True Stories From Podiatric Residency

[jonwill]

We had a case today of a DM neuropathic ankle fx that was way underfixated at StElsewhere and went into bad Charcot valgus. We did tibiotalocalc fusion with a BioMet Phoenix IM nail, platelet concentrate, and then an OrthoFix Ilizarov style ring fixator to protect it all. A lot of fixation, but the pt is big, neuropathic, and gonna weightbear on it almost right away, so the attending wanted to hedge his bets. Our 2nd year did most of the case, and I scrubbed for awhile until I got paged out for ER and some consults. Good case, but a lot of stuff looks good on the table and doesn't end up so well on long term follow up. Time will tell... tough neuropathic salage attempt. I will try to get a clinical pic of this frame on my rounds if he stays the weekend.

Also had an adult flatfoot case and an ankle scope + stab case on the sched yesterday in addition to the usual HAV, digitals, Tailors, etc.

Interesting pre-op pic. I'd be interested to know why the prior surgeon did what they did. They may have had a good reason. I'm hoping it wasn't simply because the patient was a neuropathic DM and they were afraid to operate on them so they did some minimal procedure. I've seen quite a few DM ankle fractures that weren't fixed simply because the patient was a DM and higher risk. But as you see here, the complications of NOT fixing it or not fixing it adequately are often worse than the complications of fixing it.

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[Feli]

Interesting pre-op pic...

I thought the post op pic was kinda interesting too

Yah, I agree... hopefully it was just under-estimation of the ankle fracture injury and not timid approach due to DM skin/wound concerns. It's tough to comment unless we had all the ER xrays, clinical picture, etc. Hindsight is always 20/20, so it's tough to say...

As much as I hate refer to the "throwaway journals," SDN's own LCR and former MVP poster DrFeelgood had a good piece on DM ankle fx in PodiatryM recently... can't find the link, though. Moral of the PM article quoted a recently presented ortho poster or manuscript suggesting treating DM neuropathic ankle fx with roughly double fixation, double time NWB and protected WB, and twice as frequent clinic f/u appts that you'd use for a healthy person. Probably a good rule of thumb.

 

[krabmas]

I thought the post op pic was kinda interesting too

Yah, I agree... hopefully it was just under-estimation of the ankle fracture injury and not timid approach due to DM skin/wound concerns. It's tough to comment unless we had all the ER xrays, clinical picture, etc. Hindsight is always 20/20, so it's tough to say...

As much as I hate refer to the "throwaway journals," SDN's own LCR and former MVP poster DrFeelgood had a good piece on DM ankle fx in PodiatryM recently... can't find the link, though. Moral of the PM article quoted a recently presented ortho poster or manuscript suggesting treating DM neuropathic ankle fx with roughly double fixation, double time NWB and protected WB, and twice as frequent clinic f/u appts that you'd use for a healthy person. Probably a good rule of thumb.

Feli,

I usually agree with all of your posts but I felt the need to reply to this one.

PM and Podiatry Today are not Journals in any sense. They are magazines.

 

[krabmas]

Just got back from Eritrea, Africa from a mission trip. They have 1 ortho surgeon per million people. Did lots of cases that will hopefully change lives over there, since they depend on their feet for ambulation and lively hood.

While we were there a bus went off a cliff so we did lots of trauma cases as well.

 

[Feli]

Just got back from Eritrea, Africa from a mission trip. They have 1 ortho surgeon per million people. Did lots of cases that will hopefully change lives over there, since they depend on their feet for ambulation and lively hood.

While we were there a bus went off a cliff so we did lots of trauma cases as well.

I'd imagine that one ortho surgeon per million people does leave a ton of trauma neglected. It probably also forces the gen surg and trauma surgeons to attempt some ortho trauma procedures also... if they're not horribly inundated with their own workload? When you consider the evolution of medicine, science, economy, social structure, etc that's occured in most of the rest of the world, it's simply amazing how many light years behind most of the African countries remain.

I'm sure you saw some neat cases over there and helped out a lot of folks.

 

[jonwill]

Just got back from Eritrea, Africa from a mission trip. They have 1 ortho surgeon per million people. Did lots of cases that will hopefully change lives over there, since they depend on their feet for ambulation and lively hood.

While we were there a bus went off a cliff so we did lots of trauma cases as well.

That's freakin awesome krab!

 

[krabmas]

That's freakin awesome krab!

Awesome that the bus went off the cliff, or the mission - JK

A few of the cases:

post-polio syndrome - pantalar w/ ilizarov, T-C fusion w/ talectomy w/ tibial lengthening w/ ilizarov, PTT transfer x many

STJ fusion

Lapidus w/ no C-arm and maxi saw

5 hammertoe arthroplasty w/ derotational skin plasty x 2

Ankle fusion

pantalar w/ delta frame (it's what we had sterile)

And the trauma cases:

man vs pasta maker - complex lacerations fingers 2-5 w/ comminuted middle phalanx fx 3 and 4. Amputation of digit 3 a week later.

3 forearm bothbone fx

several hip type fractures - subtroch, fem neck...

open femoral shaft - 11yo fell out of tree trying to feed his 30 goats. In the dry season to feed the goats since there is no grass you must climb the tree and shake the braches so the leaves will fall for the goats to eat.

multiple tibial shaft fx

open reduction and pinning of thumb MCP joint

We did a total of 61 cases in 10 days.

 

[Feli]

Had a long day... I&D with hardware removal for a MRSA abscess s/p pilon ORIF, deep sewing needle removal from a heel, and then a marathon pantalar desis with internal fixation + ring fix over it all that I double scrubbed with our chief resident. The patient was a Charcot diabetic who a St Elsewhere surgeon had tried to fuse the TN and CC with just a couple staples (she obviously re-collapsed into rocker bottom foot with ulcer).

Our OR schedule also had a TAL/ankle scope, few bunions and hammertoes, I&Ds, Jones fx, SutureBridge exostosis, and some other stuff going on today.

 

[krabmas]

pt interaction with me today...

Me: when does it hurt

Pt: when I walk on it

later in the discussion


Pt: maybe it is not a weight bearing bone in my foot (her excuse to not be NWB)

Me: well, that may be true, but since you said it hurts when you walk on it, I think it is probably a weight bearing bone in your foot.

 

[jonwill]

pt interaction with me today...

Me: when does it hurt

Pt: when I walk on it

later in the discussion


Pt: maybe it is not a weight bearing bone in my foot (her excuse to not be NWB)

Me: well, that may be true, but since you said it hurts when you walk on it, I think it is probably a weight bearing bone in your foot.

That's pretty funny. My favorite part of practice has to be when patients tell you how they want to be treated.

Me: Your foot pain is coming from your foot type and particularly high arches. You need some orthotics in your shoes to control your foot and support your arches. This should relieve the pain.

Patient with insane cavus foot: Oh, I don't want to do that.

Me: Let's talk about shoe gear then.

Patient: I'm very particular about my shoes so that ain't gonna happen.

Me: Well...would you like to discuss some surgical options?

Patient: DEFINITELY NOT!

Me: I guess your feet don't hurt that bad then. Come back when they do!

Things have been going well. My patient base is growing quickly and I've been doing 2-3 cases a week. I did an ORIF ankle on Thursday and did an EHL repair on Friday (from a laceration). I've got another met fracture coming up next week. Now I just have to get my elective stuff rolling.

 

[Feli]

... I just have to get my elective stuff rolling.

That is definitely the bottom line in "the real world."^^

Yesterday, one of our young alumni did a no pay circumferential ankle ulcer VersaJet + skin graft sub followed by a no pay lateral leg peroneal deep laceration... great fun + learning for me as a resident. But at the end of the day, the elective hammertoes + clinic pts he did earlier in the week or the couple inpt wound consults he did after the trauma cases weren't nearly as fun for the residents, but they were certainly how he got paid this week.

 

[jonwill]

That is definitely the bottom line in "the real world."^^

Yesterday, one of our young alumni did a no pay circumferential ankle ulcer VersaJet + skin graft sub followed by a no pay lateral leg peroneal deep laceration... great fun + learning for me as a resident. But at the end of the day, the elective hammertoes + clinic pts he did earlier in the week or the couple inpt wound consults he did after the trauma cases weren't nearly as fun for the residents, but they were certainly how he got paid this week.

Luckily that isn't a problem I have. All of my patients are insured and the trauma actually pays pretty well. But I know that's a different story in Mo-town.

 

[Feli]

Luckily that isn't a problem I have. All of my patients are insured and the trauma actually pays pretty well. But I know that's a different story in Mo-town.

Yah, if I ended up staying here for some reason, about the only ERs I'd want to send me calls and f/u are maybe Critt and Beau-GP or Beau-Troy (...maybe).

That's cool you are in an area where the ER actually helps you. You must be suburban? I've barely ever seen an ER at a metro that's more than 50% insured pts. Or are you in some nirvana where the DPMs actually get paid for taking ER call and fracture cases like them bone doctors do?

 

[jonwill]

Yah, if I ended up staying here for some reason, about the only ERs I'd want to send me calls and f/u are maybe Critt and Beau-GP or Beau-Troy (...maybe).

That's cool you are in an area where the ER actually helps you. You must be suburban? I've barely ever seen an ER at a metro that's more than 50% insured pts. Or are you in some nirvana where the DPMs actually get paid for taking ER call and fracture cases like them bone doctors do?

I'm in a city that has three hospital entities. The level 1 trauma/county hospital is the university and that's where most of the "self pay" ends up. It is the "Detroit Receiving" of the area. My group works between the other two major hospital systems. Our offices are literally behind their hospitals and my partners are pretty well known in the area. If the ER calls one of our offices, we'll get them in that day. So they pretty much stabilize it and send it my way. Out of all of the trauma I've gotten, I've only had to go to the ER once (calc fx) which I admitted and did that night.

 

[pinipig523]

I'm in a city that has three hospital entities. The level 1 trauma/county hospital is the university and that's where most of the "self pay" ends up. It is the "Detroit Receiving" of the area. My group works between the other two major hospital systems. Our offices are literally behind their hospitals and my partners are pretty well known in the area. If the ER calls one of our offices, we'll get them in that day. So they pretty much stabilize it and send it my way. Out of all of the trauma I've gotten, I've only had to go to the ER once (calc fx) which I admitted and did that night.

So are all calcaneal fractures emergent procedures? I've seen several calcaneal fractures and they follow up as outpatient after we splint them with a post-mold and reinforce NWB.

 

[jonwill]

So are all calcaneal fractures emergent procedures? I've seen several calcaneal fractures and they follow up as outpatient after we splint them with a post-mold and reinforce NWB.

No they aren't unless you suspect compartment syndrome or they are open. I admitted him and did it that night because I wanted to do the fracture percutaneously and it is easiest to do it acutely because all the pieces move easily.

But you're correct. Most of the time, there isn't anything wrong with sending them out.

 

[krabmas]

No they aren't unless you suspect compartment syndrome or they are open. I admitted him and did it that night because I wanted to do the fracture percutaneously and it is easiest to do it acutely because all the pieces move easily.

But you're correct. Most of the time, there isn't anything wrong with sending them out.

Jonwill, as always I agree. Just wanted to add...

Sometimes, even though we wish everything had operative indications, come calc fx are treated non-op due to patient preference, medical history/morbidity..., no joint involvement...

 

[Feli]

Got to remove a metal hemi 1st MPJ implant and fuse the joint yesterday... revisional surgery is really where I feel we get to learn the most sometimes. Good case.

 

[krabmas]

Got to remove a metal hemi 1st MPJ implant and fuse the joint yesterday... revisional surgery is really where I feel we get to learn the most sometimes. Good case.

awesome.

I got to do my 3rd total ankle and achilles tendon repair yesterday.

The achilles was my patient! I think it will be a while before the excitement wears off.

 

[jonwill]

awesome.

I got to do my 3rd total ankle and achilles tendon repair yesterday.

The achilles was my patient! I think it will be a while before the excitement wears off.

Sweet! I did another ankle ORIF yesterday. I've been on call this week and got some decent trauma. I actually got a non-operative calcaneal fracture (see posts above).

 

[347932]

As a resident ten years ago, I was primary assist on kidney transplants and several ruptured Abdominal Aortic Aneurysm during my Vascular Surgery rotation. THAT was some intra op stress.

 

[347932]

I had a good week. Besides the regular stuff, I did a revisional evans (non-union) with iliac crest graft, achilles tendon rupture, lapidus, and flatfoot (gastroc recession, evans, fdl transfer).

Try to convince your attendings to try using callus distraction techniques for their Evans procedures. It eliminates the non union potential and no graft required.

 

[krabmas]

Try to convince your attendings to try using callus distraction techniques for their Evans procedures. It eliminates the non union potential and no graft required.

He is the attending

 

[347932]

He is the attending

LOL oops...

 

[jonwill]

LOL oops...

That's OK Kidsfeet. I still feel like a resident!

 

[347932]

That's OK Kidsfeet. I still feel like a resident!

LOL as do I! Always learning. Once again sir, my apologies.

 

[Feli]

Shotgun vs radius in a robbery last night... (shotgun wins)

It was a bad open fx with median nerve injury. The guy managed to live, though; he blocked the pellet load with his arm... torso and contralat shoulder only had some superficial lead. I&D, ex-fix, VAC, and cont ancef/tobra... attending said the guy will probably get a wrist fusion with graft down the line if all goes well?

 

[347932]

Shotgun vs radius in a robbery last night... (shotgun wins)

It was a bad open fx with median nerve injury. The guy managed to live, though; he blocked the pellet load with his arm... torso and contralat shoulder only had some superficial lead. I&D, ex-fix, VAC, and cont ancef/tobra... attending said the guy will probably get a wrist fusion with graft down the line if all goes well?

Study up on those gunshot/trauma cases. When I did the oral ABPS boards a few years ago, one third of the cases presented where gunshots. I hadn't seen a GSW since residency, but they decided it was important that year.

 

[jonwill]

Shotgun vs radius in a robbery last night... (shotgun wins)

It was a bad open fx with median nerve injury. The guy managed to live, though; he blocked the pellet load with his arm... torso and contralat shoulder only had some superficial lead. I&D, ex-fix, VAC, and cont ancef/tobra... attending said the guy will probably get a wrist fusion with graft down the line if all goes well?

That takes me back. I miss D town.

 

[Foot Doc]

well, I figured its been awhile so i'd better check in to let everybody know I'm still alive.

I took a job here in Louisville after finishing residency @ Jewish. Been really, really busy so far in private practice and loving every minute of it!

First case was an achilles rupture repair and i've done 20 or so since that first case in mid-july when hospital privileges were approved. So far I have done malleolar osteotomies with ocd repair, hammertoes, met orif, achilles repair, distal chevron bunion, lapidus, flat foot recon, I&D's, etc.........

Have my first calcaneus ORIF on for next friday!

 

[Feli]

...Have my first calcaneus ORIF on for next friday!

That's cool... as long as it's not OchoCinco... he's on my fantasy team.

 

[hightower]

Study up on those gunshot/trauma cases. When I did the oral ABPS boards a few years ago, one third of the cases presented where gunshots. I hadn't seen a GSW since residency, but they decided it was important that year.

Hopefully this isn't a dumb question, but if you don't do residency near a major metropolitan you may not see many (if any) gunshot wounds. When you say "study up" on those cases, are you talking about cases/scenarios out of medical texts?

 

[347932]

Hopefully this isn't a dumb question, but if you don't do residency near a major metropolitan you may not see many (if any) gunshot wounds. When you say "study up" on those cases, are you talking about cases/scenarios out of medical texts?

Yes. Study as much as you can about open fractures and wound management in acute trauma.

 

[hightower]

Yes. Study as much as you can about open fractures and wound management in acute trauma.

Thanks!

 

[janV88]

BUMP!

I know we got a few residents on this forum, let's hear your stories!

 

[Feli]

We had a pretty cool past week... ankle fx, TAL with forefoot ulcer + met head excis with TCCast, cavus recon, Kidner + TAL, a couple of SutureBridge cases, bilat de-syndacts with autografts, and the usual mix of HAV with Lapidus, Austins, etc.

This is usually a "slow" time of year surgically due to a lot of pts having new deductible and/or being snowbirds, but we're staying petty busy in the ORs. We had two different attendings each do a scheduled block of 7 cases this week.. and both blocks even finished by 5pm (nice for me since I was the one on call for late cases )

 

[Feli]

bump...

A few of the other StJ residents and I reviewed a case study of Charlie Sheen live in Detroit last night. As for "actual podiatry stuff" lately? Well, you know... ankle fractures, Lapidus, TTC Charcot desis, lat ankle lig recon, etc. I also got my first "C" ankle scope on Friday... got to microfracture an antero-lat talus OCD from an old ankle sprain.

 

[dtrack22]

Feli: "Boooo. I want a refund!"

Sheen: "I've already got your money dude."

Sounds like re-runs of Two and a Half Men would have been more entertaining...

 

[Feli]

Feli: "Boooo. I want a refund!"

Sheen: "I've already got your money dude."

Sounds like re-runs of Two and a Half Men would have been more entertaining...

Well, I was giving it 50/50 that he'd even show up... and I thought it was ok. I will give him props for trying to put on a decent show.

In any live show (esp one that was pretty unscripted, such as his), there will be hit and miss parts to it, but his monster ego and any "boo"s or other heckling definitely didn't mix. It got to be a bad, escalating cycle of the crowd "boo"ing and him insulting them in return pretty fast.

http://www.youtube.com/watch?v=qAQbPGf662c

 

[DPMer]

I scrubbed my first BKA. Which is not the big of deal but what was weird is the vascular surgeon only cut of the guys feet. Literally just above the feet. I understand why and all of that pooh, but it was weird to see such a distal BKA or should I say AAA (above ankle amputation).

Maybe it was a Symes procedure?

 

[347932]

Maybe it was a Symes procedure?

Symes procedures retain the hindfoot, STJ.

What he was likely referring to is a procedure where they use the fibula as a strut and place it within the tibia on a horizontal axis by creating a groove for the fibular fragment to rest within in the tibia, just proximal to where the ankle joint was. I believe it is said that this type of "BKA" helps preserve better WB and prosthetic placement, but I'm not a vascular surgeon, so it would be better to ask them.

 

[Foot Doc]

or a guillotine amp with plans for a later more proximal amp?

 

[Feli]

I hate when this thread tries to die... it's a good one that shows pre-pods and pod student (and residents) why they're workin so hard

...attached are pics of a case an alumni of our program did... guessin she works in a VA or military to do stuff that's this proximal, but who knows? It generated interesting academic discussions among the residents:

-would ext fix (+/- limited ORIF) have been better in terms of wound/infect/fracture blood supply?
-would IM nail have been better? (therefore ortho trauma referral?)
-shoud primary (or secondary infection-related) BKA - and 900% chance of eventual ankle desis - have been discussed with the patient pre-op (I sure would... but then again, I'm Dr. Doom on basically everything... under promise, over deliver).

In the end, a lot of stuff looks good on the table. Those darn follow up visits are a surgeon's humble pie, and a lot of people hate to eat humble pie (myself included). These neat trauma recon cases really keep us learning and thinking... but you can bet one of my partners or associates is WELCOME to all of these if they want em (I will be busy cranking out 4 Austins, a flatfoot, and a TMA in the same OR time ).

 

[emericana]

I hate when this thread tries to die... it's a good one that shows pre-pods and pod student (and residents) why they're workin so hard

...attached are pics of a case an alumni of our program did... guessin she works in a VA or military to do stuff that's this proximal, but who knows? It generated interesting academic discussions among the residents:

-would ext fix (+/- limited ORIF) have been better in terms of wound/infect/fracture blood supply?
-would IM nail have been better? (therefore ortho trauma referral?)
-shoud primary (or secondary infection-related) BKA - and 900% chance of eventual ankle desis - have been discussed with the patient pre-op (I sure would... but then again, I'm Dr. Doom on basically everything... under promise, over deliver).

In the end, a lot of stuff looks good on the table. Those darn follow up visits are a surgeon's humble pie, and a lot of people hate to eat humble pie (myself included). These neat trauma recon cases really keep us learning and thinking... but you can bet one of my partners or associates is WELCOME to all of these if they want em (I will be busy cranking out 4 Austins, a flatfoot, and a TMA in the same OR time ).

Sweet! Any more recent stories/pics? Would love to hear them. Starting at Temple this fall!

 

[RockFoot]

man this thread is awesome... come back to life!!

 

[EJL08]

I need some more inspiration! Somebody had to have done something interesting recently. I'm but a lowly pre-pod and have to live vicariously through you guys.

 

[jonwill]

I need some more inspiration! Somebody had to have done something interesting recently. I'm but a lowly pre-pod and have to live vicariously through you guys.

I had a 10 year old patient in my office last Thursday. The prior Friday, he was playing in a baseball game and slid into a base, turning his ankle. He was able to get up and "walk it off". On Saturday, his ankle was slightly sore so he wore an ankle brace while he continued the rest of the tournament. On Sunday, his ankle was a bit more sore and he began to spike fevers. By Tuesday, he couldn't walk on it very well. His mother took him to the ER where xrays were taken and he was diagnosed with an ankle sprain. He continued to spike fevers which was attributed to a virus. On Thursday, I saw him in my office and on physical exam, he had a swollen, hot ankle. He was unable to range the ankle at all because it hurt too bad and he was obviously in a ton of pain. SOMEBODY TELL ME WHAT I SHOULD DO NEXT!!!

 

[dtrack22]

Hopefully other students will contribute. Don't worry about being wrong since I will most likely make you look like a genius...

I would order an MRI. I'm thinking there was some sort of microtrauma or stress fx that was missed by the ER or just didn't present on Xray. MRI would show osseous and soft tissue defects, where a bone scan would be limited to stress fx. The spiking fevers in a child could be explained by trauma, but I would probably get a blood culture to be safe.

 

[Podophile]

Tap it!

 

[that1guyfromFL]

The skin warmth, spiking fever and increasing swelling that many days after the injury makes me think infection.


Maybe a cellulitis secondary to the trauma?


Start an antibiotic with wide coverage and run blood cultures to make sure the kid isn't becoming septic.