 2-4yrs and the navicular
ultimately resumes normal shape and density
-Note-there is different condition also called Kohl's dz which refers to
osteochondrosis of the primary ossification center of the patella
Legg-Calve-Perthes Disease
-osteochondrosis of the femoral head
-10% are bilateral
-most common form of osteochondrosis
-the younger the child the better the prognosis
-history of trauma precedes 30% of cases
-male : female(5:l)
Svmptoms
-insidious in onset
-limping
-generalized groin pain
-referred pain to the knee is common
Osgood-Schlatter Disease
-osteochondrosis of the tibialtuberosity
-more common in boys
-caused by excessive traction of the patellar ligament from the patellar
ligament
-symptoms-local pain and swelling with tenderness on palpation
-self limiting and treatment is symptomatic
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Sever's Disease
-osteochondrosis of the calcaneus(apophysis)
-caused by excessive traction of the Achilles tendon
-more common in patients with equinus
-radiographic diagnosis is difficult-the normal epiphysis can have 2 or
more centers(appearing fragmented), irregular borders, and is often
sclerotic
Treatment
-RICE
-NSAIDS
-elimination of sports
-heel lifts
-Achilles stretching exercises
OTHER LESS COMMON OSTEOCHONDROSIS
Buschke's Dz
-osteochondrosis involving the cuneiforms
Diaz or Mouchet's dz
-osteochondrosis involving the talar body(usually associated with trauma)
Thiemann's dz
-osteochondrosis involving the epiphyseal ossification centers in the
phalanges
Iselin's dz
-osteochondrosis involving the 5th metatarsal base
Lewin's dz
-osteochondrosis involving the distal tibia
Ritter's dz
-osteochondrosis involving the fibular head proximally
Treve's dz
-osteochondrosis involving the fibular sesamoid
Renandier's dz
-osteochondrosis involving the tibia sesamoid
Lance's dz
-osteochondrosis involving the cuboid
Assmann's dz
-osteochondrosis involving the head of the 1st metatarsal
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CONGENITAL DISLOCATED HIP

-Occurrence is 0 . 1 %
-60% are on left side, 20-30% B/L
-Increased incident in:
1. females(5 to 8 times greater)
2. children with older sibling with a dislocated hip(10 times more likely)
3. breech presentation
4. joint laxity
5. first born
-Commonly associated with oligohydrarninos, torticollis, metatarsus
adductus, and calcaneal valgus
-Classic signs in older children include: limited abduction, asymmetric
thigh folds, relative femoral shortening, a limp, positive Trendelenberg
test, externally rotated foot, waddling gait.
-Best position for the hips to prevent dislocation is flexed and abducted
-When a dislocation occurs the femoral head is usually posterior and
superior to the acetabulum
-Most dislocations occur during the first 2 weeks after birth
Etiology
-Ligamentous laxity
-Acetabular dysplasia
-Mal-positioning
a)ln-utero(i.e. breech)
b)Postnatal(carrying babies with hips adducted and extended)
Clinical Diaanostic Studies
ORTOLANI'S SIGN
With the baby supine hips and knees are
flexed to 90". The hips are examined
one at a time by grasping the baby's
thigh with the middle finger over the
greater trochanter and lifting and abducting
the thigh while stabilizing the pelvis and
opposite leg with the other hand. The test
is positive when a palpable click is felt as
the femoral head is made to enter the
acetabulum.
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BARLOW'S SlGN
With the baby supine the hips and
knees are flexed. With the thumb on
the lesser trochanter in the groin and
the middle finger of the same hand on
the greater trochanter laterally, gently
apply pressure down on the knee while
simultaneously applying lateral pressure
with the thumb. The dislocatable hip
then becomes displaced with a palpable clunk as the head slips over the
posterior aspect of the acetabulum. This is a provocative test which
actively dislocates an unstable hip.
ANCHOR'S SIGN
With the baby prone and legs adducted
and extended. Look for asymmetry of
thigh and gluteal folds. There will be
more folds on the dislocated side.
GALEZZI'S SIGN(aka Allis' Sign)

While the hips and knees are flexed, a
dislocated hip result in a lower knee
position on the affected side. May be
false positive in B/L cases.
ABDUCTION TEST
With the baby supine hips and knees
are flexed to 90. Abduct the knees to
resistance. A dislocated hip will have
limitation of abduction on the affected
side.
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NELATON'S LINE
Particularly useful in children with B/L dislocations. An imaginary line is
drawn connecting the anterior iliac spine and the tuberosity of the ischiurn. If the tip of the greater trochanter is palpable distal to this line the
hip is dislocated.
Radioaraphic Diaanostic Studies
Hilgenreiner's Line(Y Line)-A line connecting the most inferior portion
of the acetabulurn on both sides
Ombredanne's Line(Perkins Vertical Line)-Draw a line perpendicular
to Hilgenreiner's line at the outer most aspect of the acetabulum.
QUADRANT SYSTEM
NORMAL
DISLOCATED
NORMAL
DISLOCATED
After drawing the Hilgenreiner's and

Ornbredanne's Lines the normal
position of the developing femoral
head should be in the lower medial
quadrant. A dislocated hip will show
at least part of the femoral head in the
outer upper quadrant.
ACETABULAR INDEX
Draw a line extending through the
most medial and lateral aspect of the
acetabulum. The angle created betwee
this line and Hilgenreiner's Line is the
Acetabular Index. This value should
be between 27-30" at birth and decrease
to 20" by age two. An angle greater
than 30indicates a dislocated hip.
SHENTON'S CURVED LINE

(Menard's Curved Line)
Draw a line up the medial side of the
femoral neck to continue up into the
oberator foramen. This should be a
continuous arc, with a hip dislocation
the obterator foramen is too low.
DISLOCATED
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VON ROSEN'S SIGN
CHAPTER 29
NORMAL
DISLOCATED
(Frog Leg View)

An A/P radiograph is taken with the
hips extended and the thighs abducted
45 and medially rotated. A line drawn
through the long axis of the femur. In a
normal hip this line should extend
line will bisect the ASIS.
VON ROSEN'S METHOD

Draw the Hilgenreiner's Line, then draw
a parallel line passing through the
upper margin of the pubic symphysis.
In a dislocated hip the femur will
extend up between these lines
Hil
enreiner's
WIBERG'S CE ANGLE
Based on the assumption that if the
femoral head is inadequately covered
by the acetabulum it will develop DJD.
This test shows how much is covered.
Draw a line connecting the center of
the femoral head(C) with the lateral
most aspect of the acetabulum(E).
Measure the angle created by this line
and Ombredanne's Line. If this angle is le
0 in a child over 5
years, there is an increased likelihood of developing DJD
Treatment
-treatment is aimed at aligning the femoral head in the acetabulum
and holding it there, by keeping the hips in a flexed and abducted
position
-with early detection this may be accomplished by specific pillow
arrangement in the crib, double or triple diapering, a Pavlik harness,
or a Spica cast
-as the child grows traction plus closed reduction is required
-If undiagnosed by age 6 or 7 open reduction and eventually a hip
implant may be required due to permanent arthritic changes.
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CHAPTER 29
CLUB FOOT(TALIPES EQUINOVARUS)

INTRODUCTION
-a triplanar deformity involving:
ANKLE EQUINUS
HINDFOOT VARUS
FOREFOOT ADDUCTION
-1 :1000 live births
-Male to Female(2:l)
-50% B/L
-R>L
-Lowest incident in Asians, highest in Polynesians
TYPES
IdiopathicNonidiopathic-
Interuterine position
Spina Bifida, CP, MD, meningitis, post-polio, traumatic,
Streeter's Dz
EVALUATION
SIGN
NORMAL CLUBFOOT
Kite's Angle
20-40
0-15
Calcaneal Inclination Angle
20-25
-17
Talar head/neck relative to body: Adduction
10-20
80-90
Plantarflexion 25-30"
45-65"
HORIZONTAL BREACH
While the talar head and neck are medially deviated the talar body and
trochlear talar surface may be slightly externally rotated within the mortise, leading to an external torsional deformity of the tibia and fibula.
The lateral malleolus becomes displaced posteriorly off it's articular talar
facet leading to a decrease in the bimalleolar axis(the angle between
the longitudinal bisection of the hindfoot and the malleolar plane) normal
value of 75-90", if clubed angle decreases to less than 75.
BEATSON AND PEARSON ASSESSMENT METHOD

-The talus and calcaneus are longitudinally bisected on a lateral and
A/P x-ray. The calcaneus is bisected on the lateral film by using the CIA
- The talocalcaneal angle of the A/P view is added to the talocalcaneal
angle of the lateral. If the sum is less than 40, the foot is clubbed
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Simons's Assessment Method(Simonsls rule of 15)

-The talus, calcaneus, and first metatarsal are longitudinally bisected
on an A/P x-ray with the foot positioned it the maximally corrected
position. In a clubfoot the talo-first metatarsal angle was greater than
15 and the talocalcaneal angle was less than 15".
TREATMENT
SERIAL CASTING(begin as soon as possible)
-Stretching and manipulation should be performed prior to cast application
-Apply tincture of benzoin to child's skin to help undercast stick to skin
-A cast is applied with 2 inch cast material(short or long leg cast may be
used, generally in infants use a long leg to prevent cast from slipping off.
Flex knee at 75-90")
-Mold cast in with the foot in the reduced position
-Reduction of the clubfoot deformity should be performed in the followino order:
ADDUCTION
Mneumonic-AVEnue
VARUS
(Adduction, Varus, Equinus)
EQUINUS
-Last cast is bivalved and used as a night splint
-If there are no signs of improvement after 12wks consider surgical
intervention
-Complications of cast treatment
a) Metatarsus adductus
b) Heel varus
c) Pes plano valgus-over correction
d) Rocker bottom-over zealous correction of the equinus
e) AVN or talar head flattening-infant connective tissue is stronger
than infant bone and cartilage. During casting tremendous forces are
exerted on the navicular and talar head
f) Navicular subluxation-usually dorsally over talus
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OPERATIVE TX
SOFT TISSUE RELEASE(children 3-12 months)

-Two most popular incisions
1. medial hockey stick, with a secondary lateral if necessary
2. cincinnati incision
POSTERIOR RELEASE
-Reflect the origin of abductor hallucis and plantar fascia
-Z-plasty of Achilles tendon
-Release of the posterior, medial, and lateral ankle joint
-Release of the posterior, medial, and lateral STJ. In doing so the
posterior talofibular and calcaneofibular ligaments are severed
MEDIAL RELEASE (Talonavicular and medial STJ release)
-Z-plasty of the posterior tibialtendon
-Release of the talonavicular joint. In doing so the spring ligament and
Henry's knot are severed
-Release entire medial STJ, which will include the superficial deltoid ligament
LATERAL RELEASE(Performed through the STJ in the single medial
incision approach)
-Release of the interosseous talocalcaneal ligament
-Release of the bifercate ligament
-Release of the lateral STJ.
OSSEOUS PROCEDURES(1yr-4yrs)
-after the child reaches at least one year old, bony correction of the
deformity may also be performed along with soft tissue releases
Lichtblau
Evans
Ganley's
(Anterior calcaneal
osteotomy)
(Cuboid-calcaneal
ostectomy)
(closing abductory
cuboid osteotomy)
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CONGENITAL VERTICAL TALUS(A.K.A.

Conaenital Convex Pes Plano Valgus,
Reverse Clubfoot. Persian Slipper,
Rockerbottom Flatfoot)
DESCRIPTION
-Primary dislocation of the navicular dorsally on the
neck of the talus locking the talus in a vertical position
-Forefoot is abducted and dorsiflexed at the midtarsal
joint
-Calcaneus is in valgus and equinus
-RIGIDITY is the hallmark of the deformity
-Contracted gastroc-soleus, and
elongated spring ligament
-Majority B/L
-R>L
-Often occurs with other congenital
deformities most notably Arthrogryphosis
-Foot may actually touch the front of the tibia at birth
-Walking is not delayed because the condition is not painful in
childhood, however gait is awkward, clumsy and almost peg-like and
shoes may be difficult to wear
-Talar head is prominent on medial plantar aspect of foot and may
have a callus over it from bearing most of the body weight
-STJ facets are abnormal
Anterior-absent
Middle-hypoplastic
Posterior-malformed(misshapen)
RADIOGRAPHIC EVALUATION
-Definitive diagnosis is determined by taking a lateral x-ray and
comparing it to a second lateral x-ray with the foot maximally plantarflexed demonstrating that the talonavicualar relationship does not
change. Navicular is not evident radiographically until age 3 so it is difficult to establish its subluxation.
-Line bisecting talus(on lateral x-ray) is parallel to tibia
-Talocalcaneal angle on A / Pis increased, usually > 4 0
-Talar neck is hypoplastic and so may have an hourglass shape and
may have a flat surface
-Navicular articulates with the dorsal neck of the talus
-(-)Hubscher maneuver
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TREATMENT
CLOSED REDUCTION
-rarely successful
-Manipulation and casting is recommended as a means of
stretching the soft tissues for future definitive surgical treatment in an
attempt to avoid skin sloughing
OPEN REDUCTION
3 MONTHS-3YEARS
-If closed reduction fails, open reduction should be performed at 3
months of age
-Many procedures have been described, they all involve a posterior
release and reduction of the talonavicular joint
3-6YEARS
-In addition to open reduction an extra-articular arthrodesis(Green-Grice
type) or arthroereisis may be attempted to maintain reduction and stabilize the STJ
6 YEARS AND UP
-At this point it's best to postpone surgery until skeletal maturity(l0-14
years of age) at which time a triple arthrodesis is performed which may
require removal of the head and neck of the talus to obtain reduction
FLEXIBLE PES PLANUS(FLATFEET)

FLEXIBLE VS. RIGID
Flexible
-(+) Hubscher Maneuver
-(+)Resupination test
-not painful
-Longitudinal arch present
during WB
-(-)Hubscher maneuver
-(-)Resupination test
-painful
-Causes include: coalition,
vertical talus
DESCRIPTION
-higher incidence in blacks
-most are asymptomatic
-the foot appears externally rotated in relation to the leg
-WB axis of the LE is medial to the mid-axis of the foot
-most infants are flatfooted and develop an arch during the 1st decade
of life
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S Y M P T O M S ( q u i t e varied)
-often asymptomatic
-muscle cramps(esp. calf and anterior leg)
-arch pain
-heel pain
RADIOGRAPHIC EVALUATION
LATERAL
Meary's angle
CIA
A/P
Kocalcaneal angle
Talonavicular articulation
NORMAL
0
20-25"
FLATFOOT
1-1 5 mild, >15severe
4 5
<25
<50%
>25
60-70%
CAUSES
-compensated FF varus
-compensated FF valgus
-RF equinus
-adducted foot
-abducted foot
-neurotrophic feet
-muscle inbalance
-post tibialtendon rupture
-ligamentous laxity(Ehlers-Danlos, Marfan's, Down's, Osteogenesis
imperfecta)
-calcaneovalgus
-enlarged or accessory navicular
TREATMENT
Conservative
In young children manipulation, strapping, and casting may be beneficial, while in older patients orthotics are beneficial
-flexible flatfoot with short tendon Achilles(FFF-STA) is not an indication
for orthotics or arch supports because the STA will prevent recreation of
the arch and instead cause increased pressure under the talar head
-with these children use a heel cup whose margins have been increased
to 25mm. This keeps the heel in a more vertical position
-adding a medial flare of about 1/8" on the rearfoot post will help eliminate some of the excess pronation
Surgical(based on plane dominance)
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CHAPTER 29
Transverse plane
Evans
Opening osteotomy of the
1.5 cm proximal to the calcaneocuboid joint and insertion of a
bone graft
Kidner
-removal of prominent navicular tuberosity or accessory navicular and
transplantation of the posterior tibialtendon into the underside of the
navicular bone
Sagittal plane
Lowman
-talonavicular wedge arthrodesis
-TAL
-tibialis anterior rerouted under the navicular and sutured into the spring
ligament
-medial arch tendon as accessory ligament for tenodesis of the medial
arch
-tendodesis of medial arch with slip of the Achilles tendon, which is left
attached to the calcaneus and folded forward along the medial arch as
an accessory ligament and desmoplastic-causing adhesions of the
talonavicular ligaments
-desmoplasty of the talonavicular ligament
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CHAPTER 29
Cotton
-Opening dorsal wedge on the 1st cuneiform
Hoke
-Plantarly based wedge removal and fusion of the
navicular and the two medial cuneiforms
Miller
-Naviculo-1st cuneiform-1 st metatarsal fusion
-Posterior tibial tendon and spring ligament advancement using an
Young(Keyhole Technique)
-Reroute the anterior tibial tendon through a keyhole in the navicular
without detaching it from it's insertion
-posterior tibial advanced under the navicular
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Frontal plane
Chambers
-Raise the posterior facet of the STJ
using a bone gratt under the sinus tarsi
Baker
-osteotomy inferior to the STJ posterior
facet with bone graft
Selakovich
-opening wedge osteotomy of the
sustentaculum tali with bone graft
restricts abnormal STJ motion
arthroeresis(see implants)
Calcaneal osteotomies
Gleich
-oblique osteotomy displaced anteriorly
-helps increase the calcaneal inclination
silver
-lateral opening wedge with graft
CHAPTER 29
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CHAPTER 29
Koutsogiannis
-oblique crescentic osteotomy
Triple arthrodesis
-reserved for second stage salvage procedure
Grice and Green Extraarticular Subtalar Arthrodesis

-a bone graft is inserted laterally in the sinus tarsi between the talus and
calcaneous. This procedure is acceptable for children because it provides excellent stability without interfering with the growth of the tarsal
bones.
SKEWFOOT(zfoot, serpentine foot, compensated metaductus)

-adducted forefoot, normal midfoot, and a valgus hindfoot
-usually aquired from gradual compensation of metatarsus varus that
occurs with WB or improper manipulation and casting
-fixed hindfoot valgus and severe rigid MTA
-increased calcaneocuboid angle, normal 0-5"(line along the lateral
aspect of the calcaneus and a line along the lateral aspect of the
cuboid)
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CAVUS FOOT TYPE(PES CAVUS)

DESCRIPTION
-High arched foot
-Elevated longitudinal arch
-Primarily a sagittal plane deformity
-Painful calluses under metatarsal heads
-Chronic inversion ankle sprains
-Heel, knee or hip pain may develop secondary to lack of shock
absorption from the abnormal architecture of the foot
RADIOLOGICAL EVALUATION
-Take WB and NWB to determine if deformity is reducible
-"Bullet hole" sinus tarsi
SIGNS
NORMAL
CAVUS FOOT
CIA
20-25
>30
Angle of Meary
0
>6"
Angle of Hibbs
135-1 40"
>150
CLASSIFICATION(L0CATE APEX OF DEFORMITY)

Metatarsal cavus
Lesser tarsus cavus
Forefoot cavus
Combination
Lisfranc's joint
Lesser tarsal bones
Chopart's joint
Apex generalized over lesser tarsals
CAUSES
-Cavusfoot is often the first manifestation of many neuromuscular disorders including: spina bifida, Charcot-Marie Tooth disease, Friedreichs
ataxia, poliomyelitis, spinal cord tumors, myelomeningocele, CP,
infection, syphilis, trauma, spinal cord lesion
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CHAPTER 29
TREATMENT
CONSERVATIVE
-Shoe modification and orthotics can alleviate symptoms by increasing
the weight bearing surface of the foot and relieving painful callus under
the ball of the foot
-In young patients passive stretching, manipulation and casting may be
beneficial
-Extra depth shoes combined with a metatarsal bar
SURGICAL
Soft tissue-for flexible deformities
Plantar Fascial Release

Steindler Stripping
-Plantar fascia, and the long plantar ligament is released
-Abductor hallucis, FDB, and abductor digiti quinti are stripped from the
periostium of the calcaneus
TENDON TRANSFERS ARE EFFECTIVE TREATMENT FOR
FLEXIBLE DEFORMITIES
Jones Tenosuspension
Heyman procedure
-transfer of all four extensor tendons to their respective metatarsal heads
Hibbs Procedure
Split Tibialis Anterior Tendon Tranfer(STATT )
Peroneus Longus Tendon Transfer
Tibialis Posterior Tendon Transfer
Peroneal Anastomosis
-At the lateral ankle the peroneus longus is anastomosed to the
Peroneus brevis. This decreases plantarflexion of the 1st metatarsal
and increases eversion forces of the foot
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CHAPTER 29
Peroneus Longus and Tibialis Posterior Tendon

Transfer to the calcaneus
-Peroneus longus is cut in the area of the cuboid and attached to the
lateral boarder of the Achilles tendon
-Tibialis posterior is cut and attached to the medial boarder of the
Achilles tendon
OSSEUS PROCEDURES-for rigid deformities
Japas
-a rnidtarsal V-osteotomy(apex of the V is ,
proximal and at the highest point
of the cavus, usually in the navicular).
The lateral limb of the V extends
through the cuboid, and the medial
limb of the V extends through the
-No bone is excised, the distal part of the osteotomy
is shifted dorsally
DuVries
-dorsiflexory fusion through the MTJ
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Dwyer
-lateral closing wedge or an openlng
medial wedge
McElvenny-Caldwell procedure
-dorsiflexory fusion of the 1st
metatarsal-1st cuneiform joint
-If the deformity is severe then a
naviculocuneiform joint fusion
is added
DFWO(1st or all metatarsals)

-Dorsiflexoryosteotomy of the 1st
metatarsal or all metatarsals
Jahss(Truncated tarsometatarsal wedge osteotomy)

-Dorsiflexory wedge osteotomy across the
tarsometatarsal articulations
CHAPTER 29
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TARSAL COALITIONS
DESCRIPTION
-a bridge between two or more tarsal bones that restrict motion
-most common cause of peroneal spastic flatfoot(the spasm occurs as
a response of the body to immobilize the STJ)
-male > female
-pain is usually insidious in onset or may follow athletics or minor
trauma
-occasionally anterior and posterior muscles are in spasm causing a
varus deformity
-incidence is -1%
--50% B/L
-TC and CN coalitions are roughly equal in distribution and account for
over 90% of tarsal coalitions
-common peroneal blocks may be used to relax the spastic peroneals
and fully evaluate ROM
SYMPTOMS
-deep, aching pain aggravated by activity, relieved by rest
-decreased ROM
-muscle spasm(peroneals are often fatigued from over use)
-halo sign
-talonavicular beaking
-anteater nose sign
CAUSE
-Congenital(failure of segmentation of primitive mesenchyme)
-Aquired(infection, arthritis, trauma, iatrogenic)
Fusion tissue tvpe
Syndesmosis-flbrous
Synchondrosis-cartilaginous
Sy nostosis-osseous
ORDERING A CT FOR STJ

-coronal(frontal) plane scan
-contiguous sections
-between 2-5mm slices
-from the posterior talo-calcaneal facet to the navicular
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Genera
495
CALCANEONAVICULAR
CHAPTER 29
TALONAVICULAR
-45%
CALCANEOCUBOID
2% of tarsal
-an
symptoms
years
often localized to the
area over the
-moderate decrease
ROM at STJ
-MO at 45"
an tncomplete fusion the
Harris-Beath
bony ends are irregular and
post facets are not parallel
lack cortical
facet not be well demarkated
-close proximity of
Lateral
calcaneous and
beaking
of lat process of
of the
as
approaches the calcaneous
-narrow post STJ facet
-mid facet not visualized
talar head
-ball-and-socket ankle
Lateral
I -concave undersurface of talar neck
of the
halo
or sunburst
process of the calcaneus
can be seen
the sinus tarsi)
up" towards the navicular
-consists of 3 views to see all 3
begin at 12-16 years
-pain in
tarsi or over
to medial
-decreased ROM at STJ and MTJ
tarsi steroid injections
improves
Procedure)
belly in defect, suture to
-triple arthrodesis-if DJD present
-if painful, occurs at

is usually bump
from shoe gear over the
Lateral
-absence of dorsal portion
of cyma line
Lateral
absence of plantar
of cyma
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CHAPTER 29
METATARSUS ADDUCTUS
DESCRIPTION
-Adduction of the FF at tarso-metatarsal joints
-Rearfoot is normal
-1 in 1000 live births
-55% B/L
-males=females
-prominent styloid process
-intoed gait with frequent tripping
-the severity of the adduction progressively
decreases from medial to lateral
-Usually idiopathic, rarely associated with
neuromuscular disease
-10% are associated with dislocated hip
-86% resolve satisfactorily without treatment, spontaneous improvement
should be almost complete at about 3 months if it is to occur
CAUSE
-intrauterine position
-tight abductor hallucis muscle
-absent or hypoplastic medial cuneiform
-abnormal insertion of anterior tibialtendon
CLASSIFICATIONS
Dvnamic
-baby is born with straight feet for 1st 7-8 months, then baby develops a
"C" shaped foot due to tightening or contracture of the abductor hallucis
tendon. Hallux is pulled into adduction with WB. Treatment involves
cutting or lengthening the abductor muscle
Flexible
-strainghtens out or over corrects when force is applied to the medial
aspect of the foot. Treatment is with straight last shoe
Rigid
-little change in FF to RF position with medial pressure. Biggest problem is shoe fit(prominent styloid process). Treatment is serial casting or
surgical
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Crawford and Gabriel Classification

Stroking the lateral border of the foot will cause peroneal muscle
contractions which will demonstrate the degree of active forefoot
mobility
Type I
Type II
Type I II
Flexible
(forefoot will correct
past neutral into
slightly overcorrected)
Partial flexibility
(does not correct to
neutral actively but
does passively)
Rigid
(does not correct to
neutral actively or
passively)
Bleck Classification
Bisect the heel and extend the line distally to see where it falls on
the toes
(between 2nd-3rd toe)
(through 3rd toe)
(beween3rd-4th toe)
(between 4th-5th toe)
MEASURING THE METATARSUS ADDUCTUS ANGLE

CLASSIC METHOD
Reference points
Medial-proximal aspect of 1st metatarsal base
Medial-distal aspect of the talo-navicular
articulation
Lateral-proximal aspect of the 4th metatarsal base
Lateral-distal aspect of the calcaneo-cuboid joint
Metatarsus adductus angle above 20" is
considered adducted
MTA angle at birth is 25-30", at 1 year(begin
walking) it's -20" and by 4 years it's at the adult
normal of -1 5
PEDIATRICS
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LEPOW TECHNIQUE
Take the perpendicular of a line passing
through the lateral base of the 5th and
medial base of the 1st metatarsals and
compare with the 2nd metatarsal
-values are comparable to values obtained
by the traditional method
MTA angle at birth is 25-30",
at 1 year(begin walking) it's -20
and by 4 years it's at the adult
normal of -1 5
ENGLE'S ANGLE
Bisect the intermediate cuneiform and
compare with the 2nd metatarsal. A
normal value using this method is 24.
The angle increases with an adducted
foot.
TREATMENT
CONSERVATIVE(children < 3 years old)
-manipulation and serial casting are the standard treatment
-shoes, orthotics
-splints(Ganley), braces
PEDIATRICS
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CHAPTER 29
SURGICAL
CHILDREN 2-6 or 8 YEARS-SOFT TISSUE PROCEDURES
Heyman, Herndon, and Strong

-release all soft tissue structures at Lisfranc's jt except lateral and
plantar lateral ligaments
-initially described using one transverse skin incision, revised to 2 or 3
longitudinal incisions
Thompson procedure
-resection of the abductor hallucis muscle
-release medial head of FHB if necessary
Lange
-capsulotomy of the 1st metatarsal-1st cuneiform joint
-division of the abductor hallucis
Lichtblau
-sectioning of the hyperactive abductor hallucis
CHILDREN 8 YEARS AND OLDER-OSSEOUS PROCEDURES
Berman and Gartland

-laterally based crescentic
osteotomies of metatarsal base 1-5
Lepird
-closing wedge osteotomy of 1 and 5 metatarsal bases
-oblique rotational osteotomies of the three central metatarsals
PEDIATRICS
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Johnson osteochondrotomy
-closing abductory base wedge osteotomy of
the 1st metatarsal
-resection of osteocartilaginous 2.5mm
wedge from the lesser metatarsals
Fowler
-opening wedge osteotomy of the medial
cuneiform with insertion of bone graft
Peabody-Muro
-excision of the base of the central three
metatarsals
-osteotomy of 5th metatarasal
-mobilization of the 1st-metatarsal-cuneiform
joint
Steytler and Van Der Walt

-oblique osteotomy of all metatarsals
McCormick and Blount

-arthrodesis of 1st-metatarsal-cuneiform jt
-0steotomy of metatarsals 2, 3, and 4
-possible wedge resection of cuboid
PEDIATRICS
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CHAPTER 29
POLYDACTYLY
-Supernumerary digits
-More common in blacks and females
-Associated with:
Down's syndrome
Lawrence-Moon-Biedl syndrome
Chondroectodermal dysplasia trisomies 13 and 18
30% have positive family Hx
CLASSIFICATION
Preaxial-involves the hallux(15%)
Central-involving digits 2, 3, or 4(6%)
Postaxial-involving the 5th digit(79%), 6 subtypes
a"
Normal metatarsal
with distal phalangeal
duplication
Normal metatarsal
shaft withwide
head(most common)
Short block
metatarsal
T-shaped
metatarsal
Y-shaped
metatarsal
Postaxial polydactyly can also be divided into:
Type A-Well formed articulated digit

Type B-rudimentary often without skeletal component
Partial or complete
ray duplication
PEDIATRICS
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CHAPTER 29
TREATMENT
-Supernumerary digits are removed for cosmetic reasons and for comfort in shoes
-With all other factors equal remove the most peripheral digit
-Surgery should be avoided until at least 1 year of age when the full
pattern of skeletal involvement becomes clear and when the child can
better tolerate anesthesia
SYNDACTYLY
-Webbing between toes
-M>F
-Traumatic syndactyly may occur most notably as a result of burns
-Acrosyndactyly-partial joining of digits with proximal opening, usually
due to IU environmental factors
CLASSIFICATION
Type1(most
common)
-Zyngodactyly
-Partial or complete webbing of the 2nd and 3rd toes
Type II
-Synpolydactyly
-One soft tissue mass covering the 4th, 5th, and 6th toe
Type I I I
-Associated with metatarsal fusion
Davis and German Classification System
Incomplete-webbing doesn't extend to distal toes
Complete-extends to distal toes
Simple-phalanges not involved
Complicated-phalanges involved
TREATMENT
-If cosmesis is not a concern no treatment
-Desyndactyly procedure(see plastic Sx chapter)
MACRODACTYLY
-Local aiaantism of one or more toes
-Usually unilateral
-M>F
-Heredity does not play a role in the deformity
-Usually involves toes 1 st, 2nd, or 3rd,
-May be associated with neurofibromatosis
PEDIATRICS
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-Blood vessels and tendons are not affected

-Poor circulation because blood vessels have not enlarged with the digit
-Can often affect the metatarsal head as well as the phalanges
-Involvement of 2 or 3 adjacent digits is more common than single digit
involvement
CLASSIFICATION
Static deformity-growth rate is proportional to other digits(most common)
Progressive deformity-disproportionately fast growth rate until puberty
TREATMENT
-Condition is not painful and treatment is performed for cosmetic and
shoe fitting purposes
-Epiphysiodesis-the soft cartilage of the physis is resected with a knife
or by multiple drilling, the bone will still increase in girth
-Amputation or partial amputation
-Plastic reduction/debulking procedures(see plastic Sx chapter)
BRACHYMETATARSIA
-Shortened metatarsal
-Although the deformity is isolated to the metatarsals, the patient usually
precieves the problem to be in the toe itself because the toe is what
appears short clinically
-Most commonly affects the 1 stor 4 th,metatarsal
-Most commonly B/L and symmetrical
-Females to males(25:l)
-Becomes evident between 4-1 5 years
-Plantar callus may develop on adjacent metatarsal heads
-Clinical signs include a floating toe/short toe and a plantar fissure of
sulcus where the metatarsal head should be
-Toe is functionless due to lack of mechanical advantage
-Affected toes are dorsally displaced often causing problems with shoe
gear
-Associated conditions:
Down's syndrome
Pseudohypoparathyroidism
Pseudopseudohypoparathyroidism
Poliomylitis
Trauma
Idiopathic
Albright
Turners syndrome
PEDIATRICS
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CHAPTER 29
CLASSIFICATION
Type I I
Tvoe I I I
Tyoe IV
-shortening of the 1st metatarsal only

-shortening of 1 or 2 of the lesser metatarsals(usually 4th
and/or 3rd)
-shortening of the 1st and 1 or more(but not all) of the
lesser metatarsals
-shortening of all the metatarsals
TREATMENT
-Palliative treatment includes orthotics and accomodative devices
-Surgical treatment consists of reestablishing a normal metatarsal
parabola by:
Lengthening the short metatarsal
bone graft
callus distraction
Shortening long adjacent metatarsals
-Surgery correction should be delayed until after skeletal maturity
-Surgical procedure(using a bonegraft)
V-Y skin plasty
Z-plasty EDL lengthening(FDL lengthening is not necessary)
Sectioning of the short extensor and interossei
Insert bone graft(up to 1.5cm) and fixate with K-wire
-Monitor digital circulation for the first 24hrs
-Nonweightbearing cast for 2%-3 months after surgery
CALCANEOVALGUS
-characterized by excessive dorsiflexion of the ankle and eversion of
the foot
-caused by abnormal intrauterine position
-dorsal surface of the foot is in contact with the anterior surface of the
leg
-usually resolves spontaneously with growth but may require serial casting
PEDIATRICS
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CHAPTER 29
CEREBRAL PALSY
DESCRIPTION
-A broad term used to describe several static non~roaressiveneuro
muscular disorders resulting from brain damage before, during, or
immediately after birth
-Types of CP include
Spastic CP(most common, 70%)
Athetoid CP(20%)
Ataxic CP(10%)
Rigidity CP
Tremor CP
Atonic CP
SIGNS AND SYMPTOMS

-"Scissors gait" due to adductor spasticity
-Speech defects, retardation, seisures, visual defects
-Ankle equinus
TREATMENT
-PT, OT, splinting, bracing
MUSCULAR DYSTROPHIES
DESCRIPTION
-Inherited chronic proaressive myopathic disorders who's exact
pathogenesis is unknown
-Characterized by progressive weakness, atrophy, loss of DTR's,
secondary contractures, and deformity
-Pseudohypertrophy-an apparent hypertrophy of certain muscles
specifically the calves, the apparent muscle bulk is actually fat deposits.
Although these muscles may look over developed they are actually
weaker than normal.
-Proximal muscle weakness involvement more than distal
-Diagnosis involves clinical evaluation, EMG, muscle biopsy, and an
elevated CPK
TREATMENT
-keep patients active-inactivity often leads to worsening of the underlying
muscle disease
-There is no cure, treatment is aimed at maintaining ambulation for as
long as possible(PT, braces, weight control, surgery to control contractures)
PEDIATRICS
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CHAPTER 29
ANKLE EQUINUS
507
CHAPTER 30
ANKLE EQUINUS
DEFINITION,
ANATOMY,
TYPESICAUSES,
SYMPTOMS,
TREATMENT,
CHAPTER 30
ANKLE EQUINUS
508
CHAPTER 30
EQUINUS
Definitions
1) A limitation of passive ankle joint dorsiflexion to less than 90"
2) At least 10" of dorsiflexion past 90" is required for normal gait
Anatomy
Gastrocnemius-crosses 3 joints
-origin-femur
Soleus-crosses 2 joints
-origin-tibia
Plantaris-crosses 3 joints
-origin-lateral head of femur
-tendon runs between gastroc and soleus
-absent 7% of time
SILFVERSKIOLD TEST
(tests for gastroc equinus)
-passive dorsiflexion is measured with the knee extended and then with
the knee flexed
-if this value increases there is an equinus due to a tight gastroc.,
because the gastroc. crosses the knee joint and the soleus does not
TypesICauses
MUSCULAR
Spastic equinus
CP(hyperreflexia, +babinski, +clonus)
Duchennels(post muscle contractions, weaklatrophic muscles, absent
reflexes)
Congenital equinus
Birth Hx, Childhood Dz
note: toewalking for the first 3-6 months of ambulation is a normal
variant
Acquired
improper casting with foot plantarflexed
repetitive use of high-heel shoes iatrogenic
ANKLE EQUINUS
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CHAPTER 30
OSSEOUS
Talotibial exostosis
hard and abrupt end ROM upon dorsiflexion
stress lateral x-ray may aid diagnosis
Pseudoequinus
apparent equinus due to cavus foot type
Symptoms
-toe
-plantar
-calf
heel
pain
stride length
calcifications in Achilles tendon)
patients)
sians
lordosis
-hip flexion
recurvatum
-digital contractures
-knee flexion
-abducted angle of gait
Treatment
Conservative
-stretching, braces, heel lifts
Suraical
Gastrocnemius recession
(these procedures do not lengthen the
strictly for a gastrocnemius equinus,
Vulpius and
-inverted V-shaped cut through the
gastroc aponeurosis
muscle and are used

test)
ANKLE EQUINUS
510
CHAPTER 30
Strayer
-transvese cut through the
Gastroc aponeurosis
-suture proximal flap to soleus
Fulp and McGlamry

-tongue in groove(tongue portion proximal)
Baker
-tongue in groove(tongue portion distal)
ANKLE EQUINUS
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CHAPTER 30
-release origin of gastroc from femoral

chondyles
to proximal
ANTERIOR ADVANCEMENT OF ACHILLES TENDON

(indicated in a spastic equinus to decrease strength of triceps surae)
Murphy procedure
-transfer Achilles insertion to dorsum of calcaneus just posterior to
posterior facet of STJ
-weakens the triceps surae at the ankle joint by 50% but weakens
off ability by only 15%
-several fixation techniques have been described
-modification-reroute Achilles tendon
to FHL tendon
Murphy
fixation
Downey and
fixation
screw
fixation
ANKLE EQUINUS
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CHAPTER 30
TEND0 ACHILLES LENGTHENING

(performed on the conjoined tendon of the
gastrocnemius and soleus muscle)
Z-plasty
(sagittal plane)
2-plasty
(frontal plane)
Hauser
posterior 213 proximally
and medial 213 distally
ANKLE EQUINUS
513
CHAPTER 30
White
-section anterior 213 distally and
medial 213 proximally
Hoke
-triple hemisection with first and last cut
medially and second cut laterally
-these incisions are made through skin
stab incisions
Conrad and Frost

-sectioning the medial % at the distal
end and lateral % proximally
ANKLE EQUINUS
514
CHAPTER 30
REARFOOT SURGERY
515
CHAPTER 31
CHAPTER 31
REARFOOT SURGERY
AMPUTATIONS,
ANKLE ARTHROSCOPY,
ANKLE FUSIONS,
ANKLE IMPLANTS,
CALCANEAL FRACTURE REPAIR,
COMPARTMENT SYNDROME,
DISTAL
INJURIES,
EXTERNAL FIXATION,
LISFRANC'S
MPJ SEQUENTIAL RELEASE FOR A HAMMERTOE,
FRACTURE REPAIR,
SEQUENTIAL RELEASE FOR AN OVERLAPPING 5TH TOE,
STJ ARTHROEREISIS,
TALAR NECK FRACTURE REPAIR,
TRIPLE ARTHRODESIS,
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CHAPTER 31
TRIPLE ARTHRODESIS
Fusion of:
-talonavicular joint
-talocalcaneal joint
-calcanealcuboid joi
-fixation is usually with 6.5 or 7.0 mm cannulated screws for the STJ
and 2 staples at 90 for the CC and TN joints
-hind foot should be positioned in slight valgus, the body can
compensate for valgus(varus should be avoided at all cost)
-the TN fusion requires the longest time for revascularization
-the result of this procedure is that there is extra stress on the ankle joint
and the ankle joint should be free of DJD pre-op
-sliding the calcaneus posteriorly on the talus will raise the arch and
sliding the calaneus anteriorly on the talus will lower the arch
INDICATIONS
-pes cavus
-residual clubfoot
-neuromuscular dz
-calcaneal fx
-tarsal arthritis
-tarsal coalition
-collapsing pes valgo planus
-ruptured posterior tibia1 tendon
INCISIONS
Lateral incision(0llier's incision)-runs from inferior and slightly posterior
to the fibular malleolus out distally over the sinus tarsi to end at the
junction of the base of the 4th and 5th metatarsals, good access to
STJ and CC joint
Medial incision, from medial malleolus to navicular cuneiform joint,
good access to TN joint and for TC fixation
ORDER OF RESECTION AND FIXATION

-resect MTJ(CC then TN) this allows access to the STJ
-resect STJ
-temporarily fixate STJ
-temporarily fixate MTJ(TN then CC)
-check with C-arm
-fixate STJ
-fixate MTJ
POST-OP
-apply Jones compression dressing immediately post-op for 2-3
days(avoid casting because it will swell)
-remove at 48hrs
-at 2-3 days pull drain and apply a BK NWB cast
-at 3 weeks D/C cast and remove sutures
-apply removable BK NWB cast for an additional 4 weeks
-progressive WB and PT for an additional 3 months
-return to work 6 months
REARFOOT SURGERY
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CHAPTER 31
means the limitation of joint movement

-the implant devices are inserted laterally in the sinus tarsi just distal to
the posterior facet of the calcaneous
-the goal of STJ arthroereisis implants is to limit pronation and reduce
by blocking the contact of the lateral talar process against
heel
the calcaneal sinus tarsi floor
-removal of the implant in later years when the patient has achieved
skeletal maturity is controversial
-two basic types of implant, one with a stem that is fitted into a hole
drilled into the floor of the sinus tarsi and requires some bone resection.
The other type is simply screwed into the sinus tarsi with no bone
INDICATIONS
-4-8 years in children with symptomatic flexible pes

or adults
tendon dysfunction
with posterior
-TC
plane)
-50% TN articulation
-heel eversion 8-1
-FF varus
with superimposition of metatarsal on lateral x-ray
treatment should be tried for 1-2 years without success
before performing a STJ arthroereisis
IMPLANTS
Lundeen Subtalar Implant
Los Gatos, CA (800) 421-5303
-polyethylene
STA-Peg Subtalar Implant

-Wright Medical: Arlington, TN (800)
-polyethylene
REARFOOT SURGERY
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CHAPTER 31
Subtalar MBA Implant

-Maxwell-Brancheau Arthroereisis
-cannulated
-titanium alloy
-fully threaded and does not
require bone cement
-longitudinal slots absorb impact
stress
Kalix
-Newdeal(Wright Medical)Arlington,
TN (800) 238-7188
-not cannulated
-the implant is titaneum with a
polyethylene sleeve to absorb impact
stress
ANKLE ARTHROSCOPY
INDICATIONS
-joint pain of unknown etiology
-arthritis
-synovitis/capsuIitis
-loose chondral/osseous fragments
INSTRUMENTSKERMINOLOGY
Cannula-rigid hollow tube used to establish and maintain portal for both
the scope and instruments
Trochar-pyramidal(sharp) tipped rod placed in the cannula and used to
pierce the soft tissue and capsule. After the portal has been
established the trochar is removed leaving the cannula in place
Obturator-same as a trochar with a blunt tip. Less destructive when
bone contact is made. Used to penetrate the joint when placing the
cannula in an already established portal
Scope-generally a 4.0mm is used with a 30" viewing radius
Sweeping-side-to-side and up-and-down movement of the scope to
view anatomical areas
Pistoning-Moving the scope in for magnification and moving the scope
out for better orienwion
Triangulation-bringing the scope and another instrument together,
through two different portals
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CHAPTER 31
IRRIGATION
Normal saline or Ringer's solution may be used, but Ringer's is preferred because it is less damaging to chondrocyte metabolism
PORTALS
Anterior-Medial Portal-medial to anterior tibial tendon and lateral to the
medial malleolus. Avoid the saphenous nerve and saphenous vein
Anterior-Lateral Portal-lateral to the Peroneus tertius tendon and
medial to the lateral malleolus. Avoid the superficial peroneal nerve
Anterior-Central Portal-lateral to the EHL tendon and medial to the
EDL tendon. Avoid the anterior tibial artery, the deep peroneal nerve
Posterior-medial Portal-medial to the Achilles, lateral to the tarsal
canal. Avoid the posterior tibial artery, and the tibial nerve
Posterior-Lateral Portal-lateral to Achilles and medial to the fibular
malleolus. Avoid the sural nerve, lesser sa~henousvein, and
the peroneal tendons
Anter~or-lateral
nterlor-rnedlal
ortal
Posterior-rnedlal
Portal
GUTTERS
Postenor-lateral
REARFOOT SURGERY
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CHAPTER 31
AMPUTATIONS
METATARSOPHALANGEAL
AMPUTATION
TRANSMETATARSAL
AMPUTATION
LISFRANC'S AMPUTATION
CHOPART'S
AMPUTATION
-the tibialis anterior tendon is
reattached through a drill hole
in the talar neck to prevent
equinus
REARFOOT SURGERY
521
CHAPTER 31
SYMES AMPUTATION
-flaps must be planned such that the WB surface is sensate skin
-use a drain
-2 stage Symes amp.
-performed when there is an infection
-same as one step Symes Amputation but split into 2 steps
Stage I-after the talus and calcaneus are removed the void is
temporarily packed and partially sutured with retension sutures
Stage Il-performed 3-5 days later when the immediate threat of
infection has decreased. The malleoli and distal tibia are resected
and the procedure is completed
VARIATIONS OF THE SYME'S PROCEDURE

-both use a piece of the calcaneus to maintain limb length
PIRIGOFF AMPUTATION
BOYD AMPUTATION
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CHAPTER 31
LISFRANC'S FRACTUREIDISLOCATION
REPAIR
-Most injuries occur in the dorsal direction
-The Lisfranc's ligament is the strongest interosseous tarsometatarsal
ligament and the integrity of the Lisfranc's joint depends upon this ligament. It's disruption can result in the lateral displacement if the rest if
the tarsometatarsal joints.
-There is no interosseous ligaments
between the 1st and the 2nd metatarsals
LISFRANC'S LIGAMENT
-attaches the medial cuneiform
to the second metatarsal
-aka-the medial interosseous
tarsometatarsal ligament
-strongest interosseous
tarsometatarsal ligament
-this ligament plus the recessed 2nd
metatarsal are responsible for most
of the stability at the Lisfranc's joint
-responsible for the avulsion type fracture of the
base of the medial aspect of the 2nd metatarsal
DIAGNOSIS
-Stress abductory radiographs may be helpful
-Look for avulsion fractures of the 2nd metatarsal
-Though often not appreciated radiographically small fractures plantarly
are usually present along the joint and a CT may help with the diagnosis
-A dorsal or plantar deviation of the second metatarsal base from the
medial cuneiform may be palpated or appreciated radiographically
TREATMENT
Open or closed anatomic reduction with percutaneous pinning as close
to the time of injury as possible is the treatment of choice
Casting unstable joints without fixation or primary arthrodesis is rarely
effective
The second metatarsal is reduced first followed by the 1st then 3-5
Inadequate reduction results in long term arthrosis
-The
long term sequela of this injury, when not adequately reduced, is
arthrosis at which time arthrodesis is indicated
REARFOOT SURGERY
523
CHAPTER 31
CALCANEAL FRACTURE REPAIR

Lateral wall blow-out-during a Calcaneal fracture when the posterior
facet is driven down into the body of the Calcaneus it causes a hydraulic
tangential burst and the lateral wall of the Calcaneus to shear off.
repairs should be done in the 4 hour window after injury
before acute swelling begins, if you miss this window wait -7-10 days
within 2 weeks
until swelling has subsided but perform
-The goal is to reestablish height and length to the calcaneus and
realign the articular cartilage
-mechanism of injury is by way of the lateral process of the talus being
driven down into the neutral triangle
-Watch for compartment syndrome in these patients
Rowe, Essex-Lopresti, Sanders
ANATOMY
Essex Lopresti describes the most common fracture lines and fragments
for the most common fracture pat
FRACTURES
1. Primary Fracture-Common to
both fracture types. Vertical
fracture oriented from superior
to inferior at the Gissane's angle.
Due to the lateral process of the
talus being driven down into the
calcaneus.
2. Secondary Fracture-Determined
by the direction of force.
FRAGMENTS
A. Superomedial
constant fragment, sustentacular
fragment)-fragment to which all
others are fixated
Anterolateral fragnment
Lateral fragment-with the joint
depression type it's termed semil
fragment and with the tongue type it's
termed thalamic or comet fragment
typically displaced
varus and laterally
Tongue Type
REARFOOT SURGERY
524
CHAPTER 31
TREATMENT
-0RIF should be performed within 12 hours before excessive edema
prevents manipulation, if this window is exceeded wait 3-14 days until
swelling decreases, but perform ORlF within 2 weeks of injury before
hematoma organization and soft tissue contractures make manipulation
of fracture fragments difficult.
For Sanders type IV fractures primary arthrodesis is recommended due
to the high level of comminution.
-Lateral extensile incision is most popular approach
-Monitor patients closely for compartment syndrome.
SX APPROACH
-Lateral extensile incision-90 degree incision is placed on the lateral
aspect of the calcaneus. This incision is full thickness to bone and the
flap is lifted subperiosteally taking with it the peroneal tendons, the sural
n., and the extensor retinaculum.
-All fracture fragments are rebuilt and realigned to the sustentacular or
constant fragment. The sustentaculum tali usually maintains its special
position due to the numerous tendons structures holding it in place
Order of reduction:
1. Temporarily remove or fold back the lateral wall to gain exposure to
the fractures
2. Insert a Steinmann pin transversely in the posterior tubercle
fragment. This pin is used as a "joystick" to manipulate the
posterior tubercle to reestablish length and height of the rearfoot.
K-wires are then used to hold it in place by pinning it to the
sustentacular fragment.
3. Reconstruct and rearticulate the posterior facet. Use an elevator
to lift up the posterior facet and restore the subchondral bone
plate and k-wires are driven transversely thought this fragment into
the sustentacular fragment
4. Construct K-wire jail
5 . Pack any defects with cancellous bone graft(usually the area of the
neutral triangle). This step is optional
6. Lateral wall is then replaced and fixation(plates, screws, etc.)
REARFOOT SURGERY
525
CHAPTER 31
TALAR NECK FRACTURE REPAIR

-Talar neck fractures account for 50% of talar fractures
-The goal is immediate anatomical reduction and
rigid internal fixation
-While internal fixation is always required,
closed reduction should be attempted to
take pressure off any neurovascular structure
-Controversy exists regarding mechanism of injury;
forced dorsiflexion vs. axial loadina in the neurtral position
-With a Hawkins type Ill and IV the talar body disldcated posteriorly
-Canale x-ray view, a modified A/P radiograph that gives an excellent
image of the talar neck
-Fixation is accomplished from anterior to posterior with 3.5mm cortical
screws, 2 screws are recommended to prevent varus/valgus rotation of
the head. Alternatively, screws may be driven from posterior to anterior
-If screws are placed through the talar head, sink the screw heads
PlLON FRACTURE REPAIR

-These injuries tend to result in a varus deformity due to the extra
stability of the fibula
-If a fracture is "unfixable" due to severe comminution or otherwise,
treatment of choice is traction, via calcaneal pin traction(6ohler-Braun
frame) or external fixation for 5-8 weeks followed by ankle fusion.
-If ORlF is attempted treatment should be in the following order:
1.
anatomical reduction of fibula
2.
plate the fibula
3.
realign articular surface of the tibia
4.
fill void with bone graft
5.
apply buttress plate medially(to prevent varus)
REARFOOT SURGERY
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CHAPTER 31
ANKLE IMPLANTS
-Problems include: talar subsidence, loosening, and malleolar fractures
-Newer ankle implants are mobile bearing vs. fixed bearing
-Newer ankle implants consist of 3 components a metal piece that
attaches to the tibia, another metal piece that attaches to the talus and a
third piece made of a special grade surgical plastic that acts as a bearing or washer. This bearing allows for shock absorption as well as up
and down motion, side-to-side motion and rotation
-Implants are cementless
-The 3 piece implants allow both axial rotation and gliding motion in both
the mediolateral and anteroposterior directions
Agility Ankle
-Technically a 2 piece implant but
because it is a semi-constrained implant,
functions like a 3 piece
-Only ankle implant FDA approved(FDA
approved 1992)
-Insertion of this implant incorporates an
arthrodesis of the distal tibtfib requiring a
transsyndesmotic screw
-Tibia1 component is composed of titanium with a polyethylene element
secured inferiorly to articulate with the talar component. The talar component is cobaltchromium
-3 sizes available, left and right are different
-Dupuy, Warsaw, Indiana (800) 473-3789
Buechel-Pappas Implant
-New Jersey LCS(Low Contact Stress)-this is the
precursor to the BP impant
-Titanium alloy tibia1 and talar component with an
ultra high molecular weight "meniscal" element
-Talar component has a central trochlear groov
-Available in 6 sizes
-Only implant that can be used post-failed
ankle fusion(provided the fibula is intact) and
in cases of AVN of the talus
-Cremascoli Orthopedics(a division of
Wright Medical Technologies)
REARFOOT SURGERY
527
STAR
-Scandinavian Total Ankle Replacement
-3 component
-Tibia1 and talar components are made of
Chromium-Cobalt alloy
-The talar surface has a central rib
running anterior to posterior
-Hydroxyapatite-coated implant with a
polyethylene free-gliding disc between a
flat tibia1 glide plate and a talar cap
-Link, Germany
Hintegra
-3 component
-Tibia1 and talar components are made
out of Cobalt Chrome alloy with
Hydroxyapatite coating
-New Deal(Wright Medical)
(800) 447-71 55
CHAPTER 31
REARFOOT SURGERY
528
CHAPTER 31
ANKLE FUSIONS
-Gold standard for severe painful OA of the ankle
-Ankle is fused at 90"
-To fix a dorsiflexion/plantarflexion or anglular deformities on a
previously fused ankle joint, wedge resection of the tibia should be
considered
-Many techniques have been described some include resection of the
lateral malleoli for greater exposure to the joint. The malleoli may be
discarded or reapplied after cartilage resection as an onlay strut graft for
extra stability
OTHER FUSION TYPES:
Endoscopic-can't be done with varus or valgus ankle deformities
External fixation-provided excellent compression, can be used when
there is infection present, and may allow for early WB
Iliac crest distraction graft fusionankle fusion salvage p
when the talus is mis
is insufficient
Consists of a slidi
IM rod-also fused the STJ
REARFOOT SURGERY
529
CHAPTER 31
EXTERNAL FIXATION
GENERAL
Advantages:
-decreased soft tissue dissection
-in cases of large bone defects, skeletal architecture can be
maintained
-can be used with infection
-allows for adjustment to be made post-op(angular corrections,
distraction, compression)
-early ROM and early WB.
-Apply x-fix apparatus at least 2-3 cm off skin to accommodate
post-op swelling
-If a piniwire hurts it's either loose or infected
-Wires and pins should be placed bicortically, unicortical placement
burns bone causing necrosis and infection
unicortical
(Incorrect)
Bicortical
(Correct)
TERMINOLOGY
Dvnamvzation-Before the x-fix is removed the patient should go through
a period of dynamization whereby all wires and pins are loosened and
the patient is allowed to WB. This allows for axial forces without
distraction which strengthens the bone and decreases the potential of
fractures when the x-fix is removed.
Ligamentotaxis-The pulling of fracture fragments into alignment using
distraction
PlNSNVlRES
Pins-half pins have a greater diameter that wires and do not go all the
way throught the extremity. The strongest double half pin
configuration is divergent followed by convergent and then parallel.
--thinner
than half pins but 1.5-2 times stronger due to tensioning.
Tension banding wires -60(1000 N) on the foot and -130(1,40ON) on
the tibifib. When inserting wires through a muscle, ideally the muscle
should be stretched(extended) if possible.
REARFOOT SURGERY
530
CHAPTER 31
CALLUS DISTRACTION
-Preserve periosteum
-Apply pins and as much frame as possible before cutting bone
-The optimal rate of distraction is
by
intervals qid
-Compress site for 7 days prior to distraction
performed at proximal
junction
activity occurs proximally and distally to the center of
growth zone during
distraction
CROSS SECTIONAL ANATOMY AND PIN PLACEMENT
Greater Saphenous Vein
Tendons
Achilles Tendon
REARFOOT SURGERY
531
CHAPTER 31
Muscle &Tendon
Muscle
eep Peroneal
Brevis Tendons
Flexor
Tendon and Mus
Lesser Saphenous
Nerve
REARFOOT SURGERY
532
CHAPTER 31
Gastrocnemius
head
Patellar Ligament
Sartorius Tendon
ommon Peroneal
Popliteal
\
Gastrocnemius
Artery
head)
REARFOOT SURGERY
533
CHAPTER 31
COMPARTMENT SY N D R O M E ( a 1 s o see p.569)

-a 5th compartment has been described in the rearfoot called the
calcaneal compartment containing the quadratus plantae muscle. This
compartment is significant in calcaneal fractures
CAUSES
crush injuries, calcaneal fractures
SYMPTOMS
-severe pain out of proportion to injury
-pedal compartment pressures tests are unreliable, diagnosis is often
made clinically with symptoms including; tense swelling, flexion
deformities, cyanosis, absent pulses, and neurological changes
TESTING
-Wick catheter(Stryker Stick)-used to measure pressure within a leg or
foot compartment
-opinions vary regarding pressure at which a fasciotomy should be
performed ranging from from 40 mmHg to 30 mmHg
-resting intracompartment pressure is -5 mmHg, during exercise it can
get as high as 50 mmHg
-to test the central compartment, the needle is inserted from medial to
lateral just under the base of the 1st metatarsal through the abductor
hallucis muscle. As the needle is advanced through the abductor
muscle the medial compartment pressure is measured
-the central compartment can also be accessed dorsally at one of the
interspaces, the interossous compartment is measured as the needle is
advanced towards the central compartment
-to access the calcaneal compartment direct the needle in a similar
fashion to the medial approach for the central compartment but more
proximal under the calcaneus
REARFOOT SURGERY
534
CHAPTER 31
FASCIOTOMY
-either 2 dorsal incisions, one medial incision or a combination of both
-no tourniquet
-generous incisions
-the foot is fileted open but no debridement is preformed
-should be performed within 8 hours of injury, after 8 hours permanent
nerve damage occurs
-incisions are left open and delayed primary closure or skin graft is
applied 5-7 days later
DORSAL APPROACH
may be preferred if repair of a Fx/dislocation of Lisfranc's is also
planned. Incisions are made over the 2nd and 4th metatarsals
MEDIAL APPROACH
-the calcaneal compartment is accessed by a medial approach made
more proximally
REARFOOT SURGERY
535
CHAPTER 31
DISTAL TlBlOFlBULAR SYNDESMOTIC

INJURY
GENERAL
-normally the syndesmosis shows elasticity of 1-2 mm when moving the
talus from plantarflexion to dorsiflexion
-this injury is often undiagnosed in the absence of fractures(diastasis of
less than 5 rnm are difficult to diagnose radiographically)
-often present with a history of ankle sprain that was slow to heal with
pain on palpation of the syndesmosis
-pain may be present with dorsiflexion as the wider anterior portion of
the talus is rotated into the mortise and separates the bones
Complete tib-fib diastasis is traditionally associated with PER ankle
fracture
ANATOMY
-the distal tibiofibular syndesmosis is composed of 4 ligaments. From
anterior to posterior they are:
Anterior lnferior Tibiofibular ligament
Tibiofibular lnterosseous ligament
lnferior Transverse Tibiofibular Ligament
Posterior lnferior Tibiofibular ligament
Tibiofibular lnterosseous
ligament
ANTEF
Anterior Inferior
Tibiofibular ligament
lnferior Transverse
Tibiofibular Ligament
REARFOOT SURGERY
536
CHAPTER 31
DIAGNOSIS
CLINICAL
-Distal compression test:
medial lateral compression at the level of the malleoli elicits
pain due to compression of the ligaments
-Proximal compression test:
medial lateral compression at the midleg level elicits pain due
to distraction of the ligaments
-External rotation test:
Pain is elicited with external rotation of the foot when the knee is
bent at 90 and the leg is stabilized
RADIOGRAPHIC
-Tibiofibular overlap:
seen on AfP
distance between medial aspect of the fibula and the lateral
border of the anterior tibial prominence
less than 10mm is +, on the mortise view normal is 1 mm
-Tibiofibular clearspace:
seen on AfP view
distance between lateral border of the posterior tibial
malleolus and the medial border of the fibula
greater than 5 mm is +
-Medial clear space:
assessed on a mortise view
distance between the lateral border of the tibia and medial
border of the talar body should be within 1-2 mm of the
uninjured side or less than 4 mm when evaluated by itself
-Syndesmotic clear space view
distance between the incisura fibularis (tibial notch) and the
medial border of the fibula measurement is made l c m
proximal to the tibial plafond
normal is less than 6 mm on N P and mortise view
REARFOOT SURGERY
537
CHAPTER 31
TREATMENT
Transsyndesmotic screw
-surgical treatment usually includes a transsyndesmostic
screw through 4 cortices. Screws are removed at 3-4 months,
screws left in tend to fail due to the normal motion between
the tib-fib
-elastic fixation-transsyndesmotic screw going through 3
cortices of the fibula and lateral tibia, the theory being that this
will allow some motion preventing the screw from breaking
Ligament repair
-primary repair, graft repair with plantaris
Syndesmotic fusion
-controversy exists regarding the optimal position of the ankle
when performing fusion of the syndesmosis for fusion ranging
from 90 to maximally dorsiflexed
Ankle fusion
MPJ SEQUENTIAL RELEASE FOR A HAMMERTOE

1.
2.
3.
4.
5.
release of extensor expansion

tenotomyllengthening EDUEDB
transverse MPJ capsulotomy
release collateral ligaments
plantar plate release-Metatarsal(McG1amry)scoop
SEQUENTIAL RELEASE FOR AN OVERLAPPING 5TH TOE

1.
2.
3.
4.
5.
6.
Z-plasty or V-Y skin plasty

Z-tendon lengthening(for severe cases transfer tendon to met head)
Release extensor hood
Capsulotomy(dorsally and medially)
Plantar plate release(McG1amryelevator)
Plantar skin wedge excision
REARFOOT SURGERY
538
CHAPTER 31
TRAUMA
539
CHAPTER 32
TRAUMA
ACHILLES RUPTURE,
BITES-CAT,
BITES-DOG,
BITES-HUMAN,
BURNS,
COMPARTMENT SYNDROME,
FRACTURE-ANKLE,
FRACTURE-CALCANEUS,
FRACTURE-EPIPHYSEAL PLATE,
FRACTURE-JONES,
FRACTURE-NAVICULAR,
FRACTURE-OPEN,
FRACTURE-POST PROCESS OF TALUS,
FRACTURE-SESAMOID,
FRACTURE-TALAR NECK,
FRACTURE-TIBIAL
FX),
FROSTBITE,
HYPOTHERMIA,
DISSECANS,
PERONEAL
p559
PUNCTURE WOUNDS,
SPRAINS,
ANTERIOR RUPTURE,
POSTERIOR RUPTURE,
TRENCH
foot),
TURF TOE,
CHAPTER 32
TRAUMA
540
CHAPTER 32
OPEN FRACTURE
-Fx where the bone penetrates the skin
-also called compound fractures
-these injuries are obviously considered contaminated and if they have
gone without treatment for 6-8hrs they are considered infected
-open Fx's are considered a medical emergency and patients should be
admitted
CLASSIFICTION(GUSTILLO
AND ANDERSON)
TYPE l
-Fx with open wound < l c m in length
-clean, minimal soft tissue necrosis
-Fx is usually transverse or short oblique
-minimal or no comminution
-if a bone graft is required for repair, may be done immediately
TYPE I1
-Fx with open wound > I c m in length
-clean, minimal soft tissue necrosis
-Fx is usually transverse or short oblique
-minimal or no comminution
-if a bone graft is required for repair, best done at the time of delayed
primary closure when there is no evidence of infection'
TYPE Ill
-Fx with extensive open wound
-contamination andfor necrosis of skin, muscle, N N structures, and soft tissue
-often comminution
-if a bone graft is required for repair, best done at 3 months after the
reactive bone callus has deminishedl
lllA
-Type III with adequate soft tissue converage of bone
lllB
-Type Ill with extensive soft tissue loss with periosteal stripping
and bone exposure
lllC
-Type Ill injury with arterial injury requiring microvascular repair
)f an external fixator is required, a bone graft may be used at the time of initial intervention
Pen G 10-20 milllon units IV daily dividedq6h in farm accidents and other tetanus prone environment
TRAUMA
541
CHAPTER 32
TREATMENT
-C and S
-wound debridementlirrigation
-Fx stabilization
-tetanus prophylaxis
-antibiotics2(Cefazolin 1-29 IV followed by l g IVPB q8h until cultures are
available)
VASCULAR EVALUATION
-Fluorescein, a non-toxic dye, is administered IV and observed under
UV light after 10-20 minutes vascular tissue will fluoresce.
STRESS FRACTURE
-fracture in a normal bone due to cyclic loading on a bone
-95% occur in the lower extremity, most notably the neck of the 2nd
metatarsal
-may take 14-21 days to present radiographically after a bony callus has
developed. If x-rays are inconclusive a three phase technetium bone
scan may be positive as early as 2-8 days after onset of symptoms
GREENSTICK FRACTURE
-incomplete fracture in which cortex on only one side is disrupted; seen
in children due to their soft bones
TURF TOE
-traumatic soft tissue injury to the
1st MPJ caused by forced
hyperextension of the joint
-more common in sports played on
synthetic surfaces, hence the
name "turf toe"
-results in plantar capsular and
ligamentous injury
SYMPTOMS
-painful MPJ
-edema
-decreased ROM
TRAUMA
542
CHAPTER 32
JAHSS CLASSIFICATION
Type I
-dorsal dislocation of the proximal phalanx in
which the metatarsal head punctures through
the plantar capsule
-intersesamoidal ligament is intact and there
are no fractures
-deform~tyis trght and difficult to close reduce
Type IIA

the plantar capsule
-the intersesamoidal ligament is ruptured
(sesamoids no longer remain apposed to one
another)
-the deformity is loose and easier to close
reduce
Type llB
the plantar capsule
-the intersesamoidal ligament remains intact
and there is an avulsion fracture of one of the
sesamoids
-deformity is tight and difficult to close reduce
TREATMENT
-RICE
-strapping/splinting
-protective padding(i.e. dancer's pad)
-shoes with a firm sole to prevent dorsiflexion of MPJ's
SESAMOID FRACTURE
-must distinguish from bipartite sesamoid(incidence 20%)
-compare to earlier film
-irregular jagged edges of separation
-longitudinal or oblique division lines
-bone callus formation
-interrupted peripheral cortices
TRAUMA
543
CHAPTER 32
TREATMENT
-conservative-splint, dancer's pad, post-op shoe, NWB
-suraical-removal
~GsamoidRemoved Posslble Compllcatron
tiblal
hallux valgus
fibular
hallux varus
tlbial & fibular
ma~us(hammer~ng)
-
w ~ t hIPJ fuslon and Jones
suspension
ANKLE SPRAINS
DIAGNOSIS
Position of foot at time of injury
Inversion sprain with foot dorsiflexed
-calcaneofibular ligament is most likely damaged
-rupture of this ligament may also tear the peroneal tendon sheath
Inversion sprain with foot plantarflexed
-account for 95% of ankle sprains
-talofibular ligament is most likely damaged
Arthrograms
-only useful in acute ruptures while ligaments are still damaged, after
5-7 days fibrosis may seal off injury and arthrograms will be of no use
-dye is injected into the ankle joint and should remain in the ankle joint
on x-ray
-some individuals have a normal connection between the ankle joint
and the peroneal tendon sheath and should not be misdiagnosed as a
rupture
-also check the integrity of the articular cartilage, dark band of the
cartilage with the radiopaque(white) dye between-"Oreo cookie sign",
if the cartilage is damaged dye will extend into the subchondral bone
Radiographs
Anterior draw
Anterior talofibular ligament
-anterior displacement =2cm as compared to the contralateral side
indicates a ruptured
Posterior talofibular ligament
-resists posterior displacement of the talus in the ankle mortise
-rarely ruptures, only in a severe traumatic accident
Stress inversion
Calcaneofibular ligament
-talar tilt of >5" as compared to the contralateral side indicates a
TRAUMA
544
CHAPTER 32
TREATMENT
Nonsurgical treatment is aimed at decreasing inflammation and splintingisupporting the damaged tissues to prevent reinjury
Surgical treatment involves procedures that reinforce and stabilize the
damaged and elongated structures often involving tendon transfers
EVERSION SPRAINS
-Eversion sprains are very rare
Schoolfied's Procedure
The deltoid ligament is detached from the tibia, the foot is
maximally inverted and the ligament is reattached superiorly to
the dettachment site. The deltoid ligament is effectively
advanced.
DuVries Procedure
A large cruciate form incision is made in the deltoid ligament and
then sutured back together. The theory behind the procedure is
that the resultant scar tissue will effectively reinforce and
stabilize the medial ankle.
Wittberger and Mallory's Procedure

The tibialis posterior tendon is split longitudinally down to it's
insertion. Half the tendon is dettached proximally and passed
inferiorly to superiorly throught a drill hole in the distal tibia and
sutured back on itself with the foot forcibly inverted.
INVERSION SPRAINS
Brostrum Procedure
Consists of reconstruction of torn or elongated lateral ankle
ligaments and retinaculum by imbrication (overlapping) and
suturing
TRAUMA
545
CHAPTER 32
EVANS
CHRISTMAS AND
SNOOK (modified
SAMMARCO
DIRAIMONDO
TRAUMA
546
CHAPTER 32
LARSEN
MERCADO
TRAUMA
547
CHAPTER 32
ANKLE FRACTURES
1. Bosworth's Fx-Lat malleolar Fx wlankle displacement
2. Cotton's Fx-Trimalleolar Fx
3. Dupuytren's Fx-Pott's Fx
4. Maisonneuve's Fx-Prox fibular Fx(fibular neck)
5. Pott's Fx-Bimalleolar Fx
6. Tillaux-Chaput Fx-Avulsion Fx of ant inferior lat tibia1
7. Wagstaffe Fx-Avulsion Fx of ant inferior med fibula
8. Volkmann Fx-Post malleolar Fx
CLASSIFICATION(Lauge-Hansen)
SAD(~upination-~dduction)
Staae 1-Rupture of lateral collateral lig, or transverse lat malleolus Fx.
S t a ~ e2-Oblique medial malleolar Fx.
SER(Supination External Rotation)-most common
StaCJe 1-Rupture of ant inf tibiofibular lig, or a Tillaux-Chaput Fx or
Wagstaffe Fx.
S t a ~ e2-Spiral fibular Fx beginning at the level of the
syndesmosis(post. spike) SER stage 2 is the most common Fx.
Staae 3-Post. malleolus Fx (small frg) or post inf tibio-fibular lig will
rupture.
Staae 4-~ransverseFx of medial malleolus or rupture of the deltoid lig.
PAB(~ronation-~bduction)
Staae 1-Trans Fx of medial malleolus(below syndesmosis) or
rupture of the deltoid lig.
StaCje 2-Rupture of the ant inf and post inf tibio-fibular ligs or a
Tillaux-Chaput or Wagstaffe frg.
Staae 3-Oblique Fx of the fibula at the level of syndesmosis(lat spike).
-
TRAUMA
548
CHAPTER 32
Rotation)-worst kind
-Trans Fx of medial
or rupture of the deltoid lig.
2-Rupture of the ant syndesmosis and rupture of the

interosseous membrane or Tillaux-Chaput frg or Wagstaffe frg.
3-spiral Fx of the fibula above the level of the syndesmosis,
can be as high as the fibular neck (Maisonneuve's Fx)
of the post
frg)
(Based on the location of the fibular Fx with respect to the syndesmosis)

below the level of the syndesmosis
Tvpe
at the level of the syndesmosis
Tvpe
above the level of the syndesmosis
PLATE FRACTURED
Type
Type
Type
Same
Above
Lower
Through
V Really bad
TRAUMA
549
CHAPTER 32
CALCANEUSFRACTURES
Calcaneus fractures are most common in males -45yrs of age as a
result of falling from a height. 20% of calcaneal fractures are associated
with a spinal fracture between T i 2 and L2(L1 most common).
Mondor's Sign-ecchymosis going from the malleoli to the sole of
the foot, pathognomic of calcaneal fractures.
Bohler's Angle-normal is 18-40", average -30-35", decreases in
calcaneal fractures.
Gissane's Angle-normal is 120-14O0,a fractured calcaneus will
cause this angle to increase
CLASSIFICATION(Rowe)
Type IA
-Medial tuberosity Fx
Type IIA
-Post beak Fx
(no Achilles involvement)
Type IIB
Post beak Fx
(Achilles involved)
~2
TRAUMA
550
Type Ill
-Extraarticular body Fx
Type IV
-Intraart~cularbody Fx
without depression
Type V
-1ntraarticular body Fx with
depression(comrn~nution)
CLASSIFICATION(Essex-Lopresti)
(~ntraarticularcalcaneal fractures)
Type A (Tongue Fx)
-Occurs when talus IS dr~venstra~ght
down Into the neutral trlangle
-Pr~maryFx is from Gissane's angle
down to ~ nsurface
f
of the calcaneus
-Secondary Fx extendrng from primary Fx
out post aspect of calcaneus
Type B (Jo~ntDepressron)
-The vector of force IS more anteroposter~or
-Primary Fx same as type A
-Secondary Fx around post facet wrth
possible comminut~on
-Worse prognosis
CHAPTER 32
TRAUMA
551
CHAPTER 32
Sander's CT Classification
-Based on CT coronal and axial sections
-The posterior facet is divided into 3 sections by lines A and B and line
C is at the sustantaculum tali
-Fractures are classified according to the number of intraarticular fragments and the location of the fracture lines
Type 1
-Any nondisplaced intraarticular fracture
Type II
-1 fracture through posterior facet(creating 2 fragments)
'4
Type ll A
Type ll B
Type II C
Type Ill
-2 fracture through posterlor facet(creating 3 fragments)
r-?
Type Ill AB
Type Ill AC
Type Ill BC
Type IV
-3 or more intraarticular fracture lines(comminution)
TRAUMA
552
CHAPTER 32
OSTEOCHONDRITIS DISSECANS
(Talar dome fractures)
rn
MECHANISM OF INJURY 1 LOCATION OF LESION

Dors~flex~on-Inversion Anterlor-Lateral
Plantarflexion-lnvers~on ' ~edzi-?&&
i kr~
p p
mnemonic-DIAL-A-PIMP
CLASSIFICATION(Berndt-Harty)
Type I Small area of subchondral bone
compression with the overlying cartilage
intact
Type 11 Partial detached osteochondral

fragment
Type 111 Completely detached fragment

remaining in crater
Type IV Displaced osteochondral

fragment
TALAR NECK FRACTURES

Classification(Hawkin's)
Type I
-nondisplaced talar neck fracture

-only disrupts blood vessels entering the body via the dorsal talar
neck and intraosseous vessels crossing the neck(-20% chance of AVN)
Type II
-displaced talar neck fracture with subluxed or dislocated STJ
-disrupts dorsal neck arterial branches plus branches entering
inferiorly from the sinus tarsi and tarsal canal(-40% chance of AVN)
Type I l l
-displaced talar neck fracture with dislocation of the STJ and ankle joint
-all three major blood supplies are disr~pted(-100~/~
chance of AVN)
Type IV
-displaced talar neck fracture with complete dislocation of the STJ
-ankle joint plus subluxation or dislocation of the talonavicular joint
-all three major blood supplies are disrupted(-100% chance of AVN)
TRAUMA
553
CHAPTER 32
FRACTURE OF POST PROCESS OF TALUS

(Steida's process, Shepard's Fx)
-involves the lateral tubercle of the posterior process
-mechanism of injury is forced plantarflexion where the posterior
process is compressed between the posterior malleoli and the
calcaneal tuber
-must differentiate from os trigonum
-test for this fracture by plantarflexing the foot and dorsiflexing hallux,
this will elicit pain in a fracture due to the FHL which courses between
the medial and lateral posterior talar processes
-nutcracker sign-pain with forced plantarflexion of ankle
CAUSE
Excessive plantarflexion-leads to impingement against the posterior
tibia1 plafond
Excessive dorsiflexion-leads to an avulsion type fracture due to the
talofibular ligament
JONES FRACTURE
-a transverse diaphyseal Fx at the junction of the shaft and the base
distal to insertion of the Peroneus Brevis muscle. The Fx is
supraarticular on the shaft.
-a Jones Fx should not be confused with an avulsion Fx of the styloid
process
TRAUMA
554
CHAPTER 32
TlBlAL PLAFOND FX(PIL0N FX)

CLASSIFICATION(Ruedi and Allgower)
TYPe 1
Type II
-distal tibia1 Fx with

-distal tibia1 Fx
without displacement significant displacement
Type Ill
-distal tibia1 Fx with

significant displacement
and comminution
A 0 Classification(based on degree of articular

involvement)
Type A: extraarticular
A1
metaphyseal simple
A2
metaphyseal wedge
A3
metaphyseal complex
Type 6: partial articular
61
pure split
B2
split depression
63
multifragmentary depression
Type C: complete articular
Cl
articular simple, metaphyseal simple
C2
articular simple, metaphyseal multifragmentary
C3
articular multifragmentary
TRAUMA
555
LISFRANC'S FWDISLOCATION
CLASSIFICATION(Hardcastle)
Type A(tota1 or homolateral)

-disruption of the entire Lisfranc jt complex
in a sagittal or transverse plane(almost
always lateral)
-most common type
Tvpe B(partia1)
Type B1
-medial incongruity with the 1st metatarsal
forced medially
-medially displacement involving the 1st
met alone or with met's 2, 3, 4, but not 5.
Type B2
-lateral incongruity with the lesser metatarsals
forced laterally
CHAPTER 32
TRAUMA
556
CHAPTER 32
Tvpe C(divergent)
Type C1
-partial divergence with the 1st met medially
and the 2nd met laterally displaced
Type C2
-total divergence with the 1st met displaced
medially and the lesser met's displaced laterally
NAVICULAR FRACTURES
CLASSIFICATION(Watson-Jones)
TYpe 1
-navicular tuberosity
fracture
-usually caused by an
avulsion Fx of the
posterior tibia1 tendon
on forceful eversion
Type II
-avulsion fracture of
the dorsal lip
Type Ill
-navicular body
fracture
TRAUMA
557
CHAPTER 32
ACHILLES RUPTURE
Description
The Achilles tendon inserts on the middle
of the posterior aspect of
the calcaneal tuberosity. Rupture of the Achilles tendon usually occurs
in the area of poorest blood supply, 2-6 cm proximal to the calcaneal
insertion. Pt's usually remember the precipitating traumatic incident and
may hear a pop at the time of rupture. Symptoms include pain, swelling,
and weakness. Excessive dorsiflexion of the ankle when compared to
the opposite side. Active plantarflexion of the foot is still sometimes
possible with a full rupture due to the posterior and lateral muscle
groups.
and plantaris
The Achilles tendon consist of the gastrocnemius,
muscle tendons. An internal torsion in the Achilles tendon results in the
laterally on the posterior aspect of the calcaneus, while
inserts medially, and the plantaris far medially and anterior.
the
This anterior position of the plantaris means the calcaneus is a shorter
lever arm for this tendon and often after a complete rupture the plantaris
fibers will be the only ones still intact. The plantaris muscle is absent in
about 7% of the population.
Diagnosis
Test-Squeeze calf and foot should plantarflex, if not then this
indicates a rupture.
Kaaer's Trianale-Shouldn't be anything

in the triangle but with ATR there
tissue density because
is increased
the flaps of the tendon fall into the
triangle. The apex of the triangle may
be blunted from the retracted tendon.
An&-A
line drawn down the
posterior aspect of the Achilles
tendon should produce a straight
but with a ATR this angle
decreases
dell-in Achilles tendon.
TRAUMA
558
CHAPTER 32
Treatment
Conservative Tx
-older, sedentary patients
-begin with a NWB gravity BK equinus cast and gradually bring foot
up to neutral position by successive casting every 2 weeks.
Surgical Tx
-Young, athletic watients
-reapproximate iendon ends and suture
-after the tendon is repaired the foot must be cast in equinus and
worked up to neutral.
Boswo
A strip of the gastrocnemius tendon
is freed proximally, flapped distally
and passed through the proximal
Bugg and Boyd

Three fascia lata
ruptured tendon
Lindholm
TWO outer strips of the gastroc.
aponeurosis are flapped distally
to reinforce the tendon repair
Repair using P. brevis tendon

Peroneus brevis is detached from
it's insertion, placed through a
drill
join the
TRAUMA
559
CHAPTER 32
PERONEAL SUBLUXATION/DISLOCATION
-skiing is the most common sports related injury
-the patient usually complains of a "snapping" sensation during and
there after the traumatic incident
Fibula
-spontaneous relocation is common but
Fibrous Ridge
usually results in chronically dislocating
peroneals
Peroneal
Tendons
-an avulsed cortical fleck fracture may be
seen lying parallel to the lateral maleollus
on a mortise view
Retinaculum
NORMAL A N A T - w
CLASSIFICATION
(Eckert and Davis)
Grade I
(most common)
-the retinaculum
separates from the
fibrocartilagenous
ridge
TREATMENT
Grade II
-involves the fibro
cartilagenous ridge
along with the retinaculum detaching
from the fibula
Grade Ill
(least common)
-involves an avulsion
fracture of the
fibula
TRAUMA
560
CHAPTER 32
AND
-
TRAUMA
561
CHAPTER 32
TlBlALlS POSTERIOR RUPTURE

-usually occurs at the area of lowest vascularity-behindthe medial malleolus
-causes the longitudinal arch to collapse, patient may notice a
progressive unilateral flattening of their arch
-loss of forceful inversion
-have patient stand on tiptoes, the heel should invert, if it does not the
tibialis posterior may be ruptured
TREATMENT
-surgical
\rL
FHL
FHL
Cut the FDL tendon and use the proxlmal end to reinforce the ruptured tlblalls posterlor
tendon. Then suture the distal end to the tendon of the FHL to malntaln actlve plantarflexion of d ~ g ~2-5
ts
TlBlALlS ANTERIOR RUPTURE

-active dorsiflection is diminished
-usually occurs 1-2cms from it's insertion
-may see foot drop or a steppage gait
HYPOTHERMIA
PRESENTATION AT VARIOUS TEMPERATURES
98.6"F
95F
93.2"F
91.8"F
87.8"F
82.4"F
80.6"F
78.8"F
37C
35-35.5%
34C
33.2%
31C
28C
27C
26C
77.7"F 25-24C
68F
64.4"F
51 .gF
48.2"F
20C
18C
10.5"C
9C
average body temperature

patient unaware of 113 of events around them
extreme judgment errors, amnesia to current events
frequent cardiac dysrhythmias-A fib
loss of shivering
pupils dilated
flaccid body
loss of consciousness
loss of DTR's and vasoconstriction
loss of pupil reflex to light
flat EEG
lowest cardiac activity
lowest survival temperature recorded
TRAUMA
562
CHAPTER 32
TREATMENT
CAN BE DANGEROUS TO TREAT DUE TO:
-cardiac irritability
-afterdrop-paradoxical drop of core temperature occuring during
rewarming
METHODS OF REWARMING
Passive
-warm environment, insulation(blankets)
Active External -bodily contact, hot water bottle, electric blanket,
immersion, radiant warmer
Active Core
-warm IV, warm GI lavage, inhalation of heated
humidified oxygen, peritoneal lavage
-Electrocardiogram and electroencephalogram are not valid tools for
determining death during hypothermia and all available techniques of
advanced life support should be continued until the patient is rewarmed
to 35C. "They're not dead until they're warm and dead"
FROSTBITE
-injury of the tissue due to freezing
-cellular damage occurs as a result of direct injury(jagged ice crystals)
and ischemia
-if there is any possibility of refreezing, the frostbitten area should not
be thawed-refreezing increases tissue necrosis
CLASSIFICATION
First degree-superficial freezing without blistering, peeling is
occasionally present
Second degree-superficial freezing with clear blistering

Third d e g r e e -d e e p freezing with death of skin, hemorrhagic
blisters, and subcutaneous involvement
Fourth degree-full thickness freezing, resulting in loss of body

Dart
SYMPTOMS
-firm/hard and cool to the touch
-affected area appears waxy white or blotchy blue-gray
TRAUMA
563
CHAPTER 32
TREATMENT
-symptoms of pain, burning, pruritis may not be apparent until the
body part is thawed
-analgesics are usually required during thawing
-profound edema, hemorrhagic blisters, necrosis and gangrene may
occur
-superficial frostbite(frostnip) can be rewarmed by applying constant
warmth with gentle pressure from a warm hand(without rubbing) or by
placing the affected body part against another part of the body that is
warm
-full thickness frostbite is best treated by rapid thawing at
temperatures slightly above body temperature
-immerse body part in warm water 40-42"C(104-107.6F) until it has
returned to normal temperature(-30 minutes)
-keep affected area elevated at room temperature uncovered or with a
loose sterile dressing
-amputation or debridement should not be performed until a line of
demarkation between viable and dead tissue is established, this may
take 3-5 weeks
-massage, application of ice water or extreme heat is contraindicated
CHILBLAINS(Pernio)
-a recurrent localized skin lesion resulting from cold
-seen more commonly in cold climates with high humidity
-lesions are usually painful, pruritic, and burning
-lesions are edematous, erythematous or violaceous and may blister
and ulcerate
-treatment includes protecting area from trauma and secondary
infection
TRENCH FOOT(lmmersion foot)

-caused by prolonged immersion in cool or cold water
-the affected limb becomes swollen and appears waxy and mottled
-symptoms initially include numbness and tingling
-treatment includes elevating the extremity and gently rewarming the
limb resulting in hyperemia followed by erythema, intense burning and
tingling
-blistering, swelling, erythema, ecchymoses, and ulceration may occur
-a posthypothermic phase occurs at 2-6 weeks resulting in cyanosis to
the limb
TRAUMA
564
CHAPTER 32
BURNS
-intact blisters should be left alone
-circumferential burns of the extremities may restrict blood flow,
causing increased tissue pressure with resultant ischemia-in these
cases escharotomy is indicated
-dressings are applied to encourage healing and prevent infection,
topical medications for this purpose include Silver nitrate solution,
Silver sulfadiazine, and Sodium mafenide
BURN SIZE
"Rule of nines"
-used to estimate the percentage of body burned in adults
Anterior
Posterior
"Rule of Palm"
-scattered burns can be estimated by comparing size of the patient's
hand, which constitutes about 1'/,0/~ of the body surface
-NOTE: when one entire foot is burned its approximtely aquivalent to
31/2% of the body
TRAUMA
565
CHAPTER 32
rH
DEGREE
DEPTH
1st degree
Superficial erythematous
epidermis
Partial
thickness
burns
the epidermis)
Full
thickness
burns
Superficial
Partial
dermis but does thickness
not penetrate
Deep
the dermls
Partial
thickness
3rd degree
Full
(damage extends thickness
through derm~s)
(involves only
2nd degree
(involves the
APPEARANCE TEXTURE
Normal
PINPRICK
HEALING
SENSATION
5-10 days
yes
no scar
Edematous
blistered
Edematous Yes
10-21 days
minimal scar
Pink or white
Thick
Possibly
25-60 days
dense scar
No
No spontaneous
healing(usually
White, black or leathery

brown
requires skin graft)
dense scar
TRAUMA
566
CHAPTER 32
TREATMENT
-damage continues to progress from the burn site even after the
source has been eliminated
-cooling the area with cold water(25"C or 77F) can shorten this period
of burn progression
-extremly cold water or ice is contraindicated
-blisters should be left intact and covered with sterile gauze
impregnated with petroleum or antiseptic petroleum(i.e. Xeroform)
-circumferential wounds of the leg may have an eschar that constricts
and impedes circulation-escharectomy and possibly fasciotomy may
be necessary
-skin graft(autograft)
-effective topicals for burns are silver nitrate solution, silver
sulfadiazine, and mafenide acetate
-monthslyears later contractures and scarring may need to be
released to maintain a plantigrade foot
-xenograft or allograft may be effective in extensive burns to impede
dermal ischemia and provide protection of wound surface
-tetanus prophylaxis
DOG BITES
-responsible for 80% of bite wounds
-5% become infected
-organisms(no single species accounts for the majority of infections)
Staphylococcus species
Streptococcus species
Pasteurella rnultocida
Pseudomonas species
Capnocytophaga canimorsus(forrner1y DF-2)
CAT BITES
-30% become infected because feline teeth are sharp and narrow
-wounds caused by cat claws are considered equivalent to bites with
regard to infection because cats are constantly grooming themselves
and have saliva on their claws
-organisms
Pasteurella multocida(responsiblefor the majority of infections)
-Pasteurella infections advance rapidly(within 24hrs)-important
diagnostic tool because most other pathogens take longer then 24hrs
to manifest
TRAUMA
567
CHAPTER 32
Cat-scratch disease(fever)
-infectious organism is Bartonella henselae
-symptoms:
tender raised papule at site of inoculation
followed by local lymphadenopathy
low grade fever and malaise
HUMAN BITES
-30% become infected(1nfection numbers vary)
-organisms(higher percentage of anaerobic infections than in other
animal bites)
-Streptococcus species(esp. Streptococcus viridans )
-Staphylococcus species
-Eikenella corrodens(acts synergistically with viridans
streptococci to produce a more fulminant infection)
-Haemophilus influenzae
-anaerobic species(Bacteroides, Fusobacerium, Prevotella,
Porphyromonas, Peptococcus, Peptostreptococcus)
BITE CATEGORIES
occlusional iniuries-actual biting of another person or self
clenched fist iniuries(CF1)-occurs when one person strikes another in
the mouth with a clenched-fist. Despite their innocuous appearance can
result in serious infections because once the long extensor tendons over
the knuckles retract they carry bacteria deep into the tendon sheath.
-human bites are also capable of transmitting infectious disease such as
hepatitis B or HIV
TREATMENT FOR HUMANIANIMAL BITES

wound management
-aerobiclanaerobic cultures, gram stain
-x-ray(check for Fx, OM-base line)
-irrigate copiously
-suturing the wound is controversial-facial wounds are usually sutured
for cosmetic reasons
antibiotic orophvlaxis
-recommended for all human bites, most cat bites but only in highrisk(bites on the hand, bites extending into a joint or to bone) dog bites
-Penicillin-drug of choice
Amoxicillin/clavulanic acid(Augmentin) 250-500mg PO tid will
cover most bite pathogens
TRAUMA
568
CHAPTER 32
vaccinations
-the need for a tetanus shot should be evaluated
-the need for rabies prophylaxis should be evaluated
-bites of household pets-If the dog or cat is healthy and available for
observation for 10 days, a rabies vaccine is not required unless the
animal develops rabies
-other animal bites-contact the local health department and consult
about the prevalence of rabies in the species of animal involved
PUNCTURE WOUNDS
-puncture wounds resulting in cellulitis-usually caused by
-puncture wounds resulting in osteomyelitis-usually caused by
Pseudomonas aeruginosa
TRAUMA
569
CHAPTER 32
COMPARTMENT S Y N D R O M E ( a l s 0 see p.533)

Increased pressure in one of the osseo-fascia1compartments of the leg
or foot resulting in closing off of blood supply. An acute ischemic
episode ensues resulting in necrosis of muscle and nerve followed by
replacement with scar and subsequent contractures(Volkmann's contractures). Compartment syndrome can occur in the foot but is much more
common in the leg where there is more muscle that can absorb fluid.
Requires rapid diagnosis and treatment to avoid irreversible nerve and
muscle damage. Acute compartment syndrome left untreated for more
than 12 hours usually results in irreversible muscle or nerve damage.
SIGNSISYMPTOMS
-severe pain(out of proportion to clinical signs)
-paresthesias
-pulses and SPVPFT are usually intact(a1though elevated enough to
cause muscle and nerve damage, compartment pressure is rarely high
enough to occlude major vessels)
-contractures
DIAGNOSIS
-various catheter devices have been developed which can be inserted
into specific compartments to measure pressure
-normal intramuscular pressures at rest is 4 mmHg
-during contraction IM pressure increases to greater than 50 mmHg
-within 5-10 minutes after contraction pressure returns to normal
-IM pressure greater than 3OmmHg for at least 8 hours is indicative of
compartment syndrome
CAUSE
-trauma(most notably crush injuries)
-surgery
-burns
-exercise
-tight cast
TREATMENT
-open fasciotomy should be performed as soon as possible to preventnecrosis and contractures
-long incisions are made into the foot and left open to depressurize the
compartment
-wounds are closed secondarily in 5 days
TRAUMA
570
CHAPTER 32
COMPARTMENTS
OF-THE
FOOT
-- - -- - -
--
--
COMPARTMENT
- - - - - - - - - - _ - BORDERS
- - Medial
-dorsal
I
I
inferior surface of
I
I
the lSt
metatarsal
shaft
I
-plantar and medial
I
I
medial portion
I
plantar aponeurosis
I -lateral
CONTENT
c
--------- l
-abductor hallucis
-flexor hallucis brevis
1 -tendon-FDL
1
I
I
Central
I
7----------
--
interosseous fascia -lumbricles

I -plantar
-quadratus plantae
,1
central portion of
-adductor hallucis
I
plantar aponeurosis -tendons:FDL
I
I -medial
I
PT
I
medial IM septum
peroneus longus I
-lateral
'- lateral lhl>e$tum
-_
_
-dorsal
I -abductor digiti minimi ,
I
inferior surfaceof 5th -flexor diaiti
- minimi
I
metatarsal shaft and '
' lateral lM septum
-plantar and lateral
I
lateral portion plantar ,
' aponeurosis
I
I
-medial
I lateral-IM
-s e @ w + ---dorsal
, -all 4 dorsal
inferior surfaces of interosseous muscles
the shafts of
I :all 3 plantar
I
the metatarsals
, lnterosseous muscles
:-plantar
I
I
interosseous fascia
I
I
I -lateral
, shaft of 5th
metatarsal and part
of the lateral lM
I
I
septum
-medial
I
, shaft of 1st metatarsal
, and part of the
I
I
, _ m _ e d i a l l ~ s ~ t uI
m.
-I
I
-8
Lateral
---- -- -
'Interosseous
--
- -
'
EMERGENCY MEDICINE
571
CHAPTER 33
CHAPTER 33
EMERGENCY MEDICINE
INSULIN SHOCK, p572

DIABETIC KETOACIDOSIS, p572
SYNCOPE, p573
MALIGNANT HYPERTHERMIA, p574
LOCAL ANESTHETIC TOXICITY, p575
ACUTE ASTHMATIC ATTACK, p575
ANAPHYLAXIS, p576
ANAPHYLACTOID REACTION, p576
CPR, p577
ACLS, p580
EMERGENCY MEDICINE
572
CHAPTER 33
INSULIN SHOCK
-hypoglycemia(plasma glucose of <5Omg/dL)
Causes
-overdose of insulin
-skipped meal in an insulin dependent diabetic
-strenuous exercise in an insulin dependent diabetic
Symptoms
-Tachycardia
-hunger
-increased irritability(nervousness)
-sweating and clammy(fainting)
-mental confusion and bizarre behavior
-seizures
-mild hypothermia
-coma
Treatment
If conscious
-give fruit juice(orange juice)
If unconscious
-IV 50% dextrose(50ml at 10ml/min)
-most patients regain consciousness in 5-10 minutes
DIABETIC KETOACIDOSIS
-complication of diabetes melitus resulting from extreme
hyperglycemia
-plasma glucose in the range of 350-900mgldL
Causes
-failure to take adequate amounts of insulin
-1 st manifestation of an undiagnosed diabetic
-conditions that increase the patients requirements for insulin

(infection, trauma)
Symptoms
-orthostatic hypotension with tachycardia and poor skin turgor(due to
dehydration)
-abnormal mentation or unconscious
-Kussmaul breathing-deep, rapid respiratory pattern(due to acidosis)
-fruity breath odor(due to acetone)
-UA is strongly positive for both glucose and ketones
EMERGENCY MEDICINE
573
CHAPTER 33
Treatment
-Insulin
-IV fluids
-in severe cases give bicarbonate to correct pH
SYNCOPE
-fainting
-vasovagal response
-temporary inadequate supply of blood to the brain
Causes
-fear/anxiety
-pain
-hot airless room
Symptoms
PRODROME(prior to fainting)
-lightheaded, yawning
-nausea
-patient complains of feeling hot
-dimming of vision
-skin is cool, clammy, pale, and diaphoretic
-tachycardia
UNCONSCIOUSNESS
-slow weak pulse(bradycardia replaces tachycardia)
-abnormal movements may be noted during unconsciousness
Treatment
-lay patient flat
-loosen neckwear
-inhalation of aromatic spirits of ammonia
-on recovery rest the patient and administer sips of water
-syncope may reoccur, especially if the patient stands up within 30
minutes after the attack
EMERGENCY MEDICINE
574
CHAPTER 33
MALIGNANT HYPERTHERMIA
-catastrophic reaction to general anesthesia
-an inherited trait(l:20,000)
-results from exposure to inhaled anesthetics
-due to a reduction in the reuptake of calcium by the sarcoplasmic
reticulum
-most frequently seen when receiving a combination of muscle
relaxant(usually succinylcholine) and inhalation general
anesthetic(most often halothane)
-life threatening elevation in body temperature
-overall incident of 1 :50,000
Symptoms
-fasciculations
-increased muscle tone
-jaw clenching during anesthesia induction is a typical early sign
-body muscles become rigid
-excessive body heat production
-tachycardia, tachypnea, unstable BP, arrhythmias
-cyanosis(mottled skin, dark blood at op-site)
-profuse sweating
-muscle rigidity, cardiac arrhythmias, fever, acidosis, and shock
Treatment
-surgery and anesthesia are discontinued
-patient must be cooled(lV iced Saline-not Ringer's) and surface
cooling with ice
-IV Dantrolene 2.5mglkg
-if suspect possible malignant hyperthermia patient, do pre-op CPK
level, it's elevated in 79% of patients with malignant hyperthermia
-oral Dantrolene 1-3 days after episode
-avoid amide locals if patient has a history of malignant hyperthermia
-management of metabolic acidosis
-muscle biopsy and elevated CK levels may be helpful to identify pre-op
EMERGENCY MEDICINE
575
CHAPTER 33
LOCAL ANESTHETIC TOXICITY

Cause
-exceeding toxic dose levels
-accidental intravascular injection
Symptoms
-primarily involves the central nervous system and at higher plasma
concentrations the cardiovascular system
CNS stimulation
-restlessness, agitation, confusion, dizziness, perioral paresthesias,
tinnitus, tremors of the face and distal extremities, tonic clonic(Grand
Mal) convulsions may follow
CV toxicity
-CV stimulation(HTN, tachycardia) usually begins after signs of CNS
toxicitv develop and are more a result of hvpoxia than a direct action
of the-anestheiic. Further increase in blood concentration leads to
CV depression; bradycardia, hypotension, and heart block which
may lead to cardiac arrest.
Treatment
maintain airway
0 2
twitching/convulsions
Valium 5-10mg IV/IM
cardiac depression
Atropine 0.4mg IV
epinepherine or Metaraminol 2mg IV/IM
ACUTE ASTHMATIC ATTACK

-characterized by a variable and intermittent degree of lower airway
obstruction caused by a narrowing of bronchioles due to smooth
muscle hyperactivity and edema of the mucosa
Symptoms
-breathlessness with expiratory wheezing
-cyanosis
Cause
-allergies(grass, pollen, animal hair)
-drugs
-emotional stress
Treatment
-reassurance, rest, 0 2
-at risk patients may carry an aerosol inhaler containing a
bronchodilator(salbutamol, terbutaline)
-epinephrine(same dosagelconcentration as in anaphylaxis) SQ every
20 minutes up to 3 doses. If no relief aminophylline(theophylline) IV
5-6mg/kg over 20 minutes
EMERGENCY MEDICINE
576
CHAPTER 33
ANAPHYLAXIS
-an explosive systemic allergic reaction that occurs in a previously
sensitized person who again receives the sensitizing antigen
-an IgE mediated reaction
-histamines, leukotrienes, and other mediators are released from
basophils and mast cells
C a u s e s ( c a n be just about anything)
-narcotic analgesics
-local anesthesia(esters > amides)
-drugs(PCN, sulfonamides, ASA)
-foods(nuts, strawberries, shellfish, eggs)
-bee stings
Symptoms
-typically within 1-1 5 minutes
-patient feels uneasy, becomes agitated and flushed
-urticaria(local wheals and erythema in the dermis)
-angioedema(similar to utricaria but over a larger area and involves
the SC as well as the dermis, often occurs in the eyelids, lips, or
tongue)
-pruritus
-dyspnea/apnea due to laryngeal edema and bronchospasm
(responsible for most fatalities)
Treatment
-inject .3-.5ml(.3cc-.5cc) 1:1000 epinephrine IM or SC(can also be
given IV but use caution due to possible arrythmias)
-If anaphylaxis is due to a reaction on an extremity(i.e. bee sting,
vaccination or other injection), apply tourniquet and inject another
.25ml epi 1 : 1000 SC at site
-PO/IM/IV antihistamines
ANAPHYLACTOID REACTION
-similar to anaphylaxis, but can occur after the first exposure. It does
not require sensitization. These reactions have a dose-related toxic
idiosyncratic mechanism rather than an immunologically mediated one.
EMERGENCY MEDICINE
CPR
577
CHAPTER 33
ADULT, CHILD(1-8YRS), AND INFANT(<1YR)

(determine unresponsiveness)
I
( activate EMS)
head tilt-chin lift
look, listen, feel(3-5seconds)

I
mouth to mouth
2 breaths(rate of 10-20/min)
for infants place mouth over the infants mouth and nose
ventilation unsuccessful
check carotid pulse
(5-10seconds)
Infants-check brachial pulse
(no pulse)
continue respiration
(10-12/minute)
After 4 cycles of compressions and ventilations, reevaluate the victim for signs
of circulation. If signs of circulation are
absent, resume CPR, beginning with
chest compressions
Adults-the depth of compression for an adult
should be 111,-2, at a rate of 80100lmin.
hands placement, on the lower half of the sternum
Child-the depth of compression for children
should be 1-Ill,", at a rate of 100lmin. hands
placement, the middle finger of the rescuer's
hand, farthest from the child's head, is placed
on the xiphold process the heel of the opposite
hand is then placed just above the index flnger
Infants-thedepth of Compression for infants

should be '/,-In, at a rate of 100lmin. hands
placement, the index finger of the rescuer's
hand farthest from the infant's head is placed
just inferior to an imaginary line connecting
the nipples(intermammary line). The middle
and ring finger are then placed on the
sternum adjacent to the index finger
EMERGENCY MEDICINE
578
CHAPTER 33
CHOKING VICTIM ADULT, CHILD(I-8 YRS)

conscious patient
unconscious patient
continue untildislodged or patient
victim becomes unconscious
finger sweep'
(6-10 abdomial thrusts
continue until
successful
(
)
'HEIMLICH MANEUVER-stand behlnd vlctlm,

wrap arms around vict~m'swalst. Make a fist
w ~ t hone hand, the thumb side of the fist IS
placed against the vict~m'sabdomen, in the
m ~ d l ~ nslightly
e
above the navel and well
d
The fist
below the tlp of the x ~ p h o ~process.
IS arasoed with the other hand and oressed
~nt; the victim's abdomen with 6-lo'qu~ck
upward thrust. This should be continued unt~l
the object is expelled or until the victlm
becomes unconscious.
Pregnant women-place flst on the sternum
and dellver 4 thrusts d~rectlybackward. do not
:xed force upward or downward.
For adults perform a "blind finger sweep, for
children do not attempt a blind flnger sweep.
Only perform a finger sweep on children when
foreign objects can be visualized and
removed
EMERGENCY MEDICINE
579
CHAPTER 33
conscious victim
unconscious victim
becomes unconscious
<?t
victim becomes unconscious
re~ositionhead and \
attempt ventilations again
tongue-jaw lift
look for and remove any
visible foreign body
%
5 back blows.
continue until
successful
tongue-jaw lift
look for and remove any
visible foreign body
-
--
back blows are del~veredbetween the shoulder blades
-- -
Thest thrusts are glven In the same locatlon

as infant chest compress~onsfor miant CPR
EMERGENCY MEDICINE
580
CHAPTER 33
ACLS-universal al~orithm
I determine ~nres~onsivenessl
pz'mq
I
call for defibrilator
open airway
head t~lt-chinlift
ldetermine breathlessness 1
look, listen, feel(3-5seconds)
breathing
place in rescue position
-rescue
-endotracheal
breathing intububation
-oxygen
-history
-physical examination
-viatalsians -monitor, 12 lead ECG
e
start CPR
go to algorithm
-confirm tube
placement
-confirm ventilations
-determine rhythm
and cause
pulmonary edema
go to algorithm
pg. 587
arrhythmia
too slow
go to algorithm
pg. 584
too fast
go to algorithm
Pg. 585
1I
electrical activity?
1I
Asystole
go to algorithm
p g 583
11
PEA
go to algorithm
Pg. 582
EMERGENCY MEDICINE
581
CHAPTER 33
-perform CPR until defibrillator attached

- V F N T present on defibrillator
II
defibrillate up to 3 times if needed for persistent

V F N T (200J, 200-300J, 360J)
I
rhythm after the first 3 shocks?.
persistent or
recurrent
return of
Asystole
circulation
pg. 583
pg. 582
-support airway
-support breathing
-provide medications appropriate
for blood pressure, heart rate,
administer medication of probable benefit(C1ass Ila)

in persistent or recurrent V F N T $ *
defibrillate 360J, 30-60s after each dose if medication^^

pattern should be drug-shock, drug-shock
Class I. def~nitelyheipful
Ciass I l a acceptable, probabiy helpful
Ciass Ilb acceptable. posslbly helpful
Class Ill not ~ndicated,may be harmful
'Precardial thump 1s a Class Ilb actlon ~n w~tnessed
arrest, no pulse, and no defibn'ilator~mmediaielyavailable
B H y p ~ t h e r mcardiac
i~
arrest IS treated differently afler
this point. See sectlon on hypothermla
#Therecommended dose of eplnephrine IS l m g IV
push every 3-5m1n If this approach falls, several
Class Ilb dosing regimens can be considered
-intermed!ate, epinephrine 2-5mg IV ush every 3-5mln
-escalatln~eplnephrlne 1 mg-3 mg-5 push(3 mln apad)
-h~gh.eplnephrlne 0.lmgik 1V push every 3-5mln
"Sodium bicarbonate(1 rn?!q/kg)
s Class i if patlent
has know pieexistin hyperkalemla
"Multiple sequenced shacks(200J. 200-300J. 3604 are
acce table heie(Ciass I), especially when medlcat~ons
are telayed
'i-Lidocaine 1.5mgIk IV push Repeat ~n3-5min to

total loadlng dose of h g I k then use
-8retyliurn 5mgikg IV pus? Repeat ~n5mln at
IOmgIkg
-MsQnerlumsulfate 1-29 IV in torsades de polntes
or suspected hypomagnesemlc state or severe
refractory VF
-Procalnamide 3Omgimln In refractory VF(max1mum
total 17mglkg)
S o d i u m bicarbonate(1mEqikg IV):
Class lla
- ~known
f
preexisting blcarbanate-responsive acidosls
-if overdose with Incyclic antidepressants
-to alkailn!ze the urlne In drug overdoses
Class Ilb
-if mtubated and continued long arrest interval
-upon return of spontaneous c~rculat~on
affer long
arrest Interval
Class Ill
-hypoxic lactic acidosls
EMERGENCY MEDICINE
582
CHAPTER 33
ACLS-pulseless electrical
PEA includes -electromechanical
-pseudo-EMD
rhythms
-ventricular escape rhythms
rhythms
idioventricular rhythms
-continue CPR
at once
-obtain
access
-assess blood flow using Doppler ultrasound
CONSIDER POSSIBLE CAUSES

(parentheses = possible therapies and treatments)
infusion)
-cardiac
-tension
decompression)
hypothermia algorithm, section IV)
-massive pulmonary
thrombolytics)
-drug overdoses such as tricyclics, digitalis,
calcium channel blockers
-massive acute myocardial
to acute MI algorism
II
bradycardia, give atropine l m g
Class i
helpful
Class
acceptable, probably helpful
helpful
Class Ilb'acceptable.
Class
not
may be harmful
"Sodium bicarbonate
Class
has known
hyperkalema
"Sodium bicarbonate
Class
known
overdose
-to
the
drug
and long arrest
-upon return of spontaneous
arrest
Class
"The recommended dose of
push every
ths approach fall, several Class
can be
epinephrine
epinephrine
'Shorter atropine
cardac
push, every 3-5mn

are
helpful
EMERGENCY MEDICINE
583
CHAPTER 33
-intubate at once
-obtain IV access
l ~ o n s i d e possible
r
causes
-hypoxia
-hyperkalemia
-hypokalemia
-preexisting acidosis
-drug overdose
lconsider immediate transcutaneous pacing(TCP)(
l ~ ~ i n e p h r i n1mg
e IV push, repeat every 3-5min
of efforts
Class I def~nltelyhelpful
Class Ila, acceptable, probably helpful
Class Ilb acceptable posslbly helpful
Class ill not ndlcated. may be harmful
IS a Class Ilb lntewenton. Lack of success may
be due to delays In paclng To be eflectlve TCP must
be performed early, smultaseously with dru s
Evdence does not support routine use of T ~ for
P
d,,,,,,
-Escalating epinephrine l m g - 3 ma-5 rng IV push(3
- ' S h o ~atropine
l
dosng ntewals are Class Ilb 1s asys~ O I Carrest
"Sodium bicarbonate 1mEqIkg
Class l a
- ~known
f
preexlstlng bcarbonate-responsive actdosls
-11overdose with trlcycl~cantdepressants
-to alkalnize the urine n drug overdoses
Class Ilb
- f lntubated and contnued iong arrest l n t e ~ a l
-upon return of spontaneous crculatlon atler long
arrest ntelval
Class Ill
-hypoxlc iact~cacldosls
' I f patient remalns n asystole or other agonal rhythms
afler successful ~ntubatlonand n t a rnedlcatons and
no reversible causes are Identlfled, conslder terrnlnation nf resoscitative efforts bv a ohvscan.
EMERGENCY MEDICINE
584
-secure airway
-administer oxygen
-start IV
-attach monitor, pulse
oximeter, and automatic
s~hvamomanometer
CHAPTER 33
-review history
-perform physical exam
-order 12-lead ECG
-order portable chest
roentgenogram
bradycardia
either absolute(c60 beatslmin) or relative
K+?
serious signs or symptoms?
INTERVENTION SEQUENCE
-Atropine 0.5-1 .Omg(l & Ila)
type II second-degree
-TCP, if available (I)
AV heart block? or
--Dopamine
5-20~m1kgper
third degree AV heart
min(llb)
block?
-Epinephrine 2-10pm per min (Ilb)
-1soproterenol
YES
NO
lobserve1
--
~Geparefor transvenous paced

luse TCP as a bridge device
- -
'-Serious signs or symptoms must be related to the

siow rate
Cllnlcal man~festatlonsInclude:
-symptoms(chest paln, shortness of breath decreased
level of consciousness) and slgnsilow BP. shock. pulmonary congestion, CHF, acute MI)
"Do not delay TCP while awaltlng IV accesg or lor
atropine to take ettect f patient IS symptomat~c.
'"enervated transplanted hearts will not respond to
atropine. Go at once to pacing. catecholamine ~nfui-Atroplne should be glven in repeat doses In 3-5mln
up to total of 0,04mg/kg. Consider shorter daslng Inter-
vals ID severe cllncal condltons. It has been suggested that atroplne should be used with cautlon in atrioventncular(AV) block at the Hls-Purklnle level (type II
AV block and new thlrd-degree block with wlde QRS
complexes) (Class lib)
2iNever treat thlrd-degree heart block plus ventrlcular
escape beats wlth lidocaine.
"Isoproterenol should be used, 11at all, with exteme
caut~on At low doses 11IS Class Ilb(possibIy helpful),
at higher doses t 1s Class Ill (harmful)
loVenh/patlent tolerance and mechanical capture Use
analgesa and sedatlon as needed
EMERGENCY MEDICINE
585
CHAPTER 33
ACLS-tachycardia
-access ABCs
-secure airway
-assess vital signs

-review history
oximeter, and automatic roentgenogram
lcomplex width?
-may give brelf tnal of medicationbased on

arhythmia
Adenosine
6mg, rapid IV push
1
12mg, rapid IV push
over 1-3s(mayrepeat
5-IOmgIkg
over 8-IOmin,
maxlmum total 30mgkg
1:~-blockers1
Diltiazem
-
- -
'Unstable condlton must be related to the tachycard~a

Signs and symptoms may include chest pan. shortness of breath, decreased level of consciousness low
BP, shock, pulmonary congestion. CHF acute MI
"Carotd $,nus pressure IS contraindcated ~n patients
w t h carotid biuts, a v o ~ dc e water immersion In

patlents wlth s c h e m c heall dlsease.
'If the wde-complex tachycard~aI S known wlth certalnty l o be PSVT and BP is normallelevated. sequence
can nclude verapamil.
EMERGENCY MEDICINE
586
CHAPTER 33
ACLS-electrical cardioversion
(with the patient not in cardiac arrest)
(~achycardiawith serious signs and symptoms related to the tachycardia
May give brief trial of medications based on specific arrhythmias.

Immediate cardioversion is generally not needed for rates < 150 bpm.
-Oxygen saturation
-Suction device
-IV line
l~remedicatewhenever possible'
Synchronized c a r d i o v e r s i ~ n ~ , ~
PSVT5
-----
IOOJ, 200J,
-------
Effective realmens have lncluded a sedatve(eg.

dazepam, midazolarn barbtturates, etomdate, ketamlne, methahexltal) wlth or without an analgeslc
agent(eg fentanyl. morphme meperidme) Many
expeds recommend anesthesia 11 service IS readily
available
2 N o t e need to p o s s i b l e
resynchronize
after
e a c h cardioversion
~~
If delays ~nsynchranlzatlon occur and cllnlcal condlt ~ o n sare crltlcal. go to ~rnrnedlateunsynchronzed

shocks
'Treat polymorphic VT(1rregular form and rate) l k e VF
200J 200-300J. 360J
,PSVT and atral fluner ohen responds to lower energy
levels(start with 50 J )
EMERGENCY MEDICINE
587
CHAPTER 33
ACLS-hypotension, shock. and acute ~ u l -
ary edema
Clinical signs of hypoperfusion, congestive heart failure, acute
pulmonary edema
-assess ABCs
-assess vital signs
-secure airway
-review history
-administer oxygen
-perform physical examinatior
-start IV
-order 12-lead ECG
-order portable chest x-ray
-attach monitor, pulse oximeter,
I automatic sphvamomanometer
vof
Rate ~ r o b l e m
I
l ~ h aist the nature
Administer
-fluids
-blood transfusions
-cause-specific interventions
-consider vasopressors,
if indicated
v
Diastolic BP
>I10 mm Hg2
0.5-1.Ornglkg
-Morphine IV 1-3mg
-Nitroglycerin SL
-0xvaenl1ntubatePRN
(if BP > 100rnmHg)

-Nitroprusside IV
(if BP > 100mmHg)
-Dopamine
(if BP < 100mmHg)
-Dobutamhe
11fRP > 100mmHo\
I:p&~tive end-exp?;atory
pressure (PEEP!
-Continuous posltlve
alrwav ~ressure(CPAP)
I
-
'Base management after t h l ~

polnt on lnvasive hemodynamlc monttorlng ~f possble
'Fluid bolus af 250-500ml normal saltne should be
tried If no response. consder sympathommetlca
per min(~fother drugs fall)

-Aminophylline 5mgIkg ( ~wheezing)
f
-Thrombolytic therapy (if not in shock)
-Digoxin (if atrlal f~brillat~on,
supraventricular tachycardias)
-Angioplasty (if drugs fail)
1-lntra-aortic ballon pump (br~dgeto
II
-Surgical interventions (valves, coronary

surge*i'
arterv hvnass nrafts heart transolant)
- - -
'Move to dopamlne and stop norep~nephrnewhen BP

lmproves
A d d dopamtne(and avold dobutamlne) ~f systollc BP
drop below 100mm Hg
EMERGENCY MEDICINE
588
CHAPTER 33
ACLS-acute mvocardial infarction

Community
-community emphasis on "call firsticall fast, call 911"
-National Heart Attack Alert Program
EMS SYSTEM
EMS system approach that should address
-oxygen-IV-cardiac monitor-vital signs
-nitroglycerin
-pain relief with narcotics
-notification of emergency department
-rapid transport to emergency department
-prehospital screening for thrombolytic therapy
-12-lead ECG, computer analysis, transmission to emergency department
-Initiation of thrombolytic therapy
Emergency Department
"Door-to-drug" team protocal approach
-rap~dtriage of patients with chest pain
-clin~caldeclsion maker established (emergency physician,
cardiologist, or other)
Assessment
Immediate:
-vital slgns with automatic BP
-oxygen saturation
-start IV
-12-lead ECG(MD revlew)
-brief, targeted history and
physical
-decide on eligibility for
thrombolytic therapy
Soon:
-chest roentgenogram
.blood studies(electrolytes,
enzymes, coagulation studies)
-consult as needed
Treatments to consider if there is

evidence of coronary thrombosis
plus no reasons for exclusion (some
but not all may be appropriate)
-oxygen at 4Umin
-nitroglycerin SL, paste or spray (if
systolic blood pressure >90 mm Hg)
-Morphine lV
-Aspirin PO
-Thrombolytic agents
-Nitroglycerin iV (limit systolic BP
drop to 10% if normotensive; 30%
drop if hypertenslve; never drop
below 90 mmHg systolic)
-P-Blockers IV
-Heparin IV
-Percutaneous transluminat~on
coronaly angioplasty
-routine Lidocaine admin~stration
patlents wlth AM1
in emergency
thrombolytic
therapy
EMERGENCY MEDICINE
589
CHAPTER 33
Biblioaraphy
CPR, Choking victim, and ACLS algorisms where reproduced with
permission from JAMA, Oct 28, 1992 Vol 268, No. 16 "Copyright 1992.
American Medical Association".
EMERGENCY MEDICINE
590
CHAPTER 33
PODIATRIC ABBRIVIATIONS
591
CHAPTER 34
CHAPTER 34
a
AAA
before
autolyzed antigenextracted alio
AFL
AFO
AAO
AACPM
alert, awake, and oriented

Americal Association of Coileges of
AFP
AHCPR
AAWM
American Academy of Wound

Managment
as tolerated
AK
AKA
AAT
Ab
ABC
Abd
ABE
ABG
ABI
ABPO
ABPS
absolute blood count

count
absolute
aneurysmal bone cyst
airway, breathing,
American Board of
and Primary
abdomen
abductor
acute bacterial
arterial blood gas
ankle brachial
American Board of
Orthopedics
Board of
Surgery
absolute bed rest
Accucheck blood sugar at bedside
ABR
ABS
ABX
AC
before meals
ACD
allergic contact
ACE
enzyme
College of Foot and
ACFAOM
Ankle Orthopedics and
ACFAS American College of Foot and
Ankle Surgeons
acetylcholine
ACL
anterior
ligament
support
ACLS
advanced
ACU
ambulatory care unit
AD
diagnosis
Alzheimer's dz
ADA
ADD
ADM
ADR
AFB
AF
dermatitis
Diabetic
adduction
attention
average dally dose
admission
adverse drug
bacilli
A-line
ALL
ALP
ALS
ALT
ALZ
AM
AMA
AMB
atrial flutter
ankle
ankle-foot
Agency for Health Care Policy and
Research
inferior
above knee
above knee amputation
ketoacidosis
also known as
arterial catheter
alkaline phosphatase
acute lateral sclerosis
support
advanced
alanine
Alzheimer's dz
against medical
American
ambulate
acute myocardial infarction
ANA
A
AODM
AP
A&P
APAP
Arbeitgemeinschaft fur
Osteosynthesisfragen
(translated.
for the
Study of Internal Fixation)
Appliances
All
adult onset
anterior-posterlor (x-ray)
assessment and plan
N acetyl-para-aminophenol
APMSA
Students Association
APMSB
Board
APGAR
pulse,
irritability).
tone), and
respiration
activated partial thromboplastin
ARC
ARDS
ART
ASA
related complex
American Red Cross
syndrome
adult respiratory
arthroscopic reduction and
fixation
Achilles reflex test
Association for the Study of Internal
AST
ATF
ATL
ATR
AVB
AVD
AVN
AVSS
AZT
Bab
BAND
BB
BBB
BIC
BCC
BCP
BGL
BID
BIL
BK
BKA
iliac spine
arteriosclerosis obliterans
aspartate
anterior
Achilles tendon
Achilles tendon rupture
tendon repair
block
aortic valve dz
necrosis
signs stable
afebrile,
black
before
benign
Babinski
band neutrophil
barium swallow
beta-blocker
blood bank
blue
both bones
breast
blood brain barrier
bundle branch block
because
basal cell carcinoma
birth control pills
blood cell profile
birth date
birth defect
dead
UK
for
basal ganglion
blood glucose
bone graft
blood glucose level
a
in die")
below knee
BIL
BLE
BLS
BM
bilateral
both lower
support
black male
bowel movement
BMK
BMP
BP
BPM
BPN
BPR
bathroom
BRB
BRP
BS
bright red blood

bathroom
barium swallow
BT
BUN
CABG
CAD
CAL
CANC
CASPR
CAT
CBC
CBR
CC
C&C
a day
metabolic panel
bathroom
blood pressure
birth place
beats per minute
polymyxin B, and
neomycin sulfate
blood per rectum
CHAPTER 34
BR
Bx
BZD
c
CI-CV
CA
below knee
below knee amputation
BKWP
592
CCI
CCU
CCV
CDC
CDH
CDS
CEA
CF
blood sugar
bowel sounds
breath sounds
bleeding time
blood urea
bunion
biopsy
benzodiazepine
cohtrolled
I-V)
cancer
Candida albicans
coronary artery bypass graft
coronary artery
callus
calories
canceled
Central
for
computerized axial tomography
complete blood count
complete
creatinine clearance
cold and clammy
and clip
correct
Initiative
coronary care unit
care
cell conductivity volume
Control
Center for
congenital
of the hip
controlled dangerous substances
antigen
cystic fibrosis
CFI
clenched
C&H
curette and
CHEM 6 lab test
BUN, K, Na,
and
CHEM 7 lab test

BUN,
K,
Na,
and
CHEM 12 lab test
BUN,
acid, Ca,
total protein,
chol,
total bilirubin, alkaline phos
phatase, SGOT, and LDH)
CHEM 18 CHEM 12 + CHEM 6
CHEM 23 CHEM 12 (Na, K, C02,
indirect bilirubin,
SGPT,
CHF
CHI
chol
CIA
CIG
Circ
CK
CKC
CMI
CMT
CMV
CN
593
heart
closed head injury
cholesterol
avulsion
calcaneal
calcaneal inclination angle
cigarettes
circulation
creatine kinase
closed kinetic
Laboratory Improvement Act
cell-mediated immunity
Charcot-Marie tooth
cytomegalovirus
nerve
complained of
CHAPTER 34
CT
CTD
CVD
CWS
CXR
DASA
DC
Wound Specialist
chest x-ray
dextrose
distal articular set angle
discharge
dlc
discontinue
DD
diagnosts
dry dressing
dressing dry and
differential diagnosis
Drug Enforcement
number
dorsiflexion
wedge osteotomy
DDI
COMP
COPD
COTH
COX-1
COX-2
CP
CPK
CPK-1
CPK-2
CPM
CPMA
CPME
CPMM
CPPD
CREST
CRP
CRNA
CROW
CRTX
CS
CSF
CIS
complications
compound
compress
concentration
chronic obstructive pulmonary
Council on Teaching Hospitals
cyclooxygenase
1
cyclooxygenase
2
cerebral palsy
chest pain
chronic pain
creatine phosphokinase
creatine phosphokinase MM
fraction
creatine
MB
fraction
California
Medical
Association
Council of
Medical
Educatton
constant passive motion
calcium pyrophosphate
gout)
Raynaud's dz,
esophageal dysmotility,
sclerodactyly, and
closed reduction and internal
Hematocrit
C-reactive protein
Registered Nurse
Anesthetist
walker
cast removed take x-ray
spine
cesarean
cigarette smoker
cerebrospinal fluid
culture and
culture and
tomography
Coomb's test
connective tissue dz
cerebrovascular
DF
DHEA
diabetes insipidus
debridement and Irrigation dry and
intravascular
interphalangeal joint
diffuse
skeletal
DJD
DKA
dl
DLE
joint dz
ketoacidosis
lupus erythematosus
dextrose 5% lactated Ringer's
DM
DMAA
metatarsal
PASA)
DMD
Duchenne's muscular dystrophy
DMERC Durable Medical Equipment
DMSO
DNR
DO
DOB
DOC
sulfoxide
dextrose 5% in 45% sodium
chloride
do not resuscitate
Doctor of Osteopathy
doctor's orders
dead on arrival
date of birth
drug of choice
date of injury
DP
pressure
DPM
DPP
DPT
DS
DSD
DTP
DTM
DTR
DVT
Doctor of
pedis pulse
diphtheria, pertussis, and tetanus
summary
Double strength
discharge summary dictated
dry sterile
diphtheria and tetanus
with
pertussis vaccine
tetanus toxoids, and
pertussis
dermatophyte test medium
deep tendon reflex
and tetanus
with
whole-cell pertussis
deep venous thrombosis
5% dextrose water
Dx
disease
EBL
EBV
ECCE
ECG
ECT
EDB
EDG
EDL
EDQ
EDS
EDTA
EEE
EEG
EENT
EES
EFB
e g.
EHB
EHL
EKG
EMG
EMS
EMT
ENG
ENT
EOM
EPF
EPI
EPO
ER
ES
blood loss
Epstein-Barr virus
extracapsular cataract
electrocardiogram
European Compression
extensor digitorum
electrodynography
endoscopic decompression of
neuroma
extensor
extensor
Ehlers-Danlos syndrome
594
ESR
ESWT
ET
erythrocyte sedimentation rate

extracorporeal shock wave therapy
enterostomal therapy
alcohol
FACFAS Fellow of American College of Foot
and Ankle Surgery
American College of Foot
and Ankle
and
Medicine
FB
foreign body
FBS
fasting blood sugar
FDB
flexor digitorum brevis
FDL
FDM
FF
FFD
FFF
FFF-STA
FFP
FH
FHB
FHL
FOB
FROM
FS
FSH
FT
(anticoagulant in blood
specimens)
edema, erythema, and exudate
electroencephalogram
eyes, ears, nose, and throat
FIU
FUO
elevate foot of bed

exempli
example)
extensor hallucis brevis
extensor hallucis
electrocardiogram
enzyme-linked
Ga
GAG
GB
GBS
GC
electromyogram
emergency
emergency medical
electroneurogram
ears, nose, and throat
extraocular muscles
extraocular muscles intact
endoscopic plantar fasciotomy
Provider Organization
emergency room
extra strength
CHAPTER 34
Fx
FYI
GA
GFR
GG
GH
GI
GS
GU
HAV
Hb
flexor
flexor
forefoot
focal film
flexible forefoot
flexible forefoot with short
tendo-Achilles
fresh frozen plasma
history
flexor
flexor
foot of bed
full range of
full strength
follicle
hormone
filling time
foot
follow-up
fever of undetermined origin
fracture
for your
general anesthesia
general appearance
gallium
gallbladder
syndrome
rate
globulin
growth hormone
glycosylated hemoglobin
general surgery
Gram stain
A virus
glycosylated hemoglobin
hepatitis B core antibody
hepatitis B core antigen
HBO
HBV
HCG
HCT
HCTZ
HD
HDCV
HDL
HEENT
HG
HHS
HIV
HL
HLA
HM
HMO
HMP
H&P
HPI
HR
HSV
HT
HTN
HV
Hx
hepatitis B immune globulin

oxygen
surface
hepatitis B vaccine
B
human
gonadotropin
ICS
IMN
INF
neuroma
no apparent distress
infarction
Infection
Inferior
anticoagulant
human
cell
vaccine
lipoprotein
head, eyes, ears, nose, and throat
hemoglobin
hemoglobin
Health and Human
human
virus
hallux
human leukocyte
human lymphocyte antigen
Health Maintenance
Health Maintenance Plan
of
hydrogen
history of present illness
and physical
history of present
hallux
heart rate
hour
somni")
half strength
heel spur
herpes simplex
hammertoe
heart
height
hypertension
hallux valgus
bowel syndrome
between meals
intensive coronary care unit
intercostal space
care
ID
IMA
CHAPTER 34
INR
durum
impression
IBS
595
INT
INV
IPD
IPJ
IPK
IS
inflammatory pelvic
interphalangeal
intractable plantar keratosis
JAMA
Intravenous
intravenous
Intravenous piggyback
Journal of the
JAPMA
Journal of the American
JCAHO
Joint Commission on
of Healthcare Organizations
JNT
JRRC
JT
JVD
KA
KAFO
KAO
KB
KDA
KFAO
KJ
KOH
KS
KVO
L
LA
infectious dz
incision and drainage
insulin-dependent
LARD
Ingrown toenail
Intermetatarsal
LAT
angle
inversion
intraoperative
ins and outs
lens
plaster
LASA
LASER
LATAS
LCL
LCN
Joint
Review Committee
joint
jugular venous
knee-ankle-foot
knee-ankle orthosis
ketone bodies
known drug allergies
knee-foot-ankle
keep it simple
knee jerk
potassium hydroxide
Kaposi's sarcoma
keep vein open
kilovoltage
Kirschner wire
left
local
length. angulation. rotation,
displacement
Lisfranc's
set angle
Light
by Stimulated
Emission of Radiation
lateral
left
thigh
alignment, type, articular,
stability
lateral collateral ligament
LCPD
LD
CHAPTER 34
medial dorsal
lactic dehydrogenase
lactic dehydrogenase
LDL
lowdensity lipoprotein
LE
lower extremity
lupus erythematosus
LEA
lower extremity
lower extremity fracture
LF
left foot
LH
hormone
lidocaine
LL
left lateral
left leg
left lower
long
or cast)
lower leg
long leg brace
LLC
long leg cast
LLD
limb length discrepancy
left lower extremity
LLP
long leg
LLQ
left lower quadrant
LLSB
left lower sternal border
LLWC
long leg walking cast
LLX
left lower extremity
LO
lateral
LOC
local
of
LOPS
loss of protective sensation
lactated Ringer's
left sternal border
LT
left
light touch
lactose tolerance test
LUQ
left upper quadrant
Licensed Vocational Nurse
LX
lower extremity
M
male
meter
medial
Monday
mother
muscle
milliamperage
MAC
monitored anesthesia care
allowable concentration
minimum alveolar concentration
MAFO
molded
orthosis
MBA
MC
metatarso-cuneiform
contagiosum
MCH
596
mean corpuscular
mean corpuscular hemoglobin
concentration
midclavicular
mean corpuscular
MED
medial
metatarsal
metastasis
MFT
muscle function test
MHA-TP microhemagglutination-Treponema
MET
MHW
MI
MM
MO
MPF
MPJ
MPV
MR
MRSA
MS
MT
MTA
MTJ
MTP
N
NA
NAD
NB
NC
NCV
medial heel wedge

myocardial infarction
mitral insufficiency
minimal inhibitory concentration
medial
and mortality
myeloma
malignant melanoma
measles, mumps, and rubella
medial
methylparaben
agent used as a preservative)
metatarsophalangeai
metatarsus
varus
medical record
resonance imaging
Staphylococcus
sulfate
multiple
metatarsal
metatarsus
joint
metatarsal
manipulation under anesthesia
motor
accident
nerve
normal
not
no apparent distress
bed
needle biopsy
no change
no
nerve conduction
neurological exam
NG
non-insulin-dependent diabetes
diabetes
NINVS
NKA
NKDA
non-invasive neuro-vascular
not known
no known
no known drug
no known food allergies
no known
normal
NLD
NMR
non pal
NOS
NPH
NPO
NPUAP
NS
NSC
NSCD
NSR
NSS
NSU
NTG
N&V
NVS
NWB
0
A
OCD
OD
OKC
OM
OR
OSHA
OT
OTC
ou
P
P&A
PAB
PASA
PB
PBN
597
CHAPTER 34
necrobiosis lipoidica diabeticorum

nuclear magnetic
as MRI)
not palpable
oxide synthase
seen
no
not otherwise
neutral
intermediate acting insulin)
no previous hx
nothing by
per
National Pressure Ulcer Advisory
Panel
no refills
no response
normal
non-steroidal anti-inflammatory
drug
nonservice-connected
disability
normal sinus rhythm
normal saline solution
urethritis
nitroglycerin
nausea and
status
non-weight
objective findings
PC
osteochondritis dissecans
overdose
right eye
oral glucose tolerance test
open kinetic chain
PH
PIC
PID
operations, medicines, allergies,

Illnesses
out of cast
out of plaster
surgery
out
operating room
open
Internal
left eye
Safety and Health Act
occupational therapist
over the counter
both eyes
after
phenol and
pronation-abduction
assistance range of motion
proximal articular set angle
bath
B sulfate,
and
neomycin
after
packed cells
present complaint
PCA
controlled analgesia
PCC
poison control center
PCN
penicillin
PCP
Pneumocystic carinii pneumonia
primary care
partial pressure of carbon dioxide
PCV
packed cell volume
PDR
Physician's Desk Reference
PDS
polydioxanone suture
PDU
pulsed Doppler ultrasonography
PE
physical examination
pulmonary embolism
PEARL pupils equal accommodation,
reactive to light
pupils equal and react to light and
accommodation
PER
rotation
pupils equally reactive to
and
accommodation
equal, round, and react to
PERRLA
light and accommodation
PG
PGA
PLLA
PLT
PMH
PMI
PMMA
PMN
PMS
PN
PNA
PO
POR
PP
PPAC
PPD
PPO
PPP
PR
PRBC
PRICE
acid
hydrogen concentration
personal
peripherally inserted catheter
inflammatory disease
proximal interphalangeal joint
poly-L-lactic acid
platelet
history
past
of maximum impulse
polymethylmethacrylate
polymorphonuclear leukocytes
premenstrual syndrome
progress note
nail ablation
by
residency
pedal pulse
Political
Committee
Practicing
blood
porokeratosis
orovider oraanization
pissogenic pedal papules
per rectum
packed red blood cells
protection, rest, ice, compression,
and elevation
PRN
PROM
PSA
PSH
PSR
PSST
PT
needed)
range of motion
antigen
past surgical
surgical
pressure sore status tool
pro re
ROM
ROS
RPR
physical therapy
prothrombin time
posterior
RR
RRR
RSB
RSD
RSTL
RT
RTC
PTA
Therapy
post-traumatic amnesia
PTF
PTFE
PTH
PTR
PVD
PW
PWB
PY P
QAM
QS
A
RAD
RBC
RDW
RES
REM
RF
Rh
RIG
RLE
598
prior to
posterior
are made of)
parathyroid hormone
patella tendon reflex
time
tendon disfunction
peripheral vascular disease
puncture wound
partial weight bearing
port
physical exam
prognosis
pyrophosphate kit
technetiem Tc
long acting
every
every
every
every
every
every
four
every
every
every
morning
day
4 hours
hour
night
a
other day
night
shift
RXN
S
SACH
SAD
SAS
in
rapid eye movement

Roentgen equivalent man
factor
Rhesus factor in blood
rest, ice,
and
lower quadrant
rule out
range of motion
review of symptoms
rapid plasma
for
syphilis)
residency
recovery room
rate and rhythm
and resection
regular rhythm and rate
right sternal border
reflex
dystrophy
relaxed skin tension lines
right
return to
treatment
upper quadrant
vaiue
drug
pharmacy
prescription
radiotherapy
reaction
solid ankle
heel
SBR
SC
SDS
SER
SGA
SGOT
extra depth shoes)

surgical Achilles tendon unit
subacute
strict bed rest
service connected
same day surgery
supination-external
small
age
serum
oxaloacetic
SGPT
serum
SATU
respirations
rheumatoid
absorbed dose
red blood cell
width
lower extremity
RUQ
RVU
Rx
CHAPTER 34
SH
Sgarlato Hammertoe Implant
Prosthesis
sudden infant death syndrome
let be
SIS
submucosa
SKAO
supracondylar knee-ankle
SLB
short leg brace
SLC
short leg cast
SLCC
short leg cylinder cast
SLE
lupus erythematosus
SLNWBC short leg
bearing cast
SLS
short leg splint
599
SLWC
SMA
short leg
cast
sequence multiple
CHEM)
SNS
sterile normal saline
nail technique
SNT
SOA
of ankle
SOAP
subjective, objective, assessment,
and plan
SOB
shortness of breath
SIP
status post
SPG
scrotopenogram
S-PIN
Steinmann pin
SPVPFT subpapillary venous plexus
SQ
SR
SS
SS#
S&S
SSD
SSN
STAT
STATT
STD
STG
STJ
SWHT
Sx
T
T3
T4
TAC
TAL
TAR
TATT
T-berg
TCC
TCOM
TCP
Td
TENS
TEV
TF
TIA
TID
TLS
TMC
subcutaneous
sedimentation rate
super strength
security number
signs and symptoms
silver
social security number
split tibialis
tendon transfer
sexually transmitted diseases
split-thickness
subtalar
subcutaneous
Wound Healing Tool
signs
surgery
symptoms
temperature
thyroxine
cream
tendon Achilles lengthening
total knee replacement
anterior tendon transfer
Trendelenburg
type and cross
total contact cast
transcutaneous oxygen monitor
transcutaneous pacing
transcutaneous
transcutaneous oxygen
tenotomy and capsulotomy
toxoid
tetanus and
transcutaneous electrical nerve
stimulation
talipes
to follow
translent ischemic attack
total
a
in die")
three
triamcinolone
CHAPTER 34
T&N
TNM
TOB
TP
TROM
TSA
TSH
TSP
TURB
TURP
Tx
T&X
UGPF
USSC
UTI
VA
VAN
V&D
VDRL
VLDL
VO
VRE
VRSA
VS
VV
WA
WB
WBC
W
WD
WDWN
3-WEA
WHO
WNL
W-T-D
WWAC
x
XIP
XOP
and numbness
tumor, nodes, and metastasis
tobacco
thrombophlebitis
total protein
total range of motion
type-specific antibody
hormone
hormone
total serum protein
time
total
turgor, texture, temperature
transurethral resection of bladder
transurethral
of prostate
treatment
type and cross
urinalysis
ultrasound guided plantar
fasciotomy
unguen
States Surgical
urinary tract Infection
Veterans
artery, and nerve
vomiting and
Venereal
Research
for
very low density
verbal orders
Vancomycin resistant
Vancomycin resistant
vital signs
varicose
with
weight
whole blood
white blood cell
to tolerance
wet
well developed and well nurished
wetting, emulsifying,
(solution for softening calluses)
World Health
normal
wet to dry
walk with aid of cane
except
x-ray in plaster
x-ray out of plaster
600
CHAPTER 34
GLOSSARY
601
CHAPTER 35
CHAPTER 35
GLOSSARY
Adactyly
Congenital absence of a digit.
Albright's Syndrome
A Polyostotic fibrous dysplasia with an associated endocrine abnormality.
Clinical signs include cafe-au-lait spots and precocious puberty.
Allodynia
Pain produced by a non-noxious stimulus.
Anesthesia
Loss of sensation.
Amniotic Bands(Streeter Bands)

A partial or complete ring like constriction around one of the limbs of the
fetus during development caused by early rupture of the amnion with the
chorion remaining intact
Anatomical neck
Thinnest part of the metatarsal where the shaft meets the head, located
proximal to the surgical head.
Arthrocentesis
Aspiration of a joint.
Atelectasis
Incomplete expansion of the lungs, collapse of alveoli. This is the number one reason for post-op fever.
Athetosis
Repetitive involuntary, slow, sinuous, writhing movements, especially
severe in the hands.
Axonotmesis
Injury to an axon that results in Wallerian degeneration. The nerve can
regenerate over time.
Basset's lesion
A lesion on the anterior dorsal lateral aspect of the articular cartilage of
the talus caused by rubbing from a hypertrophic anterior inferior tibiofibular ligament.
GLOSSARY
602
CHAPTER 35
Bell's Palsy
Sudden paralysis on one side of the face. Named after the physician
who first described it. In the majority of patients there is a preceding
condition such as stress, fatigue, or a common cold. The disorder
involves the 7th cranial nerve and the facial muscles it supplies.
Patients usually recover completely within several months.
Bovie
Electrocautery.
Brodies Abscess
A foci of bone destruction caused by osteomyelitis filled with pus or connective tissue.
Capsulorrhaphy
suturing of a joint capsule
Carcinoma
A malignant tumor arising from epidermis or visceral organ cells and
tend to give rise to metastases
Causalgia
a burning pain due to a specific peripheral nerve.
Charcot's triad
A symptom of MS consisting of nystagmus, intention tremor, scanning
speech(syllables are separated by pauses).
Cheyne-Stokes Respirations
Repeating cycle of gradual increase in depth of breathing followed by
gradual decrease depth of breathing until apnea occurs. Seen in CNS
disorders and uremia.
Chopart's Joint
The midtarsal joint.
Chvostek's sign
A clinical test to diagnose increased blood calcium levels. A light tap on
the facial nerve will cause the facial muscles to contract
Cicatrix
Scar.
Clinodactyly
Congenital curly toe.
Coleman Block Test

Determines if a rearfoot varus deformity is flexible or rigid. The patient
is placed on a wooden block one inch thick such that the entire foot is
standing on the block except the medial forefoot. In a flexible rearfoot
varus the 1st metatarsal will plantarflex down to the ground and the rearfoot varus will evert into a corrected position.
GLOSSARY
603
CHAPTER 35
Constitutional symtoms
Symptoms which are indicative of disorders of the whole body.
Symptoms involving more that one body system(i.e., fever, chills, weight
loss, excessive sweating).
Crescent Sign
The early sign of avascular necrosis which represents a subchondral
fracture through the insertion of the individual trabeculae.
Crista
A ridge in the plantar articular surface of the first metatarsal head that
separates the sesamoids.
Crowe's Sign
Axillary freckling, pathognomonic for von Recklinghausen's disease
Cyma Line
A smooth "S" configuration formed by the talonavicular and calcanealcuboid joints seen on a lateral x-ray. In the ideal foot the cyma line is
intact. With a pronated foot the cyma line is anteriorly displaced meaning that the talonavicular joint is anterior to the calcanealcuboid joint and
does not follow a nice " S shape. With a supinated foot the talonavicular
joint is posteriorly displaced.
Cytochrome P450
Cytochrome P450 constitues a family of enzymes that metabolize a variety of endogenous and exogenous substances in the liver, most notably
drugs. The 450 comes from the fact that they maximally absorb light at
450 nm wavelength. The significance of the enzyme comes from the
fact that many drugs may be largely dependent on a single form of P450
for their metabolism in the liver. If the enzyme is actively metabolizing a
particular drug and another drug is administered that relys on the same
for of P450 for its metabolism, the drug may reach toxic levels at relatively low doses.
Desiccate
To dry out.
Diastasis
Dislocation or separation of two normally attached bones.
Dolor
Pain, one of the classic signs of inflammation.
Down's Syndrome(a.k.a. trisomy 21)

An autosomal abnormality with mental retardation. Classic facial features include an epicanthal fold, thick lips, large tongue with deep furrows, and a small nose with a broad bridge. Other features may include
a broad short neck, clinodactyly of the 5th finger, syndactyly, polydactyly,
and a simian line(a single transverse palmer crease).
GLOSSARY
604
CHAPTER 35
Dysphagia
Difficulty swallowing.
Dyspareunia
Painful sexual intercourse.
Eburnation
The final end product of bone sclerosis and is sometimes used as a
term which is synonymous with bone sclerosis
Ecchymosis
Bruise
Ectrodactvlv
"Lobster C l a wfoot
"
Ehlers-Danlos Syndrome
Collagen and elastic tissues are abnormal resulting in thin easily

stretched hyperelastic skin. Ligamentous laxity resulting in flat feet,
genu valgus; congenital hip dislocation, and scoliosis. Aortic aneurysm
is common.
Endoneurium
The interstitial connnective tissue in a peripheral nerve, surrounds a single nerve fiber
Enthesopathy
Disorder of the muscular or tendinous attachment to bone
Epineurium
The sheath of a peripheral nerve
Eschar
Scab
Fistula
Abnormal communication between two hollow, epitheilialization organs
or between a hollow organ and the exterior(skin)
Foley
Bladder catheter
Foot Drop
Failure to raise the foot during the swing phase of gait. Often results in
a "slapping" gait. Causes may include; CVA, trauma, CMT, Polio,
Fredreich's ataxia, infection, spinal tumor/lesion, Guillain-Barre syndrome, Dejerine-Sottas syndrome
Genu valgum
Knock knees, often seen in obese female children
Genu varum
Bowleg, may be associated with Rickets, abnormal Ca and Ph metabolism, or Blout's disease
Gigli Saw
A bone saw that consists of a flexible roughened wire used to cut
through bone
GLOSSARY
605
CHAPTER 35
Gower's Sign
A classic sign of pseudohypertrophic muscular dystrophy. Due to muscle weakness patients raise themselves to the standing position by
crawling up their legs
Perineurium
The sheath surrounding each bundle of fibers in a peripheral nerve.
Hawkins Sign
A subchondral radiolucent band in the proximal talus. This indicates
bone resorption and revascularization following AVN
Hanging heel sign

Used in the diagnosis of metatarsus adductus, the deformity persists as
viewed plantarly when the foot is lifted by the toes.
Heloma Durum
Hard corn over the top of the toe.
Heloma Molle
Soft corn found between the toes
Hematemesis
Vomiting of blood.
Hematoma
Accumulation of blood within the tissue, which clots to form a solid
swelling.
Hemoptysis
Coughing up blood.
Hoffa's Sign
Seen in calcaneal fractures. The tuber fragment displaces superiorly,
relaxing the triceps and decreasing it's plantarflexory power.
Hoke's Tonsil
The fat plug in the sinus tarsi that is removed during sinus tarsi surgery.
Homan's Sign
Calf pain with forced dorsiflexion of the foot. Indicative of venous thrombosis.
Homocystinuria
Clinically very similar to Marfan's Syndrome except they are mentally
retarded and excrete large amounts of homocystine in their urine.
Hunting Response
A secondary vasodilation response that occurs after prolonged vasoconstriction due to cold application. The purpose of this response is to prevent tissue damage.
GLOSSARY
606
CHAPTER 35
Hubscher Maneuver
When the hallux is dorsiflexed during WB, the arch will rise due to the
windlass mechanism if no osseous restrictions are present.
Hyperalgesia
Excessive sensitiveness to pain.
Hyperesthesia
Increased sensation.
Hyperpathia
A b n o r m exaggerated
allly
subjective response to pain
Hypesthesia
Hypoesthesia.
Hypoesthesia
Decreased sensation.
lchthyosis
Abnormal cornification of the skin resulting in dryness, roughness, and
scaliness. Results from hypertrophy of the horny layer resulting from
excessive production of keratin.
lcterus
Jaundice.
Induration
Abnormal hardening of a tissue or organ.
lslet of Langerhans
A type of tissue found scattered throughout the pancreas involved in glucose metabolism. The lslet of Langerhans contain alpha, beta, and
delta cells. The beta cells compose about 60% of all the cells and
secrete Insulin.
Jones Compression Dressing

The Robert Jones dressing is a thick, well-padded knee bandage often
used after trauma and elective operations. Because it provides firm,
evenly distributed pressure, it is thought to minimize edema and bleeding.
Kelikian Test
Tests whether or not the MPJ is reducible. Push up on the plantar surface of the metatarsal head and see if the toe straightens out.
Kussmaul's Respiration
Deep, rapid respiratory pattern seen in coma or diabetic ketoacidosis.
Kyphosis
Excessive primary curvature of the thoracic spine(hunch back), associated with aging, especially in women.
GLOSSARY
607
CHAPTER 35
L a c h m a n Test
Tests ligament stability in the MPJ by attempting to pop the metatarsal
head out of the joint.
Lemont's nerve
Intermediate dorsal cutaneous nerve.
Lesgues Test
Test for radiating pain.
Levine's Sign
Classic sign of angina or MI, clenching of the fist and placing the fist
over the chest.
Lister's Corn
Painful corn that develops in the lateral nail groove of the 5th toe from
the varus rotation of the phalanx.
Lordosis
Excessive secondary curvature of the lumbar spine(sway back), often
seen during pregnancy.
Maceration
A white soggy appearance that the skin takes on after tissue is soaked.
The connective tissue fibers are dissolved so that the tissue conponents
can be teased appart. Often noted between the toes.
Marfan's Syndrome
An autosornal dominant primary collagen defect resulting in a very tall
and slender person. Clinical symptoms include; arachnodactyly, hyperextensibility, muscle myotonia, joint dislocation, severe pes planus, scoliosis, lens subluxation, genu recurvatum, and aortic dilation with
aneurysm.
Master Knot of Henry

An area in the rearfoot where the tendons of the flexor hallucis longus
and the flexor digitorurn longus cross. There is a thick band of connective tissue covering the tendons at this point and binding them to the
navicular.
Marjolin's ulcer
A Squamous cell carcinoma that arises in a chronic sinus due to
osteomy elitis.
Melorrheostosis
A flowing hyperostosis resembling dripping candle wax seen on x-ray of
long bones
Methylparaben
An antifungal agent often used as a preservative in local anesthetics
GLOSSARY
608
CHAPTER 35
Mercurochrome
A weak antibacterial agent. Not recommended because it tends to dry
out the wound and has been associated with contact dermatitis and
aplastic anemia.
Metatarsalgia
General nonspecific term referring to pain located in the ball of the foot.
DDx includes: stess Fx, synovitis, capsulitis, tendinitis, neuroma, buritis,
IPK, foreign body, DJD, arthritis, tumor, and infection.
Metatarsus Primus Varus

Clinical appearance is similar to metatarsus adductus but only the 1st
metatarsal is adducted and the IM is increased to >15".
Metatarsus varus
Metatarsus adductus with a varus component(often confused with clubfoot).
Morton's Foot
Short I st ray.
Mosaicplasty
Transplantation of cartilage and bone by way of a plug to fill a defect
caused by osteochondritis dissecans
Multiple Myeloma(Plasma Cell Myeloma)

A malignancy beginning in the plasma cells of the bone marrow.
Plasma cells normally produce antibodies to help destroy germs and
protect against infection. With myeloma, this function becomes impared,
and the body produces anomalous immunoglobins(Bence Jones protein)
which are ineffetive against infections. Symptoms include skeletal
pain(especially in the back and thorax), renal failure, and recurrent bacterial infections.
Myasthenia Gravis
An autoimmune disorder of neuromuscular transmission involving the
production of autoantibodies directed against the nicotinic acetyl:
choline(ACh) receptors. Women are affected twice as much as men.
Symptoms include; fatigable weakness, and ocular problems (ptosis,
diplopia, drooping eyelids). There is also often dysphagia and breathing
difficulty. Treatment involves anticholinesterase drugs and cortisone.
Neuralgia
Pain in a nerve or along the course of one or more nerve.
Neurapraxia
Bruising of a nerve with resulting numbness. Numbness is
reversible(Seddon Classification).
GLOSSARY
609
CHAPTER 35
Neurectomy
Excision of part of a nerve.
Neurofibromatosis(von Recklinghausen's Dz)

A familial condition characterized by nervous system, muscles,bones
and skin changes. Occurs in about one in 3,000 people. Clinically 2 of
the following must be present to establish the diagnosis;
1. Six or more cafe-au-lait spots greater than 15mm in
diameter, or greater than 5mm in the prepubertal patient
2. Two neurofibromas of any type or one plexiform neurofibroma
3. Axillary or inguinal freckling
4. Optic glioma
5. Two or more lisch nodules in the iris
6 . Distinctive osseous lesions(such as pseudoarthrosis)
7. A first degree relative with neurofibromatisis type 1
Neurolysis
Freeing up of a nerve.
Neurorrhaphy
Nerve repair, suturing of a cut nerve.
Neurotmesis
Complete severance of the nerve that is irreversible.
Neutral Triangle
The neutral triangle is an area of sparse trabeculation in the calcaneus.
This triangle lies just inferior to the anterior edge of the posterior talar
articular facet.
Odynophagia
Painful swallowing
Orthotist
A person skilled in orthotics and their application.
Orthotripsy
A treatment for plantar fasciitis whereby sound waves cause injury to the
tissue in the area, thereby causing them to heal themselves and reducing the inflammation that created the pain. One machine available is
called the OssaTron.
Osteoblast
A bone cell associated with bone production.
Osteoclast
A bone cell associated with bone destruction.
Osteomalacia
A condition marked by softening of the bones with pain, tenderness,
muscular weakness, and loss of weight resulting from a deficiency of
vitamin D and calcium.
GLOSSARY
610
CHAPTER 35
Osteoporosis
A decrease in bone mass.
Paget's Disease
A focal disorder of bone metabolism in which all the elements of bone
remodeling are increased resulting in bony enlargement and deformities.
The condition is often asymptomatic although pain and stiffness may
develop. Symptoms include an enlarged skull, bowing of the long
bones, and pathologic fractures.
Pantalar fusion
A triple arthrodesis plus an ankle fusion.
Parabens
Parabens(i.e. Methylparaben) are used as preservatives in various pharmaceutical preparations such as wound care products and local anesthetics. Parabens have been shown to be sensitizing agents and may
cause allergic reactions in some patients.
Loss of function.
Paresis
Slight or incomplete paralysis.
Paresthesia
Abnormal sensation.
Pedorthist
A person skilled in the design, manufacture, fit, and modification of
shoes and related foot appliances.
Perineurium
Surrounds a bundle of nerve fibers(fascicle).
Percutaneous
Performed through the skin.
Polymethylmethacrylate(PMMA)
A polymeric self-curing acrylic cement used as a mechanical filler to hold
implanted prosthesis in position. This bone cement helps disperse
mechanical stresses over a wider area. In addition to fixating prostheteics PMMA can also be mixed with powdered antibiotics and rolled into
"beads" for infected bone. The antibiotic should be broad spectrum, low
allergenic, heat stable, and have the ability to leech from the cement.
Aminoglycosides, such as tobramycin and gentamicin, fill these criteria
and are often used. Antibiotics are mixed at a concentration of at least
500mg, but no more than 1,000mg per packet of cement.
Porta Pedis
Entrance to the vault of the foot, the abductor hallucis comprises the
floor and the quadratus plantae makes up the roof.
GLOSSARY
611
CHAPTER 35
Prosthetist
The field of substituting artificial parts for missing body parts such as
adding fillers to shoes of patients with amputations.
Pseudoequinus
In a cavus deformity the ankle appears to have less dorsiflexion
because heel off occurs earlier in the gait cycle from the plantarflexed
nature of the forefoot in a cavus foot.
Pseudohypertrophy
An apparent increase in size of certain muscles without true hypertrophy, the apparent muscle bulk is actually fat deposits. May be seen in
the calves in certain types of muscular dystrophy.
Pyrexia
A fever, or febrile condition.
Radiculopathy
Impingement of the sciatic nerve within the spinal canal.
Radiolucent
Black areas on a radiograph.
Radiopaque
White areas on a radiograph.
Resupination Test
Have patient stand on tipitoes and see if the medial longitudinal arch
develops.
Reye's Syndrome
CNS and hepatic complication of influenza infection. Usually occurs
about 4-6 days after a viral infection, and although the exact pathophysiology is uncertain there seems to be a relation to children given aspirin.
Symptoms include nausea, vomiting, and altered mental status consistent with encephalopathy. Cerebral edema is usually the main cause of
death.
Rickets
A condition due to Vitamine D deficiency, especially in children. Signs
include disturbances in normal ossification such as bowing of the legs
and trumpeting of the metaphysis and epiphysis.
Rinne Test
An auditory test to compare air conduction with bone conduction. A tuning fork handle is placed on the mastoid process, when the sound can
no longer be heard, the tuning fork is placed in front of the ear.
Normally the patient will be able to hear the tuning fork when it is held in
front of the ear, in a patient with a conductive hearing loss they will not
hear the tuning fork when held by the ear.
GLOSSARY
612
CHAPTER 35
Romberg's Test
Tests position sense or cerebellar function. Patient stands feet together
and the arms outstretched with palms up. The patient is tapped by the
examiner with eyes open and closed. A positive test is loss of balance.
Redness, classic sign of inflammation.
Sarcoma
A highly malignant tumor made up of mesenchymal-supportive
tissue(muscle, bone, cartilage, tendon).
Schoeber's Test
A lOcm length is measured along the erect lower lumbar spine, the pt
bends forward. This measurement should increase by at least 4cms.
This test is positve in Ankylosing Spindylitis.
Sclerotic
An increase in the density of bone.
Scurvy
A disease due to deficiency of Vitamin C marked by anemia, spongy

bleeding gums, and brawny induration of calf and leg muscles.
Silfverskiold Test
Tests for gastroc equinus. Passive dorsiflexion of the ankle is measured
with the knee extended and then with the knee flexed. If this value
increases there is an equinus due to a tight gastroc., because the gastroc. crosses the knee joint and the soleus does not.
Sinus Tarsi
An anatomical tunnel between the sulcus calcanei(on the calcaneus)
and the sulcus tali(on the talus). The sinus tarsi is larger laterally and
located between the posterior and middle facet of the calcaneus. The
artery of the tarsal canal enters medially and the artery of the sinus tarsi
enters laterally.
Sinus Tarsi Syndrome

Subacute or chronic pain on the lateral aspect of the sinus tarsi often
following an inversion injury. Pain is elicited on ROM of the STJ and
palpation laterally at the entrance of the sinus tarsi. Treatment includes
steroid injections into the sinus tarsi or surgery to remove the fat
plug(Hoke's tonsil) in the sinus tarsi.
Somogyi effect
A rebound phenomenon occuring in diabetics who take too much insulin
in the evening resulting in hyperglycemia in the AM. When a patient is
given too much insulin at night the body responds by releasing epinephrine, ACTH, glucagon, and growth hormones which stimulate
lipolysis, gluconeogenesis, and glycogenolysis which, in turn, result in a
rebound hyperglycemia when the patient wakes up in the morning.
GLOSSARY
613
CHAPTER 35
Sphygmo-manometer
An instrument for measuring arterial blood pressure.
Stenosis
Narrowing of a passage or opening
Surgical neck
Part of the metatarsal neck located in the metaphyseal bone distal to the
anatomical neck.
Sphygmomanometer
Blood pressure cuff.
Splay Foot
A foot type having a 1st IM angle of >12', and a 4th and 5th metatarsal
angle of >8 .
Tarsal Canal
Same as the sinus tarsi.
Telangiectasia
A vascular lesion formed by dilation of capillaries that result in irregular,
clusters of red lines that blanch when pressed.
Triplane Fracture
This fracture is basically a Salter-Harris IV fracture that changes from
the sagittal plane to the transverse at the physis to the coronal plane
proximally. A fracture occurs in the distal tibia of a child whose growth
plate is still open.
Tetralogy of Fallot
A condition with; pulmonary stenosis or atresia, intaventricular septal
defect, right ventricular hypertrophy, and dextroposition of the aorta. It is
the most common cause of cyanotic congenital heart disease.
Thalassemia
A hereditary group of hemolytic anemias marked by a decrease in production of hemoglobin.
Tinel's sign
Tingling thatradiates distally along the course of the involved nerve with
percussion of the tarsal tunnel.
Trendelenberg Position
Patient positioned with head lower than feet.
Turgor
Skin turgor is a feeling of fullness and resistance to tissue deformation.
It can be tested by pinching and holding the skin for several seconds
and noting if it rebounds back, and how long it takes to rebound back to
its original shape.
GLOSSARY
614
CHAPTER 35
Turks test
Tests whether the nerve is entrapped due to varicosities beneath the
retinaculum. Test is positive if symptoms increase once a tourniquet is
inflated above venous pressure but below arterial pressure proximal to
the site of suspected entrapment.
Vasovasorium
Venous system around a nerve
Virchow's Node(SignalNode)
A palpable left supraclavicular lymph node often associated with gastrointestinal neoplasm such as pancratic or gastric carcinoma.
Virchow's Triad
Three factors that are commonly associated with the formation on
thrombi: Stasis, blood vessel injury, and hypercoagulability.
Valleix's sign
Tingling that radiates proximally along the coarse of the involved nerve
with percussion of the tarsal tunnel.
Watershed area
Refers to an area 2-6cm's proximal to the Achilles tendon insertion that
has very poor blood flow making this portion of tendon most likely to
rupture.
Wernicke-Korsakoff Syndrome
A neuropsychiatric disorder due to thiamine deficiency usually due to
alcohol abuse. Combining the features of Wernicke's
encephalopathy(confusion, gait ataxia, eye movement problems) and
Korsakoff's syndrome(amnestic component).
Weber Test
An auditory test to compare bone conduction of the two ears. Place a
tuning fork firmly against the center of the patient's forehead. Ask the
patient if he/she hears the sound more in the right ear, the left ear, or in
the middle of their head.
Wet-to-Dry
Damp gauze-dressing placed on wound and removed after the dressing
dries, providing debridement of the wound upon removal of the gauze
Wolff's Law
Final bone morphology is determined by the forces acting on it. Bone

develops the structure, lamellae and trabeculae, most suited to resist
the forces acting on it. Areas of increased force are thicker and areas of
decreased force are thinner.
Xeroform
Wound dressing with 3% Bismuth Tribromophenate in a petroleum base
INDEX
615
CHAPTER 36
INDEX
2-hour Postprandial Blood Sugar 373
2-hr PPBS 373
3M
3M Tegasorb 312
4-Phase Bone Scan 233
5 Minute Reactive Hyperemic Test 102
5-fluorouracil 76
A HAND P 11
288
Abducens Nerve 2
Abduction Test 477
Abelcet 30
Absorbable Materials 411
Pins 412
Screw 411
Acanthosis Nigricans 293
Accessory Bones 229
Accessory Nerve 2
Accordion type lengthening 433
Accuzyme 313
ACE Inhibitors 63
Acetabular Index 478
Acetaminophen 37
Acetylcysteine 73
ACHILLES 557
Kager's
557
Palpable dell 557
Rupture 557
Thompson test 557
Toyger's angle 557
Achromobacter xylosoxidans 80
Achromycin 50
Acid Fast 78
Acinetobacter calcoacetcus 80
Acinetobacter calcoaceticus 78
Acinetobacter
80
Aclovate 52
ACLS 580
583
Electrical cardloversion 586
587
Myocardial infarction-Acute588
582
Pulseless electrical
585
Universal algorithm 580

Ventricular fibrilation 581
Ventricular tachycardia581
Melanoma 287
313
Acrylamide 135
ACTH 53
80
Actinomyces israaaelii 80
Actinomyces naeslundii 80
Actinomyces odontolyticus 80
Actinomyces viscosus 80
Activated partial thromboplatin time 364
ACU-derm 312
Acumed Great Toe System 424
Acumed Small Bone
418
Acumed Suture Anchor 415
Acute Atterial Occlusion 106
Acute Arterial Thrombosis 106
Acute bacterial arthritis 193
Acute hemorrhagic fever 93
Acute motor axonal neuropathy 128
Acutrak Plus Screw 409
Adactyly 601
Adapin 60
Addison's Disease 54
Addonte 461
tendon transfer 435
Adenocard 64
Adenosine 64
Adenoviridae 92
391
Brown forceps 391
tissue forceps 391
Admit orders 343
Admitting a patient 343
Adrenoleukodystrophy 149
Advil 39
Aeromonas hydrophilia 78, 80
AFO 471
African Burkitt's lymphoma 92
29
Anerdrop 562
Agility ankle implant 526
Agranulocytes 381
INDEX
Akin Bunionectomy 451
Ak-sulfa 49
Albert's disease 328
Albright's Syndrome 601
Albumin 366
Alclometasone dipropionate 52
Alcohol 145
Aldactazide 65
Aldactone 59
Aldomet 63
Aleve 40
Alfenta 34
Alfentanil 34
AlgiDERM 313
Alginate 313
AlgiSite 313
Algosteril 313
Alkaline Phosphatase 368
Allevyn 312
Allis clamp 392
Allis' Sign 477
Allodynia 601
Allograft 254
Allopurinol68, 197
Allylamine 29
Alm Retractor 390
Alpha hemolytic bacteria 78
Alprazolam 61
ALS 122
ALT 371
Altace 63
Alteplace 42
Amaryl70
Amberry procedure 460
Ambien 62
Amcinonide 52
Amlkacin 43
Amikin 43
Amiloride 59
Amines-Injectable Anesthetics 56
Aminoglycosides 43
Amiodarone 64, 141
Amitriptyline 59
Amlodipine 66
Amniotic Bands 601
Amoxicillin 48, 380
Surgical considerations 383
Amoxicillin/Clavulante 48
Amoxil 48
Amphotec 30
616
CHAPTER 36
Amphotericin B 29, 30
Ampicillin 48
AmpicillinlSulbactam 48
AMPUTATIONS 322,520
Boyd 521
Chopart's 520
Distal symes(Toe)322
Pirigoff 521
Symes 521
Amyloidosis 134
Amyotrophic Lateral Sclerosis 122
ANA 374
Anacin 37
Anafranil 59
ANALGESICS 34
Narcot~c34
Narcotic-Combinations 35
Nonnarcotics 37
Anaphylactoid Reaction 576
Anaphylaxis 576
Anaprox 40
Anatomical neck 601
ANATOMY 14,210,258,316,408,430,530
Calcaneus 14
Cross sectlonai 530
Digit 12
Lower extremity blood supply 6
Lower extremity nerves 4
Nail 316
Screw 408
Shoe 210
Skin 258
Talus 16
Tendon 430
Toenail 13
Ancef 44,379
Anchorlok Anchor 414
Anchor's Sign 477
Anchors-Bone 413
Anemia 362
Macrocytic 363
Microcytic 363
Normocytic 363
Anesthesia 601
Anesthesiologists Surgical Risk 378
Anesthetics-General 57
Anesthetics-Injectable 55, 575
Toxicity 575
Anesthetics-To~ical55
Aneurysm 105
Aneurysmal bone cyst 247
Anexia 35
Anexsia 35
Angioleiomyoma 334
INDEX
617
Angioma 281
Angiotensin II Antagonists 63
Angitensin Converting Enzyme Inhibitors
63
An le 208
Iohlers 208
Calcaneal Inclination 209
Fowler-Philip 208
Gissane's 208
Hibbs 209
Kites 209
Meary's 209
Total Angle 208
Angle and base of gait 222
Angle of anteversion 206
Angle of declination 206
Angle of femoral torsion 206
Angle of inclination 205
ANKLE 518,543
Arthroscope 518
Fracture 547
Fusions 528
Sprain 543
AnkleIArm lndex 101
AnklelBrachial lndex 101
Ankle-Motion 205
Ankylosing Spondylitis 190
Anonychia 316
Ansaid 39
Anteater nose sign 494
Antetorsion 206
Anthrax 80
Antiadrenergic Agents-Central Acting 63
Antiadrenergic Agents-Peripherally Acting
64
ANTIBIOTICS 43 379
~ m i n o ~ l ~ c o s i 43
des
Antib~otic-antifungals
29
Antiprotozoal 44
Carbapenam 44
Cephalosporins 44
Fluoroouinolones
- - - - - - - 46Macrolides 47
Miscellaneous 50
Monobactam 47
Penicillins 47
Penicillins: Aminopenicilllns 48
Penic~llins:Extended-Spectrum 49
Penicillins: Pencillinase-Resistant 48
Prophylaxis 379
Sulfonamides 49
Tetracyclines 50
Anticoagulants 41
Anticonvulsants 67
CHAPTER 36
Antidepressants 59
Antidiarrheals 71
Antidotes 73
Anti-ds-DNA Antibody Test 374
Anti-DysrhythmicsICardiacArrest 64
Antifungals 30
Antihemophiliac Factor 365
Anti-Hyperlipidemic Agents 65
Anti-Hypertension Combinations 65
Antimicrobials-Topical 42
Antinuclear Antibody 374
Antiperspirants 31
Antiprotozoal 44
Anti-Pseudomonal penicillins 49
Antipsychotics 60
Antistreplase 42
Anyurane 69
Aortic valve 158
APGAR 468
Aplastic crisis 382
Apligraf 313
Apocrine Gland 259
Apresazide 65
APSAC 42
APlT 364
Aquaflo 313
Aquaphor 32
Aquasorb 312,313
Aquatensen 59
Arachidonic acid cascade 38
Arachnia propionica 80
Arbovirus 95,96
Aristocort 52
Aristocort A 52
Army Navy 390
Arsenic 135
Arterial Embolism 106
Arterial Insufficiency 104
Arterial Occlusion 100
Arteries 3
Anterior lateral malleolar 7
Anterior medial malleolar 7
Anterior Tibial 3, 7
Anter~ortibia1 recurrent artery 7
Arcuate 7
Artery of the sinus tarsi 3
Artery of the tarsal canal 3
Circumflex fibular 7
Common superficialplantar dlgital arteries 7
Communicating branch of the peroneal 3
Communicatina branch of the Deroneal
INDEX
Deep plantar arch 7
Dorsal digitai proper 7
Dorsal metatarsal 7
Dorsalis pedis 3, 7. 11
Femoral 7
Laterai plantar 7
Lateral sural 7
Mediai caicaneai 3
Medlal calcaneai 7
Mediai plantar 7
Medial sural 7
Perforating branch of peroneai 7
Perforating branch of the peroneai 3
Peroneal 3, 7
plantar digitai proper 7
Plantar metatarsal 7
Posterior tibia1 7, 10
Superficial branch of the lateral plantar
artery 7
Tibial 3
Arteriosclerosis Obliterans 104
Arteriosclerotic Occlusive Dz 104
Arthrocentesis 601
Arthrodesis 449,516
Arthrodial Joints 26
Arthroereisis 517
Arthrograms 543
ARTHROPATHIES 186
Ankylos~ngSpondyl~t~s
190
Dermatomvosities 199
Gout 196
Joint aspiration 186
Juvenile Rheumatoid 188
Lymes Disease 195
Osteoarthritis 189
Poiymyositis 199
Pseudogout 197
Psoriatic 192
Reiter's Syndrome 191
Rheumatoid 187
Scieroderma 199
Sepsis 192
Sjogrenj's Syndrome 200
SLE 198
Systemic features 186
Viral 195
Arthroplasties 449
Arthroscopy 518
Arthrotec 39
Ascriptin 37
Ash leaf macole 262
Aspergillosis 98
Aspergillus fumigatus 98
Aspirin 39, 242
Relieving bone tumor pain 242
618
CHAPTER 36
Assmann's Disease 475

AST 371
Asthmatic attack-Acute 575
Asystole 165
Atarax, 62
Atasoy-Type Plantar V-Y 181
Atelectasis 383, 601
Atenolol 66
Athetosis 601
Ativan 61
Atopic Dermatitis 264
Atorvastatin 65
Atraumatic forceps 391
Atrial fibrillation 167
Atrial Flutter 167
Atropine 57
Auditory Nerve 2
audouini 272
Augmentin 48
Auspitz Sign 261
Austin 444
Autograft 254
Aventyl 60
Awl 393
Axonotmesis 114, 601
Azactam 47
Azithromycin 47
Aztreonam 47
Azulfidine 49
B1 145
812 145
Babinski Reflex 345
Bacillus anthracis 78, 80
Bacillus cereus 78, 80
Bacitracin 42
Baclofen 67
Bacterial endocarditis prophylaxis 380
Bacteroides 78
Bacteroides bivius 81
Bacteroides Fragilis 81
Bactrim 49
Bactroban 42
Baker Procedure 488, 510
Baker's Cyst 188
Bamboo spine 190
Band cells 361
Barbiturates 62
Bard Parker 388
Barlow's Sign 477
INDEX
619
Bartonella bacilliformis 81
Bartonella henselae 81
Basal Cell Carcinoma 285
Basal Layer 258
Basement Membrane 258
Basophils 361
Basset's lesion 601
Baxter's Neuritis 328
Bayer 39
Beatson and Pearson Assessment MethOd
480
Beau's lines 316
Beaver Handle 389
Bebax shoe 470
Becker's Muscular Dystophies 506
Bejel 90
Bell's Palsy 154, 602
Benadry155,62
Benazepril 63
Bence-Jones protein 358, 371
Benemid 69
Benzalkonium 76
Benzocaine 56
Benzocaine-Topical 55
Benzodiazepines 61
Bepridil 66
Berman and Gartland Procedure 499
Berndt-Harty Classification 552
Beta hemolytic bacteria 78
Betamethasone 53
Betamethasone dipropionate 52
Betamethasone-Injectable54
Betapace 64,66
Betazolol 66
Bextra 40
Biatain 312
Biaxin 47
Bicarbonate 55
Bicillin-CR 48
Bicuspid valve 158
Bier block 115
Bilirubin 366
Bilobed Flap 181
Bio-Action Great Toe Implant 424
Bioclusive 312
Biofix Pins 412
Biofix Screw 411
Biolex 312
BioPro Hemi Implant 420
Biopsy 261
CHAPTER 36
Excisional 262
Punch 262
Shave 261
BIOSYN 399
Bisacodyl 72
Bishop 465
Bisoprolol 66
Bites 566
Cat 566
Clenched f~stinjur~es567
Dog 566
Human 567
Blades 388
Blair fusion 528
Blastomyces dermatidis 98
Blastomycosis 98
Bleck Classification 497
Bleeding time 363
Bleomycin 75
Bleph 10 49
BlisterFilm 312
Blocadren 66
Blood chemistry 366
Alburnln 366
Alkaline Phosphatase 366
Bilirubin 366
BUN 367
Calcium 367
Chlorlde 368
Cholesterol 368
Creatine Phosphokinase 368
Creatinine 369
ESR 372
Glucose 369
Lactate Dehydrogenase 369
Phosphate 370
Potassium 370
Protein 371
SGOT 371
SGPT 371
Sodium 372
Uric Acid 372
Blood flow phase 233
Blood pooling images 233
BLOOD SUPPLY 3,429,557
Achilles tendon 557
Talus 3
Tendon 430
Blood Urea Nitrogen 367
Blount's Disease 473
Blue nails 316
Blue nevi 280
Blue Toe 384
B-Lymphoid cells 92
INDEX
Bohler-Braun frame 525
Bohler's Angle 208
Boil 271
Bold Screw 409
Bone cement 610
Bone destruction patterns 238
Geographic 238
Motheaten 239
Permeative 239
Bone forceps 393
Bone island 242
Bone rasp 396
Bone Scans 232
Bone stimulators 253
Bone tumor-primary benign 239
Bone tumors 238
Bone tumors-General presentation of loca.
tion 241
Bone tumors-Malignant vs. Benign 239,
240
Bone tumors-primary malignant 239
Bone-imaging phase 233
BONES 14 230 250 413
~ccessdrybdnes 229
Anchors 413
Bone stimulators 253
Calcaneus 14
Delayed union 251
Electrical stimulation 253
Grafts 254
Hard callus 250
Healing 250
primary(membranous) 250
Secondary(enchondral)250
Malunion 251
Nonunion 251, 252
Ossifications 230
Pseudoarthrosis 251
Remodeling 250
Soft callus 250
Talus 16
Bony Angles 205
Bordetella pertussis 78, 81
Borrelia burgdorferi 81, 133, 195
Borrelia recurrentis 81
Bosworth Procedure 558
Bosworth's Fracture 547
Botox 73
Botulinum 78
Botulinum toxin A 73
Botulism 83
Bouchard's nodes 189
Boutonniere deformity 187
620
CHAPTER 36
Bovie 602
Bow leg 204
Braanhamella 81
Braces 469
Brachial Plexitis 130
Brachymetatarsia 503
BRALON 399
Breslow's Classification 288
Bretylium 64
Bretylol 64
Brevibloc 66
Broden X-ray View 228
Brodie's Abscess 306
Brodies Abscess 602
Bromi-Lotion 31
Brostrum Procedure 544
Brown nail 316
Brown procedure 461
Brucella 78, 81
Brucellosis 81
Brun(Spratt) curette 391
BuecheCPappas Implant 526
Buerger's Dz 104
Buffalo hump 54
Bugg and Boyd Procedure 558
Bulla 260
Bullous Diabeticorum 290
Bumetanide 58
Bumex 58
BUN 367
Bundle of His 158
BUNION 442 458
~valuatiod442
DASA 443
Hallux abductus angle 442
Hallux abductus interphalangeai angle
443
Intermetatarsalangle 442
Metatarsal protrusion distance 443
Metatarsus adductus angle 442
PASA 443
Tibialis sesamoid position 443
Procedures 444
Ak~n451
Austin 444
Cheilectomy 450
Cotton 451
Crescentis 447
Drato 446
Green-Watermann 445
INDEX
Hiss 451
Hohmann 445
Juvara 448
Kalish 446
Keller 449
Kessell-Bonney 450
Lambrinudi 447
Lapidus 449
Logroscino 448
Loison-Balacescu 448
Ludloff 447
Mau 447
Mayo 449
McBride 451
McKeever 450
Mitchell 446
Peabody445
Reqnauld 451
Reverdin 444
Reverdin-Green 444
Reverdin-Laird 444
Reverdln-Todd445
SCARF 446
Silver 450
Stone 449
Watermann 445
Wilson 446
Youn swick 444
Tailor's 358
Exostoses 460
Bunionette 458
Bupivacaine 56
Buprenex 34
Buprenorphine 34
Burkholderia cepacia 81
Burns 564
Burrow 260
Bursa 10,328
Achillodynia 328
Adventitious bursa 328
Anterior Achilles bursitis 328
Calcaneal Bursitis 328
Retroachilles 10
Retrocalcaneal 10
Retrocalcaneal bursitis 328
Subcutaneous calcaneal 10
Subcutaneous caicaneal bursa 328
Subtendinous calcaneal 10
Subtendinous calcaneai bursa 328
Buschke's Disease 475
BuSpar 62
Buspirone 62
621
CHAPTER 36
Butabarbital 62
Butalbital 37
Butenafine 29
Butisol 62
Butorphanol34
Butterfly rash 198
Button anchor 432
Buttress and Button Anchor 432
Buttressing 238
Buttressing Plate 412
Cafe au lait spots 295, 336

Calamine 32
Calan 66
Calcaneal Inclination Angle 209
Calcaneal tuberosity 14
Calcaneovalgus 504
Calcaneus 14.523.549
Anatomy 14
Fracture 549
Fracture repair 523
CalciCare 313
Calcium 367
Calcium Channel Blockers 66
Calcium pyrophosphate dihydrate 197
Caliciviridae 96
Callus Distraction 530
Callus/Corns 294
Calymmatobacterium granulomatis 82
CAM-OUT 408
Campbell or Johnson 464
Camprylobacter pyiori 85
Campylobacter fetus 82
Campylobacter jejuni 76, 82
Canale X-ray View 228
Candidiasis 98
Canes 176
Canidia albicans 98
canis 272
Cannula 518
Cantharidin 75
Capillary Hemangioma 281
Capnocytophaga ochraceus 82
Capoten 63
Capozide 65
Capsulorrhaphy 602
Capsulotomies 452
Captopril 63
Carbamazine 67
Carbapenam 44
INDEX
Carbenicillin 49
Carbocaine 56
CarboFlex 313
Carbon Disulfide 136
Carbuncle 272
Carcinoma 286, 602
Cardene 66
Cardiac Apex 159
Cardiac rhythms 164
Asystole 165
Atrial Fibrillation 167
Atrial flutter 167
F~rstdegree heart block 164
Junctional rhythm 169
Normal sinus rhythm 769
Paroxysmal atrial tachycardia 167
Paroxysmal supraventricular tachycardla
167
Premature atrial contraction 166
Premature ventricular contraction 168
Second degree heart block 164
Type 1. Wenckebach's 164
Type II, Mobitz's 164
Sinus Arrhythmia 165
Sinus Bradycardia 166
Sinus Tachycardia 166
Thlrd degree hean block 165
Ventricular fibrillation168
Ventricular tachycardla 168
Wolff-Parkinson-WhiteSyndrome 169
Cardiobacterium 82
Cardizem 66
Cardura 64
Carisoprodol 67
Carmol 31
CarraDres 313
Carra-Film 312
CarraGauze 31 3
CarraGinate 313
CarraSmart 312
CarraSmart Film 312
CarraSorb 313
Carrasyn 312
Carrington 312
Carteolol 66
Cartrol 66
Carvedilol 66
Carville healing sandle 314
Castellani's Paint 29
Castor oil 72
Casts-in urine 360
CAT scan 232
622
CHAPTER 36
Cataflam 39
Catapres 63
Catapres-TTS 63
catarrhalis 81
Cat-scratch disease 81
Causalgia 602
Cave disease 98
Cavernous Hemangioma 282
Cavus F O O ~490
CBC 361
ceclor 45
Cefaclor 45
Cefadroxil 44
Cefadyl 45
Cefamandole 45
Cefazolin 44, 379
Cefdinir 45
Cefditoren 45
Cefepine 46
Cefixime 45
Cefizox 46
Cefmetazole( 45
Cefobid 46
Cefonicid 45
Cefoperazone 46
Ceforanide 45
Cefotan 45
Cefotaxime 46
Cefotetan 45
Cefoxitin 45
Cefpodoxime 46
Cefpodoxine 45
Cefprozil 45
Ceftazidime 46
Ceflin 45
Ceflizoxime 46
Ceftriaxone 46
Cefuroxime 45
Cefzil 45
Celebrex 40
Celecoxib 40
Celestone 53
Celestone-Injectable 54
Cellulitis 270
Celontin 68
Cement-bone 610
Centrax 61
Cephalexin 44
Cephalexin hydrochloride 44
Cephalexin monohydrate 44
INDEX
Cephalosporins 44
Cephalothin 45
Cephapirin 45
Cephradine 45
Cephulac 72
Cerclage wire 410
Cerebral Palsy 505
Cerebyx 67
Cervical ligament attachment site 14
Cetacaine Spray 55
Cetamide 49
Cetaphil 32
Chaddock Reflex 345
Chagas' Disease 133
Chambers Procedure 488
Champagne Bottle Legs 123
Chancroid 78, 84
Charcot foot 307
Charcot-Marie-Tooth Disease 123, 147
Charcot's triad 602
Cheilectomy 450
Chemistry panel 366
Chest X-ray 379
Chevron osteotomy-Bunion 444
Cheyne-Stokes Respirations 602
Chickenpox 92,276
Chickenpox-Childhood vaccine 468
Chilblains 563
Childhood Immunization 468
Chinese Finger Trap 433
Chlamydia pneumoniae 82
Chlamydia psittaci 82
Chlamydia trachomatis 82
Chloral hydrate 62
Chloramphenicol 50, 140
Chloramphenicol-Topical 42
Chlordiazepoxide 61
Chloride 368
Chloromycetin 42, 50
Chloroprocaine 56
Chlorothiazide 59
Chlorpromazine 60
Chlorpropamide 70
Chlorthalidone 59
Choking Victim 578
Cholac 72
Cholesterol 368
Choline magnesium trisalicylate 39
Chondroblastoma 245
Chondrocalcinosis 197
623
CHAPTER 36
Chondromas 244
Chondromyxoid fibroma 245
Chondrosarcoma 245
Chopart's Joint 602
Christmas and Snook Procedure 545
Christmas disease 364
Christmas Factor 365
Chromomycosis 97
Chronulac 72
Chvostek's sign 602
Cicatrix 260, 602
Ciclopirox Olamine 29
Cilostazol41
Ciloxan 46
Cimentidine 76
Cincinatti Incision 184
Cin-Quin 64
Cipro 46
Ciprofloxacin 46
Cisplatin 140
Citrobacter diversus 82
Citrobacter freundii 82
Citrucel 71
CK 368
Cladosporium 97
Claforan 46
Clarithromycin 47
Clark's Classification 288
CLEAR SPACE 536
Medial 536
Tibiofibular 536
Cleocin 50
Clindamycin 50, 380
Clinodactyly 602
Clinoril 40
Cloaca 306
Clobetasol propionate 52
Clocortolone pivalate 52
Cloderm 52
Clomipramine 59
Clonazepam 61, 67
Clonidine 63
Clonus Reflex 345
Clorazepate 61
Closed kinetic chain 214
Clostridium botulinum 78
Clostridium difficile 78, 82
Clostridium perfringens 78
Clostridium tetani 73,78
Clotrimazole 28
INDEX
Clotting cascade 365
Cloud sign 196
Cloxacillin 48
Cloxapen 48
Clozapine 60
Clozaril 60
Club Foot 480
Clubax 470
Clubbing 316
Coagulation Cascade 365
~oa&lationStudies 363
Activated Partial Thromboplastin Time 364
Bleedlng Time 363
Partial Thrombopiastin Time 364
Platelet Count 364
Prothrombin Time 364
Coalitions 494
Coast of Maine 295
Cobalamin 145
Cobra pad 216
Cocaine 56
Coccidioides immitis 98
Coccidioidomycosis 98
Codeine 34
Codman's triangle 236
Coin on edge 474
Colace 71
Colchicine 140
Colchicine- 68
Cold sores 92
Cold Therapy 174
Cole Procedure 492
Coleman Block Test 602
Collagen fibers 430
Collagenase 313
Collar 210
Collimators 222
Colorado Tick Fever 95
Colovage 72
CoLyte 72
Combipres 65
Comfeel 312,313
Common Cold 95
Common moles 279
Common pathway factors 364
Compartment Syndrome 533,569
Compazine 69
Compensated metaductus 489
Compound nevi 280
Compound-W 75
Compression Pump 314
624
CHAPTER 36
Compression therapy 313

Compressive Screws 409
Compton effect 222
Computer Axial Tomography 232
Concentric contraction 176
Condyloid Joints 26
Condyloma acuminatum 93
Congenital Convex Pes Plano Valgus 483
Congenital Dislocated Hip 476
Congenital Vertical Talus 483
Congruent Great Toe Fusion Plate 450
198
Dermatomyositis 199
Polvmvos~tis199
~clerobermaI99
Sjogren's Syndrome 200
SLE 198
Conrad and Frost Procedure 513
Constilac 72
Constitutional symtoms 603
Contact Dermatitis 263
Contrast baths 172
Control Release Suture 401
Coral-red 270
Cordarone 64,141
Cordran 52
Core Care 312
Coreg 66
Corgard 66
Corkscrew 416
Corns 294
Coronoid fossa 14
Cortef 53
Corticosteroids-Topical 52
Side effects 51
Cortisone 53
Cortone 53
Cowert 64
Corynebacterium diphtheria 133
Corynebacterium diphtheriae 76,83
Corynebacterium minutissimum 270
Corynebacterium ulcerans 83
Corzide 65
Co-trimoxazole 49
Cotrin 49
Cotton Procedure 451,467
Cotton's Fracture 547
Coumadin 41
Counter Rotational System 470
Cowell Procedure 495
COX-1 36
INDEX
COX-2 38
Coxa valga 205
Coxa vara 205
Coxackie 95
Coxiella burnetii 83
Cozaar 63
CPK 368
CPK-BB 368
CPK-MB 368
CPK-MM 368
CPPD 197
CPR 577
Cranial Nerves 2
Crawford and Gabriel Classification 497
C-reactive protein 372
Creatine Phosphokinase 368
Creatinine 369
Creeping Substitution 255
Crescent Sign 603
Crescentic osteotomy 447
CREST 199
Crista 603
Critical Angle 208
Crohn's disease 201
Cross Sectional Anatomy 530
Crowe's Sign 603
Crucial Angle 208
Cruex 29
Crural Ligament 11
Crust 260
Crutches 176
Cryoanesthesia 55
Cryotherapy 75
C r ~ ~ t o c o c c o s98
is
C r y p t ~ ~ o c c neoformans
us
98
CRYSTALINE-INDUCEDARTHRITIS 196
Gout 196
Pseudogout 197
Crystals-in urine 360
Curafil 312
Curafoam 312
Curagel 313
Curasol 312
Curasorb 313
Curettes 391
Curosorb 313
Cushing's Disease 54
Cutaneous Mycoses 272
Cuticle 13
Cutifilm 312
625
CHAPTER 36
Cutinova 312, 313
Cutivate 52
Cyclobenzaprine 67
Cyclocort 52
Cyclooxygenase 38
Cyma Line 603
Cyst 260
CYSTS 337
Epidermal inclusion 337
Ganglionic 337
Cytochrome P450 603
Cytomegalovirus 92, 131
!Q
399
Dalacin C 50
Dalfopristin 51
Dalgan 34
Dalmane 61
Damason-P 35
Dancer's pad 217
Danis-Weber Classification 548
Dantrium 67
Dantrolene 67
Dapsone 51,140
Darier's tumor 333
Darvon 35
Darvon Compound 35
Davis procedure 460
Daypro 40
Dear tick 195
Debridement-Ulcer 306
Decadron 53,54
Declomycin 50
Deep Tendon Reflexes-scale 345
Deep Venous Thrombosis 110
Deferoxamine 73
Deficol 72
Defluvium unguium 318
Degenerative joint disease 189
Dejerine-Sottas Disease 148
Delayed image 233
Delayed union 251
Deltasone 53
Deltoid Ligament 8
Demadex 58
Demeclocycline 50
Demerol35
Dengue Fever 96
Denis-Browne Bar 469
Denver bar 216
INDEX
Depacon 68
Depakene 68
Depakote 68
Dependoviruses 93
Depo-Medrol53
Dermacea 313
DermaCol 312
Dermafilm 312
Dermagrafl313
Dermal nevi 280
DERMALENE 399
DERMALON 399
DermaSite 312
DermaStat 313
Dermatitis 263
Dermatofibroma 282
Dermatofibrosarcoma protuberans 333
Dermatological Lesions 280
Dermatomes 116
Dermatomyositis 199
Dermatophyte Test Medium 261
Dermatophytosis 272
DernateM 312
Derotational Skin Plasty for 5th Digits 182
Desenex 29
Desiccate 803
Desipramine 60
Desonide 52
Desowen 52
Desoximetasone 52
Desyndactyly Procedure 183
Developmental Landmarks 468
DeVries Incision 184
DeVries tailor's bunion procedure 460
Dexamethasone 53
Dexamethasone-Injectable54
Dexon 54,399
Dezocine 34
DiaB 312
DiaBeta 70
Diabetes 289, 300, 572
Cutaneous manifestations289
Education 315
insulin shock 572
Ketoacidosis 572
Diabetic amyotrophy 130
Diabetic Dermopathy 290
Diabetic Medication-Oral 70
Diabinese 70
Diaphysis 241
626
CHAPTER 36
Diarrhea medications 71
Diascopy 261
Diastasis 603
Diastasis-distal tiblfib 535
Diathermy, Microwave 174
Diathermy, Shortwave 174
Diaz Disease 475
Diazepam 61
DIC 364
Dichloroacetic acids 75
Dickson and Dively procedure 460
Diclofenac 39
Dicloxacillin 48
Dicondylar coronal plane 206
Dictations 346
Bun~onectomy347
Hammertoe repair 348
Neuroma 349
Dideoxycytidine 144
Diebold and Bejjani 465
Differential 361
difficile 78
Diflorasone diacetate 52
Diflucan 30
Diflunisal 39
Digiblind 64
Digoxin 64
Digoxin-immume Fab 64
Dilantin 68
Dilaudid 35
Diltiazem 66
Dimenhydrinate 69
Diphenhydramine 55,62
Diphtheria 133
Diphtheria-Childhood vaccine 468
Diphtheroids 78
Diprivan 57
Diprolene 52
Diprolene AF 52
Disalcid 40
Discharge summary 344
Discoid Eczema 265
DISH 593
Dislocated Hip 476
Dislocated Peroneals 559
Disopyramide 64
Dissociative anesthesia 57
Disulfiram 141
Diulo 59
Diuretics 58
INDEX
Diuril 59
Docusate 71
Dolobid 39
Dolophine 35
Dolor 603
Donnagel 71
Doppler 101
Down's Syndrome 603
Downey and McGlamry Procedure 511
Doxazosin 64
Doxepin 60
Doxycycline 50
Dramamine 69
Drato 446
Dressing forceps 391
Dressing-Jones Compression 606
Dressings-Wound 312
Droal6l
Dronabinol 69
Drug schedule classification 34
Drumstick shaped bacteria 73
Drysol 31
DTM 261
DTP 74
DTP-Vaccine 468
DTR's-scale345
Ductus arteriosus 158
Dulcolax 72
DuoDERM 312
Duo-DERM 312
Duofilm 31, 75
Duoplant 31,75
Dupuytre's contracture 333
Duranest 56
Duricef 44
DuVries Peroneal Procedure 559
DuVries Procedure 492
DuVries Procedure-eversion sprains 544
DVT 110,384
DVT(pr0phylaxis) 41
DWFO Procedure 493
Dwyer Procedure 493
Dyazide 65
Dychenne's Muscular Dystrophies 506
DynaCirc 66
Dynamic Compressive Plate 412
Dynamyzation 529
Dynapen 48
Dyrenium 59
Dysgonic fermenter 83
627
CHAPTER 36
Dyshidrosis 267
Dyshidrotic Eczematous Dermatitis 267
Dyspareunia 604
Dysphagia 604
Dystrophic nail 316
Dystrophies, Muscular 505
sa
EBI Minifixator 418

Ebola virus 93
eburnation 604
Eccentric 241
Eccentric contraction 176
Ecchondromas 244
Ecchymosis 604
Eccrine Gland 259
ECHO 95
EC-Naprosyn 40
Econazole 28
Ecotrin 39
Ectrodactyly 604
Eczema 263
Edecrin 58
Edema scale 345
Edwardsiella tarda 83
EES 47
Ehlers-Danlos Syndrome 604
Eikenella corrodens 83
EKG 162
Determlning Heart Rate 162
EKG paper 162
Heafl rhythms 163
Elasto-Gel 312, 313
Elavil 59
Electric stimulation 175
Electrodesiccation of warts 75
Electromyography 127
Elephant foot 252
Elevation-Dependency Test 101
Elevator, Freer(Periostea1)396
Elevator, Key 395
Elevator, McGlamry 395
ELSA 374
Elmslie 546
Elocon 52
Emery-Dreifuss Muscular Dystrophy 506
EMG 127
EMLA cream 55
Emollients 32
Empirin 39
Empirin with Codeine 35
INDEX
E-mycin 47
Enalapril 63
Enarthrodial Joints 26
Enchondroma 244
Enchondromatosis 244
Endep 59
Endo-Fix Interference Screw 411
Endoneurium 604
Endotenon 430
Enflurane 58
Engle's angle 498
English anvil 393
Enostosis 242
Enoxacin 46
Ensure 312
Enteric-Cytopathogenic virus HumanOrphans 95
Enterobacter aerogenes 83
Enterobacteriacease 78
Enteroceccus faecium 90
Enterococcus faecalis 83,90
Enterococcus faecium 84
Enteroviruses 94
Enthesopathy 604
Entrapment neuropathies 118
Joplin's neuroma 119
Morton's neuroma 118
Tarsal Tunnel Syndrome 120
Enzymatic debriders 313
Enzyme-linked immunoabsorbent assay
374
.. .
Eosinophils 361
Epidermal Inclusion Cyst 337
Epidermophyton 272
Epilock 312
Epinephrine 55
Epineurium 604
Epiphyseal Ischemic Necrosis 473
Epiphyseal Plate Fracture 548
Epitenon 430
EpiView 312
Eponychium 13,316
Epsom salt 72
Epstein-Barr 92
Equalactin 71
Equinus 508
Talotibial exostosis 509
Erb's point 159
Erosion 260
Ertapenem 44
Erwinia herbicola 84
628
CHAPTER 36
Erycette 42
Erysipelas 271
Erysipelothrix rhusiopathiae 84
Erythema chronicum migrans 195
Erythrasma 270
Erythrocyte Sedimentation Rate 372
Erythromycin 47,380
Erythromycin-Topical 42
Eschar 604
Escherichia arogens 78
Escherichia coli 78, 84

Esgic 37
Esidrix 59
Esmolol 66
Essex-Lopresti Classification 550
Estazolam 61
Esters-Injectable Anesthetics 56
Ethacrynic acid 58
ETHIBOND 399
ETHILON 399
Ethmozine 64
Ethosuximide 67
Ethyl chloride 55
Etidocaine 56
Etodolac 39
Eucerin 32
Eumycotic mycetoma 97
Evans Osteotomy 482, 486
Tendon Procedure 545
Eversion Sprains 544
Ewings sarcoma 248
EXAM 303,345,378
H&P 351
Lower extremity 345
Preoperative 378
Ulcer 303
Excoriation 260
Exelderm 28
Exercise Test 101
Ex-Lax 72
Exophilia wernickii 97
Exostosis-Subungual 323
Extensile Incision 184
Extensor Substitution 214
External Fixators 418, 529
Extrinsic pathway factors 364
Exuderm 312
Fabella 229
Facioscapulohumeral Musc. Dyst. 506
INDEX
629
Fallat and Buckholz 458

Fascicles 430
Fasciotomy-compartment syndrome 534
FASTak 416
Fasting Blood Sugar 369
FBS 369
FDI 426
Felbamate 67
Felbatol 67
Feldene 40
Felodipine 66
Felty's Syndrome 188
Femur-Angles 205
Fenoprofen 39
Fentanyl 34, 57
Fever 383
Fiberall 71
FiberCon 71
Fibrin 365
Fibrinogen 365
Fibroblastic phase 307
Fibrolytics-topical 31
Fibroma 332
Fibrosarcoma 246,333
Fillauer Bar 470
Film 312
Filoviridae 93
Filovirus 93
Fioricet 37
Fioricet with Codeine 35
Fiorinal 37
Fiorinal with Codeine 35
First degree heart block 164
Fissure 260
Fistula 604
FIV 95
Five "W"s384
Five Minute Hyperemic test 102
Flagyl 51
Flatfeet 484
Flatline 165
Flaviviridae 96
Flavivirus 96
Flavobacterium meningosepticum 84
Flecainide 64
Fleet Enema 72
Fleet Mineral Oil 72
Flexderm 313
Flexeril 67
Flexible Digital Implants 426
CHAPTER 36
FlexiGel 313
FLEXON 399
Flexor Hallucis Longus Muscle 19
Flexor Stabilization 214
Flexor Substitution 214
Flexor tendon transfer 435
Flexosplint 472
Flexzan 312
floccosum 272
Florone 52
Floxin 47
Fluconazole 30
Flumazenil 73
Fluocinolone acetonide 52
Fluocinonide 52
Fluoroquinolones 46
Fluoroscopy 235
Fluothane 58
Fluoxetine 60
Flurandrenolide 52
Flurazepam 61
Flurbiprofen 39
Fluticasone propioate 52
Fluticasone propionate 52
Fluvastitin 65
Fluvoxamine 60
Foam 312
Foley 604
Folliculitis 271
Fonsecaea97
Foot Drop 604
Forceps 391
Fortaz 46
Fosinopril 63
Fosphenytoin 67
Four-Layer Bandage 314
Four-phase bone scan 233
Fowler Procedure 500
Fowler-Philip Angle 208
FRACTURE 523,540
Ankle 547
Calcaneal 523. 549
Repair 525
Epiphyseal Plate 548
Greenstick 541
Jones 553
Lisfranc's FxiD~slocation
555
Navicular 556
Open 540
OsteochondritisDissecans 552
Sesamoids 542
INDEX
Stress 541
Talus 525. 552
Neck 552
Posterior process 553
Re air 525
Tibial llafond 554
fragilis 78
Francisella 78
Francisella tularensis 84
Freer elevator 396
Freiberg's Infraction 473
Friedman Counter Splint 472
Friedreich's Ataxia 124
Frost matrixectomy 320
Frostbite 562
Fulp and McGlamry Procedure 510
Fulvicin 30
Fungal arthritis 195
Fungal Culture 261
Fungicare 29
FungiNail 29
Fungizone 29
Fungoid 28
Fungoid Tincture 28
Fungus-skin infection 272
Furazolidone 71
Furosemide 58
Furoxone 71
Furuncle 271
Fusobacterium 78, 84
FyBron 313
Gabapentin 67
GAIT 212,423
Analysis 212
~ointmotions213
Muscle action 212
Patterns 218
Antalgic 219
Atax~c218
Dyskinetic 218
Equinus 218
Fenistrating 219
Spastic 218
Steppage 218
Trendelenberg 219
Vaulting 218
Waddling 218
Galezzi's Sign 477
Gallium-67 234
Ganglionic Cyst 337
630
CHAPTER 36
Gangrene 100
Ganley Spint 469
Ganley's type osteotomy 482
Gantanol 49
Gantrisin 49
Garamycin 43
Gardnerella vaginalis 84
Gas gangrene 83
Gas producting organisms 78
Gel phenomenon 187
Gentamicin 43
Gentell 312
Gentian Violet 31
genu valgum 204,604
Genu varum 204,604
Geocillin 49
Geographic Bone Destruction 238
Gerbert or Rappaport 463
German Measles 96
Gestational Diabetes 301
Giant cell tumor 246
Giant Cell Tumor of Tendon Sheath 332
Giant osteoid osteoma 242
Gigli Saw 604
Ginglymus Joint 26
Girdlestone Procedure 435
Gissane's Angle 208
Glands 259
ADOCrlne 259
~'ccr~ne
259
Sebaceous259
Gleich Procedure 488
Glide hole 409
Glimepiride 70
Glipizide 70
Glomus Tumor 284
Glossopharyngeal Nerve 2
Glucocorticosteroids-Oral 53
Glucophage 70
Glucose 369
Glucose Tolerance Test 373
Glucose-in urine 357
Glucotrol 70
Glucotrol X 70
Glyburide 70
Glycosylated Hemoglobin 373
Glynase 70
Glyset 70
Gold 141
Gold Sodium Thiomalate 40
INDEX
GoLytely 72
Gonarrhea 78
Gonococcal arthritis 193
Gordochom 29
Gordon sign 345
GORE-TEX 399
Gottron's sign 200
Gout 196
Gout Medications 68
Gower's Sign 605
Granisetron 69
Granulocytes 361
Granuloma Annulare 293
Granulosum Layer 258
Gray lunula 316
Gray nail 316
Great Tarsal Joint 229
Green nail 316
Greenstick Fracture 541
Green-Watermann 445
Grice and Green Extraarticular Subtalar
Arthrodesis 489
Grid 222
Grifulvin 30
Grisactin 30
Griseofulvin 30
Gris-PEG 30
Growth Factors 313
Guanabenz 63
Guanadrel64
Guanethidine 64
Guanfacine 63
Guarnieri Inclusion Bodies 93
Guillian-Barre Syndrome 122,128
Gustillo and Anderson 540
Gut 399
Gutters 519
gypseum 272
H&P 351
H&P-Lower extremity 345
Haber and Kraft 463
Haemophilus aphrophilus 84
Haemophilus ducreyi 84
Haemophilus influenzae 85
Haemorphilus influenzae 78
Hafnia alvei 85
Hageman Factor 365
Hagland's Deformity 329
Hair on end 238
631
CHAPTER 36
Halazepam61
Halcinonide 52
Halcion 61
Haldol 60
Half and half nails 318
Hallux Limitus 454
Hallux rigidus 454
Hallux varus 456
Halo sign 494
Halobetasol proponate 52
Halog 52
Haloperidol 60
Haloprogin 28
Halotex 28
Halothane 58
Hambly 545
Hand Ties-Suture 404
Hanging heel sign 605
Hansen's dz 78
Hapalonychia 316
Hard x-rays 222
Hardcastle Classification 555
Harpoon Anchor 413
Hauser Procedure 512
Haverhill fever 90
Hawkin's Classification 552
Hawkins Sign 605
HBsAb 92
HBsAg 92
HCTZ 59
HEART 158 382
~natorny'l58
Blood flow through 158
Cardiac Rhythms 164
Murmurs 159
Aort~cRegurgitation 161
Aortic Stenosis 160
Atr~alS e ~ t aDefect
l
162
Innocent vs. Pathological 160
Loudness Scale 160
Mitrai Regurgitation 161
Mitrai Stenosis 161
Patent Ductus Arteriosus 162
Pulrnonic Regurgitation 161
Pulmonic Stenos~s161
Tricuspid Regurgitation 162
Ventrlcuiar Septal Defect 162
Sounds 159
Heat Therapy 172
Heberden's nodes 189
Heel Counter 210
INDEX
Heel lifts 217

Heel Lock 217
Heel Pain 326
Due to nerve entrapment 328
Heel Spur Syndrome 326
Heimlich Maneuver 578
Helicobacter pyl0ri 85
Heloma dura 294
Heloma Durum 605
Heloma molle 294,605
Hemangioma 281
Hematemesis 605
Hematocrit 362
Hematological agents 41
Hematoma 385,605
Hemoglobin 362
Glycosylated373
Hemoglobin S disease 382
Hemolysis 78
Hemophilia A 364
Hemophilia B 364
Hemoptysis 605
Hemostat 392
Hepadnaviridae 92, 96
Heparin 41
Hepatitis A 95
Hepatitis 8 92, 131
Hepatitis B- Childhood vaccine 468
Hepatitis C 96, 131
Hepatitis D 96
Hepatitis E 96
Herbert Screw 409
HerberUWhippleScrew 409
Herellea vaginicola 80
Herpes Simplex 131,274
Herpes simplex-1 92
Herpes simplex-2 92
Herpes Zoster 131, 275
Herpetic whitlow 274,316
Herpetoviridae 92
heterograft254
Hexacarbons 136
Heyman procedure 438
Heyman, Herndon, and Strong 499
Hibbs tenosuspension 437
Hilgenreiner's Line 478
Hintegra Ankle Implant 527
HIP 204,476
Dislocation 476
Abduction Test 477
Acetabuiar index 478
632
CHAPTER 36
Ailis' Sign 477

Anchor's Sign 477
Barlow's sign 477
Galezzi's Sign 477
Hilgenreiner's Llne 478
Neiaton's Line 478
Ombredanne's Line 478
Ortolani's Sign 476
Quadrant System 478
Shenton's Curved Line 478
Von Rosen's Method 479
Von Rosen's Sign 479
Wiberg's CE Angle 479
Range of motion 204
Hippocratic nails 316
Hiss procedure 451
Histoplasma capsulatum 98
Histoplasmosis 98
HlV 95
Hives 260
HLA-B27 375
Hoffa's Sign 605
Hohmann 445,462
Hoke Procedure 487,513
Hoke's Tonsil 605, 612
Homans Sign 605
Homocystinuria 605
homograft 254
Horizontal breach 480
Horny Layer 258
Horse hoof 252
Hubscher Maneuver 606
Human Adenoviruses 92
Human Immuno-deficiency Virus-1 132
Human leukocyte antigens 375
Humulin 301
Humulin L 70
Humulin N 70
Humulin R 70
Humulin U 70
Hunting Response 605
Hurricaine Spray 55
Hutchinson's sign 288
Hyalagan 189
Hyaluronidase 31
Hycodan 34
Hvdrochloroauine 40
Hydrochlorothiazide 59
Hydrocodone 34
Hydroco1312
INDEX
633
CHAPTER 36
Hydrocolloid 312
Hydrocortisone 52, 53
Hydrocortisone butyrate 52
Hydrocortisone valerate 52
HydroDIURIL 59
Hydroge 312
Hydromorphone 35
Hydron 312
hydropad 312
Hydrosorb 312
Hydroxyzine 62
HyFil 312
Hygroton 59
Hylore164
Hyperalgesia 606
Hyperbarics 316
Hyperchromia 362
Hyperesthesia 606
Hypergel 312
Hyperglycemia 300
hyperhydrosis 73
Hyperion 312,313
Hyperion Film 312
Hyperkalemia 370
Hypernatremia 372
Hyperpathia 606
Hyperproteinemia 371
Hyperuricemia 372
Hypesthesia 606
Hypochromia 362
Hypodermis 259
Hypoesthesia 606
Hypoglossal Nerve 2
Hypoglycemia 300
Hypoglycemics 70
Hypokalemia 370
Hyponatremia 372
Hyponychium 13,316
Hypoproteinemla 371
Hypothalamic-Pituitary Neg. Feedback 53
Hypothermia 561
Hypothyroid Neuropathy 153
Hytone 52
Hytrin 64
Hyzaar 65
II
lamin 312
Ibuprofen 39
lbutilide 64
Ice pack 174
lchthyosis 606
lcterus 606
llizarov 418
llosone 47
IM rod 528
lmidazole 28
lmipramine 60
lmiquimod 75
Immersion Foot 563
Immunization 468
lmodium 71
Impetigo 268
IMPLANTS 417,517
Arthroereisis 517
Kalix Implant 518
Lundeen Subtalar lmplant 517
STA-Peg Subtalar lmplant 517
Subtalar MBA lmplant 518
Stayfuse 417
Weil-CarverHammertoe 417
IMPLANTS-JOINT 420, 526
Acumed great toe lmplant 424
Ankle 526
Agility 526
Buechel-Pappas 526
Hinteara 527
STAR 527
Bio-actlon great toe lmplant 424
Bio-Pro 420
Flexible Digital lmplant 426
GAIT lmplant 423
InterPhlex 427
InterPhlex lmplant 427
K2 Hemi 421
Kinetik great toe lmplant 424
Koenig 423
La Porta 422
Lawrence 422
LPT Great Toe 421
Metal Hemi-Toe 421
Primus 423
Reflexion Toe 425
Sgariato design MPJ lmplant 425
ShawRod 426
SHIP 426
Swanson flexible 421, 425
Swanson Tltanlum Hem-Implant420
Total toe Implant 423
Weil type swanson design lmplant 426
Inch worm procedure 183
Incisions 184
Inclusion bodies 95
lndapamide 59
lnderal 66
INDEX
lnderide LA 65
Indices
~~- 362
Indium-111 234
lndocin 39, 68
lndomethacin 39,68
Induration 606
INFECTION 384
Post-Op 384
Inflammatory phase-wound 307
Influenza A 94
Influenza B 94
Influenza C 94
lnfracalcaneal Heel Spur 327
lnfracalcaneal nerve entrapment 328
Ingrown toenail 319
Inorganic Phosphorus 370
INR 363
Insole 210
INSTRUMENTS 387
Adison Brown Forceps 391
Adison forcepts 391
Adison Tissue Forceps 391
Allls Clamps 392
Alm Retractor 390
Army Navy 390
Atraumat~cForceps 391
Awl 393
Bard Parker 388
Beaver handle 389
Blades 388
Bone Forceps 393
Bone Rasp 396
Bone Rongeur 393
Brun(Spratt) Curette 391
Dressing Forceps. 391
English Anvil 393
Freer Elevator 396
Hemostat 392
lris Scissors 394
Kelly Forceps 392
Key Elevator 395
Kocker 392
Malleable 390
Mayo Scissors 394
McGlamry Elevator 395
Metzenbaum Scissors 394
Mosquito 392
Nail Curene 391
Needle holder 392
Ochsner 392
One-Two's 391
Osteotome 395
Periosteal Elevator 396
Ragnells 390
Rongeur 393
634
CHAPTER 36
Seeburger 390
Self-retaininaretractor 390
Senns 390
Skin Hooks 390
Spatula & Packer 395
Sponge Forceps 393
Suture Removal Scissors 394
Towel Clamp 392
Trephine 395
Volkmann Curette 391
Weitlaner 390
Wire Cutters 396
Insulin 70, 301
Insulin Shock 572
Intact 312
Intermittent Claudication 100
lnterosseous lipoma 247
Intractable plantar keratoma(1PK) 295
lntradermal Nevi 280
lntrasite 312
Intraungual hematoma 316
Intrinsic muscles of the foot 20
Intrinsic pathway factors 364
lnvanz 44
Inversion Sprains 544
lnvolucrum 306
lontophoresis 175
losartan 63
lpos heel relief 314
lpos Shoe 472
lris scissors 394
Ischemic Index 101
Ischemic Toe Conditions 384
Iselin's Disease 475
Islet of Langerhans 606
lsmelin 64
lsoflurane 58
lsokinetic contraction 176
Isometric contraction 175
lsoniazid 141
Isoproterenol 64
lsoptin 66
Isotonic contraction 176
lsradipine 66
lsuprel 64
ltraconazole 30
lvermectin 291
Ixodes dammini 195
Jahss classification(sesamoids) 542

Jahss Procedure 493
INDEX
Janimine 60
Japas Procedure 492
Javara 448
Jobst stockings 313
Johnson osteochondrotomy 500
Joint fluid analysis 187
JOINTS 12 204 229
Great ~arsai'229
Lateral Tarsometatarsal 229
Medial Tarsometatarsal 229
Metatarsophalangeal 12
Ranaes of motion 204
Ankle 205
HIP204
Knee 204
MPJ 205
STJ 205
Types of Joints 26
Jones Compression Dressing 606
Jones Fracture 553
Jones Peroneal Procedure 560
Jones tenosuspension 436
Joplin's Neuroma 119
Junctional nevi 279
Junctional rhythm 169
Juvenile rheumatiod arthritis 188
Juxtacortical(parostea1) 241
K2 Hemi lmplant 421

Kager's Triangle 557
Kalginate 313
Kalish 446
Kalix-Arthroereisis lmplant 518
Kaltocarb 313
Kaltostat 313
Kanamycin 43
Kantrex 43
Kaopectate 71
Kaplin matrixectomy 321
Kaplin tailor's bunionectomy 463
Kaposi's Sarcoma 284
Keating 462
Keck & Kelly 329
Keflex 44
Keflin 45
Keftab 44
Kefzol 44
Keith Needle 398
Kelikian Procedure 546
Kelikian Test 606
Keller 449
635
CHAPTER 36
Kelly & Keck 329
Kelly forceps 392
Kelly Procedure 560
Keloid 283
Kenacort 53
Kenalog-10 53
Kenalog-40 53
Kenalog-Injectable 54
Kenalog-Topical 52
Keratolytics 31
Kerlone 66
Kessell-Bonney 450
Ketalar 57
Ketamine 57
Ketoacidosis 572
Ketoconazole 28, 30
Ketones-in urine 358
Ketonuria 358
Ketoprofen 39
Ketorolac Tromethamine 39
Key elevator 395
Keyhole Procedure(Young)487
Kidner Procedure 486
Kilovolts 222
Kinetik Great Toe lmplant 424
Kingella 85
Kirschner wires 410
Kites Angle 209
Klebsiella pneumonia 78
Klebsiella oxytoca 85
Klebsiella pneurnoniae 85
Klikian 461
Klonopin 61, 67
Knee-Motion 204
Knighton classification 302
Knock knee 204
Kocker 392
Koenig 423
KOH Test 261
Kohler Disease 474
Koilonychia 318
Koutsogiannis Procedure 489
Krachow and Cohn Technique 433
Kussmaul's Respiration 606
Kutler-Type Bi-axial V-Y 181
K-wires 410
Kyphosis 606
Kytril 69
I
4
La Porta lmplant 422
INDEX
Labetalo166
Lace Stays 210
Lachman Test 607
Lac-Hydrin 12% 32
Laciniate Ligament 10
Lactate Dehydrogenase 369
Lactobacillus 78
Lactulose 72
Lag phase 307
Lag Technique 409
Lambrinudi 447
Lamictal 68
Lamisil 29, 30
Lamotrigine 68
Lamoxactam 46
Lance's Disease 475
Landry's Paralysis 122
Lange Procedure 499
Langer Splint 470
Langerhan Cells 259
Langerhans, Islet of 606
Lanolin 32
Lanoxicaps 64
Lanoxin 64
Lapidus-Bunionectomy 449
Larson Procedure 546
LASER 595
Laser(CO2) treatment of warts 75
Lasix 58
Last 211
Latamoxef 46
Lateral deviation angle 458
Lateral Extensile Incision 184
Lateral flare 215
Lateral squeeze test 119
Lateral Tarsometatarsal Joint 229
Lauge-Hansen Classification 547
Lawrence Total Implant 422
Laxatives 71
Layers of the foot 25
LD 369
LDH 369
isoenzymes 373
LDH "flip" 373
Leach and lgou 464
Lead 137
Lee Procedure 545
Left shift 361
Legg-Calve-Perthes Disease 474
Legionella 85
636
CHAPTER 36
Legionella pneumophilia 78
Legionnaires dz 78
Legionnaires' disease 85
Leiomyoma 334
Leiomyosarcoma 334
Lemont's nerve 607
Lente 70, 301
Lenticular capsulotomy 453
Lentigo Maligna Melanoma 287
Lentivirinae 95
Lepird procedure 499
Lepow technique 498
Leprosy 86,133
Leptorrichia buccalis 86
Leptospirosis 86
Lescol65
Lesgues Test 607
Leukocyte esterase 358
Leukocytes 361
Leukocytosis 361
Leukonychia 318
Leukopenia 361
Leukotrienes 38
Levaquin 46
Levatol66
Leventen 465
Levine's Sign 607
Levo-Dromoran 35
Levofloxacin 46
Levoprome 37
Levorphanol35
Lewin's Disease 475
Lexxel65
Librium 61
Lichen Planus 278
Lichen Simplex Chronicum 266
Lichenification 260
Lichtblau 482
Lichtblau Procedure 499
Lidex 52
Lidex-E 52
Lidocaine 56
Lidocaine-Topical 55
Ligamentotaxis 529
Ligamentous Laxity(Ehlers-Danlos) 604
Ligamentous Laxity(Marfan's) 607
LIGAMENTS 8 120 522,
Anterlor lnfdrior fibioflbular ligament 535
Anterior talofibular 8
Bifurcate 9
INDEX
637
Caicaneofibular8
Calcaneotibial 8
Cervical 9
Attachment to Calcaneus 14
Attachment to talus 16
Crurai 11
Deep anterior talotibial 8
Deep posterior talotibial 8
Deltoid 8
inferior Transverse Tiblofibuiar Ligament
535
Laciniate 10
Lisfranc's 522
Long plantar 9
Navicuiotibiai 8
Peroneus longus 9
Plantar 9
Plantar calcaneonavicuiar 9
Plantar intermetatarsai9
Posterior Inferior Tibiofibular ligament 535
Posterior taiofibular 8
Short plantar 9
Spring 8
Superficial talotibial 8
Taiocalcaneonavicualar 8
Tibiofibuiar interosseous ligament 535
Ligamentum arteriosum 158
Limb length discrepancy 214
Limberg flap 181
Limb-Girdle Muscular Dystophy 506
Lindholm Procedure 558
Lindsay's nail 318
Linezolid 51
Lioresai 67
Lipitor 65
Lipoma 335
Liposarcoma 335
Liquid Pred 53
Lisfranc's FxlDislocation 522,555
Lisinopril 63
Lister's Corn 607
Listeria monocytogenes 86
Livingston 125
Lock jaw 73
Locoid 52
Lodine 39
Logroscino 448
Loison-Balacescu 448
Lomefloxacin 47
Lomotil 71
Long Plantar Ligament 9
Lopressor 66
Lopressor HCT 65
CHAPTER 36
Loprox 29
Lorabid 45
Loracarbef 45
Lorazepam 61
Lorcet 36
Lordosis 607
Lortab 36
Lotensin 63
Lotensin HCT 65
Lotrel
65
-.
.... .
.
Lotrimin 28
Lotrisone 28
Lou Gehrig's Disease 122
Lovastatin 65
Lover's heel 191
Lovibond's angle 316
Low-Dye Strap 217
Lowman Procedure 486
LO20159
LPT Great Toe Implant 421
Ludloff 447
Lumbosacral Plexitis 130
Luminai 68
Lundeen implant 517
Lunuia 13,316
Lupus 196
Luvox 60
Lyme disease 81,133
Lymes disease 195
Lymphadenitis 111
Lymphangitis 111
Lymphedema Ill
Lymphocytes 361
Lymphoma 332
Lyofoam 312
Lyo hilized bone 254
Maceration 260,607
Macroaggregated albumin 234
Macrodactyly 502
Macrolides 47
Macronychia 318
MacroPro 312
Macule 260
Madura foot 97
Maffuccis syndrome 244
Magnesium Hydroxide 72
Magnesium sulfat 64
Maisonneuve's Fracture 547
Malassezia furfur 97
INDEX
Malignant freckle 287
Malignant Hyperthermia 574
Malignant Synovioma 338
Malleable 390
Malleolar Position 206
Malunion 251
Mando145
Mann 462
Maple sugar urine disease 357
Marcaine 56
Marfan's Syndrome 607
Marie-Striimpell's disease 190
Marinol 69
Marjolin's ulcer 607
Martel's sign 196
Mason-Allen Stitch 432
Master Knot of Henrv 607
MATRIXECTOMY 319
Chemical 319
Suraicai 320
Frost 320
Kapiin 321
Lapidus 322
Modified Frost 320
Plastic Lip 321
Suppan 322
Symes 322
Whitney 322
Winograd 321
Zadik 323
Matrixectomy-chemical 319
maturation phase-wound 307
Mau 447
Mavik 63
Maxaquin 47
Maxide 65
Maxiflo 52
Maxiflor 52
Maxipime 46
MAXON 399
Maxorb 313
Mayo Block 115
Mayo scissors 394
Mayo-Bunionectomy 449
MBA Implant 518
McBride bunionectomy 451
McCormick and Blount Procedure 500
McElvenny-Caldwell procedure 493
McGlamry elevator 395
MCH 363
638
CHAPTER 36
McKeever tailor's procedure 461

McKeever-Bunionectomy 450
MCV 363
Mean Corpuscular Hemoglobin 363
Mean Corpuscular Volume 363
Meary's Angle 209
Measles 94
Measles-Childhood vaccine 468
Mebara 62
Meclofenamate 39
Meclomen 39
Medial Tarsometatarsal Joint 229
Medipren 39
Mediskin 313
Medrol 53
Medrol Dosepack 53
Mee's lines 318
Mefenamic acid 39
Mefilm 312
Mefoxin 45
melaninogenicus 78
Melanocytes 259
Melanoma 287
Ameianotic 288
Melanonychia 318
melanotic whitlow 287
Melgisorb 313
Mellaril 60
Melorrheostosis 607
mentagrophytes 272
Mentax 29
Mepergan Fortis 36
Meperidine 35
Mephenytoin 68
Mephobarbital62
Mepilex 312
Mepiva~aine56
Mercado 463
Mercado Procedure 546
Mercurochrome 608
Mercury 137
Meropenem 44
MERSILENE 399
Mesantoin 88
Meshing 178
Mesotenon 430
Metal Hemi-Toe Implant 420
Metamucil71
Metaphysis 241
Metastatic tumors 239
INDEX
Metatarsal 207
Bar 216
Declination angle 207
Distal protrusion 207
Length 207
Metatarsal Adductus 496
Measuring Techniques 497
Metatarsal Protrusion Distance 443
Metatarsalgia 608
Metatarsus Primus Adductus angle 442
Metatarsus primus elevatus 456
Metatarsus Primus Varus 608
Metatarsus varus 608
Metaxalone 87
Metformin 70
Methacycline 50
Methadone 35
Methicillin 48
methicillin resistant S. aureus 89
Methocarbamol 67
Methotrexate 188
Methotrimeprazine 37
Methoxyflurane 58
Methsuximide 68
Methyclothiazide 59
Methylcellulose 71
Methyldopa 63
Methylene diphosphate 233
Methylmethacrylate 610
Methylparaben 607
Methylprednisolone 53
Metolazone 59
Metoprolol 66
Metronidazole 51
Metzenbaum scissors 394
Mevacor 65
Mexical-hat procedure 451
Mexiletine 64
Mexitil 64
Mezlin 49
Mezlocillin 49
MIC 596
Micatin 28
Mickey finn 62
Miconazole 28
Micrococcus 78
Micro-guard 28
Micronase 70
Micronychia 318
Microsporum 272
Microzide 59
639
CHAPTER 36
Midamor 59
Midazolam 57,61
Mid01 39
Midsole 210
Miglitol 70
Milk of Magnesia 72
Milkinol 72
Miller Procedure 487
Miller-Fisher syndrome 128
Milliamperage 222
Milontin 68
Mineral Oil 72
Mini-Mayo block 115
Minipress 64
Minirale 418
Minizide 65
Minocin 50
Minocycline 50
Misonidazole 142
Mitchell 446
Mitek anchors 413
Mitraflex 312
Mitral valve 158
Mitrolan 71
MMR-Childhood vaccine 468
Mobitz's heart block 164
Modane 72
Moduretic 65
Moexipril 63
Moisture1 32
Molluscum Contagiosum 93, 274
MOM 72
Mometasone furoate 52
Moncheberg's Dz 105
Mondor's Sign 549
Monicid 45
Monistat-Derm 28
Monobactam 47
Monochloroacetic acids 75
MONOCRYL 399
Monocytes 361
Monodox 50
Monofilament wire 410
Mononeuropathies 151
Mononucleosis 92
Monopril63
MONOSOF 399
Moon faces 54
Moraxella 81
Moraxella lacunata 78
INDEX
Moraxella catarrhalis 78, 86
Morganella morganii 86
Moricizine 64
Morphine sulfate 35
Morton's Neuroma 12
Morton's Foot 608
Morton's Neuroma 118
Nelve Sclerosing Injections 155
Mosaicplasty 608
Mosquito 392
Motefen 71
Motheaten bone destruction 239
Motrin 39
Mouchet's Disease 475
Mouse-like appearance 199
Moxalactam 46
Moxam 46
MPJ Release Technique 537
MPJ-Motion 205
MPM 312
MRI 231
MS Contin 35
Muehrcke's nails 318
Mulder's sign 119
Multiple Myeloma 608
Multiple Sclerosis 121
Multipodusll'nard splint 314
Mumps 94
Mumps-Childhood vaccine 468
Mupirocin 42
Murmurs 159
Murphy procedure 511
Muscle Relaxants 67
Muscles 17 258 558
~ b d u c t o~i i ~ i i o r uMinimi
m
Quinti 21
Abductor Hallucis 20
Adductor Halluc~s23
Arrector piii 258
Dorsal lnterossel 25
Extensor Digitorurn Brevis 20
Extensor Digitorurn Longus 17
Extensor Hallucis Brevis 20
Extensor hallucis capsularis 17
Extensor Haliucis Longus 17
Flexor Digit1 M~nlmi24
Flexor D~gitorurn19
Flexor Digitorum Accessoriurn 22
Flexor Digitorum Brevis 21
Flexor Hallucis Brevis 23
Flexor Hallucis Longus 19
Gastrocnemius 18
Lurnbricales 22
Peroneals 559
640
CHAPTER 36
SubiuxationiDislocation559
Peroneus Brevis 18
Peroneus Longus 18
Peroneus Tertius 17
Plantar lnterossei 24
Plantaris 18
Popliteus 19
Quadratus Plantae 22
Soleus 18
Tibialis Anterior 17, 561
Rupture 561
Tibialis Posterlor 19, 561
Rupture 561
Muscular Dystrophies 505
Myasthenia Gravis 608
Mycelex 28
Mycifradin 43
Mycobacerium leprae 133
Mycobacterium tuberculosis 78
Mycobacterium aviumintracellulare 86
Mycobacterium bovis 78
Mycobacterium chelonae 86
Mycobacterium fortuitum 86
Mycobacterium kansasii 86
Mycobacterium leprae 78, 86
Mycobacterium marinum 87
Mycobacterium tuberculosis 87
Mycobacterium ulcerans 78
Mycolog 29
Mycoplasma pneumoniae 87
Mycosis 97
Mycostatin 29
Myco-Triacet 11 29
Myeloma Neuropathy 134
Mykrox 59
Myochrysine 40
Mysoline 68
YY
Nabumetone 39
Nadolo166
Nafcil 48
Nafcillin 48
Naftifine 29
Naftin 29
Nail bed 13
Nail curette 391
Nalbuphine 35
Nalfon 39
Naloxone 73
Naprosyn 40
Naproxen 40
INDEX
641
Navicular Fracture 556

NCV 127
Nebcin 43
Nebupent 44
Necrobiosis Lipoidica Diabeticorum 289
Needle holder 392
Needles 398
Negative Feedback-Steroids 53
Negri bodies 95
Neisseria gonorrhoeae 78, 87
Neisseria meningitidis 78, 87
Neisseriaceae 78
Nelaton's Line 478
Nembutal62
Neomycin 43
Neomycin-Topical42
Neosporin 42
Neostigmine 57
N e ~ blocks
e
114
Nerve Conduction Velocity 127
N e ~ Sclerosing
e
Injections 155
Nerve to the abductor digiti quinti muscle
328
Nerves 2, 114
Anterior Femoral Cutaneous 117
Baxter's 5
Blocks, Nerve 114
Ankle block 114
Bier block 115
Digital block 114
Hallux block 114
Mayo block 115
Mini-Mayo block 115
Clunial 117
Common dorsal digital 5
Common peroneal5
Communicating branch 5
Cranial 2
Cutaneous Innervation 117
Deep branch of lateral plantar nerve 5
Deep peroneai 5, 11, 117
lnnervation 118
Dermatomes 116
Dorsal digital proper 5
Entrapment neuropathies 118
Gen~tofemorai
117
iiioinguinal 117
lnfracaicaneai 5
lnfrapatellar branch 5
lnnervation of intrlnsic 118
CHAPTER 36
intermediate dorsal cutaneous 5

Lateral calcaneal 5
Lateral dorsal cutaneous 5
Lateral Femoral Cutaneous 117
Lateral plantar 5. 117
lnnervation 118
Lateral sural cutaneous 5, 117
Lower Extremity 5
Medial caicaneal 5
Medial dorsal cutaneous 5
Medial plantar 5, 117
lnnervation 118
Medial sural cutaneous 5
Nerve to the abductor digiti minimi 5
Obturator 117
Posterior Femoral Cutaneous 117
Proper plantar dlgltal 5
Saphenous 5, 117
Sciatic 5
Seddon Classification 114
Sunderland's Classification 114
Superficialbranch of lateral plantar nerve
5
Superficial peroneal 5, 117
Sural 5. 117
Tib~al5
Nesacaine 56
Neuralgia 608
Neurapraxia 114, 608
Neurectomy 609
Neurilemoma 336
Neurodermatitis 266
Neurofibroma 336
Neurofibromatosis 609
Neuroleptics 60
Neurolysis 609
Neuroma 118
Neurontin 67
Neurorrhaphy 609
Neurotmesis 114, 609
Neutral Triangle 609
Neutralization Plate 412
Neutrophils 361
nevi 279
Nevus Flammeus 281
Nicardipine 66
Nifedi~ine66
Nikolsky Sign 261
Nilsonne Procedure 545
Niistat 29
INDEX
Nisoldipine 66
Nitrite-in urine 358
Nitrituria 358
Nitrofurantoin 51, 142
Nitrous Oxide 58
Nizoral28, 30
Nocardia asteroides 87
Noctec 62
Nodular Fasciitis 333
Nodular Melanoma 287
Nodule 260
Non-A, Non-B Hepatitis 96
Noninvasive Vascular Studies 100
Nonossifying fibroma 246
Nonunion 251,252
Norco 36
Norflex 67
Norfloxacin 47
Norgesic 37
Normal sinus rhythm 169
Normlgel 312
Normodyne 66
Noroxin 47
Norpace 64
Norpramin 60
Nortriptyline 60
Norvasc 66
Norwalk 96
Norzine 69
NOVAFIL 399
Novocaine 56
NPH 70,301
NPUAP pressure ulcer staging 303
NSAlDs 38
Nubain 35
Nu-Gel 312, 313
Nujo172
NuLytely 72
Nummular(Discoid) Eczema 265
Numorphan 35
Nuprin 39
NUROLON 399
Nutcracker sign 553
NutraCol 312
NutraFill 313
NutraStat 313
NutraVue 312
Nystatin 29
Nystop 29
Gl
642
OBL Anchor 415
Obturator 518
OcclusaCHP 75
Occulomotor Nerve 2
Ochsner 392
OCL 72
Ocu-Sul49
Odynophagia 609
Off Loading devices 314
Ofloxacin 47
Ogden Anchor 414
Olfactory Nerve 2
Ollier's Incision 184
Ollier's disease 244
Ombredanne's Line 478
Omnicef 45
Omnipen 48
Oncovirinae 95
Ondansetron 69
One-two's 391
Onion skin 238
Onychatrophia 318
Onychauxic 318
Onychia 318
Onychoclasis 318
Onychocryptosis 318
Onychogenic 318
Onychogryphosis 318
Onychoheterotopia 318
Onycholysis 318
Onychomadesis 318
Onychomalacia 318
Onychomycosis 318
Onychophagia 318
Onychophosis 318
Onychoptosis 318
Onychopuntata 318
Onychorrhexia 318
Onychoschizia 318
Onychotillomania 319
Open kinetic chain 214
Oppenheim Reflex 346
Opraflex 312
OpSite 312
Optic Nerve 2
Orasone 53
Orbivirus 95
Oreo Cookie Sign 543
Oretic 59
Organophosphates 138
CHAPTER 36
INDEX
OriDerm 312
OriFilm 312
Orifoam 312
Orinase 70
Orisorb 313
Orphenadrine 67
Orthomyxoviridae 94
Orthoposer 222
Orthosorb Pins 412
Orthotist 609
Orthotripsy 609
Orthowedge shoe 314
Ortolani's Sign 476
Orudis 39
0 s Intercuneiform 229
0 s Coxa 230
0 s lntermetatarsum 1229
0 s Peroneum 229
0 s Sustentaculum Tali 229
0 s Talonavicular Dorsale 229
0 s Trigonum 229
0 s Vesalianum 229
Osgood-Schlatter Disease 474
OssaTron 609
Ossifications 230
Ossifying fibroma 243
Osteoarthritis 169
Osteoblast 609
Osteoblastoma 242
Osteochondritis Dissecans 552
Osteochondroma 245
Osteochondrosis 473
Assrnann's dz 475
Blount's Disease 473
Buschke's Dz 475
Diaz or Mouchet's dz 475
Freiberg's Infraction 473
Iselin'sdz 475
Kohler Disease 474
Lance's dz 475
Legg-Calve-Perthes Disease 474
Lewins dz 475
Osgood-Schlatter Disease 474
Renandier's dz 475
Ritter's dz 475
Sever's Disease 475
Thiernann's dz 475
Treve's dz 475
Osteoclast 609
Osteoconduction 255
Osteogenic fibroma 242
Osteogenic sarcoma 243
643
CHAPTER 36
Osteoid Osteoma 242
Osteoinduction 255
Osteoma 242
Osteomalacia 609
Osteomyelitis 305
Osteoporosis 610
Osteosarcoma 243
Osteotome 395
Ostiderm 31
Outsole 210
Oxacillin 48
Oxaprozin 40
Oxazepam 61
Oxiconazole 28
Oxistat 26
Oxycodone 35
OxyContin 35
Oxymorphine 35
Ox tetracycline 50
P&A 319
PAC 166
Paclitoxel 142
Paget's Disease 610
Pain 385
Painful crises 382
Palpable dell in Achilles 557
Pamelo 60
PANACRYL 399
Panadol37
Panafil 313
Panalok Anchor 413
Paniculus 259
Panlor DC 36
Panlor SS 36
Pannus transformation 188
PanoPlex 313
Pantalar fusion 610
Panwarfin 41
Papillary Layer 259
Papilloma 93
Papovaviridae 93
Papule 260
Parabens 610
Paracoccidioides brasiliensis 96
Paracoccidioidomycosis 98
Paraffin wax 173
Parainfluenza 94
Parallel Pitch Lines 206
Paralysis 610
INDEX
Paramyxoviridae 94
Paratenon 430
Paresis 610
Paresthesia 610
Paronychia 319
Paroxetine 60
Paroxysmal atrial tachycardia 167
Paroxysmal supraventricular tachycardia
167
Partial thromboplastin time 364
Parvoviridae 93
P a ~ o v i r u s e s93
Pasteurella 78, 566
Pasteurella multocida 87
Patch 260
Paxil 60
Paxipam 61
PDS 11 399
Peabody445
Peabody-Muro Procedure 500
PEDIATRICS 467
APGAR Scoring 468
Brachymetatars~a503
Calcaneovalgus 504
Cavus Foot 490
Cerebral Palsy 505
Club Foot 480
Coalitions 494
Congenital Vertical Talus 483
Developmental Landmarks 468
Dislocated Hip 476
Immunization 468
Macrodactyly 502
Metatarsus Adductus 496
Muscular Dystoph~es505
Osteochondrosis 473
Pes Pianus 484
Polydactyly 501
Skewfoot 489
Splints and Braces 469
Syndactyiy 502
Pedi-Dri 29
Pedorthist 610
PEG-ES 72
Penbutolol66
Pencil in cup 192
Penetrex 46
Penicillin G 48
Penicillin V 48
Penicillins 47
Penlac 29
Pennig Minifixator 418
644
CHAPTER 36
Pentam 300 44
Pentamidine 44
Pentazocine 35
Pentobarbital 62
Pentoxifylline 41
Pen-vee K 48
Pepto-Bismol 71
Peptococcus 78
P e p t o ~ t r e p t o c ~ c78,
c u ~87, 90
Percocet 36
Percodan 36
Percutaneous 610
Perhexiline 142
Perineurium 605, 610
Perioperative exam 380
Periosteal chondroma 244
Periosteal elevator 396
PERIPHERAL NEUROPATHY 127
Bacterial and Parasitic 133
Cold lnduced 153
Diabetic 130
Drug induced 135
Entrapment 150
idiopathic 154
immune-mediated Inflammatory 128
inflammatory Plexopathies 130
Nutrltional related 135
Radiation Induced 153
Renal Disease 131
Sarcoid Neuropathy 130
Traumatic 152
Treatment 155
Tumor associated 134
Vasculltic 129
Vlral 131
Peritenon 430
Perkinje fibers 158
PERMA-HAND 399
Pernio 563
Peroneal Anastomosis 491
Peroneal Dislocation 559
Peroneal tubercleltrochlea 15
Peroneus longus tendon transfer 438
Persc strgth Cruex 28
Persc strgth Desenex 28
Persc strgthcrue 28
Persian Slipper 483
Perthes Test 102
Pertussis 81
Peltussis-Childhood vaccine 468
Pes Cavus 490
Pes Planus 484
INDEX
Pestivirus 96
Petrich and Dull 461
Petriellidium boydii 97
Peyronies disease 333
PGA 411
Phase conversion 434
Phenazopyridine 37
Phenergan 69
Phenobarbital 68
Phenolphalein 72
Phenomenon, Raynaud's 103
Phensuximide 68
Phenytoin 68,143
Phialophora 97
Phonophoresis 175
Phosphate 370
Phospholipase A2 38
Photoelectric effect 222
Physical Therapy 171
Physis 241
Physostigmine 57, 73
Phyto Derm 312
Phytonadione 73
Picornaviridae 94
Piedra 97
Piedraia hortai 97
Piezogenic papule 336
Pigmented Villonodular Synovitis 337
Pilar leiomyoma 334
Pilon Fracture Classification 554
Pilon Fracture Repair 525
Pindolol 66
Pins 410
Pins(absorbab1e) 412
Piperacillin 49
Piperacillin/Tazobactam49
Pipracil 49
Piroxicam 40
Pistoning 518
Pitted Keratolysis 269
Pitting nails 192
Pituitary-Adrenal Suppresion 380
Pityriasis Rosea 278
Plague 91
PLANES 203
Coronal 203
Frontal 203
Sagittal 203
Transverse 203
Plantar Fasciitis 326
645
CHAPTER 36
Plantar Fibromatosis 333
Plantar Rest Strap 217
plantar wart 273
PLANTARIS MUSCLE 557
Absence 557
Plaque 260
Plaquenil 40
Plasma Cell Myeloma 608
Plasma Thromboplastin Antecedent 365
Plastic lip procedure 321
Platelet count 364
Plates 412
Platinum 138
Plendil 66
Plesiomonas shigelloides 87
Pletal41
PLLA 411
Plummer's nails 318
Plummer-Vinson syndrome 318
PMMA610
PMN'S 361
Pneumocystic carinii 98
Pneumocystic carinii pneumonia 98
PO4 370
Podagra 196
Podophyllun 75
Polio 94
Polio-Vaccine 468
Polocaine 56
Polycarbophil 71
Polydactyly 501
Polyderm 312
Polyester fiber 399
Polyethylene Glycol 72
Polyglactin 910 399
Polyglycolic acid 411
Poly-L-lactic acid 411
PolyMem 312, 313
Polymethylmethacrylate 610
Polymox 48
Polymyositis 199
Polymyxin-Topical 42
Polyoma 93
Poly-p-dioxanone 411
Polyskin 312
POLYSORB 399
Polysporin 42
Ponstel 39
Pontiac dz 78
Pontocaine 56
INDEX
646
CHAPTER 36
Popeye arms 506

Popliteal Block 115
Porokeratosis Plantaris Discreta 294
Porphyrias 149
Porta Pedis 610
Portals 519
Port-Wine Stain 281
Postaxial Polydactyly 501
Posting 215
Post-op check 340
Post-Op Infection 384
Post-op ManagemenffComplications383
Post-op note 342
Post-op orders 343
Postprandial blood sugar 373
Potassium 370
Pott's Fracture 547
Poxviridae 93
Pramosone 52
Pravachol65
Pravastatin 65
Prazepam 61
Prazosin 64
Preaxia Polydactyly 501
Precef 45
Prednisolone 53
Prednisone 53
Pregnancy Test 380
Premature Atrial Contraction 166
Premature vetricular contraction 168
Pre-op check 341
Preoperative evaluation 378
Prevotella melaninogenica 88
Primary Lesions 260
Primaxin 44
Primidone 68
Primus Flexible Great Toe Implant 423
Principen 48
Prinivil 63
Prinzide 65
Pro Clearz 29
Pro time 364
Proaccelerin 365
Probenecid 69, 197
Procainamide 64
Procaine 56
Procan SR 64
Prochlorperazine 69
Proclude 312
Proconvertin 365
Procuren 313
ProCyte 312
Profore 314
Progress note 340,341
Progressive Systemic Sclerosis 199
PROLENE 399
Proliferative phase-wound 307
Proloprim 51
Promethazine 69
Promine 64
Pronestyl-SR 64
Propafenone 64, 142
Prophylaxis(Pre-Op) 379
Propionibacterium acnes 88
Propofol 57
Propoxyphene 35
Propranolol 66
ProSom 61
Prosthetist 611
Prostoglandins 38
Protamine sulfate 73
Protamine zinc 70,301
Protein-blood 371
Protein-in urine 358
Proteinuria 358
Proteus 78
Proteus mirabilis 88
Proteus vulgaris 88
Prothrombin 365
Prothrombin time 364
Protriptyline 60
Providencia rettgeri 88
Providencia stuartii 88
Prozac 60
Pseudoarthrosis 251
Pseudocholinesterase 56
Pseudoequinus 611
Pseudogout 197
Pseudohypertrophy 611
Pseudomembranous colitis 78
Pseudomonas aerginosa 78
Pseudomonas aeruginosa 88
Pseudomonas mallei 88
Pseudomonas pseudomallei 88
Pseudomonas putida 88
Pseudosarcomatous Fascitis 333
Psorcon 52
Psoriasis 277
Psoriatic Arthritis 192
Psyllium 71
INDEX
647
PT 364
Pterygium 319
364
Pump Bump 329
Punched out lesions 292
Purge 72
Purilon 312
Purinol 68
Pustule 260
PVC 168
Pyoderma Gangrenosum 268
Pyogenic Granuloma 282
Pyrexia 611
Pyridium 37
Pyridoxine 142, 145
PZI
301
fever 83, 88
Quadrant
Quarter
Quazepam 61
Quinaglute 64
64
dislocation) 478
Quinidex 64
Quinidine 64
Quinine 67
Quinora 64
Quinupristin 51
RA factor 374
Rabies 95
313
Radiculopathy 611
radiolucent
Radionuclide angiogram 233
radiopaque 611
Ragnells 390
Ramipril 63
Hunt's Syndrome 275
Rapid Plasma Reagin 374
Rappaport 463
Raquet nail 319
Rasp 396
Rat bites 196
Rat-bite fever 90
Raynaud's Phenomenon 103
RBC 362
RBC Indices 362
urine 359
CHAPTER 36
Red lunula 319

Red Man Syndrome 51
Reese Arthrodesis Screw 409
Reflex Sympathetic Dystrophy
Reflexes 345
Deep Tendon 345
Superficial 345
Reflexion Toe Implant 425
Regnauld procedure 451
313
Reiter's Syndome 191
67
39
Remodeling phase-wound 307
Renandier's Disease 475
Renin-Angiotensin Mechanism
Reoviridae 95
312
Reserpine 64
Respiratory Syncytial Virus 94
Rest Pain 100
312
Restore 312,313
Restoril 61
Resupination Test 611
Reticular Layer 259
Reticulocyte Count 363
Retinaculums 10
Flexor 10
inferior extensor 10, 11
inferior peroneal
extensor 11
Superior extensor 10
peroneai 10
Retractors 390
Retrotrochlear eminence 15
Retroviridae 95
Reunite Pins 412
Reunite Screw 411
Reverdin 444
Reverdin-Green 444
Reverdin-Laird 444
Reverdin-Todd 445
Reverse Clubfoot 483
syndrome 39,611
70
Rhabdomyoma 335
Rhabdoviridae 95
Rheumatic fever 78
Rheumatoid arthritis 187
Rheumatoid Factor 374
INDEX
Rheumatoid nodules 187

Rhinovirus 95
Rhizopus 98
Rhomboid Flap 181
Rhythmin 64
Rickets 611
Rickettsia 88
Rifampin 51
Right shin 361
Riley-Day Syndrome 149
Rimactane 51
Rinne Tes 611
Ritter's Disease 475
Robaxin 87
Robaxisal 37
ROC EZ 415
Rocephin 46
Rockerbottom Flatfoot 483
Rocky Mountain spotted fever 88
Rodent ulcer 285
Rofecoxib 40
Romazicon 73
Romberg's Test 612
Rondomycin 50
Rongeur 393
Rosacea 292
Rotational Flap 180
Rowe Classification 549
Roxicodone 35
RPR 374
Rubella 96
Rubella-childhood vaccine 468
Rubeola 94
Rubor 612
rubrum 273
Rubvirus 96
Ruedi and Allgower Classification 554
Rufen 39
Rule of 15 481
Rule of nines 564
Rule of Palm 564
Run out of a screw 408
RUPTURE 557
Achilles 557
Tibialis Anterior 561
Tibiaiis Posterior 561
Rythmol 64
Sabin-live attenuated 94
SACH heel 216
648
CHAPTER 36
SAF-Gel312
Salflex 40
Salicylic acid 75
Salicylic Acid-topical 31
Salk-inactivated virus 94
Salmonella 78
Salmonella typhi 89
Salsalate 40
Salter-Harris 548
Salts 72
Sammarco and Diraimondo Procedure 545
San Joaquin Valley Fever 98
Sander's CT Classification 551
Santyl 313
Sarcoid Neuropathy 130
Sarcoma 612
Sarcoptes scabiei 291
Sausage toes 191
Scabies 290
Scales 260
Scar 260
SCARF 446
Scarlet fever 78
Schirmer test 200
Schoeber's Test 190,612
schoenleini 273
Schoolfied's Procedure 544
Schwannoma 336
Sciatic nerve 151
Scintigraphy 232
Scissors 394
Scleroderma 199
Sclerotic 612
Scope 518
Scopolamine 69
Screw 408,537
Absorbable 411
Anatomy 408
Compression 409
Insertion 409
Transsyndesmotic 537
Scrub typhus 88
Scurvy 612
Sebaceous Gland 259
Seborrheic Dermatitis 267
Secobarbital62
Seconal62
Second degree heart block 164
Secondary Lesions 260
Sectral 66
Sed rate 372
INDEX
SedativelHypnotics 61
Seddon Classification 114
Sedimentation rate 372
Seeburger 390
Seeburger Procedure 546
Selakovich Procedure 488
Self-retainig retractor 390
Semilente 70,301
Semmes Wienstein monofilament 345
Senns 390
Sensorcaine 56
Septic arthritis 192
Septra 49
Sequestrum 306
Serax 61
Serial pressures 100
Seronegative spondyloarthropathies 190
Serpasil 64
Serpentine foot 489
Serratia marcescens 76
Serratia marcescens 89
Sertraline 60
Sesamoids 13,443,542
Attachments 13
Fracture 542
Position 443
Sever's Disease 475
Sgarlato Design Hammertoe Implant 426
Sgarlato Design-lesser toe 425
SGOT 371
SGPT 371
Shank 210
ShawRod Hammertoe Implant 426
Shenton's Curved Line 478
Shepard's Fracture 553
Shigella 78
Shigella flexneri 69
Shingles 92, 131
SHIP 426
Shoe Anatomy 210
Short Plantar Ligament 9
Sickle Cell disease 382
SignaDRESS312
Signal Node 614
Sigvarus 313
Silfverskiold Procedure 511
Silfverskiold Test 508, 612
Silvadene 49
Silver dollar sign 474
Silver procedure 450,488
649
CHAPTER 36
Simian and feline immunodeficiency viruses 95
Simian Vacuolating 93
Simons's Assessment Method 481
Simons's rule of 15 481
Simple bone cyst 247
Simvastatin 65, 143
Sinequan 60
Sinus arrest 165
Sinus Arrhythmia 165
Sinus Bradycardia 166
Sinus Tachycardia 166
Sinus Tarsi 612
Sinus Tarsi Syndrome 612
SIS graft 313
SIV 95
Sjogren's Syndrome 200
Skelaxin 67
Skewfoot 489
Skin 258
Conditions 258
Dermis 259
Ep~derm~s
258
Subcutaneous Tissue 259
Skin grafts 178
Skin Hooks 390
Skin plasties 180
Skin tag 280
Skintegrity 313
Sliding Scale (Glucose) 381
Sliver sulfadiazine 49
SMA 366
SMAC 366
Smart Screw 411
Sodium-blood 372
Sof-foam 312
SOFSILK 399
Soft x-rays 222
Solitary bone cyst 247
SoloSite 313
Solu-Cortef 53
Solu-Medrol 53
Soma 67
Soma Compound 37
Soma Compounds with Codeine 36
Somogyi effect 612
Sorbex 312
Sorbsan 313
SOtal01 64, 66
Spatula & Packer 395
INDEX
Specific gravity 356
Spectazole 28
Spectinomycin 43, 51
Spectracef 45
Sphygmomanometer 613
Sphygmo-manometer 613
Spider Angioma 281
Spirillum minus 89
Spirochete 291
Spirochete-Lyme disease 195
Spironolactone 59
Splay Foot 613
Splinter hemorrhages 319
Splints 469
Split Tibialis Anterior Tendon Transfer 438
Spondyloarthropathies 190
Sponge forceps 393
Sponse1462
spoon nail 318
Sporanox 30
Sporothrix schenckii 97
Sporotrichosis 97
Sprains-ankle 543
Spring Ligament 8
Spumavirinae 95
Squamous Cell Carcinoma 286
Squeeze test 119
SSD 49
Stado134
Standard AFO 471
STA-Peg Subtalar Implant 517
Staphcillin 48
Staphylococcus aureus 89
Staphylococcus epidermidis 89
Staphylococcus saprophyticus 89
Staples 412
STAR Ankle Implant 527
Stasis Dermatitis 266
Statak Anchor 414
S T A T 438
Stayfuse Implant 417
STEEL 399
Steida's process 553
Steindler Stripping 491
Steinmann pin 410
Stenosis 613
Stenotrophomonas maltophilia 90
Stent dressing 179
Sterapred 12 day Unipak 53
Sterapred DS 12 day Unipak 53
650
CHAPTER 36
Sterapred DS Unipak 53
Sterapred Unipak 53
Steroids-Injectable 54
Steytler and Van Der Walt Procedure 500
Still's disease 188
STJ-Motion 205
Stockings 313
Stone 449
Stork legs 123
Strachan Syndrome 148
Stratum Corneum 258
Stratum Germinativum 258
Stratum Lucidum 258
Stratum Spinosum 258
Strawberry mark 281
Strayer Procedure 510
Streeter Bands 601
Streptobacillus moniliformis 90
Streptococcus group A, B, C 90
Streptococcus group D 90
Streptococcus pneumoniae 90
Streptococcus viridans 90
Streptokinase 42
Streptomycin 43
Stress Fracture 541
Stromectol 291
Stuart Factor 365
Sublimaze 34,57
SubluxationlDislocation 559
Peroneal559
Substrate phase 307
Subungual exostosis 323
Subungual hematoma 319
Succimer 73
Succinyl Choline 57
Sudek's Atrophy 124
Sufenta 35
Sufentanil 35
Sular 66
Sulbactam 48
Sulconazole 28
Sulfacetamide 49
Sulfadiazine 49
Sulfamethizole 49
Sulfamethoxazole 49
Sulfasalazine 49
Sulfatrin 49
Sulfinpyrazone 69
Sulfisoxazole 49
Sulfonamides 49
INDEX
Sulforcin 31
Sulfron 31
Sulfur 31
Sulindac 40
Sullivan's Sign 119
Sunburst 238
Sunderland's Classification 114
Superficial Spreading Melanoma 287
Suppan matrixectomy 322
Suppan Tendon Procedure 546
Suprax 45
Suresite 312
SURGERY 378
Perioperatlve380
Post-op Management 383
DVT 384
Fever 383
Hematoma 385
Infection 384
Ischemic toe 384
Pain 385
Preoperat~vecons~derations378
378
Anesthesia risk class~ficat~ons
Antibiotic prophylaxis 379
Anticoagulants 381
Cardiac Patients 383
Diabetics 381
Glucose control 381
Rheumatold patlents 381
Sickle Cell disease 382
Sterold use 380
Tourniquet 380
When to cancel 378
Surgical neck 613
SURGICAL SILK 399
SURGIDAC 399
SURGIGUT 399
SURGILENE 399
SURGILON 399
SURGIPRO 399
Surmontil 60
Sustentaculum Tali 15
Suture 400, 431
"Tracks" 401
Absorbable 401
Gut vs. Chromic Gut 401
Knots 402, 431
Packet Label Information 400
Size 401
Tensile Strength 401
Suture removal scissors 394
Swagged 401
651
CHAPTER 36
Swan neck deformity 187

Swanson Double Stemmed Hinged Implant
425
Swanson Flexible Toe lmplan 425
Swanson Flexible Toe Implant 421
Swanson Titanium Hemi-Implants 420
Sweat glands 259
Sweeping 518
Symes Amputation 521
Symes digital matrixectomy 322
Synalar 52
Syncope 573
Syndactyly 502
Syndesmotic Injury 535
Synercid 51
Synovial cyst 337
Synovial Sarcoma 338
Synthes Fixator 418
Synvisc 189
Syphilis 291,374
Systemic Lupus Erythematosus 198
T1 232
T2 232
TAC 55,56
Tacrolimus 143
Talacen 36
Talar Torsion 207
Talipes Equinovarus 480
Talonavicular beaking 494
Talus 3, 207, 552
Anatomy 16
Blood supply 3
Fracture 552
Talar neck angle 207
Talar torsion 207
Talwin 35
Talwin Compound 36
Talwin NX 36
Tambocor 64
Tarka 65
Tarsal Canal 613
Tarsal Coalitions 494
TATT 439
Taxol 142
Tazicef 46
Tazidime 46
Tazobactam 49
Td 74
Technetium-99 233
INDEX
Teczem 65
TED hose 313
Tegaderm 312
Tegagen313
Tegasorb 312
Tegopen 48
Tegretol67
Tegretol XR 67
Telangiectasia 613
Telangiectatic posterior nail folds 319
Temazepam 61
Temovate 52
Temperature conversion 2
Tempra 37
TENDON 10,430,511
Accordion type lengthening 433
Achilles 10, 511
Advancement 511
Lengthening 512
Anatomy 430
Collagen Fibers 430
Endotenon 430
Epitenon 430
Fascicles 430
Mesotenon 430
Paratenon 430
Peritenon 430
Extensor digitorum longus 11
Extensor hallucis longus 11
Flexor digitorum longus 10
Flexor halluccs longus 10
Healing 434
Peroneus brevis 10
Peroneus longus 10
Peroneus tertius 11
Tibiaiis anterior 11
Tibialis posterior 10
Transfers 434
Adductor tendon transfer 435
Flexor tendon transfer 435
Heyman procedure 438
Hibbs tenosuspension 437
Jones tenosuspension 436
Peroneus longus tendon transfer 438
STAT 438
T A T 439
Tibialis osterior tendon transfer 439
Z-plasties 833
Tendon with bony insertion 432
Tendosynovial cyst 337
Tendosynovial Sarcoma 338
Tenex 63
652
CHAPTER 36
Tennis racket shape bacteria 73

Tenoretic 65
Tenormin 66
TENS 175
Tension band fixation 410
Tension-Band Plate 412
Terazosin 64
Terbinafin 29
Terbinafine HCL 30
Terramycin 50
Terry's nails 319
tetani 78
tetanospasmin 73
Tetanus 73, 83
Tetanus-chilhood vaccine 468
Tetracaine 56
Tetracycline 50
Tetracyn 50
tetrafluoroethane 55
Tetralogy of Fallot 613
TEVDEK I1399
Thalassemia 613
Thalidomide 143
Thallium 139
Thallium-201 234
Thiamin 145
Thiemann's Disease 475
Thiethylperazine 69
THlNSite 313
Thiopental 57
Third degree heart block 165
Thomas heel 215
Thomasen 464
Thompson procedure 499
Thompson Test 557
Thorazine 60
Thoridazine 60
Thread hole 409
Three-hole suture 431
Throat-shoe 211
Throchmorton and Bradless 464
Thrombin 365
Thromboangiitis Obliterans 104
Thrombocytopenia 364
Thrombocytosis 364
Thrombolytic agents 42
Thrombophlebitis(Superficialveins) 108
Thromboplastin 365
Thromboxanes 38
Thrush 98
INDEX
653
CHAPTER 36
Tibia-Angles 206
Tibial Plafond Fracture 554
Tibial torsion 206
Tibial varum/valgum 206
Tlbialis anterlor tendon transfer 439
Tibialis posterior tendon transfer 439
Ticar 49
Ticarcillin 49
Ticarcillin~Clavulanate49
Tick fever 88
TI-CRON 399
Tielle 312
TIG 74
Tigan 69
Tillaux-Chaput Fracture 547
Timentin 49
Timolide 65
Timolol 66
Tinactin 29
Tinea barbae 272
Tinea capitis 272
Tinea corporis 272
Tinea cruris 272
Tinea nigra 97
Tinea pedis 272
Tinea Versicolor 97
Tineacide 28
Tinel's sign 613
Tobramycin 43
Tocainide 64
Tocopherol 146
Toe box 211
Toe-Aid 313
Toe-Blue 384
Toe-Ischemic 384
Toenails 13
Anatomy 13
Toe-White 384
Tofranil 60
Togaviridae 96
Tolazamide 70
Tolbutamide 70
Tolectin 40
Tolinase 70
Tolmetin 40
Tolnaftate 29
Tom, Dick, and Harry 10
Tongue Fracture 550
Tonocard 64
tonsurans 273
Topamax 68
Topicorl52
Topicorl LP 52
Topiramate 68
Toradol39
Torecan 69
Torsemide 58
Total Angle 329
Total contact cast 314
Total Toe System 423
Tourniquet 380
Towel clamp 392
Toyger's Angle 557
tPA 42
Tramadol37
Trandate 66
Trandolpril 63
Transeal 312
Transglutaminase 365
Transite 312
Transpositional Flap 180
Transsyndesmotic screw 537
Tranxene 61
Traveler's diarrhea 78
Trench fever 88
Trench Foot 563
Trendelenberg gait 219
Trendelenberg Position 613
Trendelenburg's Maneuver 102
Trental41
Trepheryma whippelii 91
Trephine 395
Trephine plug 431
Treponema carateum 90
Treponema pallidum 90, 291
Treve's Disease 475
TRIAD 312
Triamcinolone 53
Triamcinolone acetonide 52
Triamcinolone-Injectable54
Triamterene 59
TRIANGLE 557,609
Kager's 557
Neutral 609
Triangulation 518
Triazolam 61
Trichloroacetic acids 75
Trichophyton 272
Trichosporon beigelii 97
Tricuspid valve 158
INDEX
Tricyclics-Antidepressants 59
Tridesilon 52
Trigeminal NeNe 2
Trigeminal Neuralgia 154
Trilisate 39, 40
Trimethobenzamide 69
Trimethoprim 51
Trimipramine 60
Trimpex 51
Triplane Fracture 613
Triplane wedge 216
Triple Arthrodesis 516
Triple 516
Trismus 73
Trisomy 21 603
Trobicin 43, 51
Trochar 518
Trochlear Nerve 2
Trochoid Joints 26
Troglitazone 70
Truncated Cone Reamer System 450
Trypanosoma Cruzi 133
Tsuge's "inch worm" plastic reduction 183
Tuberculosis arthritis 195
Tubocurarine 57
Tularemia 78, 84
Tumor 260
Tunnel with sling 432
Turf Toe 541
Turgor 613
Turks test 614
Twister Cables 472
Two Hand Tie 404
Tylenol 37
Tylenol with Codeine 36
Tylox 36
Type Illdiabetes 301
Typhoid fever 89
Typhus 88
Tzanck Test 262
Ulcer 260
Ulcerative Colitis 201
ULCERS 103 303
~~assificadon
302
Exam 303
Pressure 313
Venous vs. Arter~al103
Ultec 312
Ultracef 44
Ultralente 70, 301
654
CHAPTER 36
Ultram 37
Ultrasonography-Diagnostic 235
Ultrasound 173
Ultravate 52
Unasyn 48
Underylenic acid 29
Ungual labia 13, 316
Unibar 470
Unicameral bone cyst 247
UniFlex 312
Uni~en
48
Univasc 63
Upper 211
Urea 31
Ureacin 31
Ureaplasma urealyticum 91
Uric Acid 372
Urinalysis 356
Urobilinogen 359
Urokinase 42
Urticaria 265
!
I
Vaccinations 468
Vagus Nerve 2
Valdecoxib 40
Valium 61
Valleix's sign 614
Valproic acid 68
Valsartan 63
Vamp 211
Vancocin 51
Vancoled 51
Vancomycin 51, 379
Vantin 45, 46
Varicella 276
Varicella-Childhood vaccine 468
Varicella-Zoster 92
Varicose Veins 107
Variola 93
Vascor 66
Vasculature to long bones 192
Vaseretic 65
Vasotec 63
Vasovasorium 614
VDRL 374
Veetids 48
Velosef 45
Venereal Disease Research Laboratory 374
Venous Dz 107
Venous Insufficiency 108
INDEX
Ventral Axial Line 116
Ventricular fibrillation 168
Ventricular tachycardia 168
Verapamil66
Verruca 75,273
Treatment 75
verrucae 93
Versed 57,61
Vertical Talus 483
Vesicle 260
Vestibulocochlear Nerve 2
Vibramycin 50
Vibrio cholerae 78,91
Vibrio vulnificus 78, 91
Vibrionaceae 78
Vicodin 36
Vicodin ES 36
Vicodin HP 37
Vicoprofen 37
VICRYL 399
VigiFoam 312
Vigilon 312, 313
Vincristine 144
Vioxx 40
Viral arthritis 195
Viranol75
Virchow's Node 614
Virchow's Triad 614
Virchow's Triad 100
Viridans 78, 567
Virology 92
Visken 66
Vistaril 62
Vivactil 60
Volkmann curette 391
Volkmann Fracture 547
Voltaren 39
von Recklinghausen's disease 295
von Recklinghausen's Dz 609
von Recklinghausen's disease 336
Von Rosen's Method 479
Von Rosen's Sign 479
Von Willebrand's disease 364
Von Willebrand's dz 363
Voutney 463
Vulpius and Stoffel Procedure 509
V-Y Plasty 182
BY
Waaner's classification 302

Wagstaffe Fracture 547
655
CHAPTER 36
Walking aids 176
Warfarin 41
Wart 75,273
Treatment 75
Washington monument capsulotomy 453
Water pills 58
Watermann 445
Watershed area of Achilles 614
Watson-Jones Classification 556
Watson-Jones Procedure 545
WBC 361
WBC's-in urine 360
Weber and Cech 252
Weber Test 614
Weil Type Swanson Design Hammertoe
Implant 426
Weil-Carver Hammertoe Implant 417
Weitlaner 390
Wenckebach's heart block 164
Wernicke-Korsakoff Syndrome 614
Westcort 52
Wet-to-Dry 614
Wheal 260
Wheaton Brace 471
Wheaton Brace System 471
Whinfield Procedure 546
Whipple's disease 91
Whirlpool 172
White Procedure 513
White toe 384
Whitney matrixectomy 322
Whittling phalanges 192
Whooping cough 78
Wiberg's CE Angle 479
Wick catheter 533
Wilson 446
Windlass mechanism 215
Winograd matrixectomy 321
Winter vomitting dz 96
Wire cutters 396
Wires 410
Wittberger and Mallory's Procedure 544
Wolff's Law 614
Wolff-Parkinson-White Syndrome 169
Wood's Light Examination 262
Woolsorter's dz 78
WOUN'DRES 312
Wound care 309
WOUND CLASSIFICATIONS 302
Kntghton 302
INDEX
NPUAP Pressure Ulcer Staging System
303
Wagner's 302
Wound closure 309
Wound Dressing 312
Wound healing-phases of 307
Wounds-Puncture 568
Wycillion 48
Wydase 31
Wygesic 37
Wytensin 63
M
Xanax 61
Xanthine oxidase 197
Xanthoma Diabeticorum 289
Xenograft 254
Xerac AC 31
Xeroform 614
Xeroradiograph 235
X-fix 529
X-rays 222
Dens~tyof various materials 223
Exposure factors 222
Contrast 222
Dens~ty222
Dlstance 222
Fidelity 222
K~lovolts222
Milliamperage 222
Film(slow vs, fast) 223
Hard x-rays 222
Requirements 223
Sofl x-rays 222
Views 223
Ankle 227
AP 227
lateral 227
Lateral obllque 227
Medial oblique 227
Mortlse 228
Anterior drawer 226
Anteroposterior(nlP)223
Axial calcaneus 225
Broden 228
Canale 228
Dorsoplantar(D1P)223
Harris-Beath 225
Isherwood 225
Lateral 223
Lateral oblique(L0) 224
Medial obllque(M0) 224
656
CHAPTER 36
Plantar axial 224

Push-pull stress 226
Ski-Jump 225
Stress dorsiflexion224
Stress inversion 226
Stress lateral 224
Talar tilt 226
Xylocaine 56
Y shaped ligament 9
Yancy 463
Yaws 90
Yellow Fever 96
Yellow nail syndrome 319
Yersinia enterocolitica 91
Yersinia pestis 91
Yersinia plague 78
Yersinia Psuedotuberculosis 91
Young Procedure 487
Youngswick 444
Yu 462
Z foot 489
Zadik matrixectomy 323

Zalcitabine 144
Zarontin 67
Zaroxolyn 59
Zeasorb-AF 28
Zebeta 66
Zefazone 45
Zestoretic 65
Zestril 63
Ziac 65
Zinacef 45
Zithromax 47
Zocor 65
Zoellner and Clancy Procedure 560
Zofran 69
Zoloft 60
Zolpidem 62
Zoster 92
Zosyn 49
Z-pak 47
Z-plasties in Achilles Lengthening 512
Z-plasty tendon lengthening 433
Z-Plasty-to relieve skin tension 182
Zydone 37
Zygomycosis 98
Zyloprim 68
Zyvox 51

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ANATOMY

BLOOD SUPPLY TO THE T A L U S

NERVES TO THE LOWER EXTREMITY

ARTERIES OF THE LOWER EXTREMITY

1st-4th Plantar metatarsal arteries

Posterior talofibular lig.

Posterior tibiofibular lig.

Posterior talocalcaneal lig.

ARTERIES OF THE LOWER EXTREMITY

1st-4th Plantar metatarsal arteries

RETINACULUMS AND TENDON ORIENTATION

-Inferior extensor retinaculum

Flexor digitorurn longus

Middle facet for talu

DORSAL VIEW OF CALCANEUS

PLANTAR VIEW OF CALCANEUS

Inferior horizontal line

LATERAL VIEW OF CALCANEUS

STRUCTURES AROUND THE

T A L U S - 3 1 5 of talus is covered by cartilage

Groove for FHL

DORSAL VlEW OF THE RIGHT TALUS

iculation with the navicular

ANTERIOR VlEW OF THE RIGHT TALUS

EXTENSOR HALLUCIS LONGUS MUSCLE

EXTENSOR DIGITORUM LONGUS MUSCLE

PERONEUS TERTIUS MUSCLE

m:lower one-quarter of the medial surface of the fibula and the

PERONEUS BREVIS MUSCLE

FLEXOR DIGITORUM LONGUS

the posteromedial aspect of the middle third of the tibial shaft

TIBIALIS POSTERIOR MUSCLE

m:posterior two thirds of the interosseous membrane and the adja-

cent tibia and fibula

FLEXOR HALLUCIS LONGUS

INTRINSIC MUSCLES OF THE FOOT

m:Superolateral aspect of the calcaneus,

just anterior to the sinus tarsi

Medial process of the calcaneal

FLEXOR DIGITORUM BREVIS

m:Plantar aponeurosis, medial

intermuscular septa, lateral intermuscular

ABDUCTOR DIGIT1 MINIMI

Lateral process of the calcaneal

m:Tendon of the flexor digitorum longus after its separation into 4

m:Arises from two heads

of origin which are separated

FLEXOR HALLUCIS BREVIS

FLEXOR DIGITI MINIM1

w:Medial side of the bases of the

3rd, 4th, and 5th metatarsal bones

m:Originate from adjacent sides

PLANTAR LAYERS OF THE FOOT

ANALGESICS - NARCOTIC, p34 '

Presc strgth Desenex

Dr. Scholl's Antiperspirant Spray

BIOFREEZEa is available in 160z., 32 oz., and gallon

CONTROLLED SUBSTANCE ACT

Hydromorphone(Dilaudid)-1-2mgIMlSC/IV q4-6h. 2mg PO q4-6h.

Tylenol with Codeine

Tylenol #l(Acetaminophen 300mg + Codeine 7.5mg) -1-2 tabs PO q4h.

V i c o d i n HP(~ydrocodone1Acetaminophen101660)-1 tab PO q4-6h, Clll

ARACHIDONIC AClD CASCADE

'There are two distinct isoforms of the Cycloox enase enzyme(C0X-1