CCLLAASSSSII FFII CCAATTII OONN SSYYSSTTEEMM

EPONYMS

Hunter. “Radiologic History Exhibit” Musculoskeletal Eponyms: Who Are Those Guys? Radiographics 2000: 20:819-836

Bosworth Frx – Fibular frx with posterior dislocation of talus. Named after David Bosworth, an NY orthopedic surgeon who introduced streptomycin for bone and joint TB.Chopart Frx – Frx/dislocation involving the midtarsal joints. Francois Chopart, surgeon in Paris, whose amps through midtarsal joint was effective and resisted infection.

Cotton Frx – Frx of lateral and medial malleolus and frx of posterior process of tibia. Fredrich Cotton, Boston surgeon, who illustrated his own 1910 book, Dislocations and Fractures. Danis-Weber Classification – First described by Robert Danis, Belgian surgeon, in 1949. His pioneering work in internal fixation led colleague Maurice E. Muller to assemble a study group in 1958 for clinical trials of internal fixation Arbeitsgemeinschaft fur Osteosynthesefragen (AO). Later, the system was imodified by Bernhard Georg Weber a prominent orthopedic surgeon in Switzerland.Dupuytren Frx – Distal fibular frx above lateral malleolus w/ associated tear of tibiofibular and deltoid ligament.displacement of talus and possible medial malleolus frx. Guillaume Dupuytren, “greatest French surgeon and meanest of men” of the 19th century, has his name associated w/ 12 different conditions/operations. Essex-Lopresti Classification – Peter Gordon EssexLopresti, surgeon at Britain’s Birmingham Accident Center during World War II, was an expert in parachuting injuries.Freiberg Infraction – Refers to deformity of head of second or third metatarsal from AVN, presumably secondary to trauma. Named after Albert Henry Freiberg, Professor of Orthopedic Surgery at the University of Cincinnati, OHIO.Gosselin Frx – V-shaped frx of distal tibia that extends into the tibial plafond and divides plafond into anterior and posterior fragments. Leon Athanese Gosselin was chief of surgery at the Hopital La Charite in Paris. Jones Frx – Base of fifth metatarsal distal to metarsal tuberosity. Described by Sir Robert Jones in 1902 after injurying himself dancing, he was the leading British orthopedic surgeon of the period. Lauge-Hansen Classification – Niel Lauge-Hansen, a prominent Danish

MM SS

Hunter. “Radiologic History Exhibit” Musculoskeletal Eponyms: Who Are Those

Fibular frx with posterior dislocation of talus. Named after David Bosworth, an NY orthopedic surgeon who introduced streptomycin for bone and joint TB.

Frx/dislocation involving the midtarsal joints. whose amps through

midtarsal joint was effective and resisted infection.

Frx of lateral and medial malleolus and frx of posterior process of tibia. Fredrich Cotton, Boston surgeon,

Dislocations and

First described by Robert Danis, Belgian surgeon, in 1949. His pioneering work in internal fixation led colleague Maurice E. Muller to assemble a study group in 1958 for clinical trials of internal fixation –

schaft fur Osteosynthesefragen (AO). Later, the system was imodified by Bernhard Georg Weber a prominent orthopedic surgeon in Switzerland.

Distal fibular frx above lateral malleolus w/ associated tear of tibiofibular and deltoid ligament. Lateral displacement of talus and possible medial malleolus frx. Guillaume Dupuytren, “greatest French surgeon and meanest

century, has his name associated w/ 12

Gordon Essex-Lopresti, surgeon at Britain’s Birmingham Accident Center during World War II, was an expert in parachuting injuries.

Refers to deformity of head of second or third metatarsal from AVN, presumably secondary to

med after Albert Henry Freiberg, Professor of Orthopedic Surgery at the University of Cincinnati, OHIO.

shaped frx of distal tibia that extends into

physician, performed classic cadaelucidate mechanisms involved in ankle injuries.Le Fort Fx of the Ankle –

portion of the distal fibular with avulsion of the anterior tibiofibular ligament. Leon Clement Le Fort, distinguisin-law to Joseph Francois Malgaigne (Fx of the pelvis), was best known for discovering direct communication between bronchial and pulmonary blood vessels and uterine prolapse surgery.Lisfranc Frxdislocation or fjoint. Jacques Lisfranc De Saint Martin, surgeon in Napoleon’s army, who described a 1

method that saved a portion of the foot after distal injury or frostbite. Also described scalene tubercle on the first rib at insertion of the scalenus anterior muscle, Lisfranc’s tubercle.Masionneuve Frx – spiral frx of the upper third of fibular w/ tear of distal tibiofibular syndesmosis and interosseous membrane. Also, associated frx of medial malleolus or rupture of the deep deltoid ligament. Jaceuqes Gilles Maisonneuve was a student of Dupuytren.Osgood-Schlatter Diseasedescribe chronic fatigue injury that affects growth and development of tibial apophysis at site of attachment of patellar tendon to the tibial tuberosity. Robert B. Osgood was a Boston orthopedic surgeon during World War I, and Carl Schlatter was a professor of surgery in Zurich Switzerland.Pott Frx – Partial dislocation of the ankle w/ frx of the distal fibular shaft and rupture of the medial ligaments. Percival Pott was a leading surgeon in London and described TB in the spine (Pott’s Disease). Salter-Harris Classificationa Canadian surgeon at the University of Toronto. Robert Harris is another CanadianUniversity of Toronto. Shepard Frx – The lateral tubercle of the posterior process of the talus frx may simulate an os trigonum. Francis J. Shepard was from England, but emigrated to Canada to become a prominent surgeon. Tillaux Frx – An avulsion injury of the anterior tibial tubercle at the attachment of the distal anterior tibiofibular ligament. Paul Jules Tillaux, French surgeon and anatomix, never clinically described frx, but did exquisite anatomic studies detailing resultexperimentally produced ankle injuries.

physician, performed classic cadaver studies in 1940-50’s to elucidate mechanisms involved in ankle injuries.

– Vertical frx of the anterior medial portion of the distal fibular with avulsion of the anterior tibiofibular ligament. Leon Clement Le Fort, distinguished French surgeon and son-

law to Joseph Francois Malgaigne (Fx of the pelvis), was best known for discovering direct communication between bronchial and pulmonary blood vessels and uterine prolapse surgery. Lisfranc Frx – Refers to frx-dislocation or frx-subluxation of TMT joint. Jacques Lisfranc De Saint Martin, surgeon in Napoleon’s army, who described a 1-minute amputation

method that saved a portion of the foot after distal injury or frostbite. Also described scalene tubercle on the first rib at nsertion of the scalenus anterior muscle, Lisfranc’s tubercle.

spiral frx of the upper third of fibular w/ tear of distal tibiofibular syndesmosis and interosseous membrane. Also, associated frx of medial malleolus or rupture of the

p deltoid ligament. Jaceuqes Gilles Maisonneuve was a student of Dupuytren.

Schlatter Disease – Term used to describe chronic fatigue injury that affects growth and development of tibial apophysis at site of attachment of patellar tendon to the

ial tuberosity. Robert B. Osgood was a Boston orthopedic surgeon during World War I, and Carl Schlatter was a professor of surgery in Zurich Switzerland.

Partial dislocation of the ankle w/ frx of the distal fibular shaft and rupture

ial ligaments. Percival Pott was a leading surgeon in London and described TB in the spine (Pott’s Disease).

Harris Classification – Robert Bruce Salter, currently a Canadian surgeon at the University of Toronto. Robert Harris is another Canadian orthopedic surgeon at the

The lateral tubercle of the posterior process of the talus frx may simulate an os trigonum. Francis J. Shepard was from England, but emigrated to Canada to become a

An avulsion injury of the anterior tibial tubercle at the attachment of the distal anterior tibiofibular ligament. Paul Jules Tillaux, French surgeon and anatomix, never clinically described frx, but did exquisite anatomic studies detailing results of experimentally produced ankle injuries.

OPEN FRACTURES – GUSTILO AND AType I – Wound <1cm long, little ST damage, no sign of crush, simple/transverse/oblique fx w/ little comminutionType II – Wound >1cm long, minor ST damage, slight/moderate crush injury, moderate comminutionType III – Extensive ST injury, high degree of comminution IIIa – ST coverage of bone is adequate, trauma high

IIIb – extensive ST damage requiring free-flap for coverageperiosteal stripping and ST contamination IIIc – any open fx w/ arterial injury requiring immediate repair

Gustilo & Anderson Prevention of Infection in the Treatment of 1025 Open Fractures of Long Bones. J Bone Joint Surg Am. 1976 Jun;58(4):453-8 Gustilo. Problems in the Management of Type III (severe) Open Frx: A New Classification of Type III Open Frx. J. Trauma. 24:8 1984.

COMPARTMENTS OF THE FOOT – MANOLI AND

Hindfoot (1) – CALCANEUS: quadratus plantae, posterior tibialartery, vein, and nerve, lateral plantar artery, vein, nerve, medial plantar artery, vein, nerve, communicates with deep legForefoot (5) – INTEROSSEUS (X4): interossei; adductor hallucis Full Length (3) – MEDIAL: flexor hallucis, abductor haLATERAL: abductor digiti quinti, flexor digiti minimi; SUPERFICIAL: flexor digitorum brevis, lumbricals (4), flexor digitorum longus tendons, medial plantar nerve Manoli and Weber. Fasciotomy of the foot: an anatomical study with special rto release of the calcaneal compartment of the foot. FAI 10(5):267

CLOSED FRACTURES – TSCHERNE

Type C0 – Little of no soft-tissue injury Type CI – Superficial abrasion and mild to moderately severe fracture configuration Type CII – Deep contaminatd abrasion with local contusional damage to skin or muscle and moderately severe facture configuration Type CIII – Extensive skin contusion or crushing or muscle destruction and severe fracture. Tscherne H, Gotzen L: Fractures With Soft Tissue Injuries. Berlin, Germany: SpringerVerlag, 1984, pp6-7.

BONE STRESS INJURY (MRI) – KGrade I – Endosteal marrow edema Grade II – Periosteal bone edema and endosteal edemaGrade III – Muscle edema, periosteal edema and endosteal marrow edema Grade IV – Fracture line Grade V – Callus in cortical bone Kiuru MJ. Bone Stress Injuries. Acta Radiol 2004; 45: 317-326

FRACTURE STABILITY – CHARNLEY

Most Stable – transverse fx Potentially Stable – short obliqe fx, <45° from transverseLeast Stable – long oblique, >45°, comminuted fxsCharnley, The Closed Treatment of Common Ankle Fractures, 4Media, 2002

NON-UNIONS – WEBER & CECH

Hypertrophic Type (vascular, reactive) 1. Elephant’s foot 2. Horse’s hoof 3. Oligotrophic

Atrophic Type (avascular, non-reactive) 1. Torsion wedge 2. Comminuted 3. Defect 4. Atrophic

Weber BG, Cech O. Pseudarthrosis; Grune and Stratton, 1976

1ST MPJ DISLOCATIONS – JAHSS CLASSIFICATION

Type I – Hallux/sesamoid dislocation, no disruption of sesamoid apparatus, irreducible to closed reduction.

ANDERSON Wound <1cm long, little ST damage, no sign of

crush, simple/transverse/oblique fx w/ little comminution 1cm long, minor ST damage,

slight/moderate crush injury, moderate comminution Extensive ST injury, high degree of comminution

ST coverage of bone is adequate, trauma high-energy flap for coverage, assoc w/

any open fx w/ arterial injury requiring immediate repair Prevention of Infection in the Treatment of 1025 Open Fractures of

Gustilo. Problems in the Management of Type III (severe) Open Frx: A New

ANOLI AND WEBER quadratus plantae, posterior tibial

artery, vein, and nerve, lateral plantar artery, vein, nerve, medial plantar artery, vein, nerve, communicates with deep leg

interossei; ADDUCTOR:

: flexor hallucis, abductor hallucis; abductor digiti quinti, flexor digiti minimi;

flexor digitorum brevis, lumbricals (4), flexor digitorum longus tendons, medial plantar nerve Manoli and Weber. Fasciotomy of the foot: an anatomical study with special reference to release of the calcaneal compartment of the foot. FAI 10(5):267-75, 1990

SCHERNE

Superficial abrasion and mild to moderately severe

Deep contaminatd abrasion with local contusional damage to skin or muscle and moderately severe facture

Extensive skin contusion or crushing or muscle

issue Injuries. Berlin, Germany: Springer-

K IURU

Periosteal bone edema and endosteal edema Muscle edema, periosteal edema and endosteal

326 HARNLEY

short obliqe fx, <45° from transverse ong oblique, >45°, comminuted fxs

The Closed Treatment of Common Ankle Fractures, 4th Ed, Greenwich Medical

ECH

Pseudarthrosis; Grune and Stratton, 1976

LASSIFICATION Hallux/sesamoid dislocation, no disruption of

irreducible to closed reduction.

Type IIa – closed reducible, disrupted intersesamoidal ligament Type IIb – closed reducible, transverse fx of sesamoidsType IIc – open reduction, both IIa and IIb.Jahss MH: Foot Ankle 1980;1:15-21

PRE-DISLOCATION

Stage I – Subtle, mild edema with dorsal and plantar to lesser MTPJ. Alignment of the digit unchanged compared to the contralateral digit. Stage II – Mild to Moderate edema. Noticeable deviation of the digit. Loss of toe purchase, noticeable in weiStage III – Moderate edema. Pronounced deviation/subluxation Yu. Predislocation syndrome. Progressive subluxation/dislocation of the lesser metatarsophalangeal joint.JAPMA, April 2002

5TH M ETATARSAL BType I – “Jones Fracture,” transverse fx of diaphyseal / metaphyseal junction. Healing potential is poor.Type II – Intraarticular avulsion fxType III – Extraarticular avulsion fxType IV – Intraarticular comminuted fxType V – (peds) Extraarticular fx through epiphysis

Type I Type II Type III Type IV Type VStewart I. Jones’ fracture: fracture of the base of the fifth metatarsal. Clin Orthop 1960; 16:190-198

5TH M ETATARSAL

Stage I – Acute fracture on chronic process, evidence of periosteal reaction, plantarmedullary sclerosis Stage II – Similar to Stage I with additional presences of medullary sclerosis and narrowing; delayed unionStage III – Obliteration of medullary canal; nonTorg, JS; Balduini, FC; Zelko, RR; Pavlov, H; Peff, TC; Das, M:the fifth metatarsal distal to the tuberosity. J. Bone Joint Surg.

NAVICULAR FRACTURES –Type I – Avulsion fx off tuberosity by PT tendonType II – Dorsal lip fx, may resemble os supranaviculareType IIIa – Transverse fx, nonType IIIb – Transverse fx, displacedType IV – Stress fx Watson-Jones R: Fractures and Joint Wilkins; 1955

L ISFRANC’S FRACTURES

Type A – Homolateral/partial incongruity of Lisfranc’s jointType B – Isolateral/partial incongruity or Lisfranc’s jointType C – Divergent fx; dislocation of Lisfranc’s jointQuenu. E, Kuss G. Etude Sur les luxations du metatarse. Reb Chir 39: 281, 1909.

L ISFRANC’S FRACTURES

Type A – either homolateral (metatarsals displaced laterally) or homomedial (metatarsals dType B – Partial incongruity; not all metatarsals are displaced in the same direction.Type C – Divergent; 1st metatarsal is medially dislocated, 2 are either partially or completely laterally dislocated.

closed reducible, disrupted intersesamoidal

closed reducible, transverse fx of sesamoids open reduction, both IIa and IIb.

ISLOCATION SYNDROME – YU

Subtle, mild edema with dorsal and plantar to lesser MTPJ. Alignment of the digit unchanged compared to the

Mild to Moderate edema. Noticeable deviation of the digit. Loss of toe purchase, noticeable in weight bearing

Moderate edema. Pronounced

Predislocation syndrome. Progressive subluxation/dislocation of the lesser JAPMA, April 2002 Apr;92(4):182-99

BASE FRACTURES – STEWART “Jones Fracture,” transverse fx of diaphyseal /

metaphyseal junction. Healing potential is poor. Intraarticular avulsion fx Extraarticular avulsion fx Intraarticular comminuted fx

(peds) Extraarticular fx through epiphysis

Type I Type II Type III Type IV Type V Stewart I. Jones’ fracture: fracture of the base of the fifth metatarsal. Clin Orthop 1960;

ETATARSAL FRACTURES - TORG Acute fracture on chronic process, evidence of

periosteal reaction, plantar-based facture line, absence of

Similar to Stage I with additional presences of medullary sclerosis and narrowing; delayed union

Obliteration of medullary canal; non-union Torg, JS; Balduini, FC; Zelko, RR; Pavlov, H; Peff, TC; Das, M: Fractures of the base of the fifth metatarsal distal to the tuberosity. J. Bone Joint Surg. 66-A:209, 1984.

– WATSON/JONES CLASSIFICATION Avulsion fx off tuberosity by PT tendon Dorsal lip fx, may resemble os supranaviculare

Transverse fx, non-displaced Transverse fx, displaced

Jones R: Fractures and Joint Injuries. Vol 2. 4th ed. Baltimore, Md: Williams &

RACTURES - QUENU & KUSS CLASSIFICATION Homolateral/partial incongruity of Lisfranc’s joint Isolateral/partial incongruity or Lisfranc’s joint

fx; dislocation of Lisfranc’s joint Etude Sur les luxations du metatarse. Reb Chir 39: 281, 1909.

RACTURES – HARDCASTLE CLASSIFICATION either homolateral (metatarsals displaced laterally)

or homomedial (metatarsals displaced medially.) Partial incongruity; not all metatarsals are displaced

in the same direction. metatarsal is medially dislocated, 2-5

are either partially or completely laterally dislocated.

Hardcastle PH, et al. Injuries to the tarsometatarsal joint. Incidence, Classification and Treatment.. J Bone and Joint Surg 1982; 64B(3):349-56.

L ISFRANC’S FRACTURES – M YERSON MTYPE A – Total Incongruity TYPE B1 – Partial Incongruity, Medial DislocationTYPE B1 – Partial Incongruity, Lateral DislocationTYPE C1 – Divergent, Partial Displacement TYPE C2 – Divergent, Total Displacement Myerson, M, FAI, 6; 228, 1986 SUBTLE L ISFRANC’S INJURY – NUNLEY STAGE 1 - <2mm diastasis, able to WB, local pointover Lisfranc ligament & medial TMT joint space, + MRISTAGE 2 – similar to Stage 1, >2-5mm diastasis, no collapse of arch. STAGE 3 – >2-5mm diastasis, collapse of arch.

Nunley. Vertullo. Classification, investigation, and management of Midfoot Lisfranc Injuries in the Athlete. Am J Sports Med. 2002; 30:871

CALCANEAL FRACTURESSigns & Symptoms: Acute pain, edema about heel, pain w/ compression/palpation, pain w/ STJ motion, fx blisters on skin, plantar medial &lateral ecchymosis (mondur’s signBohler’s Angle: “Tuberosity Joint Angle.” Measures sagittal plane relationship of talus and calcaneus – compare to contralateral side. Normal = 25-40 degrees; angle is reduced when post. facet is depressed into the body of the calcaneus

Injuries to the tarsometatarsal joint. Incidence, Classification and

M ODIFICATION

Partial Incongruity, Medial Dislocation Partial Incongruity, Lateral Dislocation

UNLEY & VERTULLO <2mm diastasis, able to WB, local point-tenderness

over Lisfranc ligament & medial TMT joint space, + MRI 5mm diastasis, no collapse

5mm diastasis, collapse of arch.

Nunley. Vertullo. Classification, investigation, and management of Midfoot Sprains: Lisfranc Injuries in the Athlete. Am J Sports Med. 2002; 30:871-878.

RACTURES Acute pain, edema about heel, pain w/

compression/palpation, pain w/ STJ motion, fx blisters on mondur’s sign)

“Tuberosity Joint Angle.” Measures sagittal compare to

40 degrees; angle is reduced post. facet is depressed into the body of the calcaneus

Critial Angle of Gissane: supports the lateral talar process. articular distortion because it reveals the angular relationship of the calcaneal facets. Normal = 125increased greater than 180 degrees with displacement of the posterior facet in joint depression fractures Knight J, Gross EA, Bradley G, LoVecchio F. The utility of Boehler’s angle and the critical angle of Gissane in diagnosing calcaneus fractures in the emergency deAcad Emerg Med. 2005;2:114-115.

ROWE CType Ia – plantar calcaneal tuberosity fx, secondary to eversion force (medial tuberosity) or inversion (lateral tuberosity.) View w/ axial calcaneal, lateral foot.

Type Ibthe sustentaculum tali, secondary to inverted landing of heel. View w/ axial calcaneal.Type Icsimilar to os calcaneum secundum. Occurs as a bifurcate ligament avulsion, secondary to adduction and pla

lateral, lat oblique isherwood.Type IIa – “beak fracture,” meaning a lift-off of the posterior superior surface of the calcaneus; some cortex still intact. Occurs when heel strikes ground w/ knee

Type IIIa – simple fx, oblique through calcaneal body not involving the STJ. Occurs secondary to a fall, landing on both heels w/ the feet inverted or everted. View w/ lateral foot, axial calcaneal. Type IIIb – same as IIIa, but comminuted.

Measure of calcaneal strut that

supports the lateral talar process. Is more specific for intra-articular distortion because it reveals the angular relationship

Normal = 125-140 degrees; Is ater than 180 degrees with displacement of the

posterior facet in joint depression fractures Knight J, Gross EA, Bradley G, LoVecchio F. The utility of Boehler’s angle and the critical angle of Gissane in diagnosing calcaneus fractures in the emergency department.

CLASSIFICATION plantar calcaneal tuberosity fx,

secondary to eversion force (medial tuberosity) or inversion (lateral tuberosity.) View w/ axial calcaneal, lateral foot.

Type Ib – shearing fx of the sustentaculum tali, secondary to inverted landing of heel. View w/ axial calcaneal. Type Ic – anterior process fx, may appear similar to os calcaneum secundum. Occurs as a bifurcate ligament avulsion, secondary to adduction and plantarflexion. View w/

lateral, lat oblique isherwood. “beak fracture,”

off of the posterior superior surface of the calcaneus; some cortex still intact. Occurs when heel strikes ground w/ knee

extended and foot dorsiflexed. View w/ lateral foot radiograph. Type IIb – avulsion fx of the tendo Achilles, same as a IIa but with complete dislocation.

simple fx, oblique through calcaneal body not involving the STJ. Occurs secondary to a fall, landing on both heels w/ the feet inverted or everted. View w/ lateral foot,

same as IIIa, but comminuted.

Type IVa&b – same as type III, but w/ STJ involvement.

Type Va – intraarticular STJ fx w/ comminution and depression of the articular segment. Type Vb – intraarticular fx of the calcaneo-cuboid joint.

Rowe CR, Sakellarides H, Freeman P: Fractures of os calcis - a longstudy one hundred forty-six patients. JAMA 1963; 184: 920-923

ESSEX-LOPRESTI CLASSIFICATION Tongue Type – Axial load planterflexed Joint Type – Axial Load Dorsiflexed

Essex-Lopresti P: The mechanism, reduction technique, and results in fractures of the os calcis, 1951-52. Clin Orthop 1993 May; 3-16

SANDER’S CLASSIFICATION

(Note: This classification system requires the fracture to be visualized w/ coronal CT scan at widest width of calcaneus)Type I (A, B, and C) – one part, nondisplaced articular fx.

Type II (A, B, and C) – two part fx of posterior facet.

same as type III, but w/ STJ involvement.

intraarticular STJ fx w/ comminution and

cuboid joint.

a long-term follow-up 923

Lopresti P: The mechanism, reduction technique, and results in fractures of the os

LASSIFICATION (Note: This classification system requires the fracture to be visualized w/ coronal CT scan at widest width of calcaneus)

one part, nondisplaced articular fx.

two part fx of posterior facet.

Type III (AB, AC, and BC) depressed segment. Type IV – comminuted fx of posterior facet.

-The current standard for nonthe Rowe system. For intracoronal CT scan is indicated, and the Sanders system is typically used to classify. -The goal of ORIF for intraarticular calcaneal fractures is to increase the height, decrease the width, return to neutral, and restore anatomy and articular surface.Sanders R, Fortin P, DiPasquale T: Operative treatment in 120 displaced intraarticular calcaneal fractures. Results using a prognostic computed tomography scan classification. Clin Orthop 1993 May; 87-95

(AB, AC, and BC) – three part fx w/ central

comminuted fx of posterior facet.

The current standard for non-articular calcaneal fractures is

the Rowe system. For intra-articular calcaneal fractures, a coronal CT scan is indicated, and the Sanders system is

he goal of ORIF for intraarticular calcaneal fractures is to increase the height, decrease the width, return to neutral, and restore anatomy and articular surface. Sanders R, Fortin P, DiPasquale T: Operative treatment in 120 displaced intraarticular

neal fractures. Results using a prognostic computed tomography scan classification.

TALAR NECK FRACTURES – HAWKIN ’S CLASSIFICATIONThese fxs are usually seen in MVAs or short-Type I – minimal displacement, 7-15% chance of AVNType II – STJ subluxation, 35-50% chance of AVNType III – ankle dislocation, 85% chance of AVNType IV – STJ/ankle/TNJ dislocation, 100% chance of AVNHawkin’s Sign – subchondral lucency of the body of the talufollowing fx; appears 6-8 weeks post fx; = revascularization

Hawkins L: Fractures of the neck of the talus. JBJS 1970;52A:991

TALAR DOME LESIONS – BERNDT-HARDY CStage I – small area of compression in subchondral bone. Stage II – partially detached osteochondral fragment. Stage III – completely detached fragment, in crater.Stage IV – complete fx, out of crater. Poor prognosis.

DIAL a PIMP denotes the location of talar dome lesions dorsiflexion internal rotation = anterior lateral lesion, plantarflexion inversion = medial posterior lesion.Medial Lesions: (PIMP, 56%) Deep, cup shaped, less likelyLateral Lesions: (DIAL, 44% ) Thin, wafer shaped, easily displaced.Berndt, A.L. & Harty, M.: Transchondral fractures of the talus. J Bone Joint Surg [Am] 41: 988-1020, 1959

FRACTURES OF THE TALAR BODY - Group I – Talar Dome Fracture/OCD (use BerndtGroup II – Shear Fracture – 50% AVN, requires ORIF

• Coronal • Sagittal • Horizontal

Group III – Posterior Tubercle Fracture – Shepherd’s FxGroup IV – Lateral Process Fracture (Fjeldborg)Group V – Crush injury – highly comminuted

LASSIFICATION -height falls

15% chance of AVN 50% chance of AVN

ankle dislocation, 85% chance of AVN STJ/ankle/TNJ dislocation, 100% chance of AVN

subchondral lucency of the body of the talus 8 weeks post fx; = revascularization

1970;52A:991-1002

CLASSIFICATION small area of compression in subchondral bone. partially detached osteochondral fragment. completely detached fragment, in crater. complete fx, out of crater. Poor prognosis.

talar dome lesions – ateral lesion,

osterior lesion. 6%) Deep, cup shaped, less likely to displace.

asily displaced. Berndt, A.L. & Harty, M.: Transchondral fractures of the talus. J Bone Joint Surg [Am]

SNEPPEN Talar Dome Fracture/OCD (use Berndt-Hardy)

50% AVN, requires ORIF

Shepherd’s Fx Lateral Process Fracture (Fjeldborg)

highly comminuted

Sneppen O, Chrstensen SB, Krogsoe O,Orthop Scand 48: 317-324, 1977 LATERAL TALAR PROCESS

Type I – Simple fx from AJ articulation to STJType II – Comminuted fx involving calcaneal & fibular articulations Type III – Chip fx of anterior/inferior portion of lat process

Hawkins LG: Fractures of the lateral process of the talus. J Bone Joint Surg 1965; 47A: 1170-1175

EPIPHYSEAL FRACTURES

Type I – shearing force, separation of epiphysis from metaphysis w/o fx, seen at birth and in young children.

Sneppen O, Chrstensen SB, Krogsoe O, et al: Fractures of the body of the talus. Acta

ROCESS - HAWKIN ’S CLASSIFICATION Simple fx from AJ articulation to STJ Comminuted fx involving calcaneal & fibular

ip fx of anterior/inferior portion of lat process

Hawkins LG: Fractures of the lateral process of the talus. J Bone Joint Surg 1965; 47A:

RACTURES – SALTER -HARRIS CLASSIFICATION

shearing force, separation of epiphysis from metaphysis w/o fx, seen at birth and in young children.

Type II – fx line extends through physis and exits metaphysis. Shearing or avulsion force, + Thurston Holland sign.Thurston Holland Sign – triangle shaped metaphyseal fx.Type III – fx line extends through physis and exits epiphysis (intraarticular). Due to shearing force. Type IV – intraarticular fx through epiphysis, physis, and metaphysis. Prognosis is poor. Type V – compression fx, compacted germinal cells of physis die and cause premature closure. Poor prognosis.Type VI (Rang) - contusion of perichondral ring of physis, acts like type V if a bony bridge develops – prognosis good.Type VII (Ogden) – epiphyseal fx not affecting physisType VIII (Ogden) – partial fx of metaphysis, growth linesType IX (Ogden) – degloving loss of periosteum on diaphysisRB Salter, WR Harris Injuries involving the eiphyseal plate. JBJS Vol 45. 1963. p 587632 DIAS-TACHDJIAN CLASSIFICATION Supination-Inversion – grade I (A) Supination-Inversion – grade II (B) Supination-Plantarflexion (C)

Supination-Ext Rotation – grade I (D) Supination-Ext Rotation – grade II (E) Pronation-Eversion-Ext Rotation (F) Juvenile Tillaux Fracture (G) Triplanar Fracture (H)

Dias LS, Tachdjian MO: Physeal injuries of the ankle in children. Clin Orthop Relat Res 1978;136:230–233

ANKLE FRACTURES - LAUGE-HANSEN CLASSIFICATION

The first word in this classification denotes the position of the foot at time of injury; the second word denotes the motion of the leg. The numerical grades w/in each class occur each in chronological order and relate to the severity of trauma.Supination – Adduction I – transverse fx of the lateral malleolus II – vertical fx of the medial malleolusPronation – Abduction I – Rupture of deltoid ligament/medial malleolar fx II – Rupture of ant inferior tibio-fibular ligament III – Bending fx of fibula 1cm proximal to plafondPronation – Dorsiflexion I – Fx of medial malleolus II – Large anterior lip fx of tibia III – Fracture of superior lateral malleolus IV – Fracture of third malleolus (posterior tibia)Supination – External Rotation (SER) I – Rupture of ant inferior tibio-fibular ligament

fx line extends through physis and exits metaphysis. Shearing or avulsion force, + Thurston Holland sign.

aped metaphyseal fx. fx line extends through physis and exits epiphysis

intraarticular fx through epiphysis, physis, and

compression fx, compacted germinal cells of physis die and cause premature closure. Poor prognosis.

contusion of perichondral ring of physis, prognosis good.

not affecting physis partial fx of metaphysis, growth lines

degloving loss of periosteum on diaphysis RB Salter, WR Harris Injuries involving the eiphyseal plate. JBJS Vol 45. 1963. p 587-

Dias LS, Tachdjian MO: Physeal injuries of the ankle in children. Clin Orthop Relat Res

LASSIFICATION The first word in this classification denotes the position of the

of injury; the second word denotes the motion of the leg. The numerical grades w/in each class occur each in chronological order and relate to the severity of trauma.

transverse fx of the lateral malleolus vertical fx of the medial malleolus

Rupture of deltoid ligament/medial malleolar fx fibular ligament

Bending fx of fibula 1cm proximal to plafond

Fracture of superior lateral malleolus Fracture of third malleolus (posterior tibia)

fibular ligament

II – Spiral oblique fx of lateral malleolus (extending anterior inferior to posterior superior.) III – Rupture of post inferior tibio IV – Deltoid rupture/fx of medial malleolusPronation – External Rotation (PER) I – Rupture of deltoid ligament/medial malleolar fx II – Rupture of ant inferior tibio Intra-osseous ligament, intra III – Spiral fx above syndesmosis (high fibular fx) IV – Rupture of post inferior tibioAll external rotation injuries may cause separation of the tibio-fibular syndesmosis.

Lauge-Hansen N. Fractures of the ankle. II Combined experimentalexperimental-roentgenologic investigations. Arch Surg 1950; 60:957

LATERAL MALLEOLAR FRACTURE

Type A – Fracture below the level of the tibial plafondType B – Fracture at the level of the tibial plafondType C – Fracture above the level of the tibial plafondDanis R. Les fractures malleolaires. In: Danis R (ed): Theorie et practique de

l'osteosynthese. Paris, Masson et Cie, 1949, pp133Weber BG. Die Verletzungen des oberen Sprunggelenkes, ed 2. Bern, Stuttgart, Wien,

Verlag Hans Huber, 1972 MEDIAL M ALLEOLAR FRACTURE

Type A – Avulsion of tip of medial malleolusType B – Avulsion at the level of the ankle jointType C – Oblique fx Type D – Vertical orientationMuller M, Allgower M, Scheider R, Willenegger H. Manual of Internal Fixation. 3Springer-Verlag, 1991.

CHRONIC TIBIOFIBULAR

Type I – Straight lateral subluxation of the fibula, w/ medial clear space on x-ray (due to interposition of delroid ligament)Type II – Lateral fibular subluxation w/ plastic or angular deformity (due to fibular microfracture)Type III – Posterior rotatory subluxation of distal fibula behind talus w/ PITFL intactType IV – Complete Ankle Diastasis w/ talus dislocated superiorly, wedged between the tibia and fibula.Edwards S, DeLee C. Ankle diastasis without

M IDTARSAL FRACTURES

1) Medial Force (30%) �Type A - flake fx of dorsal talus or navicular and lateral calcaneus or cuboid Type B - medial displacement of FF w/ TN and CC Type C - FF rotates medially around interosseous talocalcaneal lig w/ TN disassociation and CCJ intact2) Longitudinal Force (40%) worst prognosis of nonType A - maximally PF ankle giving a characteristic pattern of through and through navicuA1 - force through 1st ray: crushes medial 3displaced medially A2 - force thru 2nd ray: crushes middle 3tuberosity displaced mediallyA3 - force thru 3rd ray: crushes lateral 3tuberosity displaced mediallyType B - submaximally PF ankle resulting in dorsal displacement of superior n3) Lateral Force (17%) Type A - FF forced into valgus w/ fx of navicular tuberosity or dorsal talus and compression fx Type B - TNJ displaces laterally w/ comminution of CCJ4) Plantar Force (7%) Type A -avulsion fx of dorsal navicular or talus & antType B - impaction fracture of inferior CCJ

ique fx of lateral malleolus (extending anterior inferior to posterior superior.)

Rupture of post inferior tibio-fibular ligament Deltoid rupture/fx of medial malleolus

External Rotation (PER) Rupture of deltoid ligament/medial malleolar fx Rupture of ant inferior tibio-fibular ligament, osseous ligament, intra-osseous membrane Spiral fx above syndesmosis (high fibular fx) Rupture of post inferior tibio-fibular ligament

All external rotation injuries may cause DIASTASIS – fibular syndesmosis.

Hansen N. Fractures of the ankle. II Combined experimental-surgical and roentgenologic investigations. Arch Surg 1950; 60:957-85

RACTURE – DANIS-WEBER CLASSIFICATION

Fracture below the level of the tibial plafond Fracture at the level of the tibial plafond Fracture above the level of the tibial plafond

In: Danis R (ed): Theorie et practique de l'osteosynthese. Paris, Masson et Cie, 1949, pp133-165

Weber BG. Die Verletzungen des oberen Sprunggelenkes, ed 2. Bern, Stuttgart, Wien,

RACTURE – M ULLER CLASSIFCATION Avulsion of tip of medial malleolus Avulsion at the level of the ankle joint

Vertical orientation Muller M, Allgower M, Scheider R, Willenegger H. Manual of Internal Fixation. 3rd Ed.

IBIOFIBULAR DIASTASIS – EDWARDS & DELEE Straight lateral subluxation of the fibula, w/ medial

ray (due to interposition of delroid ligament) Lateral fibular subluxation w/ plastic or angular

bular microfracture) Posterior rotatory subluxation of distal fibula

behind talus w/ PITFL intact Complete Ankle Diastasis w/ talus dislocated

superiorly, wedged between the tibia and fibula. without fracture. Foot Ankle 1984;4:305-12

RACTURES – MAIN & JOWETT � precursor to STJ dislocation

dorsal talus or navicular and lateral

medial displacement of FF w/ TN and CC joints FF rotates medially around interosseous

talocalcaneal lig w/ TN disassociation and CCJ intact (40%) worst prognosis of non-crush

maximally PF ankle giving a characteristic pattern of through and through navicular compression fracture

ray: crushes medial 3rd w/ tuberosity

ray: crushes middle 3rd w/ middle 3rd & tuberosity displaced medially

ray: crushes lateral 3rd w/ medial 2/3 & tuberosity displaced medially

submaximally PF ankle resulting in dorsal displacement of superior navicular, crush of inferior on x-ray

ced into valgus w/ fx of navicular tuberosity talus and compression fx of CCJ (Nutcracker fx) TNJ displaces laterally w/ comminution of CCJ

avulsion fx of dorsal navicular or talus & ant process impaction fracture of inferior CCJ

5) Crush Injury (6%) Main and Jowett. Injuries of the Midtarsal Joint. J Bone Joint Surg Br

PILON FRACTURES – RUEDI & ALLGOWER

Type 1- Mild to moderate displacement & no comminution, w/o major disruption of ankle joint Type 2- Moderate displacement & no comminution w/ significant dislocation of ankle joint Type 3- Explosion fx, severe comminution & displacement

Ruedi T, Allgower M. Fractures of the lower end of the tibia into the ankle joint. Injury, 1969; 1: 92-99. AO CLASSIFICATION (M UELLER ) Type A - extra articular Type B - partially articular Type C - completely articular All three can involve: a. no comminution or impaction in articular or metaphyseal surfaceb. impaction involving supra-articular metaphysic c. comminution & impaction of articular surface with metaphyseal impaction

Muller ME, Nazarian S, KochP, et al.; Springer-Verlag, Berlin. fractures. 1990

LATERAL ANKLE SPRAINS

The ATFL injured more frequently followed by the anterolateral ankle capsule, CFL, and then PTFL. The ATFL is oriented so that it is under most tension during plantarflexion. The angle between ATFL and CFL in the

J Bone Joint Surg Br 57-B (1): 89.

LLGOWER CLASSIFICATION Mild to moderate displacement & no comminution,

& no comminution w/

, severe comminution & displacement

Ruedi T, Allgower M. Fractures of the lower end of the tibia into the ankle joint. Injury,

a. no comminution or impaction in articular or metaphyseal surface

articular surface with metaphyseal

Verlag, Berlin. Classification AO des

PRAINS The ATFL injured more frequently followed by the anterolateral ankle capsule, CFL, and then PTFL. The ATFL is oriented so that it is under most tension during plantarflexion. The angle between ATFL and CFL in the

sagittal plane is 105 degrees. The CFL idorsiflexion and also with frontal plane inversion of STJ. Two tests can be used test mechanical instability of the ankle: The anterior drawer test and talar tiltANTERIOR DRAWER TESTCastaing: 5-8 mm of anterior displacement = ATF rupture10-15 mm = ATF, CF > 15 mm = ATF, CF, PTF

TALAR TILT TEST Bonnin: 00 to 150 = ATFL rupture. 150 to 300 = ATFL and CFL rupture.More than 300 = ATFL, CFL, and PTFL.Karlsson: 50 to 100 > contralateral ankle or more than 15abnormal.

ANKLE SPRAIN

Grade I – partial rupture of CFLGrade II – complete rupture of ATFLGrade III – complete rupture of ATFL, CFL, and/or PTFLGrade IV – complete rupture of all 3 lateral ligaments + partial rupture of deltoid ligamentDias LS. The lateral ankle sprain: an experimental study. J Trauma 1979;19(4):266

ANKLE SPRAIN – O’D1st Degree – ligament stretch w/ minimal disruption2nd Degree – partial ligament disruption w/ joint instability3rd Degree – complete ligament disruptionO'Donoghue DH: Treatment of Injuries to Athletes. 2nd ed. Philadelphia, Pa: WB Saunders Co; 1970

ANKLE SPRAIN –1st Degree – partial or complete tear of ATFL2nd Degree – partial or complete tear of ATFL3rd Degree – partial or complete tear or ATFL, CFL, & PTFLLeach RE, Naiki O, Paul GR, Stockel J. Secondary reconstruction

of the lateral ligaments of the ankle. Clin Orthop 1982; 226:169

STJ

Subtalar joint dislocations are commonly to the position of the foot in relation to the talusType I – Medial dislocation of STJ or “Acquired clubfoot”Type II – Lateral dislocation of STJ or “Acquired flatfoot”Type III – Anterior/posterior dislocation of STJBuckingham WW Jr. Subtalar dislocationSTRAUS DC: Subtalar dislocation of the foot. J Bone Joint Surg

PTTD – JOHNSON AND

Stage I – Medial pain, tenosynovitis, mild weakness on heelraise test Stage II – Medial/lateral pain, tendon elongation, flexible pes planus, weakness on heel raise, + too many toes signStage III – Medial/lateral pain, tendon degeneration, fixed pes planus, no inversion on heel raise, + too many toes sign, STJ arthritis

sagittal plane is 105 degrees. The CFL is stressed in dorsiflexion and also with frontal plane inversion of STJ. Two tests can be used test mechanical instability of the ankle: The

talar tilt . EST

8 mm of anterior displacement = ATF rupture

> 15 mm = ATF, CF, PTF

= ATFL and CFL rupture.

= ATFL, CFL, and PTFL.

> contralateral ankle or more than 150 unilaterally is

PRAIN – DIAS CLASSIFICATION partial rupture of CFL complete rupture of ATFL complete rupture of ATFL, CFL, and/or PTFL complete rupture of all 3 lateral ligaments +

partial rupture of deltoid ligament : an experimental study. J Trauma 1979;19(4):266-9 O’DONOGHUE CLASSIFICATION

ligament stretch w/ minimal disruption partial ligament disruption w/ joint instability complete ligament disruption

O'Donoghue DH: Treatment of Injuries to Athletes. 2nd ed. Philadelphia, Pa: WB

– LEACH CLASSIFICATION partial or complete tear of ATFL partial or complete tear of ATFL & CFL partial or complete tear or ATFL, CFL, & PTFL

Leach RE, Naiki O, Paul GR, Stockel J. Secondary reconstruction of the lateral ligaments of the ankle. Clin Orthop 1982; 226:169-73

DISLOCATION Subtalar joint dislocations are commonly classified according

to the position of the foot in relation to the talus Medial dislocation of STJ or “Acquired clubfoot” Lateral dislocation of STJ or “Acquired flatfoot” Anterior/posterior dislocation of STJ

Subtalar dislocation of the foot. J Trauma 1973;13:753-765 DC: Subtalar dislocation of the foot. J Bone Joint Surg 30: 427, 1935.

OHNSON AND STROM Medial pain, tenosynovitis, mild weakness on heel-

Medial/lateral pain, tendon elongation, flexible pes planus, weakness on heel raise, + too many toes sign

Medial/lateral pain, tendon degeneration, fixed pes planus, no inversion on heel raise, + too many toes sign, STJ

Stage IV – Medial/lateral pain, tendon degeneration, fixed pes planus, no inversion on heel raise, + too many toes sign, STJ arthritis, Valgus talus, Ankle arthritis

Johnson KA, Strom DE. Tibialis posterior tendon dysfunction. Clinical Orthopedics. 1989;239:196-206 Myerson, MS. Adult acquired flatfoot deformity: Treatment o dysfunction of the posterior tibial tendon. Instr. Course Lecture, AAOS. 1997; 46: 393

PTTD – M UELLER CLASSIFICATION

Based on Etiology Type I – Direct injury Type II – Rupture secondary to systemic diseaseType III – Idiopathic Type IV – Rupture secondary to mechanical dysfunction

Mueller TJ: Acquired flatfoot secondary to tibialis posterior dysfunction: Biomechanical aspects. J. Foot Surg. 30:2, 1991

PTTD – CONTI CLASSIFICATION

Stage I – One or two fine, longitudinal tears Stage II – Intramural degeneration, variable diameter, wide longitudinal tears Stage III – Scarring in tendon, complete tearConti S et al. Clinical significance of MRI in pre-operative planning for reconstruction of posterior tibial tendon ruptures. Foot and Ankle 1992; 13:208

PTTD – ROSENBERG CLASSIFICATION

Stage I – Hypertrophic tears in tendon (appears bulbous)Stage II – Atrophic tears Stage III – Complete tear

Medial/lateral pain, tendon degeneration, fixed pes planus, no inversion on heel raise, + too many toes sign, STJ

Johnson KA, Strom DE. Tibialis posterior tendon dysfunction. Clinical Orthopedics.

Myerson, MS. Adult acquired flatfoot deformity: Treatment o dysfunction of the posterior tibial tendon. Instr. Course Lecture, AAOS. 1997; 46: 393-405.

LASSIFICATION

Rupture secondary to systemic disease

Rupture secondary to mechanical dysfunction

Mueller TJ: Acquired flatfoot secondary to tibialis posterior dysfunction: Biomechanical

LASSIFICATION (MRI)

Intramural degeneration, variable diameter, wide

Scarring in tendon, complete tear planning for reconstruction of

LASSIFICATION (MRI) Hypertrophic tears in tendon (appears bulbous)

Rosenberg ZS, et al: Rupture of posterior tibial tendon: CT and MR imaging with surgical correlation. Radiology 1988;169:229

ACHILLES RUPTURE

The achilles is an conjoined tendon that internally rotates to insertion. It has a “watershed” ar

insertion. The vascular supply is received at the myotendinous junction, osseous insertion, and paratenon anteriorly

Daughterplantarflexion) to diagnosis rupture.

Patients will recall a “Pop” sensand feel “stuck”. There will be pain and

edema at the area, with a palpable gap. Patients may present with an antalgic gait.Type I –Type II –gap Type III

Type IVKuwadarupture

RADIOPAQUE

Type Itendon insertion and the posterosuperior aspect of the calcaneus Type II : Localized to the distal 1 to 3 cm of the Achilles tendon Type IIIA : Intratendinous, involving a large portion of the tendon Type IIIB : Intratendinous, involving ALL of the tendon from the myotendinous junction to the insertion.Morris KL, Giacopelli JA, Granoff D. Achilles. J Foot Surg 1990;29:533-542.

PERONEAL TENDON DISLOCATION

Grade I – retinaculum ruptured from cartilaginous lip to posterior lateral malleolus Grade II – distal 1-2cm fibrous lip of malleolus is elevated w/ retinaculum Grade III – a thin fragment of bone w/ cartilage is avulsed from deep surface of peroneal retinaculum & deep fasciaGrade IV (Oden) – a mid-

: Rupture of posterior tibial tendon: CT and MR imaging with

surgical correlation. Radiology 1988;169:229-235

UPTURE – K UWADA CLASSIFICATION The achilles is an conjoined tendon that internally rotates to insertion. It has a “watershed” area at 2-6cm proximal to

insertion. The vascular supply is received myotendinous junction, osseous

insertion, and paratenon anteriorly. Use the Daughter-Thompson Test (passive plantarflexion) to diagnosis rupture.

Patients will recall a “Pop” sensation and feel “stuck”. There will be pain and

edema at the area, with a palpable gap. Patients may present with an antalgic gait.

– Partial rupture of tendon – Complete rupture of tendon, <3cm

– Complete rupture, 3-6cm gap Type IV – Complete rupture, >6cm gap Kuwada GT. Diagnosis and treatment of Achilles tendon rupture. Clin Podiatr Med Surg 1995;12: 633-52

ADIOPAQUE LESIONS OF THE TENDO ACHILLES __________

Type I: Localized to the Achilles posterosuperior aspect of the

: Localized to the distal 1 to 3 cm of the Achilles

: Intratendinous, involving a large portion of the

: Intratendinous, involving ALL of the tendon from ion to the insertion.

Morris KL, Giacopelli JA, Granoff D. Classifications of adiopaque lesions of the tendo 542.

ISLOCATION - ECKERT & DAVIS

retinaculum ruptured from cartilaginous lip to

2cm fibrous lip of malleolus is elevated w/

a thin fragment of bone w/ cartilage is avulsed from deep surface of peroneal retinaculum & deep fascia

-substance tear

Eckert WR, Davis EA Jr: Acute rupture of the peroneal retinaculum. J Bone Joint Surg Am 1976 Jul; 58(5): 670-2

OSTEOMYELITIS – BUCKHOLZ

Type I – wound induced osteomyelitis Ia – open fx w/ complete discontinuity Ib – penetrating wound Ic – post-op infection Type II – mechanogenic infection IIa – implants, internal fixation IIb – contact instability/bone on bone apposition Type III – physeal osteomyelitis Type IV – ischemic limb disease Type V – combination osteo of types I-IV Type VI – osteitis from septic arthritis Type VII – chronic osteomyelitis Buckholz, JM 1987. The surgical management of osteomyelitis: with special reference to a surgical classification. J. Foot Surg. 26:S17-S24

OSTEOMYELITIS – CIERNY -M ADER CLASSIFICATION

Type I – medullary osteo Type II – superficial osteo Type III – localized osteo Type IV – diffuse osteo Type A – good immune system and vascularityType B – local or systemic immune compromiseType C – tx will be more harmful to patient than diseaseCierny G, Mader JT: Adult chronic osteomyelitis. Orthopaedics 1984; 7

OSTEOMYELITIS – WALDVOGEL CLASSIFICATION

Type I – Hematogenous osteo Type II – Osteo secondary to contiguous sourceType III – Osteo assoc w/ vascular insufficiencyType IV – Chronic osteo Waldvogel FA et al: Osteomyelitis: a review of clinical features, therapeutic

considerations and unusual aspects. N Engl J Med 1970 Jan 22; 282(4): 198

OSTEOMYELITIS – PATZAKIS CLASSIFICATION

Zone I – Distal metatarsal neck (most common)Zone II – MT neck to MTJ (least common) Zone III – calcaneus or talus Patzakis PJ, Calhoun JH, Cierny G, Holtom P, Mader JT, Nelson CL Symposium: Current Concepts in the Management of Osteomyelitis. Contemporary Orthopaedics28(2): 157-185 passim, 1994

TARSAL COALITIONS – DOWNEY

A. Juvenile (Osseous Immaturity) Type I – extra-articular coalition Ia – no secondary arthritis, tx w/ badgley procedure Ib – secondary arthritis, tx w/ resection, triple arthrodesis Type II – intra-articular coalition IIa – no secondary arthritis, tx w/ resection or triple arthrodesis IIb – secondary arthritis, tx w/ triple arthrodesis

B. Adult (Osseous Maturity) Type I – extra-articular coalition Ia – no secondary arthritis, tx w/ resection or triple arthrodesis

retinaculum. J Bone Joint Surg

UCKHOLZ

penetrating wound

: with special reference to

LASSIFICATION

good immune system and vascularity local or systemic immune compromise tx will be more harmful to patient than disease

. Orthopaedics 1984; 7 LASSIFICATION

Osteo secondary to contiguous source Osteo assoc w/ vascular insufficiency

: Osteomyelitis: a review of clinical features, therapeutic considerations and unusual aspects. N Engl J Med 1970 Jan 22; 282(4): 198-206

LASSIFICATION Distal metatarsal neck (most common)

, Cierny G, Holtom P, Mader JT, Nelson CL Symposium: Contemporary Orthopaedics,

OWNEY

no secondary arthritis, tx w/ badgley procedure secondary arthritis, tx w/ resection, triple arthrodesis

dary arthritis, tx w/ resection or triple arthrodesis

no secondary arthritis, tx w/ resection or triple arthrodesis

Ib – secondary arthritis, tx w/ triple arthrodesis Type II – intra-articular coalition IIa – no secondary arthritis, tx w/ triple or isolated arthrodesis IIb – secondary arthritis, tx w/ triple arthrodesisDowney, MS: Tarsal coalitions: a surgical classi81:187-197, 1991

TARSAL COALITIONS –CLASSIFICATION

Type I – Congenital coalitionPerlman MD, Wertheimer SJ: Tarsal coalitions

TARSAL COALI TIONS

I. Isloated Anomaly Ia – TC, CN, CC, or NC Ic – massive tarsal coalitionII. Part of Complex Malformation IIa – assoc w/ other synostoses (carpal coalition, synphalangism) IIb – manifestation of a syndrome (Apert’s, Nievergelt

III. Associated w/ Major Limb AbnormalitiesPOLYDACTYLY

A. Wide Metatarsal Head B. T-shaped Metatarsal HeadC. Y-shaped Metatarsal HeadD. Digital Duplication E. Complete Duplication Venn-Watson EA: Problems in polydactyly of the foot. Orthop Clin North Am 1976 Oct; 7(4): 909

POLYDACTYLY – TETAMY

Post-axial polydactyly onlyType A – Complete digit that articulatesw/ 5th MT head or duplicate 5Type B – Accessory digit w/o osseous attachmentTetamy Sa, McKusick VA: Synopsis of hand malformations with particular emphasis on genetic factors. Birth Defects 5(3):125, 1969

POLYDACTYLY – BLAUTH

Type A – Arrangement based o A1 – distal phalanx A3 – proximal phalanx Type B – Transverse numbering of digits medial to lateralBlauth W., Olason AT Classification of Trauma. Surg., 1988, 107,. 334-344

SYNDACTYLY

Type I – incomplete webbing between digitsType II – complete webbing to ends of digitsType III – simple syndactyly, no phalangeal involvementType IV – complicated, phalangeal bones appear abnormalDavis JS, German WJ (1930) Syndactylism. Arch Surg 21 : 32

CHARCOT FOOT – EStage 0 – swelling, warmth, w/ joint instabilityStage I – destructive phase w/ joint laxity, subluxosteochondral fragmentationStage II – coalescence; absorption of debris and fusion of larger fragments to adjacent boneStage III – remodeling; revascularization and remodeling of bone and fragments Eichenholz SN. Charcot Joints. Springfield: CYu, Evaluation and Treatment of Stage 0 Charcot’s Neuroarthropathy of the Foot and Ankle. JAPMA 92(4): 210-220, 2002 Shibata, Results of arthrodesis of the ankle in leprotic neuropathy pts. JBJS 1990

CHARCOT FOOT

Pattern A – Plano-valgus-Pattern B – Rocker bottom footPattern C – Ankle deformity in varus directionPattern D – Extremely flat foot.

secondary arthritis, tx w/ triple arthrodesis articular coalition

no secondary arthritis, tx w/ triple or isolated arthrodesis secondary arthritis, tx w/ triple arthrodesis

Downey, MS: Tarsal coalitions: a surgical classification. J Am Podiatr Med Assoc

– PERLMAN AND WERTHEIMER

LASSIFICATION Congenital coalition Type II – Acquired coalition

Tarsal coalitions. J Foot Surg 1986; 25(1): 58-67 TIONS – TACHDJIAN CLASSIFICATION

Ib – multiple combinations of Ia massive tarsal coalition

II. Part of Complex Malformation assoc w/ other synostoses (carpal coalition, synphalangism) manifestation of a syndrome (Apert’s, Nievergelt-Perlman)

III. Associated w/ Major Limb Abnormalities OLYDACTYLY – VENN & WATSON

shaped Metatarsal Head shaped Metatarsal Head

Watson EA: Problems in polydactyly of the foot. Orthop Clin North Am 1976 Oct; 7(4): 909-27

ETAMY & M CKUSICK CLASSIFICATION axial polydactyly only

Complete digit that articulates MT head or duplicate 5th MT

Accessory digit w/o osseous attachment Tetamy Sa, McKusick VA: Synopsis of hand malformations with particular emphasis on

5(3):125, 1969 LAUTH & OLASON CLASSIFICATION

Arrangement based on duplication distal to prox A2 – middle phalanx A4 – metatarsal A5 – tarsal bone

Transverse numbering of digits medial to lateral W., Olason AT Classification of polydactyly of the. hands and feet. Arch. Orthop.

YNDACTYLY – DAVIS & GERMAN incomplete webbing between digits complete webbing to ends of digits simple syndactyly, no phalangeal involvement complicated, phalangeal bones appear abnormal

WJ (1930) Syndactylism. Arch Surg 21 : 32-. 75. 5 EICHENHOLTZ , SHIBATA , YU

swelling, warmth, w/ joint instability destructive phase w/ joint laxity, subluxation, and

osteochondral fragmentation coalescence; absorption of debris and fusion of

larger fragments to adjacent bone remodeling; revascularization and remodeling of

Joints. Springfield: Charles C. Thomas, 1966 Evaluation and Treatment of Stage 0 Charcot’s Neuroarthropathy of the Foot and

Shibata, Results of arthrodesis of the ankle in leprotic neuropathy pts. JBJS 1990

OOT DEFORMITY – ONVLEE -abductus foot

Rocker bottom foot Ankle deformity in varus direction Extremely flat foot.

Onvlee GJ. The Charcot Foot. A critical review and an observational study of a group of 60 patients. Thesis. The netherlands: University of Leiden, 1998.

CHARCOT ANATOMIC CLASSIFICATION Zone 1 – Distal and proximal interphalangeal joints, metatarsophalangeal joints Zone 2 – Tarsometatarsal joints (Lisfrancs) Zone 3 – Naviculo-cunieform joints, talo-navicular joint, calcaneocuboid joint Zone 4 – Ankle joint, subtalar joint Zone 5 – Calcaneus Sanders LJ, Frykberg RG. The Charcot Foot. In: Frykberg RG, ed. The high risk foot in diabetes mellitus. First edition. New york: Churchill Livingstone, 1991: 325-335. HALLUX L IMITUS /RIGIDUS – DRAGO, ORLOFF , AND JACOBS Grade I – Functional limitus Hallux equinus/flexus, plantar subluxation of proximal phalanx, MPE, no DJD, hyperextension of HIPJ, pronatory architecture, joint ROM normal NWB, but is limited on WB. Grade II – Adaptation; proliferative/destructive joint change Flattening of 1st MT head, pain on end ROM, passive ROM limited, osteochondral defect/cartilage fibrillation & erosion, small dorsal exostosis, subchondral eburnation, periarticular lipping or phalanx base and 1st MT head

Grade III - Joint deterioration/arthritis, established arthrosis Severe flattening of 1st MT head, osteophytosis dorsally, non-uniform narrowing of joint space, degeneration of articular cartilage, erosions, creptius, subchondral cysts, pain on ROM, assoc inflammatory arthritis Grade IV – Ankylosis/Hallux Rigidus Obliteration of joint space w/ loss of majority of articular surface, exuberant osteophytosis w/ joint mice, less than 10° ROM, deformity, malalignment Drago JJ, Oloff L, Jacobs AM: A comprehensive review of hallux limitus. J Foot Surg 23: 213, 1984

HALLUX L IMITUS /RIGIDUS – REGNAULD CLASSIFICATION 1st Degree – Limitation of 1st MPJ ROM to 40°, pain at end ROM, narrowing of joint space, flattening of MT head, periarticular spurring, no sesamoidal dz 2nd Degree – Arthrosis, enlargement of joint, loss of ROM, painful ROM, crepitus, narrowing of joint space, flattening of MT head, periarticular spurring, sesamoid hypertrophy 3rd Degree – Ankylosis, crepitus, little or no ROM, pain, loss of joint space, marked hypertrophy of joint, joint mice, marked involvement of sesamoids Regnauld B. Hallux rigidus. In The Foot, pp 345-359, edited by B Regnauld, Springer-Verlag, Berlin, 1986

HALLUX L IMITUS /RIGIDUS – MODIFIED REGNAULD /ORLOFF CLASSIFICATION

Stage I – Functional hallux limitus No DJD, no pain on end ROM, limited ROM on WB but normal NWB Stage II – Joint adaptation Pain on end ROM, flattening of 1st MT head, small dorsal osteophyte Stage III – Joint deterioration Crepitus on ROM, non-uniform joint space narrowing, subchondral sclerosis and cyst formation, osteophytosis, severe flatting of 1st MT head Stage IV – Ankylosis Obliteration of joint space, osteophyte fragmentation, minimal to no ROM Vanore JV et al. Clinical Practice Guideline First Metatarsophalangeal Joint Disorders Panel. Diagnosis and treatment of first metatarsophalangeal joint disorders. Section 2: hallux rigidus. J Foot Ankle Surg 42:124-136, 2003

HALLUX VALGUS DEFORMITIES Mild – Hallux Valgus <20, Intermetatarsal angle <11, MPJ may be congruent, up to 50% subluxation of fibular sesamoid Moderate – Hallux Valgus btw 20-40, Intermetatarsal angle btw 11-16, MPJ may be subluxed, fibular sesamoid displaced 75% Severe – Hallux Valgus >40, Intermetatarsal angle >16, MPJ significant subluxation, fibular sesamoid displaced 100% Couglin MJ and Mann RA. Chapter 6: Hallux Valgus. Surgery of the Foot & Ankle, 8th edition. Mosby Elsevier, Philadelphia: 2007.

AVN OF THE 2ND METATARSAL – FREIBERG Type I – no DJD, articular cartilage intact Type II – periarticular spurs, articular cartilage intact

Type III – severe DJD, loss of articular cartilage Type IV – epiphyseal dysplasia, multiple head involvement Freiberg AH: Infraction of the second metatarsal bone, a typical injury. Surg Gyn Ob 1914; 19: 191-163

AVN OF THE 2ND M ETATARSAL – KATCHERIAN Level A – fissures noted in distal metaphysis or epiphysis Level B – increased fissuring w/ bone resorbtion Level C – increased fissuring w/ central collapse of MT head Level D – collapse & fx w/ fragments on either side of joint Level E – complete collapse of MT head Katcherian DA: Treatment of Freiberg's Disease. Orthop Clin North Am 25: 69, 1994

COMPLEX REGIONAL PAIN SYNDROME – IASP (1993) CRPS type I (RSD) – regional pain, sensory changes,

abnormalities of temperature, abnormal sudomotor activeity, edema, and abnormal skin color

CRPS type II (causalgia) – All former symptoms in addition to a peripheral nerve lesion.

Reinders. Complex regional pain syndrome type I: use of the international association for the study of pain diagnostic criteria defined in 1994. Clin J. Pain 18: 207-215, 2002.

NERVE INJURY – SEDDEN Neuropraxia – interruption of nerve impulse due to extrinsic pressure, resulting in pinpoint segmental demyelination Axonotmesis – severance of individual nerve fibers, resulting in partial severance of nerve Neurotmesis – complete severance of nerve, resulting in wallerian degeneration Seddon HJ: Three types of nerve injuries. Brain 1943; 66: 237

NERVE INJURY – SUNDERLAND CLASSIFICATION 1st Degree – disruption of nerve impulses w/o wallerian degeneration 2nd Degree – disruption of axon, w/ wallerian degeneration distal to the point of injury 3rd Degree – fibrosis of nerve, regrowth w/ fusiform swelling 4th Degree – incomplete severance of nerve 5th Degree - complete severance of nerve Sunderland S: A classification of peripheral nerve injuries producing loss of function. Brain 74:491-516, 1951

FOOT ULCERATION – WAGNER Grade 0 – Skin is intact, no open lesions. Grade 1 – Skin only lesion, large or small, dirty or clean Grade 2 – Deeper lesion involving tendon, muscle, or bone Grade 3 – Grade 2 w/ infection (abscess, osteomyelitis) Grade 4 – Partial gangrene in the forefoot Grade 5 – Entire foot is gangrenous, no procedures possible Wagner FW Jr. The diabetic foot. Orthopedics 1987;10:163-72

UTSA CLASSIFICATION Grade 0 – pre or post ulcerative lesion, epithelialized Grade 1 – superficial wound, w/ out tendon, capsule or bone Grade 2 – wound penetrating to capsule, tendon, or bone Grade 3 – wound penetrating to bone or joint Type A – Clean, vascular wound Type B – Infected, vascular wound Type C – Clean, ischemic wound Type D – Infected, ischemic wound Lavery LA, Armstrong DG, Harkless LB. Classification of diabetic foot wounds. J Foot Ankle Surg. 1996 Nov-Dec;35(6):528-31

BURN CLASSIFICATION 1st Degree – superficial, involving outer layer of skin, erythema, no blisters 2nd Degree – superficial or deep, may or may not have blisters assoc w/ erythema, anesthetic 3rd Degree – full-thickness destruction of skin, can extend to bone and is anesthetic. Includes electric burns, radiation burns, and frostbite. Can lead to physeal growth arrest.

Minor – <10% TBSA in adults; <5% TBSA in children or elderly; <2% full-thickness burn – outpatient managementModerate – 10%-20% TBSA in adults; 5%-10% TBSA in children or elderly; 2%-5% full-thickness burn; highinjury; suspected inhalation injury; circumferential burn; concomitant medical problem predisposing to infection (eg, diabetes, sickle cell disease) – Hospital AdmissionMajor – N20% TBSA in adults; N10% TBSA in children and elderly; N5% full-thickness burn; high-voltage burn; any significant burn to face, eyes, ears, genitalia, or joints; significant associated injuries (eg, fracture, other major trauma) – Refereral to Burn Center J Burn Care Rehabil 1990;11:98-104 and from Guidelines for the Operations of Burn Units. Resources for Optimal Care of the Injured Patient: 1999, Committee on Trauma, American College of Surgeons.

M ALIGNANT M ELANOMA – CLARK

Level 1 – epidermis to dermal/epidermal junctionLevel 2 – papillary dermis Level 3 – to reticular dermis Level 4 – reticular dermis Level 5 – subcutaneous fat Clark, W.H., Jr.: A classifiation of malignant melanoma in man correlated with histogenesis and biologic behavior. In Montagna W, Hu F (eds): and Skin, Vol 8, The Pigmentary System, Pergamon Press, New York, 1966: 612

MALIGNANT M ELANOMA –BRESLOW’S CLASSIFICATION (SURVIVIAL

Level 1 - <0.75mm 83-100%Level 2 – 0.76-1.5mm 37-90% Level 3 – 1.51-2.25mm 37-83% Level 4 – 2.26-3.0mm 44-72% Level 5 - >3mm 9-55% Breslow, A.: Thickness, cross-sectional areas and depth of invasion in the prognosis of

cutaneous melanoma. Ann Surg 1970;172:902-908

BENIGN AND M ALIGNANT TUMORS -

BENIGN TUMORS (applies to both bone and soft tissue)Stage 1: Lesions are static or tend to heal spontaneouslyStage 2: Lesions have a more aggressive radiographic appearance, are less mature histologically, and show evidence of continued growth Stage 3: Lesions are locally aggressive and histologically immature and show progressive growth that is not limited by natural barriers. M ALIGNANT LESIONS Stage determined by three different sub-categoriesGrade: Histology with aid of radiographic findings and clinical correlation G1: Low grade, uniform cell type without atypia, few G2: High grade, atypical nuclei, mitoses pronouncedSite: T1: Intracompartmental (Confined within limits of periosteum), T2: Extracompartmental (Breach in an adjacent joint cartilage, bone cortex (or periosteum) fascia lata, quadriceps,

5% TBSA in children or outpatient management

10% TBSA in thickness burn; high-voltage

injury; suspected inhalation injury; circumferential burn; itant medical problem predisposing to infection (eg,

Hospital Admission N10% TBSA in children and

voltage burn; any genitalia, or joints;

significant associated injuries (eg, fracture, other major

104 and from Guidelines for the Operations of Burn

1999, Committee on Trauma, American College of Surgeons. LARK

epidermis to dermal/epidermal junction

, Jr.: A classifiation of malignant melanoma in man correlated with histogenesis and biologic behavior. In Montagna W, Hu F (eds): Advances in Biology

, Vol 8, The Pigmentary System, Pergamon Press, New York, 1966: 612-647

–

URVIVIAL RATES) 100%

sectional areas and depth of invasion in the prognosis of

ENNEKING (applies to both bone and soft tissue)

or tend to heal spontaneously Lesions have a more aggressive radiographic

appearance, are less mature histologically, and show evidence

Lesions are locally aggressive and histologically growth that is not limited by

categories Histology with aid of radiographic findings and

G1: Low grade, uniform cell type without atypia, few mitoses, G2: High grade, atypical nuclei, mitoses pronounced

T1: Intracompartmental (Confined within limits of

T2: Extracompartmental (Breach in an adjacent joint cartilage, bone cortex (or periosteum) fascia lata, quadriceps,

and joint capsule) Metastasis: M0: No identifiable skip lesions or distant metastases.M1: Any skip lesions, regional lymph nodes, or distant metastases.

Enneking WF: Musculoskeletal Tumor Surgery. New York, Churchll Livingstong, 1983

PLANTAR FIBROMATOSIS

Grade 1 – Focal disease isolated to a small area on the medial and/or central aspect of the fascia. No adherence to the skin. No deep extension to the flexor sheath.Grade 2 – Multifocal disease, with or without proximal or distal extension. No adherence to the skin. No deep extension to the flexor sheath. Grade 3 – Multifocal disease, with or without proximal or distal extension. Either adherence to the skin or deep extension to the flexor sheath. Grade 4 – Multifocal disease,distal extension. Adherence to the skin and deep extension to the flexor sheath. Sammarco, G. James M.D. Mangone, Peter G. M.D. Classification and Treatment of Plantar Fibromatosis. FAI 21(7), 563

NAIL INJURIES

Zone 1 – to distal phalanx Tx: w/o bony exposure, let granulate if <1cm, graft if >1cm injuryIf bony exposure, treat as zone 2 injuryZone 2 – distal to lunula Stasoy/Kutler pedicle flaps after wound is cleanZone 3 – proximal to lunulaAmputation of distal phalanx (including DIPJ)

Rosenthal EA. Treatment of fingertip and nail bed injuries, 14:675-697, 1983

M0: No identifiable skip lesions or distant metastases. M1: Any skip lesions, regional lymph nodes, or distant

Enneking WF: Musculoskeletal Tumor Surgery. New York, Churchll

IBROMATOSIS – SAMMARCO Focal disease isolated to a small area on the medial

and/or central aspect of the fascia. No adherence to the skin. No deep extension to the flexor sheath.

Multifocal disease, with or without proximal or extension. No adherence to the skin. No deep extension

Multifocal disease, with or without proximal or distal extension. Either adherence to the skin or deep extension to the flexor sheath.

Multifocal disease, with or without proximal or distal extension. Adherence to the skin and deep extension to

Sammarco, G. James M.D. Mangone, Peter G. M.D. Classification and Treatment of Plantar Fibromatosis. FAI 21(7), 563-9: 2000

NJURIES – ROSENTHAL

Tx: w/o bony exposure, let granulate if <1cm, graft if >1cm injury If bony exposure, treat as zone 2 injury

Stasoy/Kutler pedicle flaps after wound is clean proximal to lunula

on of distal phalanx (including DIPJ)

Rosenthal EA. Treatment of fingertip and nail bed injuries, Orthop Clin North Am

CLINICAL ANTIBIOSIS Infection: Pathologic presence of bacteria in a wound or tissue site, numbering 106. It is clinically signified by inflammation, erythema, pain, warmth, and loss of function. History: May present with nausea, vomiting, shaking, chills. Get history of prior tx, PMH, allergies, social Hx, travel Hx, and any pets the patient may have. (Cats = pasturella) D/Dx: Gout, DVT (r/o venous Doppler/venogram), chronic venous insufficiency (bilateral pitting edema, hemosiderin deposition), acute charcot, acute trauma, normal wound healing, post-surgical healing. Labs: WBC>10, left shift, elevated ESR, CRP. Hospital Admission: Indicated for osteomyelitis, large draining wound, sustained fever (over 101F), diabetes, immunocompromised state, gas present in tissues, failure of PO antibiosis, sepsis indicated on blood labs.

PENICILLINS Original Penicillins Not used often in foot infections – for gonococcus, anaerobes PEN G: IV or IM – 5-6 million U q4h PEN VK: PO – 250-500mg QID, causes hypokalemia Aminopenicillins Good broad spectrum, but useless against staph. AMPICILLIN : IM, IV, PO – 250-500mg QID or 2g q4h AMOXICILLIN : PO only – 250-500mg QID Semisynthetic PCNnase resistant, good vs. staph, used in specific situations NAFCILLIN : IM or IV – 1-2g q4-6h, metabolized in liver DICLOXACILLIN : PO – 250-500mg QID Uriedopenicillins (Expanded Spectrum) Active against pseudomonas, resistance is common CARBENICILLIN : No use in lower extremity TICARCILLIN : IV – 3-4g q4h, high in sodium PIPERICILLIN : No use in lower extremity Beta-Lactamase Inhibitors First choice antibiotics w/ cephalosporins Staph, Strep, Anaerobes, Gram - coverage TIMENTIN (TICARCILLIN + 100MG CLAVULANATE ) IV – 3.1g q6-8h Empiric for DM foot infections, bites AUGMENTIN (AMOXICILLIN + 125MG CLAVULANATE ) PO – 250/500/875 BID Good for outpatient DM, bites UNASYN (1 PART AMPICILLIN + ½ PART SULBACTAM) IV – 3g loading dose, 1.5g following doses Better at gram + but worse for gram – than timentin ZOSYN (PIPERICILLIN + TAZOBACTAM) IV – 4.5g q8h Better against enterococci

CEPHALOSPORINS First Generation Cephalosporins Good for gram +, most common pre-op prophylaxis CEFAZOLIN (ANCEF): IV or IM, 1g q8h CEFALEXIN (KEFLEX): PO, 250-500mg BID/QID CEFADROXIL (DURICEF): PO, 500mg q12h Second-Generation Cephalosporins Used mainly for ear infections, pneumonia – not podiatry IV: CEFOXITIN (MEROXIN), CEFUROXIME (ZINACEF), CEFOTETAN (CEFOTAN)

PO: CEFACLOR (CECLOR) 250-500mg TID, CEFUROXIME

(CEFTIN), CEFPROZIL (CEFZIL) Third-Generation Cephalosporins More gram -, less gram +, fortaz also anti pseudomonal IV: CEFTRIAXONE (ROCEPHIN) 1-2g QD (long half-life) Rocephin principal antibiotic in Lyme disease treatment CEFTAZIDIME (FORTAZ): some antipseudomonal coverage PO: CEFDINIR (OMNICEF) 300mg BID, better staph coverage CEFPODOXIME (VANTIN), CEFIXIME (SUPRAX) Fourth-Generation Cephalosporins Good gram + and gram -, antipseudomonal CEFEPIME (MAXIPIME) IV, 1-2g q12h

CARBAPENEMS PRIMAXIN (IMIPENEM + CILASTATIN): PO 500mg q6h Gram +, gram -, anaerobes – cilastatin added to protect kidneys. Expensive, save for life-threatening infections MEROPENEM (MERREM) some antipseudomonal coverage ERTAPENEM (INVANZ): IV, IM, 1g q24h Good against enterobacteria, but not pseudomonas AZTREONAM (AZACTAM): IV, 1-2g q8h Only good against gram – anaerobes; use in combination

AMINOGLYCOSIDES Staph, strep, gram -, but not anaerobes ADRs: reversible nephrotoxicity, irreversible ototoxicity, Neuromuscular blockade if infused too quickly GENTAMYCIN , TOBRAMYCIN , AMIKACIN Loading doses: Gentamycin/Tobramycin – 2mg/kg Amikacin 7.5mg/kg Maintenance doses: Gent/Tobra – 6mg/kg/day Amikacin 15mg/kg/day Peak level: Gent/Tobra 6-10µg/ml, Amikacin 20-30µg/ml Trough level: Gent/Tobra 2µg/ml, Amikacin 10µg/ml (Peak = immediately after dosing, Trough = 20-30 minutes before dosing)

FLOUROQUINOLONES CIPROFLOXACIN (CIPRO): PO 500/750mg, IV 400mg BID Good gram – coverage, antipseudomonal Not for peds, Sx prophylaxis, or weak/tenotomized tendons LEVOFLOXACIN (LEVAQUIN): PO or IV 500/750mg BID Good for staph and strep, not as strong antipseudomonal M OXIFLOXACIN (AVELOX): PO or IV 400mg QD Good staph, strep, and antipseudomonal GATIFLOXACIN (TEQUIN): Not for foot infections, lengthens QT TROVAFLOXACIN (TROVAN): Taken off market for hepatic failure

SULFONAMIDES BACTRIM/SEPTRA (TRIMETHOPRIM + SULFAMETHOXAZOLE): PO only - QD dosing, double-strength (DS) 160mg TMX, 800mg sulfamethoxazole Broadest possible spectrum, not antipseudomonal Allergies common

MACROLIDES ERYTHROMYCIN : PO 250-500mg QD, IV 1g QD Good against staph, gram + and gram – anaerobes AZITHROMYCIN (ZITHROMAX): PO 500mg QD day 1, 250mg QD days 2-4. Postbiotic effect for 10 days following dosing. Gram +, some Gram – organisms, usually for pts who are allergic to other antibiotics, or peds (Paronychia) CLARITHROMYCIN (BIAXIN): Not often used for foot infections

TETRACYCLINES

TETRACYCLINE, DOXYCYLINE , M INOCYCLINE Limited use in podiatry – mainly used for acne, Lyme disease

CHLORAMPHENICOL Mainly a historical footnote; not really used anymore

ANTI -ANAEROBIC M ISCELLANY

M ETRONIDAZOLE (FLAGYL): PO or IV, 500mg TID Mainly gram – but some gram +, amebiasis, colorectal Sx Used also to treat pseudomembranous colitis (see below) CLINDAMYCIN (CLEOCIN): PO 150-300mg BID, IV or IM 600-900mg q8h. Good bone penetrance, good for anaerobes Can cause pseudomembranous colitis

ANTI -GRAM + M ISCELLANY VANCOMYCIN (VANCOCIN): PO 125mg QD (only for c. difficile), IV 1g q12h – infuse slowly Good for all gram + except VRSA and VRE. ADRs: nephrotoxicity, ototoxicity, red man syndrome (rash) Can be used for prophylaxis if PCN, clindamycin allergic Peak – 20-500µg/ml, Trough - 10µg/ml, like aminoglycosides SYNERCID (QUINUPRISTIN + DALFOPRISTIN): IV 7.5mg/kg q12h Used for VRE L INEZOLID (ZYVOX): PO, IV 600mg BID Used for MRSA, all gram +. Can cause thrombocytopenia RIFAMPIN : PO 300mg BID Good for resistant staph and strep Causes rash, orange discoloration of all body fluids.

ADVERSE REACTIONS -Pseudomembranous Colitis – Clindamycin, cephalosporins, uriedopenicillins: Tx w/ metronidazole, oral vancomycin -Tendon rupture, cartilage degeneration – Ciprofloxacin -Ototoxicity (irreversible), nephrotoxicity (reversible), neuromuscular blockade – Gentamycin, Tobramycin, Amikacin -Ototoxicity, nephrotoxicity, red man synd. – Vancomycin -Hypokalemia – Pen G, Pen VK: Tx w/ K-exelate -Thrombocytopenia, bone marrow suppression – Linezolid -Rash, orange discoloration of body fluid – Rifampin -QT interval lengthening – Tequin

ANTI -PSEUDOMONAL DRUGS Penicillins: Ticarcillin (weak), Timentin (weak) Cephalosporins: Fortaz (weak), Maxipime (strong) Carbapenems: Meropenem (weak) Quinolones: Cipro (strong), Levaquin (weak), Avelox (strong) Aminoglycosides: Tobramycin (strong)

EMPIRIC TREATMENT OPTIONS Soft tissue infections: Unasyn, Zosyn, Timentin, Maxipime, Invanz, Avelox, Cipro, Levaquin, Bactrim.

SURGICAL PROPHYLAXIS Indications: Prolonged surgery, immunocompromise, trauma, implant surgery. Most Common: Ancef, Rocephin, Vancomycin, Clindamycin Never Used: Quinolones, particularly cipro. Administration: IV, ½h prior to surgery (usually done in OR)

LOWER EXTREMITY M ICOBIOLOGY REVIEW GRAM + COCCI

Staph Aureus – Coagulase +

Incidence: Normal flora, common infection, high resistance ABx: 1st Cephalosporins, PCNase resistant PCN, Cleocin, Bactrim, Erythromycin, Vanco (resistant), Cipro (resistant) Staph Epidermidis/Saprophyticus – Coagulase – Incidence: Normal flora – Epi seen in implant sx, sap in UTI ABx: Same as S. Aureus Strep Pyogenes – Group A, Strep Agalactiae – Group B Incidence: Pyo usually superficial, Agalactiae seen in DM ABx: PCNs, 1st gen Cephalosporins, Cleocin, Vanco Strep Faecalis/Faecium – Group D/Enterococci Incidence: GI flora, highly resistant, ST infection component ABx: Gentamycin + PCN/Ampicillin/Amoxicillin or Vanco Peptostreptococcus/Peptococcus – Anaerobic Incidence: DM foot infections ABx: PCN, 1st gen Cephalosporins, Cleocin, Erythromycin

GRAM + BACILLI Clostridium Tetani – Anaerobic, Spore-forming Incidence: Ubiquitous in environment, puncture wounds ABx: PCNs (mainly useless b/c of neurotoxin production) Clostridium Perfringens – Anaerobic Incidence: Fast growing, gas gangrene (necrotizing fasciitis) ABx: Sx debridement indicated – PCN, Cleocin, Imipenem Corynebacterium – diptheroid Incidence: Nosocomial, Immunocompromised infections ABx: Cleocin, Erythromycin, Vanco

GRAM – COCCI Neisseria Gonorrhoeae Incidence: Major cause of septic arthritis is LE, resistant ABx: Rocephin, Cipro (resistant)

GRAM – RODS (ENTERIC ) Bacteroides Incidence: Most common in DM infection, resistant ABx: Flagyl, primaxin, cleocin, 3rd or 4th gen cephalosporins Enterobacter/Citrobacter/Morganella/Serratia Incidence: Nosocomial infections, elderly ABx: 3rd gen cephalosporins, cipro, bactrim, aminoglycosides Escherichia Coli Incidence: Common in LE infections ABx: Any cephalosporin, ampicillin, cipro, bactrim Proteus/Providencia Incidence: Normal flora, common in interdigital infections ABx: Cephalosporins, Ampicillin, Cipro, Bactrim

OTHER GRAM – RODS Aeromonas Hydrophilia Incidence: Injuries sustained under water (fresh water) ABx: Cipro, Bactrim, Primaxin, Aminoglycosides Haemophilus Influenzae Incidence: Most common in children, nosocomial infections ABx: 3rd/4th gen cephalosporins, bactrim, ampicillin Pseudomonas Aeruginosa Incidence: Ubiquitous, common in osteomyelitis ABx: See left