True Stories From Podiatric Residency

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Feli said:
I thought it was cool you could go back since all the Qs were in sets. Some of the pics looked like they were copies from a 1mp camera, though.

I think it went real well... some hard anesth and pharm questions, but should get good news in early or mid July.
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Yea, some of those radiographs were ridiculous. I couldn't even make out the image. And I'm supposed to make a diagnosis???
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jonwill said:
I passed part III! :cool: I put an Ilizarov frame on yesterday on a charcot patient.
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That's an ilizarov in your avatar, correct? How does it differ putting it onto a "standard" patient? Aren't the bones softer/collapsed in a charcot foot? -- have to be more careful when drilling?
 
rom3o said:
That's an ilizarov in your avatar, correct? How does it differ putting it onto a "standard" patient? Aren't the bones softer/collapsed in a charcot foot? -- have to be more careful when drilling?
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My avatar is actually a taylor spatial frame which is based off of an ilizarov frame but is a static frame as opposed to a dynamic one. Their are a few different indications for charcot but we put the frame on the patient while in the acute phase to hold the foot and its bones in a correct position prior to complete breakdown.
 
jonwill said:
My avatar is actually a taylor spatial frame which is based off of an ilizarov frame but is a static frame as opposed to a dynamic one. Their are a few different indications for charcot but we put the frame on the patient while in the acute phase to hold the foot and its bones in a correct position prior to complete breakdown.
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Hail to the chief;)

I'm on Kaiser for the next 3 months. Clinic several days a week OR one day a week. Tomorrow - Lis Franc homolateral dislocation and 2 lapidi.
 
jonwill said:
My avatar is actually a taylor spatial frame which is based off of an ilizarov frame but is a static frame as opposed to a dynamic one. Their are a few different indications for charcot but we put the frame on the patient while in the acute phase to hold the foot and its bones in a correct position prior to complete breakdown.
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I def see this is the real deal surgery procedures ... how much money does something like that bring in ? ... i was told a triple orthodesis involving an external fixator brings in over 10K ... so im guessin the one ur refering to is even more complex hence more money ?
 
G0dFather said:
... i was told a triple orthodesis involving an external fixator brings in over 10K ...
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lol... "triple orthodesis involving an external fixator brings in over 10K" for the ex fix hardware company? Maybe.
The hospital or surg center might possibly make 10k off the anesthesia, surgery fees, meds, inpatient bed stay, etc etc etc... who knows. However, there's no way any triple pays a surgeon fee even close to $10k. I think that in terms of surgeon billing, a triple is usually a triple... regardless of what fixation you use (screws, staples, plates, ilizarov, etc).

...and also, since it's almost always an elective procedure, there's no legit reason to use an ex fix for 95+% of triples if you ask many good attending F&A surgeons. You will see things done various ways, but if the attending(s) you are shadowing or getting your info from are using ex fix on triples or other elective procedures with great regularly, you could probably consider shadowing other docs.
 
-Got my first C today... I&D with osteoset and graftjacket. Woohoo
-On my other case, was told that I need to practice suturing since I struggled to sew around the ex fix we had put on :p
-Observed our 2nd year doing a PT transfer through interosseous memb... neat case.
 
Feli said:
-Got my first C today... I&D with osteoset and graftjacket. Woohoo
-On my other case, was told that I need to practice suturing since I struggled to sew around the ex fix we had put on :p
-Observed our 2nd year doing a PT transfer through interosseous memb... neat case.
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Nice! I just got back from my 2nd ER call in 2 nights lol. Nothing surgical though. Scrubbed a TMA with percutaneous TAL for a gangrenous foot. Tis the season for infections I guess lol.
 
Feli said:
lol... "triple orthodesis involving an external fixator brings in over 10K" for the ex fix hardware company? Maybe.
The hospital or surg center might possibly make 10k off the anesthesia, surgery fees, meds, inpatient bed stay, etc etc etc... who knows. However, there's no way any triple pays a surgeon fee even close to $10k. I think that in terms of surgeon billing, a triple is usually a triple... regardless of what fixation you use (screws, staples, plates, ilizarov, etc).

...and also, since it's almost always an elective procedure, there's no legit reason to use an ex fix for 95+% of triples if you ask many good attending F&A surgeons. You will see things done various ways, but if the attending(s) you are shadowing or getting your info from are using ex fix on triples or other elective procedures with great regularly, you could probably consider shadowing other docs.
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:thumbup:
 
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First weekend on ER/floor call... open fx on Fri, met fx last night, and who knows what will come today/tonight?

Actually found time to watch some of UFC 100 without beeper going off much, but now it's time to catch up on dictations :p
 
A few weeks ago, we had a run on 5th met fx's. We must of had 5-6. This past week was a run on achilles tendon ruptures and ankle fractures. You gotta love summer.
 
We had some good variety on our sched today... flatfoot recon, lat ankle stab + calc slide, wounds, HAVs, and about a half dozen other cases. My surg party ended yesterday, though... got about 30 B+Cs in the previous two weeks, but now on floors/clinic and piled in paperwork until Rads next month.

...I've officially caved in and ordered a rubber ink stamp with my name and service's call pager number so that I can simply initial next to it. Yes, that is only a few steps away from taped glasses and a pocket protector, but I'm afraid my hand will eventually fall off from signing a dozen times for each inpatient surgery's peri-op notes/orders... and signing nearly that many times for each outpatient sx... and don't forget signing 10+ notes on am rounds, pm rounds, and/or ER call nights. Figured that being in a surgical profession, for 5 bucks, might be worth lowering my risk of carpal tunnel? :p
 
Feli said:
...I've officially caved in and ordered a rubber ink stamp with my name and service's call pager number so that I can simply initial next to it. Yes, that is only a few steps away from taped glasses and a pocket protector, but I'm afraid my hand will eventually fall off from signing a dozen times for each inpatient surgery's peri-op notes/orders... and signing nearly that many times for each outpatient sx... and don't forget signing 10+ notes on am rounds, pm rounds, and/or ER call nights. Figured that being in a surgical profession, for 5 bucks, might be worth lowering my risk of carpal tunnel? :p
Click to expand...

And non-clinical people wonder why physicians have such horrible signatures! :laugh:
 
Feli said:
We had some good variety on our sched today... flatfoot recon, lat ankle stab + calc slide, wounds, HAVs, and about a half dozen other cases. My surg party ended yesterday, though... got about 30 B+Cs in the previous two weeks, but now on floors/clinic and piled in paperwork until Rads next month.

...I've officially caved in and ordered a rubber ink stamp with my name and service's call pager number so that I can simply initial next to it. Yes, that is only a few steps away from taped glasses and a pocket protector, but I'm afraid my hand will eventually fall off from signing a dozen times for each inpatient surgery's peri-op notes/orders... and signing nearly that many times for each outpatient sx... and don't forget signing 10+ notes on am rounds, pm rounds, and/or ER call nights. Figured that being in a surgical profession, for 5 bucks, might be worth lowering my risk of carpal tunnel? :p
Click to expand...

I'm guessing this is your pod surgery rotation...can you elaborate on the hours you are putting? Is there a typical day (time wise) such as 6am for pre-rounds, etc then out at 6-8 at night? What's your call schedule like? Thanks Feli
 
Feli said:
We had some good variety on our sched today... flatfoot recon, lat ankle stab + calc slide, wounds, HAVs, and about a half dozen other cases. My surg party ended yesterday, though... got about 30 B+Cs in the previous two weeks, but now on floors/clinic and piled in paperwork until Rads next month.

...I've officially caved in and ordered a rubber ink stamp with my name and service's call pager number so that I can simply initial next to it. Yes, that is only a few steps away from taped glasses and a pocket protector, but I'm afraid my hand will eventually fall off from signing a dozen times for each inpatient surgery's peri-op notes/orders... and signing nearly that many times for each outpatient sx... and don't forget signing 10+ notes on am rounds, pm rounds, and/or ER call nights. Figured that being in a surgical profession, for 5 bucks, might be worth lowering my risk of carpal tunnel? :p
Click to expand...

Haha that's a great idea actually. Meanwhile, here I am signing my notes and Rx's like a sucker. What's worse than carpal tunnel is caffeine over-load. This call-week turned me into a true coffee-addict and I'm only 2 weeks into my training lol. We've been swamped with amps and infections (and gangrenes) - cool cases from an academic presepective: medical/surgical management, orders, etc. Had one revisonal neuropathic ankle fx and a fair shair of HAVs and toes. Good times!
 
worked over 100 hours the first week of July being on "Big Brother" call with a newby first year.....gotta say he held up well though.

Got everything from ankle, calc fractures, GSW, wounds, degloving injuries, forefoot fx's, you name it!
 
Foot Doc said:
worked over 100 hours the first week of July being on "Big Brother" call with a newby first year.....gotta say he held up well though.

Got everything from ankle, calc fractures, GSW, wounds, degloving injuries, forefoot fx's, you name it!
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Yep, third year life is pretty sweet!
 
Medial column fusion, OLT repair with maleolar osteotomy, and syndesomtic repair. Gotta love on-service months!
 
Yesterday, I did a ORIF of a calcaneal fracture that was 5 weeks old. We basically had to re-fracture the entire thing to get everything back into position. We plated it as well as did a primary STJ fusion.

I also repaired an achilles tendon.
 
jonwill said:
Yesterday, I did a ORIF of a calcaneal fracture that was 5 weeks old. We basically had to re-fracture the entire thing to get everything back into position. We plated it as well as did a primary STJ fusion.

I also repaired an achilles tendon.
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what was the decision making process to fix the calc so long out and fuse the STJ? As opposed to allowing it at this point to heal and fuse it later when the pain was unbearable?

Was her heel to wide for a shoe?
Was it extremely comminuted? MOI?

Just want to stir some discussion.


I've been in clinic but I did a cavus foot recon (think I posted about that, dunno?)

Lots of nail avulsions

put lots of people in CAM walkers

Casted an ankle sprain

felt 2 positive anterior drawer signs - when the talus goes "clunk" when it pops out of the mortis anteriorly I call that positive.

Gave lots of injections while "peppering" the plantar fascia and then dispensed OTC orthotics and lots of directions for icing, stretching, NSAID use w/ and w/out GERD, and contrast soaks.

Clinic can be fun especially when you don't feel too rushed and there are nurses and MA to assist and the patients are nice.
 
krabmas said:
what was the decision making process to fix the calc so long out and fuse the STJ? As opposed to allowing it at this point to heal and fuse it later when the pain was unbearable?

Was her heel to wide for a shoe?
Was it extremely comminuted? MOI?

Just want to stir some discussion.


I've been in clinic but I did a cavus foot recon (think I posted about that, dunno?)

Lots of nail avulsions

put lots of people in CAM walkers

Casted an ankle sprain

felt 2 positive anterior drawer signs - when the talus goes "clunk" when it pops out of the mortis anteriorly I call that positive.

Gave lots of injections while "peppering" the plantar fascia and then dispensed OTC orthotics and lots of directions for icing, stretching, NSAID use w/ and w/out GERD, and contrast soaks.

Clinic can be fun especially when you don't feel too rushed and there are nurses and MA to assist and the patients are nice.
Click to expand...

The story goes the guy did it on a motorcycle. It was a complete lateral wall blow out with varus and the calc was pretty much dusted. Interestingly enough, the guy didn't go anywhere for a week or so. Once he finally decided to go to someone, he went to a podiatrist in the burbs who got an xray and then CT. He doesn't do this kind of stuff and called us. Needless to say, by this time it was already near a month old. We got him into our trauma clinic and the biggest problem was that it was such a bad fracture, he would have never been able to ambulate because of the severe deformity. He was young, healthy, and depended upon mobility for a living so waiting really wasn't an option in this case.

We went in, had to re-fracture everything, got the height and width back, got it out of varus, and plated it (with a fair amound of hydroset used as well). As you can imagine, the STJ was non-existent so we fused it as well. So the overall goal was to get this guy back to near baseline asap. If the fracture wasn't as severe or the patient didn't depend on ambulation (the guy is a bodybuilder and also works on loading docks), waiting may not have been such a bad idea. HOPEFULLY, by the end of the year, we can have this guy back to work.
 
jonwill said:
The story goes the guy did it on a motorcycle. It was a complete lateral wall blow out with varus and the calc was pretty much dusted. Interestingly enough, the guy didn't go anywhere for a week or so. Once he finally decided to go to someone, he went to a podiatrist in the burbs who got an xray and then CT. He doesn't do this kind of stuff and called us. Needless to say, by this time it was already near a month old. We got him into our trauma clinic and the biggest problem was that it was such a bad fracture, he would have never been able to ambulate because of the severe deformity. He was young, healthy, and depended upon mobility for a living so waiting really wasn't an option in this case.

We went in, had to re-fracture everything, got the height and width back, got it out of varus, and plated it (with a fair amound of hydroset used as well). As you can imagine, the STJ was non-existent so we fused it as well. So the overall goal was to get this guy back to near baseline asap. If the fracture wasn't as severe or the patient didn't depend on ambulation (the guy is a bodybuilder and also works on loading docks), waiting may not have been such a bad idea. HOPEFULLY, by the end of the year, we can have this guy back to work.
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Sounds like a great case. We don't have hydroset at our hospital do you like it? Do you think it is better than the cheaper cancellous chips for packing voids?
 
krabmas said:
Sounds like a great case. We don't have hydroset at our hospital do you like it? Do you think it is better than the cheaper cancellous chips for packing voids?
Click to expand...

The nice thing about hydroset is that it sets in a matter of minutes and then you can actually drill and place screws through it. So it makes it ideal for something like a calc fx with a large defect that will require hardware. Other than that, I'd probably just use the bone chips.
 
jonwill said:
The story goes the guy did it on a motorcycle. It was a complete lateral wall blow out with varus and the calc was pretty much dusted. Interestingly enough, the guy didn't go anywhere for a week or so. Once he finally decided to go to someone, he went to a podiatrist in the burbs who got an xray and then CT. He doesn't do this kind of stuff and called us. Needless to say, by this time it was already near a month old. We got him into our trauma clinic and the biggest problem was that it was such a bad fracture, he would have never been able to ambulate because of the severe deformity. He was young, healthy, and depended upon mobility for a living so waiting really wasn't an option in this case.

We went in, had to re-fracture everything, got the height and width back, got it out of varus, and plated it (with a fair amound of hydroset used as well). As you can imagine, the STJ was non-existent so we fused it as well. So the overall goal was to get this guy back to near baseline asap. If the fracture wasn't as severe or the patient didn't depend on ambulation (the guy is a bodybuilder and also works on loading docks), waiting may not have been such a bad idea. HOPEFULLY, by the end of the year, we can have this guy back to work.
Click to expand...

Jon, I'm just curious - has the thought of primary STJ fusion been brought up amongst your surgical team (Bone-block arthrodesis for example)? Reason I ask is because it seems like you guys did a fair amount of work to resect joint and then plate it in a position out of varus as the fracture was beginning to heal, albeit malunionited. What's your opinion on primary fusions in these situations from your experience at a Level-1 trauma institution?

Great case! Thank you for the feedback.
 
PMSIII said:
Jon, I'm just curious - has the thought of primary STJ fusion been brought up amongst your surgical team (Bone-block arthrodesis for example)? Reason I ask is because it seems like you guys did a fair amount of work to resect joint and then plate it in a position out of varus as the fracture was beginning to heal, albeit malunionited. What's your opinion on primary fusions in these situations from your experience at a Level-1 trauma institution?

Great case! Thank you for the feedback.
Click to expand...

We do some primary stj fusions and we did primarily fuse this STJ as well. The reason we had to mess with the calc is that it was so mal-positioned, he really wouldn't have been able to walk well on it (shoe gear would have been a nightmare). But yea, things like bone block arthrodesis definitely have a place. I'm doing another calc tomorrow afternoon and hopefully, I'll be able to get away with not fusing anything. Although with calc fractures, sooner or later, it usually comes to that.
 
I've been on rounding/clinic/ER/consults for the past couple weeks. Plenty of lacs and sprains in ER with a few fx mixed in. Some interesting 2nd opinion clinic pts... post-trauma arthritis, revisional surg referrals, etc. Tomorrow is the last day of clerkship for one of our students who has been tagging along with me most of this month, so I told him "you're the resident" tomorrow... he can write all notes, see ERs, eval clinic and consult pts, try to dictate if he wants, etc and I just supervise/assist/correct for him. Hope he has been payin attention :D

...Meanwhile, on our OR schedules, we've had a couple of ankle desis last week, calc fx plating yesterday, bullet removal today, desyndactylization, lots of HAV and hammertime, wounds and amps, tendon laceration, etc in the past couple weeks. That's all for the cool kids on surgery, though... as current "floor boy," I'm just glad I don't have any more venous+lymphedema b/l compression dressing pts on the floors right now.

..Radio (aka get some research started, spend time with the wife) is next month for me... then back to pod surg in Sept.
 

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Feli said:
I've been on rounding/clinic/ER/consults for the past couple weeks. Plenty of lacs and sprains in ER with a few fx mixed in. Some interesting 2nd opinion clinic pts... post-trauma arthritis, revisional surg referrals, etc. Tomorrow is the last day of clerkship for one of our students who has been tagging along with me most of this month, so I told him "you're the resident" tomorrow... he can write all notes, see ERs, eval clinic and consult pts, try to dictate if he wants, etc and I just supervise/assist/correct for him. Hope he has been payin attention :D

...Meanwhile, on our OR schedules, we've had a couple of ankle desis last week, calc fx plating yesterday, bullet removal today, desyndactylization, lots of HAV and hammertime, wounds and amps, tendon laceration, etc in the past couple weeks. That's all for the cool kids on surgery, though... as current "floor boy," I'm just glad I don't have any more venous+lymphedema b/l compression dressing pts on the floors right now.

..Radio (aka get some research started, spend time with the wife) is next month for me... then back to pod surg in Sept.
Click to expand...

lol are you sure he will enjoy writing notes?
 
cool_vkb said:
lol are you sure he will enjoy writing notes?
Click to expand...
Well, no, I'm not sure anyone likes writing notes or dictating... but the whole point of clerkships is to prep you for being a resident next year. You will during your 4th year that some of your clerkship hospital programs will let students do basically nothing besides hold up the wall in clinic, watch residents write notes on the floor, and try in vain to see the surgical field from behind the shoulders of 3+ scrubbed residents/attendings. You might get to occasionally hand them a piece of tape or your pen/scissors when they ask. ;)

Sure, you can learn from watching (and some students aren't ready to do much more than that), but I found the clerkships that let me participate in pt care, surg, etc and generally do more hands-on were the best ones in terms of increasing my knowledge/interest level and preparing me for what my current responsibilities are. Programs like mine, Jon's, etc have no shortage of pts, surgery, ERs, etc... so most good students get to be fairly active.
 
I did a CRPP of a calc fracture yesterday. I also learned an important lesson. Generally, when you steal a car and then run from the cops in a high speed chase, it doesn't end well. :)
 
Funny. I did a gunshot wound that entered through the posterior calcaneus and tracked through and ended up shattering and landing in the 4th metatarsal.

Of course all gunshot wounds that enter the ER automatically generate a call to the police. He told the police that he dropped his toolbox which contained a box of bullets and that one of the bullets happened to "explode" and shoot into his foot!

It turns out that he apparently owed someone money, and when he attempted to take off, the other guy shot him.

As you can guess, gunshot wounds to the back of the foot are always because the "victim" is running away. Regardless, it was an interesting case, and it's always exciting when you remove the bullet and drop it in a metal pan and it makes that loud noise....just like in the movies.
 
PADPM said:
Funny. I did a gunshot wound that entered through the posterior calcaneus and tracked through and ended up shattering and landing in the 4th metatarsal.

Of course all gunshot wounds that enter the ER automatically generate a call to the police. He told the police that he dropped his toolbox which contained a box of bullets and that one of the bullets happened to "explode" and shoot into his foot!

It turns out that he apparently owed someone money, and when he attempted to take off, the other guy shot him.

As you can guess, gunshot wounds to the back of the foot are always because the "victim" is running away. Regardless, it was an interesting case, and it's always exciting when you remove the bullet and drop it in a metal pan and it makes that loud noise....just like in the movies.
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At least he had a pretty creative story. I get tired of the "I was just walking down the street minding my own business." :laugh:
 
saw a complete plantar fascial rupture the other day due to fluoroquinolone usage.

today in clinic... plantar fascia, neuroma, fungal nails, ingrown nails, callus, insertional achilles tendonitis...
 
haglunds, ankle scope, lapidus, ankle ORIF, bunion, bunion, STJ arthroeresis
 
Sanders IIB calcaneal fracture from a fall off a three-storey building. Patient was trying to get into his friend's apartment through the window because he "forgot his keys" lol. We intend on doing an ORIF after the edema resolves.

We also had a patient who fractured her talus, navicular (Laterally and dorsally displaced), cuboid (nutcracker), and Lisfranc's in a very nasty bike accident - Luckily, no compartment syndrome or compromise to her neurovascular status but that will be one heck of a reconstruction for sure (pending soft-tissue edema resolves of course)
 
radial nerve repair x 2 tonight. Thats 3 in 2 weeks!

one was the radial nerve and 2 were dorsal radial sensory nerve.

CMT cavus foot recon - dwyer, cole, PTT tx, DFWO last friday

STJ fusion last friday

Since I am on a clinic rotation it has been slow with the surgeries.
 
logged my 1,000th case!

thats right, CASE, not procedure

get some
 
yesterday - peroneal nerve release, percutaneous fasciotomy of the anterior and lateral compartments, tarsal tunnel release, proximal tibial osteotomy w/ gigli saw, distal tibial osteotomy w/ gigli saw, midfoot osteotomy w/ gigli saw.
distal femoral deformity correction w/ ex-fix and plate

Today: femoral lengthening, tibial deformity correction, femoral deformity correction.

Drew lots of angles and dangles.

I've been at the Limb Deformity course in Baltimore, unfortunately I did not get to do this stuff on real people.
 
krabmas said:
yesterday - peroneal nerve release, percutaneous fasciotomy of the anterior and lateral compartments, tarsal tunnel release, proximal tibial osteotomy w/ gigli saw, distal tibial osteotomy w/ gigli saw, midfoot osteotomy w/ gigli saw.
distal femoral deformity correction w/ ex-fix and plate

Today: femoral lengthening, tibial deformity correction, femoral deformity correction.

Drew lots of angles and dangles.

I've been at the Limb Deformity course in Baltimore, unfortunately I did not get to do this stuff on real people.
Click to expand...

Yea, but aren't we having fun?!!!! My cadaver lab is tomorrow.
 
jonwill said:
Yea, but aren't we having fun?!!!! My cadaver lab is tomorrow.
Click to expand...

That was the best day, I had that day one. I peaked and then it was down hill - JK

The foot and ankle biomet was pretty good. The lectures were kept short unlike the taylor spacial frame where the lecture during the lab went on for 2 of the 4 hours.


Did you like the cadaver lab?
 
krabmas said:
That was the best day, I had that day one. I peaked and then it was down hill - JK

The foot and ankle biomet was pretty good. The lectures were kept short unlike the taylor spacial frame where the lecture during the lab went on for 2 of the 4 hours.


Did you like the cadaver lab?
Click to expand...

Yea, it was fun but I'm getting burned out. U of Maryland is pretty nice.
 
Presented at an international Orthopaedic meeting in Leeds, UK last Thursday and Friday and staying for another week for vacation so I don't have any good OR stories from the last week.
 
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