Nail, digit, and ff surgery

quickster2008's version from 2016-01-12 04:55

Section 1

Question Answer
What are the common causes of recurrence following a phenol/alcohol procedure?1."old" or expired phenol 2. insufficient phenol application 3.inadequate hemostasis. 4.removing insufficient toenail border
"Granuloma pyogenicum" refers to?Granulation tissue in the medial or lateral nail groove.
Where is the hyponychium anatomically?Lies under the free margin o f the nail bed.
How does an exostoses differ from osteochondroma?Fibrocartilage caps the bone instead ofa hyaline cap.
The advantages ofthe Frost procedure include'!Maximum exposure to the nail matrix area.
What are the common digital blocks utilized for anesthesia prior to a surgical nail procedure?Two-point block, H-block, and the unilateral block of Steinberg.
Effective initial treatment for an infected ingrown toenail border is?Partial nail avulsion, PO antibiotic therapy, soak feet
What is a more common reported disadvantage of the flexor tendon transfer in digital surgery?Prolonged edema and stiffness.
What are the advantages in the use of the flexor tendon transfer for digital surgery?1.Possible prevention of a joint fusion; 2.Decreased incidence of mallet toe; 3.Realignment of the MTP joint.
What is the proper sequence ofthe steps used during the sequential reduction of a dorsally subJuxed MPJ? Release of extensor hood expansion,release of collateral ligaments, release of plantar joint tissues.


Question Answer
Given severe osteomyelitic destruction of a distal phalanx secondary to an ulcerated distal heloma, what procedure would be indicated?Distal Symes amputation.
What is the Hoffman procedure?Resection of metatarsal heads i-5.
What is an advantage of the plantar transverse incisional approach for the rheumatoid forefoot reconstruction?The plantar approach provides good exposure to the severely plantarflexed metatarsal heads.
What is the "hood apparatus"?the medial and lateral fibrous extensions of the extensor tendon. Composed of long & short extensor tendons, lumbricals, and interossei.
how many plantar and how many dorsal interosseiPI-3, DI-4
What are the forces and functions of the interossei muscles?pull of the interossei muscles neutralizes the force of the t1exor muscles at the MPJs
what causes extensor substitution phenomenon in hammertoes?equinus, anterior cavus, peripheral neuropathy, as the intrinsic muscles are often affected first
What are the benefits of a compressive, forefoot bandage?Reduction o f edema, maintaining positioning as healing occurs, and diminished risk o f infection.
What is the most common etiology of the heloma molle'!head of PP of 5th digit displaced against lateral condlye of 4th PP. 4th toe may be longer or shorter than usual altering the normal convex-concave relationship btw the toes
function of hood apparatusfunctions such that the pull of the long and short extensor tendons creates dorsiflexion of the proximal phalanx at the metatarsophalangeal joint via the "sling" portion of the apparatus.
plantar interossei muscle insertionbase oflhe proximal phalanx, medially
dorsal interossei muscle insertioninsert on the base of the proximal phalanx laterally except the first dorsal interossei which inserts from medially.
extensor substitution occurs when during gaitpropulsion, swing phase, and heel contact when the extensor digitorum longus and brevis muscles are active.

Section 2

Question Answer
pathology of brachymetatarsiaThe toe is usually straight, but in an extended position, and floats above the weight-bearing plane. A deep sulcus is present beneath the short metatarsal.
correction of brachymetatarsia?lengthening the shortened metatarsal, often lengthening extensor tendons and skin as welL
What are the disadvantages of the flexor tenotomy and capsulotomy?Decrease in digital purchase postoperatively, high rate of recurrence of deformity, and limited application.
What may be considered the major cause for the recurrence of a hammered digit following digital surgery?Instability at the metatarsophalangeal joint.
What is the relationship between the deep transverse intermetatarsalligament (DTlL) and the interossei and lumbricales?The plantar and dorsal interossei lie dorsally and the lumbricales plantar.
What is the primary cause of flexor stabilization?Excessive pronation causing instability.
Overpowering of or by the flexor digitorum longus muscle will result in what deformity?Dorsiflexion of the MPJ, and plantarflexion of the PIPJ and DIP].
To develop the classic hammertoe, the pull of which tendons are needed?Both the FDL and FDB are needed.

Section 3

Question Answer
What is the pathophysiology of an intermetatarsal neuroma?Perineural fibrosis.
What is the epidemiology of the intermetatarsal neuroma?Female predominance, unusual in persons younger than 18 year old, it is most common for a patient to have a single neuroma, rather than multiple ones, and most often found in the second or third interspaces.
The intermetatarsal neuroma most often involves which nerve?Third common digital branch ofthe medial plantar nerve.
What is an uncommon finding when re-operating on a Morton's neuroma? Inordinate scar tissue is usually NOT seen. An amputation neuroma or an intact accessory nerve trunk distal to the DTIL is seen as well as the DTIL (deep transverse intermetatarsalligament), which has reapproximated itself.
What anatomical structure(s) is cited as entrapping the intermetatarsal nerve?The deep transverse intermetatarsal ligament.
What are the specific complications associated with surgical excision of the neuroma'!Stump neuroma, vascular embarrassment, and digital and/or MPJ mechanical instability.
Joplin's neuroma involves which anatomical structure?Plantar proper digital nerve.
Common causes ofthis entrapment neuropathy known as a Joplin's neuroma include:Sporting activities such as running, soccer, basketball, snow skiing that involve pivoting, impact, and motion surrounding the first metatarsophalangeal joint. Chronic compression from a tight shoe. A prominent medial epicondyle of the first metatarsal.
The neuroma known as Iselin's neuroma is found:In the 1 interspace.
Hueter's neuroma is found:In the 4th interspace.
The relaxed skin tension lines in the sub-metatarsal head region or plantar forefoot run:Parallel to the plantar transverse lines along the lesser digits.
The incisional planning of a derotational arthroplasty of the SIb digit includes:2 semi-elliptical incisions coursing from proximal lateral to distal medial.
What is Freiberg's Infraction?Osteochondrosis of the metatarsal head most commonly the second, appearing most often in the second decade of life.
What is a common etiology of an epidermal inclusion cyst? It may follow a surgical procedure in which epidennis is introduced subepidermally, forming an intradermal foreign body that causes pain and inflammation.
Which of the following describes a benign longitudinal ungual pigmentation?Longitudinal melanonychia.
A longitudinal ungual pigmentation in a fair skinned individual without any precursor or injury should indicatePossible precursor for acral Jentiginous melanoma and the need for nail avulsion and biopsy.
What is the etiology of keloids?Represent fibrous reactions at surgery or injury sites. The reaction involves myofibroblasts and may be related to abnormalities of capillary endothelium during granulation. Keloids may be associated with fibromatoses and with peptic ulcers and enostoses.
Does infantile digital fibromatosis require treatment?The lesions occur in fingers and toes and may regress spontaneously or require surgical excision.
Do digital mucous cysts communicate with the joints'!Yes, they may communicate with the distal interphalangeal joint and will often recur with local curettage.
The clinical presentation of a child with shortened digits and hallux valgus may signify?Myositis ossificans progressiva.
A solitary, subungual, reddish-purple, painful lesion may be a?Glomus tumor.

Section 4

Question Answer
The PIPJ arthrodesis effectively?Converts the toe to a rigid lever on which the long flexor and extensor tendons can function effectively.
What are the indications for an extensor tenotomy procedure?Indicated in a flexible extensor hammertoe but may also effectively be used as an adjunct to the digital arthroplasty.
At what level should an extensor tenotomy procedure be performed?Proximal to the extensor hood apparatus.
What are the results of a flexor tendon transfer?Functions like the PIPJ arthrodesis, removes a dynamic deforming force, and stabilizes the MPJ in plantarflexion.
What are the advantages of the peg-in-hole arthrodesis?Increased bone-to-bone contact, increasing the fusion rate. No fixation is actually required. Shortening ofan elongated toe.
What planes may be involved in dislocation of a metatarsophalangeal joint?Sagittal, transverse, and frontal may all be involved.
What is the fourth-fifth intermetatarsal angle that is generally considered symptomatic and elevated?9 degrees or higher.
What does the lateral deviation angle measure?It measures structural defomlity of the fifth metatarsal itself.
What is a logical step-wise approach to the severely overlapping fifth toe.Resection o f the head o f the proximal phalanx, lengthening o f the extensor digitorum longus tendon, dorsal and medial capsu}otomy, release of the plantar plate, and removal of a plantar skin wedge. K-wire stabilization may also be required.
Describe the Hibbs procedure?The extensor digitorum longus tendons are detached distally and tenodesed into the midfoot, at the level of the third metatarsal base.
What is the most commonly chronically dislocated joint in the foot? Second metatarsophalangeal joint.
Which anatomical structure is generally considered the most significant factor in the stabilization of the MTPJ?Plantar plate.
What is the Lachman test?With the second metatarsal immobilized and the proximal phalanx held in 20 to 25 degrees of dorsiflexion, the proximal phalanx is translated vertically in a dorsal direction. This is a tcst for MPJ instability or the ability to resist dorsal subluxation.
What studies are traditionally used to assess instability at the second metatarsophalangeal joint?Plain radiographs, MRI, and arthrography.