Hershey Board Certification ReviewOutline Study Guide

by

Jonathan M. Singer, D.P.M.Diplomate American Board of Podiatric Surgery

Fellow American College of Foot and Ankle SurgeonsDiplomate American Board of Podiatric Orthopedics & Primary Podiatric

MedicineFellow American College of Foot & Ankle Orthopedics & Medicine

Edited byJames Lawton, D.P.M., Gene K. Potter, D.P.M., Ph.D.,

and Samuel L. Deitch, D.P.M.

ContributorsPeter F. Kelly, D.P.M., Gene K. Potter, D.P.M., Ph.D.,

Steven J. Berlin, D.P.M., Steven Kravitz, D.P.M., GuidoLaPorta, D.P.M., M.S., James Lawton, D.P.M., Arthur E.Helfand, D.P.M., Fredrick E. Youngblood, M.D., DouglasGlod, D.P.M., Christopher E. Attinger, M.D., Libby Cone,M.D., Edwin J. Juda, D.P.M., William H. Simon, D.P.M.,

John Walter, D.P.M.© 1998 Pennsylvania Podiatric Medical Association

AcknowledgementsWilliam Goldfarb D.P.M. and Nancy Sullivan, for

supporting me and believing this book could be done

James Lawton D.P.M., and Gene Potter, D.P.M. for theirinvaluable contributions in the general editing these

review notes

Jordon Fersel, M.D., for editing the chapters onAnesthesia, and Emergency Medicine,

Deborah Wozniak, M.D., for editing the chapters onPerioperative Management, Fluid Management, and

Postoperative Complications

Warren Joseph, D.P.M., and Steven Maffei, D.P.M. forediting the chapter on Infectious Diseases

Steven Kravitz, D.P.M., for editing the chapter onBiomechanics

George Vito, D.P.M. for editing the chapter on InternalFixation

Peter F. Kelly, D.P.M. for writing the chapter on Lasersand Laser Physics

Gene K. Potter, D.P.M., Ph.D. and Steven Berlin, D.P.M.for editing the chapters on Dermatology, Bone Tumors,

and Soft Tissue Tumors

Gene K. Potter, D.P.M., Ph.D., for proof reading, editing,and adding his phenomenal talent to this book

Guido LaPorta, D.P.M., M.S. for writing the chapter onAnkle Arthroscopy

The Hershey Board Certification

Review Outline Study Guideis prepared for distribution by the

Hershey Surgical Seminars CommitteePennsylvania Podiatric Medical AssociationGuido La Porta, D.P.M., General Chairman

Author: Jonathan M. Singer, D.P.M.General Editor: James Lawton, D.P.M.Copy/Content Editor: Gene K. Potter, D.P.M., Ph.D. Cover Design: Marissa SingerCoordinator: Nancy SullivanPublished by the Pennsylvania Podiatric Medical Association ISBN # 0-9639030-04

Copyright © 1998Pennsylvania Podiatric Medical Association 757 Poplar Church Road Camp Hill, Pennsylvania 17011 (800)-841-3668All rights reserved

This book is protected by copyright. No part of this book may be reproduced in any form or by any means, including photocopying, or utilized by any information storage or retrieval system without written permission from the copyright owner.

Accurate indications, adverse reactions, and dose schedules for drugs are provided in this book, but It is possible that they may change. The reader is urged to review the package information data of the manufacturers of the medications mentioned.

The author has made every effort to ensure the accuracy of the information herein. However, appropriate information sources should be consulted, especially for new or unfamiliar procedures. It is the responsibility of every practitioner to evaluate the appropriateness of a particular opinion in the context of actual clinical situations and with consideration to new developments. The author, editors, and publisher cannot be held responsible for any typographical or other errors found In this book.

Printed in the United States of America.

Table of ContentsChapter 1: Emergency Medicine Cardiopulmonary Resuscitation: page 2-3Advanced Life Support: page 3-4Office Emergencies: page 5-7Medical Emergencies (Cardiac Dysrhythmias): page 7-9Summary of CPR: page 9Other Medical Emergencies: page 9-12Shock: page 12-13Blood and Blood Products for Emergency Use: page 13-17

Chapter 2: AnesthesiaAnesthesia Classifications: page 20General Anesthesia: page 20-23Intravenous Anesthesia: page 23Local Anesthesia: page 23-26Special Cases for Lowering the Maximum Allowable Dose: page 26Pediatric Anesthesia: page 26-27Lumbar Epidural and CaudalAnesthesia: page 27-28Complications of Endotracheal Intubation: page 31Nerve Injury During Anesthesia: page 31-32Other Medical Compliccations From Anesthesia: page 32-34

Chapter 3: Perioperative ManagementThe Healthy Patient: page 36The Diabetic Patient: page 36-38The Hypertensive Patient: page 38-39The Patient on Steroid Therapy: page 39-40The Asthmatic Patient: page 40-41The Alcoholic Patient: page 41The Patient on Anticoagulant Therapy: page 41-42The Patient With Clotting Abnormalities: page 42The Rheumatoid Patient: page 43The Sickle Cell Patient: page 43-44The Cardiac Patient: page 44-45The Pulmonary Disease Patient: page 45Perioperative Management of the Infant and Child: page 45-47Mitral Valve Prolapse patient: page 47-48The Gouty Arthritis Patient: page 48

Chapter 4: Preoperative EvaluationScreening Procedures: page 50-61Summary of Perioperative Lab testing: page 61-62

Chapter 5: Postoperative Care & Complications

Fever: page 64-65Altered Mental States: page 65Water and Electrolyte Imbalance: page 65-66Oliguria: page 66Chest Pain: page 67Postoperative Hypertension: page 67Postoperative Infection: page 67-68Anxiety and Pain Management: page 68-69Nausea: page 69Constipation: page 69Shivering: page 69DVT: page 69-70Compartment Syndrome: page 70-73Hemorrhage: page 72-73Septic Syndrome: page 73Thyroid Storm: page 73-74

Chapter 6: infectious DiseasesSpecific Diseases: page 76-81Principles of Antiinfective Therapy: page 81-84Antibiotics: page 84-90Drug Fever: page 90-91Specific Antimicrobial Therapy: page 91-92Surgical Considerations: page 92-93Necrotizing Infections: page 93-94Osteomyelitis: page 94-102Septic Arthritis: page 102Mycology: page 102-103Viral Diseases: page 104Rickettsial Diseases: page 104Protozoan and Metazoan Infections: page 104-105

Chapter 7: Wound HealingRepair of Skin: page 108-111Factors That Interfere With Wound Healing: page 111-113Growth Factors in Wound Repair: page 113Surgical Approaches: page 113-114Wound Dressings: page 114Suture Materials and Needles: page 115-116Tourniquets: page 116-118

Chapter 8: Plastic SurgerySkin Grafting: page 120-122Local Cutaneous Flaps: page 122-124Local Muscle and Cutaneous Flaps: Page 124Fasciocutaneous Flaps: page 124-125Microsurgery and Free Flaps: page 125-126Diagrams of Skin Flaps: page 126-130

Chapter 9: Bone HealingPrimary Bone Healing: page 132Complications of Bone Healing: page 133-135Treatment of Nonunions: page 135Fusion: page 135Bone Grafting: page 135-137Aseptic Necrosis Following 1st Metatarsal Osteotomy: page 138-139Electrical Bone Stimulation: page 40Cartilage Healing: page 140

Chapter 10: Burns and FrostbiteAssessment and Treatment of Burns: page 142-145Burn Deformities: page 145-146Other Types of Burns: page 146Frostbite: page 146-147

Chapter 11: Fluid Management and Replacement in the Surgical PatientFluid Management: page 150-152Complications of Total Parenteral Nutrition: page 152Replacement Therapy: page 152-153Blood Products and Indications for Use: page 153-156Composition of IV Fluids: page156-157

Chapter 12: Bone TumorsIntroduction: page 160Staging Techniques: page 160-161Surgical Staging System: page 161Radiology of Bone Tumors: page 161-162Bone Tumors: Page 163-168Cystic Lesions of Bone: page 168-169Other Tumors and Cancers: page 169-170Bone Tumors: A Quick Reference Chart: page 170-171Phases in Cancer Development: page 171Benign vs. Malignant: page 172

Chapter 13: DermatologyThe Skin: page 174Dermatological Lesions: page 175-182

Chapter 14: The ArthropathiesCauses of Joint Pain: A Summary: page 184The Arthropathies: page 184-195Lab Testing for the Arthropathies: page 195Articular Disorders Affecting the Heel: page 195-196Synovial Fluid Analysis: page 197Charcot Foot: page 198-199

Chapter 15: Peripheral Vascular Disease

Patient Evaluation: page 202-212The Vascular Diseases: page 212-215

Chapter 16: Internal & External FixationObjectives of Fixation Devices: page 218Requirements of Implant Materials: page 218Principles Affecting Internal Fixation: page 218Internal Fixation Devices: page 219-229AO Objectives: page 229AO Principles: page 229-230AO Technique: page 230-235Jumping Screws: page 235-236Other Techniques: page 236-238Complications of Fixation Devices: page 238External Fixation: page 239Large Bone Fixation: page 239-252Small Bone External Fixation: page 253-254

Chapter 17: Nail Disorders & SurgeryNail Entities: page 256-260Nail Anatomy: page 260Surgical Nail Procedures: page 262-263

Chapter 18: NeurologyNeurological Pathways: page 266Presenting Features: page 266-270Assessment of Clinical Problems: page 270-278Innervation of the Lower Extremity: page 278-281Tarsal Tunnel Syndrome: page 282-284Classification of Nerve Injuries: page 284-285Neuromuscular Causes of Cavus Foot: page 285Types of Nerve Surgery: page 285-288

Chapter 19: PediatricsEvaluation of the Pediatric Patient: page 290-293Pedicatric Biomechanics-Normal Values: Newborn to Adult: page 293Congential Deformities: page 293-302Pediatric Radiology: page 302-304Pediatric Gait Patterns: page 304-305Intoe Gait: page 306-307Pediatric Fractures: page 307-318The Limp in Childhood: page 318-319Juvenile Hallux Valgus: page 319-320Biomechanical Examination of the Child: page 320-323Corrective Casting Techniques in Infants: page 323-324The Toe-Walking Child: page 324-326

Chapter 20: Drugs and Drug InteractionsIntroduction to Drug Interactions: page 328Antibiotic Drug Interactions: page 328-329Anticoagulant Drug Interactions: page 330Antihypertensive Drug Interactions: page 330-331Antipsychotic Drug Interactions: page 331Cardiac Drug Interactions: page 331-332Diuretic Drug Interactions: page 332Non Steroidal Anti-Inflammatory Drug Interactions: page 332-333Oral Contraceptive Drug Interactions: page 333Mechanisms of Drug Interactions: page 333-335Specific Drugs: page 335-344

Chapter 21: Surgery of the Congenital FootFlatfoot Surgery (flexible): page 346-355Subtalar Joint Blocking Procedures: (Arhroereises and Arthrodesis): page 355-356Flatfoot Surgery (rigid): Convex Pes Plano Valgus: page 356-358Metatarsus Adductus Surgery: page 358-362Cavus Foot Surgery: page 362-367Clubfoot Surgery: page 368-373

Chapter 22: Generalized Disease Conditions of BoneSoft Tissue Overgrowth: page 376Abnormalities of Alignment: page 376-377General Increased Bone Density: page 377Osteopenia: page 377-378 Marrow Abnormalities: page 378-379The Dysplasias: page 379-380

Chapter 23: RadiologyStandard Radiographic Techniques of the Foot and Ankle: page 382-383Specific Radiographic Studies: page 383-391Anatomic Angles: page 391-396 Common Structural Measurements(Diagrams): page 396-402 Pediatric Radiology: page 402-406 The Osteochondritities: page 406-407The Accessory Bones of the Foot:page 407

Chapter 24: Hallux Valgus & Related DisordersGoals of HAV Surgery: page 410

Anatomical Facts of the 1st MPJ:page 410-411Predisposing Factors: page 412 Biomechanics: page 412-414 Etiology of HAV: page 414-415 Deformity Types: page 416-417 Radiological Measurements for HAV:page 417-418Physical Examination: page 418-419Preoperative Considerations: page419Arthroplasty Procedures: page 419420Capsule-Tendon Balancing Procedures: page 421-422Implant Arthroplasty Procedures:page 422-426Arthrodesing Procedures: page 426429Proximal Phalangeal Osteotomies:page 429-431Distal Metatarsal Osteotomies: page432-436Proximal Metatarsal Osteotomies:page 436-438Shaft Osteotomies: page 438-439 Combination Procedures: page 439 Other Procedures: page 439-440 Hallux Rigidus and Limitus: page440-445Hallux Varus: page 445-446Hallux Hammertoe: page 446 Diff. Diagnosis of Pain In the Sesamoid Area: page 446 Complications of HAV Surgery: page 447HAV Procedure Chart and Their Indications: page 448

Chapter 25: TraumaMedical Management and General Assessment of the Trauma Patient:page 450-451Assessment of Lower Extremity Injury: page 451General Evaluation and Treatment of Fractures: page 451-452 Calcaneal Fractures: page 452-460 Talar Fractures: page 460-463 Osteochondral Fractures: page 463465Navicular Fractures: page 466-470 Cuboid Fractures: page 470-472 Cuneiform Fractures: page 472Fifth Metatarsal Base Fractures: page472-474Metatarsal Fractures: page 474-480 Ankle Fractures: page 480-493

Midtarsal Joint Dislocations: page 494Tarsometatarsal Joint Dislocations/Fractures: page 494-498Ankle Inversion Sprain: page 498505Deltoid Ligament Ruptures: page506-507Compartment Syndrome: page 507508Open Fracture Classification Systemand Tx: page 508-510Soft Tissue Injuries: page 510-511 Crush, Gunshot, and Lawnmower Injuries: page 511-512 Puncture Wounds: page 512 Epiphyseal Plate Injuries: page 512-514Digital Fractures and Dislocations:page 514-5151st MPJ Trauma: page 516-517 Nail Bed Trauma: page 517-518 Toe Tip Injuries With Tissue Loss:page 518-519Dog and Cat Bites: page 519

Chapter 26: Digital Deformities and SurgeryHammertoe Syndrome: page 522-528Mallet Toe Syndrome: page 528-529 Claw Toe Deformity: page 529 Overlapping 5th Toe: page 529-532 Hallux Hammertoe: page 532-533 Lesser Digital Arthrodesis: page 533 Hallux Interphalangeal Arthrodesis: page 533Lesser Digital Arthrodesis: page 533-534Overlapping 2nd Toe: page 534Syndactylization: page 534-535 Digital Implants: page 535-537 Floating Toe Syndrome: page 537 Blue Toe Syndrome: page 538-539 Polydactylism: page 539-541

Chapter 27: Muscle and Tendon PathologyMuscle Physiology: page 544-548 Principles of Tendon Repair: page 548-552Tendon Lengthening and Tenotomy: page 552-554 Tendon Transfers: page 554-556 Tendon Grafts: page 556-557 Posterior Tibial Tendon Rupture: page 557-559Posterior Tibial Tendon Dysfunction (Acquired Adult Flatfoot Syndrome): page 559-560

Peroneal Tendon Pathology: page 560-562Achilles Tendon Rupture: page 562-566Lateral Ankle Stabilization Procedures: page 566-571 Postoperative Care and Training Following Tendon Transfer: page 571-572Tenosynovitis: page 572

Chapter 28: Lesser Metatarsal SurgeryAnatomy (Metatarsals 2-3-4): page 574-575Differential Diagnosis of Metatarsalgia: page 575Surgical Treatment of the IPK: page 575-578Lesser Metatarsal Joint Replacement: page 578-579Panmetatarsal Head Resection: page 579-581Metatarsus Adductus: page 581-585 Freiberg's Disease: page 585-587 Tailor's Bunion: page 587-589Splayfoot: page 589 Brachymetatarsia(Brachymetetopody): page 589-591 Skewfoot: page 591-592

Chapter 29: Ankle Conditions Differential Diagnosis of Chronic Ankle Pain: page 594Tarsal Tunnel Syndrome: page 594-597Sinus Tarsi Syndrome: page 597-599Peroneal Subluxation: page 599-600Ankle Arthrodesis: page 600-602 Lateral Ankle Instability: page 603 Chronic Lateral Ankle Instability: page 604-607Chronic Medial Ankle Instability: page 607Ankle Equinus: page 607-611 Malunion and Nonunion of the Malleolei: page 611-614

Chapter 30: Heel Conditions Anatomy of the Heel: page 616-617 Radiological Evaluation of the Calcaneus: page 617-618 The Heel in Systemic Disease: page 618-621Seronegative Arthritis and Heel Pain: page 621-622

Heel Spurs and Heel Spur Syndrome: page 622-623Tumors of the Heel: page 623-626 Tarsal Coalitions: page 626-629 Sever's Disease: page 629-630 Causes of Heel Pain (a summary): page 630-631Haglund's Deformity: page 631-632

Chapter 31: Amputations General Surgical Technique: page 634Digital Amputations: page 634-635 MPJ Amputations: page 635 Transmetatarsal Amputations: page635-636Tarsometatarsal Amputations (Lisfranc's): page 637Midfoot Amputations (Chopart's):page 638Amputation of the Ankle (Syme's, Boyd, Pirogoff): page 638-639 Below Knee Amputation: page 639-640

Chapter 32: Biomechanics Normal Values: page 641Criteria of Normalcy in the Lower Extremity: page 642-643Adult Biomechanical Examination:page 643-645Common Structural Variations: page 646-648Planes of Motion: page 648-649 Axes of Joint Motion: page 649-653 Angular and Axial Deformities in Children: page 654-656Anatomy of Gait: Activity of Muscles:page 656-663Observation of Gait: page 663-664Subtalar Joint Measurements: page664-666Subtalar Joint Function: page 666-667Midtarsal Joint Function: page 667-668

Chapter 33: Anatomy Neuroanatomy: page 670-676 Angiology: page 676-680 Myology: page 680-695 Arthrology: page 695-704

Chapter 34: Soft Tissue Tumors Soft Tissue Tumors: page 706-715

Chapter 35: Physical Medicine and Rehabilitation

Physical Modalities and Diseases:page 718-720Therapeutic Modalities and Procedures: page 720-730

Chapter 36: ArthroscopyAnkle Arthroscopy: page 731-740

Chapter 37: Laser Applications in Podiatric Surgery Laser and Laser Physics:page 741-751Clinical Applications in Podiatric Surgery: page 751-775

Chapter 38: Specific Radiological PathologyMRI Pathology: page 777-800