Escolar Documentos
Profissional Documentos
Cultura Documentos
Principles of Diagnosis
and Treatm ent
EDITORS
BRENT B. WIESEL, MD
Chief, Shoulder Service
Department of Orthopaedic Surgery
Georgetown University Hospital/MedStar Health
Washington, District of Colombia
WUDBHAV N. SANKAR, MD
Assistant Professor of Orthopaedic Surgery
Division of Orthopaedic Surgery
The Childrens Hospital of Philadelphia
Philadelphia, Pennsylvania
JOHN N. DELAHAY, MD
Professor of Orthopaedic Surgery
Department of Orthopaedic Surgery
Georgetown University Hospital/MedStar Health
Washington, District of Colombia
SAM W. WIESEL, MD
Chair and Professor of Orthopaedic Surgery
Department of Orthopaedic Surgery
Georgetown University Hospital/MedStar Health
Washington, District of Colombia
Contents
Contributors vii
Preface ix
Basic Science 1
10
11
12
13
14
15
16
17
18
19
Index 799
Contributors
JACOB N. ABLIN, MD Intern al Medicine, Sackler School of
Director of In tern ation al Cen ter for Pediatric an d Adolescen t Hip Disorders, Director, Hip Research Program , Rady
Ch ildren s Hospital, UCSD, San Diego, Californ ia
Surgery, Th e Roth m an In stitute; Associate Professor of Orth opaedic Surgery, Th om as Jefferson Un iversity Sch ool of
Medicin e, Philadelphia, Penn sylvania
DANIEL J. CLAUW, MD Professor of An esth esiology, Medicin e
Departm en t of Orth opaedic Surgery, Georgetown Un iversity Hospital, Washington, District of Colom bia
JOHN L. ESTERHAI, MD Professor, Departm en t of Orth o-
th opaedic Surgery, Hospital of th e Un iversity of Pen n sylvan ia, Ph iladelph ia, Pennsylvan ia
ROBERT M. KAY, MD Associate Professor, Departm en t of Or-
Departm en t of Orth opaedic Surgery, Georgetown Un iversity Hospital, Wash ington , District of Colom bia
ANDREW F. KUNTZ, MD Residen t, Departm ent of Or-
th opaedic Surgery, Hospital of th e Un iversity of Pen n sylvan ia, Ph iladelph ia, Pen n sylvan ia
MICHAEL K. KUO, MD Assistan t Professor, Departm en t of
Weill Corn ell Medical College; Ch ief, Metabolic Bon e Disease Service, Departm en t of Orth opaedics, Hospital for
Special Surgery, New York, New York
viii
Contributors
th opaedic Surgery, Georgetown Un iversity Hospital, Wash ington, District of Colom bia
th opaedic Surgery, University of Pen n sylvan ia, Ph iladelph ia, Pen n sylvan ia
BENJAMIN A. MCARTHUR, MD Resident, Departm ent of Or-
th opaedic Surgery, Head, Division of Sports Medicin e, Un iversity of Virginia Departm ent of Orthopaedic Surgery;
Ch arlottesville, Virginia: Team Physician , Jam es Madison
University
KAREN MYUNG, MD, PhD Assistan t Professor of Orth opaedic
Surgery, Ch ildren s Hospital Los An geles, Assistan t Professor of Orthopaedic Surgery, Departm ent of Orth opaedic
Surgery, Un iversity of South ern Californ ia Keck Sch ool of
Medicin e, Los An geles, Californ ia
CHARLES L. NELSON, MD Atten din g Orth opaedic Surgeon ;
of O rth opaedic
Surgery, Georgetown Un iversity Hospital, Wash in gton , District of Colom bia
Surgery, Un iversity of Pen n sylvan ia, Hospital of th e Un iversity of Pen nsylvan ia, Philadelphia, Pennsylvania
DAVID L. SKAGGS, MD Professor of O rth opaedic Surgery,
paedic Surgery, Weill Corn ell Medical College; Fellow, Departm en t of Orth opaedic Surgery, Hospital for Special
Surgery, New York, New York
TURNER VOSSELLER, MD Fellow, Foot an d An kle Surgery,
Deptartm en t of Orth opaedic Surgery, Georgetown Un iversity Hospital, Washin gton, District of Colom bia
BRENT B. WIESEL, MD Chief, Shoulder Service, Departm ent
th opaedic Surgery, Jefferson Medical College; Ch ief, Sh oulder an d Elbow Service, Th e Roth m an In stitute at Jefferson ,
Thom as Jefferson University Hospitals, Philadelphia, Penn sylvania
paedic Surgery, Georgetown Un iversity Hospital, Wash in gton, District of Colom bia
th opaedic Surgery, Georgetown Un iversity Hospital, Wash in gton , District of Colom bia
Preface
Th e goal of th is book is to create a compreh en sive, readable resource for orthopedic residents during the early years
of th eir train in g. We en vision Principles as a book that in tern s can read from cover to cover durin g th e course of
their PGY1 year to gain a broad base of knowledge before they start their orth opedic rotations. The individual
subspecialty chapters will again be h elpful during th eir
PGY2 an d PGY3 years as a con cise review of an en tire
subspecialty that they can read prior to starting a n ew
rotation .
Th e book is divided in to two section s. Th e gen eral prin ciples portion presen ts orth opedic basic scien ce in sufficien t
detail to prepare th e reader for th e in -train in g an d board
exam in ation s. It con tain s ch apters on th e basics of th e various m odalities com m only used for patient evaluation in
orth opedics an d th e evaluation an d treatm en t of m usculoskeletal infection, m etabolic bone disease, an d m usculoskeletal oncology. In addition, an overview of rheum atologic diseases affecting th e m usculoskeletal system an d the
prin ciples guidin g th e treatm en t of orth opedic traum a an d
sports m edicine patients are included.
In th e subspecialty section , each ch apter addresses th e
functional anatomy, patient evaluation (history, physical
exam in ation , an d im agin g), traum atic in juries, an d atraum atic con ditions for a specific region of the body. For each
diagn osis, th e typical presen tation , option s for n on oper-
Basic Science
Sectio n 1
John N. Delahay
INTRODUCTION
A thorough understanding of genetics, em bryology, and
postn atal developm en t of th e m usculoskeletal system is
needed to engage in a discussion of m usculoskeletal
an om alies. Approxim ately 5% of babies are born with
som e type of con genital defect. Many defects require a
period of growth an d developm en t before th ey becom e
apparent. An appreciation of n orm al developm ent of the
m usculoskeletal system is integral to a m ore complete
un derstan din g of th ese con gen ital defects of th e m usculoskeletal system .
O n e of th e m ost well-studied areas of m usculoskeletal
developm en t is th e physis or growth plate. A th orough un derstan din g of th is structure is essen tial for th e treatm en t of
m any pediatric orth opaedic diseases and fractures. Furth erm ore, m any of th e biologic processes th at naturally create
bon e in th e growin g skeleton are curren tly bein g explored
for m anipulation in an attempt to improve bone healing in
problem atic adult fractures.
GENETICS
Although there have been m ore than 3000 genetic disorders iden tified, very few gen es are respon sible for m usculoskeletal diseases. Most genetic diseases fall into one of
three categories. The first group consists of isolated gene
defects th at are govern ed by th e prin ciples of Men delian in heritan ce. Ch rom osom al abnorm alities, such as deletions
an d translocation, are included in the second group. Lastly,
a heterogeneous group of polygenic defects are th e result
of an in terplay between gen etic an d en viron m en tal factors.
Gen etic defects can presen t at any age from in fan cy to
adulthood. Th e prevalence of genetic defects will also vary
Th e th ird category of gen etic disease results from rearran gem en ts within a given chrom osom e. These abnorm alities can include extra chrom osom es, referred to as
trisomy, or partial or complete loss of a chrom osom e. In
addition , m osaics and translocation s can be grouped under
th is h eadin g. Many of th ese ch rom osom al abn orm alities
result in spon tan eous abortion s. It h as been estim ated th at
approxim ately 1% of live-born children have som e type of
chrom osom al aberration. Trisomy 21 (Down syndrom e)
is the m ost com m on disease in th is category with an in cidence of 1 per 700 live birth s.
men are indicated by filled squares. Asymptomatic female carriers are indicated by half-filled circles. (Reprinted with permission
from Morrissy RT, Weinstein SL. Lovell and Winters Pediatric Orthopaedics. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
ORTHOPAEDIC EMBRYOLOGY
Intramembranous and Enchondral Ossification
All bon es of the m usculoskeletal system begin as m esen chym al con den sation s from a prim ary germ layer with
m ultiple m echanical an d chem otactic factors actively influencing the cellular differen tiation. These con densations
of cells typically form bon e in on e of two ways. In tram em bran ous bon e form ation occurs with th e con den sation of
NUMBER OF
INDIVIDUALS
THRESHOLD
OF RISK
LIABILITY TO DISEASE
(GENETIC & ENVIRONMENTAL)
Figure 1.5 Normal limb rotation. A: At 48 days, the hand and foot plates face each other.
B: At 51 days, elbows are bent laterally. C: At 54 days, the soles of the feet face each other.
D: The lateral rotation of the arms and medial rotation of the legs result in caudally facing elbows and
cranially facing knees. (Reprinted with permission from Morrissy RT, Weinstein SL. Lovell and Winters
Pediatric Orthopaedics. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
Neuromuscular Development
In th e secon d week of life, th e em bryo itself is bilam in ar, th at is, ectoderm an d en doderm . At th e caudal end
of th e bilam in ar em bryo is an area referred to as th e prim itive streak, a cluster of cells that in vaginates between the
two layers of th e bilam inar em bryo. The third layer subsequen tly form ed is referred to as th e m esoderm . This
m esoderm is critical to the developm ent of th e bulk of th e
m uscular and skeletal system s. It should be rem em bered
th at th e n eural structures of th e cen tral n ervous system
are ultim ately developed from cells originatin g from the
ectoderm .
Aroun d the third week, ectoderm al induction results in
th e form ation of a n eural plate. Th e edges of th is plate curl
dorsally to form a n eural tube (Fig. 1.6). Begin n in g in th e
cen ter an d con tin uin g to each en d th is n eural tube will begin to close (Fig. 1.7). Obviously, failure to close cranially
results in an en ceph aly, an d failure to close caudally results
in spina bifida. A population of ectoderm al cells parallel to
th e closed n eural tube, referred to as n eural crest cells,
are the precursors of the dorsal root ganglia an d m uch
of th e periph eral n ervous system . Most of th e n eural tube
developm en t is guided by n otoch ordal in duction . Th e n otochord, which has been previously derived from the prim itive knob, a cellular aggregate of the bilam inar em bryo,
Neural plate
Neural fold
give rise to the m usculature of the th oracic and abdom inal cavities, as well as the rib cage (Fig. 1.8). The in tim ate proxim ity of th e m edial and interm ediate m esoderm clearly dem on strates why GU system an om alies are
th e m ost com m on associated defects in con gen ital m usculoskeletal disease. Next in frequency are cardiac anom alies,
own in g to th e fact th at th e h eart is also of m esoderm al
origin .
At about 4 weeks of em bryologic life, the paraxial
m esoderm will segm ent into blocks of cells referred to as
som ites. The som ites will n um ber between 42 and 44.
Once th e som ites have segm ented, beginning cran ially and
progressin g caudally over a 10-day period, th ey will furth er
differen tiate in to th ree cell m assesa derm atom e, a m yotom e, an d a sclerotom e, form in g skin , m uscle, an d skeleton respectively (Figs. 1.9 an d 1.10). The lim b buds will
develop from progressive differen tiation of th ese som ites.
As m en tion ed earlier, th e lim b buds are iden tifiable aroun d
th e fifth week of em bryon ic life.
Development of Joints
Neural crest
Epidermis
Neural tube
Mesodermal Differentiation
Two large m asses of m esoderm are seen on each side
of th e n eural tube an d are th us referred to as paraxial
m esoderm . Th ree distin ct areas in th is paraxial m esoderm
have been identified: (1) m edial m esoderm ultim ately will
form axial m usculature, (2) the in term ediate portion of
the paraxial m esoderm in large part develops into the genitourin ary (GU) system , an d (3) th e lateral m esoderm will
Anterior
neuropore
closing
Anterior
neuropore
Central canal
(containing amniotic fluid)
Neural tube closed
Ectoderm
1
Mesodermal
somites
2
Neural groove
Neural
fold
Notochord
Posterior
neuropore
open
Posterior
neuropore
Figure 1.7 A: At the initial stages, both anterior and posterior neuropores are open. B: Closing of
the neural tube progresses both cranially and caudally. (Reprinted with permission from Gilbert SF.
Developmental Biology. 3rd ed. Sunderland, MA: Sinauer Associates, 1991.)
physiology of th e n orm al growth plate, as well as its bioch em istry and its m echanical properties. This growth plate
is a unique anatom ic structure. It is the essential m echan ism by wh ich m am m als are able to enlarge their en doskeleton . Wh ereas lesser an im als m ust m olt an exoskeleton in an effort to grow, th e physis allows for lon gitudin al
growth of th e h igh er organ ism . It is clear, h owever, from
the beginning that this unique anatom ic structure has its
own obsolescen ce built in . Not on ly does it stop producin g
bon e, but it is in large m easure con sum ed by its own product. Durin g th e tim e it exists, th e physis, for all its un ique
an d critical importance, creates a m echan ical flaw in the
Migrating
sclerotome
cells
Dermatome
Condensation of
chondrocytes from
sclerotome cells
Myotome
Dorsal
aorta
Nephrotome of
developing kidney
Somatic
mesoderm
layer
Splanchnic
mesoderm
layer
Intraembryonic
coelom
Gut
Somatic
mesoderm
layer
Gastrulation
Rostrocaudal specification
Segmentation
Somite
Dorsoventral specification
Dorsal identity
Ventral identity
Dorsoventral differentiation
Dermamyotome
Sclerotome
Myotome
Dermatome
Anterior half
Posterior half
D
Medial sclerotome differentiation
Prospective
neural arch
Prospective
vertebral body
Prospective
pedicle
Prospective
intervertebral disc
Rib anlage
E
Chondrification
Ossification
The epiphysis is a secon dary ossification cen ter an d typically ossifies from a cen tral area, which th en grows centrifugally (Fig. 1.12). Th e epiphysis is n orm ally subjected
to compressive forces. Con versely, an apophysis is also a sec-
Notochord
Sclerotome
Myotome
Myotome
Intersegmental
arteries
Plane of
section B
Loosely
arranged
cells
Intersegmental
artery
Aorta
Myotome
Notochord
Neural tube
Condensation
of sclerotome
cells
Plane of
section D
B
Densely
packed
mesenchymal
cells
Nucleus
pulposus
Anulus
fibrosus
Myotome
Artery
Nerve
Body of
vertebra
Figure 1.10 A: Transverse section through a 4-week-old embryo. The top arrow shows the direc-
tion of growth of the neural tube and the side arrow shows the dorsolateral growth of the somite
remnant. B: Coronal section of the same-stage embryo showing the condensation of sclerotomal
cells around the notochord with loosely packed cells cranially and densely packed cells caudally.
C: A transverse section through a 5-week-old embryo depicting the condensation of sclerotome cells
around the notochord and neural tube. D: Coronal section illustrating the formation of the vertebral
body cranial and caudal halves of adjacent sclerotomes resulting in the segmental arteries crossing the bodies of the vertebrae and the spinal nerves lying between the vertebrae. (Reprinted with
permission from Moore KI, Persaus TVN. Before We Are Born. Essentials of Embryology and Birth
Defects. 4th ed. Philadelphia, PA: WB Saunders, 1993:257.)
bon e. Again , a sign ifican t am oun t of en doplasm ic reticulum h as been dem on strated in th is region . Th e top cell
in each of th e colum n s is th ough t to be th e germ in al cell
for th e longitudin al growth of the colum n below. There is
a high level of proteoglycan in this zone. Matrix vesicles
are also presen t in h igh n um bers, suggestin g th eir role in
m atrix m in eralization . O xygen ten sion levels are h igh est in
this zone due to the rich vascular supply seen here. Considerin g th e anatomy an d biochem istry of this region , the
m ajor fun ction s of th e proliferatin g zon e are cell proliferation an d m atrix production , both of wh ich are required for
lin ear growth .
Figure 1.11 Structure and blood supply of the growth plate. ([2011]. Used with permission of Elsevier. All rights reserved.)
The Metaphysis
Any discussion of th e growth plate would not be com plete with out a word about th e subjacen t m etaphysis.
within the epiphyseal cartilage. The solid arrow indicates a wellvascularized cartilage canal with a branch into the hypertrophic
cells, triggering the ossification process. (Reproduced with permission from Beaty JH, Kasser JR. Rockwood and Wilkins Fractures
in Children. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins,
2006.)
Metaphyseal bone begins just distal to the last intact transverse septum . This specific region where the calcified cartilage becom es vascularized is referred to as prim ary spon giosa bone (Fig. 1.11). O steoblasts can be identified lining
up on th e lon gitudin al bars of calcified cartilage. Assum in g
this cartilage to be calcified, the process of ossification can
begin spon tan eously. In certain m etabolic disease states,
specifically rickets, in wh ich calcification has not occurred,
ossification can n ot proceed n orm ally. As on e goes deeper
in the m etaphysis, the calcified cartilage cores of the trabeculae will be seen to disappear. At th e poin t at wh ich n o
calcified cartilage is present, the trabeculae are referred to
as secon dary spongiosa bone. Th e functions of the m etaphysis are vascular in vasion , bon e form ation , an d bon e
rem odelin g. In regard to bon e rem odelin g, resorption occurs on the internal surface of the cortical bone resulting
in cut backor funn elization of the end of the long bone.
Th is m ech an ism is exactly th e opposite of wh at on e will
see at the level of th e diaphysis.
Fin ally, two periph eral structures surroun din g th e
growth plate are n oteworthy. Th e first structure is th e ossification groove of Ranvier, wh ich is a wedge-sh aped rin g of
cells surrounding the m argins of the plate at the level of
the resting zone. This structure is felt to provide support
an d allow for latitudin al growth of the physis. The second
periph eral structure is th e perichondrial ring of La Croix. Th is
is a fibrous sleeve that m erges with the periosteum and
provides addition al m ech an ical support.
Patterns of Growth
Characteristically, long bon e growth is gen erally considered to be a lon gitudin al ph en om en on . Th e an atom y of
th e previously described physis clearly em ph asizes its lin ear
orien tation an d its predisposition to grow in th is fash ion .
However, som e latitudin al growth is essential for norm al
plate developm en t. Th is growth is accom plish ed both by
interstitial growth within the plate and appositional growth
at the periphery in the region of the groove of Ranvier. Latitudin al expansion of the physis will obviously be precluded
in areas th at are juxtaposed to the subch ondral plate once
th e subch on dral plate h as developed.
Th ere are a n um ber of region al variation s in plate
growth . Most of th e tim e th ese variation s result from m echanical lim itation to interstitial expansion. As m entioned
earlier, th e subch on dral plate is on e of th e m ajor m ech an ical factors lim itin g plate growth. Differential growth of
th e various ossification cen ters is also typical. Th e distal
h um erus is a good example of such differen tial growth.
Th e troch lea an d capitellum are in itially equal in size. Th e
ossification cen ter of th e capitellum ten ds to develop earlier
and m ore rapidly, and in doing so, it restricts its own interstitial expan sion . The trochlea does n ot appear until later
and therefore can ultim ately achieve a larger size because it
h as a longer period of in terstitial growth . Ultim ately, when
both of th ese cen ters fuse, latitudin al growth of th e distal
h um erus becom es a periph eral fun ction at th e level of the
epicon dyles.
10
progression on an gular deform ities of th e lower extrem ities. Th e in tegrity of th e periosteum acts as an oth er m ech an ical restrain t on th e plate. Because it attach es directly to
the perichondral ring of Lacroix, it will control the am oun t
of latitudin al an d lon gitudin al growth seen .
O bviously, th e vascular supply to th e plate is critical for
growth in tegrity. Any disruption or dam age to th is supply
of th e plate will clearly im pede its ability to fun ction an d
grow n orm ally.
A n um ber of system ic factors h ave also been implicated
in n orm al plate fun ction . Gen etic as well as n utrition al factors certain ly play a role in physeal m an ipulation . However,
m ost in dication s are th at h orm on al con trol is th e prim ary
regulator of plate fun ction .
Growth horm one is a peptide h orm one produced by
the pituitary glan d th at stim ulates physis activity by affectin g cellular proliferation via its m ediators, som atom edin s
an d sulfation factor. Excessive levels of th is h orm on e will
cause an anticipated growth plate widening and ultim ately
gigan tism . Sh ould th e plate be closed at th e tim e of excessive growth stim ulation, acrom egaly results. Th is condition
is typified by in creased apposition al bon e growth . O n th e
oth er h an d, deficien cy of th is h orm on e typically slows th e
plate growth . However, because th e plate ten ds to rem ain
open lon ger, th e ultim ate h eigh t is variable. Th is fin din g
suggests th at growth horm one h as no effect on plate closure, but rather a regulatory effect on the rate of proliferation an d osteogen esis.
Thyroid h orm one has a prim arily troph ic effect on
cartilage growth an d is essential to the norm al health
an d growth of cartilage. Recen tly, a syn ergistic effect with
in sulin -like growth factor h as been suggested. Excess levels of thyroid h orm on e h ave wide-ran gin g system ic effects
but relatively few m usculoskeletal m an ifestation s. Low levels of thyroid h orm on e, h owever, result in growth retardation , erosion of th e ch on droepiphysis, an d degradation of
m ucopolysacch arides.
Glucocorticoids are steroid horm ones produced by th e
adren al cortex an d sim ilarly seem to exert a troph ic effect
on cartilage. A physiologic level is required for n orm al physeal function. In the face of excessive levels, derived either
en dogen ously or exogen ously, th ere is a stun tin g effect on
the ch ondrocytes with decrease in m itotic and synthetic activity. In adequate levels of adren al steroids can also result
in stun tin g, but to a lesser degree.
Sex h orm on es, an drogen s an d estrogen s both , are
steroid h orm ones. The androgens are felt to exert their effect
in th e hypertroph ic zon e. Testosteron e seem s to stim ulate
rapid cell division, calcification, and prem ature physeal closure. Con versely, deficiency states of androgenic h orm on es
are ch aracterized by a m arked delay in physeal closure, resultin g in the typical eunuchoid body h abitus. Estrogen ,
on th e oth er h an d, apparen tly h as a m ore com plex effect
on th e plate. Som e suppressive activity on plate fun ction
has been dem on strated with excessive levels of estrogen
activity.
Plate Closure
Physiologic closure of th e growth plate is a com plex ph en om en on. Clearly, there are h orm on al as well as local factors th at m an ipulate th is process. On ce physeal growth h as
stopped, initial closure of the plate begins. The portion of
the plate that closes first and the pattern of closure vary
from bone to bon e. Ultim ately the growth plate, as we kn ow
it, disappears, and the m etaphysis fuses to the secondary
ossification cen ter.
Fem ales close th eir physes earlier th an m ales, probably
due to estrogen s, wh ich accelerate cartilage replacem en t
an d osseous m aturation . In any event, the process begins
with th e form ation of an ossified bridge between th e epiph ysis and the m etaphysis. It ends with a complete disappearan ce of the cartilaginous physis. As m entioned previously,
the location of the initial bridge in the transverse plane of
the plate varies from bone to bone.
RECOMMENDED READINGS
Ballock RT, OKeefe RJ. Current con cepts review: th e biology of th e
growth plate. JBJS Am 2003;85-A:715 726.
Day TF, Yang Y. Wnt and hedgehog signaling pathways in bone developm ent. JBJS Am 2008;90:19 24.
Dietz FR, Math ews KD. Current concepts review: update of the gen etic bases of disorders with orthopaedic m anifestation s. JBJS Am
1996;78-A:1583 1598.
Sectio n 2
11
John N. Delahay
INTRODUCTION
Cartilage and bon e are th e basic buildin g blocks of th e
m usculoskeletal system . This ch apter describes the cellular
composition , m icroscopic structure, and basic physiology
of th ese im portan t tissues.
CARTILAGE
Cartilage is a specialized, fibrous con nective tissue. Its function varies on the basis of its histologic type. Th ere are
essen tially th ree h istologic types of cartilage. In addition ,
the growth apparatus of the skeleton includes physeal and
epiphyseal cartilage, wh ich are varian ts of th ese basic subtypes. Table 1.1 shows th e composition of the various types
of cartilage.
Types of Cartilage
Hyaline cartilage: This tissue covers the ends of lon g
bon es, form in g th eir articular surfaces. Hyalin e cartilage is importan t for its ability to resist compressive
forces and provide a relatively frictionless surface for
sm ooth joint m otion .
Fibrocartilage: The m atrix of fibrocartilage is h igh in collagen fibers. Th ese fibers ten d to be visible by ligh t
m icroscopy. Th e m en isci, th e an n ulus fibrosus, an d
the symphysis pubis are largely fibrocartilage. Biom ech an ically, fibrocartilage is design ed to resist ten sile
load.
Elastic cartilage: Elastic cartilage is composed prim arily
of elastic fibers. It is foun d in th e extern al ear, th e
epiglottis, an d th e tip of th e n ose. Elastic cartilage
has a m oderate ability to resist tensile load, but it
also allows for som e con trolled deform ation .
Articular Cartilage
From an orth opaedic stan dpoin t, th e m ost im portan t h istologic type of cartilage is hyalin e cartilage. It is a very tough ,
resilien t, firm m aterial th at allows for alm ost friction less
m otion of the joints. The average thickness of th e articular
surface is between 2 an d 4 m m , with som e surfaces bein g
as thick as 7 m m . Norm al adult hum an articular cartilage
is typically described as being divided in to four histologic
zon es (Fig. 1.13).
Histologic Zones
Tangential (Gliding) Zone
Th e tan gen tial zon e is th e m ost superficial zon e of flatten ed
cells. Collagen fibers are arran ged parallel to th e join t surface an d h elp lim it sh ear forces.
Transitional (Intermediate) Zone
Th e cells in th is zon e are roun d or ovoid an d are ran dom ly
distributed th rough out th e m atrix in th is region . Th ese cells
m anifest sm all m em brane processes, which are noted to
exten d in to th e m atrix. Th ere is a h igh er level of m etabolic
activity in this zone.
Radial Zone
Th e cells in th is zon e are arran ged perpen dicular to th e
articular surface. Mem brane processes are sim ilarly noted
in this region and interconnect th e cells. In addition,
glycogen -contain ing storage granules can be foun d in these
cells. Th is zon e con tain s th e h igh est con ten t of proteoglycan s an d th e lowest con ten t of water.
Calcified Zone
Sm all irregular cells with pyknotic nuclei are found in lacun ae surrounded by h uge am oun ts of hydroxyapatite crystal.
Tidemark
Th is is a wavy basoph ilic lin e th at appears wh en th e growth
plate closes. Th is lin e is seen to be in terposed between th e
radial zon e an d th e calcified zon e. No blood vessels can be
seen to cross this line in norm al articular cartilage.
Lamina Splendens
Th is surface layer con sists of tigh tly packed collagen bun dles tan gen tial to th e surface an d sligh tly subjacen t to it.
It is felt th at th is m aterial causes surface un dulation s seen
in articular cartilage and represen ts part of the complex
lubricating system .
12
TABLE 1.1
Water (%)
Collagen (%)
GAG
Elastin
Other
72
81
74
71
66
37
78
53
18
15
2
12
0.6
19
16
48
19
16
Includes monocollagen proteins, calcium phosphorous, other ions, and macromolecules such as DNA
and RNA.
Reprinted with permission from Wiesel SW, Delahay JN. Principles of Orthopaedic Medicine and Surgery.
Philadelphia, PA: Saunders; 2001.
Th e th ird m atrix con stituen t is a complex proteoglycan m acrom olecule, referred to as aggrecan (Fig. 1.14).
Th is m olecule con sists of a large protein core to which
are attach ed upwards of 100 ch on droitin sulfate m olecules
an d 40 to 50 keratan sulfate ch ain s. Th ese substan ces
are polysacch aride m olecules an d are un ique to articular
cartilage. The polysaccharide m olecules, specifically the
ch on droitin an d keratin sulfate, are attach ed rough ly perpen dicular to th e protein core, wh ich , in turn , is attach ed to
a cen tral filam en tous core of hyaluron ic acid via a lin k protein . Th e distribution of th e aggrecan m olecules is n ot h om ogen eous. Th e h igh est con cen tration s of th ese m olecules
can be foun d in the perilacunar areas, whereas their concentrations seem to be less in the superficial zones. Sim ilarly, based on th e age, th e location , an d th e disease state,
there is a variation in the am oun t of chondroitin-4-sulfate,
ch on droitin -6-sulfate, an d keratan sulfate. Th e im portan ce,
h owever, of these m acrom olecules rem ains unquestioned.
A
Figure 1.13 Cartilage morphology: (A) superficial layer collagen stains red with eosin; intermediate layer proteoglycan stains bluish with hematoxylin. The basal layer with increasing collagen,
binding the cartilage to the bone and stains predominantly red with eosin. The subchondral bone
below, primarily collagen and mineral, stains densely red. (B) Diagram on right outlines the corresponding zones and cellular morphology. (Reprinted with permission from Damron T. Orthopaedic
Surgery Essentials. Oncology and Basic Science. Philadelphia, PA: Lippincott Williams & Wilkins, 2008.)
TABLE 1.2
Cells
95
Matrix
Water
Mineral
Organic
Collagen
Proteoglycan
Protein
5
70
30
60
25
15
Aggrecan
(CS/KS)
Link protein
13
HA
Decorin (DS)
Lumican (KS)
or
Fibromodulin (KS)
Biglycan (DS)
Figure 1.14 Cartilage proteoglycans. Aggrecan is the major aggregating proteoglycan (25% of dry
weight): it is associated with compression and linked to hyaluronic acid (HA). The other proteoglycans
are nonaggregating and associate with and stabilize fibrils. (Reprinted with permission from Damron
T. Orthopaedic Surgery Essentials. Oncology and Basic Science. Philadelphia, PA: Lippincott Williams
& Wilkins, 2008.)
14
H2 O
Synovial fluid
Compression
Bone
Requirements:
cartilage is in equilibrium, with the swelling pressure of the proteoglycan balanced by the tensile force in the collagen fibril. With
compression, water is squeezed out of the cartilage and a new equilibrium is reached, with an increased swelling pressure of the proteoglycan balancing the applied compression. When the compression is removed, water is drawn in and the former steady state is
achieved. (Reprinted with permission from Damron T. Orthopaedic
Surgery Essentials. Oncology and Basic Science. Philadelphia, PA:
Lippincott Williams & Wilkins, 2008.)
Pathologic Changes
Aging
Th e ch on drocytes in th e agin g articular surface ten d to in crease in size, in crease their content of lytic en zym es, and
Osteoarthritis
Both biom echan ical an d bioch em ical m ech an ism s are
seen in the degradation of cartilage leadin g to osteoarthritis. Three overlapping stages can be seen: cartilage m atrix
dam age, ch on drocyte respon se to tissue dam age, an d th e
declin e of th e ch on drocyte syn th etic respon se an d progressive loss of tissue.
With th e disruption of th e m atrix, th ere is a con com itan t
increase in the water content. There is a decrease in proteoglycan aggregation and aggrecan concen tration. Decreases
in length of glycosam inoglycan chain s are also seen. Th e
collagen con ten t ten ds to rem ain relatively con stan t. Th ere
are generally som e distribution changes of collagen between the various layers. Chondrocytes detect tissue dam age and release m ediators th at result in both anabolic an d
catabolic alteration s in cartilage m etabolism . Early, th ere
is an increased rate of DNA synthesis and cell replication.
Th ere is an in creased rate of protein an d glycosam in oglycan syn th esis. Ultim ately, th e en tire reparative effort fails,
and at this point, water content, glycosam in oglycan conten t, an d, to a lesser degree, collagen con ten t gradually decrease. As th ese ch an ges occur, th e m ech an ical properties
of th e articular surface suffer an d m ech an ical failure of th e
cartilage is im m in en t (Fig. 1.16).
15
Fissures
Safranin O
staining change
Fibrillation
Cartilage
loss
Tidemark
Subchondral
A bony end plate
Calcified
cartilage
cartilage removed at surgery. (B) A high-power magnification of surface fibrillation showing the vertical cleft formation and widespread large, necrotic regions of the tissue devoid of cells. (Reprinted with
permission from Buckwalter JA, Einhorn TA, Simon SR. Orthopaedic Basic Science: Biology and Biomechanics of the Musculoskeletal System. 2nd ed. Rosemont, IL: American Academy of Orthopaedic
Surgeons, 2000.)
BONE
Bone is a connective tissue that serves m ajor roles as a
structural support for the m usculoskeletal system an d as
a dyn am ic reservoir for calcium . Th is latter fun ction is essen tial in the m aintenan ce of n orm al skeletal h om eostasis as well as calcium an d phosph ate m etabolism . Bon e is
in a constant state of flux between con tinual bon e form ation and bone resorption; the processes are norm ally finely
balan ced. Th e balan ce between resorption an d form ation
is con trolled by a n um ber of local and system ic factors. The
alteration in any of th ese system s will clearly affect the way
in which the norm al bone turnover is regulated.
ran dom ly and loosely arranged. The cells are large and irregular an d are located in very rudim en tary lacun ae. Wh ile
com m only seen in the fetus an d prepubertal child, after
growth completion, woven or im m ature bone is not seen
except in th e presen ce of path ologic states. In th ese situation s, th e presen ce of woven bon e in dicates h igh rates of
bon e turn over.
In th e adult skeleton , all th e bon e presen t is lam ellar
bon e. In can cellous bon e, th e lam ellar bon e is con figured
in a very loose h on eycom b with few blood vessels en terin g
the bone surface of the trabeculae. Cortical bone (haversian bon e), on th e oth er hand, is a very h ighly ordered,
geom etrically arranged structure. The basic unit of cortical
bon e is th e osteon or Haversian system th at is built aroun d
a cen tral capillary can al. Th is can al is surroun ded by layers
of m in eralized bon e m atrix. Th e m atrix collagen in each
successive layer has a different orientation (Fig. 1.17), givin g th e bon e ply stren gth . Th e osteocytes are located in
lacun ae, an d th e cellular processes radiate from th e lacun ae
in sm all ch an n els called can aliculi (Fig. 1.18).
permission from Gamble JG. The Muscoloskeletal System: Physiologic Basics. New York, NY: Raven Press, 1988.)
16
Epiphysis
Cartilage
Trabecular Bone
Medullary
(marrow)
cavity
Trabeculae
Osteoclast
Osteoblasts
Osteocytes
Cortical
(compact)
bone
Capillaries in
haversian and
Volkmann's
canals
Concentric
lamellae
Periosteum
Capillaries in
haversian
canals
Capillary in
Volkmann's
Canal
Interstitial
lamellae
Osteocyte
Circumferential subperiosteal lamellae
In any given section of haversian bon e, th ere are m ultiple osteon al system s. Between osteon al system s, th ere is
additional lam ellar bone filing the void. These lam ellae
are referred to as interstitial lam ellae. In addition, surroun din g th e wh ole cortex itself is a layer of lam ellar bon e,
referred to as th e outer circum feren tial lam ellae.
Bone Circulation
Bone has a vascular flow accoun ting for 8% of th e cardiac output in th e n orm al restin g state. Most of th e cells
in adult bon e are with in 0.1 m m of a sm all blood vessel.
O n a m acroscopic level, th e blood vessel en ters th e bon e
typically th rough th e n utrien t foram en (Fig. 1.19). O n ce in teriorized, th e blood vessels arborize exten sively th rough
the m edullary canal an d periphery to the periosteum . In
addition , blood vessels supplyin g th e periosteum arborize
over th e surface of th e bon e. Th e n utrien t artery system
is a h igh -pressure system , wh ereas th e periosteal system is
a low-pressure system with resultant centrifugal flow. Th is
reverses in th e settin g of disruption of th e en dosteal system . Periosteal blood supply is adequate to feed th e outer
third of th e cortex, whereas the in terosseous or m edullary
supply carries the in n er two-thirds of the cortex.
Bone Cells
Bone cells have th e usual cellular structure and cellular organ elles. In bon e, th ere are several differen t cell lin es. O n e
17
Attached muscle
Periosteal
capillaries
Interfascicular venules
Cortical capillaries
Endosteal capillaries
Medullary
sinusoids
Medullary
artery
Central
venous sinus
Articular
cartilage
End-arterial terminals
Metaphyseal arteries and
terminals of the medullary
arterial system
Principal nutrient
artery and vein
Medullary sinusoids
V
V
V
or reversal lin e. Th is h istologic m ark em ph asizes th e con tin uously reciprocatin g bon e-form in g an d bon e-resorbin g
activity essen tial for n orm al skeletal h om eostasis. Th e
average cem ent line is approxim ately 1 m in width . It
is easily stain ed with th e usual tech n iques because of its
bioch em ical differen ces with th e surroun din g m atrix.
18
tron (B) photomicrographs of osteoblasts. (Reprinted with permission from Buckwalter JA, Einhorn
TA, Simon SR. Orthopaedic Basic Science: Biology and Biomechanics of the Musculoskeletal
System. 2nd ed. Rosemont, IL:
American Academy of Orthopaedic
Surgeons, 2000.)
Th ere are n um erous types of collagen , all of wh ich preserve its ch aracteristic triple h elical structure. Th ose m ost
importan t to th e m usculoskeletal system are type I collagen, wh ich is seen in bon e, skin , ten don , an d blood vessel wall, and type II collagen, which is seen in articular
cartilage an d th e n ucleus pulposus. In vestigation s in to
collagen polym orph ism an d th e m olecular bases are actively ongoing. Num erous collagen dysplastic diseases, as
well as th eir gen etic defects, con tin ue to be elucidated
(Table 1.4).
TABLE 1.3
Percentage
Solids
92%
Water
8%
Solid composition
Mineral phase
Organic phase
65%
35%
60%
40%
95%
3%
2%
TABLE 1.4
Defect
EhlersDanlos syndrome
Types IIII
Type IV
Type VI
Type VII
Type IX
Fibrillogenesis defects
Decreased type III collagen
Lysyl hydroxylase
Persistence of N-propeptide
Defective cross-linking
Marfan syndrome
Osteogenesis imperfecta
Type I
Type II
Type III
Menkes syndrome
Mineralization
Th e process of m in eralization occurs in two distin ct ph ases:
initiation followed by proliferation or accretion. The process of initiation requires a com bin ation of even ts. Specifically, in crease in the local concentration of precipitatin g
ions, followed by exposure of th ose ion s to m in eral nucleators, begins the propagation process. Inhibitors and reg-
19
Bone Resorption
Th e process of bon e form ation clearly appears to be m ore
com plex th an th at of bon e resorption . Th is process in volves
th e hydrolysis of collagen an d th e dissolution of bon e m in eral. It is well docum en ted th at th e osteoclast m ust sim ultan eously do both . Th ere is n o m ech an ism in place for th e
sim ple dissolution of bone m ineral, leaving unm in eralized
osteoid. As described earlier, th e osteoclast is th e critical cell
for the resorption of bone. The brush border of this m ultinuclear cell is always in con tact with th e bon e th at is actively
bein g resorbed. Electron m icrograph s of th ese cells dem on strate an in creased n um ber of m itochondria adjacent to the
brush border, suggestin g th eir fun ction in th e tran scellular
transport of calcium ion . In addition, n um erous lysosom es
are identified in this area, which seem s appropriate, considerin g th e fact th at th ese organelles contain num erous
hydrolytic en zym es.
Th e process is th ough t to be in itiated by th e lysosom al
degradation of bon e collagen . On ce th e in itial degradation
begin s, fragm en ts of th e disrupted collagen are taken up
by th e cell an d are furth er hydrolyzed. Collagenase cleaves
tropocollagen into two m ajor fragm ents. Parathyroid horm one seem s to directly increase the local con centration of
collagen ase en zym e. Con siderin g th e role of parathyroid
20
Bone Remodeling
Th e rem oval of bon e an d its subsequen t redeposition are
an on goin g process. Th e process is som ewh at age depen den t. Approxim ately 80% of total skeletal m ass is cortical
bon e, an d approxim ately 20% of skeletal m ass is can cellous
bon e. In th e youn g skeleton , turn over rates can be as h igh
as 50% per year in certain diaphyseal bon es. With agin g,
this num ber decreases to 2% to 3% per year. The process of
resorption begin s with a wave of osteoclastic activity in th e
form of cutting cones. These osteoclastic cuttin g heads re-
Sectio n 3
RECOMMENDED READINGS
Buckwalter JA, Glim ch er MJ, Cooper RR, Recker R. Instruction al course
lecture: bone biology. Part I: structure, blood supply, cells, m atrix,
and m ineralization . J Bone Joint Surg Am. 1995;77:1256 1275.
Buckwalter JA, Glim ch er MJ, Cooper RR, Recker R. Instruction al course
lecture: bone biology. Part II: form , m odeling, rem odeling, and
regulation of cell function. J Bone Joint Surg Am. 1995;77:1276
1289.
ODriscoll SW. Curren t con cept review: th e h ealin g an d regen eration
of articular cartilage. J Bone Joint Surg Am. 1998;80-A(12):1796
1812.
John N. Delahay
INTRODUCTION
Th e study of m ech an ics is critical to un derstan din g of th e
prin ciples of orth opaedic surgery, in term s of both
the norm al functionin g of the m usculoskeletal system and
the aberrant behavior due to alterations of the m echanical environm en t. Th e study of biom aterials is also an integral part of th e field in asm uch as m any im plan ts are used
in th e m an agem en t of m usculoskeletal affliction s. An un derstan din g of th ese im plan ts an d th e properties of th e
m aterial from wh ich th ey are m ade is critical to an appreciation of their use. The purpose of this chapter is to assist
the reader in un derstanding th e basic principles of biom ech an ics an d biom aterials.
BIOMECHANICS
Forces
A force is simply defined as a push or pull and technically
is on e of th ree types.
1. Tensile force, which tends to pull objects apart
2. Compressive force, wh ich ten ds to push objects togeth er
3. Sh earin g force, wh ich ten ds to m ake on e part of an object
slide over an im m ediately adjacen t part.
Forces can act separately or in com bin ation with on e
an oth er. It is importan t to un derstan d th at forces are essen tially vector quantities. Th at is, they h ave a m agn itude,
a lin e of application, a direction or sense, and a point of ap-
F quad
21
F pat
F reaction
F pat
F quad
F reaction
B + C (downward forces) = A (upward force). (Reprinted with permission from Le Veau B. Williams and Lissner: Biomechanics of Human Motion. Philadelphia, PA: Saunders, 1977.)
Th e form ula for force is F = m a (m ass acceleration), wh ich allows on e to defin e force in term s of any un it
desired. Th e stan dard force un it is th e Newton , wh ich is defin ed as th e force n eeded to accelerate 1 kg of m ass 1 m / s2 .
In ertia is th e resistin g force th at ten ds to keep th e 1 kg of
m ass in its existin g state of m otion. Th e term weight represents a special form of force, specifically that which results
from gravity. The force with wh ich a given m ass is attracted
toward th e cen ter of a gravitation al body is represen ted by
its weight. Unfortunately, the term kilogram is widely used
to in dicate weigh t an d m ass. Th erefore, th e use of th at term
creates confusion as to the force. The term Newton is th e
preferred term to in dicate force.
22
8
Yield point
Ultimate
strength
6
Force (N)
Max force
5
X
Breaking
point
Stress
3
2
Stiffness
Failure
Elastic zone
1
0
10
12
Displacement (mm)
a linear, elastic structure. (Reprinted with permission from Damron TA, Morris CD, Tornetta P, et al. Oncology and Basic Science.
Philadelphia, PA: Lippincott Williams & Wilkins, 2007.)
Strain
Plastic
strain
deformation
StressStrain Curve
Wh en an elastic m aterial is subjected to an in creasin g ten sile stress th at carries the m aterial beyond the elastic lim it,
a stressstrain curve can be plotted (Fig. 1.26). In considerin g th is curve, th e lin e between zero an d th e yield poin t
is straight, sh owin g th at stress is proportion al to strain for
sm all strains in accordan ce with Hookes law. A specim en
will exh ibit lin ear elastic beh avior up to a certain lim it,
wh ich is referred to as th e yield poin t. Beyon d th e yield
poin t stress is n o lon ger proportion al to strain , an d th e
deform in g object is n o lon ger capable of regain in g its original length when the disturbing force is rem oved. If the
force is rem oved beyond the yield poin t, the strain retraces
the broken line back to the baseline and the object is left
with perm an en t deform ation . Th e importan t features of
this curve are as follows:
Yield point is th e stress at wh ich m arked in crease in deform ation occurs without an in crease in load.
Ultimate tensile strength (UTS) is the highest point on the
curve. Th is is th e m axim um apparen t stress th at th e
m aterial can with stand. UTS is frequently referred to
as the strength of th e m aterial.
Elastic region is th e portion of th e curve from zero to th e
yield poin t. This portion of the curve is typically linear. It is with in th is portion th at stress is proportion al
to strain and Hookes law is valid.
Plastic region is the portion beyond the yield poin t where
the deform ing strain is not proportion al to the applied stress.
Modulus of Elasticity is represented by the slope of the
line in the elastic portion. The m odulus is also a m aterial property. Th e h igh er th e n um ber, th e greater
the hardn ess of the m aterial. Essentially, this m odulus in dicates th e poun ds per square in ch (psi) of
Loading
Forces can load an object in a n um ber of ways. Th e object
frequently used to m odel loading m ech anism s is a solid
bar of m aterial or a beam . Th is bar of m aterial can be used
to compare th e ch an ges th at are seen as various loads are
applied and as the direction of these loads is altered. Tensile koading results from a force applied alon g th e lon g axis
of th e bar, stretch in g th e bar an d causin g any given crosssection al area to decrease in size. Compressive loading con versely will ten d to sh orten th e bar an d will ten d to in crease
any given cross-section al area. Th e specific dim en sion s of
the chan ge can be determ ined usin g Poissons ratio.
Bending is actually a form of composite loading. Usin g
the m odel of a cantilever beam in which the m aterial is
fixed at on e en d an d loaded at th e oth er, isolated loadin g
pattern s can be appreciated as th e beam is ben t. On th e
convex side of bendin g, tensile stresses are generated and
ten sile strain is observed. On th e opposite, or con cave, side
of th e ben d, compressive strain is n oted, resultin g from
compressive stresses generated. Located in the center of the
beam is a n eutral plan e, wh ere th e stresses are zero. Th e
prin ciples are applicable to th e failure of lon g bon es. Wh en
subjected to bending loads, the bones beh ave m uch like a
cantilever beam , that is, tensile stress on the convex side
an d compressive stress on th e con cave side.
The way in which th e m aterial is distributed over the
cross section in any beam of m aterial will alter the loading
pattern . An im portan t property, th e area m om en t of in ertia,
defin es th is m aterial distribution to ben din g of a structure
un der static loadin g.
Torsional loading results wh en a torque is applied to a
cylinder of m aterial. In doing so, stresses are created with in
this cylinder. Th e polar moment of inertia is that property of
the cross-sectional area of a cylindrical structure th at is a
m easure of the distribution of th e m aterial about an axis
perpen dicular to th e cross section (Fig. 1.27). For example,
the distribution of the m aterial at greater distances from
this central axis tends to improve the torsional rigidity of
the cylinder in question. The polar m om ent of inertia can
dram atically affect torsion al loadin g an d, as such , plays an
important role in the fracture patterns seen in long bones.
For example, th e polar m om en t in th e proxim al tibia is
greater th an in th e distal tibia. Th erefore, torsion al failure
is predictably m ore likely to occur distally, and clinically,
that is the case.
Cross-sectional shape
Square
23
Polar moment of
inertia (J)
0.141 h4
h
h
Solid rod
Thick-walled
tube
r 4/2
ri
ro
(r o4 r i4)/2
r 3t/2
t
Thin-walled
tube
24
Viscoelasticity
Many n on biologic m aterials beh ave in a purely elastic m an ner. Th at is, the stress and strain are linearly proportional
an d con stan t. Most of th e m etals an d ceram ics th at are
used in orth opaedics beh ave in a classically elastic fash ion .
Polym ers, on the other hand, behave differen tly. Polym ers
sh ow a degree of rate depen dence. That is, the stress developed depen ds n ot on ly on th e strain but also on th e tim e
taken to reach th at strain . Th is beh avior of rate depen den ce
is referred to as viscoelasticity.
For a viscoelastic m aterial, th e stress developed depen ds
on th e strain an d th e tim e, th at is, th e stressstrain curve can
be altered by ch an gin g th e strain rate. Th e m odel frequen tly
used to dem on strate biologic viscoelastic beh avior is th e
earlobe (Fig. 1.28).
Using this curve as a reference one can identify th ree
ph en om en a th at are typical of a viscoelastic m aterial.
Damping
Th is ph en om en on is explain ed by th e syrin ge in wh ich th e
resistan ce or force required to m ove th e plun ger in to th e
syrin ge increases as the rate of m ovem ent of the plunger
in creases. Th is property of a m aterial, offerin g greater resistan ce as th e speed is in creased, is called dam pin g.
Creep
Followin g th e sudden application of a given load, th ere is
an in itial deform ation , followed by a subsequen t addition al
deform ation , wh ich occurs as a fun ction of tim e un der th e
sam e in itial load. For exam ple, we lose som e h eigh t durin g
the course of the day. This loss of height is due to creep
of th e in tervertebral disks. Slowly over tim e, th ey th in
down ; th e n et effect wh en sum m ated is loss of h eigh t.
Relaxation
Relaxation describes a decrease in stress within a deform ed
structure over tim e, wh en the deform ation is held con stant.
Wh en a Harrin gton rod is used on th e con cave side of a
scoliotic curve to straighten th e spin e, there is an im m ediate
tightening of th e ligam entous structures on the concavity of
the curve. The stresses within th ose ligam entous structures
lessen with tim e.
Collagenous Tissues
Ligam ent and tendon are essentially passive structures and
inh erently are not respon sible for active m otion. They are
composed of three fiber types: collagen, elastic fibers, an d
reticular fibers. Both ligam en t an d ten don fun ction prim arily in tension. Their m echanical properties are a function of th e orientation of the fibers, the m aterial properties
of th e fibers, an d th e relative proportion of collagen to
elastin .
Structurally, th e direction of th e fibers varies between
the tendon and the ligam ent. In tendon, the collagen bundles are parallel, as on e would expect, m akin g th em th e
ideal tissue to withstand high tensile load. Ligam ent m ust
function throughout the full range of a given joint. Therefore, the fiber orien tation m ust be far m ore diverse. Typically, nonparallel arrays of collagen fibers are seen. While
ligam ents, like tendons, are prim arily composed of collagen fibers, th ey con tain a m uch larger portion of elastic
fibers. Th e properties of th e two fibers are som ewh at different. Collagen is a ductile m aterial, showing a stressstrain
curve sim ilar to that of bone. The elastic fibers show significan t deform ation or strain with relatively m inim ally applied load, but on ce failure occurs, it occurs quickly.
Th e size an d sh ape of a ligam en t are critical issues in
its behavior. As one would expect, the larger the crosssection al area, th e stronger the ligam en t. The speed of loading, as is the case with other viscoelastic biologic tissues,
also plays a role in ligam ent failure. The anterior cruciate ligam ent (ACL) has been shown to function m uch like
bon e in th at, as th e loadin g rate in creases, th e ligam en t is
able to store m ore energy prior to failure. Unfortunately,
wh en th e ligam en t does fail at th ese h igh rates, it ten ds
to be with in th e substan ce of th e ligam en t with disastrous
con sequen ces. At lower loading rates, the bony insertion
of th e ligam en t is m ore vuln erable an d th erefore th e tibial
spine avulsion is m ore likely. This data suggest that with
an increase in loading rate, th e strength of the bone increases m ore than the strength of the ligam ent. Hence, the
ligam ent failure occurs at h igh er loading rates.
25
TABLE 1.5
Metals
In orth opaedic surgery, essen tially, th ree m etallic alloys are
employed for im plan t fabrication : (a) stain less steel, (b)
chrom e-cobalt, and (c) titan ium . Stain less steel is a m ixture
of prim arily iron an d n ickel. It h as th e lowest yield stren gth
of th e th ree alloys. However, its ben efit is a lon g plastic
region of th e stressstrain curve, m akin g it the m ost ductile
of th e th ree m aterials. Th erefore, it is able to absorb large
am ounts of strain energy prior to failure (Table 1.5). Most
fracture fixation implants are fabricated from stainless steel.
Ch rom ecobalt alloy has the highest UTS, and it is
th erefore th e stron gest. It also h as th e h igh est m odulus
of elasticity, m akin g it th e stiffest of th e th ree m aterials
(Table 1.6).
Titan ium -based alloys in clude alum in um an d van adium to h arden th e m aterial. Th ese alloys h ave excellen t
corrosion resistan ce an d good fatigue properties (Table
1.7). However, wear h as been a sign ifican t problem . Th eir
m odulus is the lowest of th e three alloys. Therefore, m any
suggest th at these are th e best for implan t application s, because th eir m odulus is closest to th at of bon e. However,
it is importan t to realize that m odulus values of n one of
th e th ree are even close to th e m odulus value of bon e. In
addition , their UTS is below that of ch rom e-cobalt, despite
th e fact th at th eir yield stren gth is som ewh at h igh er. Additionally, their ability to deform plastically is lim ited.
Th e ch oice of a m etal for a given application h as h istorically been som ewhat idiosyn cratic. Dependin g on the
application, th e cost, the surgeons prejudice, and other
factors, differen t m etals h ave been ch osen over th e years.
26
TABLE 1.6
Linear
Branched
Disadvantages
Galvanic corrosion to stainless steel
Concerns regarding nickel content
Cobalt and chromium ion release
High elastic modulus
Expensive
Difficult to process
Reprinted with permission from Damron TA, Morris CD, Tornetta P, et al.
Oncology and Basic Science. Philadelphia, PA: Lippincott Williams &
Wilkins, 2007.
Crosslinked
Figure 1.29 Polymer chain arrangements. (Reprinted with permission from Damron TA, Morris CD, Tornetta P, et al. Oncology
and Basic Science. Philadelphia, PA: Lippincott Williams & Wilkins,
2007.)
Polymers
Ultra High Molecular Weight Polyethylene
At th e present tim e, the polym er of ch oice in the fabrication of im plan t com pon en ts is ultra h igh m olecular weigh t
polyethylen e (UHMWPE), wh ich is essen tially a lon g-ch ain
threadlike m olecule of very high m olecular weight chains
of varyin g len gh ts (Fig. 1.29). Th ese ch ain s are m esom orph ic, in th at th ey h ave regular atom ic arran gem en ts in som e
direction s, but n ot in oth ers. As on e would expect, th e polym ers get stron ger as th e ch ain len gth in creases. Stren gth
can be improved by increasing the cross-lin king. Polyethylen e itself is a wh ole class of compoun ds, wh ich differ by
m olecular weigh t, bran ch in g, den sity, an d capacity for crystallization . In gen eral, th e h igh er th e m olecular weigh t, th e
higher the crystallinity, and th e harder th e product. Th e m ech an ical properties depen d on th e m olecular weigh t, th e
TABLE 1.7
Polymethyl Methacrylate
Polym ethyl m eth acrylate (PMM) has frequently been referred to as cem ent and is frequently used to secure orthopaedic implants. It is essentially a luting agent, which
creates a m echanical interlocking bond between adjacent
surfaces. A glueor adhesive, on the other h and, creates a
ch em ical bond between th e surfaces. PMM is supplied in
the form of a white powder, which consists of sm all balls of
PMM polym er, an d a vial of m on om er th at con tain s a stabilizer to preven t polym erization un til after m ixin g. Wh en
the m onom er is m ixed with the polym er, benzoyl peroxide catalyzes th e process of polym erization. This particular
polym eric m aterial is a th erm osettin g resin . Th e polym erization occurs in the presence of heat. However, once th e
m aterial has set, no am ount of heating can reverse its configuration . Th e sin gle m ost importan t factor in th e settin g
tim e of PMM is the am bient temperature of th e room . The
cooler the room , the longer the setting tim e. In addition,
the type of m ixing, the rate of m ixing, and th e patients
body tem perature all will alter th e rate of settin g.
Implant Failure
A n um ber of m ech an ism s can cause th e failure of a given
implant. Metal, plastics, and cem ent are all vulnerable to
Third bo dy
Abras ive
Adhe s io n
Fatig ue
Figure 1.30 Examples of material wear. (Reprinted with permission from Damron TA, Morris CD, Tornetta P, et al. Oncology and
Basic Science. Philadelphia, PA: Lippincott Williams & Wilkins, 2007.)
Fatigue
Most implants are m ade to tolerate th e loads encountered
below th eir yield poin t. Som e im plan ts will fail un der extrem e cyclic loading con ditions due to the process of fatigue. Fatigue is th e result of repetitive or fluctuating application of load. Each m easured load application is below the
yield point, but when applied cyclically, fatigue failure with
crack propagation can occur. Th e en duran ce lim it is that
critical load below which n o am ount of cyclic loading will
produce failure. Im plan ts sh ould be design ed to fun ction
below th e en duran ce lim it. As loads exceed th e en duran ce
lim it or are applied cyclically, fatigue of the implan t m ay
occur. Ductility does n ot in an d of itself preclude fatigue,
because on ly a m oderate am oun t of plastic deform ation of
an implant can be tolerated before failure is seen. Imperfection s in design or fabrication such as cracks, notch es,
impurities, and sharp an gles predispose th e implants to fatigue failure.
Wear
Wear is th e m echan ical rem oval of m aterial from th e surfaces in relative m otion to each oth er (Fig. 1.30). For exam ple, th e slidin g of on e object over an oth er produces wear.
27
Corrosion
Corrosion is the electrochem ical breakdown of a m etallic surface. The ion ic transfer, from on e m etal to a m ore
base level, produces th e surface breakdown of a m etallic
implant. Stainless steel is th e best example of the corrosion
problem . If th e surface coatin g of a m etallic im plan t were
to be disrupted, the un derlying base m etal is exposed to th e
surroundin g m ilieu. Depending on the base m etal, corrosion m ay th en proceed. In the case of stainless steel, exposure of th e base m etal (iron) usually stim ulates an obvious
corrosive respon se. If exten sive, blacken in g of th e adjacen t
soft tissues can be seen . The surface protective layer of an
implant is referred to as the passivation layer. The coating
is designed to protect the implant from a corrosion attack
and is applied at the tim e of m anufacture.
RECOMMENDED READINGS
Jazrawi LM, Kum m er FJ, DiCesare PE. Altern ative bearin g surfaces for
total join t arthroplasty. J Am Acad Orthop Surg 1998;6(4):198 203.
Lucas GL, Cooke FW, Friis EA. A Primer of Biomechanics. New York, NY:
Sprin ger, 1998.
Sch m alzried TP, Callah an JJ. Curren t con cepts review: wear in total
h ip an d kn ee replacem en ts. JBJS Am 1999;81:115 136.
G. Ru ssell Huf fm an
INTRODUCTION
Epidem iology, biostatistics, an d eviden ce-based m edicin e
are the tools by which n ew knowledge is attain ed and in corporated into the practice of orthopaedic surgery. The
m ethodology that these fields utilize is applied in everyday practice. It is th erefore critically im portan t th at th e
orth opaedic surgeon be fam iliar with th e tools an d m eth ods of biostatistics in order to critically evaluate available
eviden ce surroun din g th e diagn osis an d treatm en t of orthopaedic populations and m usculoskeletal disease.
Epidemiology is th e study of th e distribution an d risk factors for disease. Biostatistics is the application of statistical
or m ath em atical m eth ods to th e collection , organ ization ,
and interpretation of clin ically relevant biological, m edical,
or fun ction al data. Evidence-Based Medicine is th e practice
of applyin g th e results of scien tific studies to th e practice of
m edicine in general, and orthopaedic surgery in specific.
Inference is th e derivation of logical con clusion s from existing knowledge regarding a specific condition . Biostatistical
procedures allow in feren ces to be m ade with a quan tifiable
certain ty. In feren ces are m ade regardin g probable causes
and associations with disease, success of treatm ents, and
factors th at m ay in fluen ce a specific con dition . Th is provides th e fram ework of epidem iological study.
DATA
Data are a collection of facts from wh ich con clusion s m ay
be drawn or derived. Data are used durin g patien t in ter-
VARIABLES
In form ation acquired for a given ch aracteristic of a un it of
interest (m ost often a patien t in clinical studies) can be referred to as a variable. For example, in a study of patients
with proxim al h um erus fractures, on e m ay be in terested
in knowing the age of the patient, the gender of the patient, how m any partsthe fracture was, whether or not the
patien t was a sm oker, wh at th e occupation of th e patien t
was, and wh eth er or not the patient was treated operatively.
Each defin ed param eter is gath ered an d th en recorded in a
database for subsequen t an alysis. For th e above exam ple,
suppose the variable of interest is tim e until union. Various statistical tests m ay be used to assess for an association
between th e variable of in terest an d th e oth er variables in
th e study, such as age of th e patien t or n um ber of parts
in the fracture.
Independent variables are variables that determ ine (or
are though t to determ ine) the value of the dependent variable accordin g to th eir value. In an experim ental design,
th e in depen den t variable of in terest is un der th e con trol of
30
TYPES OF DATA
Data are organ ized by wh eth er th ey are strictly n um eric
(con tin uous), ordered (ordin al), or categorical (qualitative). Continuous variables are n um eric values wh ere th e
data can th eoretically take any value with in a ran ge of
values. Num bers such as range of m otion, newton s of
force, and temperature can be considered con tinuous. For
comparing two differen t treatm ents or population s with
continuous variables, the Studen ts t test can be used for
statistical analysis. For th ree or m ore groups with con tinuous variables, th e an alysis of varian ce (ANOVA) test can be
used, an d for com parin g on e group to itself at a later date,
the paired t test can be used. Ordinal variables are data
that are represented in an ordered (valued) fash ion, but in
wh ich th ere is n o specific scale by wh ich th e values differ.
Th ese data are represen ted by in tegers (i.e., 1, 2, 3, . . . ). A
prim e exam ple of ordin al data in orth opaedic surgery is
the pain scale. Typically, nonparam etric tests are appropriate for statistical an alysis of th is type of data, as th ey are
often n ot n orm ally distributed. Th e Man n Wh itn ey U test
is appropriate for two in depen den t groups, th e Kruskal
Wallis test is appropriate for m ore than two groups, and the
Wilcoxin Sign ed-Ran k test is often appropriate for paired or
test retest data. Categorical (Nominal) variables are qualitative categories in wh ich th ere is n o specific value assign ed
to th e data, but th e data differ in som e qualitative way.
For exam ple, suppose on e wan ted to compare in jury rates
in th e NBA, on e m ay break th e players down by position .
Each position has no inherent value, but they differ from
each oth er in som e qualitative way. A special type of categorical data is th e binary variable, a variable in wh ich a
patien t eith er h as or doesn t h ave a certain ch aracteristic,
for example, that patien t is either alive or dead, got treatm en t A or did n ot, an d played or did n ot play. Fish ers
exact test m ay be used to com pare two categorical groups,
Pearsons chi-square test m ay be used to compare two or
m ore groups, an d McNem ars test can be used for paired
variables.
DATA DISTRIBUTION
Con tinuous data m ay be param etric or nonparam etric.
Nonparametric data are data in wh ich th e distribution of
the population values is n ot sim ilar to any specific standard
distribution . Parametric, or distribution al, data can often
be described by on e m ath em atical equation . Th ese equations assum e that the population from which the sample
cam e is distributed sim ilar to a standard distribution. The
m ost com m on distribution that data follows is a Gaussian,
or n orm al, distribution . Th is distribution is bell sh aped
an d is illustrated by Figure 2.1.
Th e y axis ( f ( x)) represents the probability (or percen tage frequen cy) of observing a certain value. The x axis represen ts th e ran ge of poten tial values. Th e area un der th e
curve is equal to 1 an d is the cum ulative probability of
observin g any value un der th e curve. Th e m ean value is
assum ed to be the apex of the curve. In a norm al distribution , 95% of values fall with in 2 standard deviations
(SD) of the population m ean; this represents the 95% confidence interval. Furth erm ore, 69% of values fall with in 1
SD, an d 99% of values fall with in 3 SD. In a n orm al distribution, m ean, m edian, and m ode are all equivalen t. In
gen eral, th e mean is th e sum of all observation s divided
by the num ber of observations (the average). The median
value is the 50th percentile value, or th e value under which
h alf of th e observations occur. For n onparam etric data, m edian values are m ore robust because th ey are n ot in fluen ced
by outliers (the skewness of th e data) to as great a degree.
Th e mode is the m ost frequen tly observed value. Chi-square
distribution an d th e bin om ial (logit fun ction ) distribution
are other standard distributions used to m ake inferences
about data. Skewness represen ts m ore data bein g clustered
in low values of x or h igh values of x, in oth er words, an
asym m etry in the data (Fig. 2.2). Kurtosis is wh en th e data
are m ore or less peaked than norm al (m ore or less close
to th e m ean). Statistical tests for skewness an d kurtosis are
available in m ost com m ercially available statistical packages to determ ine whether or n ot param etric testin g is appropriate.
f(x)
31
Low Kurtosis
Right Skew
Gaussian
Left Skew
INFERENCE
Th e m ain purpose of biom edical research is to h elp us gain
knowledge about th e truth or reality of a clin ical problem .
Th is is th e purpose of in feren ce, a system atic usage of data
to derive a broader con clusion . By usin g statistical m eth ods, we can draw con clusion s about population s on th e
basis of a sam ple drawn from th at population . Our ability
to do th is can be comprom ised by error. Systematic error
is error that can be characterized by bias, confoun ding, or
ch ance. Random error is error built in to m easurem en t tools
due to im perfection of th e tool bein g used. System atic error
can be m in im ized by rigorous study design and attention to
detail. Ran dom error often can n ot be con trolled for un less
a better test with m ore precise m easurem ents is available.
Alternatively, random error (or chance) m ay be dim in ished
by increasing the size of the sample studied so th at it m ore
closely resem bles the entire population about which an inference is m ade. Our confiden ce in inference derived from
statistical tests is m easured by a studies power and by the
ability to reject th e null hypothesis.
ERRORS IN INFERENCE
Bias is a n onrandom system atic error in the design or execution of a study th at m ay result in m istaken in feren ce
about association of causation between th e independent
an d dependent variables. There are a few com m on types of
bias about wh ich every research er sh ould be aware. Selection bias involves situations in which two groups differ in
som e significant way oth er than the independent variable
of in terest. For exam ple, suppose a study was con ducted
in which union rates were observed for two different treatm en ts of tibial fractures. Now suppose one group had m ore
wom en an d th e oth er h ad m ore m en , th ere is selection bias
between treatm en ts th at leads to a poten tial for confounding
of th e effect of treatm en t m eth od on un ion rate by sex of th e
patien t; th is bias m ay be m in im ized by ran dom ization or
m atching con trols. Recall bias is com m on in retrospective
studies, and it can occur wh en a patien t is asked to rem em ber qualities about h is or h er con dition at som e poin t in th e
past. Th e patien t m ay n ot rem em ber h is or h er story perfectly. This bias m ay be m inim ized by controls, so that at
68% 1SD
95% 2SD
High
Kurtosis
least bias is con sisten t, or by perform in g prospective studies in wh ich all pertin en t data are recorded as th ese occur.
Measurement bias can be noted if an investigator asks question s, or records data, in such a way th at m ore accurate data
are collected in on e treatm en t group (i.e., surgical) th an in
an oth er group (i.e., n on surgical). Th is bias can be m in im ized by blin din g research ers to th e treatm en t type or by
h avin g in depen den t reviewers. Sampling bias occurs wh en
patien ts in th e sam ple are sign ifican tly differen t, in som e
crucial ways, from the population in which the researcher is
in terested in m akin g in feren ces. Th is m ay lead to a decrease
in external validity or gen eralizability of results to population s outside th e study sam ple. Publication bias is noted
wh en publish ed studies tend to h ave a greater effect size
than all completed studies. Another type of publication
bias is publication of on ly positive or sign ifican t results.
Th is can be assessed for durin g m eta-an alysis usin g fun n el plots (Fig. 2.3). Missing data, or nonresponse bias, can
lead to its own special types of ch allen ges. Most com m ercially available software packages deal with m issing data
by listwise deletion. Th at is to say, if a patien t is m issin g any
param eter, th en th at patien t is elim in ated for th e purposes
of an alysis. If th e data are m issin g com pletely at ran dom ,
this m ethod of dealing with m issing data is probably the
m ost robust an d does n ot in troduce addition al bias in to
the study, but it does decrease power by m aking th e sam ple size sm aller. Essen tially, you are left with a subsam ple
of th e origin al sam ple. Wh en th e data are n ot m issin g com pletely at ran dom , it is often n ecessary to employ a statistician to perform special tests on the data to determ in e the
m ost appropriate way to deal with th e m issin g data.
Confounders are variables that h ave an association with
both th e in depen den t an d depen den t variables of a study.
Variables such as age, gender, socioeconom ic status, m edical com orbidities, an d in jury severity are com m on examples of con foun ders. Suppose an in vestigator wan ts to
determ in e wh eth er a cem en ted or cem en tless im plan t h as
greater lon gevity. Th e research er would n eed to factor in by
statistical adjustm ent, m atching, or random ization age and
activity level; oth erwise, th e effect m ay be con foun ded by
these factors (Table 2.1). When the study is retrospective,
there sh ould be a dem ographic table that clearly evaluates
poten tial con foun ders, an d if th ere is a differen ce, con sideration sh ould be m ade to statistically adjust for con foun din g
32
SE(log OR)
0.4
0.8
1.2
1.6
0.01
0.1
10
100
OR
by using suitable statistical m ethods (i.e., m ultivariate analysis, stratification , or m atch in g). Ran dom ized trials elim inate con foun ders if the sample sizes are adequate, but con founding variables should still be screen ed for potential
confoundin g.
Chance is the probability that two unrelated events will
seem related by random occurren ce or vice versa. Chan ce
can take two form s. Type I error is th e conclusion that a true
association between variables exist wh en in reality th ere is
no difference. Type II error is th e probability of failing to
fin d an association wh en on e actually exists (Table 2.2). If
m ultiple comparison s are bein g perform ed, it is importan t
to adjust for m ultiple tests in order to n ot in flate th e type I
error.
TABLE 2.2
TABLE 2.1
Cemented
Uncemented
P value
67
56
66
54
.48
.45
True association
No association
Study Shows
Association
Study Shows
No Association
Study is accurate
( p = 1 )
Type I error ( p = )
Type II error ( p = )
Study is accurate
(p = 1 )
33
TABLE 2.3
LEVELS OF EVIDENCE
Level
Therapeutic
Prognostic
Diagnostic
II
III
IV
V
Case series
Expert opinion
34
Retrospective
Prospective
study onset
Exposure
Outcome
Cases
Cohort
INQUIRY
Exposure
Outcome
study onset
adjust for confounding. Significant bias in the form of recall, reporting, or sampling bias can exist. These studies are
typically level III or IV eviden ce depending on the sophistication of the study design an d analysis.
Prospective cohorts are observation al an alytical studies that follow a population with a specific exposure or
treatm ent over tim e to iden tify outcom es of interest. The
Fram in gh am Heart study is on e of th e m ore fam ous coh ort
studies that investigated the risk factors for heart disease.
Coh orts can estim ate disease incidence, evaluate a diseases
course or natural history, and identify risk factors. The cohort study has th e ability to identify n ested case-control
studies within the cohort (i.e., an in terim outcom e is iden tified and studied). The power of the study increases with
increasing disease frequen cy (num ber of patients with the
outcom e of in terest). Coh orts are h owever expen sive an d
labor intensive, often require m ultiyear gran ts and a com preh en sive data collection system , an d are susceptible to
bias, error, con foun din g, an d loss of follow-up. Typically,
the effect m easure is reported as a relative risk, that is, th e
risk of an exposed in dividual to develop th e disease com pared with th e risk of th e un exposed in dividual to develop
the disease. Typically, prospective cohorts are level II to
III eviden ce depen din g on soph istication , data collection
m ethod, and rate of follow-up.
Randomized clinical trials (RCTs) are experim en tal studies that involve usage of con curren t (RCT), sequential
(crossover), or historical controls. Th e gold standard RCT
is th e random ized double-blind, placebo-controlled trial.
RCTs require a protocol that establishes eligibility (in clusion an d exclusion criteria), sam ple size (a power an alysis), ran dom ization (to m inim ize bias and con foun ders),
blin din g (to m in im ize perform an ce, detection , an d in terviewer bias), stopping rules, m onitoring for compliance,
safety assessm ent, an d in ten tion to treat analysis to m in im ize nonresponder bias. Alth ough th ese studies are th e
gold standard of biom edical research, these are extrem ely
expen sive an d logistically difficult. Eth ically, th ese studies require the optim al treatm ent to be truly unknown. The
level of evidence is I or II dependin g on th e above listed factors, type of ran dom ization , an d patien t reten tion (> 90%
for level I). Random ized clin ical trials have excellent intern al validity, because th e result occurred un der ideal experim en tal con dition s. It is also im portan t to n ote th at if
inclusion and exclusion criteria are too stringen t, a clin ical
trial m ay have very poor external validity (m ay be poorly
gen eralizable to th e population as a wh ole).
In addition to observation al an d experim en tal studies,
reviews are an oth er form of research . Expert opin ion is
level V evidence, but it is a form of review based on expert
experien ce. Systematic reviews (level IIa an d IIIa) are an
eviden ce-based sum m ary of th e literature th at uses a com plete search an d critical an alysis of th e study. If th e studies
involved are level III eviden ce, then the system atic review
is also level III. Meta-analysis is th e process by wh ich qualitative m eth ods are applied to compile th e results of several
35
HYPOTHESIS TESTING
Th e classic approach to determ in e statistical significance is
to compare observed findings with expected findin gs. This
com parison allows on e to determ in e if an outcom e could
h ave occurred sim ply by ch an ce. Th e comparison between
treatm ents or between a risk factor and an outcom e typically takes on th e n ull hypoth esis th at th ere is n o differen ce
between treatm en ts or th ere is n o association between a risk
factor (in depen den t variable) an d a con dition (depen den t
variable). Th e altern ative hypothesis states that there is a
true difference between the groups. Type I error exists if on e
finds no difference/association when th ere truly is one, an d
a type II error exists if one finds a differen ce where n on e
exists (Table 2.2). Wh ere m ultiple hypotheses exist, one
m ust adjust the type I error to account for that num ber of
m ultiple tests, oth erwise the type I error will cum ulatively
increase with increasin g num bers of hypoth eses.
P values are th e probability of an even t occurrin g by
chance alone; these values are th e result of th e statistical
test th at is perform ed. Th e p value is a m easure of the
stren gth of th e eviden ce in favor of th e null hypothesis.
If p > , th en th e n ull hypoth esis m ay be rejected. P values do not provide units, are not a m easure of the strength
of an association, and there is little inherent precision to
a p value. Sim ilarly, the p value does n ot con vey practical
sign ifican ce but rath er an observed probability based on
th e sample studied. Confidence intervals are con structed
around a m ean, an d if the result is statistically significant,
th e in tervals do n ot overlap or, in th e case of odds ratios, do
not in clude on e. Th ese con fiden ce in tervals are based on
th e alph a levels determ in ed at study on set. Th ese values are
m ore precise than p values because these provide a range
of values. Alpha is th e probability of con cluding that two
th in gs are differen t wh en in fact th ey are n ot. Th e lower th e
, the m ore rigorous the criteria are for rejecting the null
hypoth esis, an d th e less likely a research er is to con clude
th at th ere is a differen ce wh en th at differen ce was th e result
of chance alone. The m ost com m on is 0.05; at th at level,
th e probability of m akin g a type I error (con cludin g th ere
is a differen ce when th ere is n one is 1 in 20). is th e probability of m aking a type II error, that is, concluding there
is no difference wh en in fact there is. Power is 1 . Wh en
a study dem onstrates that there is a significant difference,
36
TABLE 2.4
Number of
Groups
2
2
>2
>2
2
>2
2
>2
2/> 2
Independent
Paired
Students t test
MannWhitney U test
ANOVA
KruskalWallis test
MannWhitney U test
KruskalWallis test
Fisher test
Pearson chi square
Log-rank statistic
Paired t test
Wilcoxin signed rank test
Repeated-measures ANOVA
Friedman test
Wilcoxin signed rank test
Friedman test
McNemar test
Cochran Q test
Conditional logistic regression
Power analysis is essential to determ ine how m any patients are necessary to detect th e difference a research er
is in terested in. If the researcher sets the difference at th e
m inim um clinically important difference, if n o difference
is detected, it is safe to say that th ere is n o clinically importan t differen ce between groups. Th e elem en ts of a power
analysis are the type I error rate that is acceptable, the type
II error rate th at is acceptable, th e varian ce of th e expected
m ean, the sample size, and an entity called the delta (effect
size). Delta is the m inim um detectable chan ge. In m any
cases, th e varian ce will be un kn own , an d an effect size is
estim ated on th e basis of wh at th e research er con siders to
be clin ically im portan t. In gen eral, post h oc power an alysis sh ould be avoided, because at th e en d of th e study,
the power has already been determ in ed by the num ber of
patien ts en rolled.
Clinical significance is distin ct from statistical sign ificance. A study can find a statistically significant result, but
the m agnitude of difference, or th e param eter studied, m ay
n ot m atter practically or clin ically. If a study h as a large sam ple size, a statistical differen ce m ay be detected, but th at differen ce m ay not be clinically important. For example, suppose two tech n iques for m easurin g leg len gth s followin g
total h ip arth roplasty are available, an d th e two m eth ods
differ by 0.1 m m , but because of th e n um ber of patien ts or
precision of in strum en ts, th e statistical differen ce is foun d
to h ave a p value of .001. It could be said that the differen ce between these two m ethods is h ighly statistically
significant but do not dem onstrate clinically important
differen ces.
Measures of Effect
Other tests are used to give inform ation about the association between variables. Unadjusted tests include probability, odds, odds ratio, relative risk, and hazard ratio.
Probability takes the form of a value between 0 and 1 an d
represen ts th e likelih ood of an even t h appen in g on th e basis of the n um ber of events over th e num ber of trials; for
exam ple, tossin g a coin sh ould h ave a probability of 0.5.
Odds are th e probability of observin g an even t in a trial over
the probability of not observin g th at event; for a coin toss,
odds would be equal to 0.5/ 0.5 or 1. Th e odds ratio represents the odds of exposure to a risk factor between a case
group an d a con trol group. Th e relative risk represen ts th e
inciden ce of disease in an exposed population over the in cidence of disease in an unexposed population. The hazard
ratio compares two groups in term s of th e risk of an event
occurrin g in a particular period of tim e. Hazard ratios can
be calculated with Kaplan Meier survival an alysis. Many
37
TABLE 2.5
1.0
Multivariate
Continuous
Binary
Time series
Pearsons r
Odds ratio
Hazard ratio (Kaplan Meier)
Linear regression
Logistic regression
Cox regression
0.8
Sensitivity
Outcome
0.6
0.4
0.2
0.0
0.0
0.2
0.4
0.6
0.8
10
0.8
10
1 - Specificity
TEST CHARACTERISTICS
1.0
0.8
Sensitivity
0.6
0.4
0.2
0.0
0.0
0.2
0.4
0.6
1 - Specificity
38
Visual analog scales can be used to m easure patient satisfaction , pain , an d gen eral outcom e.
RECOMMENDED READINGS
Abel U, Koch A. Th e role of ran dom ization in clin ical studies: m yth s
and beliefs. J Clin Epidemiol. 1999;52;487 489.
Ben son K, Hartz AJ. A com parison of observation al studies and random ized con trolled trials. N Engl J Med. 2000;342:1878 1886.
Bern stein J, McGuire K, Freedm an KB. Statistical sam pling and hypoth esis testing in orthopaedic research. Clin Orthop Relat Res.
2003;413:55 62.
Bern stein J. Eviden ce-based m edicin e. J Am Acad Orthop Surg. 2004;
12(2):80 88.
Freedm an KB, Back S, Bern stein J. Sam ple size an d statistical power of
ran dom ized con trolled trials in orth opaedics. J Bone Joint Surg Br.
2001;83(3):397 402.
Hun sacker FG, Cioffi DA, Am adio PC, Wrigh t JG, Caugh lin B. The
Am erican Academy of Orthopaedic Surgeon s outcom es instrum ents: norm ative values from the gen eral population. J Bone Joint
Surg Am. 2002;84(2):208 215.
Kocher MS, Zurakowski D. Clinical epidem iology and biostatistic:
a prim er for orthopaedic surgeons. J Bone Joint Surg Am. 2004;
86-A(3):607 620.
Im aging in
Orthopaedic Surgery
Tu rn er Vosseller
John N. Delahay
Th is ch apter will offer a brief in troduction in to th e m ajor im agin g m odalities used in orth opaedic surgery. Th e
m ost basic m edium of im aging rem ains plain radiography,
wh ich can provide a wealth of in form ation quickly for relatively little cost. In the past 30 years, the im aging repertoire
available to the orthopaedic surgeon has expan ded greatly,
with th e adven t an d widespread availability of computed
tom ography (CT) scan s an d m agn etic reson an ce im agin g
(MRI). Ultrasonography, nuclear scintigraphy, an d bone
den sitom etry are also com m on ly used in th e evaluation of
m usculoskeletal disease. Finally, a brief discussion of safety
an d radiation exposure to the orthopaedic surgeon is in cluded.
PLAIN RADIOGRAPHY
As stated above, plain radiography is th e m ost com m only
used im agin g test in th e evaluation of orth opaedic traum a
an d m usculoskeletal pain . It gives excellent visualization of
the osseous anatomy as well as som e in direct inform ation
about the surrounding soft tissues. Because of their ease of
acquisition and low cost, plain x-rays are alm ost always the
first step in th e im agin g workup, an d diagn ostic errors can
occur wh en th ey are om itted.
When evaluatin g plain x-rays, it is importan t to rem em ber th at th e im age is a two-dim en sion al represen tation of
a three-dim ensional structure. On a single x-ray view, displacem en t of a fracture in on ly two out of th e th ree possible
plan es of displacem en t is visualized. For exam ple, an an teroposterior (AP) view of th e wrist dem on strates displacem en t in the m edial lateral plane and the superiorin ferior
plan e but does n ot provide any in form ation regardin g dis-
placem en t in th e AP plan e. In order to evaluate displacem en t in th e AP plan e, a secon d film th at is orth ogon al
to th e first m ust be obtain ed. A lateral view of th e wrist
will dem on strate the AP displacem en t as well as superior
in ferior displacem en t.
For the distal joints an d extrem ities, obtaining the two
orth ogon al views is easily accom plish ed by rotatin g eith er
the extrem ity or the x-ray beam 90 degrees. For th e m ore
proxim al join ts, such as th e h ip an d sh oulder, th is is n ot
possible, so special radiograph ic views h ave been developed to provide th e n ecessary in form ation . In addition to
these views, a num ber of special techniques have been developed to better visualize structures th at are n ot well seen
on routin e AP an d lateral radiograph s. Th e followin g section s con tain a description of m any of th ese special views
used in th e evaluation of each of th e m ajor an atom ic region s of th e body. Illustration s of m any of th e tech n iques
described, as well as exam ple radiograph s, are con tain ed in
the later ch apters in this book that cover the orthopaedic
subspecialties. The reader is also encouraged to seek out
oth er texts th at are dedicated specifically to orth opaedic
im agin g for m ore detailed description s of radiograph ic positionin g an d techn iques.
Cervical Spine
Th e routin e traum a series of th e cervical spin e in cludes a
lateral view, an AP view, and an open mouth odontiod view.
Th e lateral view is improved by pullin g down on th e patients arm s; traction should never be placed on th e head.
A swimmers view m ay be necessary if the en tire cervical
spin e down to th e C7-T1 disk space is not visualized on th e
lateral view. This view is obtained with one of the patients
40
Shoulder
Atrue AP of th e sh oulder (Grash ey view) takes in to accoun t
the fact that the coronal plane of the glenoh um eral joint is
an gled about 40 m edially to the coronal plane of th e body
(Fig. 3.1). Th erefore, th e x-ray beam is angled about 40 m edially so th at it is perpen dicular to th e glen oh um eral join t
line (Fig. 3.2). Often the evaluation of the shoulder not
45
B
Figure 3.1 A true anteroposterior (AP) of the shoulder show-
41
B
Figure 3.3 Technique for obtaining a scapula lateral, also known as the Y-view, x-ray. With the
cassette placed on the lateral aspect of the shoulder (A), the x-ray beam is directed parallel to the
plane of the scapula (B). (Reprinted with permission from Bucholz RW, Heckman JD, Court-Brown
C, et al. Rockwood and Greens Fractures in Adults. 6th ed. Philadelphia, PA: Lippincott Williams &
Wilkins, 2006.)
42
B
Figure 3.5 A true anteroposterior (AP) radiograph (A) commonly obscures the fracture pattern.
An apical oblique view (B) is helpful to better demonstrate the fracture pattern. (Reprinted with
permission from Bucholz RW, Heckman JD, Court-Brown C, et al. Rockwood and Greens Fractures
in Adults, 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
used to evaluate for dislocation , m alalign m en t, or in tercalated segm ent in stability. The adequacy of the lateral
view can be evaluated by lookin g for th e distal pole of
the scaphoid to be in line with the hook of the ham ate.
A lateral view with th e wrist angulated approxim ately 20
off th e cassette allows for a look at th e radiocarpal join t
space, taking into accoun t the radial inclin ation . Specific
views of th e scaph oid sh ould be obtain ed in th e settin g of
traum a. Th is view is don e in th e PA projection , with th e
wrist ulnarly deviated an d with slight ceph alad angulation
of th e beam , wh ich elon gates th e waist of th e scaph oid.
However, one m ust keep in m ind that a scaph oid fracture
can have norm al radiographs initially. A clenched fist view
can be used to evaluate for scapholunate widenin g and is
typically don e in supin ation with uln ar deviation . Views of
the opposite side can be obtained for comparison. A carpal
tunnel view, obtain ed by hyperexten din g th e h an d an d di-
A
B
43
A
B
44
C
Figure 3.8 A: Postoperative anteroposterior (AP) view of a right vertical shear pelvic injury. Fixation was achieved with a right iliosacral screw in conjunction with symphyseal plating. B: Inlet view.
C: Outlet view. (Reprinted with permission from Bucholz RW, Heckman JD, Court-Brown C, et al.
Rockwood and Greens Fractures in Adults. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins,
2006.)
Special views of th e h in dfoot can provide m ore in form ation. The Broden view provides a reliable im age of th e
posterior facet of th e subtalar join t an d is used to evaluate intra-articular calcaneal fractures. It is obtained with
th e an kle in n eutral dorsiflexion , th e leg in tern ally rotated
30 , an d th e x-ray beam cen tered over th e lateral m alleolus. Canale and Kelly described a talar n eck view for evaluation of talar n eck fractures. Th is view is obtain ed with
the ankle in m axim al equin us with the foot pronated 15
an d centered 15 ceph alad (Fig. 3.10). An axial view of
the calcaneus, the Harris-Beath view, allows an alysis of
the m edial and posterior facets of the subtalar joint, as
well as an assessm ent of the alignm ent of the heel. Fin ally, the Cobey view depicts h eel position an d axis relative
45
Figure 3.9 Standard radiographic trauma series. Internal oblique view (A), a lateral view (B), an
anterior-posterior (C), and an external rotation oblique (D) reveal a minimally displaced split fracture
of the lateral plateau. (Reprinted with permission from Bucholz RW, Heckman JD, Court-Brown C,
et al. Rockwood and Greens Fractures in Adults, 6th ed. Philadelphia, PA: Lippincott Williams &
Wilkins, 2006.)
CONVENTIONAL ARTHROGRAPHY
In tra-articular n eedle placem en t un der fluoroscopic guidan ce can be perform ed for purposes of contrast injection,
fluid aspiration, or instillation of steroid or analgesic m edication . Con ven tion al arth rography h as been largely replaced by MRI, but it is still a useful tool for diagn osin g
full-thickness rotator cuff tears of the shoulder and for evaluatin g th e in terosseous ligam en ts an d trian gular fibrocartilage com plex of th e wrist in patien ts un able to un dergo
MRI scan . Th e basic prin ciple is th at con trast is in jected
in to on e compartm en t an d sh ould n ot extravasate outside
46
75
15
Figure 3.10 Canale and Kelly view of the foot. The correct posi-
tion of the foot for x-ray evaluation of the foot is shown. (Reprinted
with permission from Bucholz RW, Heckman JD, Court-Brown C,
et al. Rockwood and Greens Fractures in Adults. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
COMPUTED TOMOGRAPHY
CT is a tech n ique th at gen erates cross-section al im ages
that are reconstructed from m ultiple digital radiographic
projection s or views. Th ese views are com bin ed th rough
the m ethod of back-projection to generate the crosssectional im age. Recent advances in CT in clude the developm en t of h elical or spiral scan n ers, wh ich allows con tin uous un idirection al tube m otion . Ultim ately, th is al-
47
Figure 3.11 True intra-articular tongue fracture (Type IIB). Plain radiographs are unable to indi-
cate whether the fracture involves the posterior facet. Semi-coronal and transverse CT scans verify
intra-articular displacement. Note black arrows indicating intra-articular fracture, and white arrows
indicating the intact lateral wall component typical of tongue fractures. (Reprinted with permission
from Bucholz RW, Heckman JD, Court-Brown C, et al. Rockwood and Greens Fractures in Adults,
6th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
48
Central
Med.
Su
st
.
Lateral
A B C
Typ e IIA
A B
Typ e IIB
Typ e IIC
Type III AB
BC
Typ e III AC
Typ e III BC
A B C
Typ e IV
Figure 3.12 Sanders computed tomography (CT) scan classification of calcaneal fractures. (From
Sanders R. Current concepts reviewdisplaced intra-articular fractures of the calcaneus. J Bone Joint
Surg Am. 2000;82:233.) (Reprinted with permission from Bucholz RW, Heckman JD, Court-Brown C, et
al. Rockwood and Greens Fractures in Adults. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins,
2006.)
con stan ts, T1 an d T2. Th e so-called T1-weigh ted im ages favor proton species with sh ort T1 relaxation con stants, such
as the aliphatic hydrogen n uclei in fat. T2-weighted im ages
favor proton species with a lon g T2 relaxation con stan t,
such as th e hydrogen nuclei in free water. Because of the
49
50
C) of the knee from posterior to anterior demonstrating superior cartilage detail. (Reprinted with permission from Berquist
TH. MRI of the Musculoskeletal System. 5th ed. Philadelphia,
PA: Lippincott Williams & Wilkins, 2006.)
ten tial in stability th an tradition al flexion an d exten sion radiograph s. T2 STIR im ages are especially effective for evaluatin g ligam en tous spin al in jury.
MRI is quite sen sitive for ten don disruption s if studies
are perform ed with sufficient spatial resolution. This application is useful in th e stagin g of im pin gem en t in th e sh oulder with ten don osis with in th e rotator cuff ten don s. It can
sh ow the spectrum from tendonosis to partial-thickness
and ultim ately full-thickness tears, although it can be difficult to differen tiate ten don osis from partial-th ickn ess tearing. Short echo tim es are especially useful in th e im aging
of ten don osis wh erever it m ay occur in th e body, alth ough
MRI is m ore useful in m aking these distin ctions in the larger
rotator cuff an d th e Ach illes tendon (Fig. 3.18).
MRI is sen sitive in detectin g m uscle sprain s an d tears. In
suspected cases of h am string injury, for example, MR evaluation m ay be of som e prognostic value, particularly in elite
athletes in wh om the size of injuries, the extent of intram uscular fluid collection s, an d th e presen ce of h em orrh age can
izontal cleavage tear in the posterior horn. (Reprinted with permission from Berquist TH. MRI of the Musculoskeletal System. 5th ed.
Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
51
PCL
B
Figure 3.15 Coronal fat-suppressed T2-weighted image (A) demonstrating a medial tear (curved
arrow) with a large displaced fragment (black arrow) that gives the appearance of two posterior
cruciate ligaments (PCLs). There is also a complex tear of the lateral meniscus (white arrow) and loss
of articular cartilage. Sagittal proton density-weighted image (B) demonstrating a medial meniscal
tear with a large displaced fragment (small arrow), resulting in a double-PCL sign. (Reprinted with
permission from Berquist TH. MRI of the Musculoskeletal System. 5th ed. Philadelphia, PA: Lippincott
Williams & Wilkins, 2006.)
52
B
A
53
Figure 3.17 Lumbar disc protrusion. L3 disc herniation with the base of the herniation wider than
the distance away from the parent disc. The protrusion is evident principally as a distortion of the
cerebrospinal fluidcontaining thecal sac on the T2-weighted images (A and B) and as effacement of
the epidural fat on the T1-weighted images (C and D). (Reprinted with permission from Berquist TH.
MRI of the Musculoskeletal System. 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
ULTRASONOGRAPHY
Ultrasound has the distin ct advan tages of being sem iportable, easily tolerated, an d relatively in expen sive. With
new transducer technology, ultrasoun d can surpass MRI
an d CT in spatial resolution an d can be effectively used in
the im aging of sm all an d superficial body parts. Th e m ain
drawback to ultrasoun d is th at th e quality of th e im ages
is extrem ely dependent on the skill of the technician per-
54
NUCLEAR SCINTIGRAPHY
Th e specificity of n uclear m edicin e studies is determ in ed by
the radiopharm aceutical agent th at is adm inistered. Selective uptake of radiopharm aceutical agents occurs in tissues
in a temporally predictable fashion. The radiotracer portion
of th e radioph arm aceutical is typically a gam m a-em ittin g
Figure 3.19 SE 500/10 images of the hips in a patient with early AVN on the right. Radiographs
were normal. A: Coronal image demonstrating a small linear subchondral defect (arrow). B: Sagittal
image of the right hip more clearly defines the extent of involvement (arrows). (Reprinted with permission from Berquist TH. MRI of the Musculoskeletal System. 5th ed. Philadelphia, PA: Lippincott
Williams & Wilkins, 2006.)
55
normal radiograph (A). Coronal T1-weighted image (B) demonstrates decreased signal intensity
due to edema and a fracture at the base of the
femoral neck (arrow). (Reprinted with permission from Berquist TH. MRI of the Musculoskeletal System. 5th ed. Philadelphia, PA: Lippincott
Williams & Wilkins, 2006.)
56
57
Figure 3.22 Pathologic compression fracture of the T4 vertebral body in a 73-year-old woman
being evaluated for metastatic disease after identification of a lung carcinoma. A: Lateral thoracic
spine radiograph shows marked compression fracture of the T4 vertebral body. No other lesions
are seen. B: Large field of view T1-weighted (500/15) SE MR image of the spine shows the fracture
at T4 (asterisk) and as partial replacement of the marrow in the T3 vertebral body and T6 vertebral
body. C: Corresponding small field of view lateral T1-weighted (500/15) image shows areas of marrow
replacement to better advantage. Transpedicular biopsy of the T4 lesion revealed multiple myeloma.
(Reprinted with permission from Berquist TH. MRI of the Musculoskeletal System. 5th ed. Philadelphia,
PA: Lippincott Williams & Wilkins, 2006.)
Figure 3.23 Synovial sarcoma in the ankle of a 37-year-old woman. Coronal T1-weighted (600/20)
(A) and axial T2-weighted (2,000/80) (B) SE MR images show a large well-defined mass, with a complex
signal intensity compatible with previous hemorrhage. Note subtle area of bone invasion in A (open
arrow). (Reprinted with permission from Berquist TH. MRI of the Musculoskeletal System. 5th ed.
Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
58
BONE DENSITOMETRY
diotracer uptake within the midshaft of the left humerus, right iliac
crest, and right acetabulum, which is suspicious for bone metastasis. Increased uptake within the shoulder joints is related to osteoarthritis. (Reprinted with permission from Chew F, Roberts C,
Musculoskeletal Imaging: A Teaching File, 2nd ed. Philadelphia PA:
Lippincott Williams & Wilkins, 2006.)
RADIATION EXPOSURE
CONSIDERATIONS
One furth er subject that m ust be broached in this review
is that of radiation exposure to th e orthopaedic surgeon.
Radiograph ic visualization is a n ecessary part of m any orthopaedic procedures, an d m any orthopaedic surgeons are
59
RECOMMENDED READINGS
Dom b BG, Tyler W, Ellis S, McCarthy E. Radiographic evaluation of
path ological bone lesions: current spectrum of disease and approach to diagnosis. J Bone Joint Surg Am. 2004;86-A(suppl 2):
84 90.
Grissom L, Harcke HT, Thacker M. Im aging in th e surgical m anagem ent of developm en tal dislocation of th e hip. Clin Orthop Relat
Res. 2008;466(4):791 801.
San ders TG, Miller MD. A system atic approach to m agn etic reson an ce
im aging interpretation of sports m edicine in juries of the knee. Am
J Sports Med. 2005;33(1):131 148.
San ders TG, Morrison WB, Miller MD. Im agin g tech n iques for th e
evaluation of glen oh um eral in stability. Am J Sports Med. 2000;
28(3):414 434.
Sh in dle MK, Foo LF, Kelly BT, et al. Magn etic reson an ce im agin g of
cartilage in the athlete: current techniques and spectrum of disease.
J Bone Joint Surg Am. 2006;88(suppl 4):27 46.
Electrodiagnostic
Testing
Michael K. Ku o
INTRODUCTION
Electrodiagnostic medicine is a specific area of m edical practice in which a physician integrates inform ation obtain ed
from the clinical history, observations from physical exam ination, and scien tific data acquired from recording electrical potentials from th e nervous system and m uscle to
diagn ose, or diagn ose an d treat diseases of th e cen tral, periph eral, an d auton om ic n ervous system s, n eurom uscular
junctions, an d m uscle. Electrodiagn ostic testing typically
con sists of two components, nerve conduction studies
(NCS) and electromyography (EMG).
It is critical th at electrodiagn ostic testin g be used as an
exten sion of a focused h istory an d physical exam in ation .
Th e h istory an d exam in ation is used to form ulate an in itial
differen tial diagn osis. Based on th is differen tial diagn osis,
specific nerves an d m uscles are exam ined with NCS and
EMG. Th e tech n iques used as well as th e specific n erves
an d m uscles exam ined are initially determ ined by this differential diagnosis. The early NCS and EMG findings will
determ in e wh at addition al testin g is required an d will further narrow the differential diagnosis. The electrodiagnostic impression is determ ined not only by the test results but
also by the clinical inform ation. Relying solely on the electrodiagnostic data to form ulate an impression frequen tly
leads to m isdiagnosis. For example, n orm al NCS and EMG
for a patient with a clinical lum bar radiculitis does n ot rule
out a lum bar n erve root source for th e patien ts sym ptom s.
Th e diagn ostic lim itation s of NCS an d EMG m ake clin ical
correlation crucial.
Electrodiagn ostic testing is used as a tool for diagnosing n eurom uscular disorders. Although in form ation can
be obtain ed regardin g th e cen tral n ervous system , electro-
diagn ostic testin g is prim arily used to diagn ose periph eral
n ervous system and m uscle disorders. An atom ically th is
m ay in clude an terior h orn cells, sen sory an d m otor roots,
brach ial an d lum bosacral plexuses, periph eral n erves,
n eurom uscular jun ction s, an d m uscles. In addition to diagn osis, electrodiagnostic testin g can h elp with localization,
determ in in g severity, an d progn osis. For example, a patien t
with h an d n um bness can be diagn osed with a m edian n europathy with NCS an d EMG. Th e testin g can furth er localize
the lesion to the wrist or forearm , determ in e which nerve
fiber types are in volved (m otor/ sen sory), verify h ow m uch
axon loss versus demyelin ation h as occurred, an d give a
progn osis based on th is in form ation .
62
Patient Preparation
In preparin g for NCS, patien ts are in structed to avoid skin
cream s and lotions as surface electrodes m ay not fasten
securely to the skin . There are no absolute contrain dication s for NCS, alth ough th ese are n ot recom m en ded in
patien ts with extern al cardiac pacem akers. In patien ts with
implan ted cardiac pacem akers, NCS can be perform ed as
lon g as stim ulation n ear th e th orax is avoided. In patien ts
with central lines, stim ulation over th e central lin e site is
not recom m ended as the electrical im pulse could travel to
the heart via the cath eter.
Sensory NCS
Sen sory NCS are perform ed by placem en t of recordin g electrodes over th e n erve to be exam in ed. Th ere are two recordin g electrodes, an active electrode an d a referen ce electrode.
As both electrodes record electrical waveform s, attention to
electrode placem en t is vital. Th e active electrode is placed
over th e n erve. Th e referen ce electrode is placed distally on
the nerve 3 to 4 cm from the active electrode. An electrical
stim ulus from the stim ulator probe is applied to th e nerve
at a m easured distan ce from th e active electrode.
The electrical waveform produced is known as th e sensory nerve action potential (SNAP). Th e SNAP waveform represen ts th e sum m ation of th e in dividual sen sory action
poten tials stim ulated. Th e waveform h as th e followin g param eters: onset latency, peak latency, amplitude, duration, an d
conduction velocity(Fig. 4.1). Norm al values are available for
laten cies at defin ed distan ces an d amplitudes for specific
sen sory n erves.
Con duction velocity is calculated by dividin g th e distan ce traveled by th e electrical stim ulus by th e on set laten cy.
usually biphasic or triphasic in configuration. Latencies are measured in ms. Amplitudes are measured in V. (From Preston DC,
Shapiro BE. Electromyography and Neuromuscular Disorders. 2nd
ed. Philadelphia, PA: Elsevier, Butterworth-Heinemann, 2005, with
permission.)
Th is simple calculation can n ot be used with respect to m otor NCS as will be discussed later. Norm al con duction velocities tend to be greater than 48 m per second for upper
lim b studies an d greater than 39 m per second for lower
lim b studies.
Motor NCS
Motor NCS are perform ed by placem ent of the active electrode over the m otor endplate, usually the center of the
m uscle belly. The reference electrode is placed distally over
an in active point such as the tendon insertion. Th e peripheral n erve is stim ulated at a m easured poin t proxim ally.
Th e waveform produced is kn own as th e compound muscle action potential (CMAP). The CMAP is the sum m ated
electrical activity from depolarization of m uscle fibers un der th e active electrode. Th e m ost com m on param eters
an alyzed include onset latency, amplitude, duration, and conduction velocity (Fig. 4.2). Norm ative data are available for
latencies an d amplitudes.
Th e complexity of th e m otor on set laten cy m akes m easurem en t of m otor con duction velocities less straightforward than m easurem ent of sensory conduction velocities.
Sim ply dividin g th e distan ce traveled by th e electrical stim ulus by th e on set laten cy will n ot produce an accurate
con duction velocity because of th e variability in the neurom uscular junction tim e. To calculate a m otor conduction
velocity, the nerve m ust be stim ulated at two differen t sites,
distal an d proxim al. Th e on set laten cy from th e distal stim ulation is subtracted from th e on set laten cy of th e proxim al stim ulation. This subtracts out the neurom uscular
transm ission tim e, as well as the latency of activation, leaving the action potential tim e between the two stim ulation
poin ts. Th e con duction velocity is calculated by dividin g th e
Late Responses
In addition to sen sory an d m otor con duction studies, late
responses can be obtained to assess the proxim al portions of
the nerves. Late responses include F-waves an d H-reflexes.
Th eses waveform s in volve an action poten tial travelin g
proxim ally to th e spin al cord an d th en distally to th e recordin g electrodes.
F-waves on ly in volve m otor n euron s. Th ey are late m otor
respon ses th at occur after th e CMAP. Th ey were first n oted
in the foot m uscles, hence th e nam e, F-wave. F-waves can
be elicited from any n erve th at h as m otor axon s. Active
an d referen ce electrodes are placed th e sam e way as for
a m otor con duction study. An electrical stim ulus is applied
to th e n erve distally. A supram axim al stim ulus is used. A
CMAP (also kn own as th e M-wave) is produced when the
action poten tial travels from th e stim ulation site distally to
the recording electrodes. The F-wave is produced from the
action poten tial th at is travelin g in th e opposite direction .
Th is action poten tial travels to th e an terior h orn cells at
the spinal cord. A sm all proportion of the an terior h orn
cells will backfire, resulting in an action poten tial that
will travel back down th e n erve to th e recordin g electrodes,
and produce an F-wave (Fig. 4.3).
F-waves ten d to be sm all (1% to 5% of CMAP amplitude). Th ey also vary in laten cy. For th is reason , at least
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NCS PITFALLS
Electrodiagn ostic m edicin e is wrough t with pitfalls, som e
related to in h eren t lim itation s of th e testin g itself an d also
to tech n ical factors. As n oted previously, NCS an d EMG
sh ould be used as an extension of a focused history an d
physical exam in ation . Too frequen tly, testin g is n ow bein g
perform ed by tech n ician s with out electrodiagn ostic physician sdirect supervision or involvem ent. This often results
in excessive testing and erroneous diagnoses. The lim itations of NCS and EMG vary depending on the specific
disease processes an d diagn oses bein g evaluated.
With respect to tech n ical factors, th ere are m any. Todays
autom ated electrodiagnostic equipm ent requires m inim al
instrum entation adjustm ents. Alth ough this improves the
ease of testin g, on e m ust be careful as n orm ative data are
based on specific NCS an d EMG tech n iques usin g specific
instrum ent settings and electrode placem ent. Perform ing
testin g usin g differen t filter settin gs, sweep speeds, an d
sensitivity can affect the waveform m orphology and/or
the m easurem ent of the waveform param eters. Attention
n eeds to be m ade with respect to active an d referen ce electrode placem ent in accordance with the NCS technique
described.
For NCS, distan ce m easurem en ts are perform ed with a
sim ple tape m easure. Care m ust be taken to m ake precise
m easurem en t to reduce latency and calculated conduction
velocity errors. Over shorter in terstim ulus distances, m easurem en t errors produce significantly higher conduction
velocity calculation errors.
Physiologic factors such as age, tem perature, lim b
length/ heigh t, and anom alous innervations influence NCS
an d EMG. With respect to age, newborns have nerve conduction velocities on e-h alf of n orm al adult con duction
velocities. At the age of 3 to 5 years, conduction velocities reach adult values. After th e age of 50 years, conduction velocities drop 1 to 2 m per secon d per decade because of loss of large axons and segm ental demyelination /
remyelin ation . With advan cin g age, n erve con duction
amplitudes declin e as well. Compared with 18- to 25-year-
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66
Th e RicheCannieu anomaly occurs in up to 77% of people. It in volves an an atom ical con n ection of th e m edian
an d ulnar nerves in the hand between the recurrent branch
of th e m edian n erve an d th e deep bran ch of th e uln ar
nerve. The percentage of m edian nerve fibers involved is
quite variable. With th is varian t, it is clin ically possible to
have an all ulnar h and. In this case, a patien t with com plete severan ce of th e m edian n erve at th e wrist m ay con tin ue to h ave abductor pollicis brevis an d oppon en s pollicis
function.
At th e lower lim bs, the accessory deep peroneal nerve has
an in ciden ce up to 28% an d when present is bilateral up to
57% of th e tim e. Norm ally, th e exten sor digitorum brevis
(EDB) m uscle is innervated by the deep peroneal nerve.
In subjects with th e varian t, th e superficial peron eal n erve
gives off a branch (accessory deep peroneal nerve) to innervate the EDB. Clinically, a patient with a complete deep
peron eal n erve lesion m ay h ave a n orm al EDB EMG an d
norm al EDB fun ction.
ELECTROMYOGRAPHY
Needle EMG in volves th e use of a fin e n eedle electrode
to record electrical activity from m uscles. Th e m ost com m on ly used EMG n eedles are eith er concentric or monopolar.
Stan dard con cen tric n eedle electrodes con sist of a h ollow,
stainless steel cannula with a cen tral platin um or nich rom e
silver wire. The wire is the active electrode and the can n ula
serves as the referen ce electrode. Mon opolar needle electrodes con sist of a solid stain less steel n eedle th at is Teflon
coated except th e tip. The m onopolar needle serves as the
active electrode. A separate referen ce electrode, typically a
surface electrode, is required. The recordin g surface area of a
m on opolar n eedle is larger th an th at of a con cen tric, resultin g in recorded m otor un it action poten tials (MUAPs) with
larger amplitudes, lon ger duration s, an d m ore polyph asia.
Mon opolar n eedles are associated with m ore in terferen ce
an d backgroun d n oise but ten d to be less expen sive th an
concentric needles. Both concentric and m onopolar needles are available in differen t len gth s an d various gauges
(23 to 30 gauge). Th e m ajority of electrom yograph ers use
sterile disposable EMG n eedles, alth ough som e use n ondisposables an d sterilize th em before each use.
Patient Preparation
In gen eral, th e n eedle EMG ten ds to be m ore un com fortable th an th e NCS. It is recom m en ded th at th e patien t
be aware th at som e discom fort or pain m ay occur durin g testin g; h owever, m ost patien ts are able to tolerate th e
procedure with out problem . Patien t tolerability for electrodiagn ostic testin g is relian t on n um erous factors, in cludin g
the individuals pain tolerance as well as the exam in ers
tech n ique an d ability to keep th e patien t distracted. An algesic or an xiolytic m edication s prior to testin g can be used
Insertional Activity
Insertional activity an d muscle at rest are usually evaluated in
sam e sequence. The n eedle electrode is inserted into the
targeted m uscle wh ile th e m uscle is at rest. Th e patien ts
lim b m ay have to be repositioned to relax it adequately. The
n eedle is then quickly in serted furth er in 0.2 to 2 m m in crem en ts with a several secon d pause between in sertion s. Th e
n eedle m ovem en t m ech an ically depolarizes m uscle fibers
wh ile m oving th rough the m uscle. This depolarization is
recorded as bursts of electrical activity th at stop abruptly
after n eedle m ovem en t h as stopped. Norm al in sertion al
activity h as a duration of less th an 300 m s after n eedle
m ovem en t cessation . In creased in sertion al activity h as a
duration greater th an 300 m s after n eedle m ovem en t an d
can occur in m uscle denervation or myopathy but can be a
n orm al varian t. Decreased in sertion al activity is either the
absen ce or a sign ifican t reduction of th e electrical bursts
with n eedle m ovem en t. This can occur wh en the needle is
n ot in m uscle, but in stead in fat or scar tissue. Min im ally,
the needle electrode is inserted into four different regions
of th e m uscle at th ree differen t depth s.
Muscle at Rest
Wh en th e n eedle is bein g in serted, in sertion al activity is
assessed. When needle m ovem ent has stopped, the m uscle
at rest can be assessed. Electrical activity th at is not due to
n eedle m ovem en t or volun tary m uscle con traction is called
spontaneous activity.
Spon tan eous activity can be n orm al in th e form of miniature endplate potentials (MEPPs) and endplate spikes. Th ese
poten tials can be seen wh en th e n eedle electrode is placed
close to the m uscles endplate region. As these potentials
are norm al, and th e m ajority of other types of spontaneous
activity suggest pathology, it is critical to be able to identify MEPP and en dplate spikes. MEPP are th ought to originate from spontaneous release of single quanta of acetylch olin e at the presyn aptic nerve term in al. MEPP have sm all
amplitudes and duration, are irregular, and sound like a
seashell. Endplate spikes are m ech anically produced by
needle m ovem ent at the en dplate region, resulting in a subthreshold endplate potential. These spikes are larger th an
MEPPs; they are rapid and irregular and soun d like sputtering fat on a fryin g pan .
O th er types of spon tan eous activity frequen tly suggest path ology. Th is spon tan eous activity in cludes fibrillation poten tials, positive sh arp waves, complex repetitive
disch arges (CRDs), myoton ic disch arges, myokym ic disch arges, fasciculations, cramps, and trem ors. Each waveform has a distinct appearance and sound.
Fibrillation potentials an d positive sharp waves are often observed together. Alth ough th ey h ave different appearances,
their clinical significance is thought to be sim ilar. Fibrillations are usually biph asic or triphasic (initial downward
deflection ), of sh ort duration , of 20 to 1000 uV am plitude,
an d usually have regular rhyth m . Th ey sound like rain on
a tin roof. Th e amplitude of a fibrillation potential tends
to dim in ish with tim e. For example, fibrillation size in th e
first m on th can be up to 1000 uV. After on e year, th e size
is usually less than 100 uV. Positive sharp waves are usually biphasic (large in itial downward deflection, followed
by long upward deflection), have less than 1000 uV amplitude, and are regular (Fig. 4.7). Fibrillations an d positive
sh arp waves can occur in both neuropathic and myopath ic
processes. In a n europath ic process with m otor axon loss
an d Wallerian degeneration, m uscle fibers becom e denervated. Th e den ervated m uscle fibers can spon tan eously
produce action poten tials from sin gle m uscle fibers. Th ese
are known as fibrillation poten tials. There is controversy
on th e origin of positive sh arp waves, but m ost believe th ey
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are sim ilar to fibrillation s except that they require deform ation of a m uscle fiber by the needle electrode.
Fibrillation s an d positive sh arp waves can also occur in
prim ary m uscle disease. In a myopath ic process th at results in segm ental m uscle necrosis, portions of th e m uscle fiber m ay lose con n ection from th e term in al axon an d
becom e den ervated. O th er m yopath ic processes th at in volve significant inflam m ation an d m uscle fiber splittin g
can result in sim ilar den ervation of sin gle m uscle fibers.
Metabolic processes that affect m uscle can m ake the resting m uscle m em brane potential unstable an d also produce
fibrillations and positive sh arp waves without denervation.
CRDs are h igh -frequen cy disch arges th at ch aracteristically start an d stop abruptly. Th ey are m ade up of a run
of m ultiple spikes th at repeat regularly at a rate of 20 to
150 Hz. CRDs are th ough t to occur from eph aptic con duction along dam aged m uscle tissue. They are seen in m uscles
wh ere th ere h as been ch ron ic den ervation an d rein n ervation, such as certain myopath ies and chronic neuropath ies.
Th ey distin ctly h ave a m otorboat or m otorcyclesoun d.
Myotonic discharges are seen in myoton ic disorders, certain myopathies, and occasionally in ch ron ic neuropath ies.
Th ey origin ate from alteration s with th e m uscle m em bran e
ion channels. Ch aracteristically, th ey wax and wane with
respect to amplitude an d frequen cy, givin g th em a dive
bom bertype sound.
Clinical myokym ia is seen as a rippling m ovem ent of the
skin . Myokymic discharges occur as rhyth m ic bursts of discharges at a frequency of 0.1 to 10 Hz. Th e bursts are m ade
of a single m otor unit firin g up to 60 Hz. The rhyth m is
very regular, producing a soun d that has been described as
m archin g soldiers. Myokym ic disch arges likely originate
from eph aptic con duction alon g dam aged axon s. Lim b
myokym ia is classically seen in radiation -in duced plexopathy. As expected, th e in ciden ce of radiation plexopathy in creases with th e dose of radiation delivered. Th e on set of
radiation plexopathy varies from a few m on th s to several
years after exposures. Facial myokym ia is m ost com m on ly
seen in brain stem n eoplasm , m ultiple sclerosis, an d Bells
palsy.
Fasciculation s are clinically visible as spontaneous in term ittent con tractions of m uscle. Fasciculation potentials appear as norm al MUAPs but are very irregular. Voluntarily
activated MUAPs fire in a regular fashion an d not any slower
th an 4 to 5 Hz. Fasciculation s fire at frequen cies between
0.1 an d 10 Hz, but usually less th an 2 Hz. Th ey can be
benign and found in the norm al population, particularly
following fatigue, h eavy exercise, or caffein e. Path ological
fasciculation s are seen in m otor n euron disease such as
amyotrophic lateral sclerosis, as well as lower m otor neuron
diseases. There is no reliable way to distinguish benign
from m align an t fasciculation s. However, fin din g fasciculation potentials with other types of abn orm al spon tan eous activity (i.e., fibrillation s an d positive sh arp waves)
and abnorm al volun tary MUAPs would suggest that observed fasciculation poten tials are path ological.
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Cramps are sustain ed m uscle con traction s lastin g secon ds or m in utes. Th ey can be n orm al, or in duced by
electrolyte im balan ces, m etabolic disorders, or isch em ia.
Cramp discharges on needle EMG appear as m ultiple m otor
un its firin g in syn ch rony at 40 to 60 Hz. Th ey usually h ave
an abrupt onset and cessation but can fire irregularly in a
sputtering fashion, especially just before term in ation .
Atrem or can occur durin g volun tary m uscle con traction
but also can occur spon tan eously with th e m uscle at rest.
Tremor on needle EMG appears as synchronous bursts of
MUAPs. Trem or sounds sim ilar to myokym ia (m arching
soldiers); h owever, the in dividual bursts within a trem or
are composed of m any different m otor units, wh ereas
myokym ic bursts are m ade up of th e sam e m otor un it firin g
repetitively.
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firin g rate for a MUAP is about 30 to 50 Hz. Th is sequen ce of even ts is kn own as n orm al MUAP recruitm en t
(Fig. 4.9).
Reduced recruitm en t occurs in neuropathic disorders.
Reduced MUAP recruitm en t will be seen as a few MUAPs
firin g rapidly in stead of th e n orm al pattern . In a n europath ic disorder, eith er axon loss or demyelin ation can cause
dysfun ction of certain MUAPs. With m uscle con traction ,
the first MUAP will fire regularly at 5 Hz. With further
con traction, the first MUAP will in crease in frequency to
10 Hz. Th is is wh en th e secon d MUAP sh ould com e in . In
a n europathic disorder, th is second MUAP, and poten tially
the third MUAP (etc.), will not fire. The first MUAP keeps
increasing its firing frequency th ough. It m ay reach 20 to
30 Hz before th e n ext MUAP fires (if an oth er on e fires at
all) (Fig. 4.10).
Increased or early recruitm en t occurs in myopath ic disorders. In myopath ic disorders, th e MUAPs m ay be in tact;
however, the m uscle fibers are dysfunctional. In th is case,
the patient contracts the m uscle, the first MUAP fires at
5 Hz, but the force produced by this MUAP is m uch
less than th at anticipated due to the myopath ic process.
For this reason, the second MUAP will fire im m ediately
with th e first. Th e secon d MUAP also produces m uch less
force than expected, so the third MUAP activates im m edi-
motor unit action potential (MUAP) B and C are not present due
to a neuropathic process. MUAP A begins firing at 20 Hz because
MUAP B and C are not available. When motor unit A fires at 30 Hz,
MUAP D finally becomes activated at 20 Hz. With neurogenic recruitment, fewer motor units are firing at higher than anticipated
rates. (From Dumitru D, Amato AA, Zwarts M. Electrodiagnostic
Medicine. 2nd ed. Philadelphia, PA: Hanley & Belfus, 2002, with
permission.)
Single-Fiber Electromyography
Standard n eedle EMG evaluates MUAPs. A MUAP represents th e sum m ated electrical activity of all single m uscle
fibers belon gin g to on e m otor unit that are close enough
to the n eedle electrode to be recorded. Single-fiber EMG
(SFEMG) can evaluate the electrical activity from individual m uscle fibers. A SFEMG n eedle electrode is m ade up of
stain less steel cann ula with a central platinum wire sim ilar to a standard con centric needle; however, the wire exits through a side port of the cannula, resulting in a very
sm all recordin g surface (25 m ). Th is allows th e n eedle
to record from sin gle m uscle fibers. Fiber density an d jitter
are an alyzed with SFEMG, which has been used to better
un derstan d m otor un its in myopathy an d n europathy. Diagnostically, it is prim arily used to assess neurom uscular
jun ction disorders. Th is tech n ique is tech n ically dem an ding and n ot routinely perform ed by the m ajority of electrodiagn ostician s.
Fiber density is the n um ber of sin gle m uscle fibers from
th e sam e m otor un it with in th e uptake of th e n eedle electrode. In norm al hum an m uscles, very few m uscle fibers
from the sam e m otor un it are adjacent to each other. In
con dition s with m uscle den ervation followed by rein n ervation by collateral sproutin g, m ore m uscle fibers from the
sam e m otor unit can end up adjacent to each oth er. This
results in in creased fiber den sity, wh ich can be assessed by
SFEMG. Norm ative values for fiber density exist for various
m uscles and age groups. With advancing age, especially
after the sixth decade, fiber density gradually increases
because of den ervation / rein n ervation .
Jitter is the tim e variation between sin gle m uscle fiber
poten tial pairs. Th e variability is n orm ally between 5 an d
60 m icrosecon ds. Th e SFEMG n eedle is position ed in a
m uscle (usually the extensor digitorum com m un is), so that
two different single m uscle fiber action potentials can be
recorded at th e sam e tim e. Approxim ately 50 to 100 tim e in tervals per pair an d 20 differen t pairs are recorded. Norm al
values are available for specific m uscles and age groups. In
patien ts with n eurom uscular jun ction disorders, th e tim e
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variability between th e two single m uscle fiber action poten tials (jitter) in creases. In creasin g jitter can result in failure of n eurom uscular tran sm ission an d absen ce of th e secon d m uscle fiber action poten tial of th e pair. Th is is kn own
as blockin g.
SFEMG is th e m ost sen sitive test in th e diagn osis of myasthenia gravis (MG). As SFEMG is technically dem anding, it
is best used if RNS an d acetylch olin e an tibody test results
are n orm al in a patien t with suspected MG. Alth ough in creased jitter is quite sensitive in testing for n eurom uscular
jun ction disorders, it is n ot specific. It can also be seen in
neuropath ic and myopath ic disorders.
Figure 4.12 Conduction block. In a normal motor nerve (top), the compound muscle action po-
tential (CMAP) amplitude and morphology usually is similar between distal and proximal stimulation
sites. When focal demyelination has occurred (bottom), the distal CMAP amplitude and morphology
remains the same; however, the proximal CMAP drops in amplitude and the area becomes dispersed.
(From Preston DC, Shapiro BE. Electromyography and Neuromuscular Disorders. 2nd ed. Philadelphia, PA: Elsevier, Butterworth-Heinemann, 2005, with permission.)
71
Figure 4.13 Conduction block location and stimulation site. In these examples, a typical motor
conduction study is performed with stimulating a nerve distally and proximally and recording from a
muscle. Top: If a conduction block is present between the usual distal stimulation and the muscle, the
CMAP amplitudes will be low at both distal and proximal stimulation sites. Middle: If a conduction
block is present between the distal and proximal stimulation sites, a normal CMAP amplitude will be
recorded distally, while a reduced CMAP amplitude will occur proximally. Bottom: If a conduction
block is proximal to the most proximal stimulation site, the nerve remains normal distally; thus, both
proximal and distal stimulation sites produce normal CMAP amplitudes. (From Preston DC, Shapiro
BE. Electromyography and Neuromuscular Disorders. 2nd ed. Philadelphia, PA: Elsevier, ButterworthHeinemann, 2005, with permission.)
72
ies (NCS) with distal and proximal stimulation sites producing normal compound muscle action potential (CMAP) amplitudes. B: With
axon loss lesions, if enough time has occurred for Wallerian degeneration, CMAP amplitudes will decline at all stimulations sites.
Caveat: Notice how this pattern of abnormality could also represent conduction block distal to the most distal stimulation site (see
Fig. 4.13, Top). (From Preston DC, Shapiro BE. Electromyography
and Neuromuscular Disorders. 2nd ed. Philadelphia, PA: Elsevier,
Butterworth-Heinemann, 2005, with permission.)
In complete lesions (neurotm esis), the nerve is com pletely severed. Wallerian degen eration occurs over a 3- to
9-day period. Th e m otor an d sen sory NCS will be absen t
both proxim al an d distal to th e in jury site. On n eedle EMG,
no active MUAPs will be recruited from th e tested m uscle.
Fibrillation s an d positive sh arp waves will be seen aroun d
day 7 to day 10.
Tim in g of th e electrodiagn ostic study is crucial in evaluatin g n erve in juries. Alth ough eviden ce for focal dem yelination or conduction block can be seen im m ediately after
nerve injury, the fin din gs for axon loss an d Wallerian degeneration occur over a 3- to 9-day period. For th is reason ,
the electrodiagnostic findings for neurapraxia (focal demyelin ation ) versus axon otm esis/ n eurotm esis (axon loss)
m ay look identical durin g the first few days of injury. In the
followin g illustrations, nerve conductions perform ed im m ediately after injury look th e sam e for severe neurapraxia
versus neurotm esis. The difference is noted by day 7 to day
10. No respon se is produced with distal stim ulation for th e
neurotm etic lesion . The distal respon se rem ains norm al at
all tim es for th e n eurapraxic lesion (Figs. 4.15 and 4.16).
Optim ally, perform ing testing im m ediately after injury will
give a baseline that can be compared with testing at the
10- to 14-day poin t. From a practical stan dpoin t, waitin g to
test at th e 10- to 14-day poin t after in jury would be sufficient. If testing for a radiculopathy, waiting for 4 to 5 weeks
Mononeuropathies
Th e m ost com m on m on on europath ies are m edian n europathy at th e wrist, uln ar n europathy at th e elbow, radial
neuropathy at th e h um erus, an d peroneal n europathy at
the fibular h ead.
Median neuropathy at th e wrist is th e m ost com m on of
all m onon europathies. Clinically, it m anifests as carpal tunnel syndrom e. Patients typically com plain of n um bn ess in
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the wrist and does not pass through Guyons canal at the
wrist, it is not affected by ulnar n europathies at th e wrist
but can be affected by an uln ar n europathy at th e elbow.
If sign ifican t sen sory loss is n oted in th e m edial forearm ,
this suggests a lesion m ore proxim al to the elbow. Th e sensation to the m edial forearm is provided by the m edial
an tebrach ial cutan eous n erve, wh ich com es off th e m edial
cord of the brachial plexus; thus should be spared in an
uln ar n europathy at th e elbow.
Electrodiagnostic testin g for ulnar neuropathy at th e elbow ten ds to be less sen sitive th an testin g for m edian n europathy at th e wrist. Th is is due to tech n ical lim itation s of
the studies available. Milder lesions m ay not be detectable
by testing. Severe injuries will dem onstrate electrodiagnostic abn orm alities, but exact localization of th e in jury m ay
be difficult. Stan dard testin g in cludes uln ar sen sory, dorsal ulnar cutaneous, and uln ar m otor conduction s. Th e
m edian sen sory an d m otor con duction s are com m on ly
perform ed as well to rule out a polyn europathy or plexopathy. Th e fin din g of uln ar n erve slowed con duction velocity or a drop in amplitude across th e elbow h elp to
localize th e lesion th ere. Un fortun ately, th e error in m easurem ent an d calculating the conduction velocity across
the elbow is quite h igh , even with optim al elbow positionin g. A drop in m otor amplitude (con duction block) is useful for localizing th e lesion, but it is often not seen. A drop
in sen sory amplitude across th e elbow is difficult to call
abn orm al as n orm al temporal dispersion causes a drop
in sen sory amplitudes with m ore proxim al stim ulation .
Needle EMG m ay be n orm al in m ilder cases. In m ore severe cases, n eedle EMG will dem on strate decreased MUAP
recruitm en t an d fibrillation s/positive sh arp waves in ulnar in nervated forearm an d hand m uscles. As there are no
uln ar-in n ervated m uscles above th e elbow, th e EMG m ay
on ly be able to con clude th at an uln ar n europathy exists
proxim al to th e takeoff to th e flexor carpi uln ar m uscle.
Th e goals of electrodiagn ostic testin g for uln ar n europathy at th e elbow include localizing the lesion , determ inin g
the degree of demyelination versus axon loss, and rulin g
out oth er etiologies such as brach ial plexopathy or cervical
radiculopathy.
The m ost com m on en trapm ent site for the radial nerve is
at th e h um eral spiral groove. Th is n erve is quite susceptible
to compressive forces an d fractures as it wraps aroun d th e
m id h um erus. Patien ts can presen t with a wrist drop an d
num bness in a superficial radial sensory distribution . On
exam in ation , elbow exten sion sh ould be n orm al as th e triceps receive innervation from the radial nerve proxim ally to
the spiral groove. The exception would be tricepsweakness
secondary to direct m uscle traum a to the triceps m uscle at
the tim e of injury. Radially inn ervated m uscles distal to th e
spiral groove such as th e brachioradialis, and fin ger/ wrist
exten sors can be weak. Grip stren gth m ay seem weak, but
this is due to lack of m echanical advantage from loss of the
wrist extensors.
Electrodiagn ostic testin g in cludes radial m otor studies with stim ulation at the forearm , elbow, below spiral
groove, an d above spiral groove. A drop in m otor am plitude across the spiral groove signifies conduction block.
A drop in con duction velocity is less useful, due to error in m easurem en t. Th e superficial radial sen sory n erve
can be abn orm al if th ere h as been sign ifican t axon loss.
Needle EMG will dem on strate decreased MUAP recruitm ent. If m otor axon loss is present, fibrillations and positive sharp waves can be seen in radially innervated m uscles distal to th e spiral groove. Goals are to localize th e
lesion to the radial nerve at th e spiral groove, rule out radial
n europathy at th e axilla, radial n europathy at th e forearm
(posterior interosseous neuropathy), an d rule out brachial
plexopathy or cervical radiculopathy.
Peroneal neuropathy (or fibular neuropathy) m ost com m only occurs at th e fibular head. Th e nerve is susceptible to
com pression an d stretch in g th ere. Patien ts typically presen t
with a foot drop an d n um bn ess at th e lateral calf an d dorsum of th e foot. At th e fibular head, the com m on peroneal
n erve divides in to deep an d superficial bran ch es. Th e clinical presentation will vary depending on how m uch each
bran ch is affected. Electrodiagn ostic testin g com m on ly in cludes peron eal m otor con duction s at th e an kle, below th e
fibular head, an d above the fibular h ead. The superficial
peron eal n erve is tested with stim ulation at th e lateral calf
and will be abn orm al in lesions with sign ifican t axon loss.
Th e tibial m otor an d sural sen sory con duction s are usually obtained to rule out polyneuropathy or m ore proxim al
n europathy. Needle EMG would in clude peron eal inn ervated m uscles of th e lower lim b. To rule out a m ore proxim al lesion, testing tibial innervated m uscles and sciatic
innervated ham string m uscles is useful. The sh ort head of
th e biceps is particularly useful as it is in n ervated by th e
peron eal portion of th e sciatic n erve but above th e fibular h ead. Abnorm alities at this m uscle would place the lesion m ore proxim al to th e fibular head (sciatic nerve, lum bosacral plexus, or lum bosacral radiculopathy).
Polyneuropathies
Polyn europathy or gen eralized periph eral n europathy is
com m only assessed by electrodiagnostic studies. The differential diagnosis for polyneuropathy is vast. The goal
of electrodiagn ostic testin g is to con firm th e presen ce of
a polyn europathy and to classify it into a subcategory
to n arrow th e differen tial diagn osis. Specifically, th e testing should help determ ine whether the polyn europathy
is diffuse or m ultifocal, involves sensory an d/or m otor
fibers, an d prim arily in volves axon al loss an d/ or demyelin ation. Polyn europathy can be subdivided by electrodiagn ostic testing in to th e followin g categories: (a) uniform
demyelin atin g, m ixed sen sorim otor, (b) segm en tal demyelin atin g, m otor greater th an sen sory, (c) axon loss, m otor greater th an sen sory, (d) axon loss, sen sory, (e) axon
loss, m ixed sensorim otor, and (f) m ixed axon loss, demyelinating, sensorim otor.
For in stan ce, acute in flam m atory demyelin atin g polyneuropathy (AIDP) or Guillain-Barre syn drom e would
fall un der th e segm en tal dem yelin ation , m otor greater
than sensory polyneuropathy category. With segm ental demyelin ation , prom in en t con duction block an d abn orm al
temporal dispersion is seen . Alth ough demyelin ation is th e
m ain disease process, secondary axon loss can occur. This is
important to note as pure axon loss or pure demyelination
rarely occurs. Late respon ses such as F-waves an d H-reflexes
are frequently useful in assessing polyneuropathies as they
evaluate th e m ore proxim al portion s of th e n erves. Late
respon ses are particularly useful in AIDP, as th ey are frequen tly absen t early in th e course of th e disease wh ile th e
rest of th e electrodiagn ostic testin g rem ain s with in n orm al
lim its.
Most un iform demyelin atin g polyn europath ies are
hereditary. Hereditary m otor sensory neuropathy (HMSN)
I or Ch arcot-Marie-Tooth disease falls un der th is category.
Th e predom in an t fin din g is decreased con duction velocities with out conduction block or abnorm al temporal dispersion .
Th e m ajority of polyn europath ies are prim arily axon al.
Th e axon loss m ixed sen sorim otor polyn europathy is th e
largest category of polyneuropathy; hence the m ore difficult type of polyneuropathy to determ ine the cause. Causes
for axonal polyneuropathies include alcoholism , heavy
m etals, toxins, pharm aceuticals, connective tissue diseases,
en docrin e disorders, an d n utrition al deficien cies such as
B12 , folate, or th iam in e. NCS reveal reduced amplitudes.
Slowin g of con duction velocity can occur because of loss of
fast con ductin g axon s; h owever, con duction velocity does
not drop below 75% of norm al. If m otor axon loss is
presen t, n eedle EMG m ay sh ow fibrillation s/ positive sh arp
waves and abnorm al MUAPs.
A caveat regardin g electrodiagn ostic testin g an d
polyn europath ies is th e sm all-fiber polyn europathy. Stan dard electrodiagn ostic testin g assesses large fiber n erves. All
m otor n erves are large diam eter fibers; h owever, sen sory
fibers can be large or sm all. For th is reason , patien ts with
sm all-fiber polyn europathy m ay h ave n orm al electrodiagnostic studies. Fortunately, from a diagnostic stan dpoint,
m ost polyn europath ies will affect large an d sm all fibers.
However, com m on causes of polyneuropathy such as diabetes m ellitus an d alcoh olism , wh ich usually affect both
large an d sm all fibers, can also m an ifest predom in an tly as
a sm all-fiber polyn europathy.
Radiculopathies
Radiculopathies are disease processes in volvin g th e n erve
roots an d m ost com m on ly caused by compression from in tervertebral discs an d/ or osseoligam en tous structures. Although electrodiagn ostic testing ten ds to be sensitive for
75
76
Plexopathy
Brachial and lum bosacral plexopath ies are assessed with
electrodiagn ostic testin g in a sim ilar fash ion as radiculopath ies. Th e m ajor differen ce is plexus lesion s typically
occur distal to th e DRG. Th erefore, un like radiculpath ies,
plexus lesion s with sen sory axon loss will result in abn orm al sen sory n erve con duction s. For in stan ce, a patien t with
CONCLUSION
Electrodiagn ostic testin g used properly as an exten sion of
the clinical history an d exam ination can be an invaluable
way to assess neurom uscular disorders. The electrodiagnostic m edicine physician m ust have a strong knowledge base
in the disease processes being tested so that the clinical inform ation an d the electrodiagnostic data can be used appropriately. Atten tion to detail with respect to in strum en tation an d testin g tech n ique, is required to reduce errors.
Anatom ical variations and electrodiagnostic testing lim itation s n eed to be recogn ized. Improper use of electrodiagnostic testing will lead to m isdiagnosis. Optim al use of
electrodiagn ostic testin g can provide a defin itive diagn osis,
n arrow th e differen tial diagn oses by con firm in g or ruling
out certain types of path ology, h elp localize an d determ in e
the severity of lesions, and provide guidance with treatm ent
plan s an d progn osis.
REFERENCE
1. AANEM Nom en clature Com m ittee. AANEM glossary of term s in
electrodiagn ostic m edicin e. Muscle Nerve. 2001;24(suppl 10):S10
S11.
RECOMMENDED READINGS
Donofrio PD, Albers JW. AAEM m inim onograph #34: polyneuropathy: classification by nerve con duction studies and electrom yography. Muscle Nerve. 1990;13:889 903.
77
Musculoskeletal
Infections
An drew F. Ku n tz
John L. Esterhai
INTRODUCTION
Musculoskeletal infections are devastatin g problem s that
require sign ifican t tim e an d resources for proper treatm en t.
As a group, in fections of the bones, join ts, an d surrounding soft tissues are com m on and h ave the potential to cause
significant m orbidity. Treatm en t requires proper diagn osis
an d aggressive treatm en t. Surgical in tervention and antibiotic th erapy are th e m ain stays of successful eradication of
infection. Delayed or incomplete treatm ent can result in
ch ronic pain, deform ity, fun ctional impairm ent, and in the
worst case, loss of lim b or even death . Fortun ately, th e later
are rare and arrest of infection is typically achievable with
appropriate treatm ent.
PATHOGENESIS OF INFECTION
Th e h um an body possesses m any defen ses again st th e m ultitude of pathogens that can cause infection. On th e m ost
basic level, th ese defen se m ech an ism s in clude physical barriers, in n ate im m un ity, an d th e adaptive im m un e respon se.
In con cert, th ese system s protect th e body again st m icroscopic and m acroscopic path ogens. However, a breakdown
in any one of these defenses can result in the clinical picture
of in fection .
Th e skin an d m ucous m em bran es serve as a prim ary
barrier to in fection , blockin g th e en try of path ogen s in to
the bloodstream an d soft tissues. Even though these physical barriers are extrem ely effective in preventing infection,
they are certainly n ot absolute. When infectious m aterial
does violate th e skin or m ucus m em bran es, th e in n ate im m un e system is activated. Respon sible for th e signs and
symptom s of acute in flam m ation, activation of the in nate
80
ANTIBIOTICS
Antibiotic therapy is param ount in the treatm en t of m usculoskeletal infections. In order for antibiotic treatm ent to
be effective, an appropriate regim en m ust be selected. Typically, an tibiotic th erapy begin s with broad coverage, in order to treat th e m ost com m on path ogen s. On ce culture an d
sen sitivity data are available, th e an tibiotic regim en should
be tailored to th e specific in fection . Th is approach requires
knowledge of the m icroorganism s typically responsible for
specific infections, as well as th e m ech anism of action an d
spectrum of activity for com m on antibiotics.
Antibiotics can be broadly categorized into six groups on
the basis of their m echan ism of action. The first group of
an tibiotics in cludes th ose with activity again st th e bacterial
cell wall. Within this group, penicillins and cephalosporins
comprise a subgroup of antibiotics collectively referred to
as -lactam antibiotics. These antibiotics inhibit bacterial peptidoglycan synthesis via interaction with penicillinbin din g protein s on th e bacterial cell m em bran e. Th e spectrum of activity for th e various -lactam s is quite broad,
alth ough certain an tibiotics with in th e subgroup h ave a
narrow spectrum of coverage. -lactam ase inhibitors are a
subgroup of cell wall active antibiotics th at are available in
com bination with certain penicillin antibiotics. The com bin ation of th e two types of an tibiotics im proves coverage
again st both gram -positive an d gram -n egative organ ism s.
Vancomycin is another antibiotic in this group, interfer-
ing with insertion of glycan un its into the cell wall. Vancom ycin h as activity again st En terococcus species, Staphylococcus aureus, an d Staphylococcus epidermidis. It is th e an tibiotic of choice for MRSA and is com m on ly substituted
for penicillin or cephalosporin antibiotics in patients with
allergies to the -lactam s. Overall, th is broad group of antibiotics in cludes th e m ost com m only used antibiotics in
orth opaedics. Cell wall active an tibiotics are routin ely used
as antibiotic prophylaxis in the perioperative period and for
defin itive treatm en t of m usculoskeletal in fection s.
Th e secon d group of an tibiotics in cludes th ose active against bacterial ribosom es. Within this group, clin dam ycin bin ds to th e 50 S-ribosom al subun it, in h ibitin g
dissociation of peptidyl-tRNA from th e ribosom e durin g
tran slocation. Macrolide antibiotics (erythromycin, clarithromycin, etc.) function in a very sim ilar m anner.
Am in ogylcosides (gen tam ycin , tobram ycin , etc.) bin d to
cytoplasm ic ribosom al RNA, th ereby in h ibitin g bacterial
protein syn th esis. Th e tetracyclin es (tetracyclin e, doxycyclin e, etc.) also in h ibit bacterial syn th esis, but via in teraction with 70S- and 80S-ribosom es. Togeth er as a group,
these antibiotics provide activity against a broad spectrum
of path ogen s. Clin dam ycin is un ique am on g all an tibiotics
in that it achieves the highest an tibiotic concen tration in
bon e, wh ich is n early equal to serum con cen tration s following intraven ous adm inistration.
Rifam pin alon e com prises th e th ird group due to its
un ique m ech an ism of action . It in h ibits RNA syn th esis in
bacteria an d h as a spectrum of action again st m any gram positive an d gram -n egative bacteria. Rifam pin is rarely used
alone, as bacterial resistance to rifampin develops rapidly.
Th e fluoroquin olon es (ciprofloxacin , levofloxacin , etc.)
inh ibit DNA gyrase. All antibiotics in th is group have excellen t gram -n egative coverage. Certain an tibiotics with in
the group offer gram -positive an d atypical bacteria coverage. Unique to the fluoroquinolones is the excellen t serum
an tibiotic concentrations achieved following oral adm in istration . As a result, treatm ent with these antibiotics is often
associated with decreased cost of treatm ent and length of
h ospitalization .
Antim etabolites are another group of antibiotics, with
trim ethoprim -sulfam ethoxazole being the m ost com m on
drug in th is group. Trim eth oprim -sulfam eth oxazole is a
com bin ation of two an tim etabolites m ost effective wh en
given togeth er in fixed com bination. Trim ethoprim binds
to bacterial dihydrofolate reductase, in terferin g with folic
acid synthesis. Sulfam ethoxazole, a sulfonam ide, inhibits
bacterial dihydrofolate syn th etase, wh ich is also n ecessary for th e syn thesis of folic acid. Th erefore, th e two
an tim etabolites act synergistically to preven t th e production of folic acid, in h ibitin g bacterial developm en t.
Trim ethoprim -sulfam ethoxazole is a broad-spectrum antibiotic that h as excellent coverage against gram -n egative
organ ism s an d certain gram -positive bacteria as well.
Th e fin al group of an tibiotics in cludes th e reducin g com poun ds. Metron idazole is th e m ost com m on an tibiotic
TABLE 5.1
Mechanism of Action
Bind to penicillin-binding proteins on
bacterial cell membrane to inhibit
peptidoglycan synthesis
Interferes with insertion of glycan subunits
into the cell wall
Binds to 50S-ribosomal subunit, inhibiting
dissociation of peptidyl-tRNA from the
ribosome during translocation
Same as clindamycin
Bind to cytoplasmic ribosomal RNA to
inhibit bacterial protein synthesis
Bind to 70S- and 80S-ribosomes to inhibit
bacterial protein synthesis
Inhibits bacterial RNA synthesis
Inhibit bacterial DNA gyrase
Inhibits folic acid synthesis
Inhibits anaerobic DNA synthesis via free
radical damage to bacterial DNA
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Despite th e critical role an tibiotics play in th e preven tion an d treatm en t of m usculoskeletal in fection s, th eir use
m ust be m on itored closely, an d lim ited to appropriate situation s on ly, in order to m in im ize th e developm en t of an tibiotic resistan ce. Acquired an tibiotic resistan ce is m ediated by bacterial plasm id DNA. Subth erapeutic dosages,
treatm en t courses th at are too sh ort, an d th e use of in effective antibiotics can all lead to resistance. Resistan ce is
easily tran sm itted, wh ich m ay, in turn , in crease th e difficulty of treatin g in fection by lim itin g th e spectrum of
effective an tibiotics. In recen t years, an tibiotic resistan ce
h as been increasin g, due to all of th e reason s previously
outlin ed.
DIAGNOSIS OF INFECTION
Th e evaluation an d workup of in fection sh ould always begin with a though h istory and physical exam ination. Once
an adequate history has been obtained an d a detailed physical exam ination perform ed, radiograph ic an d laboratory
studies can aid in th e diagnosis of infection and identification of the causative pathogen. An understanding of the application an d lim itation s of th e various im agin g m odalities
and laboratory studies helps in the selection of appropriate
tests an d th e practice of cost-effective m edicin e.
IMAGING
Radiograph s are relatively in expen sive an d are excellen t
in showing bony an atomy, bone chan ges such as resorption and periosteal reaction, and in som e cases soft-tissue
swellin g. Radiographs are extrem ely helpful in evaluation
for the presen ce and configuration of orthopaedic hardware. Lucen cy at the bone-implant interface can be a sign
of in fection , but it can also represen t aseptic loosen in g.
Radiograph s effectively dem on strate fractures an d tum ors
th at can m im ic in fection on clin ical presen tation .
Computed tom ography (CT) is excellent for m ore detailed evaluation of th e m usculoskeletal system , as well as
for the assessm ent of three-dim ensional an atomy. CT is
useful in m any situation s, but it is particularly im portan t
wh en evaluatin g for fracture un ion in th e settin g of in fection, and in th e determ ination of the size of a lesion or
collection in soft tissues or bon e.
Magn etic resonance im aging (MRI) is useful for detecting m arrow changes during the early stages of infection.
It h as a sen sitivity th at approach es 100% wh en used for
th e detection of osteomyelitis. In th e settin g of osteom yelitis, local edem a and hyperem ia result in in creased sign al
on T2-weigh ted im ages an d decreased m arrow sign al on
T1-weigh ted im ages. However, th ese fin din gs can be difficult to in terpret after acute traum a, repeated in jury (such
as in the patient with periph eral neuropathy), or in the
presen ce of stain less steel orth opaedic h ardware. MRI is
82
LABORATORY STUDIES
Laboratory studies are also useful in the evaluation and
m an agem en t of m usculoskeletal in fection . Elevation of th e
periph eral wh ite blood cell (WBC) coun t with a predom in an ce of polym orph on uclear leukocytes is suggestive of
in fection . However, in greater th an h alf of patien ts with
m usculoskeletal in fection , an elevated WBC coun t is n ot
observed. Th erefore, th e eryth rocyte sedim en tation rate
(ESR) an d C-reactive protein (CRP) are th e m ore com m on ly used m arkers of in fection an d in flam m ation . Both
ESR and CRP are m arkers of acute inflam m ation. CRP begin s to rise with in 6 h ours of on set of in fection an d return s toward n orm al approxim ately 1 week after in itiation
of successful treatm en t. In con trast, th e ESR becom es elevated durin g the first 2 days of infection but does not norm alize un til rough ly 3 weeks after eradication of in fection .
As a result, th e CRP is m ore com m on ly used for diagn osis of acute in fection an d for m onitoring the response to
treatm ent. It is important to rem em ber that surgical in tervention also results in elevation of both the ESR and the
CRP.
Tissue an d fluid specim en s from th e site of in fection
sh ould be evaluated by culture and gram stain. Overall,
gram stain results in iden tification of a specific organ ism
in only one-third of cases. However, gram stain can be extrem ely specific and is often used to guide in itial an tibiotic selection . Th e gold stan dard in diagn osis of in fection
is tissue culture. Unfortunately, inadequate sampling, errors in h an dlin g an d processin g, an d effects of previously
adm inistered antibiotics can all result in incomplete and
false-n egative culture results.
Molecular gen etics m ay be th e future diagn ostic tech n ique of ch oice. Th e use of polym erase ch ain reaction
(PCR) to detect bacterial DNA with out the n eed for in
vitro culture could allow for earlier diagnosis and decrease
th e false-n egative rate from previous an tibiotic adm in istration. However, con cern s regarding false-positive results
stem m in g from th e extrem e sen sitivity of th is technique
rem ain un resolved.
ADULT INFECTIONS
Osteomyelitis
In strict defin ition , osteomyelitis refers to in flam m ation of
bon e or bon e m arrow. Sin ce th is in flam m ation is always
the result of infection , th e term osteomyelitis implies infection of bone or its m arrow contents. In the adult population , osteomyelitis m ost com m on ly results from con tiguous spread from local infection, traum a, or after a
surgical procedure such as open reduction and in ternal
fixation . Hem atogen ous spread is far less com m on , but it
does occur an d is m ost frequen tly en coun tered in in traven ous drug users. Infection with any bacteria can cause
osteomyelitis; h owever, Staphylococcus aureus is the m ost
com m on path ogen .
Classification
Osteomyelitis can be classified on the basis of patient
age (pediatric or adult), causative organism , pathogen esis
(contiguous spread, traum atic, hem atogenous), anatom ic
location , or duration of symptom s (acute, subacute,
ch ronic). These variables can be used individually or in
com bin ation for categorization. There are also a num ber
of n am ed classification system s th at focus on various clin ical aspects of osteomyelitis, but no one system is un iversally accepted. Th e m ost com m only used classification system for adult osteomyelitis is th e CiernyMader staging
system , which is based on the an atom ic location of infection within the bone an d the physiologic status of the host
(Table 5.2).
TABLE 5.2
Presentation
Th e clin ical presen tation of osteomyelitis is extrem ely variable. Host status, chronicity of infection, anatom ic location, and the offen ding pathogen(s) all factor in to the
clinical picture of each individual case. In general, system ic symptom s can in clude fever, ch ills, n igh t sweats,
an d m alaise. However, the absence of any or all of these
symptom s does not preclude a diagnosis of osteomyelitis.
Amyriad of local symptom s m ay also exist. Pain, erythem a,
warm th, and swelling are th e m ost com m on local indicators of osteomyelitis. A drain in g sin us tract m ay serve as
the cause of, or result from , an underlying bone infection.
Wh en th e lower extrem ity is in volved, a limp, pain with
weigh t-bearin g, or an in ability to bear weigh t m ay also be
associated with osteomyelitis.
History and Physical Examination
A thorough history should focus on the location, severity,
an d chronicity of local and system ic symptom s. A history
of previous m usculoskeletal surgery, open fracture, or in fection (in cluding a history of osteomyelitis) m ust always
be in vestigated. Curren t an d previous m edication s in cluding antibiotics, as well as drug allergies, should be obtained.
Vital signs should always be part of every physical exam in ation, as fever, tachycardia, and hypotension can all indicate
system ic illn ess or, in th e worst case, septic sh ock related to
hem atogenous spread of in fection. A detailed physical exam in ation should focus on local symptom s by evaluating
83
for erythem a, warm th , swelling, and tenderness to palpation . Evaluation of th e skin an d soft tissues m ust in clude
careful inspection for localized fluctuance and draining sin uses. In th e setting of prior fracture, bon e stability an d
ten dern ess at th e fracture site are assessed in order to determ in e clin ical fracture un ion . With con firm ed or suspected
osteom yelitis adjacen t to a join t, th e presen ce of an effusion or pain with range of m otion m ay indicate spread of
in fection in to th e join t resultin g in septic arth ritis.
Diagnostic Studies
As previously m en tion ed, both im agin g an d laboratory
studies are used in com bination to m ake the diagnosis
of osteomyelitis. However, th e on ly way to m ake a defin itive diagnosis is with tissue culture. This can be ach ieved
th rough surgical biopsy or n eedle aspiration in som e cases.
However, the com bin ation of h istory an d physical exam in ation, im aging, an d basic laboratory studies are often sufficient to raise suspicion for th e diagnosis of osteomyelitis
and initiate empiric antibiotic therapy.
Differential Diagnosis
Th e clin ical presen tation of osteomyelitis can be very sim ilar to the presentation of tum ors or fractures. Therefore,
th ese diagn oses m ust always be con sidered wh en suspicion for in fection is raised. On ce th e diagn osis of osteomyelitis h as been m ade, th e differen tial diagn osis of
causative path ogen s is exten sive. Overall, Staphylococcus aureus is the m ost com m on causative organism . In the setting of ch ron ic osteomyelitis, Staphylococcus epidermiditis,
Pseudomonas aeruginosa, Serratia marcescens, an d Escherichia
coli are also com m on causative organism s. Microbacteria,
fungi, and less virulent path ogens m ust be considered in
th e im m un ocomprom ised h ost.
Treatment
Successful treatm en t of osteomyelitis involves an aggressive, m ultifaceted approach . In cases of acute hem atogen ous osteom yelitis (AHO), an tibiotic th erapy alone can
be successful, with surgical debridem en t reserved for refractory scenarios. However, cases of chronic an d nonh em atogen ous osteomyelitis typically require soft-tissue
and bony debridem ent in conjunction with system ic and
local antibiotic therapy for successful results. Wh en lim b
salvage is th e goal of treatm ent, wound m anagem en t as
well as treatm en t of fracture n on un ion s, bony defects, an d
skeletal in stability m ust follow initial surgical debridem ent
and in itiation of an tibiotic therapy. Successful treatm ent
of osteomyelitis can be prolon ged an d associated with
sign ificant m orbidity. Th erefore, amputation should rem ain a treatm en t option in the m ost complex an d lim bth reaten in g situation s.
Adequate surgical debridem ent of nonviable bone and
soft tissue is param oun t in successful treatm ent of osteomyelitis. Debridem en t m ust proceed un til viable, bleeding tissue is confirm ed at th e surgical m argin s. In the
84
presen ce of n on h ost m aterials such as orth opaedic im plan ts, rem oval of all foreign m aterials is typically n ecessary
for cure. This is due to the rapid form ation of biofilm s by
the infectin g bacteria. Biofilm s are resistant to host defen ses
an d an tibiotic pen etration an d, th erefore, typically require h ardware rem oval for effective treatm en t. However, in
the setting of a healing fracture, the decision to retain or rem ove h ardware can be difficult. In th e acute settin g, prior to
the diagnosis of a non union, rigid internal fixation m ay be
retain ed in order to m ain tain fracture stability. If th e fracture goes on to un ion but in fection persists, th e im plan t
sh ould be rem oved. In th e setting of a n onunited fracture
an d loose h ardware, all loose implan ts sh ould be rem oved.
Fracture reduction an d stability sh ould be m ain tain ed by
an oth er m eth od such as extern al fixation . Wh eth er h ardware is present or not, adequate and aggressive debridem en t m ust in clude sen din g a sufficien t am oun t of local
tissue for path ology evaluation an d laboratory culture with
an tibiotic sen sitivity an alysis. Alth ough th orough debridem en t can be devastatin g to lim b fun ction an d stability, in adequate debridem en t is likely to result in treatm en t failure.
Early initiation of system ic antibiotic th erapy is also
critical to the successful treatm ent of osteomyelitis. Broadspectrum , em piric treatm ent should be started as early as
possible, with subsequen t an tibiotic th erapy tailored to a
specific organism on the basis of woun d biopsy and culture results. Th e stan dard of care for adult osteom yelitis
is 4 to 6 weeks of in traven ous an tibiotics. However, oral
therapy can have a role in lim ited situations. On ly antibiotics with good soft-tissue bioavailability such as lin ezolid
an d th e fluoroquin olon e an tibiotics are com m on ly used
in an oral regim en . Regardless of th e route of an tibiotic
adm in istration , th e surgical woun d an d th e ESR an d CRP
sh ould be m onitored over tim e to determ ine the success of
treatm en t.
In addition to system ic an tibiotic treatm en t, local delivery of an tibiotics h as also been sh own to be very successful.
Th e use of an tibiotic-impregn ated polym ethylm eth acrylate
(PMMA) cem ent allows for delivery of high concen trations
of an tibiotic to local tissues with a reduced risk for system ic
side effects and toxicity. Vancomycin, tobramycin, and cefepim e are all com m only used in this m anner as these
drugs are available in powder form an d un affected by th e
h igh tem peratures gen erated durin g settin g of th e cem en t.
PMMA can serve a dual purpose of providin g structural
support in th e presen ce of a bone defect as well as allowing for local delivery of antibiotics. Antibiotic-impregnated
PMMA can also be fash ion ed in to sm all beads, wh ich can
th en be packed in to th e soft tissues, allowin g for local
antibiotic delivery without providing structural support
(Fig. 5.1).
Followin g successful surgical debridem en t an d in itiation of antibiotic therapy, m anagem ent of both surgical an d n on surgical woun ds m ust begin early. Defin itive
woun d m an agem en t depen ds on th e status of th e local
soft tissues. When possible, prim ary closure or delay prim ary closure of a woun d is preferred. Wh en prim ary closure is n ot possible, eith er local or free m uscle flap coverage
sh ould be con sidered. Benefits of m uscle flaps include the
reestablish m en t of a physical barrier to in fection from outside sources as well as the elim ination of dead space, wh ich
results in in creased local delivery of system ic an tibiotics.
Before com m itting to tran sfer of a m uscle flap, th e viability and status of the m uscle to be used m ust be adequately
assessed. Transfer of dam aged and nonviable m uscle will
on ly in crease th e risk of local in fection , in stead of providin g
th e ben efits of a viable m uscle flap.
Th e fin al stage of treatm en t for osteomyelitis in volves
addressin g bone defects that result from infection and/ or
surgical debridem en t. Typically, bone defects are addressed
Septic Arthritis
Sim ilar to adult osteom yelitis, septic arth ritis in th e adult
population can result from h em atogen ous or adjacen t
tissue spread or direct inoculation of th e joint following traum a or surgery. Hem atogenous spread of bacteria
is m ost com m on. Im m unocomprom ised h osts, including
those with rheum atoid arthritis, system ic lupus erythem atous, or h um an im m un odeficien cy virus, an d th ose takin g
ch ronic im m unosuppressive m edication s, are at in creased
risk an d susceptibility to join t in fection . In traven ous drug
abusers are at an in creased risk as well, due to repeated
episodes of bacterem ia. Sin gle join t in volvem en t is m ost
com m on, although m ultifocal infection is not rare. Overall, the knee is th e m ost com m on ly affect joint.
All healthy joints possess several unique defenses to
infection. The synovial fluid in a healthy joint is significantly bactericidal. In addition, synoviocytes have phagocytic potential, allowing for rem oval of bacteria and other
path ogen s from th e in tra-articular en viron m en t. Th ese defense m echan ism s are altered in patients with rh eum atoid
arthritis an d lupus, resultin g in an increased risk of infection. Previously dam aged joints are also m ore susceptible
to in fection , due in part to syn ovial n eovascularity an d in creased syn ovial adhesion factors, both of which increase
the chance for hem atogenous bacterial spread an d joint
seedin g.
Followin g join t in oculation , activation of th e in n ate im m un e response results in local recruitm ent of polym orph on uclear leukocytes. Th e resultan t release of en zym es
from the recruited inflam m atory cells, syn oviocytes, and
bacteria in itiates degradation of glycosam in oglycan s in th e
articular cartilage. Th e end result is destruction of in traarticular cartilage. A large joint effusion can also cause a
rise in in tra-articular pressure, resultin g in th e poten tial for
reduced blood flow an d aseptic n ecrosis. Th is cascade of
even ts begin s early after in fection an d requires urgen t atten tion an d treatm en t in order to avoid join t destruction .
85
Classification
Th ere is n o specific classification system in place for septic
arth ritis. Infections can be grouped on th e basis of route
of in oculation , path ogen in volved, an d ch ron icity of in fection. In adult septic arth ritis, the m ost com m on classification is to divide nongonococcal from gonococcal arthritis. In young, sexually active adults, the m ost com m on
causative path ogen is Neisseria gonorrhoeae. Oth erwise,
S. aureus is th e m ost com m on path ogen . Periprosth etic in fections represent a separate class of septic arthritis and will
be discussed later in th e ch apter.
Presentation
Th e classic clin ical presen tation is on e of a pain ful, eryth em atous join t with a sign ifican t effusion . Patien ts typically h old th e affected join t m otion less. Wh en a join t of th e
lower extrem ity is involved, the patient m ay present with
th e in ability to bear weigh t on th e in volved lim b. System ic
sym ptom s of fever, chills, an d m alaise m ay be presen t. Just
as with osteomyelitis, host status, chronicity of infection ,
anatom ic location, and offending pathogen all factor in to
th e clin ical presen tation .
History and Physical Examination
Th e h istory of presen t illn ess sh ould focus on th e curren t
sym ptom s as well as th e patien ts overall m edical history
and any precipitating factors. The patien t should be questioned regarding previous surgeries, traum a to the affected
join t, an d any previous join t aspiration s. Pre-existin g join t
pain m ust be fully explored. A h istory of gout or pseudogout, rh eum atoid arth ritis, lupus, or any oth er system ic
illness m ust be in vestigated as well. A history of outdoor
activity or tick bite should also be sought to evaluate for the
possibility of Lym e disease (see Ch apter 11). Likewise, any
h istory of h um an or anim al bite sh ould be elucidated. A
th orough social h istory sh ould in clude th e patien ts sexual
activity, given the h igh prevalence of gonococcal arthritis in
th e youn g, sexually active adult. Fin ally, th e patien ts list of
m edications should be reviewed for any im m unosuppressive agen ts th at m ay im pair th e defense against infection or
m edications that m ay predispose the patient to gout.
Th e m ost com m on fin din gs on physical exam in ation are
eryth em a an d warm th associated with a join t effusion an d
sign ificant pain with joint m otion. In the im m unocompeten t h ost, m icrom otion pain or pain with even th e sligh test
m ovem ent of the joint should be considered septic arthritis un til proven otherwise. However, it is very important
to rem em ber that in the elderly or im m un ocomprom ised
patien t, th ese sign s an d symptom s m ay be dim in ish ed.
Eviden ce of previous surgery or traum a to th e affected
join t is im portan t to in vestigate. Ath orough physical exam ination should also evaluate other joints for sim ilar signs
of in fection . In n on gon ococcal arth ritis, m on oarticular in volvem en t occurs in 85% to 90% of cases. Polyarticular involvem en t is m ore com m on in cases of gon ococcal, viral,
Lym e, an d reactive arth ritis. Polyarticular arth ralgias, fever,
86
Diagnostic Studies
Although typically of m inim al use, x-rays are often obtain ed durin g th e evaluation an d workup of septic arth ritis.
X-rays m ay reveal th e presen ce of a foreign body followin g
a traum atic in jury, or ch on drocalcin osis an d juxta-articular
erosion s th at could sign ify ch ron ic or previous gouty arth ritis. In th e settin g of ch ron ic septic arth ritis, x-rays m ay reveal join t space n arrowin g or complete join t space obliteration with arth rofibrosis. However, in acute septic arth ritis,
the m ost com m on findings on x-ray are join t effusion and
soft-tissue swelling.
CT is m ore likely th an x-ray to reveal an effusion ; h owever, CT is oth erwise of m in im al h elp. MRI, on th e oth er
hand, is excellent for evaluation of soft-tissue edem a. Th erefore, MRI is the im aging m odality of choice for evaluation
of a join t effusion an d surroun din g soft-tissue swellin g.
Th is is especially true for evaluation of th e spin e an d sm all
join ts of th e h an ds an d feet. Ultrasoun d m ay reveal an effusion wh en a larger joint such as th e elbow, hip, or knee
is in volved. Ultrasoun d can be very useful wh en used to
guide a n eedle aspiration of a join t.
System ic laboratory m arkers of in flam m ation will be elevated in th e settin g of septic arth ritis. ESR an d CRP can n ot
be used to m ake a diagn osis of septic arth ritis but are com m on ly used to m on itor clin ical improvem en t followin g
treatm en t. An elevated system ic WBC coun t is presen t on ly
in 50% of patien ts with septic arth ritis. Sim ilarly, blood
cultures are rarely useful, being positive for the causative
organ ism in 50% of patien ts with n on gon ococcal arth ritis
an d in on ly 10% of th ose with gon ococcal arth ritis.
When gon ococcal arth ritis is suspected, a m ucosal surface culture sh ould be perform ed. In th e settin g of acute
gon ococcal arth ritis, cervical samples are positive for gon ococcus bacteria in m ore than 90% of wom en and urethral
samples are positive in up to 75% of m en . Pharyngeal specim en s are less reliable th an specim en s obtain ed from th e
prim ary source of in fection , such as th e ureth ra or cervix.
Positive culture from any m ucosal m em brane is m uch less
com m on with chron ic and dissem inated gonococcal in fection s. PCR an alysis of cervical, vagin al, ureth ral, an d urin e
specim ens allows for screen in g of the asymptom atic patien t
an d can be used in con jun ction with tissue culture.
The gold standard in the diagnosis of septic arth ritis rem ain s arth rocen tesis with an alysis of th e syn ovial fluid.
Join t fluid should be sent for WBC coun t with differential,
crystal analysis, gram stain , and culture. Diagnosis of septic
arth ritis is confirm ed when the syn ovial fluid WBC count
is greater than 50,000 cells per m m 3 , with a differential of
greater th an 75% polym orph on uclear cells. It is critical to
rem em ber th at a cell coun t lower than th is does n ot preclude a diagn osis of septic arth ritis, as th e im m un ocom prom ised h ost m ay n ot be capable of m oun tin g such an
im m une response. A diagnosis of gout or pseudogout can
be m ade wh en crystal an alysis reveals n egatively or positively birefringent crystals, respectively. Gram stain of the
syn ovial fluid m ay n ot be diagnostic for a specific organism
but can be used to tailor in itial an tibiotic th erapy. Syn ovial
fluid culture is m ost important, but positive only in 90%
of patien ts with n on gon ococcal arth ritis an d in 25% of patients with gonococcal arthritis. Previous adm inistration of
an tibiotics can result in false-negative culture results. PCR
tech n iques can also be used to amplify an d detect bacterial
DNA presen t in th e syn ovial fluid. However, th ese tests are
not curren tly part of stan dard syn ovial fluid an alysis.
Differential Diagnosis
Th e differen tial diagn osis of septic arth ritis is broad. As
previously m en tion ed, septic bursitis can closely resem ble in tra-articular in fection . However, careful exam in ation ,
use of appropriate im agin g, an d m in dful aspiration of th e
bursa an d n ot th e join t (or vice versa) will con firm th e
diagn osis of on e versus th e oth er. Th e clin ical presen tation of crystalline arth ropathy can also be identical to that
of septic arth ritis. Join t aspiration with crystal an alysis is
typically required to confirm a diagnosis of gout or pseudogout. Reactive arth ritis is an autoim m un e con dition th at
closely m im ics septic arthritis. The classic triad of arthritis,
especially if it is polyarticular, con jun ctivitis, an d ureth ritis, and a history of previous viral or bacterial infection
sh ould raise the suspicion of reactive arthritis. In the case
of reactive arth ritis, join t aspiration m ay reveal an elevated
WBC coun t, sim ilar to th at seen in septic arth ritis, but gram
stain an d culture are n egative. On ce the diagnosis of septic arthritis is m ade, the differen tial diagnosis of causative
organ ism s is exten sive. Clin ical h istory an d syn ovial fluid
culture are then used to determ ine th e pathogen and dictate
defin itive treatm en t.
Treatment
Surgical treatm en t is th e stan dard of care for n on gon ococcal septic arth ritis. Join t arthrotomy with irrigation
an d debridem en t has traditionally been the treatm en t of
ch oice. However, arthroscopic irrigation and debridem ent
are com m on for larger, easily accessible joints. Regardless
of th e m eth od of surgical in terven tion , treatm en t aim s to
relieve join t pressure th rough evacuation of effusion , an d
rem ove bacteria, in flam m atory m ediators, an d en zym es
via copious irrigation. Early treatm en t with this approach
can m inim ize cartilage dam age. When in fection in volves
intra-articular hardware or allograft m aterial, rem oval of
the non host m aterial is often required. In the setting of
ch ronic or recurrent infection s, complete synovectomy is
often perform ed. Wh en surgical in terven tion is n ot possible, due to th e patien ts com orbidities or oth er exten uatin g
circum stances, serial joint aspirations can be effective. Serial aspiration s sh ould n ot be con sidered for septic arth ritis
of th e h ip or sm all join ts.
In addition to surgical decompression an d join t lavage,
an tibiotic therapy m ust be started early, typically once joint
fluid cultures have been collected. When system ic antibiotics h ave to be started prior to surgical in terven tion , an
attempt should be m ade to obtain adequate join t fluid
via arth rocentesis before antibiotic adm inistration. Otherwise, culture results m ay be falsely n egative. In th e h ealthy
adult, therapy typically begins with a th ird-generation
ceph alosporin to treat for both S. aureus an d N. gonorrhoeae.
An tibiotic th erapy can th en be adjusted on th e basis of culture results. A m inim um of 4 weeks of antibiotic therapy is
standard for n on gonococcal arthritis.
Th e treatm en t of acute gon ococcal arth ritis varies significantly from nongonococcal septic arth ritis. Followin g
join t aspiration an d con firm ation of gon ococcal in fection, intravenous antibiotic therapy with a third-generation
ceph alosporin is in itiated. On ce clin ical im provem en t is
noted, typically 24 to 48 hours after antibiotic initiation,
antibiotic th erapy is changed to an oral third-generation
ceph alosporin . Oral an tibiotics are con tin ued for a m in im um of 1 week or until the resolution of symptom s.
Patien ts with large join t effusion s m ay require a lon ger
course of an tibiotics un til th e effusion h as resolved, but
surgical drainage is rarely required. Patients with ch ronic
or dissem in ated gon ococcal in fection s require in traven ous
antibiotics for 4 to 6 weeks and should be m onitored closely
87
PEDIATRIC INFECTIONS
Osteomyelitis
Pathogenesis
Un like adult osteomyelitis, osteomyelitis in the pediatric
population is m ost com m on ly acute in presen tation an d
h em atogen ous in origin . In fection due to traum a, surgery,
or spread from a local site is less com m on . Sim ilarly, subacute an d chronic presentations of osteomyelitis are less
com m on th an in adults. Pediatric osteom yelitis usually occurs in th e m etaphysis of lon g bon es, especially th e fem ur an d the tibia. In the m etaphyseal region , end-arteries
transition into large venous sinusoids and circulation is
sign ificantly slowed; this allows blood-borne organism s to
m igrate through vessel walls and deposit in th e porous cancellous bon e (Fig. 5.2). In addition , th e m etaphysis h as a
relative lack of ph agocytic cells, m akin g it easier for bacteria to establish a clin ical in fection . On ce form ed, purulence can spread th rough th e cancellous bone and eventually rupture through the thin m etaphyseal cortex, creating
a subperiosteal abscess (Fig. 5.3). Increasing pressure under th e periosteum can cause isch em ia to th e un derlyin g
cortical bon e, wh ich m ay becom e n ecrotic. Th e dead bon e
th at results from th is process is kn own as a sequestrum .
Since the overlying periosteum rem ains viable, n ew bone
Figure 5.2 (A) In the metaphysis, a low flow state is present as end arteries transition into venous
lakes; this allows bacteria to migrate through vessel walls. This region is also relatively deficient in
phagocytic cells. B: Once established, the infection will eventually track through the porous metaphyseal cortical surface and elevate the surrounding periosteum. If the metaphysis is intra-articular
(see section on septic arthritis), the infection can break into the joint and cause a septic arthritis.
C: The elevated periosteum lays down new bone initially (involucrum), and the dead bone becomes
a sequestrum. (Reproduced with permission from Dormans JP, Drummond DS. Pediatric hematogenous osteomyelitis: new trends in presentation, diagnosis, and treatment J Am Acad Orthop Surg.
1994;2:333341.)
88
B
Figure 5.3 (A) Sagittal and (B) axial MRI (magnetic resonance imaging) images demonstrating
osteomyelitis of the distal tibia with a large posterior subperiosteal abscess. (Courtesy of Wudbhav
Sankar, MD.)
Classification
O steom yelitis in ch ildren is gen erally classified by th e
ch ron icity of sym ptom s. As m en tion ed, acute osteomyelitis
is th e m ost com m on presen tation . Subacute osteomyelitis
is caused by a sim ilar m ech an ism but usually in volves a
less virulen t path ogen . Patien ts often h ave m ild to m oderate sym ptom s for several weeks or m on th s before th e
Presentation
Ch ildren with acute osteomyelitis classically present with
pain , fever, an d refusal to bear weigh t on th e in volved extrem ity. In the n eon atal population, presentation can be
m uch m ore subtle, m akin g diagnosis a challenge. The differential diagnosis for pseudoparalysis of a lim b in the
n eon ate m ust always in clude osteom yelitis un til infection
is defin itively excluded.
History and Physical Examination
A careful an d detailed h istory m ust be obtain ed from th e
ch ild and care provider. Attention should focus on com plain ts of system ic illn ess such as fever, ch ills, or m alaise.
A history of recent bacterial or viral infection at any site
including th e respiratory and gastrointestinal system s is
important to obtain. Likewise, any history of surgery or
traum a m ust be noted. A thorough m edical h istory should
always be included in any workup, including details of contact with sick in dividuals. In ch ildren old en ough to cooperate, a h istory of acute on set of symptom s with localized
bon e pain is m ost com m on . In th ese patien ts, th e pain is
Diagnostic Studies
Sim ilar to th e workup of adult osteomyelitis, both laboratory an d im agin g studies are routin e in th e evaluation of pediatric osteom yelitis. In th e settin g of AHO , th e m ost com m on finding on plain radiograph s is soft-tissue swellin g.
Focal osteopen ia an d periosteal ch an ges in cludin g elevation, th ickening, an d n ew bone form ation can also be observed but are not typically present un til later in the course
of disease. It is im portan t to rem em ber th at th ese radiograph ic ch an ges lag beh in d clin ical symptom s by up to
2 weeks, both at clin ical presen tation an d after appropriate
treatm ent has been initiated. Lytic lesions are typically not
eviden t un til m ore th an 50% of th e bon e m atrix h as been
destroyed.
CT is n ot com m on ly n ecessary in th e diagn osis of pediatric osteomyelitis. Wh ile ultrasound m ay be helpful to localize an abscess, MRI is th e m ost com m on im aging m odality for the evaluation of osteomyelitis in children. Both th e
high sen sitivity and specificity of MRI and the absen ce of
exposure to radiation h ave in creased th e use of MRI in th is
population . Because of its superior soft-tissue resolution ,
MRI is extrem ely useful for differentiating cellulitis from osteomyelitis an d for rulin g out th e presen ce of a n eoplasm .
In addition to its diagn ostic utility, MRI allows accurate localization of subperiosteal an d soft-tissue abscess, which is
extrem ely h elpful in guidin g surgical treatm en t.
Although th e use of bon e scan s has been som ewhat
replaced by MRI, th is m odality is still useful especially
wh en th e site of in fection is un clear. Acute osetomyelitis generally dem onstrates increased uptake on all three
ph ases. In certain cases, a cold scan can be eviden ce of
severe and/ or chron ic osteomyelitis. Th e biggest lim itation
of bon e scan n in g, h owever, is a relative lack of specificity
sin ce a h otscan can be caused by traum a, tum or, or even
disuse.
Laboratories studies routinely ordered for evaluation of
pediatric osteom yelitis in clude a periph eral WBC coun t
with differen tial, ESR, an d CRP. On clin ical presen tation ,
an elevated CRP will be present in greater than 95% of children with AHO . Elevation of th e ESRabove 40 m m per h our
is also com m on. Elevation of the peripheral WBC coun t is
m uch less reliable, with an elevated result observed on ly in
89
50% of cases. Blood cultures can be helpful but are negative in rough ly h alf th e patien ts. Th e m ost reliable way to
obtain a defin itive diagn osis is with bon e aspiration or surgical culture, wh ich reveal th e causative organ ism in up to
85% of cases.
Differential Diagnosis
A broad differential m ust be kept in m in d wh en evaluatin g
a child with suspected osteomyelitis. While the clinical presentation m ay be clearer in the older child, in the neonate
and young child, symptom s are often vague and studies
m ay be n ondiagnostic. Fracture and tum or can com m only
presen t in a very sim ilar m an n er an d th erefore m ust be
excluded durin g th e workup. Septic arth ritis m ust also be
excluded. In ch ildren with sickle cell an em ia, bon e in farction m ust be differen tiated from acute osteomyelitis.
Treatment
An tibiotics sh ould be in itiated early, preferably after bon e
aspiration or surgical culture has been perform ed. Initial
antibiotic th erapy should be directed at the m ost com m on
path ogen for th e ch ilds age group. Because S. aureus is com m on in every age group, antibiotic therapy should always
provide coverage for this organism . Both oral and in travenous antibiotic regim ens have been proven successful,
depending on the clinical presentation and the responsible organ ism . The m ost com m on course of antibiotics is 4
to 6 weeks.
In patien ts with AHO , prompt in itiation of an tibiotic
th erapy m ay preven t th e n eed for surgical in terven tion . Surgical incision and drainage is indicated if an abscess develops or if th e ch ild fails to respond to m edical th erapy alone.
With appropriate an tibiotic treatm ent, roughly 50% of patien ts do not require surgery due to the lack of abscess form ation . In cases of late presentation , chronic osteomyelitis,
septic arth ritis of th e adjacen t join t, or n on h em atogen ous
origin, surgical treatm ent is often necessary.
Septic Arthritis
Pathogenesis
Septic arthritis in children is often caused by sim ilar
path ogen s as for osteom yelitis, but patien ts gen erally
presen t m ore rapidly with m ore severe symptom s. Join t
infections in the pediatric population are typically due to
h em atogen ous spread, alth ough spread from an adjacent
infection and direct inoculation from surgery or traum a
can occur. As discussed in th e previous section , con tiguous spread from adjacen t m etaphyseal osteomyelitis in
n eon ates is possible due to blood vessels th at traverse the
physis. In ch ildren , septic arth ritis can be caused by adjacen t m etaphyseal osteom yelitis in th e elbow, sh oulder,
h ip, an d ankle sin ce a portion of th e m etaphysis is con tain ed with in th e capsule for th ese join ts. Overall, th e kn ees
and hips are the m ost com m only involved joints in all age
groups.
90
Classification
Th ere is n o specific classification system of septic arth ritis
in ch ildren . In fection s are typically classified as acute or
ch ron ic an d by th e m ech an ism of in fection . Th e age of th e
patien t is also useful to con sider.
Presentation
Clin ical presen tation is very sim ilar to th at of osteomyelitis, alth ough symptom s are often m ore severe. Like oth er
in fection s, th e m ost com m on clin ical symptom s on presen tation are fever, pain, an d refusal to m ove th e involved
join t. O lder patien ts, in particular, are m ore likely to verbalize th eir pain as associated with m otion of th e in volved
join t. Th us, pseudoparalysis is a com m on presen tation , as
is th e refusal to bear weigh t wh en a lower extrem ity join t is
in volved.
History and Physical Examination
Th e ch ild an d th e caregiver sh ould be question ed regardin g th e on set of symptom s an d th e presen ce of con stitution al symptom s. Sym ptom s associated with rh eum atic
fever an d poststreptococcal arthritis, such as m igratory
arth ritis, pain ful subcutan eous n odules, rash an d/ or carditis, sh ould be specifically question ed. A h istory of traum a,
in cludin g bite an d pun cture woun ds, sh ould be in vestigated. In addition to th ese specific question s, a th orough m edical an d surgical h istory sh ould always be
obtain ed.
Physical exam in ation typically reveals a pain ful, eryth em atous, an d swollen join t. Th e h allm ark physical fin din g
is severe pain with even m icro-m otion of th e affected join t.
When the lower extrem ity is in volved, the in ability to bear
weigh t is com m on. In the setting of h ip joint infection,
the extrem ity is typically held in a position of sligh t flexion , with m ore pron oun ced abduction an d extern al rotation . Th is position m axim izes th e volum e of th e h ip join t,
thereby reducing irritation of the joint capsule that results
from th e joint effusion.
Diagnostic Studies
Diagn ostic studies are th e sam e as th ose discussed for osteomyelitis in th e ch ild. O n ce again , elevation of th e peripheral WBC count is present only in 50% of patients.
However, the ESR an d CRP are elevated in m ore than 90%
of patien ts with septic arth ritis. Any ch ild suspected of h avin g a septic join t sh ould h ave h is or h er join t aspirated to
m ake th e defin itive diagn osis. Syn ovial fluid sh ould be sen t
for WBC count, gram stain, culture, and crystal an alysis.
Sim ilar to th e adult population , elevation of th e join t fluid
WBC count above 50,000 cells per m m 3 is h ighly suggestive
of septic arth ritis. Som e ch ildren , h owever, m ay m an ifest
lower cell counts. Therefore, an evaluation of the gram stain
an d culture are very importan t for determ in in g th e appropriate treatm en t.
Plain radiograph s of th e affected join t m ay reveal an
effusion with or with out surroun din g soft-tissue swellin g.
Differential Diagnosis
Th e differen tial diagn osis for septic arth ritis in cludes osteomyelitis an d join t effusion caused by in flam m atory
arthropathy including rheum atic fever, poststreptococcal
arthritis, and juvenile rheum atoid arthritis. Lym e disease
is a septic arthritis of sorts but is nonpyogen ic and rarely
requires surgical treatm en t (see Ch apter 11). Wh en th e h ip
is involved, th e m ost important condition to consider in the
differen tial diagn osis for septic arth ritis is tran sien t syn ovitis (see Chapter 11). According to a study by Koch er et al.
in 1999, four signs and symptom s can be used to differen tiate th ese two con dition s. Wh en a ch ild presen ts with
a fever, in ability to bear weigh t, a periph eral WBC count
greater th an 12,000 cells per m m 3 , and an ESR greater th an
40 m m per h our, the diagnosis is septic arthritis m ore than
99% of the tim e. When only three of these signs or symptom s are presen t, th e probability of septic arth ritis drops
to 93%. Septic arth ritis is th e correct diagn osis in 40% an d
3% of patients when on ly two or one variable is present,
respectively.
Treatment
Septic arth ritis sh ould be con sidered a surgical em ergen cy,
an d irrigation an d drainage in the operating room is th e
gold standard of treatm ent. Both open and arthroscopic
tech n iques h ave been proven successful, but surgery m ust
be accom plish ed urgen tly in order to avoid dam age to th e
articular cartilage. Urgent treatm ent is even m ore important
for septic arthritis of the hip in order to avoid necrosis of
the fem oral head th at can result from the increased intraarticular pressure created by th e join t effusion. Sim ilar to
adult septic arthritis, serial aspiration of easily accessible
join ts m ay be appropriate in select scen arios.
In addition to surgical decompression , early an tibiotic
therapy m ust be in itiated. Once synovial fluid has been obtain ed for culture, em piric an tibiotic th erapy sh ould begin .
Culture and sensitivity results can then be used to tailor antibiotic th erapy as they becom e available. A m inim um of
three weeks of treatm ent is routine, with the poten tial for
con version from intravenous to oral antibiotics as clinical
improvem ent is observed.
PERIPROSTHETIC INFECTIONS
With the num ber of joint arthroplasties perform ed each
year exceeding one m illion in the United States alone,
the complications of these procedures pose a significant
burden on both th e affected in dividual an d th e h ealth
care system . One devastating complication of joint replacem en t surgery is periprosthetic infection . The incidence of
periprosth etic in fection is rough ly 1% for all form s of
arthroplasty. Infection results from direct in oculation or
hem atogenous spread of th e offendin g organ ism . Direct
inoculation can occur at the tim e of surgery, in the early
postoperative period in th e settin g of a drain in g woun d, or
at any tim e following join t replacem ent due to traum a to
the joint. Hem atogen ous spread can occur at any tim e but is
m ost com m on in the two years followin g placem ent of the
arthroplasty. It is theorized that the increased infection rate
durin g th is period is related to th e relative hypervascularity
of th e syn ovium th at results from surgery an d in complete
host m echan ical protection of the componen ts.
Classification
Periprosthetic infection s are com m only classified on th e
basis of th e duration of sym ptom s. Acute in fection s can occur in the im m ediate postoperative period or at any tim e rem ote from arthroplasty due to acute h em atogenous spread.
Acute infection s in the postoperative period are defined
as those presen ting with in 4 weeks of the in itial surgery.
Acute hem atogenous infections are those in which symptom s h ave persisted for less th an 2 to 4 weeks in a previously
well-fun ction in g, asym ptom atic join t. Ch ron ic in fection s
are those that have persisted for longer than 4 weeks. Th is
classification is important in determ ining the appropriate
treatm ent.
Presentation
Th e presen tation of a periprosth etic in fection can be iden tical to septic arth ritis of a native joint. Local symptom s
m ay include pain , drain age, and decreased range of m otion.
System ic sym ptom s m ay also be presen t, but th eir absen ce
does n ot exclude th e diagn osis of in fection . In m any cases,
pain is th e on ly sym ptom . In fection m ust also be con sidered as th e cause of failure in any failed arth roplasty.
History and Physical Examination
Wh en periprosth etic in fection is on th e differen tial diagnosis, history should first focus on the duration of symptom s. Truly acute in fection s m ust be differen tiated from
ch ronic and acute-on-chronic processes. Often, th e history is th e on ly way to m ake th is determ in ation . Wh en
an acute hem atogen ous infection is suspected, a source of
bacterem ia such as a recen t den tal or urologic procedure,
infection at a rem ote site, or even penetrating traum a at an oth er site sh ould be sough t. Th e h istory of woun d h ealin g
an d appearance is important wh en a chronic infection is
91
bein g con sidered. Any h istory of woun d drain age or delayed woun d h ealin g sh ould raise th e suspicion for in fection origin atin g durin g th e origin al perioperative period.
Eryth em a, edem a, pain , an d decreased ran ge of m otion are all com m on fin din gs on physical exam in ation .
Although wound drainage in the im m ediate postoperative
period m ay in crease th e risk of in fection , it is n ot a defin ite
sign of in fection. However, wound drainage at any other
poin t followin g arth roplasty is h igh ly con cern in g for in fection. Chronically draining woun ds m ust be inspected
thorough ly for the presen ce of sin us tracts th at m ay com m un icate directly with th e join t an d prosth esis.
Diagnostic Studies
Th e diagn ostic workup for a periprosth etic in fection sh ould
always begin with basic laboratory tests including WBC
coun t, ESR, an d CRP. In fection can essen tially be ruled out
wh en th e ESR, CRP, an d periph eral WBC coun t are all n orm al. However, wh en any on e of these laboratory values is
elevated or wh en clin ical suspicion in dicates, join t aspiration should be perform ed. The aspirate m ust be sent for cell
coun t an d culture. Un like septic arth ritis in a n ative join t,
th e cutoff value for diagn osin g in fection based on th e n um ber of leukocytes in th e join t fluid aspirate is lower. Based
on n ewer data, th e cutoff value h as been proposed as low
as 1,700 WBCs per m icroliter of joint aspirate. However,
2,500 cells per m icroliter is curren tly th e m ost com m on ly
accepted value. In the absence of previously adm inistered
antibiotics, positive culture results carry up to 86% sensitivity and 94% specificity for in fection. When antibiotics
h ave been adm in istered prior to aspiration , n egative culture results do n ot indicate the absence of in fection. Alth ough join t fluid is often sen t for gram stain an alysis, th e
results from such a procedure h ave very low sen sitivity an d
specificity as wear debris can be m isin terpreted as bacteria. Wh en preoperative testin g fails to con firm a diagn osis of in fection , intra-operative frozen section analysis of
th e periprosth etic tissue an d implan t m em bran es sh ould
be perform ed. Alth ough criteria for diagn osin g in fection
based on frozen section an alysis h as n ot been defin itively
establish ed, m ore th an five n eutroph ils per h igh -powered
field is routinely regarded as suggestive of infection.
Other serum m arkers and laboratory techn iques have
been proposed an d in vestigated recen tly in order to fin d
m ore sensitive and specific tests for diagnosing periprosth etic in fection . However, n on e are routin ely used at th is
poin t. On e prom isin g serum m arker is in terlukin -6 (IL-6), a
factor produced by m on ocytes an d m acroph ages. Alth ough
th e serum IL-6 level can be elevated in th e settin g of in fection, inflam m atory arthropathy, or recent surgery, values
n orm alize with in 48 h ours of operation an d are not elevated in the presence of aseptic loosening. Molecular biology tech n iques h ave also been in vestigated. PCR h as been
used to detect th e presen ce of bacteria, m ost com m on ly
by iden tifying th e 16S rRNA gene conserved by nearly all
bacterial species. Un fortun ately, use of PCR h as resulted
92
B
Figure 5.4 Radiographs in a patient status post right total hip arthroplasty. At initial follow-up,
radiographs show (A) a well-fixed acetabular component with no evidence of loosening. One year
later, radiographs demonstrate (B) lucency around the entire acetabular component. Further workup
confirmed the diagnosis of infection.
Differential Diagnosis
Although S. aureus is the m ost com m on pathogen in
periprosth etic in fection s, th e differen tial diagn osis for poten tial causative organ ism s is quite broad, an d th e possible source and m echan ism of infection is even greater.
Treatment
Because of th e m orbidity of periprosth etic in fection s, every
effort sh ould be m ade to preven t th eir occurren ce. Prior to
join t replacem en t surgery, patien ts sh ould un dergo routine assessm ent to ensure good dental hygiene and the
absen ce of in dolent in fection, such as a urinary tract infection. Antibiotics are always given im m ediately prior to
surgery an d durin g th e acute postoperative period. Wounds
that con tinue to drain following join t arthroplasty should
be m an aged carefully. Followin g join t replacem en t surgery,
patien ts m ust be in form ed of th e n eed for sin gle-dose an tibiotic prophylaxis prior to any dental or surgical procedure. Previous recom m en dation s for an tibiotic prophylaxis
on ly durin g th e first 2 years followin g join t arth roplasty
h ave been chan ged an d n ow in dicate th e n eed for prophylaxis for as long as the prosth esis rem ains in place.
Wh en preven tion of in fection fails, successful treatm en t
always in volves surgical irrigation and debridem ent of the
involved join t and the adm inistration of intravenous an tibiotics for 4 to 6 weeks. Definitive treatm ent depends
on th e ch ron icity of th e in fection , h ost respon se to th e
93
NECROTIZING FASCIITIS
Alth ough n ecrotizin g fasciitis is on e of th e least com m on
soft-tissue infections, it is associated with significant m orbidity an d m ortality. Prom pt diagn osis an d in itiation of appropriate treatm en t are critical for patien t survival. Wh en
94
Classification
Gram stain an d culture results can be used to classify n ecrotizin g fasciitis in to on e of th ree groups. Type 1 in fection s
are m ost com m on , accoun tin g for 80% to 90% of all cases.
In th is type of n ecrotizin g fasciitis, gram stain an d cultures
reveal a polym icrobial in fection , in volvin g an aerobic an d
non group A streptococcus bacteria. Wound cultures typically reveal th e presence of four to five bacteria species. Type
1 infection s are associated with abdom inal an d perineal
woun ds an d frequen tly affect th e im m un ocom prom ised
host. Type 2 infection s are m ost com m on in the extrem ities
an d result from th e presen ce of group A -hem olytic streptococci species. Staphylococcusspecies are th e m ost com m on
second species presen t when in fection is not due to group
A -hem olytic streptococci alone. Type 3 infections often
result from exposure to seawater or m arin e an im als an d
are ch aracterized by th e presen ce of th e gram -n egative rod
m arin e vibrios.
Presentation
Prom pt an d correct diagn osis of n ecrotizin g fasciitis can be
m ade extrem ely difficult because of its often ben ign in itial
presen tation . Th e m ost com m on presen tation is quite sim ilar to th at of cellulitis with a localized region of in flam m ation , swellin g, an d eryth em a. Necrotizin g fasciitis is often
differen tiated from cellulitis by a disproportion ate level of
pain an d rapid progression of sign s an d sym ptom s. Com m on ly, region s of skin in duration an d eryth em a expan d
rapidly, at a rate of greater than 1 cm per hour, despite the
adm in istration of in traven ous an tibiotics. Classic sign s of
necrotizing fasciitis appear later and con sist of blister and
bullae form ation , skin discoloration an d slough in g, an d
crepitus due to the presence of gas in the soft tissues. Bullae an d blisters m ay in itially drain serosan guin eous fluid
but later becom e h em orrh agic. As th e fascia an d overlyin g superficial fat n ecrose, th e classic dish water pus an d
foul-sm elling drainage becom e obvious. In addition, the
in ten se pain observed early in th e course of th e disease
m ay give way to localized an esth esia, as cutan eous n erve
en din gs are destroyed. Fever an d ch ills m ay presen t early,
but symptom s of system ic sh ock, in cludin g hypoten sion ,
tachycardia, an d altered m en tal status, are com m on later.
Ren al an d h epatic failure, coagulopathy, an d acute respiratory distress syn drom e can all en sue.
History and Physical Examination
A proper history and physical exam ination will result
in h eigh ten ed clin ical suspicion for n ecrotizin g fasciitis,
which is critical for early in itiation of treatm en t. Alth ough
necrotizing fasciitis m ost com m only results from an in jury
to th e affected site, th e patien t m ay n ot recall such an in jury.
Any lesion that allows bacteria to breach the skin can result
in n ecrotizin g fasciitis. Blun t an d pen etratin g traum a, sur-
gical in cisions, burns, insect bites, and ulcers h ave all been
implicated as the cause of infection, but in up to 45% of
infections, the portal of bacteria entry is not evident. Physical exam ination findings are quite varied and related to
th e m any poten tial sign s an d sym ptom s described in th e
previous section . In fection typically begin s in th e extrem ities but can rapidly spread to the trunk. Involvem ent of the
trunk and perineal region is associated with significantly
h igher m orbidity an d m ortality.
Diagnostic Studies
Basic laboratory studies sh ould in clude a com plete blood
cell coun t, comprehensive m etabolic panel, and coagulation studies. Anem ia, throm bocytopenia, hyponatrem ia, hypocalcem ia, azotem ia, hypoproteinem ia, hypoalbum in em ia, an d hyperbilirubin em ia are all com m on .
ESR, CRP, an d creatin in e kin ase values are typically elevated. Laboratory values m ay be norm al in early infection but becom e progressively m ore abnorm al as th e disease progresses. Several m odels h ave been developed to
h elp diagnose n ecrotizing fasciitis an d distin guish it from
oth er soft-tissue in fection s. In on e sim ple m odel developed
by Wall et al., sim ultaneous hyponatrem ia, with a serum
sodium level of less than 135 m m ol per liter, and leukocytosis, with elevation of the WBC count to greater than
15,400 cells per m icroliter, is 90% sensitive for n ecrotizing
fasciitis. However, th is m odel sh ould on ly be used to rule
out th e diagn osis of n ecrotizin g fasciitis as both th e specificity and th e positive predictive value are low, at 76% and
26%, respectively. Th e Laboratory Risk In dicator for Necrotizin g Fasciitis (LRINEC) is another com m only used m odel
that com bines the results of six com m on laboratory studies (CRP, WBC count, hem oglobin, sodium , creatinine, an d
glucose) to predict the probability of n ecrotizing fasciitis.
Th e positive predictive value of th is m odel is 92% wh en
used to detect early cases of disease.
In addition to laboratory studies, radiograph ic evaluation is critical in m akin g a tim ely diagnosis. Plain film s are
m ost often norm al, even in th e presen ce of disease, but are
h elpful for detectin g gas in th e soft tissues wh en present.
CT is very useful in the evaluation of a suspected patient.
Com m on findings in the presen ce of disease include gas
in the soft tissues, fascial thickening, an d stranding and
attenuation of the subcutan eous fat. However, a negative
CT does not rule out the diagnosis. A CT scan can also be
extrem ely h elpful in delin eatin g th e exten t an d m argin s of
soft-tissue in volvem en t. Th e sensitivity of MRI is greater
than 90%; however, MRI is of a lesser priority in the evaluation of patien t due to th e am oun t of tim e required to
obtain a m ean in gful study.
Differential Diagnosis
Necrotizin g fasciitis is m ost com m on ly m isdiagn osed as
cellulitis. As previously m ention ed, early stages of necrotizin g fasciitis m ay be nearly identical to cellulitis, so adequate clin ical suspicion sh ould result in furth er workup
to defin itively con firm or exclude th e m ore serious con dition. Other diseases that m ay be confused with necrotizing
fasciitis in clude erysipelas, lymph an gitis, gas gan gren e, an d
acute febrile neutrophilic derm atosis.
Treatment
Successful treatm en t relies on prompt diagn osis with subsequen t surgical debridem ent and in itiation of broadspectrum antibiotic therapy. Surgical in terven tion sh ould
be appropriately aggressive, with rem oval of all in volved
skin, fascia, and m uscle during th e initial debridem en t.
Th e resultin g woun d m ust be evaluated on a daily basis
for furth er progression of the infection and tissue necrosis.
Repeat debridem en t is often necessary until a stable, viable woun d is achieved. Between debridem ents, the wound
sh ould be covered with sterile dressin gs to prom ote h ealing and decrease the risk of secondary infection. In som e
circum stances, lim b amputation is required initially in order to preserve th e patien ts life. Followin g appropriate surgical debridem en t, the resulting wound(s) and soft-tissue
defect(s) m ay require skin graftin g or free tissue tran sfer
for definitive coverage and closure. It is important to rem em ber that surgical in tervention is the only treatm ent for
necrotizing fasciitis proven to reduce m ortality.
Antibiotic therapy m ust be initiated as soon as necrotizin g fasciitis is suspected and m icrobial cultures are obtain ed. In itial em piric th erapy sh ould in clude coverage
for gram -positive, gram -negative, and anaerobic organism s. Broad-spectrum empiric coverage typically includes
clindamycin in com bination with im ipenem , m eropenem ,
ampicillin/ sulbactam , or piperacillin/ tazobactam . The antibiotic regim en can be tailored to culture and sen sitivity
results on ce available. Alth ough an tibiotic th erapy is critical to successful treatm ent, it can never be used as the sole
interven tion . Antibiotics can help reduce the system ic effects of th e infection and decrease bacterial load but cannot
eradicate th e in fection alon e. Th is is due to lim ited an tibiotic delivery to th e site of in fection , wh ich results from poor
vascularity of the fascia that is further comprom ised by the
infection itself.
95
In addition to surgical debridem en t an d an tibiotic adm in istration n ecessary for successful treatm en t, supportive
care with appropriate fluid resuscitation an d blood pressure m ain ten an ce are often needed in the septic patien t.
Nutrition al support is critical in all patien ts due to th e loss
of fluid, electrolytes, an d protein th rough th e often large
surgical woun d(s). Adjunctive therapy with intravenous
im m un oglobulin G, recom bin an t h um an -activated protein
C, an d hyperbaric oxygen h ave all been reported to improve
outcom es but h ave yet to becom e stan dard in treatm en t
protocols.
SUMMARY
Musculoskeletal infection s affect patients of all ages, can involve any anatom ic region in the body, and result from any
on e of an in fin ite n um ber of etiologies. Successful treatm ent relies on proper and tim ely diagnosis followed by
antibiotic therapy, surgical intervention , or both. Careful
attention m ust be given to infections in the settin g of fractures and the presen ce of orth opaedic h ardware. Given the
m orbidity of m usculoskeletal infections and the treatm ent
required for successful eradication , future research m ust focus on prom pt an d accurate diagn osis as well as preven tion .
RECOMMENDED READINGS
Bauer TW, Parvizi J, Kobayashi N, Krebs V. Current con cepts review: diagnosis of periprosth etic infection. J Bone Joint Surg Am.
2006;88:869 882.
Bellapian ta JM, Ljun gquist K, Tobin E, Uh l R. Necrotizing fasciitis.
J Am Acad Orthop Surg. 2009;17:174 182.
Cierny G III, DiPasquale D. Treatm ent of chronic infection. J Am Acad
Orthop Surg. 2006;14:S105 S110.
Dorm ans JP, Drum m ond DS. Pediatric hem atogen ous osteomyelitis:
n ew tren ds in presen tation , diagnosis, and treatm ent. J Am Acad
Orthop Surg. 1994;2:333 341.
Mader JT, Wang J, Calhoun JH. Antibiotic therapy for m usculoskeletal
infection. J Bone Joint Surg Am. 2001;83:1878 1890.
Patel A, Calfee RP, Plan te M, et al. Meth icillin -resistan t Staphylococcus
aureus in orthopaedic surgery. J Bone Joint Surg Br. 2008;90:1402
1406.
Metabolic Bone
Diseases
Aasis Un n an u n t an a
Ben jam in McArthu r
INTRODUCTION
Metabolic bone disease encompasses a group of disorders
that impair balances between bone form ation and bon e
resorption or defects in m in eralization of bon e. Th eoretically, any disease affectin g bon e cells, collagen, noncollagenous protein, or m ineral deposition could adversely
affect bone and, therefore, con stitute disease in volving
bon e m etabolism . Th e m ost com m on an d perh aps m ost
important m etabolic bone disease is osteoporosis. Other
significant m etabolic bon e diseases in clude rickets an d osteom alacia, ren al osteodystrophy, an d Pagets disease of
bon e. Th is ch apter will provide basic kn owledge of factors
that lead to the developm ent of m etabolic bone disease,
along with an overview of m etabolic bone disorders that
are com m only encountered during clinical practice.
is gen erally 10 5 -fold greater than intracellular concentration of calcium . Forty percen t of th e circulatin g calcium is
boun d to album in , 45% is in th e active, free, ion ized form ,
an d 15% is bound to ph osph ate an d oth er in organ ic ion s.
Abn orm alities in the serum protein concen trations alter the
am oun t of calcium in th e extracellular fluid. Th erefore, it
is importan t to calculate th e corrected serum calcium level
wh en th e circulatin g album in is abnorm al in order to get
an accurate estim ate of th e free calcium , or on e can directly
m easure th e actual free, ion ized calcium .
Calcium in the skeleton exists as a hydroxyapatite crystal in th e m in eral ph ase of bon e. Th e crystal con tributes
to th e m ech an ical properties of bon e an d also serves as a
calcium and phosphate reservoir that can be rapidly m obilized to support n um erous biological system s if n eeded.
Th e biological action s of calcium are attributed to the ion ized fraction , wh ich is readily exch an geable with pools of
calcium in bone, blood, and intracellular sites. Calcium
regulates a n um ber of essen tial cell fun ction s such as in tracellular sign alin g an d n eurom uscular activity in cludin g
m uscle con traction .
Calcium is prim arily absorbed in the duodenum and
proxim al jejun um an d is controlled principally by 1,25dihydroxy-vitam in D. Gastric acid is n ecessary for th e absorption of calcium . Despite calcium intake of 400 to
1500 m g per day, the n et calcium absorption from the intestin e is between 200 an d 400 m g per day. Th e system s of
absorption an d excretion are tigh tly coupled an d regulated
by the ionized serum calcium concentration . The kidneys
filter between 8 to 10 g of calcium per day, of wh ich on ly 2%
to 3% is excreted. Most of th e filtered calcium is reabsorbed
through passive m echanism s in the proxim al tubules with
98
Parathyroid Hormone
PTH, produced by th e ch ief cells of parathyroid glan d, plays
a m ajor role in calcium hom eostasis. Th e actions of PTH are
directly th rough bon e an d kidn eys an d in directly th rough
stim ulation of 1-hydroxylation of 25-hydroxy-vitam in D
to 1,25-dihydroxy-vitam in D. In bon e, PTH stim ulates th e
release of calcium an d ph osph ate. In th e kidn ey, it produces th e reabsorption of calcium an d in h ibits th at of
ph osph ate. In addition , PTH in creases th e activity of th e
ren al 1-hydroxylase, thereby enh ancin g the synthesis of
1,25-dihydroxy-vitam in D, which , in turn, in creases the intestin al absorption of calcium an d ph osph ate. As a result of
these three actions, serum calcium rises, wh ile serum ph osph ate declin es. Gen erally, th ere are th ree m ain physiological regulators of PTH secretion an d synthesis: extracellular
calcium , phosphate ions, and 1,25-dihydroxy-vitam in D.
Am ong the three regulators, extracellular calcium con centration is th e m ost im portan t physiological regulator of th e
secretion of PTH.
Vitamin D
Wh en exposed to sun ligh t, cutan eous ch olesterol (7dehydroch olesterol or provitam in D 3 ) absorbs solar radiation and transform s itself into previtam in D 3 , wh ich rapidly
un dergoes an isom erization process to vitam in D 3 . Vitam in
D 3 is th en tran slocated from th e skin in to th e circulation ,
wh ere it is boun d to vitam in D bindin g protein. Vitam in
D is also foun d in food. Th e m ajor n atural sources of vitam in D are oily fish such as salm on an d m ackerel, fish liver
oils, an d cod liver oil. Th ere are two types of vitam in D:
vitam in D 2 an d vitam in D 3 . Vitam in D 2 derives from yeast
an d plan ts, wh ereas vitam in D 3 is foun d in oily fish an d
cod liver oil an d also m ade in th e skin . Vitam in D 2 is approxim ately 30% as effective as vitam in D 3 in m ain tain in g
vitam in D status.
Once vitam in D enters the circulation , it is transported an d m etabolized by liver to 25-hydroxy-vitam in D
(Fig. 6.1). It is 25-hydroxy-vitam in D th at clin ician s use
to determ in e th e status of vitam in D wh eth er deficien cy,
sufficien cy, or in toxicated. Because the liver has a large capacity to produce 25-hydroxy-vitam in D, m ore th an 90%
of th e liver tissue h as to be in jured before it is un able
to m ake an adequate quan tity of 25-hydroxy-vitam in D,
which is transported to the kidneys where the enzym e 1hydroxylase m etabolizes 25-hydroxy-vitam in D to 1,25dihydroxy-vitam in D, wh ich is an active form of vitam in D.
This hydroxylation step is activated by PTH but repressed
by calcium as well as by the active form of vitam in D itself. In addition , th e active form of vitam in D activates the
24-hydroxylase en zym e in the kidney, which creates 24,25dihydroxy-vitam in D, an in active form of vitam in D.
Th e m ajor fun ction of 1,25-dihydroxy-vitam in D for
bon e m in eralization process is to m ain tain blood levels
of calcium an d ph osph orus in th e n orm al ran ge for proper
m in eralization . 1,25-dihydroxy-vitam in D, h owever, does
not h ave a direct effect in th e m in eralization process.
There are several addition al roles of th is active vitam in
D in cludin g in creased bon e-specific alkalin e ph osph atase,
99
Calcitonin
Calcitonin is a peptide that is secreted by thyroid C cells.
It con sists of 32 am in o acids an d acts again st osteoclasts
in their resorptive function. Calcitonin is m etabolized by
m any organ system s, in cluding the kidney, liver, bone,
an d even the thyroid gland. The secretion of calcitonin is
100
TABLE 6.1
Serum
Bone-specific alkaline
phosphatase
Osteocalcin
Carboxyterminal propeptide
of type I collagen (PICP)
Aminoterminal propeptide
of type I collagen (PINP)
Serum
Tartrate-resistant acid
phosphatase
N-telopeptide of collagen
cross-links (NTx)
C-telopeptide of collagen
cross-links (CTx)
Urine
Free and total
pyridinolines (Pyd)
Free and total
deoxypyridinolines (Dpd)
N-telopeptide of collagen
cross-links (NTx)
C-telopeptide of collagen
cross-links (CTx)
101
Figure 6.3 The collagen molecule is a triple helix consisting of two pro- 1(I) chains and a single
pro- 2(I) chain. The collagen triple helix is cross-linked to adjacent molecules at the amino(N)- and
carboxy(C)- terminals (as circled in the figure). During osteoclast-mediated resorption of bone, the
collagen molecule is degraded, releasing these cross-linked N-telopeptides (NTx) and cross-linked
C-telopeptides (CTx). NTx and CTx are specific for bone resorption. (Adapted from Unnanuntana A,
Gladnick BP, Donnelly E, Lane JM. The assessment of fracture risk. JBJS Am. 2010; 92:749.)
Bone is a composite m aterial, consistin g of m inerals, protein s, water, cells, an d oth er m acrom olecules (lipids, sugars, etc). Although bone cells are the principal regulators of
bon e m etabolism , bon e m atrix an d m in erals h ave a fun ction in th e control of the cell-m ediated process. Therefore,
the inorganic and organ ic compon ents of the bon e h ave
both structural an d regulatory properties.
Th e degree of m in eralization of bon e tissue, wh ich reflects the m ineral property of bon e, influences n ot only th e
m echanical resistance of bon es but also the BMD m easured
by dual-energy X-ray absorptiom etry (DEXA). Sim ilar to
the m ineral content, collagen and oth er extracellular m atrices are importan t con stituents of the bony composition .
Th e n on collagen ous protein s are n ot as abun dan t as collagen , but th ey provide for th e regulation of m in eralization ,
wh ich reflects bon e stren gth . Th e degree of m in eralization
of bon e tissue can be determ in ed by tetracyclin e-labeled
transiliac bone biopsy, Fourier tran sform ed infrared spectroscopy (FTIR), and phosph orus-31 solid-state n uclear
m agn etic reson ance spectroscopy (31P solid-state NMR).
Th e FTIR tech n ique can exam in e th e relative am oun t of
m inerals and m atrix con ten t, collagen m aturity, and the arran gem en t of apatite an d organ ic m atrix, wh ereas th e 31P
solid-state NMR im agin g can be used to m easure quan ti-
102
be obtain ed by usin g th ree-dim en sion m icrocom puted tom ography or h igh -resolution m agn etic reson an ce im agin g.
Epidemiology
In th e Un ited States alon e, an estim ated 10 m illion people older th an 50 are affected an d an oth er 34 m illion
are at risk. Th e fracture in ciden ce am on g affected Am erican s is approxim ately 1.5 m illion per year. O f th ese,
approxim ately 700,000 are vertebral fractures, 300,000
are h ip fractures, an d 200,000 are wrist fractures. Wom en
are affected m ore com m on ly th an m en . In addition ,
m en are n oted to h ave a relatively later on set of disease,
up to on e decade on average. Th e lifetim e probability of
hip fracture is 14% in Caucasian wom en an d 5% to 6% in
Caucasian m en . O th er eth n ic groups can vary con siderably
in term s of th eir in ciden ce of fracture. African Am erican s
have a con siderably lower rate of fracture than do Cau-
casian s, with on ly 3% an d 6% for m en an d wom en , respectively. The risk of fracture in Mexican Am erican wom en has
been n oted to be in term ediate, greater th an th at of African
Am erican s but less th an th at of Caucasian s.
Th ere is sign ifican t m orbidity an d m ortality associated
with low-en ergy fractures. Vertebral fractures m ay be a
source of ch ron ic an d disabling pain. Approxim ately oneth ird of patien ts with h ip fractures are disch arged to n ursing hom es, and the 1-year m ortality rate am ong patients
with h ip fracture is approxim ately 20%. Th us, orth opaedic
surgeons m ust be in creasin gly suspicious of this disease in
certain patien t dem ograph ics, ach ieve a firm un derstan ding of the pathogenesis of osteoporotic bon e and the condition s th at result in bon e fragility, an d becom e fam iliar
with th e curren t strategies for diagn osis, preven tion , an d
treatm ent of osteoporosis.
Classification
Osteoporosis is classically divided into two categories, prim ary and secondary. Prim ary osteoporosis is the result of
predictable physiologic ch an ges in BMD, wh ich can result in clinical disease in som e patients. It m ay be on e
of two types. Type I, or postm en opausal osteoporosis, is
associated with the relative estrogen deficit seen in postm en opausal wom en. The lack of estrogen seen in the years
followin g m en opause is associated with an accelerated rate
of bon e loss. Th is is th e m ost com m on form of osteoporosis in th e gen eral population, and it is from this subgroup
that m ost of our current data on osteoporosis are derived.
Type II, or sen ile osteoporosis, is seen in m en an d wom en
alike older than 70. It is the result of age-related decline in
BMD, wh ich is com m on to both m en an d wom en begin n in g in m idlife. While wom en un dergo accelerated BMD
loss in the perim en opausal years, the rate of loss declines
103
Hormone excess
Parathyroid (primary or secondary)
Thyroid
Cortisol
Diagnosis
TABLE 6.2
Hormone deficiency
Estrogen (premenopausal or postmenopausal)
Testosterone
Diseases
Inflammation (rheumatoid arthritis, ulcerative colitis)
Tumor or malignancy (multiple myeloma, lymphoma)
Collagen vascular disease
Renal osteodystrophy
Others (liver diseases, immobilization)
Drugs
Corticosteroids
Thyroxine
Alcohol
Anticonvulsants (barbiturates, phenytoin)
Anticoagulants (heparin, coumadin)
Antimetabolites (methotrexate, cyclosporin)
(From Yue J, Guyer R D, Johnson JP, et al. The Comprehensive
Treatment of the Aging Spine: Minimally Invasive and Advanced
Techniques, Philadelphia, PA: Elseiver 2010 with permission).
To date, DEXA is considered the gold standard in the m easurem en t of BMD an d diagnosis of osteoporosis. DEXA
scan nin g as a part of osteoporosis screening typically in volves scans of the h ip, lum bar spine, and occasionally the
distal radius. Results for a given patien t are com pared to th e
average values for age-m atch ed con trols an d youn g n orm al
patien ts at th eir peak BMD, an d from th ese comparison s
th e Z-scores and T-scores are derived, respectively. T-scores
between 1 an d 2.5 stan dard deviation s below th e n orm
(between 1 to 2.5) are diagnostic for osteopenia, wh ile
scores equal to or below 2.5 are diagnostic for osteoporosis. For patients younger th an 35, diagnosis of osteoporosis
is dependent on ly on the Z-score. A Z-score of less than
1.5 is sign ifican t in th at it m ay be in dicative of a secon dary
cause of osteoporosis.
Early detection of osteopen ia an d osteoporosis with
DEXA screen in g is an importan t m ean s of reducin g th e
104
risk of fracture an d associated m orbidity. However, universal screenin g is neith er practical n or feasible. The In tern ation al Society for Clin ical Den sitom etry (ISCD) advocates
DEXA screen in g for any patien t wh o is
1. a fem ale aged 65 or older;
2. a postm enopausal fem ale younger than 65 who has
clin ical risk factors for fracture, such as low body m ass
in dex, prior fracture, or use of a high-risk m edication;
3. a wom an during the m enopausal tran sition with clinical risk factors for fracture;
4. a m ale aged 70 years or older;
5. a m ale aged 70 years or younger with clin ical risk factors
for fracture;
6. an adult with a history of a fragility fracture;
7. an adult with an illness known to cause bone loss or
low BMD;
8. an adult taking a m edication known to cause bone loss
or low BMD;
9. any patient being considered for pharm acologic treatm en t of bon e loss;
10. any patien t curren tly bein g treated for low BMD in order to m on itor th e treatm en t effect; or
11. any patien t not receiving therapy in whom evidence of
bon e loss would lead to ph arm acologic treatm en t.
In addition to these guidelin es, it is important to take
in to accoun t oth er factors th at m ay in crease a patien ts
propen sity for low BMD or fracture. Patien ts with poor gen eral h ealth , alcoh olism , dem en tia, frailty, recen t discon tin uation of estrogen replacem en t th erapy, or lon g-term h istory of estrogen deficien cy sh ould be con sidered for DEXA
scan n in g even if they do n ot fit into the ISCD criteria.
Laboratory Investigations
In addition to diagn ostic im agin g, som e routin e tests
sh ould be perform ed to obtain baseline values as part of
the initial workup. These include complete blood cell count
with differen tial, urin alysis, an d blood ch em istry profiles
with serum calcium an d ph osph ate. Because vitam in D deficien cy is very com m on am on g elderly population s, with
a prevalen ce of approxim ately 50%, all elderly patien ts
sh ould be tested for vitam in D deficiency by m easurin g
levels of 25-hydroxy-vitam in D. If low, adequate vitam in
D supplem en tation is en couraged. Vitam in D deficien cy,
as defined by a serum 25-hydroxy-vitam in D of less than
20 n g per m L, is associated with poor m uscle fun ction as
well as m in eralization defects. Markers of bon e turn over
are important to indicate the status of bone m etabolism .
Measurem en t of bone m arkers is helpful for following a
patien ts respon se to treatm en t over tim e. Th erefore, it is advisable to get a baseline value as part of the initial workup.
Wh en secon dary osteoporosis is suspected on th e basis of clin ical fin dings or because th e patient is relatively
young an d presented with fragility fracture, specific tests
sh ould be con sidered to evaluate contributing causes that
m ay require additional m edical attention. These include basic laboratory investigation of a complete blood cell count
with differen tial, eryth rocyte sedim en tation rate, serum
calcium and ph osph ate levels, liver fun ction tests, thyroidstim ulatin g h orm one level, testosteron e level in m en, and
a serum protein electroph oresis if myelom a is con sidered
(Table 6.3). When abnorm alities are detected, th e patient
sh ould be referred to a specialist for furth er evaluation and
specific treatm ent.
105
TABLE 6.3
Hyperthyroidism
Hypogonadism
Diabetes
Diagnostic Study
Serum calcium, serum phosphate, parathyroid
hormone levels
TSH, T3, free T4
LH, FSH, estrogen, testosterone (men)
Blood glucose
GI disorders
Crohns disease, ulcerative colitis
Liver disease
Primary biliary cirrhosis, chronic active
hepatitis
TSH, thyroid-stimulating hormone; LH, luteinizing hormone; FSH, follicle-stimulating hormone; CBC,
complete blood cell count; ESR, erythrocyte sedimentation rate; CRP, c-reactive protein; BUN = blood urea
nitrogen. (From Yue J, Guyer R D, Johnson JP, et al. The Comprehensive Treatment of the Aging Spine:
Minimally Invasive and Advanced Techniques, Philadelphia, PA: Elseiver 2010 with permission).
Treatment
Nonpharmacologic Treatment
A m ultidisciplin ary approach is critically importan t in th e
m anagem ent of osteoporosis. Nonpharm acologic treatm en t is used concurren tly with pharm acologic therapy to
optim ize fracture risk reduction . Th us, every patien t sh ould
be con sidered for n onph arm acologic m an agem en t. Com m on ly used nonpharm acologic treatm en ts include, but are
not lim ited to, calcium an d vitam in D supplem entation, fall
preven tion , an d balan ce an d exercise program s.
A negative calcium balance or suboptim al levels of
25-hydroxy-vitam in D m ust be addressed first before any
ph arm acologic in terven tion is un dertaken sin ce th ese represen t a con stan t impetus for bon e dem in eralization an d
decreased bon e den sity an d stren gth . Th e recom m en ded
daily calcium requirem en t is between 1200 an d 1500 m g
per day. In addition to en couragin g dietary sources of cal-
Pharmacologic Treatment
Th e ph arm acologic agen ts curren tly available are com m only divided into two groups: an tiresorptive and anabolic. Antiresorptive agen ts have been developed to
106
address th e h igh -turn over state. Th ese in clude estrogen , selective estrogen receptor m odulators (SERMs), calciton in ,
an d bisph osph on ates. Th e an abolic agen t, parathyroid
horm one, provides active building of bone m ass an d has
been suggested to treat th e low-turn over state.
Estrogen
Estrogen is an an ti-osteoporotic agen t that has been shown
to in crease bon e m ass an d th us decreases th e risk of vertebral an d h ip fracture by approxim ately 30% to 40% as
compared with patients taking placebo. Estrogen, however,
has been foun d to increase rates of stroke and deep vein
throm bosis, while com bined estrogen and progesterone
therapy is associated with increased risks of cardiovascular
disease, breast can cer, dem en tia, an d gall bladder disease.
As a consequence, estrogen is m ainly used in the early postm en opausal period to treat postm en opausal syn drom e an d
then lowered to the lowest dose that effectively controls
symptom atology. The risks associated with estrogen form ulation s preclude th eir use as prim ary agen ts in th e treatm en t
of osteoporosis.
Selective Estrogen Receptor Modulators
Selective Estrogen Receptor Modulators (SERMs) are a class
of agen ts th at bin d to estrogen receptors. Th ey h ave a sign ifican t effect on breast tissue an d bon e cells; h owever, th ey
act as an tagon ists in th e oth er receptor sites. Of th e SERMs
currently bein g used for clinical settings, only raloxifene
has been approved for the prevention and treatm en t of osteoporosis. Early data suggest th at raloxifen e decreases th e
risk of breast cancer by 70%, which h as m ade raloxifene
a preferred agen t am on g osteoporotic patien ts with breast
can cer risk. Although raloxifene has been shown to reduce
the risk of vertebral fracture, there was no significant reduction in th e overall risk of n on vertebral fracture. In addition , by stim ulatin g estrogen receptors, raloxifen e in creases
the risk of pulm onary em boli and throm boph lebitis and
m ay cause profoun d postm en opausal symptom s. Th erefore, clinicians m ust weigh th e benefits of the reduced
risks of vertebral fracture and invasive breast cancer again st
the in creased risks of ven ous throm boem bolism and fatal
stroke wh en considerin g th is agen t for osteoporosis m anagem en t.
Calcitonin
Calciton in is available as both a paren teral in jection an d
a nasal spray. The intranasal spray is the m ost com m only
used form ulation due to its superior com plian ce an d ease of
use. Calciton in reduces th e risk of vertebral fracture; h owever, th ere is on ly a m odest in crease in BMD. In addition ,
calciton in treatm ent sh ows no benefit for reducing the risk
of h ip an d oth er n on vertebral fractures. Th ere is som e data
suggestin g the analgesic effect of calcitonin . Alth ough there
is a hypoth esis th at calciton in -in duced an algesia m ay be
m ediated by in creased beta-en dorph in s an d m ay directly
affect pain receptors in th e cen tral n ervous system , th e ex-
act m echanism is still unkn own. Therefore, the current in dication for calciton in treatm en t is for alleviatin g pain ful
vertebral compression fractures. It sh ould be discon tinued
as soon as pain has been controlled, since other pharm acologic agents are m ore effective in preventin g future
fractures.
Bisphosphonates
Bisphosph onates have been a m ain stay of osteoporosis
treatm ent for the past 30 years. The chem ical structure of
th is class of drugs is closely related to th at of in organ ic
pyroph osph ate (PPi), a com m on byproduct of n um erous
synth etic reaction s, wh ich has been shown, in vivo, to have
a h igh affin ity for hydroxyapatite an d an associated in h ibitory effect on calcification . Th e bisph osph on ates share
th is h igh affin ity for hydroxyapatite an d as a result are
rapidly absorbed an d retain ed in bon e. O n ce th ere, th ey
inhibit bone resorption by inducing osteoclast apoptosis.
Bisph osphon ates h ave been proven effective for th e reduction of fracture risk in patien ts with osteoporosis an d a
n um ber of oth er m etabolic bon e diseases. Data from th e
Fracture In tervention Trial, a m ulticenter random ized control study, revealed a relative reduction in risk of 47% for
h ip fractures an d 55% for clin ical vertebral fractures in patients taking alen dron ate when compared to placebo. Their
efficacy an d ease of use h ave led to widespread use of th ese
agen ts as first-line therapy for osteoporosis and osteopen ia. Both oral an d in traven ous form ulation s are available
(Table 6.4). Wh ile oral adm inistration m ay be m ore conven ien t, in travenous adm in istration is often utilized for patients with severe gastrointestinal complaints after oral intake, a h istory of severe gastroesph ageal reflux or peptic
ulcers, or disorders th at com prom ise absorption such as
sh ort bowel syn drom e or Crohn s disease.
Adverse effects of bisphosphonates include flu-like
sym ptom s, especially with intravenous adm inistration, severe gastroesophageal reflux, and, rarely, osteon ecrosis of
th e jaw. Furth erm ore, by in h ibitin g bon e rem odelin g, bisph osph on ates slow fracture h ealin g an d sh ould be avoided
or discon tin ued in th e settin g of acute fracture. In addition ,
th ere h as been a growin g con cern over th e years regardin g
th e poten tial for bisph osph on ates to in duce a frozen bon e
syndrom e wherein prolonged oversuppression of bon e rem odeling results in deleterious effects on bone quality,
wh ich m ay culm in ate in low-en ergy fractures (Fig. 6.6).
Several reports in the literature m ake reference to an association between long-term alendronate use an d atraum atic or low-en ergy fem oral shaft fractures. Although a
causal relation sh ip h as n ot been dem on strated, th ese fin dings, in com bination with anim al studies dem onstratin g
reduced repair an d accum ulation of m icrodam age in an im als treated with alendronate, suggest that impaired bone
turn over m ay put patients at risk for low-energy fractures.
Non eth eless, bisph osph on ates rem ain on e of th e m ost
poten t agen ts available for th e reduction of fracture risk in
osteoporotic patien ts. O n e solution th at h as been adopted
107
TABLE 6.4
Trade
Name
Recommended
Dose
Route of
Administration
Alendronate
Fosamax
Oral
Risedronate
Actonel
Ibandronate
Boniva
Zoledronic acid
Reclast
10 mg/d
70 mg/wk
5 mg/d
35 mg/wk
75 mg/2 wk
150 mg/mo
150 mg/mo
3 mg/3 mo
5 mg/y
Instructions
Oral
Oral
Intravenous
Intravenous
Teriparatide
Teriparatide, a recom binant fragm ent of hum an PTH, represen ts a relatively n ew an d powerful agen t for th e treatm ent of osteoporosis. It is th e only anabolic agent approved
for th e treatm en t of osteoporosis in the United States. Teriparatide is adm in istered as a daily subcutan eous in jection. Wh ile con tinuous adm in istration of PTH, as seen in
prim ary hyperparathyroidism , results in in creasin g bon e
resorption , by m ech an ism s th at rem ain un clear, th e adm inistration of low-dose interm ittent PTH in the form of
teriparatide acts as a powerful in ducer of bon e form ation .
Wh ile cost is curren tly a m ajor lim itin g factor in th e use
of teriparatide as a first-lin e th erapy for osteoporosis, it rem ains an important agent for the treatm ent of patients with
following con ditions:
1. patien ts with low-turn over osteoporosis;
2. patients wh o have been on bisph osph onates and still
have fragility fracture;
3. patients with declining bon e densities while taking bisph osphonates
Teriparatide h as been associated with osteogen ic sarcom a wh en given in extrem ely h igh doses to laboratory
rats. As such , its use is con train dicated for any pediatric
patien t or a patien t with a h istory of recen t radiation
th erapy, as both m ay be associated with an in creased
incidence of osteogenic sarcom a. Teriparatide should be
discon tin ued after 2 years of treatm en t. After th at, bisph osph on ate th erapy sh ould be in itiated to m ain tain its
results.
femoral shaft fracture. Fracture after prolonged treatment with bisphosphonates is characterized by (A) simple or transverse fracture;
(B) beaking of the cortex on one side; (C) hypertrophied diaphyseal
cortices; and (D) result from minimal or no trauma.
108
the skeletal growth. While importan t distinctions exist between th ese two diseases, th ey arise from sim ilar etiologies
an d th us th ere is m uch overlap between th e clin ical, radiograph ic, an d h istologic presen tation s of each . Rickets an d
osteom alacia h ave a relatively h igh er prevalen ce in population s th at receive lim ited sun ligh t th rough out th e year,
or wear cultural attire th at precludes ultraviolet exposure
to th e skin , especially in parts of Asia an d th e Middle East.
In Un ited States, it is estim ated th at 25% of elderly people
have chronically low levels of vitam in D because of un dernourishm ent and low exposure to sunligh t. In addition , th e
absorption of vitam in D from th e gastroin testin al tract is
reduced in th is particular age group.
TABLE 6.5
to th e m ore active 1,25-dihydroxy-vitam in D (wh ich facilitates intestinal absorption of calcium ); and (c) enhancing
the osteoclast-m ediated resorption of bone. The increased
parathyroid activity reduces serum ph osph ate as a result of
decreased tubular reabsorption of ph osph ate. Th is results
in hyperphosphaturia and hypophosphatem ia. Th e bone
ch anges are related to a decrease in the available calcium
an d phosphate needed to synthesize calcium hydroxyapatite and a secondary hyperparathyroidism , which causes
osteoclastic destruction of th e existin g bony structure. Low
levels of vitam in D m ay also occur in persons with in adequate dietary in take, gastroin testin al m alabsorption (celiac
sprue, status post gastrectomy, and chronic pancreatitis), or
ch ronic low exposure to sunlight. Certain anticonvulsants
m ay accelerate th e catabolism of vitam in D in the liver,
causin g decreased levels in the serum .
Th ere are two form s of vitam in D resistan t rickets secon dary to in h eren t defects of th e vitam in D m etabolic path way, design ated as type 1 an d type 2 depen den t rickets.
Type 1 depen den t rickets refers to a deficien cy of th e 1hydroxylase en zym e th at con verts 25-hydroxy-vitam in D
to 1,25-dihydroxy-vitam in D, wh ereas type 2 depen den t
rickets is an in h eren t defect in th e vitam in D in tracellular
receptor. As a result of th is en d organ in sen sitivity in type 2
depen den t rickets, th e circulatin g level of 1,25-dihydroxyvitam in D is exceedin gly high. Interestingly, there is eviden ce th at certain tum ors m ay secrete a factor th at causes
ren al proxim al tubule deran gem en t, resultin g in reduced
vitam in D synthesis or phosphate deficiency, which can
also lead to skeletal dem ineralization.
Wh ile vitam in D deficien cy is th e prim ary etiology
of rickets an d osteom alacia, oth er less com m on causes
of skeletal dem in eralization exist. X-lin ked hypoph osph atem ia is th e m ost com m on in h erited etiology for rickets. Th e disease causes isolated ren al ph osph ate wastin g,
leading to hypophosphatem ia. The specific treatm en t for
this condition is oral adm in istration of phosphate. Renal
tubular abnorm alities such as renal tubular acidosis and
Fancon i syn drom e cause renal wasting of m ineral con ten ts
including ph osph ate and, therefore, result in a vitam in D
resistan t form of rickets/osteom alacia. Fin ally, a deficien cy
in alkalin e phosphatase enzym e produces abn orm al m ineralization of bon e an d th us creates clin ical features th at
overlap with rickets in th e ch ild an d osteom alacia in th e
adult.
Clinical Presentation
Th e developin g skeleton requires an abun dan t source of
calcium and phosphate in order to properly m ineralize during periods of rapid bone growth. In children with rickets, th e process of m in eralization can n ot keep pace with
the production of n ew osteoid. The result is a relatively
dem in eralized skeleton th at lacks th e com pressive stren gth
of n orm al bon e, an d subsequen tly develops con siderable
deform ity in a predictable pattern . Weigh t-bearin g bon es
109
TABLE 6.6
Ca2+
PO4 3-
AP
PTH
25-OHVit D
1,25-OH2 Vit D
Urine
Ca2+
Associated
Findings
N,
N
N,
Ca2+ , calcium; PO4 3 , phosphate; AP, alkaline phosphatase; PTH, parathyroid hormone; 25-OH-Vit D, 25-hydroxyvitamin D; 1,25-OH2 -Vit D, 1,25-dihydroxy-vitamin D; , increase; , decrease; N, normal. (Adapted from Mankin
HJ. Metabolic bone disease. In: Jackson DW, ed. Instructional Course Lectures, volume 44. American Academy of
Orthopaedic Surgeons, 1995:10.)
are the m ost noticeably affected, such as the forearm s in infan ts learn in g to crawl. O lder ch ildren wh o walk m ay suffer
varus or valgus deform ity of the lower extrem ity. Children
m ay be irritable an d complain of bone pain , dental caries,
m uscle aches, and weakn ess exacerbated by activity.
Min eralization is of particular importan ce at th e epiphyseal plate, wh ere a zon e of calcification precedes th e
replacem en t of cartilage by n ewly form in g bon e. Patien ts
with rickets can n ot efficien tly calcify th e cartilage in th is
region , resultin g in a m arked profusion of cells in th e n on calcified zone of hypertrophy. This presen ts clinically as a
widen in g of th e epiphyses, m ost n oticeably in th e wrists,
elbows, kn ees, an d an kles. Oth er com m on fin din gs on
physical exam in ation th at result from bony dem in eralization in clude shortness of stature, frontal bossing, a soften ing of th e skull, prom inence of the costochondral junctions
(the so-called rachitic rosary), and a thoracic kyphosis.
Th e clin ical presen tation of adults with osteom alacia is
sim ilar in m any respects to that of ch ildren with rickets.
Bone pain, m uscle ach es, an d weakness are typical com plain ts. O steom alacic patien ts m ay also presen t with polyarth ralgias, which m ay be m istaken for rheum atoid arthritis. O steom alacia occurs by definition after the skeleton has
already m atured; therefore, som e of the characteristic findings in rickets (bowing deform ities of the lim bs, widening
of th e epiphyses) are n ot n ecessarily foun d in osteom alacic
patien ts.
Laboratory Investigations
A variety of etiologies m ay cause th e skeletal dem in eralization typical of rickets and osteom alacia, and each is associated with a characteristic set of biochem ical derangem ents
Radiographic Features
Plain radiograph s of th e patien t with suspected osteom alacia or rickets are h elpful in ch aracterizin g th e exten t of skeletal dem in eralization . Patien ts with rickets classically sh ow
widen in g of th e epiphyseal plates, with cuppin g an d flaring of the distal ends of the lon g bones. Cortical thinning
is apparent, and a ground-glass appearance of the cancellous bon e m ay be presen t secon dary to th e layers of un m ineralized osteoid being deposited around the bony trabeculae. Focal deposition s of un m in eralized osteoid m ay
also be apparent on plain radiographs as radiolucent areas
exten din g perpen dicularly across th e cortex. Th ese pseudofracturesare kn own as Loosers lin es an d ten d to occur
on th e con cave aspect of lon g bon es, at th e m edial fem oral
n eck, in ferior to th e lesser troch an ter, on th e isch ial and
pubic ram i, at th e posterior aspect of th e rib, on th e clavicles, an d at th e lateral aspect of the scapulae (Fig. 6.7). In
cases wh ere th e presen ce of Loosers lin e is question able, a
bon e scan m ay be h elpful in iden tifyin g th e cortical m in eral defect. Loosers lin es are ch aracteristic of both rickets
and osteom alacia and m ay propagate in to a true fracture if
th e patien t is left un treated. Bon e scan an d MRI can detect
fractures not visible on radiographs.
110
oral adm in istration of ph osph ate an d th e active form of vitam in D. Th ose with on cogen ic causes of skeletal dem in eralization should have th eir tum ors completely rem oved,
even if ben ign . Patien ts with ren al tubular acidosis or oth er
ren al tubular abn orm alities th at causes loss of bon e m in eral con ten t can be treated with ph osph ate replacem en t
an d supplem ental vitam in D. Electrolyte im balances need
m onitorin g an d treatm ent, and the underlying renal disease sh ould also be treated if possible. Fin ally, th e provider
sh ould con sider chan ging any drugs or other m edical interven tion s th at m ay cause iatrogen ic skeletal dem in eralization.
RENAL OSTEODYSTROPHY
Renal osteodystrophy is a path ologic bone condition in
wh ich th e prim ary cause of th e disorder is ch ron ic ren al
failure. Because of th e adven t of m odern m edical treatm en t,
patien ts with ch ron ic ren al disease are livin g lon ger an d are
m ore physically active. Th erefore, the chance of this group
of patien ts presen tin g to th e orth opaedic com m un ity eith er
for elective surgery or in an em ergency traum a situation
increases.
Figure 6.7 Plain radiograph of the ulna of a patient with rickets
Treatment
Atreatm ent strategy for the patient with rickets or osteom alacia sh ould be selected to address th e un derlyin g etiology
of skeletal dem in eralization . In patien ts with n utrition al
rickets, calcium and vitam in D supplem entation is appropriate. A com m on dosin g regim en is ergocalciferol 50,000
IU on e to two tim es per week, with 1,000 to 1,500 m g of
calcium per day. The treatm ent should last from 6 m onths
up to 1 year. If th e patien t h as a syn drom e of gastroin testinal m alabsorption , an in jectable form of vitam in D sh ould
be con sidered. Patien ts with depen den t rickets sh ould be
carefully studied and treated with 1,25-dihydroxy-vitam in
D for both type 1 an d type 2 depen den t form s. However,
treatm en t with h igh doses of vitam in D produces a variable
clinical response in type 2 depen den t patien ts. Th e specific
treatm en t for patien ts with X-lin ked hypoph osph atem ia is
Pathophysiology
Kidneys are the vital organs for regulatin g calcium hom eostasis. Th e proxim al con voluted tubule is th e site th at produces 1,25-dihydroxy-vitam in D. Th is h orm on e is a prim e
regulator of in testin al calcium absorption an d provides th e
feedback m echanism to inh ibit PTH synth esis. In addition, kidneys serve as th e prim ary route for excretion of
waste products including ph osph ate, alum inum , and other
toxic agen ts. Th erefore, ch ron ic ren al failure results in a sign ifican t rise in blood urea n itrogen , creatin in e, an d ph osph ate. Th e in jury to ren al tissue creates a reduced tubular
m ass, which interrupts 1,25-dihydroxy-vitam in D synthesis. Th is leads to a drop in serum calcium , which causes a
m arked increase in serum PTH and resulting secondary hyperparathyroidism . Th e bon e path ology, th erefore, sh ows
sign s consisten t with both rickets or osteom alacia and hyperparathyroidism (Fig. 6.8).
Th e path ophysiology of ren al osteodystrophy is subdivided in to two groups: high turn over and low turnover.
Th e h igh -turn over state is th e classic form of th is disease.
Th is form of ren al osteodystrophy is associated with h igh
PTH. Serum levels of PTH m ay be 5 to 10 tim es above
the upper level of norm al in patients with secondary hyperparathyroidism . In th e presen ce of elevated PTH levels, bon e turn over rem ain s h igh an d th us in creases th e activity of both osteoblasts and osteoclasts. Conversely, the
low-turn over state is associated with norm al to low serum
PTH. Th e path ogen esis of low-turn over ren al osteodystrophy is com plex an d in cludes a large n um ber of factors
such as alum in um -based phosphate binder and peritoneal
111
trophy. The skeletal presentation in patients with renal osteodystrophy shows changes consistent with
both rickets and osteomalacia and osteitis fibrosa cystica, which is an antiquated term for hyperparathyroidism. (Adapted from Mankin HJ. Metabolic bone
disease. In: Jackson DW, ed. Instructional Course Lectures, volume 44. American Academy of Orthopaedic
Surgeons, 1995:15.)
Clinical Presentation
Th e clin ical m an ifestation s of ren al osteodystrophy are diverse and nonspecific. Bone pain is usually diffuse and
m ay be associated with weigh t-bearing positions. Proxim al
m uscle weakness is also relatively com m on. Children with
ren al osteodystrophy m ay m an ifest with lin ear growth failure, deform ities of th e lon g bon es, slipped capital fem oral
epiphysis, an d fractures. Th e elevation of both serum calcium and phosphate levels leads to extraskeletal calcification. These include periarticular calcification, vascular
calcification of m edium and sm all arteries (Monckebergs
sclerosis), an d calcification of the visceral organs such as
lungs, heart, kidn eys, or skeletal m uscle. Som e patients m ay
presen t with isch em ic n ecrosis of th e skin (calciphylaxis),
wh ich is a rare con dition with catastroph ic con sequen ces.
Radiographic Features
Gen erally, th e im agin g studies of patien ts with ren al osteodystrophy sh ow ch an ges con sisten t with both rickets/
osteom alacia an d hyperparathyroidism . In its severe form ,
hyperparathyroid bon e disease m ay predom in ate an d
m anifest as subperiosteal or subchondral erosions. The
classic sites of subchondral resorption are at the distal clavicle, sacroiliac joints, and pubic symphysis, while subperiosteal resorption occurs alon g th e m edial border of th e
proxim al tibia, th e radial border of th e m iddle ph alan ges,
showing subperiosteal resorption at the medial border of the proximal tibia (arrowheads). (Courtesy of Bernard Ghelman, MD.)
112
ing a well-demarcated lytic lesion in the proximal femur. The cortices are thin on both sides but remain intact. This localized area of
bone destruction is known as brown tumor. Treatment of underlying hyperparathyroidism results in the resolution of these lesions.
(Courtesy of Bernard Ghelman, MD.)
en dplates con den ses in to radiopaque ban ds, givin g a distin ct striped appearan ce of altern atin g lucen t an d opaque
ban ds kn own as rugger jerseyspin e (Fig. 6.12).
Treatment
Th e treatm en t of ren al osteodystrophy is depen den t on
the renal disease. The goals are to m aintain serum levels
of calcium an d ph osph orus as close to n orm al as possible, to avoid alum in um an d iron toxicity, and to preven t th e developm en t of parathyroid hyperplasia or, if
secondary hyperparathyroidism has already developed, to
reduce th e serum PTH level to acceptable value. Dietary
restriction of ph osph orus can h elp in regulatin g serum
ph osph ate levels an d th us preven tin g soft-tissue calcification . Active vitam in D sterols (1,25-dihydroxy-vitam in D)
are importan t to correct vitam in D deficien cy an d to con trol hyperparathyroidism . Recen tly, a n ew agen t for th e
treatm en t of hyperparathyroidism , cin acalcet hydroch loride, wh ich blocks PTH actions, has been introduced and
seem s to be extrem ely useful in decreasing the levels of
PTH. In situation s wh ere serum PTH rem ain s excessively
high, surgical rem oval of parathyroid tissue m ay also be
required.
PAGETS DISEASE
Pagets disease of bone (also known as osteitis deform ans)
is a localized disorder of bon e rem odeling. The disease process is initiated by increases in bone resorption, with subsequent compen satory increases in new bone form ation.
Because of th e rapid bone turn over rate, th e affected bon e
loses its control of the bony structure and thus results in
disorgan ized m osaic pattern of woven an d lam ellar bon e.
Although m ost patien ts are asymptom atic, those affected
with th is disease m ay experien ce a variety of clin ical symptom s an d sign s depen din g on th e severity, n um ber, an d
location of the affected skeletal sites. Th e clinical presen tation in cludes bon e pain , secon dary osteoarth ritis, bon e
deform ity, an d com plication s from bony com pression to
the adjacent soft-tissue structure, such as neural tissue
surroundin g th e pagetoid bone.
113
the overall bone turnover is equivalent. The h istopathologic fin din g is depen den t on th e stage of th e disorder to
affected bon e. Th e early ph ase is dom in ated by in creased
bon e resorption by activated osteoclasts, resultin g in a lytic
lesion th at is appreciated radiograph ically as blade of
grass lesion in lon g bone or osteoporosis circum scripta
in skull. Th ese osteoclasts are m ore n um erous an d con tain m ore n uclei th an do n orm al osteoclasts. In order to
respon d to th e in creased bon e resorption , osteoblasts are
recruited to th e affected area. Durin g th is blastic ph ase, because of the n ature of rapid turnover, the n ewly deposited
collagen fibers are laid down in a disorgan ized pattern,
creating a m ore prim itive woven bone. Th is results in an irregularity of con tour of th e n ew trabeculae an d cortices. In
addition , th e bon e m arrow is in filtrated by th e osteoclasts,
osteoblasts, an d blood vessels between th e trabeculae, creatin g th e hypervascular state of th e bon e.
Over tim e, the hypervascularity and hypercellularity
process extin guish es by itself, leavin g th e en d result of a
sclerotic, en larged, m osaic pattern . This is a sclerotic phase
or a so-called burn ed out Pagets disease in wh ich n eith er
bon e form ation n or resorption takes place. Gen erally, all
ph ases can be seen at th e sam e tim e in differen t areas of
the patients with Pagets disease.
Figure 6.12 Anteroposterior radiograph of the lumbosacral
Pathology
Pagets disease is a disorder in which bone is synthesized
an d degraded at rapid rates but generally equal. Therefore,
Clinical Presentation
Pagets disease is m ost com m on ly diagn osed in in dividuals older than 50. Many patients, th erefore, h ave Pagets
disease for a period of tim e before th e diagn osis is m ade.
It m ay presen t as a m on ostotic lesion , wh ich affects on ly
on e bon e, a portion of bon e, or a polyostotic lesion , wh ich
involves two or m ore bones. The m ost com m on areas of
involvem ent include the pelvis, fem ur, spine, skull, and
tibia. Upper extrem ities, hand, and feet are less com m only
affected. In general, m ost patients with Pagets disease are
asymptom atic an d the diagnosis is m ade when abnorm al
blood ch em istry such as an elevated alkalin e ph osph atase
is noted or when an inciden tal finding from the radiograph s is foun d. Th e developm en t of symptom s or com plication s of Pagets disease is in fluen ced by area of in volvem en t, the exten t of m etabolic activity, and th e effect
of pagetoid bon e to th e adjacen t structure.
Bon e pain, eith er m ild or severe, is probably the m ost
com m on sym ptom . Bon e pain m ay be associated with a
h igh -turnover state when th ere is hypervascularity at th e
area of involvem ent. Bowing deform ity especially of the
fem ur and tibia are com m on and can lead to secondary osteoarth ritis from alteration of th e m ech an ical axis an d abn orm al gait pattern . Pagets disease of th e vertebral bodies
can produce sign s an d symptom s sim ilar to spin al sten osis, wh ile Pagets disease of the skull m ay affect cranial
n erves, causin g cranial n erves palsies in cran ial n erves II,
VII, VIII. Increased blood supply to the affected bone results in a large am ount of cardiac output and, if prolonged
and untreated, m ay impair left heart function and lead to
114
Diagnosis
When Pagets disease is suspected, th e diagnostic evaluation in cludes a th orough m edical h istory, physical exam in ation , laboratory in vestigation s, an d im agin g studies.
Patien ts with Pagets disease usually show elevated serum
bon e-specific alkalin e ph osph atase levels, wh ich in dicate
in creased osteoblast activity, wh ereas h igh con cen tration of
NTx or CTx in th e urin e reflects in creased bon e resorption .
Although these findings are n ot specific, the utility of these
m arkers is prim arily to assess th e respon se of treatm en t an d
to follow th e course of disease over tim e.
The findin gs from plain radiograph s include four im portan t fin din gs: (a) th e width an d som etim es len gth of
in volved bon e are greater th an n orm al; (b) th e cortices
are wider; (c) th e trabeculae in th e m edullary can al are
coarse but disorganized; and (d) the m edullary bone often
contains lytic areas of various sizes (Fig. 6.13). Gen erally,
the characteristic findings from plain radiograph and clinical features of Pagets disease can elim in ate oth er differen tial diagn oses.
Treatment
Patients who are asymptom atic can be treated conservatively by serial follow-up with radiographs, bone scan,
an d assays for bone m arkers. There is no clear indication for treating this group of patients. Two logical recom m en dations for treatm en t of Pagets disease are to relieve
sym ptom s an d to prevent future complications. It is still
inconclusive whether asymptom atic patients with active
disease (elevated alkalin e ph osph atase) sh ould be treated.
In th is settin g, m edical treatm en t m ay preven t th e patients from developing later problem s or complications,
especially in th e youn ger patien t for wh om m any years
of coexisten ce with th e disease is likely. However, th ere
is no clinical study to prove that disease suppression reduces th e progression of bon e deform ity. Specific th erapeutic agents available in th e United States for treatm en t of Pagets disease include bisphosphon ates and
calcitonin.
Th e action of bisph osph on ates is prin cipally by altering calcium m etabolism and inhibiting osteoclast activity.
Currently, four bisphosphonates have been recom m ended
as the first- lin e drugs of treatm ent: alendronate, risedron ate, pam idron ate, an d zoledron ic acid. Th e dosage for
treatm ent of Pagets disease, h owever, is higher and m ore
frequent than that recom m ended for treatm ent of postm en opausal osteoporosis. Studies showed th at patients
treated with intravenous bisphosphonates have a rem ission
in their symptom s and a m arked change in their bioch em ical profiles. In addition, bisphosphonate therapy has been
sh own to reduce arth ritis difficulty, spinal canal narrowing,
h earin g loss, and fracture rates.
Calciton in h as been sh own to be effective in Pagets disease for m ore th an 30 years. However, on ly th e in jectable
form ulation is approved by the FDAfor treatm ent of Pagets
disease. Th e improvem en t of clin ical sign s an d sym ptom s
is noted in a few weeks, and the reduction of serum alkaline ph osphatase is usually observed after 3 to 6 weeks of
treatm ent. The initial starting dose is 100 IU everyday. O nce
the patient observes the symptom atic ben efits from m edication , the dose sh ould be reduced to 50 to 100 IU every
oth er day. Because n ew gen eration bisph osph on ates offer
greater efficacy an d are easier to use, calciton in is n ow reserved for patien ts who cannot tolerate or have contraindications to bisphosphon ate therapy.
Patien ts who develop osteoarthritis, fractures, or spinal
stenosis m ay n eed to be treated with surgical intervention.
However, surgery in these patients m ay be complicated by
excessive blood loss, h igh -output cardiac failure, h eterotopic bon e form ation , or loosen in g of th e implan t. Th erefore, patients need careful attention durin g the pre- and
postoperative period. It is recom m en ded to give bisph osph on ates before an elective surgery. Th e goal is to reduce
hypervascularity associated with active disease, wh ich will
reduce th e am oun t of blood loss an d poten tial complication from left heart failure.
SUMMARY
Metabolic bone diseases are a group of disorders that occur
as a result of changes in osteoblast an d osteoclast fun ction.
Th e osteoblast an d osteoclast play a m ajor role to m ain tain
structural and m aterial properties of bon e, control the syn thesis of bone m atrix, and regulate m ineral m etabolism as
well as th e m in eralization process. Th us, an alteration of
these cell function s results in a variety of clinical disorders.
An understandin g of the pathogenesis of such diseases and
an attempt to define the cause of the patien ts acute problem is the key for treatm ent. Th is requires a thorough m edical history, physical exam in ation, im aging studies, and appropriate laboratory in vestigation s. Orth opaedic surgeon s
sh ould be aware of these biologic and biochem ical disor-
115
ders an d fam iliar with th eir clin ical presen tation . Th e ultim ate success in treatm en t of th e orth opedic m an ifestation s
of th ese disorders often n ecessitates direct correction of th e
un derlyin g disease process.
RECOMMEND READINGS
Holick MF. Vitam in D deficien cy. N Engl J Med. 2007;357(3):266 281.
Lin JT, Lan e JM. Osteoporosis: a review. Clin Orthop Relat Res. 2004;
(425):126 134.
Mankin HJ, Mankin CJ. Metabolic bone disease: an update. In: Ferlic DC, ed. Instructional Course Lectures. Rosem ont, IL: Am erican
Academy of Orthopaedic Surgeon s, 2003:769.
Regin ato AJ, Coquia JA. Musculoskeletal m an ifestation s of osteom alacia and rickets. Best Pract Res Clin Rheumatol. 2003;17(6):1063
1080.
Siris ES, Jacobs TP, Can field RE. Pagets disease of bon e. Bull N YAcad
Med. 1980;56(3):285 304.
Jacob N. Ablin
118
Durin g early developm en t, cells th at will even tually becom e B cells (a n am e derived from the in volvem en t of a
bursa in th is process in birds) m ature in depen den t of th e
thym us. These cells develop cell surface m arkers such as
surface im m unoglobulin s (Igs), an d their m ajor fun ction
is to produce an tibodies.
An important concept for understandin g th e function of
both Tan d Bcells is th e process of clon al expan sion . In early
developm en t, th e im m un e system h as cells th at could th eoretically respon d to virtually any possible an tigen . Th e subsequen t interaction of th e in dividual with the en viron m ent
will largely determ ine which of these cell lin es are stim ulated to expan d an d replicate (i.e., clon al expan sion ) an d
which are deleted (because they react with self-antigen s).
Th is latter con cept th at describes th e loss of reactivity to
self-antigens is term ed immune tolerance.
Another basic distinction important for un derstanding
the way in which the im m une system function s in sickness
an d in h ealth is th at between th e in n ate an d th e adaptive im m un e respon se. Th e in n ate im m un e respon se is a
phylogen etically m ore an cien t system design ed prim arily
for com bating infectious agents. This response is ch aracterized by n ot bein g depen den t on previous exposure to
an tigen to respon d. Th ese cells recogn ize fixed path ogen associated m olecular pattern s. Th is rapid respon se m ech an ism is, h owever, lim ited in its ability to react to n ovel
threats. The adaptive im m un e system , on the other han d,
functions through selection and m utation of the im m une
cells to m ount a h ighly targeted response to a previously
en coun tered an tigen .
Antigen-Presenting Cells
Th is class of cells h as m any roles both in th e in n ate an d
the adaptive im m une respon se. In th e latter, the first step
is th e in teraction between an tigen an d an tigen -presen tin g
cells (APCs). There are a num ber of cell types that are capable of actin g as APCs, in cludin g B cells, tissue m acroph ages,
an d site-specific cells such as den dritic cells in th e skin or
Kupffer cells in the liver. In general, th ese cells first processantigen by intern alizin g protein and digesting the protein in to peptides, an d th en presen tth ese peptides on th e
cell surface for recognition by another class of lymphocytes
known as T cells, through an interaction with specific T cell
receptors (TCRs).
T Cells
T cells (particularly th e CD4+ subset of T cells, also called
helper T cells) are respon sible for th e recogn ition of an tigen s on APC cells in a T-celldepen den t an tibody respon se.
When th e im m un e system is fun ctioning properly, T cells
will respond to foreign antigens but n ot to self-antigen s.
Th is process occurs prim arily in th e thym us an d in volves
the positive selection of clones of cells that respon d to foreign an tigen s an d th e elim in ation of clon es th at respon d
to self-an tigen s. In addition , rapid cell death (apoptosis)
of activated T cells m ust occur at th e term in ation of th e
B
MHC class II Pathway
Calreticulin
Peptide-MHC
Complex
Peptide-MHC
Complex
CLIP
Secretory
Vesicle
Tapasin
Endosome
HLADM
TAP
Complex
ER
Peptide Proteosome
ER
MIIC
(e.g., SLE, RA), wh ereas others (e.g., ankylosing spon dylitis, reactive arth ritis) are characterized by a relative CD8+
excess. Th is run s in parallel to our un derstan din g of th e
im m unogenetic risk factors for these types of disorders.
For exam ple, th e seron egative spon dyloarth ropath ies (SSs)
(e.g., ankylosing spon dylitis) are stron gly associated with
the presence of the HLA-B27 (or related haplotypes, e.g.,
B7, Bw22, B42) haplotypes, and CD8+ cells have specificity
for these MHC I products. In contrast, the im m unogenetic
risk for developin g disorders such as SLE or RA is con ferred
by certain MHC class II h aplotypes (e.g., HLA DR4), again
in parallel with the m ore prom inent role of CD4+ cells
in the pathogenesis of these disorders. This phenom enon
of reciprocal roles of CD4 an d CD8 cells also appears to
be eviden t wh en person s with autoim m un e disorders becom e infected with the hum an im m unodeficiency virus
(HIV). The lowering of the CD4+ count associated with
this disease frequently leads to an improvem en t in CD4+
depen den t disorders such as SE or RA but a m arked worsen in g of CD8+ depen den t disorders such as th e SSs.
Differen t types of an tigen s also elicit differen t types of im m un ologic responses. For example, som e antigens, such as
mycobacterium an d fun gi, elicit exclusively a cell-m ediated
respon se, wh ereas m ost path ogen s elicit a m ixed respon se.
B Cells
Once activated, the m ajor function of the B cell is to produce an tibodies. Th is activation can occur via a T-cell
depen den t or a T-cellindependent m echanism . In the
T-celldepen den t system , th e CD4+ cell is activated via
an interaction with a specific APC. Som e antigens are capable of directly in teractin g with B cells, in depen den t of
T cells, and lead to a less-specific Ig response. A
sm all proportion of B cells will develop in to long-lived
119
Immunoglobulins
Igs are th e product of activated m ature Bcells. Th ere are n in e
classes of Igs, each of wh ich con sists of two h eavy ch ain s
and two light chains. For each type of Ig, th ere is a constant
region th at is largely respon sible for th e physiologic fun ctions of the Ig m olecule (e.g., complem ent activation) and
a variable dom ain th at is largely respon sible for th e an tigen
specificity of th at particular Ig. Each of the subclasses of Ig
serves different function s (Table 7.1).
Autoantibodies are Igs directed against self-antigens. The
two m ost com m only considered autoantibodies are antinuclear an tibodies (ANAs) an d rh eum atoid factor (RF). ANAs
are antibodies directed again st various componen ts of the
cell n ucleus. Th ese an tibodies are a serological h allm ark of
autoim m une disease such as SLE, in which they are present
in 99% to 100% of patients. Several factors need, however,
to be con sidered before ordering th is test. First, a substantial percen tage of th e general population (as high as 30%)
will h ave a positiveresult for th is assay usin g n ewer, m ore
sensitive tech niques. Because of the low specificity of this
test, it sh ould be ordered on ly wh en th ere is a h igh pretest
probability th at th e person h as a disease ch aracterized by
a positive ANA. If th is test is foun d to be positive, th en furth er testin g for extractable n uclear an tigen s can be con sidered (e.g., an ti-Ro [SSA], an ti-La [SSB], an ti-Sm , an ti-RNP,
anti-dsDNA) since th ese are m uch less com m only present
as false-positive tests in norm al individuals.
TABLE 7.1
IgA
65
++
20
+
10
++
+
+
+
+
90
+ /
10
+ /
+
+
+
+
+
23
25
+
+
+
+
23
?
+
+
+
+
89
3.5
+
+
+
+
23
?
6
24
6
?
IgM
IgD
IgE
++
5
7
3
0.4
2.5
0.02
120
RFs represen t a h eterogen eous group of an tibodies directed again st th e Fc portion of IgG. As with ANA, th is test
sh ould be ordered only in persons with a high pretest probability of RA, since wh ile approxim ately 80% of person s
with RA will h ave a positive value, RF will also be presen t
in som e norm al individuals and in a proportion of patients with a variety of oth er disorders, in cludin g viral an d
bacterial in fection s, oth er rh eum atic diseases, an d lym ph oproliferative diseases. Alth ough th e rate of false positive
RF is lower for RF th an for ANA, ordering this test in persons with out evidence of syn ovitis or elevated inflam m atory in dices will lead to far m ore false positives th an true
positives.
Antibodies directed against cyclic citrullinated peptides
(anti-CCPs) h ave been found in serum of m any RA patients; a specificity rate as h igh as 98% h as been reported
for this an tibody.
However, it is importan t to recogn ize th at the serum
levels of RF, anti-CCPs, and ANA do not correlate with the
level of disease activity, so th at once th ese tests are ordered
an d known to be positive, there is little value of followin g
these values longitudinally in an individual patien t.
Complement
Th e complem en t system con sists of a series of protein s th at
are in volved in m ediating a variety of inflam m atory effects.
As with other compon ents of the im m un e system , this system is vital in protectin g th e organ ism s again st in fection
(particularly bacterial pathogens) but can be respon sible
for tissue dam age in rheum atic disorders.
Th ree separate path ways of complem en t activation h ave
been iden tified: th e classical path way, th e altern ative path way, and the lectin pathway (LP) (Fig. 7.2). Although these
121
Type I
IgE Mediated
Th e com bin ation of an IgE an tibody bin din g to th e Fc receptor of a basoph il or m ast cell an d an an tigen bin din g
to that antibody leads to stim ulation of these cells. Products con tain ed in basoph ilic gran ules in clude h istam in e,
seroton in , bradykin ins, and other substances. This type of
reaction is m ost prom in en t in allergic diseases.
Type II
Direct Antibody-Mediated Effects on Cells
Autoan tibodies bin din g to self-an tigen s on a cell or tissue can cause complem ent fixation an d/or direct cytotoxic
killing of that particular cell. An example occurs in som e
types of hem olytic anem ia, wh ere red blood cells (RBCs)
are destroyed when autoantibodies bind to cell surface antigen s. Th is type of reaction is relatively un com m on .
Type III
Immune Complex Formation
In con trast to type II reaction s, wh ere an tibody bin ds to
antigens on a cell or tissue surfaces, in this instance, soluble an tigen s bin d to an tibodies in th e circulation . Th ese im m une complexes m ay bin d to cell surface receptors or activate complem en t and cause an in flam m atory process in the
tissue(s) where they are deposited. Many classic system ic
autoim m une disorders, such as SLE, are characterized by
th e presen ce of circulatin g an d tissue im m un e com plexes.
However, it rem ain s un clear how m uch of the disease process is actually caused by th ese im m un e complexes.
Type IV
Direct Cell Injury
Several types of im m un e cells, including both T cells and
CD8+ cells, can cause direct cell injury, whereas other types
of cells such as CD4+ cells can affect cell in jury by attracting other types of cells. This m echanism is probably operative in a n um ber of autoim m un e an d oth er rh eum atic
disorders.
122
TABLE 7.2
123
TABLE 7.3
124
Physical Examination
Both a general physical exam in ation and a m usculoskeletal
exam in ation are im portan t in th e patien t wh o presen ts with
arth ritis. As n oted earlier, th ere are a pleth ora of n on articular features th at can accom pany arth ritis.
In the m usculoskeletal exam ination, the goal of th e evaluation is to (1) determ in e th e exten t of in volvem en t, (2)
localize th e an atom ic structure(s) in volved, an d (3) determ in e wh eth er th e process is in flam m atory or n on in flam m atory. To determ in e th e exten t of in volvem en t, it is im portan t to perform a gen eralized exam in ation of th e join ts
an d soft tissues, even if th e patien t presen ts with a localized complain t. Th e patien t with a system ic in flam m atory
process will very frequen tly presen t with th e complain t of
pain in a sin gle join t. Lim itin g th e focus to th at join t will
lead to an improper diagn osis an d in effective treatm en t.
The best m anner to localize the anatom ic structure(s)
in volved is to perform th e m usculoskeletal exam in ation
by palpatin g with firm pressure (enough to blanch th e exam in ers fin gern ail) over both join ts an d soft tissues, first
in region s of th e body wh ere th e person is n ot complain in g of pain and finally in the affected region. This type
of exam in ation accom plish es several objectives. On e is to
assess th e patien ts overall pain th resh old. If in dividuals
have tendern ess over bones and soft tissues in a n um ber
of region s in th e body, th ey m ay suffer from a gen eralized
disturban ce in pain processin g (e.g., fibrom yalgia) rath er
than a process localized to a specific region. This type of exam in ation also will detect wh eth er periarticular structures
(e.g., tendon in sertion s, bursae) are in volved. Secon d, th is
procedure iden tifies in dividuals wh o m ay h ave m ore th an
on e process th at is coexpressed an d respon sible for sym ptom s (e.g., th e patien t with osteoarth ritis [OA] of th e h ip
or kn ee an d con curren t troch an teric or an serin e bursitis
in volvin g th ose sam e region s, respectively).
Using the above-m ention ed technique, special attention
is paid to th e join ts, an d in particular, exam in in g th e join t
for evidence of synovitis. To the unskilled exam in er, an
en larged join t represen ts arth ritis. But with experien ce,
palpation of en larged join ts can differen tiate th e firm an d
less pain ful bony proliferation secon dary to osteophytes
(as occurs with Heberden an d Bouch ard n odes in th e distal
in terph alan geal [DIP] an d proxim al in terph alan geal [PIP]
join ts of th e h an ds in OA) from th e ten der, boggyswellin g
seen in ch ronic in flam m atory arthritis due to synovial proliferation an d/ or join t effusion s.
Diagnostic Testing
Again , the evaluation of the patient with arth ritis parallels th at of th e patien t with oth er orth opaedic problem s,
alth ough certain poin ts bear emph asis. Perh aps, th e m ost
importan t poin t to emph asize is th at th e h istory an d physical exam ination typically yield far m ore useful inform ation
than do laboratory studies. This can be stated in two differ-
125
TABLE 7.4
USE OF GROSS ANALYSIS, MUCIN CLOT TEST, AND TOTAL AND DIFFERENTIAL LEUKOCYTE
COUNTS IN THE CLASSIFICATION OF SYNOVIAL FLUIDS
Criteria
Normal
Noninflammatory
(Group I)
<4
Clear to pale yellow
Transparent
Very high
Good
None
< 50
< 25
Often > 4
Xanthochromic
Transparent
High
Fair to good
Often
< 3,000
< 25
Inflammatory
(Group II)
Purulent
(Group III)
Often > 4
Xanthochromic to white
Translucent to opaque
Low
Fair to poor
Often
3,00050,000
> 70
Often > 4
White
Opaque
Very low
Poor
Often
50,000300,000
> 90
A bedside test for indicating viscosity of synovial fluid the more viscous and stringy the fluid is when it is
dripped the more normal.
(Reprinted with permission from Koopman WJ, Moreland LW. Arthritis and Allied Conditions: A Textbook of
Rheumatology. 15th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2005.)
person with arth ritis. In addition to a CBC coun t an d a differen tial count, the appearan ce and viscosity of th e fluid
sh ould be assessed, an d th e protein and glucose concentration in th e fluid sh ould be determ in ed. Gram stain in g
an d culture are useful for th e diagn osis of septic arth ritis,
wh ereas exam inin g th e fluid un der a polarizin g m icroscope
allows detection of crystals respon sible for crystal-in duced
arth ropathy, for example, gout an d pseudogout. Tables 7.4
an d 7.5 in dicate h ow th is in form ation can be used, togeth er
with th e h istory, physical exam ination, and oth er diagnostic tests, in assessin g th e patien t with arth ritis.
RHEUMATOLOGIC DISORDERS
A brief overview of a n um ber of rh eum atic disorders th at
m ay presen t with orthopaedic problem s is given in th e
following section. Space constraints severely lim it both the
breadth an d depth of th is section , an d th e reader sh ould
refer to several excellen t rh eum atology textbooks for a
m ore extensive overview of th ese and other rheum atologic
disorders.
Rheumatoid Arthritis
RA is the m ost com m on form of chronic, system ic inflam m atory arthritis. It is estim ated th at 1% to 2% of th e population worldwide suffers from th is disorder. Population based studies m ay overestim ate th e prevalen ce of true
RAs, as m any people identified in such studies m ay have
self-lim ited form s of inflam m atory arth ritis (e.g., postviral arth ritis) or do n ot h ave in flam m atory arth ritis at all.
Non eth eless, th is is likely th e m ost com m on autoim m un e
rh eum atic disease. As with m ost autoim m un e disorders,
wom en are affected m ore com m on ly th an m en , with a ratio
of approxim ately 2.5 to 1. RA can strike at any age, from th e
youth to the elderly. As with m ost autoim m une disorders,
126
TABLE 7.5
Osteoarthritis
Early rheumatoid arthritis
Trauma
Osteochondritis dissecans
Osteonecrosis pigmented
Osteochondromatosis
Crystal synovitis; chronic or subsiding
acute (gout and pseudogout)
Systemic lupus erythematosusb
Polyarteritis nodosab
Scleroderma disease
Amyloidosis (articular)
Polymyalgia rheumatica
High-dose corticosteroid therapy
Rheumatoid arthritis
Reactive arthritis
Crystal synovitis, acute (gout,
pseudogout, other)
Psoriatic arthritis
Arthritis of inflammatory bowel
disease
Viral arthritis
Rheumatic fever
Behcet disease
Fat droplet synovitis
Some bacterial infections, e.g.,
coagulase-negative
Staphylococcus, Neisseria,
Borrelia, Moraxella
Bacterial infections
Tuberculosis
Pseudosepsis
(Reprinted with permission from Koopman WJ, Moreland LW. Arthritis and Allied Conditions: A Textbook of
Rheumatology. 15th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2005.)
127
TABLE 7.6
Definition
Morning stiffness
Arthritis of three or more
joints
Arthritis of hand joints
Symmetric arthritis
Morning stiffness in and around the joints, lasting at least 1 hour before maximal improvement
At least three joint areas simultaneously with soft tissue swelling or joint fluid observed by a joint areas
physician; the 14 possible areas are (right or left): PIP, MCP, wrist, elbow, knee, ankle, and MTP joints
At least one area swollen in a wrist, MCP, or PIP joint
Simultaneous involvement of the same joint areas on both sides of the body (bilateral involvement of PIP,
MCP, or MTP acceptable without perfect symmetry)
Subcutaneous nodules over bony prominences or extensor surfaces, or in juxtaarticular regions, observed by
a physician
Abnormal amount of serum rheumatoid factor by any method for which the result has been positive in < 5%
of control subjects
Erosions or unequivocal bony decalcification localized in or most marked adjacent to the involved joints
(osteoarthritis changes excluded), typical of rheumatoid arthritis on posteroanterior hand and wrist
radiographs
Rheumatoid nodules
Serum rheumatoid factor
Radiographic changes
128
ch aracteristic deform ities seen in th e digits (e.g., swan neck deform ity, boutonn iere deform ity, and ulnar deviation at th e m etacarpoph alan geal [MCP] join ts) are due to
a com bin ation of join t destruction an d laxity of ligam en ts
an d ten don s. Ten osyn ovitis com m on ly can lead to clin ical
symptom s in RA, especially trigger fingerswhen the flexor
ten don s of th e digits are in volved.
Extraarticular m anifestations of RA are also com m on,
especially in person s with a positive serum RF. Rh eum atoid
nodules m ost com m on ly occur on th e exten sor surfaces of
the arm in the olecranon region but can occur nearly anywhere in the body, particularly on oth er exten sor surfaces.
Th e form ation of n odules can becom e accelerated in person s with RA given m eth otrexate.
There are a variety of form s of pulm on ary disease in
RA. As with m any cardiopulm on ary m an ifestation s in patien ts with autoim m un e disorders, th is occurs in n early all
RA patien ts in autopsy series but is less com m on ly clin ically apparent. Interstitial fibrosis preferentially involving
the basilar regions is m ost com m only seen. Pleural involvem en t, n odules in th e lun g (especially fulm in an t in coal
m in ers an d term ed Caplan syn drom e), an d bron ch iolitis
obliteran s are also seen .
Cardiac in volvem en t, wh ich m ay in clude pericarditis,
myocarditis, an d cardiac conduction defects (perh aps due
to rh eum atoid n odules in volvin g th e con duction system ),
can be seen in RA. Vasculitis m ay also occur in person s
with RA, and in th is settin g, it is term ed rheumatoid vasculitis. Th is can involve both sm all- an d m edium -sized vessels of the skin, peripheral n erves, and visceral organs.
Felty syn drom e is th e com bin ation of RA, splen om egaly,
isch em ic leg ulcers, an d n eutropen ia. Th ese person s also
com m only exhibit lymphadenopathy and throm bocytopenia, and som etim es splenectom y is necessary for effective
treatm en t.
The natural history of RAhas becom e better understood
recen tly an d h as led to con sideration of differen t treatm en t
paradigm s. It h as becom e in creasin gly clear th at m uch of
the joint dam age in RA occurs in th e first several years of
the illness. Th us, old pyram id treatm en t strategies that
slowly added one drug at a tim e have been replaced by
m ore aggressive paradigm s. Also, in th e past, RA h ad been
considered an indolent, debilitating disorder characterized
by a slow progressive course, with eventual rem ission in
som e patients. It is now clear that patien ts with RA h ave
significantly increased m ortality and die 10 to 15 years earlier th an expected. Th is excess m ortality appears to be m ultifactorial, in cludin g an in creased risk of in fection s, cardiovascular disease, and pulm onary and gastrointestinal (GI)
complications.
There is no unanim ity on exactly how to treat RA, but
nearly all persons with out a con train dication to taking non steroidal anti-inflam m atory drugs (NSAIDs) will benefit
from takin g this class of m edication . It is un usual for RA
to be con trolled with th is agen t alon e, an d in m ilder disease, a logical step is to add hydroxych loroquin e (200 m g
twice daily). The principal concern with this agen t is retin al toxicity. Hen ce, twice-yearly oph th alm ologic exam inations are typically recom m ended. For patients with m ore
aggressive disease or those who fail hydroxychloroquine,
weekly m eth otrexate is a logical n ext ch oice. Th is m edication is typically given orally on ce weekly, begin n in g at
7.5 m g per week an d escalatin g as h igh as 20 m g or m ore per
week. Folic acid is typically coadm in istered at 100 m g/ d to
h elp avoid GI toxicity. Sh ort-term side effects of th is m edication include diarrhea, nausea, fatigue, and stom atitis,
wh ereas th e m ore serious toxicities are liver disease an d
hypersen sitivity pn eum on itis. Leflun om ide, wh ich acts as
an antipyrim idine agent, is of sim ilar effectivity (and toxicity). When and where to use corticosteroids in the chronic
treatm ent of RArem ains controversial, with som e data suggestin g th at lon g-term , low-dose (e.g., < 10 m g/ d of predn isone) is both helpful an d relatively free of side effects.
Th e treatm en t of RA h as been revolution ized over th e
last decade due to the introduction of biologic anticytokin e
m edications into com m on clinical use. Three m edications
th at act by n eutralizin g th e activity of TNF- h ave been in troduced (inflixim ab, etan ercept, and adalim um ab). These
agen ts, which are adm inistered by the intravenous or subcutan eous route, h ave proven extrem ely effective in cases
refractory to con ven tion al m edication s. Sin ce th ese drugs
inhibit a m ajor component of the im m une system , th eir
use m ay expose th e patien t to in fection with path ogen s
such as Mycobacterium tuberculosis. Prior in fection with th is
path ogen m ust, th erefore, be ruled out before in itiatin g
such treatm en t.
Another biologic agent that has been recently introduced for th e treatm en t of RA is rituxim ab, wh ich acts by
targetin g B-cell lym ph ocytes, wh ich express th e CD20 an tigen . Th is m edication , origin ally developed for th e treatm ent of B-cell m align ancies, can brin g about lon g-term
clin ical rem ission (lastin g up to 1 year) after a sin gle in fusion . In troduction of additional classes of biological agents,
includin g inhibitors of IL-1, IL-6, and so on, is likely to furth er im prove th e m an agem en t of RA.
Osteoarthritis
OA likely represen ts a n um ber of differen t path ologic processes, all characterized by progressive loss of articular cartilage and new bone form ation in the subchondral region
(sclerosis) and the join t m argins (osteophytes). OA is the
m ost com m on joint disease, affecting the m ajority of people (in som e site) older th an 65 years an d n early all people
older th an 80 years. Alth ough in creasin g age is th e sin gle
largest risk factor for OA, other genetic and en viron m ental
factors play a role, especially for certain join ts. For exam ple,
gen etic factors play a sign ifican t role in OA of th e h an ds,
especially in wom en . In th e kn ee, gen etic factors play a m in or role. For this join t, obesity decreased m uscle strength in
the quadriceps and a history of m ajor kn ee traum a are the
m ost con sistently iden tified risk factors. Although m ajor
129
also in n early any ch ron ic pain con dition . Non eth eless,
this points out that treatm ents such as those described for
n on an atom ic pain syn drom es such as fibromyalgia should
be con sidered for n on m ech an ical m ech an ism s th at m ay be
operative in m any patien ts wh o presen t with pain an d are
found to have OA and in patients in whom th ere is a poor
relation sh ip between symptom s an d path ology.
Th e m an agem en t of OA is prim arily n on surgical, un til
very late in th e disease. Several n onph arm acologic th erapies h ave been sh own to be effective in ran dom ized con trolled trials, in cludin g patien t education , weigh t loss (in
person s wh o are obese, particularly for th e kn ee), stren gth en in g exercises (again especially for th e kn ee), an d aerobic
exercise. Topical application s of h eat or cold can be a h elpful adjun ct in som e patients. The use of various orthotics,
in cludin g in soles, braces, h eel lifts, an d splin ts can be of sign ifican t use in th e appropriate situation s. Likewise, the use
of a can e can im prove pain origin atin g from h ip OA. O th er
n onph arm acological strategies for com batin g pain in OA
such as spa th erapy, acupuncture, and tran scutaneous electrical n erve stim ulation m ay offer pain relief to OApatien ts,
alth ough th ey are less welleviden ce-based. Th e Arth ritis
Foun dation h as establish ed m any of th ese program s an d
is a valuable resource for th is type of patien t in form ation .
In person s wh o do n ot respon d to n onph arm acologic
therapy, acetam in ophen is often effective. In patients who
fail acetam inophen alone, topical capsaicin cream or intraarticular corticosteroids can be con sidered, especially for
the kn ee joint. If these treatm ents are in effective, then use
of low-dose NSAIDs, followed by h igh -dose NSAIDs, is a
reason able option (see Ph arm acologic Th erapy). Several
n ew therapies for OA of th e kn ee h ave recen tly em erged,
an d th eir place in th e treatm en t algorith m rem ain s un clear.
Multiple sm all, ran dom ized con trolled trials studies h ave
suggested that glucosam ine and chon droitin sulfate m ay
be effective in relievin g pain in OA of th e kn ee. Large-scale
studies are n ow being conducted to confirm th ese fin dings.
Several in traarticular hyaluron ic acid preparation s for th e
use in kn ee OA are available. Th ese products m ust be given
with a series of in jection s and were shown to be m ore effective than sham injection and the use of acetam inophen.
Th is treatm en t m odality m ay be m ost effective in th ose who
h ave a con traindication to usin g an NSAID or th ose wh o
h ave failed a trial of several NSAIDs.
Th e use of n arcotic an algesics is usually reserved for
severe cases of OA that fail to obtain satisfactory relief
from other m edications and treatm ent m odalities. Careful patient selection is important due to the side effects
of th ese m edication s (particularly in elderly patien ts). Th e
outstan din g progress m ade over recen t years in th e treatm en t of in flam m atory join t disease such as RA h igh ligh ts
the relative paucity of options currently available for in fluen cin g th e actual process of cartilage degradation , wh ich
is th e h allm ark of OA. A n um ber of treatm en ts h ave been
studied for th is indication, including tetracyclines, growth
factor an d cytokin e m an ipulation, and the use of diacerein,
130
Seronegative Spondyloarthropathies
Th e four classic SSs are an kylosin g spon dylitis, reactive
arthritis, inflam m atory bowel diseaseassociated arthropathy, an d psoriatic arth ritis. These disorders are considered
togeth er because th ey sh are an im m un ologic predisposition (HLA-B27) that leads to both (1) sim ilar articular
features (an inflam m atory arthritis involvin g the axial
skeleton ), an d (2) com m on extraarticular features (e.g., inflam m atory eye disease, cardiac conduction defects, aortic
valve disease). Even th e approxim ately 80% of individuals
wh o are HLA-B27 positive do n ot develop a SS h ave an
independent risk of developin g the classic extraarticular
features seen in this spectrum of illn ess.
Ankylosing Spondylitis
Ankylosing spondylitis is the prototypical disease in this
category. Th e characteristic features of this illness are shown
in Table 7.7. Th e earliest joint involved in m ost persons with
this disorder is the sacroiliac join t. Clinically, these individuals will com plain of in dolen t on set of m orn in g stiffn ess
an d pain in volving the low back, which typically improves
with exercise. O th er ch aracteristic features of th e pain seen
TABLE 7.7
131
TABLE 7.8
132
lumbar spine. Both sacroiliac joints (large arrows) are fused (grade
IV sacroiliitis), and there are bilateral, symmetric syn-desmophytes
(small arrow), resulting in the typical bamboo appearance of
ankylosing spondylitis. (Reprinted with permission from Koopman
WJ, Moreland LW. Arthritis and Allied Conditions: A Textbook of
Rheumatology. 15th ed. Philadelphia, PA: Lippincott Williams &
Wilkins, 2005.)
ch im eric m onoclonal antiTNF- antibody (3 5 m g/ kg every 6 8 weeks after an initial saturation phase), and etanercept, a 75-kD TNF- receptor fusion protein (25 m g subcutaneously two tim es each week), are in curren t use and
lead to sign ificant improvem ent in signs and symptom s.
Reactive Arthritis
Reactive arthritis (form erly Reiter disease) is classically described by the clin ical triad of arth ritis, urethritis, an d conjun ctivitis. Sin ce th e in itial description , it h as becom e clear
that there are several variation s on this them e, with som e
individuals havin g only two of th ree m anifestations (i.e.,
incomplete reactive arthritis), and others havin g colitis in stead of ureth ritis. This syndrom e typically develops in a
gen etically susceptible h ost followin g in fection of th e gen itourinary or GI tract with organism s such as Chlamydia,
Salmonella, Shigella, Yersinia, or Campylobacter; hence the
term reactive arth ritis.
Th e arthritis that occurs in reactive arth ritis is typically
asym m etric an d oligoarticular, with a predilection for th e
large joints of the lower extrem ities. Occasionally, the synovial fluid cell coun ts in th is disorder can be very h igh , in
Psoriatic Arthritis
Psoriatic arthritis shares m any features with reactive arth ritis, and in som e instances, these two conditions are indistinguishable. The presence of psoriasis is n ecessary for th e
diagn osis of psoriatic arth ritis (alth ough in som e in stan ces,
the arthritis antedates th e rash ). Only approxim ately 5% of
133
Enteropathic Arthritis
Enteropathic arthritis is th e term com m on ly used to describe
th e arth ritides associated with in flam m atory bowel diseases. Th e two m ain form s of en teropath ic arth ritis are: (1)
acute episodes of peripheral oligoarticular arth ritis that resem ble reactive arth ritis and are typically associated with
flares of th e colitis, an d (2) an axial spon dyloarthropathy
th at is closely related to HLA-B27 positivity an d follows
a slow, in dolent course that is largely independent of th e
bowel disease.
Crystal-Induced Arthropathies
Th ere are th ree types of crystal-in duced arth ropath ies th at
will be discussed: (1) gout, (2) calcium pyroph osph ate
deposition disease (CPDD), an d (3) hydroxyapatite deposition disease (HADD). It is im portan t to recogn ize
th at n early any crystallin e or particular substan ce th at can
som eh ow be introduced into the joint or soft tissues (e.g.,
injected steroid, fragm ents from prostheses, plant th orns)
can lead to a localized in flam m atory respon se.
Gout
Alth ough gout refers to th e disease process th at occurs
wh en m on osodium urate crystals deposit in various tissues in th e body, on ly th e articular m anifestations will be
emph asized. Th e serum uric acid con cen tration prim arily
determ in es wh eth er m on osodium urate crystals will deposit in tissues. Purin e m etabolism is largely gen etically determ in ed, but m ale gen der, in creased age, in creased body
weigh t, h igh -purin e diet, diabetes, hyperten sion , alcoh ol,
and other drugs (e.g., diuretics, cyclosporin e) will raise
serum concentration of uric acid. The higher th e serum
uric acid con cen tration , th e m ore likely an in dividual will
develop gout. It is importan t to recogn ize th at on ly a sm all
percen tage of hyperuricem ic in dividuals ever develop gout.
Rh eum atic features of gout include som e com bin ation
of acute attacks of m on oarticular or polyarticular arth ritis and m ore indolent changes caused by accum ulation
of uric acid crystals (toph i). Th e first m etatarsoph alan geal
(MTP) joint of the foot is the m ost com m only involved
join t durin g a first attack of gout. Oth er periph eral join ts
in the lower extrem ity (e.g., other MTP joints, m id foot, an kle, an d knee) are next m ost com m on ly involved, followed
134
to calcium pyrophosphate dihydrate crystals that are pleom orphic in both size and sh ape, are less inten sely birefringen t, an d th us appear pale yellow an d blue.
Th e m an agem en t of gout can be divided in to treatm en t
of th e acute attack an d prophylaxis again st future attacks.
Th e goal in treatin g th e acute attack is to in h ibit th e ability of WBCs to phagocytize the crystals. Th e m ost effective
drugs in th is settin g are NSAIDs, an d in dom eth acin is a preferred agent because of the rapid onset of action and potent
anti-inflam m atory properties. Any other NSAID, including
COX-2 inh ibitors, can also be used, but those with a rapid
on set of action are preferred. Colch icin e can also be h elpful
durin g an acute attack of gout, alth ough th e GI in toleran ce
of th is m edication frequen tly lim its th e effectiven ess. Classically, the patien t is in structed to take 0.6 m g tablet on ce
h ourly un til th e attack subsides, un til side effects occur,
or un til a total of 10 tablets are taken . Colch icin e, an d to
a lesser exten t NSAIDs, is m uch m ore effective when treatm ent is begun rapidly. The reason for this is likely that these
anti-inflam m atory regim ens (especially colchicin e) act in
part by in h ibitin g ch em otaxis of leukocytes to th e join t,
and once this has occurred, th ese agents are m uch less
effective. In person s with con train dication s to colch icin e
(renal or hepatic impairm ent) or NSAIDs, corticosteroids
can be effectively used to treat acute gout attacks. Th ese can
be adm in istered in tra-articularly, or system ically, if th ere is
m onoarticular involvem ent. When these are given system ically, th e person typically needs to receive treatm ent for
several days to avoid a rebound effect (alternatively, a single intram uscular dose of a depot form of corticosteroids
can be given ).
Wh en person s h ave frequen t attacks of gout, or wh en
th ere is eviden ce of toph aceous (or extraarticular) disease,
th erapy directed toward lowerin g serum uric acid level
sh ould be in itiated. A low purin e diet, or avoiding alcohol
use, is som etim es all th at is n ecessary to lower serum uric
acid level. If behavioral m odifications are ineffective, then
eith er uricosuric drugs or allopurin ol can be used. Th ese
drugs sh ould n ot be used in th e settin g of an acute attack,
as this can paradoxically precipitate a worsening of th e
attack. Probenecid is the m ost com m only used uricosuric
drug, an d it can be started at 500 m g/ d an d in creased to
2 g/ d. This drug is effective only in persons with relatively
n orm al ren al fun ction ; it sh ould n ot be used in th ose with
a h istory of n eph rolith iasis, an d patien ts m ust be coun seled to m ain tain a h igh fluid in take. Allopurinol is a drug
th at in h ibits th e en zym e xan th in e oxidase, th us in h ibitin g
th e production of uric acid. It can be used as an altern ative
for uricosuric treatm ent, e.g., in patients with impaired
ren al fun ction or n eph rolith iasis. Allopurin ol can be given
begin n in g at doses ran gin g from 100 m g (in th e elderly or
th ose with im paired ren al fun ction ) to 300 m g on ce daily.
Th e prin cipal con cern with th is drug is hypersen sitivity reaction, so patients m ust be warn ed to stop this m edication
im m ediately if th ey develop a rash or pruritus. Approxim ately 5% of in dividuals taking allopurin ol will develop
TABLE 7.9
135
136
B
A
C
Figure 7.6 (A) Weakly birefringent monoclinic and triclinic calcium pyrophosphate dihydrate disease (CPPD) microcrystals in synovial fluid removed from a chronically symptomatic knee (polarized
light, original magnification 1,250). (B) Phagocytosed crystal (arrow) in a polymorphonuclear leukocyte
(phase contrast, original magnification 1,250). (C) Anteroposterior radiograph of the knee, showing
typical punctate and linear deposits of CPPD in the menisci and articular hyaline cartilage. (Reprinted
with permission from Koopman WJ, Moreland LW. Arthritis and Allied Conditions: A Textbook of
Rheumatology. 15th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2005.)
TABLE 7.10
Percentage with
Manifestation
Cumulative
Percentage
30
14
29
40
21
4
2
6
16
18
9
56
27
54
70
53
10
5
18
38
46
20
Polymyalgia Rheumatica
Polym yalgia rheum atica (PMR) is a com m on disorder occurring alm ost exclusively in persons older than 50 years
an d ch aracterized by stiffness and pain in the proxim al
m uscles. The on set m ay be abrupt or in dolent. Patients
will h ave prom in en t gellin g wh en ever th ey are in active
for prolon ged periods. In som e persons, th ere is swelling
an d/or synovitis of the hands associated with this condition. In a subset of individuals, PMR coexists with tem poral arteritis, wh ich can be associated with visual symptom s, h eadach es, jaw claudication , an d alopecia. Patien ts
with th ese symptom s or with temporal artery ten dern ess on
palpation sh ould h ave a tem poral artery biopsy(s) to determ in e wh eth er temporal arteritis is presen t because m ore
aggressive treatm ent regim ens are used for th is subset of
patien ts. Doppler exam in ation of th e tem poral arteries is a
useful diagn ostic adjun ct.
In th e appropriate clin ical settin g, th e diagn osis of PMR
is con firm ed by findin g a m arkedly elevated ESR. Other
diagn oses th at sh ould be con sidered are fibromyalgia an d
hypothyroidism . An oth er diagn ostic test is treatm en t with
interm ediate doses of corticosteroids, usually 20 m g of
predn ison e per day for several weeks with a rapid taper
to 5 to 10 m g/ d. In patien ts wh o do n ot respon d rapidly
an d completely to corticosteroids, the diagnosis should be
137
TABLE 7.11
question ed. Typically, patien ts will n eed to stay on corticosteroids at least 1 to 2 years an d som etim es m uch lon ger.
Infectious Arthritis
Bacterial Agents
Septic arthritis from com m on pathogen s is covered in detail in in fection ch apter of th is book. Such processes usually
138
Nonbacterial Agents
Less com m only, join ts (or soft tissue structures) can becom e infected with nonbacterial agents such as tuberculosis or fun gi. With th e exception of tuberculosis, wh ich
can cause a septic arthritis in persons with norm al im m une
function, m ost persons who have joint infection s with these
types of organ ism s h ave an un derlyin g defect in im m un e
function.
Viral Agents
Nearly all viral agen ts can lead to th e developm en t of a
postviral arth ritis in a sm all percen tage of affected in dividuals. It appears as th ough th e m ost com m on cause of
postin fectious arth ritis in person s wh o seek m edical atten -
Lyme Disease
Lym e disease is a m ultisystem illn ess caused by th e tickborn e spiroch ete Borrelia burgdorferi. Th e characteristic lesion develops within days to weeks of a bite by an infected tick. This lesion is term ed erythema chronicum migrans
an d evolves into an annular lesion with a central clearing. Once the organism becom es hem atogen ously spread,
a variety of m anifestations can occur, in cluding sim ilar
an nular lesion s in other regions of the body, fever, lym ph aden opathy, myalgia, arth ralgia, an d fatigue. Th is early
ph ase, even if treated, typically evolves in to an in term ediate phase, characterized by arth ritis, cardiac, an d/ or neurological in volvem en t. Th e true arth ritis of Lym e disease
(in contrast to the arthralgia an d myalgias that occur early)
develops m on th s after th e exposure. Th is will usually begin as interm ittent episodes of inflam m atory arthritis in volving the large joints and, over years, will progress to
becom e a con stan t m on oarticular or oligoarticular arth ritis involving large joints. The knees are frequently involved, and in severe cases, joint erosion s an d dam age m ay
occur.
PHARMACOLOGIC THERAPY
Overview
Th e basic prin ciple of ph arm acologic th erapy for any disorder is to use th e least toxic an d least expen sive m edication
for the illness being treated. This is particularly true for
the rheum atic diseases, where there are several relatively
Analgesics
Acetam inophen is an effective an d safe an algesic for m any
noninflam m atory rheum atic conditions. For example, in
OA, several ran dom ized con trolled trials h ave suggested
that this compound is as effective as either the O TC or
prescription stren gth of NSAIDs. Th e prin cipal toxicity of
acetam in ophen is hepatic, although th is typically occurs in
person s eith er con sum in g con curren t h epatotoxin s (especially alcoh ol) or exceedin g the recom m ended dose. Tram adol is a m oderate-strength analgesic th at can be considered in persons who require an an algesic but do not
respon d to acetam in oph en . Fin ally, n arcotics can be effective in both th e sh ort- and lon g-term m anagem ent of pain,
although both tolerance and addiction are potential problem s.
NSAIDs
Th e NSAIDs represen t on e of th e m ost com m on ly prescribed classes of drugs. Aspirin is the origin al an d prototypical NSAID. Th ese drugs all act largely by in h ibitin g
cyclooxygenase, the enzym e that transform s arachidonic
acid into prostaglandins, prostacyclin, and throm boxane;
the clinical relevan ce of the effects of NSAIDs on lipid
m etabolism , granulocyte m igration , and bradykin in synthesis is less well understood. Although there are n ow
dozen s of NSAIDs available, th e n ewer drugs in th is class
are not necessarily m ore effective than older ones or even
aspirin, but they are generally better tolerated (Table 7.12).
Th e m ain differen ces am on g NSAIDs are (1) h alf-life, (2)
relative poten cy at th e prescribed dose, (3) tolerability, an d
(4) cost.
When con siderin g th e appropriate NSAID, several factors sh ould be con sidered in regard to th e m edication s
half-life. If a drug is to be used to treat an acute in flam m atory con dition s (e.g., an attack of gout), a drug with a sh ort
half-life and rapid onset of action, such as indom ethacin,
sh ould be considered. On th e oth er hand, when prescribin g
NSAIDs for elderly patien ts, wh ich com prise th e subset of
NSAID users th at develop n early all of th e m ajor GI bleeds
an d death from this class of drugs, compounds with long
half-lives sh ould generally be avoided.
139
140
Sulindac (Clinoril)
Oxaprozin (Daypro)
Diclofenac (Voltaren,
Arthrotec)
Flurbiprofen (Ansaid)
Salsalate (Disalcid)
Nonselective NSAIDs
Naproxen (Naprosen,
Anaprox)
Choline magnesium
trisalicylate (Trilisate)
Salicylates
Aspirin
Tablets
Tablets
Tablets
Ophthalmic solution
Tablet
Extended-release tablet
Suspension
Capsules
Tablets
Solution
Tablets
Numerous
Formulations
6001200 mg q.d.
150200 mg b.i.d.
5001,000 mg b.i.d.
Variable, depending on
indication; maximum
(adults) 2.45.4 g/d in four
or more divided doses
Daily Dose
Hepatic
Hepatic
Hepatic
Hepatic
Metabolism
3692 h
816 h
12 h
39 h
1020 h
1h
Half-life
TABLE 7.12
Diclofenac/misoprostol combination
contraindicated in pregnancy
because of abortifacient effect of
misoprostol
Nonindicated use in JRA 24 mg/kg/d
suggested
Cholestyramine reduced
bioavailability of diclofenac
Other Considerations
141
Diflunisal (Dolobid)
Piroxicam (Feldene)
Indomethacin (Indocin)
Ibuprofen (Motrin)
Fenoprofen (Nalfon)
Etodolac (Lodine)
Ketoprofen (Orudis)
75 mg t.i.d. or 50 mg q.i.d.
6001,200 mg daily
20 mg q.d.
5001,000 mg b.i.d.
Tablets
Tablets
Capsules
Numerous
Capsules
Extended-release capsules
Suspension
Suppositories
Parenteral
Capsule
Tablets
Hepatic
Hepatic
Enterohepatic
recirculation
Hepatic
Hepatic
Hepatic with
enterohepatic
recirculation
Hepatic
Some
enterohepatic
recirculation
Hepatic
1.14 h
67 h
2.53.0 h
(continued )
Prolonged half-life in
neonates and premature
neonates
24 h
50 h
812 h
142
OA
Meclofenamate, mefenamic
acid (Ponstel)
Meloxicam (Mobic)
Nabumetone (Relafen)
Tolmetin (Tolectin)
Tablet
Suspension
Capsules
Tablets
Capsules
Tablets
Tablets
Capsule
Tablets
Formulations
10 mg q.d.; 20 mg q.d. as
needed for dysmenorrhea
10 mg p.o. every 46 h;
maximum of 40 mg daily
for 5 days
Daily Dose
Hepatic
Hepatic
Hepatic
Hepatic
Hepatic
Hepatic
Hepatic
Hepatic
Metabolism
811 h
17 h
11 h
Biphasic: initial 12 h;
terminal 5 h
24 h
1530 h
2h
Half-life
Other Considerations
b.i.d., twice daily; FAP, familial adenomatous polyposis; i.m., intramuscularly; i.v., intravenously; JRA, juvenile rheumatoid arthritis; OA, osteoarthritis; p.o., by mouth; q.d., daily;
RA, rheumatoid arthritis; t.i.d., three times daily.
Valdecoxib (Bextra)
Rofecoxib (Vioxx)
Ketorolac (Toradol)
(Continued )
TABLE 7.12
steroidal anti-inflammatory drug inhibition. (Reprinted with permission from Koopman WJ, Moreland LW. Arthritis and Allied
Conditions: A Textbook of Rheumatology. 15th ed. Philadelphia:
Lippincott Williams & Wilkins, 2005.)
Adifficult issue in clin ical practice is to decide which patients who are prescribed NSAIDs should also receive prophylaxis again st PUD. It is first importan t to un derstan d
which person s are at in creased risk of developin g th is com plication . Th e factors th at place a patien t at h igh er risk of
developin g a GI bleed in clude a h istory of PUD, ch ron ic
use of an tacids or H2 blockers, cigarette sm okin g, alcoh ol
use, an ticoagulan t use, con com itan t corticosteroid th erapy,
and being older than 65 years. The m ore of these risk factors persons have, the m ore likely they are to develop a m ajor GI bleed. But arguably, th e m ost im portan t risk factor
is being elderly. Alth ough elderly persons taking NSAIDs
are only approxim ately 1.5 tim es as likely to develop a GI
bleed as a youn ger person , n early all of th e m ortality from
NSAID-associated GI bleeds occurs in person s older th an
65 years. Th e reason for th is appears to be th at youn ger
person s tolerate GI bleeds better th an th e elderly, wh o
com m on ly will develop a m yocardial in farction , stroke, or
som e other m ajor m edical event in association with a GI
bleed.
Th e coagulation effects of NSAIDs are also widely m isun derstood in clin ical practice. Aspirin irreversibly bin ds to
cyclooxygen ase, so th at th e in h ibition of platelet fun ction
that occurs after con sum in g aspirin lasts until all of the
platelets th at were exposed to th e drug die (approxim ately
2 weeks). But all other NSAIDs reversiblybin d to cyclooxygenase, so the an tiplatelet effects of these drugs last only while
they are in the circulation (i.e., several h alf-lives). There is
no need to stop nonaspirin NSAIDs m ore than a few days
before a surgical procedure to avoid th e an tiplatelet effects
of th ese drugs.
By far, the m ost com m on renal side effect of th e NSAIDs
is a reversible decline in ren al function. This alm ost always occurs in persons who have dim inished baseline ren al
blood flow, for exam ple, in patien ts with low cardiac output states, ren al artery sten osis, or preexistin g ren al disease.
143
Corticosteroids
Because of the poten t an ti-in flam m atory effects of corticosteroids, th ese drugs are useful for th e treatm en t of a
n um ber of local an d system ic in flam m atory con ditions. A
th orough review of th e m ech an ism (s) of action s of th ese
drugs is n ot possible, but th ese drugs likely act by a variety of m ech an ism s, in cludin g in terferen ce with cell adh esion an d m igration in to inflam m atory sites; interruption
of cellcell com m unication; impairm ent of prostaglandin,
leukotriene, and neutrophil superoxide production; and
impairm ent of antigen opsonization and im m une complex
clearan ce.
Th e sh ort-term use of system ic corticosteroids is relatively well tolerated, even at higher doses. Un com m on
but serious side effects in th is settin g m ay in clude AVN,
psych osis or lesser m ood disturban ce, hyperglycem ia, hyperten sion , an d electrolyte disturban ces. In con trast, th e
long-term uses of corticosteroids, even at low doses, are
associated with a plethora of side effects, including osteoporosis, accelerated ath erosclerosis, in fection s, cataracts,
skin chan ges, an d oth ers. Because of this, and because of
th e fact th at steroids represen t by far th e m ost effective
m edications to bring inflam m atory processes un der rapid
con trol, m ost clin ician s attem pt to use h igh doses in itially
for sh ort periods, followed by as rapid a taper as possible,
eith er with complete discon tin uation or to ch ron ic regim ens (e.g., less than 7.5 m g of prednisone per day or altern ate day dosin g) th at m inim ize toxicity.
Another significant problem with chronic steroid usage is suppression of th e hypothalam icpituitaryadren al
(HPA) axis. This can occur with as little as 1 week of highdose steroid treatm en t an d occurs in n early all people wh o
receive ch ron ic corticosteroid treatm en t. Th is is importan t
because person s with a suppressed HPA axis n eed to receive exogen ous steroids wh en exposed to stressors, such
as undergoing a m ajor surgical procedure. There is n o correct regim en in th is settin g, but adm in isterin g 100 m g of
hydrocortison e paren terally on call to th e operatin g room ,
and 50 m g every 6 hours for 24 h ours, then 25 m g every
6 hours for an oth er 24 hours, is m ore than sufficient in
th is settin g (less aggressive regim en s m ay also be used).
144
TABLE 7.13
Class
Mechanism of Action
Hydroxychloroquine
Antimalarial
Sulfasalazine
Methotrexate
Leflunomide
Cyclophosphamide, chlorambucil
Azathioprine, 6-Mercaptopurine
Cyclosporine, Tacrolimus (FK506)
Antimicrobial
Antimetabolite
Antimetabolite
Alkylating cytotoxics
Purine analog cytotoxics
Calcineurin inhibitors
Sirolimus (rapamycin)
Noncalcineurin-binding macrolide
immunoregulator
Purine synthesis inhibitor
Mycophenolate mofetil
RECOMMENDED READINGS
Clauw DJ. Fibromyalgia: update on m echanism s and m anagem ent.
J Clin Rheumatol. 2007;13(2):102 109.
Drazen JM. COX-2 inhibitorsa lesson in unexpected problem s.
N Engl J Med. 2005;352(11):1131 1132.
Felson DT, Lawren ce RC, Dieppe PA, et al. Osteoarth ritis: n ew in sigh ts,
I: th e disease an d its risk factors. Ann Intern Med. 2000;133(8):635
646.
ODell JR. Th erapeutic strategies for rh eum atoid arth ritis. N Engl J Med.
2004;350(25):2591 2602.
Olsen NJ, Stein CM. New drugs for rh eum atoid arth ritis. N Engl J Med.
2004;350(21):2167 2179.
Rahm an A, Isenberg DA. System ic lupus erythem atosus. N Engl J Med.
2008;358(9):929 939.
Rice PA. Gon ococcal arth ritis (dissem in ated gon ococcal in fection ).
Infect Dis Clin North Am. 2005;19(4):853 861.
Sch um ach er HR. Crystal-in duced arth ritis: an overview. Am J Med.
1996;100(2A):46S52S.
van Vollenhoven RF. Corticosteroids in rheum atic disease: understan din g th eir effects is key to their use. Postgrad Med. 1998;103(2):
137 142.
Overview of
Musculoskeletal
Neoplasm s
Atu l F. Kam ath
Harish S. Hosalk ar
INTRODUCTION
Tum ors of th e m usculoskeletal system m ay present initially
with n on specific symptom s, m akin g it h ard to distin guish
neoplastic m anifestation s from other com m on disorders.
Wh ile bon e an d soft-tissue tum ors are rare, it is critically
important that the orthopaedist include these entities in
the differential diagnosis to avoid overlooking these poten tial serious con dition s.
Th is ch apter presen ts a system atic m eth od for evaluating tum ors of the m usculoskeletal system . It also presents a
brief overview of th e distin guish in g ch aracteristics, path ology, an d treatm en t of several of th e m ost com m on en tities.
BONE TUMORS
Patient Evaluation
In th e evaluation of a patien t with a bon e tum or, th ere
are several areas where data can be gathered that impact
upon th e differen tial diagn osis. Th ese in clude th e h istory,
physical exam in ation , an d review of im agin g studies. Ultim ately, it m ay be determ ined that histologic con firm ation
is required at which tim e careful evaluation of lesional tissue will confirm a specific diagnosis.
Th e h istory associated with th e presen ce of a m usculoskeletal tum or defin es the clinical context of th e lesion.
Age, sex, duration of symptom s, presen ce and quality of
pain , h istory of traum a, weigh t loss, sm okin g h istory, an d
Richard D. Lack m an
h istory of prior m align ancy are all im portan t h istorical factors. Critical to th e early diagn osis of a skeletal tum or is
an appreciation of th e fact th at th e early symptom s associated with skeletal n eoplasm s m im ic all types of ordinary
m usculoskeletal disorders. Any pain th at exten ds beyon d
the expected duration associated with a tentative diagnosis
sh ould raise the suspicion of an underlying tum or. Night
pain is an oth er red flag again leadin g to th e supposition of
an occult lesion alth ough m any n on n eoplastic con dition s
m ay also cause pain at n igh t.
One of the m ost disorien ting parts of a history in a patien t with an occult tum or is a h istory of traum a. Frequen tly,
patien ts will experien ce som e m ild traum a to th e affected
area an d th en n otice pain th at would probably n ot h ave
occurred in th e absen ce of an un derlyin g lesion . Th is is
frequently not clear to th e patient however who directly attributes th e local sym ptom s an d fin din gs to th e traum atic
even t. Th e h istory related in th is way frequen tly fools a
treatin g physician wh o th en follows th e local lesion un til
it becom es obvious th at th e true n ature of th e lesion goes
well beyond a m inor traum a. An example of this is the
story related by a waiter who kicked a kitchen door to open
it wh ile carryin g a h eavy tray. Th e door was stuck an d did
n ot m ove, resulting in an apparen t calf in jury. When th e
pain did n ot resolve, a com partm en t syn drom e was suspected an d it was n ot un til several m on th s later th at tissue
was obtain ed wh ich revealed an un derlyin g lym ph om a.
Sim ilar is th e h istory of an elderly fem ale on full-dose warfarin for a m ech anical heart valve who bumped her thigh
on a kitch en table an d foun d out m on th s later th at th e
146
Imaging
Plain radiograph s offer detailed in form ation for bon e lesion s, as well as som e potentially im portan t inform ation
for soft-tissue lesions. It is estim ated that about 30% to 40%
of th e bon e m ust be destroyed before th e ch an ges can be
seen in plain radiographs. It is useful to ask th e followin g
when evaluating plain radiograph s of bony lesions: Wh ere
is th e lesion located in th e bon e? Wh at is th e lesion doin g
to th e bon e? How is th e bon e reactin g to th e lesion ? Wh at
is th e periosteal respon se?
A lesion s m argin with adjacen t m edullary bon e m ay
suggest an indolent versus an aggressive process. Any lesion
that is stable and recognized by the bone as foreign will be
walled off by dense sclerotic bon e, implying a very slow
growin g or static lesion . However, lesion s n ot recogn ized as
foreign will not gen erate surrounding sclerosis despite bein g presen t for exten ded periods. A ben ign en ch on drom a,
for example, elicits no surrounding bone response because
it is n ot con sidered foreign . Multiple myelom a is a m align an t tum or but still elicits n o respon se in th e m arrow,
as plasm a cells are a n orm al part of m arrow an d h en ce n ot
recogn ized as foreign .
Marrow respon se to a lesion is th e m ost sen sitive for
ch aracterizin g aggressive lesion s. Marrow surroun din g a
lesion m ay dem on strate a geograph ic (e.g., in m ultiple
myelom a), m oth-eaten (e.g., in giant cell tum or), or perm eative (e.g., in osteosarcom a) appearan ce based on th e
degree an d n ature of th e offen din g lesion . Th e cortex exists as a m ore gross m arker of m align an t dam age to bon e,
in cludin g en dosteal scallopin g, cortical th in n in g or expan sion , an d of course gross cortical destruction. The pattern
of periosteal reaction itself is also an in dicator of th e biologic activity of a lesion . A lesion m ay elicit n o reaction
for one of two reason s: either the tum or is not perm eating
the periosteum (e.g., in giant cell tum or) or the periosteum
does n ot recogn ize th e tum or cells as foreign (e.g., in lym ph om a).
Alth ough no single periosteal reaction is un ique for a
given tum or, a con tin uous periosteal reaction in dicates a
lon g-stan din g (slow-growin g) ben ign process. An in terrupted reaction, on th e other hand, is com m only seen
in m align an t tum ors. In th ese m align an t tum ors, th e periosteal response m ay appear in an onion skin (lam ellated)
or sun burst pattern . Codm an s trian gle, a classic reactive
periosteal cuff at th e periph ery of th e tum or, m ay also be
seen. Som e unique radiographic fin din gs that poin t toward
specific differential diagnoses are listed in Table 8.1.
Computed Tomography
Th e m ajor value of a CT scan is to sh ow fin e detail in bon e.
Th is in cludes bon e form ation as well as bon e destruction .
In addition , CT scan s are th e best study to see wh eth er or
TABLE 8.1
Biopsy
Not all lesion s require a biopsy, as m any ben ign an d in active lesion s m ay be diagn osed via im agin g studies alone.
Th e ideal biopsy is on e th at provides all tissues n eeded to establish a h istologic diagn osis with out affectin g subsequen t
treatm ent option s. Current biopsy options include both
open an d n eedle tech n iques. In m ost location s, th e carefully perform ed open biopsy is still the gold stan dard, while
needle biopsy techn iques are gaining in popularity. Th e advantage of a n eedle biopsy is that it m inim izes tissue con tam in ation in th e local tissues surroun din g a tum or. Needle
tech n iques also m in im ize th e n eed for an esth esia an d can
frequently be done outside an operating room , m inim izing
expen se. Problem s associated with n eedle biopsies in clude
sampling error and a frequent in ability to obtain sufficient
tissue to m ake a definitive histologic diagnosis.
Another question that arises, especially with open
biopsy, con cern s wh o sh ould perform th e biopsy. Not all
m usculoskeletal biopsies can be perform ed by orthopaedic
on cologists, an d so h ow does on e decide wh eth er to perform a biopsy locally in the context of a general orthopaedic practice or to refer th e biopsy to a subspecialty
trained surgeon? In general, if a surgeon sees a patient and
knows from the in itial im aging studies that this is a lesion
that h e or she would not treat prim arily, then the biopsy is
best referred to th e treatin g surgeon .
For exam ple, if a com m un ity orth opaedic surgeon sees
an adolescent with an obvious osteosarcom a of th e fem ur
that would not be appropriate to treat locally, then that
biopsy is best referred to th e on cologist wh o will perform
the defin itive treatm en t. The sam e m ay be true for a large
deep m ass th ough t to m ost likely represen t a soft-tissue
sarcom a. Regardless of wh o perform s the biopsy, Table 8.2
lists several fairly simple rules that m ust be adh ered to rigorously in order to avoid subsequen t problem s.
147
TABLE 8.2
Staging
Staging of a patient with a suspected m alignan t tum or is
m andatory prior to definitive treatm ent. Fully characterizin g a lesion and its differential diagn osis prior to surgical biopsy preven ts m akin g wron g decision s th at m ay alter
th e even tual outcom e an d m an agem en t. Stagin g studies for
bon e an d soft-tissue sarcom as usually in cludes a CT scan of
th e ch est an d an MRI of th e prim ary lesion . Oth er studies
such as a CT scan of th e abdom en and pelvis or a techn etium bon e scan m ay also be in dicated, depen ding on
th e specific diagn osis an d th e propen sity of th e tum or in
question to m etastasize to areas oth er th an th e lun g. Th e
Musculoskeletal Tum or Society adopted the Enneking Surgical Staging System for bone sarcom as (Table 8.3). Awh ole
bon e, a join t, or a fun ction al m uscle group with a fascial
boun dary is each con sidered a separate com partm en t in
th is stagin g system .
TABLE 8.3
Grade
Site
Low
II
High
III
A: Intracompartmental
B: Extracompartmental
A: Intracompartmental
B: Extracompartmental
Any
148
TABLE 8.4
Osteoid osteoma
Osteoblastoma
Osteochondroma
Osteosarcoma
Blastic metastases
Pagets disease
Cartilage-Forming Tumors
Osteochondroma
Chondromyxoid
Fibroma
Chondroblastoma
Enchondroma
Chondrosarcoma
Third List
Differential Diagnosis
It is on ly th rough in tellectual disciplin e an d diligen ce th at
early diagn oses can be accom plish ed. Th e easiest way to
assem ble a complete differen tial is to h ave m em orized or
available a reason able list of com m on lesions to review
as you con template each set of x-rays. With out such m en tal organ ization , it is difficult or impossible to assem ble
a com prehensive differen tial diagn osis of a particular lesion . Table 8.4 con tain s a list of com m on n eoplasm s foun d
in bon e separated in to bon e-form in g lesion s, cartilageform ing lesions, an d a third listof m iscellaneous lesions.
By going th rough these lists each tim e an x-ray is reviewed,
on e can m ake sure to in clude m ost relevan t lesion s in a
specific differential diagnosis. Prim ary bone tum ors can
also be classified based on th eir direction of differen tiation
(Table 8.5).
TABLE 8.5
CLASSIFICATION OF MUSCULOSKELETAL
TUMORS BASED ON ORIGIN
Bone tumors
Bone origin: osteoid osteoma, osteoblastoma, osteosarcoma
Cartilaginous origin: osteochondroma, chondroblastoma,
chondromyxoid fibroma, enchondroma, periosteal chondroma,
chondrosarcoma
Fibrous origin: nonossifying fibroma, fibrous dysplasia,
osteofibrous dysplasia, desmoplastic fibroma, fibrosarcoma
Miscellaneous: unicameral bone cyst, aneurysmal bone cyst,
giant cell tumor, Langerhans cell histiocytosis, Ewing sarcoma
Musculoskeletal manifestations of leukemia
Bone lymphomas
Metastatic tumors: neuroblastoma, retinoblastoma,
hepatoblastoma, lung, renal, prostate, breast, thyroid
Infection
Metastasis
Round cell tumors
Ewing sarcoma
Lymphoma
Myeloma
Neuroblastoma
Fibrous dysplasia
Nonossifying fibroma
Simple bone cyst
Aneurysmal bone cyst
Eosinophilic granuloma
(histiocytosis)
Giant cell tumor
Stress fracture
Metabolic condition
Hemangioma
TABLE 8.6
149
Th e lesion s appear as a sm all lytic n idus often with a target appearance surrounded by significant sclerosis. The
nidusm ay be sm all an d difficult to find on x-ray; it usually appears as a sm all focus (3 to 5 m m in diam eter) surroun ded by sign ifican t sclerosis. CT scan s with fin e cuts
(i.e., 1 m m ) are th e study of ch oice for fin din g th e lesion .
Bon e scintigraphy sh ows focal in ten se uptake. If NSAID use
is n ot tolerated or sign ifican t pain persists, surgical treatm en t, in cludin g excision or radiofrequen cy ablation , m ay
be used. If th e lesion is in a location wh ere RFA or surgical excision is excessively h azardous or m orbid, m edical
treatm en t with lon g-term NSAIDs is reason able an d m ost
lesion s becom e asymptom atic via spon tan eous regression
within 4 years.
Osteoblastoma
Osteoblastom a is m ost often seen in the posterior elem ents
of th e spin e or in th e m eta-diaphyseal region of lon g bon es.
Radiograph ically, osteoblastom a appears m ore lytic an d
destructive th an osteoid osteom a. Th e n idus is usually 1 to
2 cm or occasion ally larger an d h as a less sclerotic surrounding bone. Histologically, osteoblastom a is nearly identical
to osteoid osteom a, showing excessive osteoblastic activity
and osteoid form ation with num erous gian t cells in a vascular fibrous strom a. Margin al resection or curettage an d
bon e graftin g usually provide an acceptable lon g-term result, th ough recurrence is not uncom m on.
Osteochondroma (Exostosis)
Osteoch ondrom as (Fig. 8.2) are form ed by radial growth
of bon e durin g ch ildh ood such th at th e lesion grows out
B
Figure 8.1 Osteoid osteoma. Axial and coronal CT (computed tomography) images demonstrating
the classic nidus with surrounding sclerosis of an ostoid osteoma.
150
B
Figure 8.2 Peduncilated (A) and sessile (B) osteochondromas of the proximal humerus. (Reprinted
with permission from Greenspan A, Remagen W. Differential Diagnosis of Tumors and Tumor-like
Lesions of Bones and Joints. Philadelphia, PA: Lippincott-Raven, 1998:148.)
Chondroid Forming
Enchondroma
Ench ondrom a (Fig. 8.3) is a nest of cartilage tissue typically in th e m etaphysis but occasionally diaphyseal that is
usually en coun tered as an in ciden tal fin din g. En ch on dro-
151
Chondroblastoma
Ch ondroblastom a (Fig. 8.4) typically presents as a painful
lytic lesion in the epiphysis of a child, with significant
edem a seen on MRI scan . In adolescen ts it can occasion ally
grow across an old epiphyseal lin e to in volve th e adjacen t
m etaphysis. The m ost com m on locations are the distal fem ur, proxim al tibia, and proxim al hum erus. The picture
of a pain ful epiphyseal lytic lesion with abun dan t edem a
m ay cause this lesion to be confused with infection or even
osteoch on dritis dessican s. Malign an t degen eration is extrem ely rare. Treatm en t con sists of in tralesion al curettage
an d bon e graftin g.
Third List
Aneurysmal Bone Cyst
An eurysm al bon e cyst (ABC) (Fig. 8.5) is a n on n eoplastic
reactive con dition th at is usually foun d in th e first th ree
decades of life. ABCs occur in bon e as a prim ary de novo
lesion, or th ey m ay occur in association with other vascular tum ors, such as giant cell tum or, Ewing sarcom a, osteosarcom a, or m etastatic ren al cell carcin om a. Prim ary
lesions usually occur in the m etaphyses of long bones,
especially in th e fem ur an d tibia, but th ey m ay also be
seen in th e posterior spin e. Patien ts typically present with
pain an d swellin g. Th e classic radiograph ic fin din g is an eccen tric, lytic, balloon in g expan sion with in th e m etaphysis.
Lesions frequently have a delicate rim of expanded cortical bon e, wh ich m ay be best seen on CT scan ; fluid fluid
levels with in the lesion are usually seen on MRI scans. Typical histologic features are blood-filled spaces without en doth elial lin in g. Not all lesion s require treatm en t as th ey
som etim es reach an in active state. Treatm ent is curettage
and bone grafting, with a reasonably h igh rate of local
recurren ce (25% or m ore). In ligh t of th e vascular n ature
of th ese lesion s, em bolization h as also been reported as a
h elpful adjuvan t or as prim ary treatm en t for lesion s of the
spin e wh ere surgery m ay carry significant m orbidity.
B
Figure 8.4 Chondroblastoma. A: Radiograph of lesion in proximal humeral epiphysis. B: CT (com-
puted tomography) shows the calcifications clearly. (Reprinted with permission from Greenspan A,
Remagen W. Differential Diagnosis of Tumors and Tumor-like Lesions of Bones and Joints. Philadelphia, PA: Lippincott-Raven, 1998:161.)
152
B
Figure 8.5 Anteroposterior (AP) and lateral radiographs demonstrating an aneurismal bone cyst
of the distal tibia. (Reprinted with permission from Greenspan A, Remagen W. Differential Diagnosis
of Tumors and Tumor-like Lesions of Bones and Joints. Philadelphia, PA: Lippincott-Raven, 1998:331.)
alth ough virtually any bone m ay be affected; vertebral involvem en t occurs in approxim ately 10% to 15% of cases.
Th e m ost com m on appearan ce is a well-circum scribed m arrow lesion with n o periosteal reaction . Larger lesion s m ay
dem on strate a m oth -eaten pattern with som e sclerosis.
Occasionally, a periosteal reaction is produced in accordan ce with th e in flam m atory n ature of th e lesion . In th e
spin e, LCH often presents as complete collapse of th e vertebral body with out spin e deform ity, wh ich is classically
referred to as vertebra plan a. Wh ile LCH is th e m ost
com m on cause of vertebra plan a, m align an t n eoplasm s
and occasionally infections m ay m im ic this appearan ce.
Treatm ent of symptom atic lesions in cludes curettage an d
bon e graftin g. Local steroid in jection s h ave also been used.
Chem otherapy is recom m ended in cases of dissem inated
LCH.
Nonossifying Fibroma
Non ossifyin g fibrom a (Fig. 8.8), or m etaphyseal fibrous
defect, is a ben ign lesion left beh in d by th e growth plate
in the course of endochon dral ossification. As such, it is
n ever seen in the epiphysis. It is com m on ly seen in the
lower extrem ity of children as an eccentric m etaphyseal
lesion with a geographic m argin and surrounding sclerosis.
As growth of th e patient continues and external rem odeling
occurs, lesion s th at were previously in tram edullary in th e
m etaphysis becom e intra-cortical in the m eta-diaphysis.
Wh en th is occurs, cortical th in n in g is seen as th e rem odelin g bon e grows in to th e lesion . Wh ile m ost of th ese
153
B
Figure 8.6 Simple bone cyst: fallen fragment. A: Pathologic fracture of proximal humeral diaphysis. B: Radiolucent lesion in the distal diaphysis of the fibula. (Reprinted with permission from
Greenspan A, Remagen W. Differential Diagnosis of Tumors and Tumor-like Lesions of Bones and
Joints. Philadelphia, PA: Lippincott-Raven, 1998:325.)
Figure 8.7 Anteroposterior (AP) x-ray (A) and coronal MRI (mag-
with permission from Greenspan A, Remagen W. Differential Diagnosis of Tumors and Tumor-like Lesions of Bones and Joints.
Philadelphia, PA: Lippincott-Raven, 1998:207.)
154
Fibrous Dysplasia
Fibrous dysplasia (Fig. 8.10) is a disturban ce in bon eform ing processes that causes arrest in the woven state. It is
m ost com m only diagnosed in the secon d or third decade.
Virtually any bone m ay be involved, but the proxim al fem ur is the m ost com m on location. Other areas that are
frequently involved in clude the tibia, pelvis, hum erus, radius, an d ribs. Mon ostotic disease is frequen tly an in ciden tal radiograph ic fin din g in an asymptom atic patien t.
Polyostotic disease ten ds to rem ain un ilateral rather th an
bilateral. Classic fibrous dysplasia occurs as a lon g lesion
in a lon g bon e with ground glass appearance, m edullary
calcification, and cortical thinnin g with out periosteal reaction. However, fibrous dysplasia has a broad spectrum
of appearan ce, ran gin g from a very lon g lesion in a lon g
bon e to a sm all eccen tric lytic lesion with surroun din g sclerosis. As such , fibrous dysplasia sh ould be in cluded in th e
differen tial of every ben ign -appearin g lesion in bon e. Th e
typical histologic appearance is m etaplastic woven bone
scattered through a benign fibrous tissue strom a. O ften ,
155
the woven trabeculae are disorganized and have been described as havin g a Chin ese letter appearan ce. McCune
Albright syndrom e is a polyostotic disorder m anifested by
brown ish skin lesion s an d en docrin e abn orm alities resultin g in precocious puberty. Fibrous dysplasia can very rarely
convert to m alignan cy, m ost com m only osteosarcom a, although this occurs less than 0.5% of the tim e. Surgery is
in dicated wh en th e patien t h as progressive deform ity, large
lesion s with pain , n on un ion , failure of n on surgical th erapy, or m align an cy.
Hemangioma
Hem an giom as (Fig. 8.11) of the spin e are com m on, occurrin g in approxim ately 10% of all adults an d are n otably
m ore com m on in vertebral bodies than in the posterior elem ents. Hem angiom as typically contain trabecular conden sation s surroun ded by abnorm al vascular channels, which
are m ore lucent on plain film s and CT and give the vertebral body vertical striation s on plain film s. Th is appearan ce
is popularly referred to as a jail house vertebra; the appearan ce on axial CT im ages resem bles polka-dots.Most
spin al h em angiom as are inciden tal fin dings and require
n o treatm en t. Sym ptom atic h em an giom as usually respon d
well to con servative surgical procedures. Selective arterial
em bolization is usually safer an d m ore effective treatm en t
th an radiation . An terior resection an d fusion are reserved
for pathologic collapse and neural comprom ise or refractory cases.
B
Figure 8.10 Fibrous dysplasia of the diaphysis of the tibia (A) and femoral neck (B). (Reprinted
with permission from Greenspan A, Remagen W. Differential Diagnosis of Tumors and Tumor-like
Lesions of Bones and Joints. Philadelphia, PA: Lippincott-Raven, 1998:217.)
156
Chondroid Forming
Chondrosarcoma
Malignant cartilage tum ors are prim arily tum ors of adulth ood and old age. About 85% of ch on drosarcom as
(Fig. 8.13) are low-grade. Findin gs associated with ch ondrosarcom a in clude in tralesion al lysis, en dosteal scalloping, cortical thinn ing or expansion, and pain. Most will
sh ow ch ondroid calcification, but high-grade lesions m ay
take on a purely lytic appearan ce. Ch on drosarcom as are
very resistant to radiation and chem oth erapy. Furtherm ore, they tend to recur locally and require complete surgical resection with a wide m argin to achieve cure. Th e
treatm ent of low-grade is som ewh at controversial, as som e
prefer aggressive in tralesion al curettage an d adjuvan t th erapy with phenol or liquid n itrogen wh ile others prefer wide
excision . For in term ediate an d h igh -grade ch on drosarcom a, wide-m argins are required.
Other Lesions
Ewing Sarcoma
Ewin g sarcom a (Fig. 8.14) is an un differen tiated tum or
ch aracterized by th e t(11;22) translocation in 90% of cases.
It occurs prim arily in patien ts between 5 an d 25 years of age
with a m ale predom in an ce. Twen ty percen t of patien ts will
h ave associated system ic symptom s, such as fever, chills,
an d a high erythrocyte sedim en tation rate and white blood
157
B
Figure 8.12 Anteroposterior (AP) (A) and lateral (B) x-rays of the distal femur demonstrating
the aggressive nature of conventional osteosarcoma. (Reprinted with permission from Greenspan A,
Remagen W. Differential Diagnosis of Tumors and Tumor-like Lesions of Bones and Joints. Philadelphia, PA: Lippincott-Raven, 1998:65.)
TABLE 8.7
SUBTYPES OF OSTEOSARCOMA
Parosteal osteosarcoma: A low-grade variant that occurs on the cortical surface of long bones, usually near the location of the
metaphysis. It accounts for less than 5% of all osteosarcomas and occurs more often in females. The most common sites are the distal
femur, proximal tibia, and proximal humerus. Treatment is wide surgical resection, which is often curative.
Periosteal osteosarcoma: A surface-based osteosarcoma arising in long bones, typically in the diaphyses, and low to intermediate in
grade. It accounts for less than 2% of all osteosarcoma. The most common sites are the distal femur, proximal tibia, and proximal
humerus. It grows from under the periosteum, giving rise to the typical radiographic appearance of a sunburst-type lesion over a
depressed cortical base. Treatment is wide surgical resection, with adjuvant chemotherapy for more advanced, higher grade lesions.
Hemorrhagic osteosarcoma (telangiectatic): This is a high-grade variant that is extremely lytic and destructive. On radiographs, it
resembles an aneurysmal bone cyst. Histologically, there is hemorrhage with malignant stromal cells and giant cells. Treatment is
similar to classic osteosarcoma with similar outcomes.
Secondary osteosarcoma: Secondary osteosarcoma may arise from many benign conditions including fibrous dysplasia, giant cell
tumor, osteoblastoma, osteochondroma, Pagets disease, and chronic osteomyelitis. Radiation-induced osteosarcoma can result after
any significant radiation exposure, typically greater than 30 Gray. The average delay in onset is approximately 15 years but can vary
widely. This subtype carries a poor prognosis with very high rates of metastasis.
158
solitary myelom a in clude a solitary lesion on skeletal survey, histologic confirm ation, and bon e m arrow plasm acytosis. Treatm en t of ch oice in solitary plasm acytom a is
radiation . Surgical in terven tion is typically reserved for decom pression of n eural structures in th e case of spin al in volvem en t and stabilization when the lon g bones are involved. MRI provides the earliest indication of local recurren ce, an d serum protein electroph oresis h as proven to be
th e best in dicator of dissem in ation . Th e prim ary treatm en t
for dissem in ated myelom a is system ic chem oth erapy.
Chordoma
Ch ordom a (Fig. 8.16) is a low-grade, relatively uncom m on
m alignancy of the spine typically foun d in patien ts in th eir
fourth to sixth decade. Chordom as routinely localize to th e
m idline, arise from prim itive n otochord rem nants, and are
prim arily foun d in th e sacro-coccygeal area or at th e base
of th e skull. Ch ordom as grow slowly with few early symptom s, frequen tly reach in g con siderable size before diagn osis. Many patients, h owever, have a long history of m ild
aching perineal pain or num bn ess, which should be a sign
of a poten tial pelvic tum or compressin g th e sacral plexus.
Often chordom as can be palpated directly on rectal exam ination. Surgical resection with wide m argin s is the only
curative procedure. Sin ce the tum or is a low-grade lesion,
growth is slow an d recurren ce an d even tual m etastases are
com m on.
SOFT-TISSUE TUMORS
Clinical Presentations
Most soft-tissue tum ors present with pain and/ or a m ass. It
is also rem arkable that soft-tissue m asses includin g sarcom as can reach trem endous size and yet cause m inim al or
n o symptom s. Many patien ts falsely assum e th at because
the lesion is painless it m ust also be harm less. This is obviously n ot th e case but is often respon sible for lon g delays
in diagnosis on the part of the patient or, less frequently,
the physician . Ironically, the lesions in soft tissue that are
m ost com m only painful are the benign soft-tissue tum ors,
including desm oid tum ors, hem an giom as, benign nerve
sh eath tum ors, an d soft-tissue infections.
Radiographic Evaluation
Most soft-tissue m asses are seen poorly or not at all on
plain x-rays; h owever, th ose th at sh ow calcification will be
m ore apparent. Th e m ost com m on lesion to present with
soft-tissue calcification is myositis ossificans, but synovial
sarcom a can presen t in a sim ilar m anner. Myositis typically
exh ibits h istologic periph eral m aturation an d an associated egg shell calcification, while m align ant soft-tissue
A,B
159
C,D
Differential Diagnosis
As in th e case of bon e lesion s, soft-tissue tum ors can be
quite con fusin g wh en approach ed as a large n um ber of
un related topics. Again , a system atic approach to th e diagn osis of th ese lesion s reveals a lim ited n um ber of clin ical
presen tation s. Histologically, h owever, th ey do form a large
and diverse group with fewer trends than those found in
bon e tum ors.
160
A,B
C
Figure 8.15 Multiple radiographs demonstrating the variable appearance of primary lymphoma
of the bone. (Reprinted with permission from Greenspan A, Remagen W. Differential Diagnosis of
Tumors and Tumor-like Lesions of Bones and Joints. Philadelphia, PA: Lippincott-Raven, 1998:268.)
FATTY TUMORS
Lipoma
Th is is on e of th e few diagn oses th at can be m ade con fiden tly on th e basis of MRI an d clin ical fin din gs alon e. Benign lipom as appear as m asses of uniform fat den sity and
parallel th e appearan ce of n orm al subcutan eous fat on all
sequen ces: bright on T1 and T2 sequen ces and dark on fatsuppressed T2 and STIR sequences. Therefore, a m ass seen
on MRI as a un iform fat den sity with n o in terstitial m arkin gs is diagn ostic of ben ign lipom a. Histologically, lipom as
consist of m ature fat cells with n o atypia. With out symptom s, th ese lesion s can be m on itored. If excision is warranted, m argin al resection h as a low recurrence rate. Several
lipom a varian ts exist, in cludin g fibrolipom a, an giolipom a,
spin dle cell lipom a, and hibernom a. These lesion s have a
differen t appearan ce from sim ple lipom a an d frequen tly
require biopsy to establish a defin itive diagn osis.
Atypical Lipoma
Con tin uin g alon g th e spectrum of fatty tum ors, th is ben ign
tum or h as also been labeled well differen tiated liposarcom a and lipom a-like well differentiated liposarcom a,
especially wh en foun d in th e retroperiton eum . Th is is a fatcontainin g lesion ch aracterized by lobules of fat signal on
MRI with surroundin g layers of fibrous tissue dem onstrating thin layers of h igh signal that enh ance with the use of
intravenous contrast. Histologically, lobules of norm al fat
are seen surroun ded by fibrous bands con tain ing lipoblasts
and atypical cells. These lesions are very invasive into surroun din g tissue, an d local recurren ce followin g excision is
com m on . Wh ile atypical lipom as do n ot m etastasize, th ey
do carry a 10% risk of m align an t tran sform ation , usually
to high-grade liposarcom a. Myxoid liposarcom a and pleom orphic liposarcom a exist at the far end of th e fatty tum or
spectrum , represen ting two variants with aggressive, m align an t features.
FIBROUS
Desmoid Tumor (Fibromatosis)
Desm oid tum ors are an un com m on group of ben ign softtissue neoplasm s with aggressive local behavior. They appear on MRI scan s as den se fibrosis, typically rem ain in g
dark on T1, T2, an d fat-suppressed T2 sequen ces. Un like
m ost soft-tissue tum ors, they are poorly m arginated and
often h ave a stellate m argin on MRI, reflectin g th eir extrem e invasiveness in to surrounding tissues. They are frequen tly pain ful an d dem on strate an in creased in ciden ce
in wom en following pregnancy. Histologically, desm oid
tum ors are composed of benign-appearin g spindle cells
161
puted tomography) scan (B) and axial T-1 weighted MRI (magnetic
resonance imaging) scan (C) demonstrating a chordoma. This tumor
of notochord remnants occurs almost exclusively in the sacrum or at
the base of the skull. (Reprinted with permission from Greenspan
A, Remagen W. Differential Diagnosis of Tumors and Tumor-like
Lesions of Bones and Joints. Philadelphia, PA: Lippincott-Raven,
1998:355.)
fibrosarcom as presen t a un ique picture of m align an t spin dle cells arran ged in a h errin gbon e pattern with m arked
cellularity and m oderate atypia. Local control is usually
ach ieved with a com bin ation of wide m argin al excision an d
adjuvan t or n eo-adjuvan t radiation th erapy. As ch em oth erapy h as progressed, so h as en th usiasm for its use as an adjuvan t in patien ts with large (> 5 cm ), high-grade soft-tissue
sarcom as that dem onstrate reasonable m edical risk for th is
therapy.
Fibrosarcoma
MYXOID
Myxoma
Ben ign myxom as are typically seen with in skeletal m uscle, wh ere th ey usually presen t as a pain less m ass. Th ey do
dem on strate a fairly typical appearan ce on MRI scan n in g:
th ey are usually darker th an m uscle on T1 an d un iform ly
162
brigh t on fat-suppressed T2 views, with som e edem a usually alon g th e in ferior an d superior aspects. Th is is, h owever, n ot diagn ostic for ben ign myxom a an d can be seen
with other soft-tissue m asses, both benign and m alignant. Treatm ent is m arginal excision and recurren ce is
rare.
NEURAL
Benign Schwannoma
Th is is a ben ign tum or foun d in periph eral n erves, m ost
com m only in spinal roots and in the m ajor n erves of the
extrem ities. On MRI im agin g, sch wan n om as dem on strate a
typical soft-tissue tum or pattern sh owin g low sign al on T1
an d h igh sign al on fat-suppressed T2 sequen ces. Sin ce th ey
occur com m on ly with in periph eral n erves, th ey typically
have a fusiform shape an d are lon g in th e longitudinal axis
of th e extrem ity. Histologically, th e lesion is described as
having dense Antoni A (compact spin dle cells, often in a
whorl-like pattern) an d loose An ton i B (less cellular an d
orderly) areas. Verucae bodies exh ibit typical pattern in g of
spin dle cells. Malignan t tran sform ation is extrem ely rare.
Most of th ese lesion s are symptom atic an d dem on strate
a positive Tin els sign (sh ootin g pain with percussion of
the lesion). In light of this, m ost lesions require surgical
excision . Sin ce th ese lesion s frequen tly occur with in th e
neural sh eath of m ajor n erves, excision of the lesion sh ould
be carried out in such a m an n er as to protect th e n erve of
origin as m uch as possible.
Neurofibroma
Solitary n eurofibrom a is a ben ign , fibrotic, fusiform tum or arisin g from a periph eral n erve; th e n erve of origin
m ay be too sm all to recogn ize. It occurs m ost com m on ly
in th e th ird to sixth decades. Th e lesion is usually asymptom atic except for th e presen ce of a m ass. Treatm en t is excision . In neurofibrom atosis, or Von Recklinghausen s disease, sm all cafe au lait spots appear in the first few years
of life, alon g with m ultiple n eurofibrom as, wh ich develop
later. Th e n eurofibrom as appear as soft pedun culated n odules in th e skin or as firm or soft m asses in th e deeper
163
calcified soft-tissue mass which is characteristic of synovial cell sarcoma. (Reprinted with permission from Greenspan A, Remagen W.
Differential Diagnosis of Tumors and Tumor-like Lesions of Bones
and Joints. Philadelphia, PA: Lippincott-Raven, 1998:410.)
OTHER
Synovial Sarcoma
Despite its n am e, th is lesion does n ot arise from syn ovium .
It comprises 8% to 10% of soft-tissue sarcom as an d typically occurs before the age of 50. The m ost com m on sites
are around th e kn ee and foot. Most of these tum ors occur in an extra-articular location, but very rarely m ay be
intra-articular. The radiologic features of synovial sarcom a
Malignant fibrous histiocytom a (MFH) is the m ost com m on soft-tissue sarcom a of adulthood. Sim ilar to other
soft-tissue m alignan cies, it usually presen ts as a painless
deep soft-tissue m ass. Histologically, it is com posed of atypical spin dle cells in a whorled or cartwheel con figuration.
In accordan ce with its h igh -grade status, it is a very cellular
tum or with significant atypia an d necrosis. MFH is basically a diagn osis of exclusion as it is a tum or th at fits n o
oth er m ore specific tum or type.
TABLE 8.8
Radio Sensitive
Low grade
Surgery
Chondrosarcoma
Chordoma
Adamantinoma
Surgery + radiation
Low-grade soft-tissue sarcomas
High grade
Surgery + chemotherapy
Osteosarcoma
Ewing sarcoma
Other high-grade bone sarcomas
164
RECOMMENDED READING
Lewis VO. Whats new in m usculoskeletal oncology. J Bone Joint Surg
Am. 2007;89(6):1399 1407.
Sim FH, Frassica FJ, Frassica DA. Soft-tissue tum ors: diagn osis, evaluation , an d m an agem en t. J Am Acad Orthop Surg. 1994;2(4):202 211.
Weber K, Dam ron TA, Frassica FJ, Sim FH. Malignan t bon e tum ors.
Instr Course Lect. 2008;57:673 688.
Principles of Sports
Medicine
F. W in ston Gwathm ey Jr.
Joseph M. Hart
INTRODUCTION
Medicine and sports share a com m on origin in ancient
Greece. Hippocrates, un iversally regarded as th e fath er of
m edicine, was also am ong historys first sports physicians.
Th e leadin g ath letes of h is tim e participated in th e O lympic
Gam es, an d h e was proficien t at treatin g th eir in juries,
dressin g th eir woun ds, splin tin g fractures, an d stitch in g laceration s. Th e Hippocratic m eth od for reducin g a sh oulder
dislocation rem ain s in use in to m odern tim es. Wh en Galen
was appointed physician for the gladiators of Pergam um ,
he arguably becam e historys first team physician . His athletes frequently sustain ed traum atic wounds inflicted by
heavy weapon s and wild an im als, and in the m anagem ent
of th ese in juries, h e gain ed in valuable in sigh t in to th e fun ction of m uscles, n erves, and blood vessels.
In m odern tim es, th e proliferation of organ ized sports
in society h as stim ulated th e evolution of sports m edicine
an d has established th e physician as an integral m em ber
of th e ath letic com m un ity. Physician in volvem en t in th e
m odern Olympic Gam es reflects this developing role. Prior
to 1924, th e U.S. Olympics team traveled with out a physician or other h ealth care provider. In 2008, a team of 61
health care profession als representin g m ultiple specialties
including orth opaedics, cardiology, obstetrics and gynecology, in tern al m edicin e, em ergen cy m edicin e, an d pediatrics
traveled to Beijing with the O lympics ath letes.
Sports m edicin e is a field dedicated to th e preven tion
an d treatm ent of athletic injuries and diseases and en com passes m ultiple disciplin es collectively in volved in th e care
of ath letes. Th e ath lete represen ts a un ique patien t as success in sports directly correlates with strength, condition ing, an d physical and m ental well-being. To provide optim al care, a compreh en sive approach involving physician s,
Mark D. Miller
166
PREPARTICIPATION EVALUATION
Th e preparticipation evaluation is th e key to th e preven tion of sports-related disease and injury. The objective of
this assessm ent is to screen potentially disabling or lifethreaten ing disorders and identify condition s that predispose to in jury or illn ess. It also serves to determ in e th e gen eral h ealth of th e ath lete an d provides an en try poin t in to
the health care system for adolescents. All athletes participatin g in organ ized h igh sch ool, college, an d profession al
sports are required to un dergo this system atic assessm ent
before bein g cleared to play.
Ideally, th e preparticipation evaluation sh ould take
place 6 weeks before th e start of th e sports season so
that issues that arise m ay be addressed prior to participation. For practical purposes, a complete evaluation need
be perform ed on ly upon en try to a h igh er level of participation , while an interim h ealth questionn aire and lim ited, focused exam ination suffices in subsequent years. The
objectives an d focus of th e evaluation sh ift as ath letes get
older. Am on g youn ger ath letes, screen in g preexistin g m edical and congenital con ditions that affect participation takes
preceden ce. Th e likelih ood of discoverin g a serious preexisting condition dim in ishes as ath letes advance and un dergo yearly assessm en ts. At h igh er levels, th e physician
m ay concentrate on age- or sport-specific issues, and previous in juries and concerns related to trainin g and play
sh ould be addressed.
Th e preparticipation evaluation m ay take place eith er
in th e physicians office on an individualized basis or
in a m ass screening settin g such as a high school gym n asium . Wh ile th e office h as th e advan tage of fostering
the doctorpatien t relation sh ip, m ost physician s h ave lim ited tim e available, especially during the tim e of year that
m ost evaluations need to be completed. The m ass screenin g
ven ue allows for evaluation of a larger num ber of athletes
quickly an d in troduces th e ability to utilize a collaboration
of h ealth care providers with con dition -specific train in g. In
addition, direct access to th e coaching an d athletic training
Health Questionnaire
A h ealth question n aire sh ould be completed carefully in
advance by th e athlete with input from parents an d th e prim ary care provider. The questionn aire identifies the m ajority of poten tial problem s an d sh ould focus on developm en tal and m edical, fam ily, social, allergies, m edications,
an d im m unization history. Th e review of m edical h istory
sh ould address recent illnesses, neurological deficits and
prior h ead in juries, h eart an d lun g con dition s, m usculoskeletal problem s, loss of organs, previous h eat illness,
substan ce or supplem en t abuse, and, in the fem ale ath lete,
disordered eatin g an d m en strual abn orm alities. Th e cardiovascular portion of th e h istory is especially im portan t
as heart disease is implicated in 95% of sudden deaths in
athletes youn ger than 30 years. A prior occurrence of exertion al ch est pain or syn cope, exercise-associated fatigue,
heart m urm urs, arrhythm ia, history of elevated blood pressure, or a fam ily history of prem ature death or disability
secon dary to cardiovascular disease sh ould raise red flags
an d need to be explored. The m edical h istory questionnaire
sh ould be carefully reviewed by a health care profession al
an d appropriate workup for any concernin g elem ents of
the history m ust be un dertaken prior to participation.
Physical Examination
Once the m edical history has been obtained, the athlete
sh ould undergo a th orough but focused physical exam in ation. Recording and tracking the h eigh t, weight, and body
m ass index of each athlete m ay identify disordered eating,
steroid use, or obesity. Vital signs should be taken , an d irregularities in pulse rate, blood pressure, or respiratory rate
warrant further workup.
HEENT: Th e physical exam in ation gen erally starts with
the head, eyes, ears, n ose, and th roat. Poor vision, strabism us, astigm atism , refractive errors, and anisocoria sh ould
prompt referral. Eye protection is required for ath letes with
corrected vision less than 20/ 40, absence of one eye, or
history of eye traum a or surgery.
Cardiovascular: According to the Am erican Heart Association , th e cardiovascular exam ination should in clude
blood pressure m easurem en t, auscultation for m urm urs,
palpation of lower extrem ity pulses, an d assessin g for stigm ata of Marfan syndrom e. Electrocardiography is indicated
for any abnorm al heart rhythm and m ay iden tify potentially lethal arrhythm ias. Murm urs sh ould be assessed in
stan ding and supine positions, an d cardiology referral is
recom m en ded for sign ifican t systolic m urm ur (> 3/ 6), any
diastolic m urm urs, an d all m urm urs am plified by stan din g
or Valsalva m an euver.
167
Lungs: Th e lun g exam in ation sh ould focus on detection of abn orm al breath soun ds, use of accessory respiratory m uscles, an d presence of cough . Asth m a is am ong
the m ost com m on conditions facing youn g athletes and is
ch aracterized by ch est tigh tn ess, wh eezin g, an d sh ortn ess
of breath . Exercise-in duced bron ch ospasm is n ot reliably
detected durin g preparticipation screen in g, an d any ath lete
wh o reports asth m a-like symptom s after exertion should
un dergo form al testin g.
Gastrointestinal/Gastrourinary: Th e abdom in al exam in ation sh ould be perform ed with patien t supin e with kn ees
flexed. The physician sh ould assess for organom egaly,
m asses, abdom in al disten sion , or ten dern ess. A m ale testicular exam in ation is n ot routin e but m ay be in dicated if
the patient discloses a history of undescended or absen t
testicle, pain , swellin g, m ass, or h ern ia.
Musculoskeletal: Th e m usculoskeletal exam ination
sh ould screen for m uscular or bone abnorm alities and
reassess prior in juries. Th e n eurological exam in ation m ay
be in tegrated in to th is portion of th e evaluation an d
any un explain ed weakn ess, paresth esias, or focal deficits
in dicate furth er workup. For th e gen eral participan t, a
14-point m usculoskeletal screening exam ination m ay be
perform ed (Table 9.1). More elaborate join t-specific an d
sport-specific exam in ation techniques m ay be used to
augm en t th e m usculoskeletal exam in ation , especially in
the event of a previous injury. All positive fin dings necessitate m ore detailed evaluation to preven t new injuries and
en sure th at prior in juries an d con dition s h ave been fully
reh abilitated prior to participation .
Clearance to Play
Th e culm in ation of th e preparticipation evaluation is th e
decision on clearan ce to play. Aphysician m ust carefully review all elem ents of the preparticipation evaluation to determ in e wh eth er participation is safe both for ath letes an d
th eir team m ates in th e con text of th e sport in wh ich th ey
will be participatin g. As th e physical dem an ds an d degree
of con tact vary am on g sports, th e Am erican Academy of Pediatrics h as classified sports on th e basis of con tact (Table
9.2). An ath lete precluded from en gagin g in a h eavy-con tact
sport m ay be allowed to participate in a lim ited or noncon tact sport. Treatable con dition s sh ould be addressed
expeditiously an d reassessed prior to clearan ce. On ce all
issues are reviewed, th e physician should subm it the final
decision th at th e ath lete m ay participate with out restrictions, participate only after undergoing further evaluation
or reh abilitation , participate with restriction s, or m ay n ot
participate in th e specific sport because of clearly defin ed
disqualifyin g con dition s. In th e even t th at th e ath lete an d
physician do n ot agree about clearan ce issues, a written
con sen t or legal waiver sign ed by th e ath lete an d th e paren t
sh ould be obtain ed. A second opinion m ay also be sought
by the ath lete.
168
TABLE 9.1
Assessment
(Adapted from McKeag D, Moeller JL, eds. American College of Sports Medicines Primary Care Sports Medicine.
2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2007.)
TABLE 9.2
Limited Contact
Noncontact
Basketball
Boxing
Cheerleading
Diving
Extreme sports
Field hockey
Football, tackle
Gymnastics
Ice hockey
Lacrosse
Martial arts
Rodeo
Rugby
Skiing, downhill
Ski jumping
Snowboarding
Soccer
Team handball
Ultimate Frisbee
Water polo
Wrestling
Adventure racing
Baseball
Bicycling
Canoeing or kayaking (white water)
Fencing
Field events
High jump
Pole vault
Floor hockey
Football, flag or touch
Handball
Horseback riding
Martial arts
Racquetball
Skating
Ice
In-line
Roller
Skiing
Cross-country
Water
Skateboarding
Softball
Squash
Volleyball
Weight lifting
Windsurfing or surfing
Badminton
Bodybuilding
Bowling
Canoeing or kayaking (flat water)
Crew or rowing
Curling
Dance
Field events
Discus
Javelin
Shot put
Golf
Orienteering
Power lifting
Race walking
Riflery
Rope jumping
Running
Sailing
Scuba diving
Swimming
Table tennis
Tennis
Track
(From Rice SG. American Academy of Pediatrics Council on Sports Medicine and Fitness: medical conditions
affecting sports participation. Pediatrics. 2008;121(4):841848.)
GAME COVERAGE
169
TABLE 9.4
Preparedness
Preparation for gam e-day m ust take place lon g before th e
first wh istle. Th e physician sh ould be in com m un ication
with th e adm in istration an d ath letic train in g staff about
all issues pertaining to the health and safety of the athletes.
Th e respon sibilities of th e m em bers of th e h ealth care team
sh ould be clearly defined, as well as th e chain of com m an d
for gam e-day issues such as clearance to play, em ergencies, environm ental con cern s, and playing condition s. An
efficien t an d reh earsed em ergen cy respon se plan sh ould
be in place prior to th e start of th e season an d sh ould be
verified with the athletic trainer an d em ergency person nel
prior to each practice an d gam e. Th e establish m en t of a
network of oth er health care providers in cluding prim ary
care providers, specialists, and athletic trainers facilitates
prompt treatm en t an d th orough follow-up.
Th e physician coverin g a sportin g even t from th e sidelines should be fam iliar with the com m on condition s
an d injuries th at arise from participation and should be
prepared for all poten tial causes of on -field em ergen cies
(Table 9.3). The m edical equipm ent an d supplies available on the sideline should consist of gen eral m edical essen tials and reflect the risks specific to the sport. Con tact
sports such as football require consideration for im pact
injuries, whereas endurance sports such as long-distance
run n ing necessitate treatm ent strategies for fatigue an d
dehydration . Supplies for sport-specific protective equipm en t such as the face m ask rem oval tool for football helm ets sh ould be readily available. The Am erican College of
Sports Medicin e provides recom m en dation s for con ten ts of
the m edical bag and on-site m edical supplies (Tables 9.4
an d 9.5).
RECOMMENDED CONTENTS OF A
MEDICAL BAG
Airway
Alcohol/povidoneiodine swabs
Bandage scissors, bandages, sterile/nonsterile, Band-aids
Blood pressure cuff
Cricothyrotomy kit
Dental kit (e.g., cyanoacrylate, Hank solution)
Epinephrine 1:1,000 in a prepackaged unit
Eye kit (e.g., blue light, fluorescein stain strips, eye patch pads,
cotton tip applicators, ocular anesthetic and antibiotics, contact
remover, mirror)
Flashlight
Gloves
Large bore (1416 G) Angiocath for tension pneumothorax
List of emergency numbers
Local anesthetic/syringes/needles
Mouth-to-mouth mask
Nasal packing material
Oto-ophthalmoscope
Prescription pad
Rectal thermometer
Reflex hammer
Short-acting -agonist inhaler
Skin staple applicator
Small mirror
Stethoscope
Supplemental oral and parenteral medications
Suture set/steri-strips
Tongue depressors
Topical antibiotics
Wound irrigation materials (e.g., sterile normal saline, 1050 cc
syringe)
TABLE 9.5
TABLE 9.3
Medical
Head injury
Spinal cord injury
Cardiac tamponade
Cardiac contusion
Commotio cordis
Hemothorax
Tension pneumothorax
Pulmonary contusion
Flail chest
Splenic rupture
Ruptured viscus
Fracture
Dislocation
Blood loss
Cardiac event
Cerebrovascular accident
Bronchospasm
Anaphylaxis
Pulmonary embolism
Hyperventilation
Spontaneous pneumothorax
Hypoglycemia
Hyponatremia
Dehydration
Heatstroke
Hypothermia
Lightning
Drug/medication overdose
170
D
Figure 9.1 (A-D) The logroll technique should be used when spine injury is suspected. (Reprinted
with permission from Garrett WE, Kirkendall DT, Squire DL. Principles and Practice of Primary Care
Sports Medicine. Philadelphia, PA: Lippincott Williams & Wilkins, 2000.)
proceed in a m ore con trolled settin g on th e sidelin e. In juries sh ould be fully evaluated an d treated in th e con text
of th e sport before allowin g reen try in to th e gam e. Th e team
physician sh ould be in volved in all in juries or con dition s
wh ere th e ability to participate is in question . Provision al
m anagem ent such as bandaging or taping m ay allow return to play, but the injured player should be reassessed
in sport-specific activity before final clearan ce. Decisions
about participation should be clearly com m unicated to the
player an d coach in g staff to preven t any con fusion . Any
athlete wh o expresses h esitan cy about returning to play
sh ould be h eld out un til concerns are addressed. All in juries
and conditions should be docum ented so that they receive
appropriate follow-up an d reh abilitation, and the players
fam ily an d prim ary care provider sh ould be in form ed an d
involved in decisions pertaining to continuing care.
171
Figure 9.2 (A-C) A bolt cutter or face mask removal tool should be used
to remove the face mask as soon as possible to provide access to the players
airway. (Reprinted with permission from Garrett WE, Kirkendall DT, Squire
DL. Principles and Practice of Primary Care Sports Medicine. Philadelphia, PA:
Lippincott Williams & Wilkins, 2000.)
HEAD INJURIES
More than 300,000 sports-related head injuries were
treated in U.S. em ergency departm ents in 2007, with cycling
an d football comprising the m ost frequently implicated
sports. The risk of head injury increases with the am oun t of
en ergy to wh ich an ath lete is exposed. Despite rule m odifications and advances in helm et design and other protective
equipm en t, th e force of im pact seen in som e sports such as
football, boxing, and rugby approaches that of m otor vehicle accidents. Any athlete who exhibits sign s an d symptom s
to in clude h eadach e, loss of con sciousn ess, altered m en tal
status, cran ial nerve dysfun ction , or worsening symptom s
sh ould be considered to have a significant traum atic brain
injury and should undergo a thorough neurological evaluation alon g with serial exam in ation s.
Concussion
Concussion is the m ost com m on head injury sustained
by athletes and is ch aracterized by a transient posttraum atic impairm ent of cerebral neural function. Generally,
th e result of a direct blow to th e h ead eith er by an oth er
player, an object, or th e groun d, in itial sign s an d symptom s of concussion m ay in clude loss of consciousness,
con fusion , am n esia, vision or balan ce dysfun ction , n ausea, or h eadache wh ile persistent effects include m em ory
or cogn itive deficits, sleep disturban ce, an d em otion al lability. Frequen tly, team m ates m ay iden tify a player wh o is
dem on stratin g con cussive sym ptom s. Th e sidelin e in terview is the m ost effective m ethod of detecting impairm ent,
and the Standardized Assessm ent of Concussion (SAC) perm its docum entation of symptom s for serial exam ination
(Fig. 9.4).
Th e goal of m an agem en t is to m in im ize postcon cussive syndrom e sym ptom s and prevent secon d-impact syndrom e. Postcon cussive syn drom e is ch aracterized by persisten ce of con cussion symptom s secon dary to cerebral
m etabolic derangem ents and neurotransm itter dysfunction. Athletes with prolonged postconcussive syn drom e
sh ould n ot be allowed to participate in any exertional activities and m ay require neuroim aging or expert con sultation .
Second-impact syndrom e is a rare but catastroph ic sequela
172
Other,
5%
Head/Neck,
13%
Head/Neck,
10%
Lower
Extremity,
54%
Upper
Extremity,
18%
Trunk/Back,
13%
Lower
Extremity,
54%
Upper
Extremity,
21%
Trunk/Back,
10%
A
Figure 9.3 (A) Percentages of injuries by body part during competition for 15 sports, National
Collegiate Athletic Association 19882004. (B) Percentages of injuries by body part during training/practice for 15 sports, National Collegiate Athletic Association 19882004. (Data from Hootman
JM, Dick R, Agel J. Epidemiology of collegiate injuries for 15 sports: summary and recommendations
for injury prevention initiatives. J Athl Train. 2007;42(2):311319.)
for serial examination. (Reprinted with permission from McCrea M. Standardized mental status testing
on the sideline after sport-related concussion. J Athl Train. 2001;36(3):274279.)
173
TABLE 9.6
Cantu
1 (Mild)
2 (Moderate)
3 (Severe)
AAN
AAN, American Academy of Neurology; LOC, loss of consciousness; PTA, posttraumatic amnesia; PCS,
postconcussive syndrome; RTP, return to play.
(Adapted from Patel DR, Greydanus DE, Luckstead EF Sr. The college athlete. Pediatr Clin North Am.
2005;52(1):2560, viiviii.)
Can tu an d Am erican Academy of Neurology gradin g system s h ave been developed to classify th e severity of a con cussion and provide a general outline on when to allow
return to play (Table 9.6). Accurately gradin g a con cussion
acutely m ay be difficult, an d each ath lete sh ould be m an aged on an in dividual basis. Regardless of th e grade, con cussions associated with abn orm al computed tom ography
(CT) or m agn etic reson an ce im agin g (MRI) scan s sh ould
preclude return to play for th e rem ain der of th e season .
Intracranial Hemorrhage
Clinical deterioration and developm ent of focal deficits
m ay be m anifestations of severe traum atic brain injury.
A direct blow to the h ead m ay cause a cerebral contusion,
in which cerebral parenchym al blood vessels are violated,
resultin g in bruisin g an d in tern al bleedin g. Patien ts m ay
sh ow focal sym ptom s such as partial paralysis, cranial nerve
involvem ent, or labile vital signs. A high-velocity impact to
th e temple m ay fracture th e skull, disruptin g th e m iddle
m eningeal artery to cause an epidural hematoma. In this injury, blood accum ulates in th e poten tial space between th e
skull and th e dura m ater, and the ch aracteristic clinical sequen ce begin s with a brief loss of con sciousn ess, followed
by a lucid interval, and culm inates in rapid deterioration of
n eurologic function. Th e bridgin g vein s traversin g the subdural space are vuln erable to acceleration -/ deceleration type forces. An injury to these vessels results in a subdural hematoma, an d neurological consequences m ay appear
im m ediately or develop over the course of several days or
weeks. Sym ptom s are gen erally progressive an d ran ge from
174
FACIAL INJURY
Because of th e abun dant vascularity of th e face, facial in juries are frequen tly associated with profuse bleedin g an d
sign ificant swellin g. Closed head injury an d cervical spine
injury should be considered with all facial traum as. Facial
laceration s are com m on and bleeding m ay be con trolled
with direct pressure. Un iversal precaution s sh ould be m ain tain ed wh en m an agin g any bleedin g. Followin g th orough
irrigation, sm all lacerations m ay be closed with an adhesive bandage, whereas larger wounds m ay require stitches.
Sim ple an terior n asal bleeds in volvin g disruption of th e
Kiesselbach ven ous plexus in the anterior nose m ay be controlled with direct pressure or a vasoconstrictive nasal spray
such as oxym etazoline or phenylephrine. Posterior epistaxis in wh ich brisk n asoph aryn geal bleedin g occurs from
injury to the sphenopalatine artery or other larger vessel
m ay n ot respond to nasal spray an d warrants n asal packing and transfer to the hospital for furth er m anagem en t
(Fig. 9.6).
Nasal fractures compose th e m ajority of facial fractures and usually are associated with epistaxis, soft tissue
swellin g, septal h em atom a, and obvious nasal deform ity.
Depen din g on th e degree of displacem en t, con servative or
surgical m anagem en t m ay be indicated.
Eye injuries also occur frequently in sports and m ay result in lon g-term m orbidity. Sports-related eye injuries are a
leading cause of adolescen t blin dn ess, an d 90% of these injuries m ay be avoided with protective eyewear. Sign ifican t
eye in jury m ay presen t with ph otoph obia, partial or com plete vision loss, double vision , or eye pain . Corneal abrasion m ay occur with direct traum a such as a finger to the eye
Figure
175
(Fig. 9.7). Ath letes m ay complain of photophobia an d sen sation of a foreign object. Diagnosed with fluorescein stain,
athletes with significant abrasions m ay require antibiotics
an d an eye patch. Periorbital contusion or black eyegenerally m ay be treated with con servative m an agem en t in volving ice to control swellin g and observation. Athletes
wh o sustain a black eye sh ould un dergo a th orough oph thalm ologic exam ination to ensure that the eye is not in jured an d th e orbit is n ot fractured. More serious eye in juries sh ould be referred to an oph th alm ologist.
Th e cauliflower ear, com m on ly seen in boxers an d
wrestlers, represen ts th e con sequen ces of recurren t ear
traum a (Fig. 9.8). Auricular hem atom as develop between
the skin and underlying cartilage and should be treated
with ice to reduce swellin g. Severe swellin g m ay cause cartilage breakdown, and fluid accum ulation m ay n ecessitate
aspiration.
Mouth guards sh ould be worn by ath letes participatin g
in contact sports to prevent dental injury. In the event of
den tal in jury, bleedin g m ay be con trolled with direct pressure. Loose teeth should be gently pushed back in to their
norm al position, an d fractured or avulsed teeth sh ould
be located an d placed in to Han k solution , m ilk, or sterile
salin e. An avulsed tooth should be han dled by the crown
to preven t root in jury. Ath letes wh o sustain a den tal in jury
sh ould be referred to a den tist for further care.
SPINE
According to the National Spinal Cord Injury Statistical
Cen ter, sports-related spinal cord injuries accounted for approxim ately 7.4% of all spin al cord in juries sin ce 2005, with
alm ost 25% of spinal cord injuries in patients younger than
15 years an d 15% of those in patients between 15 and 30
Greenberg MI, Hendrickson RG, Silverberg M, et al., eds. Greenbergs Text-Atlas of Emergency Medicine. Philadelphia, PA: Lippincott Williams & Wilkins, 2004.)
Cervical Spine
Neck pain , focal n eurological deficits, loss of con sciousn ess, or abn orm al reflexes m ay sign ify a spin al cord injury
and should be system atically docum ented. Spine precautions con sisting of in-line im m obilization an d logrolling
m ust be m aintain ed for all unconscious athletes an d all
th ose suspected of sustain in g a cervical spin e in jury. Players sh ould n ot be tran sported un til proper im m obilization
is in place. Cervical collars, backboards, and stretchers are
essen tial equipm en t an d sh ould be readily available for any
sportin g even t in wh ich a spinal cord injury is a possibility.
Th e h elm et of football players m ust n ot be rem oved. Rem oving a football helm et without the sh oulder pads produces un acceptable m otion in th e cervical spin e an d m ay
com prom ise th e cord. Th e player sh ould be tran sported
to the hospital, im m obilized on a spine board with helm et
and pads in place. The face m ask should always be rem oved
from the helm et as soon as possible to ensure access to the
airway. If the airway needs to be secured, the cervical spine
m ay be protected with the jaw-thrust and ch in-lift m aneuver. Th e head-tilt m an euver should be avoided.
A m ethodical radiograph ic an alysis sh ould begin with
anteroposterior, lateral, and oblique plain radiographs an d
176
B
Figure 9.9 The lateral cervical spine radiograph should be examined for alignment and evidence
of instability. (Reprinted with permission from Brant WE, Helms CA, eds. Fundamentals of Diagnostic
Radiology. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2007.)
177
m ust include the cervicothoracic junction (Fig. 9.9). Vertebral deform ity, soft tissue swellin g, loss of lordosis, stepoffs, or splayin g of posterior elem en ts sign ify spin al in jury.
In stability is in dicated by jun ction al kyph osis of m ore th an
11 degrees or anteroposterior translation greater than 3.5
m m (Fig. 9.10). The space available for the cord between
C3 and C7 averages approxim ately 17 m m in adults. Relative and absolute stenosis are present if the canal narrows
to less th an 13 m m an d 10 m m , respectively, an d represen ts
a relative or absolute contraindication to contact sports depen din g upon presen ce of sym ptom s. Spear tacklers spin e
is an entity that involves cervical stenosis and loss of lordosis typically seen in football players an d proh ibits participation in con tact sports (Fig. 9.11). Fractures m ay be fur-
178
TABLE 9.7
Odontoid anomalies
Atlantooccipital fusion
Atlantoaxial instability
Atlantoaxial rotatory fixation
Certain KlippelFeil anomalies
Spear tacklers spine
Subaxial spinal instability
Acute fracture of either the body or posterior elements
Healed fracture with residual sagittal malalignment or canal compromise
Continued pain, abnormal neurological findings, or limited motion from a healed cervical fracture
Symptomatic acute soft or chronic disc herniation
After any fusion in the presence of congenital stenosis
Im m obilization with a cervical collar sh ould con tin ue un til resolution of acute sym ptom s at wh ich tim e dyn am ic
flexion and exten sion radiographs m ay be obtained. Radiograph ic eviden ce of in stability warran ts furth er in vestigation of ligam en tous in jury with MRI. Treatm en t of
sprains con sists of conservative m an agem en t in cludin g
an ti-in flam m atories an d physical th erapy. An ath lete m ay
return to play on ce symptom s subside if th ere are n o radiograph ic abn orm alities.
Approxim ately half of all collision-sports ath letes will experien ce a stin ger at som e poin t durin g th eir career. Th e
typical complaint is a pain ful sensation th at radiates from
the neck to fingertips after a lateral blow to neck or sh oulder. Th e effects of a stin ger are sh ort-lived, an d gen erally,
return to play is perm issible if symptom s resolve. Persisten t
or recurren t sym ptom s preclude from play an d require
further workup.
Transient quadriplegia is less com m on, affectin g approxim ately 1.3 in 10,000 athletes, but entails a m ore serious in jury th an a stin ger. Usually a result of hyperexten sion often accompanied by axial loading of the neck, tran sient quadriplegia is characterized by bilateral sym ptom s
that m ay include burning, paresthesias, loss of sensation,
an d/or weakn ess in the arm s and/ or legs. The severity of
symptom s m ay range from m ild paresthesias to complete
paralysis an d m ay persist for up to 36 h ours. Ath letes with
transient quadriplegia, especially those with symptom s for
m ore than 36 hours, should receive im aging of the cervical
spine.
All athletes with symptom s of cord neuropraxia should
be presum ed to h ave a spin e in jury an d spin e precautions should be m ain tain ed un til appropriate evaluation
has taken place. Determ in ation of return to play for th ese
types of injuries presen ts a ch allenge to the sports physician . No athlete should be allowed to play with neurological deficit, painful range of m otion of neck, or pain on
axial loading of spine. Instability, disc disease, congenitally
fused segm ents, an d canal stenosis predispose athletes to
transient quadriplegia, and careful consideration of th ese
poten tially dan gerous con dition s sh ould be m ade before
allowing return to play.
Thoracolumbar Spine
Th oracolum bar spin e in juries an d con dition s also affect
the athletic population. Wh ile the m ajority of these injuries are m in or, severe in juries m ay occur, an d proper m an agem ent is important to preven t further injury. The thoracolum bar spin e m ay be con trolled with logrollin g an d
placin g th e ath lete on a backboard. Neurological fun ction
m ay be assessed by exam ining m otor and sensory function in the extrem ities, and deficits prompt m ore th orough
evaluation .
Th e m ost com m on etiology of low back pain is lumbar
strain, a condition characterized by point tenderness in th e
paraspin al m usculature of th e low back an d pain with m otion. Strains generally respond to rest, activity m odification ,
therapy, and symptom atic treatm ent. Radicular symptom s
m ay develop if a nerve root is compressed or irritated, usually from a bulging disc. Low back pain with radiculopathy
also tends to improve with conservative treatm en t. Athletes
with persisten t or progressive symptom s sh ould be referred
to a spin e surgeon .
In som e ath letes such as gym n asts an d football players, repetitive lum bar hyperexten sion produces impaction
179
of th e in ferior articular facet upon th e pars in terarticularis, leadin g to spondylolysis (Fig. 9.13). In this con dition
in which a defect develops in the pars, the athlete m ay
com plain of low back pain exacerbated by exten sion an d
paraspin al m uscle spasm an d h am strin g tigh tn ess. Bilateral
pars defects m ay lead to spondylolisthesis or slippage of th e
vertebra. Diagnosis is con firm ed by oblique radiographs
of the lum bar spine or sin gle-photon em ission CT scan.
Ath letes with suspected spon dylolysis or spon dylolisth esis
sh ould be referred to a spin e surgeon .
THORACIC INJURY
Ath letes in volved in h igh -speed or con tact sports are vuln erable to in juries of th e ch est wall an d in trath oracic organs. Rib fractures con stitute th e m ajority of ch est wall
injuries, m ost com m only resulting from blunt traum a, alth ough n on con tact an d overuse m ech an ism s m ay also
cause rib fracture. Usually in volvin g th e m idaxillary region
of ribs 4 th rough 9, rib fractures are associated with local
pain an d ten dern ess an d pain on deep in spiration . An isolated rib fracture typically m ay be treated expectantly, but
stern al fractures, pn eum othorax, flail chest, an d fractures
of th e first rib con stitute m ore serious in jury an d require
further m anagem ent.
Although protected by the chest wall, the intrath oracic
organ s are vuln erable to h igh -en ergy traum a. Cardiac con tusion m anifests as a dull ch est pain after blun t chest wall
traum a an d should be evaluated by electrocardiography
due to th e risk of associated dysrhyth m ia. Commotio cordis is
a leth al ven tricular arrhyth m ia resultin g from a direct blow
to the chest, precisely corresponding to the repolarization
ph ase of th e con tractin g h eart. Most com m on ly described
in youth baseball, com m otio cordis m ust be treated with
cardiopulm on ary resuscitation an d early defibrillation to
preven t alm ost certain death . Basic life support train in g an d
accessibility of autom ated external defibrillators are vital to
preven tin g cardiac-related m orbidity an d m ortality.
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Figure 9.14 Right-sided pulmonary contusion as demonstrated on chest radiograph (A), and axial
computed tomography scan (B). (Reprinted with permission from Greenberg MI, Hendrickson RG,
Silverberg M, et al., eds. Greenbergs Text-Atlas of Emergency Medicine. Philadelphia, PA: Lippincott
Williams & Wilkins, 2004.)
Acute onset of shortness of breath m ay signify pulm on ary injury. Transient dyspnea after a blow to the chest
or abdom en is due to a brief diaph ragm atic spasm th at
spon tan eously rem its. This is referred to by th e colloquial
ph rase gettin g th e win d kn ocked out of youan d gen erally
requires n o furth er m an agem en t on ce symptom s subside.
Pulmonary contusion m ay occur in blun t ch est wall traum a
an d often accompany rib fractures (Fig. 9.14). Pulm onary
contusions resolve with tim e, but the physician should
be aware of possible com plication s such as pn eum on ia
or respiratory distress. Sudden on set of dyspn ea, pleuritic
ch est pain , an d decreased breath soun ds are ch aracteristic
of pneumothorax, a poten tially serious con dition in wh ich
the lun g partially or completely collapses. Pneum othorax
m ay be the result of impact or m ay occur spon taneously,
an d ath letes exhibitin g symptom s should be placed on oxygen an d tran sported to a h ospital for m an agem en t. Tension
pneumothorax is a m edical em ergency characterized by dyspn ea, tachycardia, n eck vein disten sion , an d trach eal deviation . Decreased breath sounds and tympany to percussion
identify the affected side. If suspected, the ath lete m ay decompensate quickly, an d large-bore needle decompression
into the second intercostal space at the m idclavicular line
of th e affected side m ay be life-savin g.
ABDOMINAL INJURY
A sudden in crease in in tra-abdom in al pressure from a direct blow m ay disrupt th e diaph ragm or in tra-abdom in al
organ s (Fig. 9.15). Ath letes wh o sustain abdom in al traum a
m ay in itially h ave a n orm al abdom in al exam in ation , an d
serial exam inations for developm ent of tendern ess, rigidity,
an d distension m ay be required to detect a serious intraabdom in al in jury. A ruptured viscous is a surgical em ergen cy,
an d an athlete who suffers a significant bowel injury needs
to be tran sferred im m ediately to a h ospital for urgen t m an agem ent. The poor visceral sensory innervation delays on set of symptom s from intraabdom inal injury, and n on specific symptom s such as diffuse abdom inal pain , nausea,
diarrh ea, or hypoten sion m ay appear in sidiously. Developm en t of such sym ptom s in th e con text of abdom in al
traum a warrants further workup.
Splenic injury presen ts with n ausea, left upper quadran t
ten dern ess or referred left sh oulder pain (Keh r sign ) after
a blow to th e abdom en . Sm all capsular laceration s m ay
heal with out becom in g clinically apparent, but large laceration s m ay progress to splen ic rupture, resultin g in in traabdom inal hem orrhage and hem odynam ic in stability.
Splen ic en largem en t is a feature of m on on ucleosis, an d
athletes with active or resolving m on onucleosis sh ould be
restricted from con tact un til th e spleen h as return ed to n orm al size.
Righ t upper quadran t pain with radiation to th e righ t
sh oulder m ay in dicate a hepatic injury an d sh ould be evaluated with liver function tests and CT. Perium bilical or back
pain alon g with n ausea m ay be m an ifestation s of pancreatic
injury and patien ts should be m onitored closely for developm en t of pan creatitis.
Positioned posteriorly in the abdom en, the kidneys are
vulnerable to direct blows to the back. Renal contusion is
usually accom pan ied by flan k ten dern ess an d gross or m icroh em aturia. Diagnosis is confirm ed by urinalysis, intraven ous pyelogram , or renal ultrasound. CT scan with con trast m ay be obtained to detect m ore serious in juries to the
kidney such as lacerations, bleeding, or ureteral injuries.
Exten sive bleedin g with ren al fracture or vascular pedicle
injury requires urgent surgery. Because of the risk of kidney
injury, ath letes with one kidney deserve special consideration wh en determ ining clearan ce to play.
MUSCULOSKELETAL INJURY
Approxim ately 75% of injuries sustained in college athletics involve the extrem ities, with ankle sprain s accounting
for alm ost 15% of all sports-related injuries. Evaluation of
a suspected extrem ity injury should include in spection for
deform ity, laceration s, abrasion s, bruisin g, swellin g, an d
neurovascular status. Th e ran ge of m otion and stability of
the involved joint should be n oted, and associated injuries
sh ould be explored. Extrem ity injuries m ay occur in con jun ction with spin al cord in juries, an d cervical im m obilization and spine precaution s should be m aintained until
spinal cord injury is excluded. Soft tissue in juries com pose
the overwhelm ing m ajority of m usculoskeletal extrem ity
injuries sustain ed in sports. For m ost of these in juries,
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Orthopaedic Emergencies
Few extrem ity injuries constitute em ergencies, but these
sh ould be identified an d addressed promptly when assessing a down ed athlete. Fractures of the pelvis or fem ur, fractures associated with vascular injuries, penetratin g traum a,
and open fractures m ay jeopardize hem odynam ic stability
or th reaten an extrem ity, an d th e physician sh ould im m ediately provide provisional treatm ent while the em ergen cy respon se plan is initiated. Typically the result of a high-energy
m echan ism , the physician should m aintain a high index of
suspicion for con com itant head, spin e, in trathoracic, or intraabdom inal injury when evaluating th ese injuries. Vital
sign s and th e con dition of the affected extrem ity should be
m onitored closely, and th e athlete sh ould be tran sferred to
a hospital as soon as possible.
Active bleeding should be controlled with direct com pression an d elevation of th e in jured extrem ity. Un iversal
precaution s sh ould be m ain tain ed wh ile treatin g a bleeding athlete. Open fractures should be irrigated copiously
with salin e before dressin g an d splin tin g. Join t dislocation s
sh ould be reduced as soon as possible to prevent n eurovascular comprom ise an d osteon ecrosis. Som e dislocation s,
such as shoulder dislocations, m ay be reduced on the field
acutely prior to onset of m uscle spasm . Irreducible dislocation s n ecessitate prompt tran sfer to a h ospital wh ere sedation an d m uscle relaxan ts m ay be adm in istered. A n eurovascular exam in ation before an d after reduction sh ould
be docum en ted, an d ch an ges in pulses or n eurological status dem and urgent attention.
Compartment Syndrome
Compartment syndrome occurs because of elevated pressure
with in a fascial compartm en t th at atten uates blood flow
and m ay occur following injury, with exercise, or a constricting bandage or splint. Involving the leg or forearm in
m ost cases, compartm en t syn drom e is a clin ical diagn osis
based on observed tigh tn ess of a com partm en t, paresth esias, pain on passive stretch of m uscles that traverse the
com partm en t, an d pain out of proportion al to physical
exam in ation fin din gs. Sym ptom s gen erally develop gradually, an d once diagn osed, em ergent fasciotomy is needed to
preven t tissue n ecrosis. Pallor, paralysis, an d pulselessn ess
are late sign s an d signify that dam age h as already occurred.
Exertional compartment syndrome is activity-related pain
th at occurs wh en exercisin g m uscle swells, becom in g con stricted to th e poin t of ischem ia by the unyielding fascia.
Pain is gen erally quickly alleviated by rest. Measurem en t
of compartm en t pressures before an d after exercise is diagn ostic, an d treatm en t involves fasciotomy of th e affected
com partm en ts. Com partm en t pressures of m ore th an
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Muscular Injury
Muscles are in jured by direct traum a, overuse, or overstretch. A contusion is caused by direct impact, which com presses th e m uscle again st th e un derlyin g bon e. Most com m on ly affectin g th e an terior th igh an d biceps, con tusion s
m ay be preven ted with appropriate paddin g an d usually
respon d to con servative m an agem en t of a sh ort period of
im m obilization followed by ran ge-of-m otion exercises an d
stren gthen ing. Repeated traum a or inadequate reh abilitation m ay result in myositis ossificans, in which calcification
develops in th e m uscle, resultin g in ectopic bon e form ation . Delayed-onset muscular soreness develops 24 to 72 hours
after vigorous activity an d is m ost frequen tly seen at th e
start of the training when th e ath lete is n ot accustom ed to
in ten se exercise. This con dition is self-lim ited and pain m ay
be alleviated with rest an d n on steroidal an ti-in flam m atory
drugs (NSAIDs).
Gradual onset of symptom s distin guishes m uscular
soreness from muscular strain, wh ich is an overstretch in g
in jury to the m uscle, characterized by im m ediate pain and
loss of function. Ranging in severity from m ild disruption
of m uscle fibers to com plete tears, strain s or pulled m usclesm ost often affect the myotendinous junction of m uscles that cross two joints such as the ham strin gs or quadriceps an d during eccentric contraction. Symptom s include
localized tenderness, swelling, weakness, an d painful m otion . Preven tion of strain s en tails adequate stretch in g an d
conditioning, and treatm en t consists of PRICE. On ce the
acute pain an d swellin g h as improved, emph asis sh ould
be sh ifted to stren gth en in g an d reh abilitation . Rein jury is
com m on despite seem ingly sufficient therapy, and chronic
m uscle strain s m ay persist for several m on th s.
Ligamentous Injury
Th e static stabilizers of join ts, ligam en ts m ay be disrupted
un der excessive ten sion from extrem es in join t m otion . Minor dam age to the fibers of a ligam ent is designated a sprain
an d is ch aracterized by local pain an d ten dern ess, swellin g,
an d pain on join t ran ge of m otion . Th e m ost com m on ly
sprained join t, the ankle is typically in jured wh en ath letes
plan t th eir foot awkwardly an d roll or twist th e an kle. Treatm en t of m in or sprain s is symptom atic an d in cludes PRICE.
Activity sh ould be restricted to allow the ligam ent to heal, a
process th at m ay take up to 6 weeks. Protected ran ge of m otion is im plem en ted to preven t stiffn ess. Th e recurren ce rate
after return to play is h igh due to atten uation of fibers an d
comprom ise of joint proprioception. Athletes m ay benefit
from wrapping or bracing th e injured joint. Partial or complete ligament tears represen t m ore severe in juries. In addi-
tion to pain and swelling around the joint, these injuries are
associated with join t laxity or instability. Plain radiograph s
sh ould be obtain ed to ch eck for osseous injury as avulsion
fractures have a sim ilar clinical picture. Stress radiograph s
or MRI m ay assist in diagn osis.
Th e severity an d location of th e tear guide treatm en t. A
m ore con servative approach m ay be appropriate if fiber
con tin uity is m ain tain ed. Complete tears imply th at all
fibers are disrupted, an d th e ligam en t m ay n ot h eal properly if th e en ds are n ot approxim ated. In gen eral, in traarticular structures such as th e an terior cruciate ligam en t (ACL)
of th e kn ee will n ot h eal because of th e in effectiven ess of
the fibrin clot in the intraarticular environm en t. Th ese ligam ents frequently require recon struction when torn. Extraarticular structures such as the m edial collateral ligam ent of the kn ee m ay heal with conservative m anagem ent.
Th ese types of gen eralization s do n ot dictate treatm en t, an d
each ath lete an d ligam en t in jury sh ould be evaluated in dividually. Factors such as th e join t in volved, severity of
sym ptom s, sport played, and level of competition m ust be
con sidered in developin g a m an agem en t strategy. Con servative therapy con sists of a period of im m obilization an d
sym ptom atic treatm ent followed by therapy and rehabilitation . Surgical treatm en t in volves prim ary repair or recon struction usin g autograft or allograft. Return-to-play determ in ation sh ould be m ade on an in dividual basis an d
sh ould take in to accoun t the resolution of symptom s an d
the stren gth and stability of the joint.
Stress Fractures
Stress fractures result from repetitive in sults to n orm al bon e,
wh ich progressively disrupt in tern al trabeculae, even tually leadin g to cortical weakn ess. Th e tibia, m etatarsals,
an d fibula of track-and-field ath letes and m ilitary recruits
are m ost com m only involved (Fig. 9.16). This pattern of
presen tation reflects th e path ophysiology beh in d th ese
overuse in juries. Th e weigh t-bearin g bon es of en duran ce
athletes sustain cyclic traum a with inadequate recovery.
Th is repetitive stress accum ulates to overcom e th e capacity of the bone to rem odel. Upper extrem ity stress fractures
m ay also occur in sports such as baseball and tennis, which
expose th e bon es of th e arm s or h an ds to sim ilar types of
recurren t loads.
Stress fractures presen t with localized pain exacerbated
by the offending activity and transiently relieved by rest.
Pain m ay persist after cessation of activity and at night as th e
fracture evolves. Plain radiographs are unreliable during
the early stages of stress fracture but m ay show periosteal
reaction , trabecular discon tin uity, or a lin ear ban d of sclerosis. Advan ced im agin g m odalities such as MRI or bon e
scan are useful to establish a definitive diagn osis. Treatm en t generally entails activity m odification to avoid th e
excessive forces upon th e bon e, alth ough im m obilization
an d non weight-bearing on the injured extrem ity m ay be
indicated. For high-risk stress fractures such as th ose on the
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MEDICAL CONDITIONS
Cardiovascular Disease
Sudden death in an athlete, although rare, is a devastating event that is m ost com m on ly related to cardiac causes.
Th e cardiovascular screen in g portion of th e preparticipation evaluation is crucial to preventing the potentially severe outcom es of cardiovascular dysfunction or disease. Hypertrophic cardiomyopathy is implicated in m ore than one
quarter of sudden cardiac deaths in athletes (Fig. 9.17). Affecting 1 of 500 athletes, this condition is usually asymptom atic and m ay initially present as sudden death due to
dyn am ic outflow obstruction or ven tricular arrhyth m ia.
Hypertroph ic cardiom yopathy is inherited as an autosom al dom in ant trait, and fam ily history of sudden death ,
especially in a relative youn ger th an 45 years, sh ould raise
con cern . Physical exam in ation fin din gs m ay in clude a late
systolic m urm ur th at in creases in intensity on stan ding or
with Valsalva m an euver an d decreases with squattin g. Th e
affected athlete m ay report dyspn ea on exertion, chest pain ,
palpitation s, or syn copal episodes. If suspected, th e ath lete
sh ould be proh ibited from play and referred to a cardiologist. Echocardiography is diagnostic.
Marfan syndrome h as been iden tified as a risk factor for
sudden death in th e ath lete due to acute dissection of the
aortic root. A con stellation of physical exam ination findings in cluding tall stature, arachnodactyly, and lens dislocation s distin guish es th is con dition an d sh ould be recogn ized durin g th e preparticipation evaluation . Ath letes with
Marfan syndrom e should undergo a thorough cardiovascular evaluation before bein g cleared to play.
A n um ber of addition al cardiovascular con dition s with
possibly serious con sequen ces m ay silen tly affect th e ath lete. Prolonged QT syndrome is a fam ilial con dition that involves an abnorm al repolarization of the cardiac conduction system and m ay lead to syncope or fatal arrhyth m ia.
Typically asymptom atic, prolon ged Q T syn drom e m ay be
diagn osed by a Q T in terval of m ore th an 480 m illisecon ds
on electrocardiography. Congenital coronaryarteryabnormalities m ay be asymptom atic or present as exertional chest
pain from kin kin g of an an om alous vessel. Pistol Pete
Maravich , a well-known collegiate and professional basketball player, collapsed after a recreation al basketball gam e
and died at an age of 40 years from a h eart attack caused by
a congenitally m issin g left coronary artery. Valvular disease
also m ay afflict ath letes without any symptom s. Abn orm al
h eart m urm urs on physical exam in ation m erit further evaluation .
Coronary artery disease is the m ost com m on cause of
death in older ath letes. Risk factors sh ould be m in im ized to prevent complications, and athletes wh o report
184
B
Figure 9.17 (A) Hypertrophic cardiomyopathy diagram. (B) Postmortem heart specimen from
patient with hypertrophic cardiomyopathy. (A: Reprinted with permission from Springhouse, ed. Just
the Facts: Pathophysiology. Philadelphia, PA: Lippincott Williams & Wilkins, 2004. B: Reprinted with
permission from Lilly LS, ed. Pathophysiology of Heart Disease. 2nd ed. Baltimore: Williams & Wilkins,
1998.)
Asthma/Exercise-Induced Bronchospasm
Asthma, a con dition m arked by airway hypersen sitivity with
a ran ge of severity, com m on ly affects ath letes an d deserves
special consideration due to respiratory stress of ath letics.
Ch aracterized by in term itten t airway in flam m ation resultin g in bron ch ocon striction an d in creased m ucus production , asth m a causes poten tially severe sym ptom s of wh eezin g, sh ortn ess of breath , ch est tigh tn ess, an d cough in g.
Asthm a attacks, if untreated, m ay result in severe chest pain,
hypoxia, an d loss of con sciousn ess. Triggers in clude aller-
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exercise con firm s th e diagn osis. A greater th an 50% decrease indicates severe disease. Athletes m ay also develop
a cough with ch allen ge testin g, wh ich is also in dicative of
exercise-in duced bron ch ospasm . Treatm en t gen erally in volves m odification of exercise routine to m inim ize triggers
an d prophylactic bronchodilator therapy.
Asthm a does not preclude athletic participation, and
preven tion of symptom s sh ould be th e goal of m an agem en t. The athlete should be educated about early warning
signs of attack, and appropriate ph arm acological treatm en t
sh ould be readily available. A severe attack m ay warrant
supplem ental oxygenation and transfer to a h ospital.
Infectious Disease
Mononucleosis
In fectious m on on ucleosis is caused by th e Epstein Barr
virus or cytom egalovirus and eventually affects 90% of
adults at som e poin t in their lives. Spread by oral secretions, sh aring water bottles, or close contact, m ononucleosis is ch aracterized by a triad of fever, pharyngitis, and lym ph aden opathy. Splen om egaly is also associated with th is
con dition , an d th us con tact sports sh ould be avoided during acute infection to prevent splenic injury. Symptom atic
treatm ent an d prevention of possible complications com prise stan dard treatm en t, an d sym ptom s usually resolve in
4 to 8 m on th s.
Staphylococcus Infection
Staphylococcus aureus, an organ ism that com m only colonizes the n ares and skin of athletes, m ay cause serious in fection if the bodys natural defenses are breach ed. Even
sm all cuts in th e skin provide a portal for a virulent strain
of th is organ ism to establish an in fection th at m ay ran ge
from m ild local cellulitis or inflam ed boil to poten tially
fatal system ic bacterem ia. Recen tly, outbreaks am on g ath letes of com m unity-acquired m eth icillin-resistant Staphylococcus aureus, an organ ism th at previously existed on ly
in health care facilities, have instigated n ational concern
due to th e virulen ce an d ten acity of th is in fection . To preven t spread, athletes should practice good hygiene, avoid
sh arin g of towels and equipm en t, and cover skin lesions.
Antibiotics m ay be required to eradicate the organism .
Meningitis
Men ingitis is m ost com m only caused by en teroviruses and
is characterized by fever, headach e, n eck stiffness, and signs
of m en in geal irritation such as pain with passive n eck flex-
ENVIRONMENTAL ILLNESS
Heat Illness
Th e in ten sity in h eren t to ath letics puts players at risk of
h eat illn ess even during m oderate playin g con dition s since
durin g m axim al exercise, th e m uscles can produce 15 to
20 tim es m ore en ergy th an at rest. Th is en ergy is con verted
to heat and is a m ajor contributor to the developm ent of
h eat illn ess. Involvin g a spectrum of con dition s from m in or dehydration to h eatstroke, h eat illn ess results wh en
th e h eat-dissipatin g m ech an ism s of th e body are overwh elm ed.
Th e hypoth alam us is th e regulator of core temperature
in the body and is responsible for orchestratin g heat loss.
Heat exchan ge requires a temperature gradient an d occurs
by conduction via direct contact between objects, convection by transfer to circulatin g air, radiation via direct release into atm osphere, an d evaporation of perspiration.
Th e bodys m ost poten t h eat dispersion m ech an ism , perspiration, m ay transfer up to 1,000 kcal of heat per hour
into the atm osphere as the exercising athlete produces 1
to 2 liters of sweat per hour. Other heat-dissipatin g m echanism s include peripheral vasodilation, increased cardiac
output an d m in ute ven tilation , an d elevation of core
body tem perature. If th e th erm oregulatory m ech an ism s
of th e body are overcom e by in adequate hydration , poor
186
conditioning an d acclim atization , extrem e heat, or inappropriate cloth in g, th e th erm oregulatory capacity of th e
body will fail an d h eat illn ess will en sue.
Heatstroke
As the therm oregulatory system of th e body fails and the
core temperature rises, m ore serious heat-related illnesses
m ay occur. Heat exhaustion presen ts with fatigue, m alaise,
nausea, and h eadache in an athlete with norm al m en tation an d n o n eurological sym ptom s. Th e ath lete m ay appear flush ed, with profuse sweatin g an d cold clam m y skin ,
an d core body temperature m ay approach 104 F (40 C).
Th e ath lete with symptom s of h eat exh austion sh ould
be rem oved from play im m ediately an d rapidly cooled
to preven t progression to h eatstroke. Heatstroke represen ts
an em ergen cy as th e th erm oregulatory system h as been
overwh elm ed beyon d th e poin t of spon tan eous recovery.
Th e ath lete sufferin g from h eatstroke experien ces h eat exh austion sym ptom s coupled with severe m ental status im pairm en t an d core body tem perature of m ore th an 104 F
(40 C). With m ortality rates in excess of 10%, h eatstroke
warrants im m ediate activation of em ergen cy protocol while
rem ovin g cloth in g an d m ovin g th e ath lete to a cool or
sh aded location. A direct correlation has been dem on strated between the duration of elevated core tem perature
an d outcom e with in creased m orbidity an d m ortality associated with hyperth erm ia lasting m ore than 60 m in utes.
Aggressive cooling should be initiated im m ediately with
ice im m ersion , coolin g blan kets, fan s, or in tern al coolin g
m easures an d sh ould con tin ue un til core body temperature
is less th an 101.8 F (38.8 C). In travenous hydration m ay
Th e key to m an agem en t of h eat illn ess is preven tion . En couraging copious hydration and recogn ition of the signs
an d symptom s of heat illn ess should be emphasized during extrem ely hot playing con ditions. Athletes should h ave
access to plen ty of water and relief from the environm ent,
an d equipm ent and clothing should be ligh tweigh t and allow free evaporation of sweat. Th ose with a history of heat
illness require evaluation prior to participation and should
return to play in a graduated m an n er un der supervision of
the trainer. Any event in which h eat illness is a risk should
h ave ice im m ersion im m ediately available.
Hydration
Adequate hydration is critical to protecting athletes from
un toward effects of h eat, an d optim al hydration en tails
m atching fluid and electrolyte loss (Table 9.8). Hydration
status m ay be assessed by weight m onitoring before, during, and after exertion. Mild dehydration is represented by
2% to 3% body weigh t loss an d sign als n eed for hydration. Athletes with m ore than 5% weight loss are severely
dehydrated an d sh ould be proh ibited from playin g. Sports
drin ks h ave evolved to address electrolyte depletion from
exertion an d sh ould be used in con jun ction with free water.
Ath letes who consum e too m uch free water without adequate sodium in take m ay be at risk for developin g exertional
hyponatremia.
Acclimatization
Acclimatization is n ecessary prior to full participation in extrem e playing condition s such as the sum m er preseason for
m ost fall sports. Achieving an adequate level of fitness first
is important before initiating acclim atization as getting fit
in extrem e environm ents is coun terproductive. Involving
a gradual increase in environm ental exposure tim e and
TABLE 9.8
the degree and duration of exertion, proper acclim atization generally takes 10 to 14 days. During this tim e, physiological ch anges including enhanced cardiac output, heat
exch an ge m ech an ism s, an d ren al fun ction im prove th e ath letes ability to withstand hot playing conditions. Hydration
requirem en ts in crease with acclim atization .
Cold Illness
Ath letes participating in sports at cold temperatures are
at risk for developing illness or injury from exposure.
Norm ally, tem perature h om eostasis is m ain tain ed by
hypoth alam us-m ediated m ech an ism s to con serve an d produce h eat such as periph eral vasocon striction an d sh iverin g. Sim ilar to h eat illn ess, m an agem en t of cold illn ess
sh ould focus on preven tion. Weather forecasts should be
m on itored, and athletes sh ould be alerted in th e event of
cold or in clem ent weather so that they m ay dress appropriately. Insulation is improved by layerin g of cloth ing. Hydration should be encouraged regardless of th e level of thirst.
Sh elter an d rewarm in g equipm en t sh ould be available on
site, an d any athlete who shows early sign s or sym ptom s of
cold illness should be evaluated.
Hypothermia
Hypothermia occurs wh en th ese m ech an ism s are overcom e
by extrem e cold an d is defined as the cooling of core body
temperature to less th an 95 F (35 C). Ath letes exposed to
the elem ents without proper clothing, equipm en t, trainin g, or sh elter are at risk for developin g hypoth erm ia an d
m ay presen t with un con trollable sh iverin g, tachycardia,
dysarth ria, an d altered m en tal status. Ath letes with severe
hypoth erm ia, in wh ich th e core body tem perature drops to
less th an 88 F (31 C), exh ibit global physiological impairm en t that include hypotension, bradycardia, apnea, and
reduced level of consciousn ess. Th e sh iverin g respon se an d
level of alertness wane with increasing severity. Treatm en t
of hypoth erm ia varies with severity. Mild hypoth erm ia m ay
be m an aged with rem oval from cold en viron m en t, in sulation , an d rewarm ing with blan kets, h eaters, an d warm fluids. Severe hypotherm ia warrants activation of the em ergen cy respon se plan an d requires aggressive yet cautious
rewarm in g with extern al an d in tern al m eth ods. Th ese patien ts sh ould be m on itored in an in ten sive care settin g an d
rewarm in g sh ould not exceed 2 C per hour to preven t ventricular arrhyth m ia an d hypovolem ic sh ock.
Frostbite
Ath letes exposed to freezing temperatures are at risk for
frostbite. Characterized by ice crystal form ation in the extracellular spaces, frostbite generally affects bare skin and
distal extrem ities as exposure com bin ed with periph eral
vasoconstriction and dehydration leave theses regions vulnerable to freezing. Th e lower extrem ities, in particular th e
great toe, are m ost com m on ly affected. In creasin g pain an d
187
Altitude Illness
Th e reduced barom etric pressure an d low oxygen of h igh
altitude introduce unique environm ental factors to the
athlete. Hypobaric hypoxia m ay result in h igh -altitude
syn drom es such as acute m ountain sickness, high-altitude
cerebral edem a, or h igh -altitude pulm on ary edem a. Headache is generally the first symptom of altitude sickness. A
h eadach e alon g with on e or m ore addition al symptom s
to include nausea, dizzin ess, fatigue, or sleep disturbance
represen ts acute mountain sickness, a condition that usually
occurs with in 12 h ours of arrival to an altitude. Cessation
of ascen t an d adaptation to th e curren t altitude m ay alleviate symptom s, and prophylactic acetazolam ide or dexam ethasone m ay prevent developm ent of altitude sickness.
Neurological or pulm on ary symptom s m ay sign ify on set of
poten tially fatal cerebral or pulm on ary edem a an d n ecessitate supplem ental oxygenation and im m ediate descent.
188
REHABILITATION
Th e goal of reh abilitation is to restore th e lost ran ge of
m otion, strength , and function that resulted from an injury, allowin g th e ath lete to return to th eir previous level
of perform an ce. Takin g in to accoun t th e n ature an d severity of athletesinjury, th e physician in collaboration with a
trainer or physical therapist is responsible for establish ing
an appropriate reh abilitation program that allows ath letes
to safely an d quickly recover so th at th ey m ay return to
play. An un derstan din g of th e physiology of th e in jury is
required for appropriate reh abilitation , an d proper precautions should be m aintained to m in im ize pain and preven t
rein jury.
Reh abilitation is divided in to an acute ph ase focused on
con trolling the inflam m atory response, a subacute phase
em ph asizin g ran ge of m otion an d recon dition in g, an d
a chronic phase of strength ening and gradual return to
sports-specific activity. The initial objective of rehabilitation is the reduction of pain, swelling, an d inflam m ation
through the use of PRICE along with anti-inflam m atory
m edications. Im m obilization, while essential for proper
h ealin g, quickly results in loss of ran ge of m otion and
m uscle m ass and early ran ge of m otion is important to
lim it stiffn ess and weakness. Several strategies m ay be im plem en ted to restore m obility in cludin g active an d passive
ran ge of m otion , stretch in g, an d join t m obilization an d m an ipulation (Fig. 9.18). With th e advan cem en t of range of
Figure 9.18 Range-of-motion exercises help to restore joint mobility. (Reprinted with permission from Fu FH, Stone DA, eds. Sports
Injuries: Mechanisms, Prevention, Treatment. 2nd ed. Philadelphia,
PA: Lippincott Williams & Wilkins, 2001.)
m otion, a gradual m uscular stren gthenin g plan m ay be in itiated through a com bination of open and closed kinetic
ch ain fun ctional exercise techniques. Durin g open chain
exercises, in wh ich th e distal extrem ity is n ot fixed, con traction of the agonist m uscle produces m ovem ent. Conversely, closed chain exercises, in which the distal extrem ity
is fixed, rely on reciprocal co-contraction of agonist and antagon ist m uscles an d m ore closely reproduces n atural fun ctional dem ands. Enduran ce training should be perform ed
as an adjunct to strength exercises to lim it fatigue, and proprioception an d n eurom uscular train in g prom ote dyn am ic
stability and prevent rein jury. With the in crease in stren gth
an d endurance, the focus of reh abilitation sh ifts to sportsspecific exercise to prepare the athlete for return to play.
Athletes, especially h igh-perform ance athletes, m ay
push th e extrem es of reh abilitation . Aggressive th erapy m ay
be coun terproductive to recovery, an d rein jury m ay occur.
Th e team physician sh ould be in com m un ication with th e
athletic trainer an d the physical therapists about reason able rehabilitation goals and return to play.
PHARMACOLOGY OF SPORTS
Anti-Inflammatories and Analgesics
Medications have an important role in the m an agem ent of
sports injuries. Often used as an adjunct to rest or therapy,
ph arm acological treatm en t of sports in juries focuses on
suppressing th e inflam m atory respon se an d reducin g th e
pain associated with th e in jury. In th e acute respon se to tissue injury, h igh levels of in flam m atory m ediators such as
prostaglan din s, th rom boxan es, an d leukotrien es accum ulate in the area of injury. Th ese substances prom ote vasodilation, in creased vascular perm eability, and recruitm ent
of leukocytes to breakdown an d rem ove n ecrotic tissue an d
debris. Th is tissue process m an ifests clin ically as swellin g,
local heat, and pain. Chronic inflam m ation is characterized
by persistent symptom s of acute in flam m ation.
NSAIDs such as ibuprofen and n aproxen have an tiinflam m atory effects and analgesic and an tipyretic properties. Th is class of drugs is used un iversally for ath letic
injuries and functions prim arily by in hibition of the cyclooxygenase enzym e complex. Composed of two isoen zym es, COX-1 an d COX-2, cyclooxygen ase con verts arach idon ic acid to prostaglan din s. COX-1 is in volved in n orm al
prostaglan din syn th esis in th e gastric m ucosa, ren al tissue,
platelets, an d en doth elial cells, an d in h ibition of th is isoen zym e is respon sible for th e m ajority of side effects from
NSAIDs. Th e th erapeutic effect of NSAIDs is exerted upon
the COX-2 isoenzym e. In th e acute response to injury, local
COX-2 expression increases up to 80-fold, producing high
levels of prostaglandins, which in turn lead to inflam m ation and pain. Selective COX-2 inhibitors such as celecoxib
are effective at suppressing inflam m ation with fewer side
effects. Ultim ately, th e goal of NSAID th erapy is reduction
189
of in jury-associated pain an d in flam m ation so th at reh abilitation m ay occur. Un toward effects in cludin g dyspepsia,
gastric ulceration , an d ren al failure sh ould be con sidered
wh en usin g NSAIDs.
Corticosteroids possess potent anti-in flam m atory properties an d fun ction by in h ibition of th e vasoactive respon se
to in jury, suppression of leukocyte recruitm en t, an d reduction of cytokin e expression . Awide spectrum of activity an d
side effects exists am on g different corticosteroids, and the
prim ary m ean s of delivery in ath letes is oral adm in istration
an d local in jection . Oral corticosteroids h ave excellen t an tiin flam m atory properties, but system ic side effects such as
glucose intolerance, hyperten sion, osteoporosis, and im paired woun d h ealin g preclude routin e use. Local in jection s are associated with fewer system ic com plication s an d
m ay be used to decrease local in flam m ation in bursitis, ten din itis, an d arth ritis. Corticosteroids sh ould n ot be in jected
in to ten don s or ligam en ts due to in creased risk of rupture.
Acetam in oph en is an effective an algesic with lim ited
an ti-in flam m atory properties. Possessin g a m ore ben ign
side effect profile th an NSAIDs, acetam inophen m ay be
used as a sin gle agen t for m ild to m oderate in flam m ation
or as an adjun ct to NSAID th erapy. Hepatotoxicity con stitutes th e m ajor dan ger of acetam in oph en th erapy an d m ay
be preven ted by lim itin g acetam in oph en in take to less th an
4 g per day in adults.
Narcotics such as hydrocodone and oxycodone bind
opiate receptors to in h ibit con duction with in cen tral pain
path ways. Powerful an algesics, n arcotics, sh ould be reserved for pain from severe injury or postoperative pain.
Toleran ce develops over 1 to 3 weeks from upregulation of
opiate receptor expression , an d physical depen den ce m ay
result from prolon ged use. Because of risk of addiction ,
n arcotics sh ould be used sparin gly.
190
be aware of in creased sh ort-term risk of h eart attack, arrhythm ias, and sudden cardiac death with heavy use. Recogn izin g th e ubiquity of use am on g th e gen eral public,
caffeine is legal in m ost sports although the International
O lym pic Com m ittee (IO C) h as in stituted a daily th resh old
of 9 m g/ kg (approxim ately 5 cups of coffee). Ephedrine is a
sympath om im etic initially developed as a weight loss aid.
Abused by athletes wh o sought to take advan tage of its energizin gqualities, eph edrin e h as been ban n ed by th e IO C
due to in creased risks of cardiac dysfun ction . Eph edrin e
is frequently com bined with caffeine an d aspirin (ECA
stack) and has been linked to num erous deaths am on g
ath letes.
Athletes who abuse anabolic steroids aim to augm en t th e
poten t effects of en dogen ous an drogen ic h orm on es on
m uscle m ass, strength, and recovery from injury. While
testosterone an d syn th etic an alogues h ave been sh own to
improve stren gth and perform ance when taken in supraphysiologic doses, th ey possess a substan tial side effect profile. In creased rates of h eart disease, in creased aggression ,
hypercoagulability, testicular atrophy, gyn ecom astia, an d
hirsutism am on g ath letes wh o abuse anabolic androgen ic
steroids reflect th e dangers of use. Dehydroepiandrosterone
and androstenedione are precursors in th e gon adal steroid
path way an d are con verted by th e body in to testosteron e.
Wh ile th e ergogen ic ben efits of th ese testosteron e precursors h ave yet to be clearly dem onstrated, the adverse effects
of elevated testosteron e h as led to th e ban n in g of th ese substances by the IOC and m any oth er sports organization s.
Human growth hormone ( HGH) is also an endogenous
occurrin g substan ce abused for its ergogen ic effect. Developed to treat patien ts with en dogen ous growth h orm on e
deficien cy, HGH exerts an an abolic effect on m uscle growth
and increases fat m etabolism . Abuse is associated with hyperten sion an d acrom egaly am on g oth er detrim en tal physiologic effects.
Ath letes m ay boost aerobic capacity by blood dopin g.
Hom ologous or autologous transfusion prior to a sporting even t confers the advantage of increased circulating
red blood cells for en h an ced oxygen delivery. Ath letes m ay
also use synthetic erythropoietin ( EPO) to improve aerobic
capacity. Naturally produced by th e kidn eys to stim ulate
red blood cell form ation , EPO abuse m ay result in con sequen ces of hyperviscosity from polycythem ia in cludin g
heart attack, stroke, and pulm onary em bolus.
NUTRITION
Athletes in training an d competition have complex nutrition al requirem en ts to build an d m ain tain m uscle, m axim ize oxygen ation delivery, optim ize m etabolism , an d recover from injury. Insufficient caloric intake m ay result in
loss of m uscle m ass, loss of bon e den sity, m en strual dysfunction, and increased risk of fatigue, injury, or illness.
A balan ced diet th at m eets caloric n eeds with proper pro-
CONCLUSION
Regardless of sport, level of participation , an d degree of
perform an ce, ath letes con tin uously ch allen ges th e kn owledge an d skills of sports physician s. Th e diversity with in
the ath letic population requires sports physicians to play
a num ber of roles. They m ust play the role of pediatrician
to recogn ize con dition s specific to ch ildh ood an d adolescen ce, th e role of internist to m an age m edical conditions,
an d the role of orth opaedist to treat m usculoskeletal injuries. In addition , sports physician s m ust coordin ate th e
m ultidisciplinary care for athletes. They m ust un derstand
nutrition to encourage a balanced diet, iden tify m aladaptive eating behavior, and counsel athletes on the use of dietary supplem en tation . Sports physician s sh ould be fam iliar with the prin ciples of exercise an d rehabilitation from
injury. Outside the realm of m edicine, sports physician s
191
RECOMMENDED READINGS
Botr`e F, Pavan A. En h an cem en t drugs an d th e ath lete. Neurol Clin.
2008;26(1):149 167.
Guskiewicz KM, Bruce SL, Cantu RC, et al. National Athletic TrainersAssociation Position Statem en t: Man agem en t of Sport-Related
Concussion . J Athl Train. 2004;39(3):280 297.
Rice SG. Am erican Academy of Pediatrics Coun cil on Sports Medicin e
an d Fitness: Medical Conditions Affectin g Sports Participation.
Pediatrics. 2008;121(4):841 848.
Seto CK, Way D, OCon n or N. En viron m en tal illn ess in ath letes. Clin
Sports Med. 2005;24(3):695 718.
The Am erican Academ y of Fam ily Physicians, Am erican Academ y of
Orth opedic Surgeon s, Am erican College of Sports Medicin e, Am erican Medical Society for Sports Medicin e, Am erican Orthopaedic
Society for Sports Medicin e, Am erican Osteopath ic Society for
Sports Medicin e. Con sen sus statem en ts. h ttp:/ / www.aafp.org/
online/ en/ hom e/ clinical/ publichealth/ sportsm ed.htm l.
Principles of
Orthopaedic Traum a
10
Sam ir Meht a
INTRODUCTION
Th e diagn osis, m an agem en t, an d un derstan din g of patien ts
sustain ing traum atic orthopaedic injuries covers a wide array of m ech an ism s of in jury, fractures, soft tissue in juries,
an d urgency. At its heart, orthopaedic traum a care is based
on th e fun dam en tal prin ciples govern in g m usculoskeletal
injury, and its m edical and surgical treatm ent. As with all
surgical subspecialties, proper diagn osis of th e orth opaedic
patien t requires a th orough h istory an d physical exam in ation. Radiograph ic an alysis using plain radiographs and, in
certain situations, computed tom ography (CT) and m agnetic resonance im aging (MRI) are essential in providin g
additional inform ation as it correlates to the clinical exam ination.
Th is ch apter is dedicated to h igh ligh tin g prin ciples utilized to evaluate the orthopaedic traum a patient and detailin g a set of surgical em ergen cies th at all orth opaedic
surgeons sh ould be fam iliar with and com fortable iden tifying and m an aging. A working knowledge of this list of
diagn oses an d treatm en t regim en s is critical in avoidin g
significant m orbidity and m ortality in the patient with orthopaedic injuries.
Physical Examination
As m en tion ed above, orth opaedic in jures are typically diagnosed during the secondary survey. Injuries associated
with a gross deform ity of th e in volved extrem ity or large
soft tissue defect with th e underlying bone or joint exposed
m ay be obvious on exam ination and require prompt treatm ent during the secondary survey. More subtle soft tissue in juries (i.e., lacerations, abrasions, and ecchym osis)
sh ould increase the suspicion for an underlying fracture or
join t in jury (Fig. 10.1). Deform ity an d soft tissue in jury are
194
TABLE 10.1
essen tial in diagn osin g orth opaedic in juries in th e un conscious patient. All patients who are awake sh ould be
exam in ed in a system atic fash ion so as to m in im ize th e
likelih ood of m issin g an in jury. Un con scious patien ts are
thoroughly exam ined once awake (tertiary survey) for injuries n ot obvious at th e tim e of presen tation to th e resuscitation bay.
The m usculoskeletal portion of the secondary survey
starts with the proxim al upper extrem ity and is conducted
B
Figure 10.1 (A) A 37-year-old male patient with a blunt force trauma to the leg resulting in two
small lacerations over the anteromedial tibia. A high index of suspicion should be maintained with
this type of presentation. (B) Radiographs reveal a comminuted open tibia fracture.
195
Upper lateral
brachial
cutaneous n.
Medial brachial
cutaneous and
intercostobrachial n.
Posterior brachial
cutaneous and lower
lateral brachial
cutaneous n.
Medial brachial
cutaneous and
intercostobrachial n.
Posterior antebrachial
cutaneous n.
Medial
antebrachial
cutaneous n.
Medial
antebrachial
cutaneous n.
Lateral antebrachial
cutaneous n.
Radial n.
Ulnar n.
Ulnar n.
Median n.
upper extremity.
196
L3
L1
L2
L3
L4
L5
S1
S2
Posterior
cutaneous n.
S3
S4
S5
Femoral n.
Lateral
cutaneous n.
L4
Lateral
cutaneous n.
L3
Obturator n.
L5
Common
peroneal n.
S2
S1
Femoral
saphenous n.
Superficial
peroneal n.
L4
L5
Superficial
peroneal n.
Tibial n.
Sural n.
Common
peroneal n.
Sural n.
S1
Figure 10.3 Sensory distribution of the lower extremity. (A) Dermatonal distribution and (B) peripheral nerve distribution.
197
Tertiary Survey
All traum a patien ts adm itted to th e h ospital with an orth opaedic com pon en t to th eir in jury pattern sh ould receive
a thorough tertiary physical exam ination once stable. Atertiary survey should also be conducted on all patients wh o
were exam in ed in th e resuscitation bay. Patien ts wh o sustain m ajor in juries such as lon g bon e fractures or cervical
spin e injuries are at risk for being distracted by their injuries
and not recognizing pain elsewh ere from a m ore m inor injury (e.g., wrist/ sn uffbox ten dern ess from a scaph oid fracture or m etatarsal fractures of the feet). The tertiary exam in ation is specifically geared toward iden tifyin g m ore subtle
m usculoskeletal injuries that require treatm ent either as an
inpatient or at a later date as an outpatient.
OPEN FRACTURES
An open fracture is defin ed as any fracture th at com m un icates with th e extern al en viron m en t via a soft tissue defect. Typically, open fractures are the result of high-energy
traum a and m ay yield a spectrum of soft tissue in jury
from a poke hole to complete soft tissue devitalization,
periosteal strippin g, an d exposed bon e. Wh en a patien t
198
D
Figure 10.4 (A) Anteroposterior view of the left femur after a motor vehicle collision with a
comminuted femoral shaft fracture. The patient also had decreased pulses in the limb and an abnormal
ankle-brachial index (less than 0.9). (B) The patient had a small open wound on the medial side of the
thigh. (C) Exploration of the thigh revealed the deep profundus artery (arrow) at the level of Hunters
canal intact, but with direct compression by a fragment of bone. (D) The patient was temporized with
an external fixator.
arrives in th e traum a bay with an obvious extrem ity deform ity and a large soft tissue injury, the diagn osis of an
open fracture is self-eviden t. However, in th e patien t wh o
presen ts with a deform ed extrem ity an d a sm all abrasion
or laceration , an open fracture m ay be easily m issed.
O pen fractures are con sidered surgical em ergen cies an d
require prompt atten tion followin g h em odyn am ic stabilization of th e traum a patien t. In itially, tetan us prophylaxis
sh ould be adm inistered if a tetanus booster h as not been
given in th e previous 5 years (Table 10.2). In addition , in -
199
TABLE 10.2
Tetanus Toxoid
Tetanus Toxoid
Uncertain or < 2
2
3
Yes
Yes
No
No
No
No
Yes
Yes
No
Yes
No
No
Contaminated Wounds
soft tissue defect with an associated vascular injury requirin g repair. Type I an d II open fractures require prompt adm in istration of a th ird gen eration ceph alosporin such as
cefazolin. All Type III fractures require the adm inistration
of cefazolin plus th e addition of an am in oglycoside such
as gen tam icin . Patien ts wh o h ave sustain ed open fractures
with severe con tam in ation (e.g., barnyard injuries) require th e addition of pen icillin to cover gas-form in g bacteria such as Clostridium perfringens. Th e m ajor con cern with
open fractures is th e in creased in ciden ce of in fection associated with th ese injuries due to the degree of wound
contam ination as well as the degree of soft tissue loss.
In itial treatm en t in th e operatin g room en tails th orough
debridem en t an d irrigation of th e woun d with delivery of
the bony edges of the fracture into the woun d for debridem en t. Th e laceration is typically exten ded in a proxim al
an d distal fash ion to gain adequate access to th e fracture
site. Depen din g on th e fracture type, th e associated soft tissue defect, an d exten t of wound contam ination, th e treatm en t m ay in clude defin itive plate fixation , in tram edullary
(IM) rod fixation , or tem porary stabilization with extern al
B
Figure 10.5 (A) Open type II tibia fracture with transverse tibial shaft fracture and a wound that
is primarily closeable. (B) Open type III tibia fracture after significant high-energy soft tissue injury
with muscle and skin loss.
200
an d poin ts in the direction of a vessel injury. In these patients, a m ore form al study is required to identify intim al
injures to th e arterial wall versus a complete disruption of
the vessel. The findin g of an abnorm al ankle-brachial in dex m an dates an arteriogram th at can be con ducted in an
interven tional radiology suite or in the operating room at
the tim e of surgical treatm ent of the injury.
Line of injury
Line of injury
Loss of movement
on the same side as
cord damage
Loss of movement
and sensation
201
Incomplete loss
Figure 10.7 (A) Brown-Sequard syndrome, (B) central cord syndrome, and (C) anterior cord
syndrome with affected anatomical locations. (continued)
FRACTURE-DISLOCATIONS
Fracture-dislocation s are fractures th at occur aroun d a join t
an d result in a fracture of the bone with an associated
dislocation of th e join t. Th is type of in jury h as several
variations based on the fracture pattern , the bone that is
involved, an d the joint that is in volved. Dislocations in
gen eral require prompt reduction due to th e stress im parted
on th e traversin g n eurovascular structures an d soft tissue
(Fig. 10.8). In addition, joints that are left dislocated for
a prolon ged period of tim e, typically m ore th an 6 h ours,
are at risk of irreversible cartilage dam age and posttraum atic arthritis of the involved joint. Following reduction of
202
Line of injury
Loss of movement,
pain, and temperature
Still able to feel position,
vibration, and touch
COMPARTMENT SYNDROME
Th e ph en om en on of compartm en t syn drom e is a surgical
em ergen cy an d requires a h igh in dex of suspicion . Each extrem ity con tain s several m uscles th at are separated by fascial compartm ents. When the pressure within any single
or several compartm en ts reach es a level beyon d a th resh old value, th e ven ous return from th e extrem ity is in itially
comprom ised. As th e pressure con tinues to increase, the
forward arterial flow of oxygenated blood is comprom ised
resultin g in in tracompartm en tal m uscle isch em ia. Iden tification of an impen dingcompartm ent syndrom e is critical
in m in im izin g th e m orbidity associated with irreversible
m uscle isch em ia an d even tual m uscle cell death . Th e
m ost com m on sites of compartm en t syn drom e in clude th e
forearm and th e lower leg (Fig. 10.9A). This phenom enon
also can occur with in th e fascial compartm en ts of th e
203
Figure 10.8 (A) Medial ankle dislocation with fibular fracture and (B) tension-type soft tissue
defect requiring prompt reduction followed by irrigation and debridement with temporizing fixation
in the operating room.
Anterior
compartment
Interosseous
membrane
Lateral
compartment
Tibia
Deep posterior
compartment
Fibula
Superficial
posterior
compartment
Figure 10.9 (A) The four compartments of the tibia include the anterior, lateral, superficial posterior, and deep posterior. (B) The anterior and lateral compartments are released through a lateral
exposure. The superficial and deep posterior compartments can be released through a medial incision. The incisions should be extensile and should include both skin and fascia.
204
P > 30 mmHg
P < 30 mmHg
Fasciotomy
Serial exams
syn drom e. Missed compartm en t syndrom e in tibia fractures and other surgical patients m anaged postoperatively
with th ese tech n iques h ave been reported an d th erefore
they are generally avoided.
POLYTRAUMA
Th e m an agem en t of th e patien t with polytraum a is a
complex interplay of injuries, treatm ent options, and an
appreciation for th e complexity of the variability in presen tation . A polytraum a patient is one wh o h as an In jury
Severity Score greater th an 18 with m ultiple system in juries.
Th ere is a system ic in flam m atory respon se after traum a,
wh ich m ay lead to sequelae such as acute respiratory distress syn drom e (ARDS), sepsis, and/ or m ultiorgan failure.
Th is h as given rise to th e two-h itth eory. Th e first h itis
from the initial stim ulus resultin g in a system ic in flam m atory respon se. Th e secon d h it com es from a subsequen t
proin flam m atory even t such as in com plete resuscitation ,
excessive blood loss, sepsis, or a surgical procedure. Two in terleukin s h ave been implicated in th e polytraum a patien t
IL-6 as a proin flam m atory cytokin e in creasin g likelih ood
of ARDS an d IL-10 as an an ti-in flam m atory cytokin e.
Patients at risk include th ose who are clinically unstable,
a difficult resuscitation, coagulopathic (platelet count less
than 90,000), hypotherm ic (less than 32 C), in shock, require greater th an 25 un its packed red blood cells, or th ose
with bilateral lun g in jury, an d m ultiple long bon e fractures
and thoracic or abdom inal in jury.
Apolytraum a patient wh o is adequately resuscitated has
a n orm al or n orm alizin g lactate, base deficit, or m ixed
205
ven ous oxygen saturation . Th e patien t is adequately rewarm ed with an intern ational norm alized ratio less than
1.25, platelet coun t greater than 90,000, and a cerebral
perfusion pressure greater th an 70 m m Hg. However, it
sh ould be noted that th ere is a secondary period, wh ere
despite appropriate resuscitation , patien ts operated on 2
to 4 days after th eir in itial traum a m ay h ave a worsen in g of their condition (secon d h it). Therefore, significant surgical intervention m ay need to be delayed 5 to
8 days after in jury to th e lim it th e impact of th e secon d
h it (Fig. 10.11). Th is has lead to two sch ools of th ought
in th e m anagem ent of the polytraum atized patientearly
total care an d dam age con trol orth opaedics. Early total care
in volves im m ediate definitive m anagem ent of orthopaedic
in juries allowin g for early m obilization and decreased pulm on ary complication s. However, in creased m ortality an d
m orbidity h as been associated with early total care in patien ts with ch est traum a. Dam age con trol orth opaedics
temporizes fractures with extern al fixation avoidin g th e
second hit. When the patien t is stable, definitive care is
un dertaken .
In th e m ultiply injured patien t, fat em bolism is an im portan t cause of ARDS an d a m ajor source of m orbidity
an d m ortality. It m ay be poten tiated by fracture stabilization with IM n ailin g of lon g bon es. Fat em bolism syn drom e
is clinically apparent in 10% of polytraum a patients, although the actual inciden ce rate is probably m uch high er.
It m ay n ot appear un til 2 to 3 days after th e in jury an d
m ay presen t as respiratory distress (sh ortn ess of breath an d
tachypn ea), arterial hypoxem ia, tachycardia, fevers, an d a
deterioration of n eurological status (restlessn ess, con fusion , or com a). In addition, petechiae (which m ay be short
Reaction
MOF/ARDS
Second Hit
(surgical intervention)
Figure 10.11 Damage control orthopaedics is often utilized in patients with thoracic trauma resulting in a proinflammatory state. The second hit results in further aggravation
of an already heightened inflammatory response and may
lead to multiorgan failure.
Resolution
MOF/ARDS
206
FRACTURE CLASSIFICATION
O n ce a fracture h as been iden tified on radiograph s, it is im portan t to be able to con vey th is in form ation to oth ers wh o
m ay n ot h ave access to th e im ages. Fracture classification
system s serve m ultiple functions including com m unication
to oth er m edical profession als about th e severity, location ,
or com plexity of th e fracture. For example, th e Sch atzker
classification for tibial plateau fractures indicates the severity of articular surface in volvem en t an d wh eth er th e diaphysis is associated with th e m etaphysis. Th e classification
system m ay also guide treatm en t as is th e case with the
Garden classification for fem oral n eck fractures. Garden
type I an d type II fractures are con sidered stable an d m ay
be addressed with open reduction an d in tern al fixation
whereas Garden type III and type IV fractures are displaced
requirin g arth roplasty. Certain classification system s m ay
porten d progn osis of th e fracture, such as th e Hawkin s classification system for talus fractures. The Hawkin s classifi-
B
Figure 10.12 (A) The tibia fracture would be classified as an AO/OTA type 42A. The classification
would indicate that the fractured bone is a tibia (4), it is midshaft/diaphyseal (2) in location, and is
simple (A). (B) The radiograph reveals an AO/OTA type 13C fracture that would indicate humerus (1),
distal (3), and complete articular (C) since there is no articular surface attached the shaft and there is
a split through the articular surface. Ultimately, using descriptive words is the best way to describe
a fracture pattern.
fracture. The best m eth od in com m unicating a fracture pattern is usin g descriptive words about th e location of th e
fracture, the angulation, the displacem en t, the direction of
the fracture line, and the degree of com m inution.
FRACTURE MANAGEMENT
Bone Biology and Physiology
Bone h as two m ajor fun ctions. The m ech anical function
involves supporting load, allowin g m uscle action, protectin g vital organ s, an d en ablin g locom otion . Th e biologic function includes hem atopoiesis an d the important
role of calcium h om eostasis. Alm ost 99% of th e bodys
calcium is contained within bone and it is essen tial in
Vitam in D m etabolism . In addition , bone is an end organ for parathyroid horm one, calcitonin, growth horm on e,
an d corticosteroidsall of which are involved in bon e (and
calcium ) regulation. Bone is a composite of two m aterials.
Th e organ ic extracellular m atrix (35% dry weigh t) is com posed of collagen an d provides flexibility an d resilien ce.
Th e m in eral ph ase is composed of hydroxyapatite (calcium
an d ph osph ate) and provides for the hardn ess and rigidity
of bon e.
Cortical bon e is periph eral an d rem odels slowly due
to a poor porosity but is extrem ely stron g. On th e oth er
hand, cancellous bon e (m edullary or central) h as 10% of
the strength of cortical bone, is spongy, and has porosity between 30% an d 90%. Bone respon ds to stress by
altering its m echanical characteristics (Wolffs law). With
increased stress, bone will hypertrophy. Th e contrary is
truedecreased stress can lead to increased bone resorption. Un like articular cartilage, tendon, or ligam ent injury,
bon e regen erates tissue an d repairs with out scar. Th e blood
supply to the cortical bone has two m ain contribution s
the inner two-third of the cortical bone receives its blood
supply from the nutrien t vessel, whereas the outer on ethird of cortical bone receives its blood supply from the
periosteum (Fig. 10.13).
207
Fracture Healing
Fractures occur when the energy of the injury is sufficient
to overload the bone resulting in loss of continuity, loss of
support, soft tissue dam age, and dam age to the blood supply. Fracture h ealin g requires an adequate biologic en viron m ent (soft tissue, pluripotential cells, and patient factors)
and an appropriate m echanical en viron m ent (e.g., fracture
stabilization tech n ique). Within the appropriate biological
and m echanical environm ent, fractures heal via prim ary
or secon dary m odes. Th e biom ech an ics of fracture h ealing involve the am ount of m otion at the fracture site an d
th e gap size between th e fractured en ds of th e bon e. Strain
in bone is m echanical force producing elongation. Bone
form s with low strain across a fracture gap. Low strain and
n o gap result in prim ary bon e h ealin g with out callus. Low
strain an d a large gap will result in secondary bone healing with callus form ation. Prim ary bone healing is direct
rem odelin g of th e fracture th rough rigid fixation . It is also
known as a haversian rem odeling or osteon rem odeling
and does not result in callus form ation. There is direct contact between bon e en ds with n o m otion (Fig. 10.14). O n th e
oth er h an d, secon dary bon e h ealin g (in direct bon e h ealing) results from n onrigid fixation with callus form ation
th rough in tram em bran ous an d en doch on dral h ealin g. It
sh ould be noted th at in secondary bon e healin g, fragm ent
m otion stim ulates callus form ation (Fig. 10.15). However,
excessive m otion (or in stability), at critical tim es durin g
h ealin g m ay lead to non un ion (Fig. 10.16).
Fracture h ealin g occurs in th ree distin ct ph ases
inflam m atory (days), reparative (weeks), and rem odeling
(m onths) (Fig. 10.17). The in flam m atory phase results
from the torn periosteum , fracture hem atom a, necrotic
m arrow and cortex, an d inflam m atory m ediators. Th e
pluripoten tial stem cells are locally derived an d result in
osteoblast an d osteoclast differen tiation an d proliferation
th rough cellular m ediators. Th e repair ph ase organ izes th e
h em atom a with early subperiosteal woven bon e and the
start of cartilage form ation. Fin ally, woven or fiber bone
bridgin g th e fracture gap is replaced by lam ellar bon e th at
revascularizes over tim e.
Preoperative Planning
208
Figure 10.14 (A) A 42-year-old female with a left spiral fracture of the humeral shaft
after fall while on a boat. (B) The oblique fracture was directly stabilized with three lag
screws and a neutralization plate. (C) Three months later, the fracture lines are no longer
visible and the fracture has healed primarily without callus formation.
209
D
Figure 10.15 (A) Anteroposterior radiograph revealing a transverse mid-shaft right femoral shaft
fracture after a motor vehicle collision. (B) The fracture has been stabilized with an intramedullary
naila relative stability construct. (C) Two months after surgical fixation, the fracture shows brisk
callus formation, but the fracture line is still evident. (D) By 6 months, the fracture has completely
healed through secondary bone healing.
210
(room setup), an esth etic type, im agin g, in strum en ts, im plan ts, an d surgical tactic in cludin g m ultiple option s for
reduction an d fixation strategy (Fig. 10.18).
Fracture Stabilization
In dication s for fracture fixation in clude open fractures, articular fractures, polytraum a, en couragin g patien t m obilization , early join t m obilization , an d correction of align m en t. Th ere are four broad categories of fixation m eth ods
to h old a fracture: (1) splin tin g an d castin g, (2) traction , (3)
Intensity of
response
Inflammation
phase
10%
Reparative
phase
Remodeling
phase
40%
70%
Figure 10.17 The bone healing
Time
A
Figure 10.18 (A) Preoperative plan for a complex reconstruction of a (B) mal-united tibial plateau
fracture. The preoperative plan is reviewed with the surgical team and posted in the operating room.
(continued )
211
212
B
Figure 10.18 (continued )
DIAPHYSEAL FRACTURES
Th e fracture pattern , th e degree of soft tissue in jury, an d
associated injuries determ ine the treatm ent of diaphyseal
bow fracture in 18-year-old patient after a fall from two stories. The
patient had a dislocation of the other elbow, an open femur fracture,
and bilateral lung injury. He was placed into an external fixator (B) to
stabilize his arm and prevent further injury to his soft tissue.
213
Figure 10.22 Anteroposterior radiograph of a left hip revealFigure 10.20 Navicular dislocation after a motor vehicle collision stabilized with multiple Kirschner wires. The entire foot was
protected with an external fixator.
214
A
Figure 10.23 Anteroposterior view of the left femur (A) with an oblique distal femoral shaft frac-
ture treated with bridge plating (B). Callus forms secondary to the relative stability fixation construct.
If a lag screw had been placed across the fracture site to create absolute stability, the fracture would
have healed without callus.
ARTICULAR FRACTURES
Articular cartilage is composed of water (65% to 80%), proteoglycan s, type II collagen , an d ch on drocytes, wh ich are
respon sible for th e resilien ce, elasticity, an d compressive resistance of the joint surface. Articular cartilage is avascular,
an eural, an d sen sitive to in jury with lim ited h ealin g poten tial as n utrition occurs th rough diffusion durin g m otion
an d gen tle loadin g.
215
216
possible laceration an d prostate displacem en t. Fem ale patients sh ould undergo both bim anual and speculum exam inations to rule out vaginal, urethral, and bladder injury.
Vaginal or rectal laceration requires specific treatm ent.
Check airway
Oxygen suction, position: intubation: cervical spine control
Injury
Check breathing
Chest tubes; oxygen
Check circulation
IV lines, crystalloid blood; control external loss; abdominal assessment:
pelvic assessment for instability
Hemodynamically stable,
with stable pelvis
Hemodynamically unstable,
with unstable pelvis
Hemodynamically unstable,
with stable pelvis
Hemodynamically stable,
with unstable pelvis
Blood replacement
Continue assessment
and treatment
Peritoneal lavage
Urgent transport to OR
Operative fixation
of pelvis for patient
mobility
Patient Stable
External fixation of pelvis
positive
Peritoneal lavage
positive
negative
Laparotomy
Laparotomy
negative
patient still
unstable
Patient Stable
No coagulopathy:
other cases
Surgical control
Embolization
Patient Stable
Figure 10.25 Pathway for management of pelvic ring injuries based on varying hemodynamics.
AP, anteroposterior IV, intravenous; OR, operating room.
217
an giography of th e pelvic vasculature after adequate reduction in pelvic volum e. In th is scen ario, a blush or active
arterial bleedin g source m ay be iden tified via an giogram
an d em bolized at th e tim e of th e study (Fig. 10.25). Th e
m ost com m on source of arterial bleedin g in th e pelvis is
in jury to the superior gluteal artery.
Based on th e fracture pattern, the acute treatm ent in the
resuscitation bay m ay differ, but typically, a circum feren tial bin der (bed sh eet, com m ercially available wrap [e.g.,
T-pod]) is placed around the pelvis and greater trochanters
to reduce th e in trapelvic volum e (Fig. 10.26). It is imperative th at th e com m ercially available bin ders be assessed for
soft tissue pressure n ecrosis after 24 to 28 hours of application. Pneum atic antish ock garm ents have been used in
cases of shock with pelvic fractures, but their use rem ains
controversial because of complications and the difficulties
they present in exam in ation and treatm ent of the patient.
pelvic ring including fractures of the sacrum, injury to both sacroiliac joints, and separation of the pubic symphysis. (B) Clinical picture of a commercially available circumferential binder stabilizing
the pelvis and (C) reducing the intra-pelvic volume by restoring
the anatomic relationship of the bones.
218
ring revealing severe kyphotic deformity of the sacrum after a threestory fall. The patient had fracture through the left and right sides of
the sacrum connected in the middlespondylopelvic dissociation.
The physical examination findings included bilateral lower extremity
numbness with no bowel or bladder function.
219
220
B
Figure 10.30 (A) Anteroposterior (AP) pelvis radiograph after fixation of a type C or AP com-
pression type pelvic ring injury with open reduction and internal fixation of the pubic symphysis
and percutaneous iliosacral screw lag fixation of the posterior ring. (B) Percutaneous fixation of the
pelvic ring anteriorly and posteriorly after a fall from 50 feet. In addition, the patient had lumbopelvic
stabilization due to multiple fractures through the sacrum.
setting of severe retroperitoneal bleedin g, a ven a cava filter is often placed an giograph ically to preven t pulm on ary
em bolism .
ACETABULAR FRACTURES
After em ergen t resuscitation of the traum a patient who poten tially h as an acetabular fracture, assessm en t in cludes a
careful physical exam in ation and review of relevan t radiograph s. A physical exam in ation focusin g on th e acetabular
in jury sh ould in clude a well-docum en ted, complete n eurologic assessm en t of th e pelvis an d lower extrem ity, evaluation of th e soft tissues in th e troch an teric an d gluteal
region s, an d th e restin g position of th e leg. Because th e
sciatic nerve is dam aged in as m any as 20% of acetabular fractures th at in volve th e posterior wall or colum n , th e
m otor an d sen sory fun ction of th e extrem ity m ust be care-
fully docum ented. In particular, because the peroneal division is m ost at risk, foot dorsiflexion an d eversion m ust be
tested.
Closed soft tissue in juries m ay occur about th e h ip region, especially over th e trochanter. A closed degloving injury is referred to as a Morel-Lavallee lesion .Th e serosanguineous fluid collection s that develop in these cavities are
culture-positive in as m any as 31% of cases. If th is in jury
pattern is discovered, irrigation an d debridem en t of th ese
areas sh ould be perform ed, and intern al fixation sh ould
be delayed un til th e area is clean .
Plain -radiograph ic assessm en t of a patien t with an acetabular in jury begin s with th e five stan dard views of th e
pelvis: AP, iliac oblique, obturator oblique, in let, an d outlet (Fig. 10.31). These views will delineate associated pelvic
fractures, fem oral h ead injury, and h ip dislocations. The
standard AP radiograph is usually sufficient for recognition an d classification of an acetabular fracture. However,
th e 45-degree oblique (Judet) views are n eeded to fully
characterize the fracture and to determ ine whether there
is subluxation of th e h ip join t, wh ich m ay not be visible
on th e AP view. Th e obturator oblique view is taken with
th e affected side of th e patien t rotated 45 degrees forward.
Th is allows clear visualization of th e an terior colum n in
th e region of th e h ip, th e posterior wall, an d any posterior subluxation of th e h ip. Th e iliac oblique view is taken
with th e un affected side of th e patien t rolled 45 degrees
forward. Th is view profiles the posterior colum n from th e
n otch to th e isch ium and th e an terior wall, wh ich is curvilin ear and shallower than the posterior wall. Th e inlet and
outlet pelvic radiograph s m ay depict pelvic in juries th at
would affect th e m an agem en t of th e acetabular fracture.
Occasionally, anterior sacroiliac joint widening is presen t
221
A
B
222
Anterior wall
Posterior wall
Anterior column
Posterior column
Transverse
Transverse plus
posterior wall
T-shaped fracture
223
posterior an d an terior colum n s). Th e five associated pattern s in volve m ultiple fracture lin es: posterior wall + posterior colum n , tran sverse + posterior wall, an terior colum n
+ posterior h em itran sverse, T-type, an d associated both
colum n. The associated both colum n is a unique fracture
pattern , wh ich is differen t th an th e oth ers with in th e Letourn el classification system because th e associated both
colum n has n o single piece of articular surface attached to
the pelvis; that is, the entire acetabulum is dissociated from
the stable pelvis (Fig. 10.33). The various fracture patterns
h ave relevance to treatm en t altern atives an d progn osis.
In dication s for n on operative m an agem en t of acetabular fractures in cludes an in tact superior acetabular dom e,
based on th e th ree stan dard roof arc m easurem en ts (wh ich
sh ould be greater th an 45 degrees), or fractures, which
sh ow con gruency. Location of th e fracture lines will also
porten d n on operative treatm en t if th e fracture lin e does
n ot involve th e weigh t bearin g don e or on ly th e pubic portion of th e an terior colum n . Surgeon s advocate early touch
D
Figure 10.33 (A) Anteroposterior (AP), (B) obturator oblique, and (C) iliac oblique of a both
column acetabular fracture showing no portion of the articular surface attached to the stable pelvis.
The patient was initially placed into skeletal traction and then had an open reduction and internal
fixation (D) performed through a Stoppa exposure with a lateral window.
224
TABLE 10.3
General Indications
Fracture Patterns
Complications
Kocher Langenbeck
Posterior wall
Posterior column
Transverse
Transverse with posterior wall
Some T-shaped fractures
HO: 8%25%
Sciatic nerve palsy: 3%5%
Infection: 2%5%
Ilioinguinal
Anterior wall
Anterior column
Transverse with Anterior displacement
Anterior column/posterior hemitransverse
Associated both column
Extended iliofemoral
Maximal simultaneous
access to both
columns
Infection: 2%5%
Sciatic nerve palsy: 3%5%
HO: 20%50%
TRAUMATIC AMPUTATION
Traum atic amputation is defined as a loss of a digit(s)
or lim b due to a traum atic in jury. Tech n ical advan ces in
m icrovascular surgery have m ade replan tation a com m on
treatm ent of upper extrem ity traum atic amputations, and
32-year-old female after a motor vehicle collision postreduction revealing a posterior wall fracture.
225
surgical success of th ese procedures continues to be en h an ced with m odern tech n iques. Sim ilar in jury pattern s
for the lower extrem ity often do not result in replantation
due to th e excellen t outcom es with prosth etic use followin g
below th e kn ee am putation .
Th e m ost importan t factor determ in in g wh eth er a digit
or lim b can be replan ted is th e isch em ia tim e, warm or
cold. Warm isch em ia tim e is th e tim e th e extrem ity distal
to th e injury site has been without blood flow with a norm al temperature and m etabolic rate. Cold isch em ia tim e
is defined as the tim e the extrem ity distal to the injury site
h as been with out blood flow with a reduced m etabolic rate
due to lowerin g th e tem perature of th e tissues. A patien t
with a traum atic amputation sh ould h ave th e amputated
lim b wrapped in m oist gauze and placed in a bag, which
is subsequen tly placed on ice to reduce the m etabolic rate.
If th e amputated lim b is placed directly on ice, th ere is an
increased risk for frost bite as well as severe skin m aceration, potentially ren derin g the lim b useless for replantation. In general, warm ischem ia tim e sh ould be less than
6 h ours an d cold isch em ia tim e sh ould be less th an
12 h ours. Sm aller lim bs, such as a digit, m ay still be viable at 12 and 24 hours of warm and cold isch em ia tim e,
respectively.
Th e gen eral sequen ce of replan tation com m en ces with
bony fixation , exten sor ten don an d flexor ten don repair,
arterial repair, nerve repair, and lastly venous repair. Im m ediate postoperative care requires elevating the replanted
lim b, elevating the temperature of th e room environm ent,
and avoidance of n icotine and caffeine, which m ay cause
arterial constriction. In the event of significant venous
con gestion , leech es m ay be placed on th e lim b to relieve
con gestion via th e secretion of th e an ticoagulan t h irudin .
Comprom ise of the arterial inflow to the lim b warrants reexploration with in 48 h ours followin g replan tation . Th e
use of aspirin , dipyridam ole (Persan tin e), low-m olecularweigh t dextran , h eparin , an d sym path etic blockade m ay
also m in im ize the risk for arterial throm bosis an d spasm .
Determ in in g th e viability of a lim b for salvage is an extrem ely daunting task. The decision to acutely amputate
a lim b sh ould be groun ded on as m uch clin ical data as
possible, sh ould be life savin g, an d sh ould on ly h appen
with docum en tation from two services (e.g., orth opaedic
surgery an d gen eral surgery, or orthopaedic surgery and
vascular surgery, etc.) detailing the n eed for the acute am putation . In addition , ph otograph s of th e lim b sh ould be
recorded in th e m edical record (Fig. 10.38).
Scorin g system s h ave been developed to h elp assist with
determ in in g th e viability of lim b salvage versus lim b amputation . Th e m ost com m on scorin g system used is th e Man gled Extrem ity Severity Score (MESS) (Table 10.4). Earlier
studies sh owed th at an MESS score of greater than or equal
to 7 had a 100% predictable value for amputation. Th is relatively simple, readily available scoring system of objective
criteria was h igh ly accurate in discrim in atin g between lim bs
th at were salvageable an d th ose th at were un salvageable
226
Hip
dislocated?
yes
Urgent reduction
under sedation?
no
Gross hip
instability?
yes
Surgical
stabilization
no
Hip reduced?
yes
no
Evolving
neurologic
injury?
yes
Surgical
stabilization
no
Surgery
for urgent
reduction
Distal
femoral
traction
Intraarticular
fragments?
yes
Surgical
stabilization
no
Definitive stabilization
Nonconcentric
reduction
yes
Surgical
stabilization
yes
Surgical
stabilization
no
Greater than
2 mm step-off
in weightbearing region
no
Nonoperative
management
posterior wall fixation using a buttress plating technique to provide absolute stability and direct compression at the fracture site.
Figure
fracture-dislocations.
an d better m anaged by prim ary amputation in these underpowered studies. More recen t data from th e m ulticen ter,
prospective Lower Extrem ity Assessm en t Program (LEAP)
study h ave shown lim ited utility of scorin g system s in
outcom es of eith er lim b salvage or lim b amputation . Th e
clinical utility of five lower extrem ity injury-severity scoring system s was also assessed in th e LEAP study. Scoring
system s for lower-extrem ity traum atic injuries design ed
to assist in th e decision -m akin g process were used to
evaluate 546 patien ts407 lim bs rem ain ed in th e salvage
path way 6 m on th s after th e in jury. Th e an alysis did n ot
validate th e clinical utility of any of the lower-extrem ity
injury-severity scores. However, a h igh specificity of the
scores in all of the patient subgroups did confirm that low
scores could be used to predict lim b-salvage potential. Yet,
the con verse was not truelow sensitivity of th e indices
failed to support th e validity of th e scores as predictors of
227
B
Figure 10.38 (A) A 48-year-old male with a crush injury to the left foot with significant soft tissue
defect, contamination, and calcaneal bone loss (B). Reconstruction options for this limb from a soft
tissue and bone standpoint were limited and the patient elected to have a transtibial amputation. He
returned to work 8 weeks after his surgery.
TABLE 10.4
Description
1
2
3
4
Limb ischemia
1
2
3
Shock
0
1
Persistent hypotension
< 30
3050
> 50
2
0
1
2
Age (years)
Points
228
deform ity correction , sh ould result in fun ction al im provem ent. Am alun ited articular injury (i.e., an articular fracture
with step-off) can lead to early posttraum atic arth ritis particularly with weightbearing and range of m otion.
Nonunions
Despite m eticulous care an d th e best of in ten tion s, fractures
m ay not heal. An onunion is defin ed by the Food and Drug
Adm in istration as a fracture that has not healed 9 m on ths
after occurrin g, or a fracture that does not show progression
of h ealin g in th ree con secutive radiograph s 1 m on th apart.
Fractures typically do n ot h eal for four reason s: in fection ,
lack of blood supply, poor host factors, and biom echanical
instability. In m ost clinical scenarios, it is com bination of
these factors at play. One of the m ost important aspects of
n on union care is diagn osin g th e etiology of th e n onunion
as this will directly impact th e m anagem ent of the patient.
Th e in itial m an agem en t of a n on un ion starts with
the patien ts index procedure. Optim izin g fracture care at
the tim e of initial injurythrough m eticulous soft tissue
m anagem ent, lim itin g infection, and m axim izing stabilization can go a lon g way in preven tin g th e developm en t
of a n on un ion .
Diagn osis of a n on un ion occurs th rough obtain in g an
adequate history and physical exam ination and reviewing
im aging studies. Critical elem ents of the history include
tim e of injury, types of surgery, developm en t of infection,
wh eth er th e fracture was open , an d fun ction al capacity.
spite callus formation, the humerus has not healed because of inadequate stabilization.
229
plain x-rays, can often h elp th e physician iden tify th e etiology of th e n on un ion . Hypertroph ic (or hyper-vascular)
n on union s typically have a h orse h oof or eleph an t
foot appearan ce, which represents abun dant callus as a
result of a robust blood supply an d in adequate biom echanical stability (Fig. 10.40). A hypertrophic nonunion
h as th e biologic buildin g blocks to h eal, but lacks the
stability to complete th e process. Aside from exuberant callus on radiographs, patien ts m ay also exhibit increased uptake on radion ucleotide scan s, an d th is sh ould
n ot be con fused with in fection . Man agem en t of hypertrophic n onunions typically involves stabilization of the
n on union site through im m obilization or, m ore com m only, surgical stabilization with a nail or compression
plate.
At the opposite end of the spectrum , nonunions m ay
be atrophic or avascular (Fig. 10.41). Radiographs show
eburn ated, osteopen ic, an d/ or sclerotic bon e en ds. Th e
n on union is biologically devoid of h ealin g an d, as such, th e
en ds of th e bon e h ave becom e atroph ic an d osteoporotic.
Because of th e lack of blood supply, a bon e scan will typically be cold represen tin g th e lack of biologic activity. Surgical m an agem en t in volves stabilization an d addition of biologically active m aterial (e.g., autograft, bon e m orphogenic
protein ) to augm en t th e h ealin g respon se alon g with
fixation.
patient with diabetes, peripheral vascular disease, and poor nutrition. Despite surgical stabilization, there is no callus formation and
the bone ends are sclerotic with little signs of vascularity.
230
B
Figure 10.42 (A) Oligotrophic nonunion of the humeral shaft in a 42-year-old male who fell down
the stairs. Despite several months of nonoperative management, the fracture showed no callus formation and no signs of healing. With surgical stabilization (B), the fracture healed 8 weeks later. No
orthobiologic agents were necessary as the fracture ends were not necrotic.
O ligotroph ic n on un ion s do n ot sh ow callus on radiograph s but do n ot h ave sign s of sclerosis or bon e loss either (Fig. 10.42). Unlike atrophic n on unions, th e blood
supply is typically intact an d a bone scan sh ows uptake.
Th e h ealin g respon se is in adequate, an d th is m ay be due
to excessively rigid fixation , distraction at th e fracture site,
com m inution, or host factors such as poor system ic levels
of vitam in D an d calcium .
Recen t studies h ave exam in ed th e role of th e h ost in
fracture healing revealing the importance of the endocrin e
system . In the m anagem en t of n on un ions, som e surgeon s
will obtain vitam in D, calcium , thyroid stim ulatin g h orm on e, protein, album in, m agnesium , and phosphorus levels in con jun ction with routin e blood work. Ph arm acologic correction of these important m arkers of healing
in conjunction with appropriate m usculoskeletal interven tion h as been sh own to dram atically in crease n on un ion
fracture healing rates.
Lastly, infection h as been shown to delay or impede
fracture healing. Infection typically occurs in the settin g
of an open fracture but m ay also be a risk in patien ts with
prolon ged surgical exposures, revision surgery, or m edical
com orbidities. All patien ts wh o present with a nonunion,
hardware failure, or delayed h ealin g, particularly with a history th at is con cern in g, sh ould un dergo a work-up for in fection as part of their nonunion evaluation. This work-up
includes a complete blood cell count, erythrocyte sedim en -
Osteomyelitis
Postoperative wound in fections and osteomyelitis are usually related to h igh -energy in juries, which are associated
with sign ifican t woun d con tam in ation an d osseous devascularization. Other risk factors include prolonged open
woun d tim e, in adequate fixation , an d exten sive surgical
dissection an d periosteal strippin g, wh ich com prom ise
blood flow to th e woun d. Patien ts can presen t with a myriad of signs and symptom s including pain , tenderness,
fever, headach e, nausea, vom iting, erythem a, swelling, sinus tracts, drainage, and fluctuance.
Laboratory data can aid in the diagnosis of osteomyelitis. In acute osteomyelitis, the white blood cell coun t is
elevated on ly 25% of th e tim e an d sh ows an abn orm al
differen tial on ly 65% of th e tim e. Blood cultures in acute
osteomyelitis are positive on ly 50% of th e tim e. Ch ron ic osteomyelitis often sh ows a m ild an em ia with elevation s of
ESR an d CRP. Th ere m ay be a leukocytosis with a left sh it,
but th is is n eith er specific n or sen sitive. Blood cultures are
alm ost always negative.
Various im aging m odalities can be utilized to help determ ine the presence and breadth of in fection. Radiographs
are positive in 90% of cases by 3 to 4 weeks after inoculation. The earliest bone changes are those of destruction
or resorption , usually seen as m ottled areas of decreased
den sity in m etaphyseal areas. Over tim e, a th in lin e of
newly form ed bon e parallel to the sh aft m ay be detected
in the periosteal regions of the m etaphysis as new bone
results from in fection progressin g in to th e subperiosteal
region an d gradually exten din g alon g th e sh aft. If th e in fection is not controlled, th e new periosteal bone thicken s
over succeedin g few weeks becom es an in volucrum . After
several weeks have passed an d the disease is in ch ron ic
ph ase, sequestra m ay appear as opaque areas of bon e, usually surrounded by radiolucen t zone consisting of exudate
an d granulation tissue. Occasionally, an acute m etaphyseal
osteomyelitis is con tain ed locally by th e h ost defen ses. In
such instan ces, the infection becom es surroun ded by scar
tissue and a rim of reactive bon e, resulting cavity or cyst
is filled with pus, which m ay ultim ately becom e sterile.
A bon e abscess resultin g from th is localized form of th e
disease is called a Brodies abscess. An MRI m ay h elp iden tify associated abscesses, sequestra, and sin us tracts and
m ay also reveal specific changes in bone m arrow. In bon e
m arrow, inflam m atory exudate has decreased signal on T1
as compared with norm al m arrow. Infected m arrow will
have higher signal on T2. A triple phase bone scan, often
perform ed with eith er tech n etium 99m or in dium 111, is
positive 3 to 4 days after in fection . Th e th ree ph ases of
the bon e scan involve a radionucleotide angiogram , im m ediate postinjection blood pooling, and ultim ately decreased soft tissue presence with increased urinary excretion. Osteomyelitis shows increases in phases one and two,
an d focal increases in the third phase at the 3-hour tim e
poin t.
An anatom ic classification system for osteomyelitis has
been provided by Drs Cierny an d Mader (Fig. 10.43). Th e
location of the osteomyelitis can be completely m edullary
(type I), superficial with a sinus tract from the skin extending down to the cortex (type II), localized where the cortex
is violated, but the infection is contained (type III), an d
diffuse wh ere th e in fection h as eroded th rough each cortex (type IV). In addition to classifyin g th e location of th e
osteomyelitis an d its im pact on th e bon e, Drs Cierny an d
Medullary
Superficial
Localized
Diffuse
231
Septic Arthritis
Patien ts with a distan t focus of in fection can presen t with
n ew onset joint pain because of h em atogen ous spread of
a bacterial organ ism with in th e con fin es of a join t capsule (i.e., syn ovial join t). The classic clinical scenario is
a patien t with pn eum on ia or bacterial en docarditis that
presen ts with n ew on set h ip pain . In th e im m un ocompeten t patien t, th e bodys reaction to in tra-articular in fection
is to m ount a sign ifican t inflam m atory response with the
232
A,B
D,E
F
Figure 10.44 (A) Lateral radiograph of a 39-year-old male 18 months after operative stabilization
of an open tibia fracture showing an atrophic nonunion. (B) Physical examination revealed a draining
sinus tract directly over the nonunion site near the open fracture. The patient was taken to the
operating room for debridement of his sinus tract and osteomyelitis (C) and placement of an antibiotic
spacer and antibiotic nail (D). He also had a free flap performed to cover the defect (E). After
6 weeks of intravenous antibiotics, he was taken to the operating room for repair of his nonunion
with bone grafting and intramedullary nailing. Six months later, he united his fracture (F) with no signs
of recurrence of infection and intact soft tissue.
Necrotizing Fasciitis
Necrotizin g fasciitis is defin ed as an in fection of th e subcutaneous tissue overlying th e fascia of an extrem ity. Th e
m ost com m on organism in volved in this type of infection
is group A streptococcus. Patients typically present with a
superficial skin infection that looks innocuous. However,
the incitin g physical exam ination finding is pain out of
proportion to th e clin ical exam in ation .
Cellulitis is a superficial in fection of th e epiderm is an d
m ay present in sim ilar fash ion to necrotizing fasciitis. However, n ecrotizin g fasciitis is often associated with an ele-
233
vated body tem perature an d h em odyn am ic in stability (hypoten sion ). In th e early stages, h em odyn am ic in stability
m ay be absen t an d by th e tim e hypoten sion is presen t, th e
in fection m ay h ave becom e m ore exten sive. A m issed diagn osis of necrotizin g fasciitis is fatal.
Any patien t with th e diagn osis of n ecrotizin g fasciitis
requires em ergen t surgical debridem en t of th e affected region . An exten sile exposure is utilized to expose from th e
level of th e skin to th e un derlyin g deep fascia. Th e in fection
h as been described as dish water pus an d requires th orough irrigation an d debridem en t. Hypoten sive patien ts require close ICU care in th e im m ediate postoperative period
to optim ize th eir h em odyn am ic status. Repeat irrigation
an d debridem en t is th e stan dard of care an d allows for exploration of th e woun d for evaluation of in fection spread.
In travenous antibiotics are th e m ain stay of treatm ent and
duration is typically 6 weeks.
SUMMARY
Th e m an agem en t of th e orth opaedic traum a patien t is a
m ultidisciplinary effort. Th e orthopaedic surgeon is critical in th is evaluation, which includes an adequate history, thorough physical exam ination, and directed im aging
tech n iques. Ath orough un derstan din g of com m on m usculoskeletal conditions is necessary. On ce the injuries have
been defin ed, a plan is design ed to m an age th e patien ts
injuries addressing life-threaten ing fractures initially with
con trol of bleedin g an d tem porizin g stabilization . Great
care is taken to preven t th e second h it.Preoperative plann in g is essen tial in the m an agem en t of diaphyseal and articular injuries. Particular attention needs to be paid to the
preven tion of com plication s in th is often ch allen gin g patient population.
RECOMMENDED READINGS
Bh an dari M, Guyatt G, Torn etta P III, et al. Ran dom ized trial of ream ed
an d unream ed intram edullary nailin g of tibial sh aft fractures.
J Bone Joint Surg Am. 2008;90(12):2567 2578.
Bosse MJ, MacKen zie EJ, Kellam JF, et al. An an alysis of outcom es of
reconstruction or am putation after leg-threatening injuries. N Engl
J Med. 2002;347(24):1924 1931.
Garden RS. Stability and union in subcapital fractures of the fem ur.
J Bone Joint Surg. 1964;46B(4):630 647.
Gustilo RB, An derson JT. Prevention of infection in th e treatm ent of
one thousand and twen ty-five open fractures of long bon es: retrospective and prospective analyses. J Bone Joint Surg Am. 1976;58:
453 458.
Letourn el E. Acetabulum fractures: classification an d m an agem en t.
Clin Orthop Rel Res. 1980;151:81 106.
Routt ML, Nork SE, Mills WJ. High en ergy pelvic rin g disruption s.
Ortho Clin North Am. 2002;33(1):59 72.
Siebel R, LaDuca J, Hassett JM, et al. Blun t m ultiple traum a (ISS 36),
fem ur traction , an d th e pulm onary failure-septic state. Ann Surg.
1985;202(3):283 293.
Win quist RA, Han sen ST, Clawson DK. Closed in tram edullary n ailin g
of fem oral fractures. A report of five hundred and twen ty cases. J
Bone Joint Surg Am. 1984;66:529 539.
11
Pediatric Orthopaedics
Sectio n 1
Physiology
Variations in axial rotational align m ent are usually due to
m echanical forces applied in utero. Inside the wom b, the
Karen Myun g
Robert M. Kay
Presentation
Paren ts of in -toein g ch ildren typically com plain of th e cosm etic appearance, frequent trippin g, or an awkward eggbeater run n in g style. Th e cause of in -toein g can often be
deduced sim ply by th e age at wh ich th e ch ild presen ts.
Children who are just beginning to walk typically have
residual m etatarsus adductus from in trauterin e position ing. Between ages 1 and 3, internal tibial torsion is the m ost
likely culprit (Fig. 11.2). After age 3, the m ost likely cause
of in -toein g is persisten t fem oral an teversion th at h as yet
to rem odel. Out-toeing is a less com m on presentation and
is also of no functional con sequen ce.
236
A 6 mo
B 18 mo
C 4 yr
D Young adult
child with genu varum. (B) An 18month-old child with straight legs. At
some point in most children, usually
around 18 months of age, the legs
are perfectly straight as their developmental stage passes from genu varum
to genu valgum. (C) A 4-year-old child
with genu valgum. (D) Adults normally
have a mild amount of genu valgum.
(Reproduced with permission from
Skaggs DL, Flynn JM. Staying Out
of Trouble in Pediatric Orthopaedics.
Philadelphia, PA: Lippincott Williams
& Wilkins, 2006.)
237
Thigh-foot angle
TFA
40
2SD
20
0
2SD
20
40
1
Age (yr)
Figure 11.3 Genu varum in a toddler. (Reproduced with permission from Skaggs DL, Flynn JM. Staying Out of Trouble in Pediatric Orthopaedics. Philadelphia, PA: Lippincott Williams & Wilkins,
2006.)
Foot progression
angle
FPA
20
2SD
10
10
2SD
Age (yr)
solid line demonstrates mean values and the shaded area represents 2 standard deviations. (Reprinted with permission from Morrissy RT, Weinstein SL. Lovell and Winters Pediatric Orthopaedics.
Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
238
Medial rotation
Medial rotation
MR girls
80
MR boys
80
60
60
2SD
40
2SD
40
20
2SD
20
0
1
Age (yr)
2SD
11 13 1519 30s 50s 70+
Age (yr)
Lateral rotation
LR
100
80
60
2SD
40
2SD
20
1
Age (yr)
N =196
deviations for (A) knee angle and (B) intercondylar or intermalleolar distance. (Reproduced with permission from Skaggs DL,
Flynn JM. Staying Out of Trouble in Pediatric Orthopaedics. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
239
Radiographs
Although plain radiograph s h ave lim ited utility in the evaluation of torsion al variation s, stan din g full-len gth radiograph s can be very useful for workin g up m oderate to severe
an gular variations (Fig. 11.9). Usin g this radiograph, the
an atom ic axis between the fem ur and the tibia can be m easured to quantify the degree of knock-knees or bow-legs.
Special Studies
Advan ced im agin g is rarely n ecessary in th e evaluation of
torsional or angular variation s. Occasion ally, severe cases
of fem oral an teversion or retroversion m ay warran t a com puted tom ography (CT) to quan tify th e exact degree of rotation al deform ity.
Differential Diagnosis
Alth ough th e vast m ajority of torsion al an d an gular variations are physiologic an d will improve with age, it is importan t to rule out an un derlyin g path ologic con dition before
reassurin g th e fam ily th at th eir ch ild is n orm al. Torsion al
variations m ay cause tripping but should not cause a limp
n or should it be pain ful. Existen ce of eith er of these two
sym ptom s should prom pt a workup for oth er causes. Unilateral in -toeing can be due to hem iplegic cerebral palsy
(CP) or other neurom uscular condition. Out-toeing in an
older ch ild can be caused by a slipped capital fem oral epiphysis (SCFE) or coxa vara.
Angular variations outside the range of norm al can be
caused by a n um ber of differen t con dition s, m ost of wh ich
are described in detail elsewhere in this chapter. In evaluating a toddler with bowed legs, the m ost importan t diagn osis to consider is Bloun t disease (tibia vara). In particular,
Bloun t disease sh ould be suspected wh en th e ch ild is older
th an 2 years, th e varus deform ity is sh arply an gular, a lateral kn ee th rust is presen t with am bulation , th e bowin g
240
B
Figure 11.10 Anteroposterior radiographs (A) 4 weeks after and (B) 8 weeks after tibial rotational osteotomy. In this case, pins and a cast were used to achieve fixation at the osteotomy site.
(Reproduced with permission from Skaggs DL, Tolo VT. Master Techniques in Orthopaedic Surgery:
Pediatrics. Philadelphia, PA: Lippincott Williams & Wilkins, 2008.)
Treatment
Torsion al variation s rarely require form al treatm en t. Although th e presence of in-toeing or out-toeing m ay frustrate paren ts, th e vast m ajority of th ese con dition s improve
spontaneously with age. Th ere is no evidence th at bracin g or special sh oes h elp accelerate th e n atural h istory. O n
rare occasions, children with torsional deform ities that persist in to adolescence and cause fun ctional problem s can
be treated with corrective osteotomy of th e tibia or fem ur
(Fig. 11.10).
Physiologic an gular variation s sh ould also be observed
for spontan eous improvem ent. Of course, all ch ildren with
an un derlyin g etiology sh ould be treated for th eir diagn osis. Occasion ally, ch ildren will present with persisten t m oderate to severe gen u valgum in th eir early teen age years.
O perative treatm en t can be con sidered for th ose adoles-
NEUROMUSCULAR DISEASE
Ch ildren afflicted with n eurom uscular diseases frequently
m anifest severe m usculoskeletal abnorm alities. Not only
do th ey suffer from th e in trin sic effects of th e n europath ic or myopath ic abn orm alities but th ey are usually
profoun dly affected by th e secon dary bon e an d join t deform ities that result from these diseases. For m anagem ent
to be effective, it is importan t th at th e physician recogn ize
the basic differences between the neurom uscular disorders.
Certain neurologic diseases are cen tral, whereas others are
periph eral; som e affect on ly th e m otor system , wh ereas
oth ers affect both sen sory an d m otor compon en ts. CP, for
exam ple, is a cen tral n eurologic con dition with resultin g
spasticity in th e periph ery. Children with CP typically have
reason able sen sation . In con trast, myelodysplasia affects
the spinal cord and adjacent nerve roots, leavin g little m otor
241
less th an 1,500 g h ave a 25 tim es in creased risk of developin g CP. Fin ally, h ead traum a, in traven tricular h em orrh age,
an d m en in gitis are examples of postn atal causes of CP.
Figure 11.11 (A) This teenaged girl did not like the appearance
of her genu valgum and complained that her knees rubbed together
when she played sports. (B) Repeat standing radiograph after temporary hemiepiphysiodesis of the distal femur using 8 plates. (Reproduced with permission from Childrens Orthopaedic Center, Los
Angeles, CA.)
Cerebral Palsy
Pathophysiology
CP is really not one disease but rath er a syndrom e of m otor
disorders th at result from an in sult to th e im m ature brain .
Th e size an d scope of th e brain in jury affects n ot on ly th e
severity of m otor in volvem ent but also the childs speech ,
cognition , an d overall functional ability. CP is the m ost
com m on neurom uscular disorder in children an d is characterized by a static, nonprogressive central injury. As a consequen ce, the usual inh ibitory role of the cen tral nervous
system (CNS) is suppressed, resulting in increased periph eral spasticity. Over tim e, th is spasticity results in con tractures and joint deform ities. Pren atal causes in clude infections such as toxoplasm osis, rubella, cytom egalovirus, herpes, an d syph ilis, as well as m atern al drug an d alcoh ol use.
Perin atal causes include birth traum a and an oxia. In fact,
prem aturity is th e m ost com m on risk factor for CP. In fan ts
Classification
CP can be classified physiologically, geographically, or
function ally. Physiologic grouping is based on th e location of the brain lesion an d the m ovem ent disorder that
results. Spastic CP, th e m ost com m on form of CP, occurs
wh en th e pyram idal tracts of th e brain are affected. Dyskin esia, ch aracterized by ath etosis, ch orea, an d oth er in volun tary m otor m ovem en ts, occurs wh en th e extrapyram idal
region s becom e in jured. Som e ch ildren m ay h ave a m ixed
picture, with both pyram idal an d extrapyram idal features.
Geograph ic classification is based on th e distribution
of lim bs th at are affected. Hemiplegia refers to arm an d
leg involvem ent on one side of the body, diplegia describes prim arily bilateral lower extrem ity involvem ent, an d
quadriplegia affects all four extrem ities. Significant overlap
can occur between th e geograph ic classification s; for example, severe diplegia can often be confused with m ild
quadriplegia depen din g on th e exten t of upper extrem ity
involvem ent. As a result, m any physicians prefer a Gross
Motor Function Classification System (GMFCS), wh ich is
based on th e ch ilds level of am bulation an d use of assistive
devices (Fig. 11.12).
Presentation
CP can present in m any different ways. Com m on reasons
for referral include limping, leg-length discrepancies, foot
problem s, toe-walkin g, tigh t m uscles, an d/ or poor upper
extrem ity fun ction . Typically, gross m otor developm en t
is delayed; however, th is depen ds on the severity of central injury. In addition, in telligence and com m unication
skills vary depen ding on the degree of in volvem en t. Hem iplegic ch ildren often h ave n orm al in telligen ce, wh ereas
som e quadriplegic children dem on strate significant m ental
deficits an d an in ability to com m un icate in a m ean in gful
m anner.
History and Physical Examination
Most ch ildren with CP have a history of prem aturity, prolonged delivery, and/ or anoxic injury about the tim e of
birth . A detailed birth h istory sh ould also in clude problem s during pregnancy and the duration of hospitalization
after birth. A careful developm ental history m ay reveal eviden ce of developm en tal delay. On average, ch ildren sh ould
sit by 6 m onth s, stan d by 8 m onths, and walk by 12 m onths.
If a ch ild does n ot reach th ese m ileston es by 1.5 tim es th ese
ages (i.e., sit by 9 m onths, stan d by 12 m onths, or walk by
18 m on th s), an in vestigation in to the developm ental delay
is warranted. Another useful h istorical detail is early handedn ess. A preferen ce for a certain h an d prior to 1 year of
age m ay be a sign of hem iplegia.
Physical exam in ation sh ould in clude ran ge of m otion of
all joints along with an assessm en t of m uscle tone, selective m otor control, an d upper and lower extrem ity reflexes.
242
Radiographs
Th e m ost importan t radiograph in a ch ild with CP is
an an teroposterior (AP) view of the pelvis. Persistent
243
B
Figure 11.13 (A) Dorsiflexion should be measured in both with the knee extended (A) and the
knee flexed 90 degrees (B). The latter technique relaxes the gastrocnemius muscle. By comparing
the range of motion in both positions, one can assess the contribution of the gastrocnemius to the
overall tightness of the Achilles tendon. (Reproduced with permission from Childrens Orthopaedic
Center, Los Angeles, CA.)
hyperton icity aroun d th e h ips can lead to spastic h ip disease or progressive subluxation an d dislocation of th e
hip due to overpull of the adductor and iliopsoas m uscles. These hips are initially norm al at birth , so it is importan t to m on itor th em radiograph ically over tim e to iden tify
those hips that are at riskfor subluxation. The m ost com m on ly used radiographic index for quantifying the severity
of spastic h ip disease is th e Reim er m igration percen tage
(or m igration index). The m igration percentage is calculated by dividing the width of th e uncovered fem oral head
suring the popliteal angle. This is the angle formed between the
vertical and the childs leg when the hip is flexed to 90 degrees.
(Reproduced with permission from Childrens Orthopaedic Center,
Los Angeles, CA.)
Special Studies
In recen t years, quan titative gait evaluation usin g th reedim en sion al com puterized m otion an alysis h as becom e
increasingly popular to help plan appropriate surgical intervention. These studies are perform ed at specific gait laboratories an d can be extrem ely useful for system atically evaluatin g th e com plex walkin g pattern s of patien ts with CP.
the Thomas test. The contralateral hip is flexed to flatten the lumbar spine and stabilize the pelvis. The residual flexion of the hip
compared to the horizontal is the amount of hip flexion contracture that is present. (Reproduced with permission from Childrens
Orthopaedic Center, Los Angeles, CA.)
244
Hip
Surgery on th e spastic h ip accoun ts for th e largest n um ber of procedures perform ed on th e pediatric h ip. Th ese
ch ildren have sign ifican t h ip disease initiated by m uscle
im balance, the developm ent of soft tissue contractures,
subsequent bony deform ity, and ultim ately hip subluxation and dislocation. The contractures involve the hip flexors (psoas an d rectus fem oris) an d th e h ip adductors. With
progressive con tracture, th e axis of h ip rotation is altered
an d secon dary osseous changes develop. Fem oral anteversion is presen t at birth, rem ains persistent in these children,
an d accentuates the rate at which hip subluxation and dislocation occur (Fig. 11.17). Radiographs of the spastic h ip
frequently are m isin terpreted as dem onstrating significant
valgus, when in fact they are dem onstrating anteversion. It
is important to realize that children with CP are born with
n orm al h ips an d that subsequen t ch an ges are the result
of n eurom uscular im balan ce. Un treated, th ese h ips m ay
progress to severe subluxation or dislocation . Alth ough it
is som ewhat controversial, there seem s to be general agreem en t that a dislocated hip has a 50% chance of becom ing
pain ful. It is th is observation , an d th e im proved seatin g position , th at m akes the best argum ent for operative reconstruction of a subluxed or dislocated hip. Of course, the
best way to m an age th ese ch ildren is to preven t h ip subluxation through early screenin g, spasticity m anagem en t, and
appropriate surgery.
Physical th erapy, botulin um toxin in jection s, an d abduction splin tin g can be effective to m ain tain h ip ran ge of
m otion and delay th e need for surgery. In general, children
wh o h ave less th an 30 degrees of abduction an d/or a m igration in dex greater th an 25% are at risk for progressive
subluxation and should be treated with adductor ten otomy.
If a coexistin g h ip flexion con tracture exists, an iliopsoas recession should also be perform ed. For hips with m ore severe m igration indices (> 50% 60%), a varus derotational
fem oral osteotomy is warranted. The varus portion of the
osteotom y h elps redirect th e fem oral h ead so th at it poin ts
m ore directly at the acetabulum , whereas the derotation is
useful for correctin g fem oral an teversion . In severe cases,
a form al open reduction m ay be required, an d, if acetabular dysplasia exists, a resh aping acetabuloplasty such as th e
Dega or San Diego pelvic osteotomy sh ould be in cluded
(Fig. 11.18). The m anagem ent of the older child with a
fixed, pain ful, spastic h ip dislocation is problem atic. Total h ip replacem en t h as been reportedly successful, but in
m any patien ts, arthroplasty is n ot considered appropriate.
Resectional type arthroplasties, such as proxim al fem oral
resection with soft tissue in terposition , can be effective but
are clearly a salvage option.
Knee
Ham strin g con tractures and th e subsequent developm ent
of kn ee flexion deform ities are com m on problem s in th e
spastic child. Walking with flexed knees greatly increases
the energy expenditure required for am bulation and can
severely lim it th e fun ction al abilities of children with CP
245
246
A,B
C
Figure 11.20 Preoperative (A) and postoperative (B) lateral radiographs and (C) postoperative
anteroposterior radiograph of a left knee in maximum extension after treatment with distal femoralextension osteotomy with patellar advancement. The change in the patellar height can be quantified by
relating the femurtibia distance, (A), to the patellatibia distance, (B). (Reproduced with permission
from Stout JL, Gage JR, Schwartz MH, et al. Distal femoral extension osteotomy and patellar tendon
advancement to treat persistent crouch gait in cerebral palsy. J Bone Joint Surg. 2008;90:24702484.)
247
ting the fascia (but not the muscle) at the musculotendinous junction. This technique helps preserve push-off strength. (Reproduced
with permission from Skaggs DL, Tolo VT. Master Techniques in Orthopaedic Surgery: Pediatrics. Philadelphia, PA: Lippincott Williams
& Wilkins, 2008.)
248
A
C
Figure 11.25 Calcaneal lengthening osteotomy. (A) The calcaneus is cut 22.5 cm proximal to the
calcaneocuboid joint. (BC) A trapezoidal bone graft is inserted to enhance talar coverage by the
navicular. (Reproduced with permission from Skaggs DL, Tolo VT. Master Techniques in Orthopaedic
Surgery: Pediatrics. Philadelphia, PA: Lippincott Williams & Wilkins, 2008.)
an terior tibial ten don tran sfer or split posterior tibial ten don tran sfer can h elp balan ce th e foot. In m ore rigid deform ities, a h indfoot osteotomy m ay also be necessary.
Plan ovalgus feet th at h ave failed bracin g m ay be am en able
to a lateral colum n len gth en in g. Th is procedure takes advantage of th e windlass m echanism to develop an arch
an d correct th e h in dfoot. By placin g a wedge of bon e
graft in th e calcan eal n eck, th e previously sh ort lateral colum n of th e foot becom es elon gated; th is h elps swin g th e
foot into a m ore anatom ic position (Fig. 11.25). For the
spastic bun ions, m ost authors feel th at stan dard bun ion
procedures h ave an un acceptable rate of recurren ce; an d
therefore, m ost prefer an arthrodesis of the first m etatarsophalangeal (MTP) joint as a defin itive procedure.
Upper Extremity
Th e upper extrem ity is also in volved in patien ts with h em iplegic or quadriplegic CP. In m ild cases, th e extrem ity m ay
lack som e degree of coordin ation an d selective m uscle con trol; in severe cases, th e extrem ity m ay be extrem ely spastic
with the typical appearan ce of th um b-in-palm , wrist flexion , forearm pron ation , an d elbow flexion (Fig. 11.26). Although deform ities m ay initially be dyn am ic, by the tim e
ch ildren are 6 to 9 years of age, fixed con tractures usually
develop. Th e goals in treatin g th e upper extrem ity are to
improve its fun ction as a h elpin g h an d; to improve its gross
function in graspin g, pinching, and releasing; and to im prove its appearan ce. Occupation al th erapy is h elpful for
younger children to encourage the child to use the hand.
Botulin um toxin and occasion al splin tin g can h elp m anage forearm and elbow contractures. Surgical techniques
are available to correct the thum b-in-palm deform ity, the
instability of the first m etacarpoph alangeal joint, and the
instability of the carpom etacarpal joint of the thum b. Wrist
flexion deform ity h as been m an aged by ten don transfers,
ten odesis, an d wrist fusion . In severe cases wh ere improved
249
Central canal
Epidermis
Dorsal root
Ventral root
Cerebrospinal fluid
Figure 11.28 Cross section of myelomeningocele. The abnorFigure 11.27 Spina bifida occulta. Spinous processes of L2 and
L4 are visible (black arrows). An absent spinous process at L5 (white
arrow) is consistent with spina bifida occulta in an otherwise normal child. (Reproduced with permission from Skaggs DL, Flynn JM.
Staying Out of Trouble in Pediatric Orthopaedics. Philadelphia, PA:
Lippincott Williams & Wilkins, 2006.)
mal cord is part of the sac that has herniated out of the canal.
(Reprinted with permission from Morrissy RT, Weinstein SL. Lovell
and Winters Pediatric Orthopaedics. Philadelphia, PA: Lippincott
Williams & Wilkins, 2006.)
motor function in the lower extremities and the legs lie, as they
did in birth, in a position dictated by the effect of gravity. (Reproduced with permission from Broughton NS. Textbook of Paediatric
Orthopaedics. London, England: WB Saunders, 1997.)
250
tion of the hips leads to an abducted posture from weak hip adductors. (Reproduced with permission from Broughton NS. Textbook
of Paediatric Orthopaedics. London, England: WB Saunders, 1997.)
for am bulation. Patients with L4 fun ction will often develop a calcan eal foot deform ity due to th e un opposed action of th e an terior tibialis.
Low lum bar level (L5) m yelodysplasia h ave adequate
hip abductor strength in addition to stron g quadriceps
function (Fig. 11.32). Most of these patients walk with a
m in im al Tren delen burg gait usin g on ly AFO s. Th e in ciden ce of h ip problem s is low as is th e in ciden ce of scoliosis.
Foot deform ities, h owever, occur quite frequen tly; th e m ost
com m on deform ity is a calcaneal foot due to poor gastroc-
adduction and the knees in extension or hyperextension from functioning quadriceps. There is no muscle power in the feet. (Reproduced with permission from Broughton NS. Textbook of Paediatric
Orthopaedics. London, England: WB Saunders, 1997.)
hip and some flexion at the knee. Unopposed action of ankle dorsiflexors (due to weakness of the gastroc-soleus complex) leads
calcaneus position of the feet. (Reproduced with permission from
Broughton NS. Textbook of Paediatric Orthopaedics. London, England: WB Saunders, 1997.)
Presentation
Myelodysplasia is generally diagnosed in utero. The iden tification of elevated -fetoprotein in the m aternal blood
(sampled at 15 16 weeks) will trigger an am n iocen tesis.
Th is study is quite defin itive for th e diagn osis of open n eural tube defects. Ultrasoun d h as also been sh own to be reason ably sensitive in th e diagnosis of myelodysplasia. Either
way, m ost cases are identified prior to birth. After delivery
(usually by cesarean section to avoid traum a to th e herniated sac), closure of the myelom eningocele is perform ed
by a neurosurgeon within 48 h ours of birth. Approxim ately
80% of th ese ch ildren will survive th eir first year, an d 60%
to 70% of patien ts will survive to adulth ood. Patien ts are
gen erally referred for orth opaedic care at an early age to determ in e am bulatory poten tial an d m an age lower extrem ity
deform ities.
History and Physical Examination
A careful h istory m ay elicit on e or m ore of th e m ajor risk
factors for spin a bifida, in cludin g h istory of myelodysplasia
in a previous pregnancy, in adequate folic acid intake, m atern al diabetes, an d m atern al use of valproic acid durin g
the pregnancy. Folic acid supplem en tation, in particular,
is the best m ean s of preventing neural tube defects and is
a standard component of all prenatal vitam ins.
251
as high as 3% to 7%. Perform ing surgery in a norm al latex en viron m en t can risk an an aphylactic reaction with a
precipitous drop in blood pressure.
Another issue that com m on ly arises in the care of children with myelodysplasia is path ologic fracture due to
severely osteoporotic bon e. These fractures often present
with warm th , redn ess, an d swellin g but m in im al pain due
to impaired sensation (Fig. 11.34). As a result, they can
252
Figure
11.35 Thirteen-year-old
253
interfere with bracin g, hip flexor release or anterior capsulotomy m ay be in dicated. In ch ildren with m idlum bar
myelodysplasia, m ost auth ors prefer to leave bilateral dislocation s untreated. Select un ilateral dislocations m ay warran t reduction ; h owever, th is is con troversial because of th e
high inciden ce of recurrent dislocation (Fig. 11.36). Again ,
any hip con tracture that in terferes with bracing or walking
sh ould be released. Low lum bar and sacral level spin a bifida are at low risk for h ip dislocation sin ce m uscle forces
around the hip are well balanced. For th ose dislocations
that do develop, anterior releases and bony surgery sh ould
be perform ed as n eeded to ach ieve a stable, con cen tric h ip
reduction .
Knee
Several differen t kn ee deform ities m ay develop in spin a
bifida. Exten sion con tracture, flexion con tracture, an d valgus deform ity h ave all been reported depen ding on the
specific pattern of m uscle fun ction. Knee flexion con tractures are com m on, particularly in patients with thoracic or
upper lum bar spin a bifida. If a ch ild predom in an tly uses a
wh eelch air, treatm en t m ay n ot be n ecessary; h owever, if th e
deform ity in terferes with bracin g or am bulation , th en posterior soft tissue release an d/ or distal fem oral exten sion osteotomy is in dicated. Patien ts with m idlum bar myelodysplasia are at h igh risk for severe kn ee valgus due to th eir
Trendelenburg gait. Crutches along with kneeanklefoot
orth oses (KAFO s) can h elp protect th e kn ees in th ese patients.
Foot and Ankle
Foot deform ities are extrem ely com m on in spin a bifida, occurring in up to 75% of patients. In patients with higher levels of in volvem en t, equin us con tractures, vertical talus, an d
rigid clubfoot deform ities predom in ate. Th e goal of treatm en t is a supple, plantigrade foot th at easily accom m odates
sh oewear. Since m ost children will require braces, ten o-
CharcotMarieTooth Disease
CharcotMarieTooth (CMT) disease is th e m ost com m on
form of hereditary m otor sensory neuropathy. Other neuropath ies are prim arily adult diseases with out orth opaedic
implications; thus, th ey are not included in this section.
CMT disease itself is actually a group of different diseases
with differen t gen otypes but sim ilar ph en otypes.
254
A,B
Figure 11.37 (A) Front view of the lower legs and feet of a 16-year-old boy with CharcotMarie
Tooth disease. His calves are thin, and he has symptomatic cavus feet. Clawing of the toes is minimal.
(B) Posterior view demonstrates moderate heel varus. (C) The cavus foot deformity is most apparent
when viewed from the medial side. A mild flexion deformity of the great toe interphalangeal joint
is present. (Reprinted with permission from Morrissy RT, Weinstein SL. Lovell and Winters Pediatric
Orthopaedics. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
power its an tagon ist, th e tibialis an terior, leadin g to plan tarflexion of th e first ray. In an effort to balan ce th e tripod
of th e foot, th e h in dfoot compen sates by swin gin g in to a
varus position. As a result, patients ten d to overload the
lateral border of the foot and often present with calluses in
th is location . Atrophy an d con tracture of th e in trin sic m usculature of th e foot lead to clawin g of th e toes, con tracture
of th e plan tar fascia, an d elevation of th e arch . Plan tar flexion of th e m etatarsal heads can lead to increased pressure
in these areas and m etatarsalgia.
Th e in n ervation of th e h an d is also affected in CMT disease, wh ich leads to in trin sic atrophy. Han d in volvem en t,
h owever, usually does not develop un til late in th e disease
course. Hip dysplasia can also occur, perh aps because of
subtle weakn ess of th e proxim al m usculature about the hip.
Scoliosis is seen in up to 37% of adolescen ts with CMT disease. Deform ities are sim ilar to idiopath ic curves but ten d
to have m ore kyphosis than lordosis.
Physical Examination
Observation of gait in patients with CMT disease usually
reveals a drop foot durin g swin g. A steppage gait can develop, which is ch aracterized by hyperflexion of th e knee
an d hip in an attempt to help clear th e foot. Toe extension
durin g swin g can also be seen as th is h elps com pen sate
for the weakness of the prim ary ankle dorsiflexors. Lower
extrem ity exam in ation will reveal dim in ish ed deep ten don
foot flexibility. The flexible varus deformity of the hindfoot will correct to valgus when the plantar flexed first metatarsal is allowed to
drop down off the edge of the block of wood. Failure to correct to
valgus indicates the need for surgical correction of the hindfoot, in
addition to the procedures on the forefoot. (Reproduced with permission from Coleman SS, Chestnut WJ. A simple test for hindfoot
flexibility in the cavovarus foot. Clin Orthop. 1977;123:6062.)
reflexes an d decreased calf circum feren ce from global atrophy. Distal sen sation is usually decreased to all m odalities.
Evaluation of the cavovarus foot in patien ts with CMT
disease begin s with a careful assessm en t of th e skin . Lateral overloadin g m ay cause large calluses alon g th e lateral
border of th e foot. As patien ts m ay be partially in sen sate,
it is important to identify areas at risk for breakdown to
preven t th e form ation of deep ulcers. To develop an appropriate treatm en t plan for th e cavovarus foot, it is essen tial to
assess the flexibility of hindfoot. This is best done by using
the Colem an block test (Fig. 11.38). This test is perform ed
by having th e patien t stand on a block with the head of
the first m etatarsal hangin g free over the m edial edge. If
the hindfoot varus is a compensatory response to plantar
flexion of the first ray (i.e., flexible), the heel will correct
to n eutral on th e block. If th e varus deform ity h as becom e
rigid over tim e, it will n ot correct.
Hands should be exam in ed by m anual m uscle testing
to m on itor atrophy of th e in trin sic m usculature. In certain
cases, han d dynam om eters m ay be useful to provide quantitative data about the change in m uscle strength over tim e.
Hips sh ould be ran ged and exam ined for subtle in stability. A standard scoliosis exam ination should be perform ed
(see pediatric spine section) to screen for spin al deform ity.
Radiographs
Stan din g lateral radiograph s of th e foot will dem on strate
the characteristic findings of the cavovarus deform ity. Usually, the angle of the inferior border of the calcaneus and
the tibia exceeds 30 degrees, in dicating th at th e ankle is
actually dorsiflexed not plantarflexed. The apparent equinus of th e deform ity is usually due to plantar flexion
255
Special Studies
Gen etic testin g is h elpful to diagn ose m any patien ts with
CMT disease. However, since m any different genotypes
cause a sim ilar disorder, a n egative test does n ot rule out
th e disease. In gen eral, patien ts suspected of h avin g CMT
disease sh ould be referred to a n eurologist for electromyography an d n erve con duction testin g. Patien ts with type I
CMT disease tend to have decreased nerve con duction velocity on electrodiagnostic studies. In patients with type
II CMT disease, electrodiagn ostic studies typically dem on strate n orm al or m inim ally decreased conduction velocity
but decreased am plitude of action poten tials. In rare cases,
th e com bin ation of gen etic testin g an d electrophysiologic
testin g is still in sufficien t to m ake th e diagn osis. In th ese
situations, a sural n erve biopsy should be perform ed.
Differential Diagnosis
Many different diseases can produce a sim ilar cavovarus
foot deform ity as does CMT disease, includin g spinal
cord tum ors, Friedreich ataxia, diastem atomyelia, an d syrin gomyelia. A un ilateral cavovarus deform ity, in particular, sh ould raise suspicion of spinal cord pathology. It is
importan t to rem em ber that a cavovarus foot is never norm al; if a patient does n ot have electrodiagnostic or genetic
256
Treatment
Th ere is n o clin ically proven m edical treatm en t th at h alts
or slows progression of CMT disease. Treatm en t, th erefore,
is directed at correctin g deform ities an d m axim izin g fun ction . Con servative m easures are largely un successful for
treatin g cavovarus feet. Occasion ally, sh oe in serts can be
useful to elevate th e m etatarsal h eads an d reduce th e symptom s of m etatarsalgia. In patien ts with sign ifican t drop
foot gait, an AFO can improve toe clearance by preventin g excessive plan tar flexion durin g swin g ph ase. Early in
the disease process, transfer of the peron eus longus to the
peron eus brevis an d plan tar fascia release can rem ove th e
deform in g forces an d lim it progression of th e deform ity.
O n ce th e first ray becom es plan tar flexed, a dorsiflexion
osteotomy of th e first m etatarsal alon g with ten don tran sfers is necessary to balan ce th e foot. If the hin dfoot is
rigid, as assessed by the Colem an block test, a calcaneal
osteotomy sh ould be added to correct th e varus deform ity
(Fig. 11.40). Claw deform ities of th e great an d lesser toes
can be m anaged by Jon es transfers of th e exten sor tendon s to th e m etatarsal n ecks. A triple arth rodesis sh ould
be avoided if at all possible, alth ough in severe, rigid deform ities, it m ay be th e on ly m ean s of obtain in g a plan tigrade
foot.
Muscular Dystrophy
Muscular dystroph ies are a group of gen etic diseases, ch aracterized by progressive deterioration of skeletal m uscle.
By definition , the pathologic changes are confined to th e
m uscle itself with n o abn orm alities seen in th e periph -
Pathophysiology
Th e un derlyin g etiology of Duch en n e m uscular dystrophy
is the absence of the m uscle protein dystrophin . The gene
respon sible for producin g dystroph in resides on th e Xch rom osom e, wh ich explains why Duchenne m uscular dystrophy is in h erited in an X-lin ked m an n er. In m ost cases, th e
gen etic defect is a fram esh ift m utation th at results in n o
protein bein g produced. Norm ally, dystroph in acts to stabilize th e cell m em bran e cytoskeleton in m uscle. Absen ce
of dystroph in leads to in creased fragility of th e m yofiber
m em brane and leakage of cellular contents into the extracellular space. This creates an inflam m atory response
that results in loss of m uscle fibers and fibrosis of the
m uscle.
Presentation and Natural History
Boys with Duch enn e m uscular dystrophy typically presen t
between ages 3 an d 8. Th e presen tin g com plain t is often
a waddlin g gait, difficulty with stairs, clum sin ess, or progressive lower extrem ity weakn ess. Th e m uscle weakn ess
that develops is sym m etric, and proxim al m uscles are affected before distal m uscles. Lower extrem ity in volvem en t
ten ds to precede upper extrem ity in volvem en t by 3 to 5
years. Weakness of hip extensors leads to anterior pelvic
tilt and compensatory lum bar lordosis. In addition, weak
abductors can result in a Trendelenburg gait. Ch ildren m ay
also present with ankle equinus due to fibrosis an d contracture of the gastroc-soleus complex. As the disease progresses, walkin g becom es m ore difficult. By age 12, m ost
patien ts with Duch en n e m uscular dystrophy becom e fulltim e wheelchair users. Once patients lose the ability to
am bulate, scoliosis develops in the vast m ajority of patients. Spinal deform ity tends to progress relentlessly and
can complicate worsening pulm on ary function due to a
weaken ed diaph ragm an d ch est wall. Death usually occurs in the second or third decade of life due to respiratory
failure.
History and Physical Examination
Sin ce Duch en n e m uscular dystrophy dem on strates Xlinked inheritance, any fam ily history of the disease should
prompt an early workup. O n e-th ird of all cases, h owever,
are due to spontaneous m utations, so lack of fam ily history
is by n o m ean s conclusive. Any young boy wh o h as a h istory of progressive clum sin ess or weakn ess sh ould be evaluated for m uscular dystrophy. While tripping and falling are
com m on parental complain ts in the orthopaedic clinic, a
boy wh o is fallin g m ore frequen tly th an h e did in th e past
sh ould be taken seriously.
O bservation of th e ch ild walkin g m ay reveal a waddlin g gait due to lum bar lordosis an d abductor weakn ess.
257
this task and will often use their upper extrem ities to help
exten d th eir kn ees an d h ips. Ch ildren wh o appear to walk
their hands up their legs to help raise th e trunk into an upright position have a positive Gowers sign (Fig. 11.42).
As th e disease progresses, ch ildren often develop kn ee
an d h ip flexion con tractures. As th e ch ild becom es m ore
depen den t on a wh eelch air, th e spin e sh ould be carefully
m on itored for sign s an d symptom s of scoliosis.
Toe-walking can also be seen from fibrosis and contracture of th e triceps surae. Although th e gastroc-soleus m uscle is weaker than norm al, the m uscle belly often appears
enlarged. This fin din g is term ed pseudohypertrophy, is
presen t in approxim ately 85% of ch ildren with Duch en n e
m uscular dystrophy, and results from fibro-fatty replacem en t of the m uscle fibers (Fig. 11.41). In these cases, ran geof-m otion testin g of th e an kle will reveal decreased an kle
dorsiflexion , alth ough a true equin us con tracture does n ot
typically develop for several years.
Careful m an ual m uscle testin g of ch ildren with
Duch en n e m uscular dystrophy will reveal weakn ess in
the proxim al m uscle groups. The m ost classic and useful screening test for Duchenne m uscular dystrophy is the
Gowers sign . Th is test is perform ed by askin g th e ch ild to sit
on th e floor of th e exam in in g room an d to stan d up quickly
with out assistan ce. Patien ts with m uscular dystrophy an d
proxim al m uscle weakn ess will h ave difficulty completin g
Diagnostic Studies
If a diagn osis of m uscular dystrophy is suspected, th e first
step is to m easure th e creatine kin ase level in the blood.
In n orm al patien ts, th e creatin e kin ase level is less th an
300 U/ L; patien ts with m uscular dystrophy can h ave values greater th an 10,000 U/ L. Ch ildren with elevated blood
creatin e kin ase levels sh ould be referred for gen etic testing, which can yield a defin itive diagnosis in up to 95% of
patien ts. For th ose few patien ts in wh om th e diagn osis is
still uncertain after gen etic testin g, a m uscle biopsy m ay be
n ecessary. By perform ing a Western blot test on th e biopsy
specim en , one can determ in e conclusively wheth er or not
dystroph in is presen t.
Differential Diagnosis
Th e differen tial diagn osis of Duch en n e m uscular dystrophy in cludes oth er form s of m uscular dystrophy an d m yoton ic dystrophy. Becker m uscular dystrophy is a m ore
ben ign disease th at also results from a m utation in th e
dystroph in gen e. In con trast to Duch en n e disease, th e
deletion in Becker m uscular dystrophy results in eith er a
truncated dystrophin m olecule or lower am ounts of norm al dystrophin. Becker m uscular dystrophy is characterized by sim ilar pathology but a m ilder disease course than
Duch en n e m uscular dystrophy.
Lim b girdle m uscular dystrophy actually refers to a large
group of m uscle diseases th at are ch aracterized by progressive m uscle deterioration , predom inantly in the m uscles of
th e pelvic an d sh oulder girdle. Most cases are in h erited in
an autosom al recessive m anner; on set of symptom s is often in late adolescen ce or early adulth ood. In gen eral, th e
clin ical course is m ore ben ign th an in Duch en n e m uscular
dystrophy. Gen etic tests for dystroph in abn orm alities will
258
Treatment
Th e m ost prom isin g m edical treatm en t for Duch en n e m uscular dystrophy is the use of corticosteroids. Steroids are
though t to alter th e disease process by stabilizin g th e myofiber m em bran e an d reducin g th e in flam m atory respon se
caused by leaking cell conten ts. Several recen t studies have
proven th e efficacy of corticosteroids in prolon gin g am bulatory ability, preservin g pulm on ary fun ction , an d delayin g
the onset of scoliosis. In one study, one-third of patients
receivin g treatm en t were still walkin g at 18 years of age.
Subjects in th e treatm en t group were also foun d to h ave
40% greater forced vital capacity and a 50% lower rate of
scoliosis th an controls. The ben efits of prolonged steroid
therapy need to be balan ced with the risks, which include
weigh t gain , osteopenia, and cataracts.
O rth opaedic treatm en t gen erally focuses on m axim izin g
am bulatory poten tial an d treatin g spin al deform ity. Early
in th e disease process, physical th erapy an d appropriate
use of lower extrem ity orth oses can delay or lim it th e developm en t of con tractures. As m uscle weakn ess worsen s
an d con tractures do develop, surgical release of h ip an d
knee flexion deform ities m ay help preserve walking ability, alth ough such surgery is rarely perform ed curren tly.
Equinus and equinovarus contractures resistant to conservative m odalities can be treated with Achilles ten don
len gth en in g an d/or tran sfer of th e posterior tibial ten don (Fig. 11.43). As ch ildren lose th e ability to am bu-
Arthrogryposis
Th e term arthrogryposis actually applies to a variety of con dition s th at are ch aracterized by decreased fetal m ovem en t
an d congenital joint contractures. Collectively, the inciden ce of arth rogryposis is approxim ately 1 per 3,000 live
birth s. Th e in ciden ce of am yoplasia, th e m ost com m on
type of arthrogryposis, is 1 in 10,000.
Pathophysiology
Th e fin al com m on path way th at causes arth rogryposis is
decreased fetal m ovem en t, wh ich leads to m ultiple join t
con tractures in utero. This lack of m otion is m ost often due
to failure of skeletal m uscle developm en t due to an un derlying n europathic or myopathic abnorm ality. Occasion ally,
space lim itations in utero or m aternal disease can lim it fetal
m obility. Although m ajor joints initially develop norm ally
from an em bryological stan dpoint, lack of m ovem en t in
259
Classification
Arthrogryposis can be classified into three general categories based on th e degree of nonm usculoskeletal organ involvem ent. Group 1 affects only the lim bs and in cludes the
m ost typical form of arthrogryposis, amyoplasia. Group 2
disorders affect th e abdom in al viscera an d oth er organ s
in addition to th e lim bs. Examples include m ultiple pterygium syndrom e and Larsen syndrom e. Group 3 condition s
involve the CNS in addition to the joint contractures.
Presentation
Ch ildren with classic arthrogryposis typically present soon
after birth with m ultiple rigid join t contractures, absent
skin creases, an d atrophy of th e lim bs. The m ost com m on appearance is the waiters tip posture caused by shoulder in tern al rotation an d adduction , elbow exten sion , an d
wrist flexion (Fig. 11.44). Lower extrem ities usually dem on strate knees that are stiff in either flexion or extension an d
equin ovarus deform ities of th e foot. O n e form of arth rogryposis, called distal arthrogryposis, presen ts with prim arily hand and foot involvem ent (Fig. 11.45). Th ese children
h ave typical overlappin g fin gers an d th um b in palm deform ities in addition to clubfoot or vertical talus deform ities. Unlike m any syndrom es, children with arthrogryposis
h ave norm al intelligence an d actually perform better than
average in sch ool.
Differential Diagnosis
Since as m any as 150 different syndrom es can exhibit features of arthrogryposis; the m ost importan t step in m akin g
260
the diagnosis of amyoplasia or classic arthrogryposis is rulin g out an oth er kn own gen etic syn drom e. Multiple pterygium syn drom e resem bles amyoplasia in term s of th e m ultiple join t con tractures. However, den se, fibrotic webbin g
will be seen across th e flexor surfaces of the kn ee in particular (Fig. 11.46). Th ese ch ildren will also h ave gen itourin ary
an d cran iofacial in volvem en t. Larsen syn drom e is officially
considered a group 2 disorder but has m any distin guish ing
features compared with amyoplasia. Children with Larsen
syn drom e have a characteristic facial appearance (flatten ed
face, depressed n asal bridge, an d widely set eyes) an d join t
dislocation s due to ligam en tous laxity. Th ere is also a h igh
in ciden ce of spin al deform ity in th is con dition , particularly
cervical kyphosis. Occasionally, som e skeletal dysplasias
that exhibit restricted join t m otion (e.g., diastrophic dysplasia) can be con fused with amyoplasia. Usually, th e fin din gs of sh ort stature an d lim b sh orten in g are sufficien t to
differen tiate th ese diagn oses.
Treatment
Th e two m ajor goals of treatm en t are m axim izin g am bulatory ability an d upper extrem ity fun ction to allow in depen den t fun ction in g for activities of daily livin g. It is importan t
to rem em ber th at arth rogrypotic join ts fun ction poorly for
a n um ber of different reason s, includin g a thickened join t
capsule, fibrotic tendons, atrophied m uscles, tight skin, and
poorly developed bursa. Th erefore, even th e best surgical
option s can n ot be expected to recreate n orm al an atom y
nor yield freely m obile joints.
Depen din g on th e severity of th e con dition , early
stretchin g and cast correction is useful to m inim ize deform ity. Hip deform ities are com m on in arth rogryposis an d
usually con sist of dislocation an d con tracture (Fig. 11.47).
B
Figure 11.47 (A) Left teratologic hip dislocation in a child with arthrogryposis. (B) Seven years
after open reduction, the left hip remains well reduced. (Reproduced with permission from Childrens
Orthopaedic Center, Los Angeles, CA.)
261
Classification
Rickets is classified on the basis of the specific etiology. Nutritional rickets (vitam in D deficien t rickets) is th e m ost
classic form of th e disease. Alth ough rare in th e developed world due to th e fortification of m ilk products, n utritional rickets can still occur in those who are exclusively
breast-fed an d are sh eltered from sun exposure. Vitam in D
depen den t rickets h as two form s: type I an d type II. Type I
disease is caused by a deficien cy in -hydroxylase, the enzym e th at con verts th e in active form of vitam in D to th e active form in the kidney. Type II disease results from a defect
in the intracellular receptor for active vitam in D. The m ost
com m on form of rickets is vitam in D resistan t rickets, also
known as familial hypophosphatemicrickets. Th is X-lin ked disorder causes im paired ren al tubular reabsorption of ph osph ate. Oth er causes of rickets or rickets-type con dition s
include renal osteodystrophy (osteom alacia from renal disease), hypoparathyroidism (low production of PTH), an d
pseudohypoparathyroidism (lack of effect of PTH at th e
target cells).
Presentation and Physical Examination
Children with rickets have generalized m uscular weakness,
lethargy, and irritability. Motor developm ental m ilestones
such as sittin g and walking m ay be delayed. Th e child
262
Ca2+
Ca2+
Ca2+
Ca2+
Ca2+
Ca2+
Ca2+
A
Figure 11.48 The roles of the bone,
Ca2+
Ca2+
Ca2+
Ca2+
Ca2+
Ca2+
Ca2+
Ca2+
Ca2+
Ca2+
Ca2+
Ca2+
Ca2+ Ca2+
Ca2+ Ca2+
Ca2+
and often bowed. Knee deform ity is very com m on and can
m anifest as either genu varum or genu valgum . If rickets
is active during the n orm al age of physiologic genu varum
(ages 1 2 years), th en path ologic gen u varum deform ity
prevails. On th e oth er h an d, if rickets is active durin g th e
n orm al age of physiologic gen u valgum (ages 2 4 years),
Radiographs
Th e radiograph ic fin din gs in rickets m irror th e h istologic
changes (Fig. 11.50). The cortices of long bones are thin,
and the trabeculae are indistinct. Osteopenia is th e hallm ark of rickets in the child. Sin ce there is no zone of provision al calcification with the resultan t pile up of hypertrophic zone cells, the width of the physis is increased.
Sim ilarly, the classic cupping of the m etaphysis is noted
from stunting of the growth plate centrally while n orm al
periph eral apposition al growth of th e perich on dral rin g
con tin ues. Ren al osteodystrophy h as som e un ique radiograph ic features, in cludin g a salt an d pepper skull; th e
absence of a cortical outlin e at the distal end of clavicles;
and subperiosteal resorption of the ulnas, term in al tufts of
th e distal ph alan ges, an d m edial proxim al tibia. In lon gstan ding ren al osteodystrophy, brown tum ors, seen as expan ded destructive bon e lesion s, m ay appear.
Special Tests
Th e m ain diagn ostic tests in clude serum calcium , ph osph ate, alkalin e ph osph atase, an d PTH levels. Oth er laboratory tests include vitam in D, urine calcium , and urine phosph ate levels. Based on th e salien t laboratory fin din gs, th e
un derlyin g etiology of rickets can be iden tified (Table 11.1).
Differential Diagnosis
Osteom alacia is the adult counterpart to rickets an d occurs
on ly after th e physes h ave closed. Physiologic gen u varum ,
Bloun t disease, and idiopath ic gen u valgum sh ould be considered in th e differential diagn osis of genu varum and
TABLE 11.1
RICKETS
Etiology
Primary Effects
Secondary Effects
Nutritional rickets
Vitamin D deficiency
Calcium deficiency
Phosphate deficiency
25-Hydroxyvitamin D
Calcium in diet
Phosphate
1,25-Dihydroxyvitamin D, PTH
Vitamin D, PTH
1,25-Dihydroxyvitamin D,
normal PTH
1,25-Dihydroxyvitamin D
1,25-Dihydroxyvitamin D
Normal or 25-hydroxyvitamin D
Normal or 25-hydroxyvitamin D
Phosphate
Chronically PTH
Aluminum results in PTH
Phosphate, calcium
Parathyroid disorders
Hypoparathyroidism
PTH
Pseudohypoparathyroidism
Normal to PTH
PTH, parathyroid hormone.
263
1,25-Dihydroxyvitamin D
1,25-Dihydroxyvitamin D
264
D
Figure 11.50 Rickets. Change caused by rickets can be seen (A) at the wrist and (B) at the knees of
this 1-year-old child with familial hypophosphatemic rickets. The growth plates are widened and the
metaphyses are cupped, particularly at the ulna and femur. At 4 years of age (C and D) the changes
have resolved with medical treatment. (Reproduced with permission from Morrissy RT, Weinstein SL.
Lovell and Winters Pediatric Orthopaedics. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
Treatment
Medical m an agem en t of th e un derlyin g m etabolic disturban ce, usually coordin ated by a pediatric en docrin ologist,
is th e m ain stay of treatm en t. Depen din g on th e specific
cause of th e rickets, treatm ent m ay include adm in istration
of supplem en tal vitam in D, calcium , an d/ or ph osph ate.
Th e exten t of rem odelin g likely to occur depen ds on th e
am oun t of growth rem ain in g after correction of th e un derlyin g m etabolic disturban ce. Ren al osteodystrophy in volves com plex m an agem en t of th e kidn ey, usually by a
pediatric n eph rologist. In som e patien ts, aggressive m an agem en t of ren al fun ction m ay abrogate th e n eed for surgi-
265
TABLE 11.2
Skeletal Manifestation
Sclerae
Teeth
Collagen Defect
Mild
Blue
II
Lethal
III
IV
Severe
Moderate
White
White
Dentinogenesis imperfecta
Normal (IVA) or dentinogenesis
imperfecta (IVB)
From Morrissy RT, Weinstein SL. Lovell and Winters Pediatric Orthopaedics. Philadelphia, PA: Lippincott Williams &
Wilkins, 2006.
Osteogenesis Imperfecta
Pathophysiology
Osteogen esis imperfecta (O I), or brittle bone disease, is a
rare con dition , with an estim ated prevalen ce of 1 in 20,000
ch ildren . OI is not a single disorder but is rather a spectrum
of clin ical con dition s th at h ave in creased bon e fragility in
com m on. In alm ost all cases, OI results from a quan titative or qualitative defect in type I collagen form ation .
Type I collagen is th e m ajor structural protein foun d in
bon e, skin , ten don , ligam en t, corn ea, sclera, an d den tin ,
an d deficien cy in th is type of collagen results in fragility
of th e en tire skeleton . Th e m ost com m on m utation s responsible for OI in volve one of two gen es th at encode th e
ch ains of type I collagen , the COL1A1 gene or the COL1A2
gen e.
Classification
Th e m ost com m on ly used classification system for categorizing OI is the Sillence classification (Table 11.2). Although the Sillen ce system accounts for the m ajority of
patien ts, recen t gen etic an d bioch em ical research h as led
to th e discovery of four addition al types of O I. Type V disease is ch aracterized by excessive callus form ation , wh ich
can occasionally be confused with osteosarcom a. Type VI is
sim ilar to types III and IV but have norm al collagen form ation. Type VII is a rh izom elic variant with a predisposition
to th e proxim al appen dicular bon es.
Presentation and Physical Examination
Th e clin ical picture varies accordin g to th e severity an d
type of OI. Multiple path ologic fractures are th e hallm ark
of th e disease. In gen eral, th e earlier th e fractures occur,
the m ore severe the disease. The lower lim bs are m ore frequen tly in volved as th ey are m ore pron e to traum a. Repetitive fractures in th e epiphysis or physis m ay lim it growth
an d contribute to th e short stature that is com m only seen
tures have created significant bowing in all four extremities. (Reproduced with permission from Broughton NS. Textbook of Paediatric
Orthopaedics. London, England: WB Saunders, 1997.)
266
fin din gs in clude sm all, trian gular faces; defective den tin ogen esis (sm all, fragile teeth ); an d defective h earin g from
otosclerosis. Cran ial n erve palsies, h eadach es, apn eic
episodes, spasticity, nystagm us, or weakn ess sh ould alert
the physician to the potential for basilar invagin ation in
patien ts with O I.
Radiographs
Gen eralized osteopen ia is detected on plain radiograph s in
patien ts with O I. Sin ce in tram em bran ous bon e growth is
aberran t, th e n orm al cylin derization of lon g bon es does
not occur, leaving behind th in, sten otic diaphyses as th e
hallm ark of OI. The long bones appear bowed with th in
cortices (Fig. 11.52). Deform ities are presen t from m ultiple
fractures (Fig. 11.53). The pelvis m ay show acetabular protrusion . Th e spin e dem on strates osteopen ic vertebrae th at
fracture easily, resulting in flattened or bicon cave sh ape.
Th oracic or th oracolum bar scoliosis is n ot un com m on . In
addition , th e skull m an ifests worm ian bon es, isolated lakes
of bon e typically foun d in an d aroun d th e cran ial sutures.
Figure 11.52 Multiple microfractures over time have led to bow-
Special Tests
In spite of gen etic advan ces, th ere is n o sin gle test th at is
sufficien t to m ake the diagnosis of OI. This is in part due
to th e wide variety of gen etic an d bioch em ical con dition s
that can presen t with a sim ilar phenotype. The diagn osis
of OI, th erefore, rem ain s a clin ical on e based on th e en tire
clinical picture in cluding the appearance of the patient, a
history of fractures, th e presence of abn orm al sclerae or
teeth , an d ch aracteristic radiograph ic fin din gs.
ing and coxa vara of the right femur in this child with osteogenesis
imperfecta. This patient presented with hip pain and a femoral neck
fracture, caused, in part, by the proximal femoral deformity.
In certain cases, pren atal diagn osis of OI can be accom plish ed by ultrasoun d wh en lon g bon e deform ity, severely
reduced fem oral len gth , an d decreased ech ogen icity of th e
skull are recogn ized. Quantitative abnorm alities in collagen production can be detected in 87% of patien ts with
collagen an alysis of skin biopsies an d fibroblast cultures.
A,B
Figure 11.53 (A and B) Anteroposterior views of the upper extremities and (C) the lower extremities in a child with osteogenesis imperfecta. Note the deformity and callus formation from multiple
previous fractures. (Reproduced with permission from Childrens Orthopaedic Center, Los Angeles,
CA.)
Differential Diagnosis
Th e differen tial diagn osis of OI in cludes ch ild abuse, idiopath ic juven ile osteoporosis, an d rarely fibrous dysplasia.
Th e presen ce of osteopen ia, blue sclerae, fam ily h istory of
OI, an d hearing difficulties helps to distinguish OI from
ch ild abuse. Mild cases of OI, however, are often extrem ely
difficult to distin guish from n on acciden tal traum a. Th e
diagn osis idiopath ic juven ile osteoporosis, un like OI, is
usually a tran sien t, self-lim itin g ph en om en on . Fibrous dysplasia is n ot ch aracterized by th e presen ce of th in , sten otic
diaphyses on radiograph s an d h as m ore localized in volvem en t than OI.
Treatment
Recent advances in m edical th erapy have greatly improved
the m anagem ent of children with OI. By decreasing osteoclastic resorption of bon e, bisph osph on ates h ave been
sh own to increase cortical bon e thickness, decrease th e
inciden ce of fractures, relieve chronic bone pain, and increase the height of collapsed vertebrae in patien ts with
A,B
267
Figure 11.54 Leg deformity in a patient with type III osteogenesis imperfecta. (A) Preoperative
anteroposterior radiograph obtained at age 6 years demonstrates left tibial deformity. (B) Postoperative radiograph with leg in a cast shows multiple osteotomies (arrows) with intramedullary fixation.
(C) Films obtained after healing of osteotomies. (Reproduced with permission from Kocher MS,
Shapiro F. Osteogenesis imperfecta. J Am Acad Orthop. 1998;6:225236.)
268
Osteopetrosis
Pathophysiology
O steopetrosis is a sclerosin g bon e dysplasia ch aracterized by a diffuse in crease in skeletal den sity an d obliteration of m arrow spaces. Th e prim ary defect is osteoclastic dysfunction that impairs the bodys ability to resorb an d rem odel bone. Histologically, th e skeleton shows
cores of calcified cartilage surrounded by areas of norm al n ew bon e form ation . Alth ough th is bon e con tain s
norm al to increased n um bers of osteoclasts, th e cells are
abn orm al in fun ction , as dem on strated by th e absen ce
of ruffled borders an d clear zon es. As a result, bon e
an d cartilage can n ot be resorbed an d a den se pile of
prim itive trabeculae an d calcified ch on droid accum ulates
over tim e. Despite its den sity, osteopetrotic bon e is brittle
an d m ore likely to fail un der stress compared with n orm al bon e. Th e in ability to rem odel bon e also leads to
narrowed m edullary spaces an d im paired h em atopoietic
function.
Classification
Th ere are th ree form s of osteopetrosis: in fan tile m align an t,
in term ediate, an d adult tarda. In fan tile an d in term ediate
osteopetrosis are tran sm itted as an autosom al recessive
trait. Adult form is in h erited in an autosom al dom in an t
pattern .
Presentation and Physical Examination
Ch ildren with osteopetrosis often presen t with path ologic
fractures due to the fragility and brittleness of th eir bones.
Bony overgrowth of th e cran ial foram ina m ay m anifest as
cranial nerve palsies, blindness, or deafness. Osteomyelitis
an d den tal caries are n ot un com m on because of dim in ish ed vascularity of th e bon e an d a defective im m un e response. Th e lack of sufficien t m edullary space can cause
depressed bon e m arrow fun ction an d pan cytopen ia; affected patients typically present with signs and symptom s
of an em ia, recurren t in fection s, abn orm al bleedin g, easy
bruisin g, fatigability, an d failure to th rive in severe cases.
In addition , th is m arked dim in ution of bon e m arrow results in h epatosplenom egaly as extram edullary sites of
hem atopoiesis are stim ulated. For m alignan t in fantile osteopetrosis, th e clin ical course is rapidly progressive, an d
death m ay occur at a youn g age from sepsis or an em ia. O n
Radiographs
Th e h allm ark of osteopetrosis is in creased den sity of th e
bon es (Fig. 11.55). Th e m arble-like osseous structures appear den sely wh ite with out m edullary cavities. Bon e with in
bon e, kn own as endobone, is an area of radioden se tissue
that exists inside the cortices of other bones; the presence
of th is radiograph ic fin din g is path ogn om on ic of osteopetrosis. Sclerosis at th e vertebral en d plates with n orm al den sity of the cen tral body leads to a rugger jersey appearance of the spine (Fig. 11.56). In the appen dicular skeleton,
the m etaphyses are abnorm ally dilated (Erlenm eyer flask
appearance) because of impaired rem odeling an d tubularization of th e long bones. On skull film s, the basilar portions of the skull are sclerotic, and the supraorbital ridge is
den se an d quite prom in en t. Frequen tly, altern atin g ban ds
of sclerosis an d lucen cy are seen subjacen t to th e growth
plate, wh ich correlates with periods of h igh an d low disease
activity.
Special Tests
Routine blood tests are in dicated in m ost patients to screen
for pancytopenia or anem ia.
Pren atal diagn osis of osteopetrosis h as been accom plish ed in th e 25th week of pregn an cy with th e use of
fetal radiography, wh ich reveals sclerosis of osteopetrotic
bon e. Ultrasoun d h as also been used to iden tify affected
fetuses.
Treatment
Treatm ent for infantile osteopetrosis is bone m arrow transplan tation at a youn g age. A successful tran splan t can resolve both th e skeletal and hem atologic abnorm alities.
High dose 1,25-dihydroxyvitam in D th erapy with a low
calcium diet has been employed because of its ability to
stim ulate osteoclasts an d bone resorption.
O rth opaedic treatm en t ten ds to focus on fracture care
an d deform ity m anagem ent. Most fractures respond well to
closed treatm en t, although healing m ay be delayed. When
open treatm en t is n ecessary, th e extrem ely h ard bon e can
m ake fixation difficult: broken screws, drill bits, and even
drivers are a com m on experien ce. Severe deform ity m ay require corrective osteotom ies, especially coxa vara of th e h ip.
Sim ilar to th e treatm en t of fractures, surgery is tech n ically
ch allenging due to the difficulty in m aking the osteotomy
an d achieving adequate fixation.
Scurvy
Th is n utrition al defect is a classic bon e dystrophy th at
largely affects the m etaphyseal region. The extrin sic defect is a deficiency in vitam in C, which is a cofactor in
the norm al pathway of bone collagen synthesis. In its absence, th e resulting collagen is poorly cross-linked and
Figure 11.55 Six-month-old male infant with severe osteopetrosis and pancytopenia. (AE) Dense
sclerotic bones at the pelvis (A), humerus (B), and forearm (C), without evident medullary cavities.
(D and E) After successful bone marrow transplantation, the bony architecture in the humerus (D)
and the forearm (E) were normalized. (Reproduced with permission from Morrissy RT, Weinstein SL.
Lovell and Winters Pediatric Orthopaedics. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
270
logic or pathologic. In general, growth is considered aberran t wh en it falls two stan dard deviation s below th e m ean
h eight for age. Arguably, th is will in clude som e n orm al
individuals; however, it should stim ulate the exam iner to
m ore carefully pursue a diagnosis before assum ing that th e
child is physiologically short. The pathologic causes of
sh ort stature are m any but include both skeletal dysplasias
and m ucopolysacch aridoses (MPSs). An accurate diagnosis m ust be establish ed to provide appropriate m edical care
for these patien ts and to provide genetic counseling to the
patien t an d fam ily.
Achondroplasia
Pathophysiology
Achondroplasia is the m ost com m on type of skeletal dysplasia, with an estim ated worldwide prevalen ce of 1 in
15,000 to 40,000 live births. It can be inherited in an
autosom al dom inant fashion, alth ough as m any as twothirds of cases arise from spontaneous m utations. The defect in ach ondroplasia is an activatin g m issense m utation
in the gene encoding fibroblast growth factor receptor-3
(FGFR-3), m apped to chrom osom e 4. Th e m utated gene
product ultim ately results in retardation of cell division in
the proliferative zon e of the physis, thereby lim iting ench ondral bone growth. Intram em branous bone growth is
n ot affected.
Presentation
In fan ts presen t soon after birth with a ch aracteristic appearan ce (Fig. 11.57). The skull is norm al in size but appears
large relative to the shortened skeleton ; frontal bossing and
m idface hypoplasia are typical. Trun k length is within the
lower range of n orm al, but the lim bs are significantly sh orten ed in a rh izom elic pattern . Likewise, th e ribs are also
sh ort, causing the chest wall to be sm all and constricted.
Th is results in th e appearan ce of a protuberan t abdom en .
Th oracolum bar kyph osis is com m on but can improve with
age. Compensatory hyperlordosis in the lum bar region fre-
nounced shortening of the proximal limb segments (rhizomelic pattern). There is mild genu varum. The humeri are most affected. (B)
The elbows have a mild flexion contractures. He has had previous
osteotomies of the tibias and fibulas for genu varum. (Reproduced
with permission from Morrissy RT, Weinstein SL. Lovell and Winters Pediatric Orthopaedics. Philadelphia, PA: Lippincott Williams
& Wilkins, 2006.)
271
quen tly occurs. Scoliosis is seen in on e-th ird of th ese patients but is usually m ild.
Most patients with achon droplasia have som e degree of
spin al sten osis from shortened pedicles and a decreased
interpedicular distan ce. Som e patien ts m ay present with
exercise in toleran ce an d early fatigability; in severe cases,
frank myelopathy or radiculopathy can occur. The upper extrem ities typically dem on strate extra space between
th e th ird an d fourth rays of th e h an ds, causin g a triden t
h an d appearan ce. Th e lower extrem ities often exhibit in creased ligam en tous laxity, gen u varum , an d in tern al tibial
torsion.
Developm en tal m ileston es m ay be in itially delayed, but
n orm al m otor coordination even tually develops. Independen t am bulation is typically achieved by 18 to 24 m onths
of age. Ach on droplasia, like oth er skeletal dysplasias, is typically associated with norm al intelligen ce. Life expectancy
is som ewh at dim in ished, but quality-of-life studies h ave
sh own sim ilar scores compared with the general population.
Radiographs
All patien ts wh o are suspected of h avin g ach on droplasia
or any oth er type of skeletal dysplasia sh ould receive a
skeletal survey. Th is in cludes a lateral radiograph of the
skull an d n eck an d AP views of the entire spine, pelvis,
arm s, hands, and legs. The radiograph ic changes seen in
achondroplasia reflect those region s that are m ost dependen t on en ch on dral ossification . In th e lon g bon es, th e
m etaphyses are flared and the diaphyses are thick from
appositional growth. Unlike other types of skeletal dysplasia, th e epiphyses are spared. Lower extrem ity radiographs
m ay dem onstrate genu varum from abnorm alities of th e
distal fem ur, proxim al tibia, or relative overgrowth of th e
fibula. The radiographic appearan ce of the pelvis is classic in ach on droplasia. Since the h eigh t of the pelvis is a
function of enchondral bone growth, the achondroplastic
pelvis is un derdeveloped an d flatten ed with a ch am pagn e
glassoutlet, sm all sciatic notches and squared iliac wings.
At th e h ip, th e proxim al fem oral m etaphyses are widen ed
and the fem oral necks are short.
Spin e radiograph s are n ecessary to screen for scoliosis
and kyphosis. In the latter condition , the apical vertebrae
m ay becom e progressively wedge-shaped in the sagittal
plan e. Th e AP view sh ould also be evaluated for decreasing interpedicular distance, which indicates the presence of
spin al stenosis (Fig. 11.58).
Special Tests
Direct deoxyribon ucleic acid an alysis to iden tify m utation s
in th e FGFR3 gen e can be perform ed postn atally or pren atally to screen fam ilies at risk. In addition , pren atal ultrason ography can iden tify characteristic skeletal anom alies
and hydrocephalus. Advanced im aging studies, either CT
272
or MRI, m ay be n ecessary to evaluate for foram en m agnum sten osis, which is com m on due to th e disproportion ate growth of th e calvarium relative to th e basilar skull an d
neck. MRI is also useful in the workup of spinal stenosis to
localize areas of cen tral or foram in al compression .
Differential Diagnosis
Th e differen tial diagn osis of ach on droplasia in cludes oth er
causes of short stature such as rickets and other types
of skeletal dysplasia. Many differen t skeletal dysplasias
have been described, an d a com plete discussion of all of
these conditions is beyond th e scope of th is text. Som e
brief differen ces will be m en tion ed an d select con dition s
(diastroph ic dysplasia, spon dyloepiphyseal dysplasia
[SED], and m ultiple epiphyseal dysplasia) will be discussed in the following section. Short-lim bed dysplasias
in clude hypoch on droplasia, m etatropic dysplasia, ch on droectoderm al dysplasia (also kn own as Ellisvan Creveld
syn drom e), diastroph ic dysplasia, chon drodysplasia pun ctata, an d pseudoach on droplasia. Hypoch on droplasia resem bles achondroplasia but is less severe. In m etatropic
dysplasia, th e in fan t ch ild h as sh ort lim bs an d a relatively
lon g trun k, but as th e ch ild grows, severe kyph oscoliosis de-
Treatment
From a m edical stan dpoin t, in fan ts with ach on droplasia
sh ould be carefully m on itored during the first few years of
life for sleep apnea, spasticity, or hypertonia, wh ich m ay
be th e result of foram en m agn um sten osis. Alth ough th is
gen erally im proves with growth , severe cases m ay warran t
decom pression of th e brain stem . Ear, n ose, an d th roat
problem s are frequen t because of m idface hypoplasia, an d
early referral to an otorh in olaryn gologist m ay be in dicated.
From an orth opaedic stan dpoin t, treatm en t is gen erally
aim ed at controlling deform ity, m axim izing function , and
preven tin g n eurologic deterioration . Gen u varum is typically m an aged by corrective osteotomy since there is no
eviden ce th at bracin g is effective in ch ildren with ach on droplasia (Fig. 11.59). Hip deform ities should be corrected
surgically to preserve a n eutral m echanical axis an d m axim ize function. The thoracolum bar kyphosis seen in in fan ts
with ach on droplasia sh ould in itially be observed. In m ost
cases, th e deform ity resolves as the child begins to am bulate and m uscle tone improves (Fig. 11.60). In th e 10% to
15% of cases that do n ot resolve, bracing m ay be used for
flexible curves. Occasion ally, posterior fusion and instrum en tation m ay be necessary to correct persistent deform ity.
Spin al sten osis sh ould be treated with wide decom pression
(several levels above the stenotic segm ent to several levels
below) followed by posterior stabilization . Th e use of pedicle screws is preferred over wires or hooks, which occupy
space in th e already n arrowed spinal can al.
Th e topic of lim b len gth en in g is a source of sign ifican t
con troversy in the orthopaedic com m unity. Quality-of-life
studies in patients with achondroplasia have dem onstrated
excellen t fun ction , an d critics complain th at lim b len gth en in g is a lon g an d difficult process to un dertake for prim arily a cosm etic result. Proponen ts of len gthenin g cite
the ability to improve self-im age and enhance function in
an otherwise adult-sized world. Unlike m ost other types of
skeletal dysplasia, achon droplasia is am enable to len gthen in g because th e join ts are n orm al an d th e ten don s, vessels, and nerves h ave a capacity to stretch . The decision to
A,B
273
C,D
Figure 11.59 (A) This 9-year-old boy with achondroplasia has genu varum frequently seen in this
condition. (B) Standing anteroposterior (AP) radiograph of the lower extremities confirms genu varum
due to fibulae being longer than the tibiae. (C) Standing AP radiograph of the lower extremities following corrective tibial and fibular osteotomies demonstrates reestablishment of a normal mechanical
axis. (D) Postoperative clinical photograph confirms improvement in genu varum. (Reproduced with
permission from Skaggs DL, Flynn JM: Staying Out of Trouble in Pediatric Orthopaedics. Philadelphia,
PA: Lippincott Williams & Wilkins, 2006.)
A,B
C
Figure 11.60 Thoracolumbar kyphosis in a 23-month-old achondroplastic child who has not walked
yet. (A) It is most pronounced in the sitting position. (B) Radiograph shows hypoplasia of L1, with
rounding-off of the anterior vertebral body corners. (C) At 5 years of age, after a period of brace
treatment, the shape of L1, as well as the overall kyphosis has improved. (Reproduced with permission from Morrissy RT, Weinstein SL. Lovell and Winters Pediatric Orthopaedics. Philadelphia, PA:
Lippincott Williams & Wilkins, 2006.)
274
Diastrophic Dysplasia
Diastroph ic dysplasia is a severe sh ort-lim bed dwarfism
that is extrem ely rare, affecting approxim ately 1 in 100,000
live birth s. Diastroph ic dysplasia is in h erited in an autosom al recessive fash ion an d in volves th e gen e DTDST, wh ich
en codes a sulfate tran sporter protein th at is in volved in
proteoglycan m etabolism in cartilage. As a result, cells in
affected cartilage h ave an impaired growth respon se to fibroblast growth factor. Ultim ately, en ch on dral growth is
impaired.
Diastroph ic dysplasia is quite apparen t at birth , n oted
by extrem ely short stature, rhizom elic sh ortening of the
lim bs, and rigid foot deform ities (Fig. 11.61). Th e head
is n orm al-sized but th e face is dysm orph ic with a n arrow
nasal bridge, flared nostrils, and a broad m idn ose. Prom inent cheeks an d fullness around the m outh have som etim es led to th e term ch erub dwarf. At approxim ately
3 to 6 weeks of age, the external part of the ear develops cystic swellin g th at later calcifies in florets, resultin g
in th e ch aracteristic cauliflower ear. Th e h an ds are typically sh ort and broad with ulnar deviation. Abduction and
sh orten ing of the first m etacarpal leads to the ch aracteristic
appearan ce of a h itch h iker th um b. Flexion con tractures
often develop at th e elbow, h ip, an d kn ee join ts, resultin g
in severe fun ction al lim itation an d gait disturban ce. Hip
dysplasia or fran k dislocation is a com m on fin din g; bilateral dislocation s are seen in up to 25% of cases. Un like
ach on droplasia, th e epiphyses in diastroph ic dysplasia are
affected an d m ay becom e flatten ed an d arth ritic over tim e.
At the knees, genu valgum frequently occurs and m ay be
associated with patellar dislocation . A wide spectrum of
foot deform ities is seen in patients with diastrophic dysplasia. Th e m ost com m on fin din gs in clude adduction an d
valgus or clubfoot. There m ay be a wider space between
the prominent cheeks, circumoral fullness, equinovarus feet, valgus knees with flexion contractures, and abducted or hitchhiker
thumbs. (Reproduced with permission from Morrissy RT, Weinstein
SL. Lovell and Winters Pediatric Orthopaedics. Philadelphia, PA:
Lippincott Williams & Wilkins, 2006.)
275
B
Figure 11.62 (A) Cervical kyphosis in a 1-year-old child with diastrophic dysplasia and marked deformity of C4. The patient was neurologically normal. (B) Seven years later, the vertebral bodies have
been restored to a nearly normal shape without any intervention. (Reproduced with permission from
Morrissy RT, Weinstein SL. Lovell and Winters Pediatric Orthopaedics. Philadelphia, PA: Lippincott
Williams & Wilkins, 2006.)
neurologic impairm ent (Fig. 11.62). Progressive, symptom atic, or un stable deform ities require cervical decom pression an d fusion usually followed by h alo im m obilization. Scoliosis rarely responds to bracing, and posterior fusion is recom m en ded for progressive curves greater th an
50 degrees.
Deform ed h ips m ay require corrective osteotomy. In dislocated hips, closed reduction is seldom successful an d
open reduction with pelvic an d/ or fem oral osteotom ies
an d soft tissue releases is usually necessary to achieve adequate reduction . Despite on es best efforts, h ips in diastrophic dysplasia often develop early osteoarthritis and
m ay require joint arthroplasty in adulthood. Foot deform ities are often rigid in diastroph ic dysplasia, and thus are resistance to stretching casts. Surgical correction to ach ieve a
plan tigrade foot is often n ecessary on ce th e ch ilds foot h as
reach ed an operable size. Surgical recon struction in cludes
appropriate osteotom ies and soft tissue releases catered to
the individual foot. Postoperative bracing is recom m ended.
Recurrence is com m on, often necessitating repeat surgery.
Severe deform ities m ay warran t salvage procedures such as
talectom y or fusion .
skeleton with relative sparing of the physes and m etaphyses. MED is a h eterogen eous disorder, but in m ost cases,
a m utation in the gene on chrom osom e 19 th at codes for
cartilage oligom eric m atrix protein is responsible for the
disorder.
Patien ts with MED typically presen t later in ch ildh ood
an d occasion ally as late as adulth ood. Sh ort stature is m oderate: m ost patien ts ach ieve an average adult h eigh t of between 54 an d 60 in . Presen tin g complain ts in clude join t
pain , decreased ran ge of m otion , difficulty walkin g, an d
an gular deform ities of th e lower extrem ity. MED affects
m ultiple join ts in both lower an d upper extrem ities, but th e
spin e an d face are n orm al. Th e m ost severe site of involvem en t is usually th e h ips. Coxa vara an d join t subluxation
are com m on , an d coexistin g avascular n ecrosis can develop
in up to 50% of patien ts; early degen erative ch an ges result
from the flattened and m isshapen epiphysis. Knees generally dem on strate gen u valgus from hypoplastic fem oral
condyles an d sloping of the proxim al tibia. Th e ankles are
also in valgus, usually from squarin g of th e talus. In th e
upper extrem ities, com m on fin din gs in clude flexion con tractures, fin ger deform ities, an d dislocation of th e radial
h ead with com pensatory capitellar en largem en t.
Radiograph s, in cludin g a complete skeletal series, are
an essen tial part of th e diagn ostic workup. In volvem en t of
m ultiple join ts is ch aracteristic, an d secon dary ossification
centers are generally delayed in appearan ce. The epiphyses
276
in the femoral epiphyses. Such changes can occasionally be confused with those seen in LeggCalvePerthes
Spondyloepiphyseal Dysplasia
SED is an extrem ely rare skeletal dysplasia occurrin g in approxim ately 1 in 4 m illion people. Th e con dition com es
in two m ajor form s: con gen ita an d tarda. SED con gen ita
is typically in h erited in an autosom al dom in an t fash ion ,
whereas SED tarda is usually X-linked. In both cases, h owever, th e con dition can arise from spon tan eous m utation
or differen t pattern s of gen etic tran sm ission . Both form s of
the disorder result from a genetic defect in the production
of type II collagen .
SED tarda presen ts at a later age with m ilder clin ical
features than SED congenita. In th e latter form , patients
presen t with a ch aracteristic appearan ce of sh ort stature
(in volving both trunk and extrem ities), sm all m outh, pectus carin atum , sm all rib cage, and protuberant abdom en
(Fig. 11.64). Hips usually have varus deform ities and flexion con tractures that lead to a compensatory lum bar lordosis an d a waddlin g gait. Kn ees typically are in varus, and the
m ost com m on foot deform ity is equinovarus. As the nam e
implies, SED congenita affects the spin e in addition to
th e extrem ities (un like MED). Neck in stability is com m on
from odontoid hypoplasia, and a careful neurologic assessm ent is necessary in all patients to screen for myelopathy.
Scoliosis is presen t in approxim ately 50% of patients.
In con trast, SED tarda results in a m ildly sh orten ed
stature, m ostly due to sh ortening of the trun k rather th an
th e extrem ities. Spin e in volvem en t is equally m ild an d usually consists of m ild platyspondyly. Angular deform ities
of th e lower extrem ity are relatively rare, but degen erative
changes can occur in the hips and knees by early adulthood.
A skeletal survey including appropriate views of the
spin e are n ecessary as part of the diagnostic workup. Varus
deform ities of th e proxim al fem ur are typical of SED con gen ita, an d ossification of th e fem oral epiphysis m ay be
delayed. In both form s of SED, radiograph s of th e h ip
m ay reveal flattening, enlargem ent, and progressive extrusion of th e epiphysis (Fig. 11.65). In the lower extrem ities,
gen u valgum is m ore com m on th an gen u varum . Spin e
radiograph s will dem on strate flatten in g of th e vertebral
bodies (platyspon dyly), posterior wedgin g of th e vertebra,
and disc space n arrowing. Th e pattern of scoliosis, when
presen t, is sh arply an gulated over a few vertebral segm en ts.
As m en tion ed, cervical views sh ould be obtain ed periodically to look for os odon toideum , odon toid hypoplasia, or
atlantoaxial instability.
Like other skeletal dysplasias, th e orthopaedic treatm ent
of SED focuses on deform ity m an agem en t. Valgus producing osteotom ies of the proxim al fem ur are indicated for progressive varus deform ities of th e h ips. Sligh t overcorrection
sh ould be the goal because of the h igh risk for recurren ce,
and coexisting flexion contractures should be released under th e sam e an esth etic. Subluxation or extrusion sh ould
be recon structed with fem oral an d/ or pelvic osteotom y. An gular deform ities of the lower extrem ities are best m anaged
with corrective osteotomy. Clubfeet in SED are usually less
stiff th an in diastrophic dysplasia; as a result, conven tion al
prin ciples of serial m an ipulation an d castin g sh ould be attempted before resortin g to open release an d osteotomy.
Cervical instability that exceeds 8 m m or that is symptom atic should be treated by cervical fusion along with decom pression for cases with coexistin g sten osis. Because th e
cervical bon es are usually quite sm all, segm en tal fixation
is difficult and halo im m obilization is usually necessary.
Mucopolysaccharidoses
Although they are not prim ary bone dysplasias, MPSs are
frequently included in discussions of skeletal dysplasias
because th ey lead to sh ort stature.
277
year-old boy with spondyloepiphyseal dysplasia congenita demonstrates marked coxa vara and delayed epiphyseal ossification typical
of this condition. Proximal femoral valgusextensioninternal rotation osteotomy is often required for these patients. (Reproduced
with permission from Skaggs DL, Flynn JM. Staying Out of Trouble
in Pediatric Orthopaedics. Philadelphia, PA: Lippincott Williams &
Wilkins, 2006.)
Pathophysiology
MPSs are a group of in herited m etabolic disorders caused
by a deficiency of various lysosom al enzym es. Norm ally,
lysosom al enzym es are in volved in glycosam inoglycan processin g an d degradation . Deficien cy of th ese en zym es results in th e accum ulation of m etabolic end products in the
brain , viscera, an d m usculoskeletal tissues. Excess sugars
spill over and are detectable in the urin e. Norm al physeal
growth becom es disrupted wh en th ese en d products accum ulate at th e growth plate an d ch aracteristic h istologic
changes in the proliferative and hypertrophic zones of th e
physis can be seen .
Th e overall in ciden ce of MPSs is 1 in 25,000 live birth s.
Th e m ore prevalen t MPSs are tran sm itted by an autosom al recessive m ode of inheritan ce, with th e exception of
Hunter syn drom e, wh ich is transm itted in an X-lin ked recessive fash ion . Morquio an d Hurler syn drom es are th e
m ost com m on types of MPSs.
278
TABLE 11.3
MUCOPOLYSACCHARIDOSES
Syndrome
Enzyme Deficiency
Hurler
-L-iduronidase
Hunter
Sulfo-iduronate sulfatase
Sanfilippo
Morquio
Multiple enzymes
Galactosamine-6-sulfatase
-galactosidase
-glucuronidase
MaroteauxLamy
Classification
MPSs are classified by th e deficien t lysosom al en zym e an d
the type of accum ulated end product (Table 11.3).
Presentation and Physical Examination
Th e diagn osis usually becom es clin ically apparen t between
6 m on th s an d 10 years of life, depen din g on th e type of MPS
an d th e speed at wh ich th e m ucopolysacch aride accum ulates. Wh ile th ere is clin ical variability with in th is group
of syn drom es, th ese disorders sh are som e com m on clin ical features (Fig. 11.66). These include facial dysm orphism ,
sh ort stature, hepatosplen om egaly, neurologic deficits, cardiac problem s, an d join t con tractures. Men tal retardation
is associated with m ost types, as is deafn ess. Morquio syn drom e, h owever, is ch aracterized by n orm al in telligen ce.
All patients with MPS h ave thick and inelastic skin with
varying degrees of severity.
The facial dysm orphic features include a flat nasal
bridge, hypertelorism , a prom in en t foreh ead an d corn eal
cloudin g. Patients typically dem onstrate short trunk
dwarfism . An abn orm al gait often results from an gular deform ities of the lower extrem ities (usually genu valgum )
or join t con tractures due to deposition of m ucopolysacch arides in th e join t capsule an d periarticular tissues. O n e
exception is Morquio syn drom e in wh ich patien ts usually
develop gen eralized join t laxity in stead of con tracture. Hips
m ay develop progressive dysplasia an d coxa valga.
A careful n eurologic exam in ation is warran ted in ch ildren with MPS because of th e h igh in ciden ce of odon toid
hypoplasia an d atlan toaxial in stability, especially in patien ts with Morquio syn drom e. Patien ts with ton al ch an ges
are usually flaccid, n ot spastic; myelopathy can develop
early, an d sudden death h as been reported. Th e rem ain der
of th e spin e m ay dem on strate platyspon dyly an d kyph oscoliosis.
Radiographs
Just like the clinical features, the radiograph ic findings in
MPS are n ot presen t at birth but develop over tim e as th e
m etabolic products accum ulate. A skeletal survey, stan din g
Accumulated
End Products
Mental Status
Dermatan sulfate
Heparan sulfate
Dermatan sulfate
Heparan sulfate
Heparan sulfate
Keratan sulfate
Rapid deterioration
Dermatan sulfate
Variable
Variable deterioration
Severe deterioration
Normal
h ip to an kle radiographs, an d dyn am ic views of th e cervical spin e are gen erally in dicated in th e diagn ostic workup
of any MPS. Pelvic radiograph s will often dem on strate en larged and dysplastic acetabuli and coxa valga of the proximal
fem ur. The fem oral epiphysis m ay appear underdeveloped
because of a sm all ossific n ucleus, but MRI or arth rogram
will dem on strate a large, dysm orph ic cartilagin ous fem oral
Figure 11.66 The classic appearance of a mucopolysaccharidosis in a 3-year-old patient includes facial features that are mildly
coarsened, an abdominal protuberance from an enlarged spleen
and liver, a short trunk, and stiff interphalangeal joints of the fingers. (Reproduced with permission from Morrissy RT, Weinstein
SL. Lovell and Winters Pediatric Orthopaedics. Philadelphia, PA:
Lippincott Williams & Wilkins, 2006.)
279
head. Skull radiographs sh ow a th ick and en larged calvarium . The clavicles are broad, especially m edially an d
an teriorly. On spine radiograph s, the vertebrae are som ewh at flatten ed an d flam e-sh aped with an terior-in ferior
beakin g. Lateral cervical views will usually reveal odon toid
hypoplasia; flexion an d exten sion views are n ecessary to
screen for atlan toaxial instability (Fig. 11.67).
Special Tests
MPS are generally diagnosed by urin e screenin g for elevated sugar levels by using a toluidin e blue-spot test. Positive tests are followed by m ore sophisticated biochem ical
analyses of both urine and serum to determ ine the specific m ucopolysacch aride th at h as accum ulated. Iden tification of the m etabolic end product alone is not sufficient to
Morquio syndrome including an absent odontoid (A), a pelvis with capacious acetabuli and coxa valga (B), and marked genu valgum (C). (Reproduced with permission from Morrissy RT, Weinstein SL. Lovell and Winters
Pediatric Orthopaedics. Philadelphia, PA: Lippincott Williams & Wilkins,
2006.)
280
diagn ose MPS but sh ould be coupled with qualitative an alysis an d en zym e estim ation s for m ore defin itive diagn osis.
Pren atal diagn osis for m ost of th e MPS types is available
to h igh -risk m oth ers, such as th ose with an oth er affected
offsprin g. Carrier status can be determ in ed by en zym atic
assays in h igh -risk in dividuals.
Differential Diagnosis
It is difficult to distin guish th e various types of MPSs on
the basis of radiographic and clinical findings alone. One
exception is Morquio syn drom e, wh ich can som etim es be
distin guish ed from th e oth ers on th e basis of n orm al in telligen ce an d gen eralized join t laxity rath er th an con tracture.
Gen erally, en zym atic assays an d bioch em ical tests of both
urin e an d serum are n ecessary to m ake th e specific diagn osis. True skeletal dysplasias can be differentiated from MPS
by the presence of characteristic clin ical features, genetic
testin g, an d th e lack of abn orm al urin ary m etabolites.
Treatment
No cure exists for patien ts with MPS. Treatm en t, for th e
m ost part, is supportive an d directed at symptom s. In patien ts with Hurler syn drom e, en zym atic replacem en t with
recom bin an t -l -iduron idase m ay improve som e of the
clinical m anifestations of th e disorder. Un fortunately, patien ts usually presen t after th e on set of sym ptom s, an d
treatm en t can n ot reverse th e perm an en t tissue dam age
has already occurred. Allogen eic bone m arrow transplan tation m ay improve th e facial features an d th e h epatosplen om egaly but does n ot seem to alleviate th e m usculoskeletal abn orm alities. Patien ts with MPS h ave m ultiple
m edical problem s due to th e in volvem en t of several organ
system s. Consultation with the appropriate m edial specialists is n ecessary to m an age th e cardiac, respiratory, an d n eurologic issues th at can arise.
O rth opaedic treatm en t in volves correction an d/ or stabilization of th e m usculoskeletal m an ifestation s of th e disorder. Join t con tractures th at are recalcitran t to stretch in g m ay
nance image in a 12-year-old boy with Morquio syndrome and declining ability to walk shows spinal
cord compression and signal change associated
with upper cervical instability resulting from his
odontoid hypoplasia. (B) Postoperative lateral radiograph of the upper cervical spine illustrates solid
occipitalC2 posterior fusion 6 months following the
surgery. (Reproduced with permission from Skaggs
DL, Flynn JM. Staying Out of Trouble in Pediatric
Orthopaedics. Philadelphia, PA: Lippincott Williams
& Wilkins, 2006.)
require surgical release if th ey adversely affect fun ction . An gular deform ities of th e lower extrem ities that impair am bulation sh ould be treated by guided growth tech n iques
or corrective osteotomy. Cervical in stability, especially in
Morquio syn drom e, warrants atlan toaxial fusion and occasion ally occipitocervical fusion (Fig. 11.68). Progressive
kyphoscoliosis should be stabilized by spinal fusion and
instrum entation.
281
Radiographs
Because of the h igh in ciden ce of upper cervical in stability,
flexion exten sion lateral views of th e cervical spin e sh ould
be obtain ed to m easure th e atlan toden s in terval. Values
greater th an 5 m m are con sidered diagn ostic of in stability. Screening radiographs of the cervical spine are gen erally required by the Special Olympics before a ch ild with
Down syn drom e can be cleared for participation . In cases
of suspected h ip path ology, an AP an d frog lateral view of
th e pelvis is warran ted. Radiograph s typically dem on strate
flat, dysplastic acetabuli, an d flared iliac win gs. In certain
children who complain of hip instability, the fem oral heads
m ay be well covered with a norm al fem oral necksh aft angle and m oderately in creased fem oral anteversion. In these
cases, th e source in stability is laxity of th e h ip capsule an d
supportin g ligam en ts.
Special Studies
Pren atal screen in g for Down syn drom e in cludes m easures
of serum -fetoprotein, estriol, and hum an chorionic gon adotropin . These levels are decreased, decreased, and in creased, respectively, in th e presen ce of a Down fetus. If
th ese screen in g tests dem on strate an in creased risk of trisomy 21, am niocentesis and chrom osom al analysis can be
perform ed to yield a defin itive diagn osis.
CT scans m ay be useful prior to hip reconstruction to
evaluate th e version of th e acetabulum an d to iden tify areas of acetabular deficien cy. MRI of th e cervical spin e is
indicated in cases of severe atlantoaxial instability or neurologic comprom ise.
Treatment
Th e surgical treatm en t of ch ildren with Down syn drom e
can be frustratin g sin ce th e sam e ligam en tous laxity th at
causes th e in itial deform ity also in creases th e ch an ce of
recurren ce. As a result, con servative treatm en t is preferred
wh en ever possible.
Th e m an agem en t of upper cervical spin e in stability is
som ewhat con troversial. Since m ost patien ts with m oderate degrees of atlantoaxial instability will rem ain asymptom atic, and the complications of surgery can be significan t, th e role of prophylactic surgical stabilization rem ain s
un clear. In gen eral, asym ptom atic ch ildren with an atlan toden s in terval between 5 an d 10 m m sh ould be coun seled
to avoid high-risk sports such as diving and gym nastics.
282
B
Figure 11.70 The management of hip instability from Down syndrome can be challenging. This
boy presented after a few episodes of acute pain, but radiographs demonstrate a reduced, irregularly
shaped femoral heads, and irregularly shaped acetabuli that seem to provide good coverage. (B)
He returns 3 years later with a painful, fixed dislocation of the left hip, subluxation of the right hip,
and shallow, dysplastic acetabuli. (Reproduced with permission from Skaggs DL, Flynn JM. Staying
Out of Trouble in Pediatric Orthopaedics. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
Patien ts with instability th at exceeds 10 m m should be considered for upper cervical fusion . Of course, any child with
a n eurologic deficit sh ould un dergo realign m en t an d fusion . In cases of deficient posterior elem en ts or occipitocervical instability, the arthrodesis should be extended to
the occiput.
The m anagem en t of hip disorders is equally ch allengin g. Hip in stability an d recurren t dislocation s are gen erally pain less but m ay h asten th e developm en t of degen erative arth ritis (Fig. 11.70). Spica castin g an d abduction
bracin g can h elp stabilize a h ip in youn ger patien ts. In
older patien ts, especially th ose th at are sym ptom atic,
recon struction can be perform ed via a varus fem oral
osteotomy an d/ or redirection al acetabular osteotom y.
Complication s after surgery are com m on , m ost n otably redislocation an d in fection .
Patellar instability sh ould be initially treated by quadriceps strengthenin g an d stabilizin g braces. For th ose that
fail con servative m an agem en t, both soft tissue an d bony
surgery should be perform ed to m inim ize the risk of recurren ce. Usually th is in volves a m edial patellofem oral plication or recon struction in addition to a tibial tubercle tran sfer for skeletally m ature patien ts or a m edial transfer of the
lateral h alf of th e patellar ten don (RouxGoldth waite procedure) for skeletally im m ature patients. In certain cases,
treatm en t of coexistin g gen u valgum with h em iepiphysiodesis or corrective osteotomy will improve th e success
rate following surgery.
Pes planovalgus is generally pain less and treatm en t is
un n ecessary un less sym ptom s develop. In th ese cases,
sh oewear m odifications an d orth otics should be the first
lin e of treatm en t. For recalcitran t cases, calcan eal osteotomy to correct th e h in dfoot valgus can be con sidered.
Sim ilar to th e flatfoot deform ity, h allux valgus sh ould be
treated con servatively wh en ever possible. If surgery is n ecessary, th e first MTP join t sh ould be fused to m in im ize th e
risk of recurrence.
Marfan Syndrome
Pathophysiology
Marfan syndrom e results from a defect in the gene th at
codes for fibrillin , located on th e long arm of chrom osom e
15. Fibrillin is a glycoprotein that is closely associated with
elastin an d is an im portan t com pon en t of several types of
tissues, including skin, ligam en t, tendon, and blood vessels. Adefect in th is gen e ch anges the m ech anical properties
of all of th ese tissues, leadin g to in creased laxity. Fibrillin
m utations also are though t to increase the availability of
certain extracellular growth factors to cell receptors, leading to an increase in longitudinal growth . Marfan syndrom e
is gen erally inherited in an autosom al dom inant fashion,
although up to 30% of patients m ay h ave a spontan eous
m utation. The prevalence of the disease is approxim ately 1
per 10,000 people in th e Un ited States.
Presentation and Physical Examination
Like m any syndrom es of orthopaedic importance, Marfan syn drom e presen ts with a ch aracteristic appearan ce
(Fig. 11.71). Patients are gen erally tall and lanky with lon g,
thin lim bs. The digits are long and spider-like (arachn odactyly). Two ch aracteristic exam in ation fin din gs in th e
h an ds an d digits, wh ile n ot diagn ostic, are h igh ly suggestive of th e disease. Th e first is th e Stein berg sign , in
wh ich th e th um b exten ds past th e uln ar border of th e h an d
wh en th e fist is clen ch ed (Fig. 11.72). Th e secon d is overlap of the thum b and index finger when the patien ts han d
is wrapped aroun d the contralateral wrist. Facial deform ities include a high-arched palate, narrow face, and progn ath ism . Ch est wall deform ities such as pectus excavatum
or pectus carin atum are typical. Join t laxity can lead to pes
plan ovalgus, gen u recurvatum , or join t dislocation . Scoliosis occurs in m ore than 30% of patien ts. Kyphosis and
spon dylolisth esis can also be seen.
Ch ildren with Marfan syn drom e h ave m any n on orthopaedic issues that warrant evaluation by a specialist.
283
aortic aneurysm or dissection. Murm urs from aortic or m itral valve insufficiency are often audible.
Figure 11.71 Clinical appearance of a patient with Marfan syn-
Ophthalm ologic consultation is n ecessary to screen for ectopia len tis (dislocated len s) th at is caused by lax suspen sory ligam ents th at allow superior m igration of th e len s.
Testin g of visual acuity m ay reveal myopia that results from
the abnorm al shape of the globe. Referral to a cardiologist is essential as patients with Marfan syndrom e can develop dilation of the ascending aorta and m itral valve in sufficien cy. Altered elasticity in the vessel walls can lead to
Radiographs
Th e diagn osis of Marfan syn drom e is a clin ical on e; h owever, radiograph s can be h elpful to support th e diagn osis
and to evaluate an atom ical areas of concern. Spinal radiograph s m ay sh ow scoliosis, kyph osis, or spon dylolisth esis. In particular, signs of dural ectasia and pedicle dysplasia can be seen (in creased in terpedicular distan ce an d
increased sagittal diam eter of L5). Radiographically,
arachnodactyly can be quantified by m easuring the length
to width ratios of the second through fifth m etacarpals on
a posteroan terior view of th e h an d (Fig. 11.73). An AP view
of th e pelvis m ay sh ow sign s of protrusio acetabuli; th is
is defined as intrapelvic intrusion of the acetabulum such
th at th e m edial edge of th e fem oral h ead lies m edial to th e
ilioischial line (Fig. 11.74).
284
8-year-old girl with Marfan syndrome. Note the bilateral acetabular protrusio with intrusion of the medial wall of the acetabulum
to the ilioischial line.
Special Studies
In spite of th e kn owledge of wh ich gen e causes Marfan syn drom e, n o specific laboratory test exists to m ake a defin itive diagn osis. CT scan s can be useful to defin e th e bony
an atomy of complex h ip or spin e deform ities. Dural ectasia
is best dem on strated on a lum bosacral MRI. Slit lamp exam in ation an d ech ocardiography are essen tial studies for
oph th alm ologic an d cardiac evaluation s respectively.
Differential Diagnosis
Marfan syn drom e is a clin ical diagn osis th at is based on
defin ed m ajor an d m in or criteria in volvin g several organ
system s (Table 11.4). Th e differential diagnosis for Marfan syn drom e in cludes several oth er con dition s th at can
exh ibit sim ilar features. Hom ocystin uria is caused by a defect in the enzym e that converts cysteine to m ethionine.
Th e con dition resem bles Marfan syn drom e except th at it
is often associated with m en tal retardation an d a coagu-
TABLE 11.4
Minor Involvement
Ocular system
Cardiovascular system
Dural ectasia
Skeletal system
Ocular system
Cardiovascular system
Pulmonary system
Skin
Central nervous system
Treatment
Currently, there is n o specific treatm en t for the genetic defect responsible for Marfan syn drom e. Therefore, treatm en t
is aim ed at m anaging the condition s associated with the
syn drom e. As m ention ed, early referral to an ophthalm ologist an d cardiologist is importan t to preven t or treat ocular
an d cardiac problem s. The use of -blockers can reduce the
risk of aortic dilation . For in com peten t aortic roots, aortic
valves, or m itral valves, replacem ent sh ould be considered.
Th e treatm en t of scoliosis in Marfan syn drom e is sim ilar
to th at of idiopath ic scoliosis. Bracin g is recom m en ded for
curves greater than 25 degrees, alth ough som e authors have
suggested th at bracin g m ay be less effective in th is patient
population . Surgery (usually posterior spin al fusion an d
instrum entation) is indicated for progressive curves that
exceed 45 to 50 degrees. Com plication s are m ore com m on
than with idiopathic scoliosis and include pseudarthrosis,
infection, dural tear, residual curve decompen sation, and
loss of fixation in dysplastic posterior elem ents. Protrusio acetabuli is generally observed. In skeletally im m ature
patien ts, Steel h as described closure of th e triradiate cartilage to m in im ize further acetabular deepening. In older,
sym ptom atic patien ts, h ip arthroplasty can be considered.
Th e flatfeet an d occasion al join t dislocation s th at result
from generalized laxity are best m anaged conservatively
with bracin g an d physical th erapy. For severe cases, surgical correction m ay be warranted.
LIMB DEFICIENCIES
Proximal Femoral Focal Deficiency
Pathophysiology
Proxim al fem oral focal deficien cy (PFFD) refers to a spectrum of disorders ch aracterized by a variably shorten ed
fem ur with or without an abnorm ality of the fem oroacetabular articulation . Th e in ciden ce of th e deficien cy ran ges
from 1 case per 50,000 to 1 case per 200,000. The etiology
of PFFD is n ot well un derstood, but certain th eories h ave
been proposed. Th e sclerotom e subtraction th eory suggests
Type
Femoral Head
Acetabulum
Femoral
segment
285
Present
Normal
Short
Present
Absent or
represented
by ossicle
Short,
usually
Adequate or proximal
moderately
bony tuft
displastic
Severely
displastic
Short,
usually
proximally
tapered
No osseous connection
between haed and shaft
Femoral head in acetabulum
Absent
Absent
Obturator
fpramen
enlarged
Short,
deformed
(none)
Pelvis
squared
in bilateral
cases
Figure 11.75 Aitken classification for proximal femoral focal deficiency. (Redrawn from Herring
JA. Tachdjians Pediatric Orthopaedics. 3rd ed. St. Louis, MO: Saunders, 2002.)
Classification
Th e Aitken classification is th e m ost widely used classification. It divides PFFD into four categories based on the radio-
286
Imaging
Radiograph s are essen tial to determ in e th e degree of
fem oral hypoplasia and to establish the status of the h ip
joint (Fig. 11.77). The percentage of th e discrepan cy can be
estim ated by com parin g th e sh ort lim b with th e con tralateral side. O ften , ossification of th e proxim al fem ur will be
delayed, m akin g arth rography or MRI n ecessary to determ ine the presence or absence of a cartilaginous anlage.
Differential Diagnosis
Th e diagn osis of PFFD is gen erally straigh tforward. Occasion ally, PFFD can be confused with congen ital coxa vara
with an associated sh ort fem ur. Th e latter con dition h as
a varus n eckshaft an gle with deform ation of all of the
components of the head, neck, and trochan teric area and
sh orten ing of th e fem ur. This is, however, an entirely different entity, an d radiographs at approxim ately 1 year are
gen erally sufficien t to distin guish th e two con dition s.
Treatment
Th e m an agem en t of PFFD requires a m ultidisciplin ary
team , wh ich in cludes th e pediatric orth opaedic surgeon ,
prosth etists, an d physical th erapists. No sin gle treatm en t
approach applies to all cases, and each patient with PFFD
m ust be assessed individually.
In gen eral, treatm en t is guided by th e expected discrepan cy at m aturity an d stability of th e hip joint. Since the
relative proportion of th e sh orten ed lim b to th e n orm al
lim b rem ains constant durin g growth, th e expected discrepancy can be calculated by m ultiplying the percentage
of th e existin g discrepan cy (at th e tim e of diagn osis) with
A,B
287
girl with proximal femoral focal deficiency. With the ankle rotated
180 degrees, dorsiflexion of the ankle (A) results in flexion of the
prosthetic knee (B), and plantar flexion (C) results in extension of
the prosthetic knee (D). (Reproduced with permission from Morrissy RT, Weinstein SL. Lovell and Winters Pediatric Orthopaedics.
Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
288
Fibular Hemimelia
Pathophysiology
Fibular h em im elia, or postaxial hypoplasia of th e lower
extrem ity, is th e m ost com m on lower lim b deficien cy syn drom e. By defin ition , fibular h em im elia is a lon gitudin al
deficien cy of th e lateral portion of th e lower lim b in wh ich
part or all of th e fibula m ay be m issin g. It can occur in isolation or as part of PFFD an d varies in severity from m ild
to severe deform ity. Th e etiology of fibular h em im elia rem ain s un clear, but th e m ost popular th eory proposes th at
in terferen ce with th e early developm en t of th e lim b bud
plays an essen tial role.
Classification
Several classification system s exist for fibular h em im elia.
Th e Ach term an Kalam chi classification system is based on
fibular m orph ology. In type IA, th e proxim al fibular epiphysis is distal to th e level of th e tibial growth plate with
the distal fibular physis proxim al to the talar dom e. Type
IB is ch aracterized by a proxim al fibula th at is 30% to 50%
sh orter than norm al (Fig. 11.79). Th e distal fibula is presen t
but does n ot adequately support th e an kle. Type II deform ities refer to complete absen ce of th e fibula.
proximal fibula is missing. (Reproduced with permission from Morrissy RT, Weinstein SL. Lovell and Winters Pediatric Orthopaedics.
Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
Radiographs
A stan din g AP view of th e h ips to an kles sh ows th e overall
alignm ent of the affected lower extrem ity and perm its use
of th e con tralateral side as a con trol. Lim b-len gth discrepan cies are best m easured by using scanogram s (see section
on leg len gth discrepan cy). Abn orm alities in specific parts
of th e lower extrem ity can be seen an d, if n ecessary, im aged
further with specific views. For example, if there is con cern
about coexistin g PFFD and/ or acetabular dysplasia, a pelvis
an d/or hip series should be ordered. Sim ilarly, a knee series is useful for evaluatin g distal fem ur valgus, hypoplasia
of th e lateral fem oral con dyle, an d flatten in g of th e tibial
em in en ce.
Differential Diagnosis
Th e ch aracteristic clin ical appearan ce an d plain radiograph s are gen erally sufficien t to m ake th e diagn osis. As
m en tion ed, several other conditions are associated with
fibular h em im elia an d each sh ould be evaluated in dividually.
Treatment
As with PFFD, the ultim ate goal of surgery is to achieve
sym m etrical, stable, and well-align ed joints with the m in im al num ber of surgical procedures. No single set of operation s sh ould always be perform ed; in stead, in dividual
procedures sh ould be plan n ed th at address th e specific abnorm alities in each patient. Fin ally, realistic expectation s of
the tim ing, the duration of recovery, and the ultim ate outcom e m ust be com m unicated to patients and th eir fam ilies.
Treatm en t is gen erally guided by th e degree of fibular
sh ortenin g, the expected leg len gth discrepan cy at skeletal
m aturity, and the quality of the foot. Patients with m ild to
m oderate discrepancies (0% 10%) an d a fun ction al foot
can be m anaged with shoe lifts, orthoses, and/ or a welltim ed contralateral epiphysiodesis. Patients with larger discrepancies and an adequate foot generally require on e or
m ore lim b len gthening procedures. If the foot is nonfunctional either due to an unstable ankle or due to an insufficien t n um ber of rays (gen erally th ree or fewer), stron g
con sideration should be given toward an early Sym e am putation . Studies h ave sh own im proved fun ction an d n orm alized gait param eters in patients who underwent early
amputation and prosthetic fitting compared with those
wh o un derwen t (often several) lim b salvage procedures.
Amputation is certainly in dicated for th ose patients with
complete absence of th e fibula.
289
Tibial Hemimelia
Tibial h em im elia is a rare con gen ital an om aly ch aracterized by deficiency of the tibia with a relatively intact fibula.
Th e exten t of th e deficien cy is variable: th e type I form is
characterized by total absence of the tibia; type II has a
persisten t proxim al tibia; type III (rare) is ch aracterized by
th e presen ce of a distal tibia on ly; an d in type IV, th ere is a
divergen ce of th e distal tibia an d fibula, with proxim al displacem en t of th e talus. Th e prevalen ce of tibial h em im elia
is estim ated at 1 in 1,000,000 live births. Although the m ajority of cases with tibial h em im elia are sporadic, affected
fam ilies with possible autosom al dom in an t or autosom al
recessive in h eritan ce h ave been reported
Most children present early in life with th e characteristic deform ity of th e lower lim b (Fig. 11.81). If the entire
tibia is absen t, there is often a fixed proxim al and lateral
position of th e fibula with severe flexion deform ity. Th e
affected lim b is usually short, with the foot in an apparen t clubfootposition of equin ovarus. Th e m ost importan t
com pon en t of th e evaluation is to determ in e th e am oun t of
proxim al tibial th at exists an d to determ in e wh eth er th ere is
a fun ction al quadriceps. Radiograph s are usually h elpful to
determ in e th e degree of tibial hypoplasia, but ossification
of th e proxim al tibia is often delayed so ultrason ography or
MRI m ay be necessary to establish the presence or absence
of a cartilagin ous an lage.
If th e en tire tibia is absen t, th ere is often a fixed proxim al
and lateral position of th e fibula with severe flexion deform ity. Knee disarticulation is generally preferred for this
con dition , alth ough cen tralization of th e fibula (Brown
procedure) com bin ed with Sym e am putation h as been described. If en ough proxim al tibia is present such that the
quadriceps attach m en t is preserved, th e en d of th e tibia can
be fused to th e fibula with a Sym e am putation , an d a very
reason able fun ction al lim b can be ach ieved.
Radial Clubhand
Axial deficien cies on th e radial side of th e forearm are th e
m ost com m on lim b deficiencies in the upper extrem ity.
290
A,B
C
Figure 11.81 (A and B) Radiographs of an infant with complete absence of the tibia (type I
deficiency). (C) The clinical appearance, with the medial deviation and severe equinus of the foot
and the absence of any tibial structure below the distal femur. (Reproduced with permission from
Morrissy RT, Weinstein SL. Lovell and Winters Pediatric Orthopaedics. Philadelphia, PA: Lippincott
Williams & Wilkins, 2006.)
Th is particular con gen ital lon gitudin al deficien cy is reportedly tran sm itted as an autosom al dom in an t trait. Radial
clubhand is ch aracterized by partial or complete absence of
the radius, with rare involvem ent of the ulnar ray. The han d
is typically radially deviated an d m ay be lackin g a th um b
(Fig. 11.82). Th e incidence is 1 in 100,000 live birth s, with
approxim ately on e-h alf of th e cases bein g bilateral.
It is im portan t for the treating physician to recognize th at
radial deficiencies m ay be associated with other syn drom es
in up to 50% of cases. TAR syn drom e (th rom bocytopen ia
an d absen t radius) is on e of th e m ore com m on of th ese
conditions. VATER syn drom e also h as radial deficiencies
alon g with vertebral, an al, trach eoesoph ageal, an d ren al
abn orm alities.
Despite th e deform ity, h an d fun ction is usually surprisin gly good. As with m any of th ese an om alies in youn g ch ildren , adaptive tech n iques develop rapidly. Th erefore, it is
importan t n ot to sacrifice a competen t fun ction in g h an d
in an effort to correct wh at th e physician m ay feel is an
un acceptable position . Stretch in g an d splin tin g are largely
in effective for th e defin itive treatm en t of radial clubh an d
but can som etim es be h elpful to stretch th e soft tissues preoperatively. Surgically, several differen t cen tralization procedures have been described. All involve a soft tissue release
an d cen tralization of th e carpus on to th e distal uln a. Such
procedures sh ould be con sidered on ly in ch ildren with
thumb aplasia. Note the foreshortening of the forearm and the 90degree radial deviation at the wrist. (Reproduced with permission
from Morrissy RT, Weinstein SL. Lovell and Winters Pediatric Orthopaedics. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
291
ARTHRITIS
In flam m ation or irritation of th e join t can occur due to
both in fectious an d n on in fectious etiologies. Th e m ost im portan t cause of acute arth ritis in ch ildren is septic arth ritis,
wh ich is discussed in Ch apter 5. O th er com m on causes of
arthritis in clude tran sient syn ovitis, Lym e disease, and juven ile rheum atoid disease.
Transient Synovitis
Pathophysiology
Transient synovitis or toxic synovitis is a reactive arthritis
that characteristically affects the hip. While the true cause
is unknown, m ost auth ors believe that transien t syn ovitis is a nonspecific inflam m atory con dition. O thers have
suggested that th e condition is a postviral allergic synovitis
sin ce it tends to follow recent viral illn esses.
Presentation
Transient synovitis is one of the m ost com m on causes of
hip pain and limp in young children . Children typically
presen t between th e ages of 3 an d 9 with th e acute on set of
groin or th igh pain an d lim pin g. Most patien ts are afebrile
or m ain tain a low-grade fever (tem perature below 38 C).
History and Physical Examination
With a careful history, one can frequently uncover a h istory
of upper respiratory tract in fection or ear in fection with in
several weeks of th e onset of th e limp. As a result, som e
authors have suggested that the condition is a postviral allergic synovitis. Physical exam ination will reveal restricted
m otion of the hip, particularly in in ternal rotation and exten sion . Most patien ts are am bulatory an d system ic fin dings of infection are absent.
Diagnostic Studies
Laboratory studies are helpful in distinguish ing transien t
syn ovitis from septic arthritis.
In flam m atory m arkers are relatively n orm al, but on occasion , a m ild elevation in the ESR is observed. Radiograph s are typically n orm al; in rare cases, MRI or CT m ay
be n ecessary to rule out oth er diagn oses. Ultrasoun d will
often dem on strate a m ild to m oderate join t effusion (Fig.
11.83). In cases in which septic arthritis is still a concern,
aspiration of the joint will yield a definitive diagnosis as
the cell counts in transien t syn ovitis are with in the range
of n orm al.
Differential Diagnosis
Alth ough th e con dition is com m on , tran sien t syn ovitis is
a diagn osis of exclusion ; oth er cause of pain an d limp
m ust be ruled out before one settles on th e diagnosis. Th e
differen tial diagn osis in cludes lym e arth ropathy, juven ile
rh eum atoid arth ritis (JRA), an d traum a. Th e m ost importan t diagn osis to rule out is septic arth ritis. Usually, patients with septic arthritis will refuse to bear weight, have
fevers with temperature higher th an 38.5 C, and have elevated laboratory results, including white blood cell count,
sedim en tation rate, an d C-reactive protein. If there is any
doubt regardin g th e diagn osis, an arth rocen tesis sh ould be
perform ed.
Treatment
Th e treatm en t of tran sien t m on oarticular syn ovitis of th e
h ip is symptom atic as th e con dition is self-lim ited. Recom m ended therapies include activity lim itation and relief of
weigh t-bearin g un til th e pain subsides. An ti-in flam m atory
agen ts and analgesics m ay shorten th e duration of pain.
Most ch ildren recover completely within 2 to 3 weeks.
Lyme Arthritis
Pathophysiology
Lym e disease is a tick-born e in flam m atory disorder caused
by th e spirochete Borrelia burgdorferi. It is m ost com m on ly
292
Presentation
Typically, th e disease presen ts in th ree stages. Th e first stage
lasts days to weeks an d is ch aracterized by system ic symptom s (fever, m alaise) an d th e classic eryth em a ch ron icum
m igran s (ECM) (Fig. 11.84). ECM is an expan din g m acular
eryth em atous rash with a cen tral clearin g. Th is bulls-eye
rash is seen only in 50% of ch ildren and usually occurs
on th e th igh , groin , or axilla. Th e secon d stage, wh ich lasts
weeks to m onths, is typified by cardiac and neurologic involvem en t. Th e cardiac sequelae can in clude varyin g degrees of h eart block an d m yocarditis, an d th e n eurologic
fin din gs can in clude m en in gitis, en ceph alitis, ch orea, an d
Bell palsy. Th e th ird stage, wh ich can persist for m on ths
to years, is ch aracterized by fran k arth ritis. In term itten t attacks of asym m etrical join t swellin g an d pain , prim arily
in th e large join ts (e.g., kn ee), are typical. Ch ildren are, in
gen eral, m ore susceptible to th e acute sym ptom s of Lym e
disease th an th e ch ron ic effects.
History and Physical Examination
Importan t elem en ts of th e h istory in clude livin g in , or
recen t travel to, th e n orth east Un ited States, especially in
region s th at are h eavily wooded, an d oth er poten tial en viron m en tal exposures. Ch ildren an d fam ilies will often n ot
rem em ber bein g bitten by a tick, alth ough th ey m ay recall
the presence of th e ECM rash . Physical exam ination can re-
Diagnostic Studies
Laboratory tests m ay show m ild elevation in levels of
inflam m atory m arkers such as sedim entation rate or Creactive protein but are usually n ot in creased to th e levels seen in pyogen ic arth ritis. Arth rocen tesis will reveal
wh ite blood cell coun ts in th e ran ge of 25,000 to 50,000
cells/ m L. Attempts at culture, when positive, are clearly diagnostic of the disease, but retrieval of organism s is very
low. Blood tests for antibodies sh ould be routinely perform ed as part of the diagnostic workup; however, there is
a substan tial false-negative rate early in the disease process.
A two-tiered test including an enzym e-linked im m unosorben t assay (ELISA) test (h igh sen sitivity) an d a Western blot
(high specificity) is the diagnostic m ethod of ch oice.
Differential Diagnosis
Depen din g on th e severity of th e presen tation , Lym e disease can be difficult to separate from pyogen ic septic arth ritis or toxic synovitis. History an d physical exam ination
con sistent with Lym e disease should prompt appropriate
laboratory tests to confirm or rule out the diagnosis.
Treatment
Ch ildren with Lym e disease are usually treated with a prolonged course of am oxicillin . Advan ced cases th at have
crossed th e blood brain barrier m ay require ceftriaxon e.
Most ch ildren who are diagnosed early and treated appropriately will m ake a rapid an d full recovery.
Pathophysiology
Th e exact etiology of th e disease rem ain s un kn own . O ccasion al referen ces h ave been m ade to an association with
an initiating traum atic event. Th e com m on thread that relates this entity to the adult form of rheum atoid arthritis is
an exaggerated im m unologic respon se in the synovium .
Th is syn ovial proliferation an d release of lysosom al en zym es cause th e ch aracteristic progressive join t destruction .
In addition , th e th icken ed pan n us an d resultan t effusion
cause ligam en tous stretching and m echanical dam age to
the join t (Fig. 11.85). An addition al risk in children is th e
effect of th e hypervascular gran ulation tissue on th e physis.
293
294
seropositive polyarticular juvenile rheumatoid arthritis. (Reproduced with permission from Herring JA. Tachdjians Pediatric Orthopaedics. 3rd ed. St. Louis, MO: Saunders, 2002.)
Ch ildren with JRA, particularly th ose with th e polyarticular subtype, sh ould h ave th eir n ecks exam in ed for C1
C2 instability, including a careful neurologic assessm ent.
Th e stretch in g of th e tran sverse ligam en t of C1 results from
just inside the corneal limbus in a girl who had anti-nuclear antibody
(ANA)-positive juvenile rheumatoid arthritis. Her chronic uveitis was
bilateral and had resulted in a decrease in vision to 20/400 in the
right eye. (Reproduced with permission from McMillan JA, Feigin
RD, DeAngelis C, et al. Oskis Pediatrics: Principles and Practice.
Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
295
Radiographs
Plain radiograph s are th e m ost importan t form of im agin g,
but MRI can be useful in early stages of th e disease to evaluate syn ovial hypertrophy. Classic radiograph ic ch an ges in
JRAinclude sym m etric joint space narrowing, subchondral
erosion s, periarticular osteopen ia (Fig. 11.89). In addition ,
the epiphysis m ay be overgrown from hyperem ia or undersized from growth retardation. Join t subluxation can occur
in both large and sm all joints. Typical examples include
uln ar subluxation of th e m etacarpoph alan geal join ts an d
volar subluxation of the wrist (Fig. 11.90). In late stages
nile rheumatoid arthritis. Note the severe osteopenia, joint erosions, and subluxation of the first metacarpophalangeal joint. (Reproduced with permission from Koopman WJ. Arthritis and Allied
Conditions: A Textbook of Rheumatology. 13th ed. Philadelphia,
PA: Lippincott Williams & Wilkins, 1997.)
Laboratory Studies
Complete blood cell counts often show low-grade anem ia
and/ or leukocytosis. The platelet count, ESR, and CRP level
are often elevated to a m oderate degree. Rheum atoid factor
is elevated only in 10% to 15% of patients. As there is no
sin gle diagn ostic test for JRA, a constellation of physical
findings, radiographic changes, and abnorm al laboratory
values is usually required to m ake the diagnosis.
Treatment
Medical treatm en t for JRA depends on the severity and
type of disease. Mild, m onoarticular disease can often
296
join t deterioration . Syn ovectom y (eith er open or arth roscopic) can improve symptom s and prevent joint destruction. Kn ee and hip flexion contractures that impair function should be released. Growth disturbances or angular
deform ities m ay require epiphysiodesis or corrective osteotom ies. Som e severely affected join ts m ay be am en able
to fusion (e.g., subtalar join t). Larger join ts m ay require
total join t arth roplasty. Prior to any surgical procedure,
patien ts sh ould be screen ed for cervical in stability or stiffn ess th at m ay complicate in tubation . Wh en in dicated, upper cervical fusion sh ould be perform ed.
297
REGIONAL CONDITIONS
Hip
Perhaps n o other joint in pediatric orthopaedics h as attracted m ore attention than the hip. Several well-known pediatric diseases can affect th e im m ature h ip, in cludin g developm ental hip dysplasia, SCFE, and LeggCalvePerthes
disease (LCPD). Kn owledge of th e n orm al growth an d developm ent of th e h ip joint an d the vascular an atomy is
essen tial for un derstan din g th e path ophysiology an d treatm en t of these conditions.
the acetabulum, and the femoral head develop from the same primitive mesenchymal cells. A cleft develops in the precartilaginous cells
at approximately the 7th week of gestation, defining the acetabulum and the femoral head. (Reproduced with permission from Morrissy RT, Weinstein SL. Lovell and Winters Pediatric Orthopaedics.
Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
represen ts a secon dary ossification cen ter an d is an importan t con tributor to acetabular depth an d lateral coverage.
Th is lateral growth cen ter an d th e triradiate cartilage gen erally fuse by th e early teen age years.
Th e ossification cen ter of th e fem oral h ead typically appears between th e fourth an d sixth m on th s of postn atal life.
In itially, th is cen ter is sph erical; subsequen tly, it expan ds
into an ovoid shape. The fem oral neck physis is initially
con tin uous with a growth plate on th e lateral surface of
th e fem oral n eck an d th e troch an teric growth plate (Fig.
11.94). Th e fem oral n eck physis an d th e troch an teric ph ysis contribute prim arily to the longitudinal growth of the
proxim al fem ur; h owever, th e specific pattern of growth
in all th ree physes is wh at determ ines the width of the
fem oral neck, th e neckshaft an gle, and the relationship of
th e fem oral h ead to th e greater troch an ter. With in creasin g
age and m echanical loading, the trabeculae becom e m ore
and m ore stress oriented. By the age of 6 years, th e calcar of th e proxim al fem ur becom es prom in en t. Th e greater
trochan ter initially ossifies, as a secondary cen ter, between
5 and 7 years of age. Fusion is generally complete by age 18.
An important con cept is that the acetabulum and the
fem oral head develop in a con cordant fashion. Proper
acetabular developm ent requires a well-reduced, spherical fem oral h ead to provide th e n ecessary tem plate about
wh ich to form . Th e even distribution of con tact forces supplied by a roun d fem oral h ead allows th e acetabulum to
achieve an appropriate depth and coverage. Sim ilarly, the
con tact pressures provided by a close-fittin g acetabulum
are n ecessary to shape the fem oral h ead. Any abnorm ality
of th is articulation durin g early developm en t can alter th e
biom ech an ics an d result in a dysplastic acetabulum an d/ or
proxim al fem ur (Fig. 11.95).
298
seal plates: the growth plate of the greater trochanter, the growth
plate of the proximal femoral physis, and the growth plate of the
femoral neck isthmus connecting the other two. (Reproduced with
permission from Morrissy RT, Weinstein SL. Lovell and Winters Pediatric Orthopaedics. Philadelphia, PA: Lippincott Williams & Wilkins,
2006.)
Vascular Anatomy
Th e blood supply of th e h ip join t is critical to its n orm al developm en t. In gen eral, th e blood supply to th e
hip is divided into the extracapsular circulation and th e
in tracapsular circulation . Th e extracapsular blood supply
of th e proxim al fem ur is predom in an tly from th e profunda fem oris artery via its two m ajor branch es: the lateral circum flex artery (LCA) an d th e m edial circum flex
artery (MCA). Th ese two arteries form an extracapsular rin g
aroun d th e troch an teric an d basilar n eck region s. Th e LCA
supplies the anterior portion of th e rin g, whereas th e MCA
supplies the m edial, posterior, and lateral portions of th e
ring. Both arteries give rise to ascendin g cervical bran ches,
which provide the blood supply to the fem oral n eck an d
contribute to th e intracapsular circulation (Fig. 11.96). Th e
m ost importan t of th ese bran ch es is th e lateral ascen din g
cervical artery, a term inal bran ch of the MCA that supplies
the m ajority of th e fem oral epiphysis. This artery traverses
the lateral capsule in the posterior trochanteric fossa via a
narrow passage and is, th erefore, vuln erable to constriction .
Th e extracapsular rin g is a con stan t fin din g, alth ough its
size and configuration are variable.
299
(A) Femoral artery. (B) Extracapsular ring from the medial circumflex
artery and lateral circumflex artery. (C) Ascending lateral cervical
artery. (D) Physis. (Reproduced with permission from Chung SM.
The arterial supply of the developing proximal end of the human
femur. J Bone Joint Surg Am. 1976;58:961970.)
produce avascular n ecrosis of th e fem oral h ead an d perm anent deform ity of th e hip.
Pathophysiology
Although the exact etiology rem ain s un known, the fin al
com m on pathway in th e developm ent of DDH is th e increased laxity of the hip capsule, which fails to m aintain
a stable fem oroacetabular articulation. Th is increased laxity is probably due a com bination of horm onal, m echan ical, and genetic factors. One m ajor risk factor for DDH
is fem ale gen der; the increased incidence of DDH in fem ales is thought to result from in creased susceptibility to
m aternal horm on es such as relaxin, which increases ligam entous laxity. Breech positioning, especially when the infan ts kn ees are exten ded, h as been sh own in an im al m odels to in crease th e risk for dislocation . In h um an s, th e in ciden ce of DDH in breech in fan ts is up to 20%. Any oth er
con dition th at leads to a tigh ter in trauterin e space an d,
con sequen tly, less room for n orm al fetal m otion m ay be
associated with DDH. These conditions include oligohydram n ios, large birth weigh t, an d first pregn an cy. Th e h igh
rate of association of DDH with oth er in trauterin e m oldin g
abnorm alities, such as torticollis and m etatarsus adductus,
supports th e th eory th at the crowding phenom enonhas
a role in the path ogen esis. Fin ally, gen etic factors clearly
play a role. A m ajor risk factor for DDH is a positive fam ily
h istory, which is present in 12% to 33% of patien ts. Twin
studies h ave shown a 34% incidence of DDH in both identical twin s compared with 3% in fraternal twins. Genetic
predisposition s m ost likely reflect in trin sic differen ces in
collagen an d con n ective tissue laxity.
Depen din g on th e severity of DDH, th e n eon atal h ip
m ay be completely dislocated, partially dislocated, or
m ildly displaced. Som e of these h ips probably spen d
som e tim e dislocated an d som e tim e reduced. Durin g th e
n eon atal period, som e of th ese un stable h ips will gradually dock in the acetabulum and will end up norm al from
a radiograph ic an d an atom ic stan dpoin t. Oth er h ips will
fail to reduce an d will rem ain out of th e acetabulum perm anently. Th is latter group will develop several secondary
300
Ligamentum
teres
Transverse
acetabular
ligament
Classification
Th e spectrum of DDH can be divided in to dislocated, subluxated, an d dysplastic h ips. Dislocated h ips are th ose in
which the fem oral head no longer h as any contact with
the acetabulum . Subluxation occurs wh en the fem oral
epiphysis h as partially lost con tact with th e acetabulum
Presentation
Girls presen t with DDH m ore often th an do boys, by a 4:1
ratio. In 60% of cases, th e left side is th e affected side. In th e
n ewborn period, th e m ajority of patien ts are referred because of instability found durin g routine clinical exam inations by their pediatricians. After th e walking age, ch ildren
usually presen t with a lim p an d/ or leg len gth discrepan cy.
For m ost ch ildren , pain is n ot a part of th e presen tin g com plain ts. In con trast, th ose patien ts with m ild acetabular
dysplasia th at escapes detection durin g ch ildh ood m ay
presen t in early adulth ood with groin pain an d in stability of their hip.
Physical Examination
In th e n ewborn period, careful physical exam in ation is
essen tial for th e diagn osis of DDH. Th e ch ild sh ould be
301
exam in ed on a firm surface in th e supin e position . O bviously, the infant should be completely undressed to perform an adequate exam ination. An upset child will contract
the proxim al m uscles and m ake th e diagnosis of in stability nearly impossible; it is, therefore, important to keep the
ch ild relaxed by warm in g the room , providing a blanket,
or feedin g with a bottle. Th e exam in er sh ould grasp th e
infants thigh with the thum b over th e lesser troch anter
m edially and the rin g or m iddle finger around the greater
trochanter laterally. The Ortolani test is perform ed by
gen tly abductin g th e h ip wh ile exertin g an upward force
on th e greater troch an ter (Fig. 11.101). A palpable clun k
represen ts th e reduction of a dislocated (but reducible)
hip. The Barlow test is perform ed in th e sam e position with
the hip in neutral or slight adduction an d a gentle downward force applied to the h ip joint. If the fem oral head
m oves out of the acetabulum , th e hip is considered dislocatable (Fig. 11.102). These findings can be subtle and often
require a delicate touch . It is importan t to distin guish th e
clunk associated with a truly positive exam ination from
a clickthat is frequently reported by pediatrician s. Clicks
ing three different left hips with (A) dysplasia alone, (B) hip subluxation, and (C) hip dislocation.
B
Figure 11.101 Ortolani maneuver: fingers up on the greater
302
B
Figure 11.102 Barlow maneuver: palm pushes down on the
knee to push the hip out the back. (Reproduced with permission
from Skaggs DL, Flynn JM. Staying Out of Trouble in Pediatric Orthopaedics. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
Figure 11.104 Galeazzi test is positive when knees are at different height. When positive, there may be a unilateral dislocated hip.
(Reproduced with permission from Skaggs DL, Flynn JM. Staying
Out of Trouble in Pediatric Orthopaedics. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
A,B
303
C
Figure 11.105 (A and B) Parents of this 16-month-old girl were concerned that she was not
walking correctly. She has significant lordosis and a waddling gait. (C) An anteroposterior radiograph
of the pelvis demonstrates bilateral dislocated hips. (Reproduced with permission from Skaggs DL,
Flynn JM. Staying Out of Trouble in Pediatric Orthopaedics. Philadelphia, PA: Lippincott Williams &
Wilkins, 2006.)
Diagnostic Studies
Because it is superior to radiograph s for evaluatin g cartilagin ous structures, ultrasonography is th e diagn ostic m odality
of ch oice for DDH before th e appearan ce of th e fem oral
h ead ossific n ucleus (4 6 m on th s) (Fig. 11.106). Durin g
2
6
3
4
5
304
is the horizontal line intersecting the left and right tri-radiate cartilages. Perkins line (P) is drawn perpendicular to Hilgenreiners line
at the lateral corner of the acetabulum. The acetabular index (AI) is
the angle between the acetabular roof and Hilgenreiners line and is
a measure of acetabular development. The intersection of Hilgenreiners line and Perkins line creates four quadrants around the hip.
In a normal, reduced hip, the medial beak of the proximal femoral
metaphysis shoudl be in the lower, inner quadrant. A disruption of
Shentons line (S) also indicates subluxation or dislocation of the
hip. (Reproduced with permission from Morrissy RT, Weinstein SL.
Lovell and Winters Pediatric Orthopaedics. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
305
quadran t, th e h ip is eith er subluxated or dislocated. Sh en ton lin e is form ed by th e m edial border of th e fem oral
neck and the superior border of the obturator foram en .
Norm ally, th is lin e sh ould form a con tin uous arc. By definition , in terruption of Shenton line im plies subluxation at
the least, if not, fran k dislocation of th e hip.
Two other radiographic m easures are frequently used to
evaluate acetabular dysplasia. Th e acetabular in dex is th e
an gle form ed between Hilgenreiner line and a line drawn
tan gen tial to th e bony roof of th e acetabulum . In th e n orm al newborn period, th e acetabular index averages 27.5 degrees. By 6 m on th s of age, th e m ean in dex drops to 23.5 degrees, an d by 2 years of age, th e acetabular in dex is n orm ally
20 degrees or less. For in fan ts, 30 degrees is con sidered
the upper lim it of norm al. After age 8 or so, the acetabular index becom es less reliable because th e triradiate cartilage becom es harder to visualize. For older children (older
than 6 8 years), th e cen teredge an gle can be used to assess
the degree of fem oral head coverage. Prior to th is age, the
fem oral epiphysis is not ossified sufficien tly to judge an
accurate center point. The centeredge an gle is form ed by
the in tersection of Perkins lin e an d the line drawn between
the center of the fem oral head and the lateral m argin of the
acetabulum (Fig. 11.109). For ch ildren 6 to 13 years of age,
a n orm al cen teredge an gle is greater th an 19 degrees. After
the age of 14, a norm al centeredge an gle is 25 degrees or
greater. Values less th an n orm al in dicate un dercoverage of
the fem oral head from acetabular dysplasia.
In gen eral, advan ced im agin g (CT or MRI) is n ot n ecessary to m ake th e diagn osis of DDH. CT scan s, h owever,
are the m ost widely used im aging m odality for confirm ing
hip reduction after open or closed treatm ent of a dislocated
hip. In revision cases, CT scans can also be useful to define
the bony anatomy of the hip. The downsides of CT in clude
radiation exposure an d th e relatively poor visualization of
soft tissue structures. Upsides include th e rapid nature of
the test, ease of scheduling, and widespread availability.
Recently, som e authors have advocated the use of MRI to
pool after attempted closed reduction. (Reproduced with permission from Childrens Orthopaedic Center, Los Angeles, CA.)
306
sh arp dem arcation in the dye from the edge of the labrum
(Fig. 11.111). A m ajor advan tage of arth rography is th e dynam ic n ature of the test; th e stability of reduction can be
assessed in a wide variety of position s to determ in e th e
optim al position for im m obilization .
Differential Diagnosis
Idiopath ic DDH sh ould be distin guish ed from teratologic
hip dislocations, which occur in utero. Teratologic h ips
have extrem ely lim ited range of m otion and are n ot reducible on exam in ation . In gen eral, teratologic dislocation s
are associated with oth er con dition s in cludin g arth rogryposis, myelodysplasia, an d a variety of gen etic syn drom es.
Diagn osis is usually m ade on th e basis of th e clin ical exam in ation an d th e presen ce of oth er associated fin din gs.
Th e m an agem en t of teratologic dislocation s depen ds on
the specific condition and the am bulatory potential of th e
ch ild. In gen eral, closed reduction is n ot successful for teratologic dislocation s.
Treatment
Th e treatm en t of DDH varies depen din g on th e age of
the patient and the reducibility of the hip. Regardless of
whether operative or n on operative m odalities are used,
the goals of treatm en t are a concen tric reduction of the
fem oral head into th e acetabulum , m ain ten ance of this reduction over tim e, an d avoidan ce of complication s, specifically avascular n ecrosis.
Birth to 12 Months
For in fan ts youn ger th an 6 m on th s of age with a dislocated
or dysplastic h ip, a Pavlik h arn ess is th e preferred m eth od
of treatm en t (Fig. 11.112). Th is soft h arn ess con sists of
Velcro straps around the chest that are conn ected to stirrups around both feet. Th e anterior straps of the h arn ess
can be adjusted to m aintain the hips in flexion (usually
approxim ately 100 degrees); excessive flexion is discouraged because of the risk of fem oral nerve palsy. Th e posterior straps are design ed to en courage abduction . Th ese are
gen erally set to allow adduction just to n eutral, as forced
abduction by th e harness can lead to avascular necrosis of
the fem oral epiphysis. By positioning the hips in flexion
an d lim iting the am ount of adduction, the Pavlik harness
poin ts th e fem oral h eads m ore directly at th e acetabulum .
For dysplastic h ips, th is allows for deepen in gof th e socket
by encouragin g acetabular rem odeling. For dislocated hips,
the harness can guide the epiphysis into the acetabulum
an d m ain tain it in position while the soft tissues around
the hip tighten.
Newborn s h ips th at are Barlow positive (reduced but
dislocatable) or Ortolan i positive (dislocated but reducible) sh ould gen erally be treated with a Pavlik h arn ess
as soon as th e diagnosis is m ade. The m anagem ent of newborn s with dysplasia wh o are youn ger th an 4 weeks is less
clear. A sign ificant proportion of these hips will norm alize
with in 3 to 4 weeks; th erefore, m any physician s prefer to
reexam in e th ese n ewborn s after a few weeks, before m aking treatm ent decisions. After applyin g a Pavlik harness, a
follow-up ultrasound should be perform ed within 2 to 3
weeks to con firm h ip reduction . Harn ess treatm en t sh ould
be aban don ed at 4 weeks if th e h ip is n ot reduced by th is
Figure
307
11.113 Arthrograms
demonstrate
closed reduction of the developmental dysplasia of the left hip in an 8-month-old girl.
(A) Untreated. (B) Reduced. (Reproduced with
permission from Morrissy RT, Weinstein SL.
Lovell and Winters Pediatric Orthopaedics.
Philadelphia, PA: Lippincott Williams & Wilkins,
2006.)
Figure 11.114 After closed reduction, the patient should be positioned in the human position of flexion and moderate abduction
for the spica cast. (Reproduced with permission from Morrissy RT,
Weinstein SL. Lovell and Winters Pediatric Orthopaedics. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
308
B
Figure 11.115 (A) Computed tomography (CT) scan following closed reduction of the right hip.
The hip is located as judged by a line along the anterior cortex of the pubis which intersects the
proximal femoral metaphysic, the so-called CT Shenton line (thin black line). The small black arrow
demonstrates the characteristic apparent posterior subluxation of the femoral head within the acetabulum, which is present even when the hip is located. The small white arrow demonstrates mediocre
molding of the cast under the greater trochanter to help keep the hip reduced. The trochanteric molding on the other hip (large white arrow) is actually better in this patient. (B) This CT scan demonstrates
a dislocation following attempted closed reduction and spica casting. The line along the pubis does
not intersect the proximal femoral metaphysic (thin black line). There is no molding under the greater
trochanter (large white arrow). (Reproduced with permission from Skaggs DL, Flynn JM. Staying Out
of Trouble in Pediatric Orthopaedics. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
Th e addition of a pelvic osteotomy to th e open reduction should be considered for all ch ildren older than 18
m onths. These procedures can improve th e acetabular coverage an d th e stability of th e h ip followin g open reduction .
Perform in g an early in n om inate osteotomy also m axim izes
th e am oun t of acetabular rem odelin g followin g open treatm ent, thereby m inim izing the risk for residual dysplasia in
th e future. Th e Salter, Pem berton , an d Dega osteotom ies
are th e m ost popular types of pelvic osteotom ies for DDH
in walking-aged children. The Salter osteotomy is a com plete cut th rough th e ilium at th e level of th e sciatic n otch ;
th e acetabulum is th en rotated forward an d outward, h in ging on the pubic symphysis. A wedge of bone graft and intern al fixation are used to m ain tain th e acetabular position .
Th e Pem berton osteotomy is a curved but in complete cut in
th e ilium th at h in ges on th e in tact m edial wall an d th e triradiate cartilage. Th e Dega osteotom y is an oth er in com plete
transiliac osteotomy that hinges on the in tact posterom edial iliac cortex an d sciatic n otch . Th e correction from th e
Dega an d th e Pem berton osteotom ies is m ain tain ed with
a wedge of bone graft, but internal fixation is usually not
n ecessary. All th ree procedures im prove an terior and lateral coverage of th e acetabulum , wh ich is th e area th at is
prim arily deficien t in DDH.
After 2 years of age, it is m ore likely that a fem oral procedure will be n ecessary in addition to th e open reduction pelvic osteotom y (Fig. 11.116). If excessive pressure
is required to reduce the fem oral h ead intraoperatively, a
fem oral shortening osteotomy should be perform ed. This
309
B
Figure 11.116 A: Preoperative radiograph demonstrating left hip dislocation. (B) Postoperative
anteroposterior radiograph of the pelvis 1 year after open reduction, Salter osteotomy, and femoral
shortening osteotomy. (Reproduced with permission from Skaggs DL, Tolo VT. Master Techniques in
Orthopaedic Surgery: Pediatrics. Philadelphia, PA: Lippincott Williams & Wilkins, 2008.)
310
socket. All in volve a com plete tran section of the ilium plus
addition al cuts in th e pelvis depen din g on th e specific tech nique. The previously described Salter osteotom y is th e sim plest type of redirection al osteotomy an d can be used in
ch ildren up to 8 to 10 years of age to im prove an terolateral
coverage (Fig. 11.118). For older ch ildren who lack m obility
of th e pubic sym physis, a triple in n om in ate osteotom y can
be effective to ach ieve greater degrees of correction . Th is
procedure in volves tran section of th e ilium , th e pubis, an d
the ischium but preserves the integrity of the triradiate cartilage; in tern al fixation is required to m ain tain th e position
of th e acetabular fragm en t (Fig. 11.119). For older patien ts
after closure of th e triradiate cartilage, th e preferred procedure is th e Gan z periacetabular osteotom y. Th is tech n ically
dem an din g osteotom y in volves a com plete cut of th e pubis, a partial cut of th e isch ium an d ilium , an d a posterior
colum n osteotomy that connects the ischial an d iliac cuts
(Fig. 11.120). Th is osteotom y allows for sign ifican t degrees
of correction but sh ould n ot be perform ed in youn ger ch ildren because it violates th e triradiate cartilage. Sin ce th e
posterior colum n is preserved, th e osteotomy is quite stable an d requires on ly 3 to 4 screws to ach ieve adequate
fixation (Fig. 11.121).
Resh apin g osteotom ies ch an ge th e volum e an d sh ape of
the socket and are, therefore, m ost useful for a capacious
or sh allow acetabulum . Both th e Pem berton an d th e Dega
osteotomy in volve in com plete cuts in th e ilium directed
toward th e triradiate cartilage. Th e acetabular fragm en t is
then bent downward, h inging on the triradiate cartilage. A
wedge of bone graft is placed in th e osteotomy to m aintain
the acetabular position (Fig. 11.122). By varying the direction of th e osteotomy an d th e position of th e bon e graft
wedge, the increased acetabular coverage can be preferen-
311
B
Figure 11.121 (A) Anteroposterior (AP) radiograph of the pelvis demonstrating bilateral acetab-
ular dysplasia in a 45-year-old woman. (B) AP radiograph of the pelvis after bilateral periacetabular
osteotomies to improve femoral head coverage. The hardware on the right side has already been
removed.
provide an articulatin g surface. Th e Ch iari osteotomy is perform ed by m aking a complete cut in the ilium just above the
level of the hip joint. Th e proxim al fragm en t is then translated laterally while the acetabulum is m edialized, thereby
providin g in creased lateral coverage (Fig. 11.123). In tern al fixation h olds th e fragm en ts in place an d a spica cast
is rarely necessary. The Staheli shelf procedure increases
fem oral h ead coverage by building a buttress on the anterior an d lateral edge of th e acetabulum . A slot is m ade
alon g th e rim of the acetabulum just above the level of
th e join t, an d strips of corticocan cellous bon e are placed
inside to create a sh elf(Fig. 11.124). Over tim e, this shelf
will rem odel an d hypertrophy from th e pressure of th e
fem oral head.
toward the sciatic notch above the level of the triradiate cartilage.
The cut is incomplete and relies on hinging at the triradiate cartilage. Local bone graft wedges are used to hold the osteotomy
open. (Reproduced with permission from Skaggs DL, Tolo VT. Master Techniques in Orthopaedic Surgery: Pediatrics. Philadelphia, PA:
Lippincott Williams & Wilkins, 2008.)
Figure 11.123 Chiari salvage osteotomy. (Reproduced with permission from Gillingham BL, Sanchez AA, Wenger DR: Pelvic Osteotomies for the Treatment of Hip Dysplasia in Children and Young
Adults. Am Acad Orthop Surg 1999;7:325337.)
312
Pathophysiology
SCFEs are m ost likely caused by a com bin ation of m ech an ical an d en docrin e factors. Th e plan e of cleavage in m ost
SCFEs occurs th rough th e hypertroph ic zon e of th e physis.
Durin g n orm al puberty, th e physis becom es m ore vertically
orien ted, wh ich con verts m ech an ical forces from com pression to sh ear. In addition , the hypertrophic zone becom es
elon gated in pubertal adolescen ts due to h igh levels of circulating horm ones. This widening of the physis decreases
the th reshold for m echanical failure. Any other factor that
causes a delay in m etaphyseal ossification will also cause a
relative in crease in physeal h eigh t an d m ech an ical weaken in g of th e physis. Norm al ossification depen ds on a n um ber of differen t factors in cludin g thyroid h orm on e, vitam in
D, an d calcium . It is, th erefore, n ot surprisin g th at SCFEs
occur with in creased in ciden ce in ch ildren with m edical
disorders such as hypothyroidism , hypopituitarism , an d renal osteodystrophy. O besity, one of the greatest risk factors
for SCFE, affects both the m ech anical load on th e physis
an d th e level of circulatin g h orm on es. Th e com bin ation of
Classification
Historically, SCFEs h ave been classified on the basis of
ch ronology. Acute SCFEs are defin ed by hip pain for less
than 3 weeks. A chronic SCFE, on the oth er hand, is one in
wh ich th e symptom s h ave lasted lon ger th an 3 weeks, often for m any m on th s prior to presen tation . Ch ildren with
a h istory of prolon ged h ip pain wh o presen t with a sudden
increase in their symptom s are said to have an acute-onch ronic SCFE. Although easy to use, the chronologic classification h as two m ajor lim itations. First, it does not offer
m uch inform ation regarding progn osis, and second, it depen ds on recall of th e patien t an d fam ily, wh ich m ay n ot
be accurate. Curren tly, th e preferred classification m eth od
for SCFEs is based on the stability of the slip. By definition ,
a stable SCFE is one in which th e child is able to walk and
bear weigh t on th e affected leg with or with out crutch es. In
313
Presentation
Th e classic patien t presen tin g with a SCFE is an obese,
African Am erican boy between th e ages of 11 and 16.
Girls presen t earlier, usually between 10 to 14 years of age.
Ch ron ic and stable SCFEs ten d to present after weeks to
m on th s of symptom s. Patients usually limp to som e degree an d h ave an extern ally rotated lower extrem ity. Most
patien ts com plain of groin symptom s, but isolated th igh
pain or kn ee pain is a com m on presen tation from referred
Physical Examination
Observation of gait in a child with a stable SCFE reveals
several characteristic findings. Children typically limp and
dem on strate out-toein g of th e in volved extrem ity. Th is latter fin din g is because as part of th e displacem en t, th e
fem oral neck externally rotates in relation to the epiphysis.
Attempts to ran ge th e h ip will reveal sign ifican t restriction s
to flexion and internal rotation as the proxim al m etaphysis impin ges on th e rim of the acetabulum . In typical
D
Figure 11.126 This 9-year-old girl presented to her primary care doctor with a 4-month history of
knee and thigh pain. Knee (A) radiographs and an anteroposterior view of the pelvis (B) were obtained
but no frog lateral views. The radiographs were interpreted as normal. Two months later, the child
was referred to a pediatric orthopaedist who ordered appropriate radiographs. These radiographs
revealed a now moderately displaced slipped capital femoral epiphysis bilaterally (C and D). (Reproduced with permission from Skaggs DL, Flynn JM. Staying Out of Trouble in Pediatric Orthopaedics.
Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
314
cases, bringing th e hip into flexion will cause obligate extern al rotation of th e h ip an d extrem ity as th e acetabulum
forces the fem oral neck laterally (Fig. 11.127). This rangeof-m otion lim itation from fem oroacetabular impin gem en t
can be painless at first. Over tim e, however, dam age can occur to the labrum and the articular cartilage, wh ich results
in pain with flexion an d in tern al rotation of th e h ip.
Radiographs
Most SCFEs can be diagn osed with an AP view of th e pelvis
an d frog lateral views of both h ips (Fig. 11.128). In patien ts
with an un stable SCFE, a sh oot-th rough lateral is preferred
over th e frog lateral to m in im ize un n ecessary traum a to th e
epiphysis from m ovin g th e leg. On e of th e earliest radio-
right slipped capital femoral epiphysis, the examination demonstrates obligate external rotation
as the hip is flexed (A). No rotation with hip flexion is seen on the
normal side (B). (Reproduced with
permission from Skaggs DL, Flynn
JM. Staying Out of Trouble in
Pediatric Orthopaedics. Philadelphia, PA: Lippincott Williams &
Wilkins, 2006.)
B
Figure 11.128 Radiographs of a 12 year-old-boy with 3 months of hip pain show typical findings
of a slipped capital femoral epiphysis (SCFE). (A) Anteroposterior (AP) view demonstrates physeal
widening, osteopenia, decreased epiphyseal height, increased metaphyseal-teardrop distance, and
asymmetry of Klein line. (B) Although many of these features are seen on the AP view, the most striking
feature is how much more easily the displacement is seen on the frog lateral view. The importance
of obtaining lateral views when evaluating for SCFE cannot be overemphasized. (Reproduced with
permission from Morrissy RT, Weinstein SL. Lovell and Winters Pediatric Orthopaedics. Philadelphia,
PA: Lippincott Williams & Wilkins, 2006.)
315
Plain radiograph s are also useful for gradin g th e severity of a SCFE. The slip angle is calculated by m easuring the
fem oral head sh aft an gle of th e involved side and com parin g th is to th e n orm al, con tralateral side (if both sides
are slipped, 10 degrees can be used as a n orm al value)
(Fig. 11.129). Differences less than 30 degrees are considered m ild. Slip angles between 30 and 60 degrees are
m oderate, an d values greater than 60 degrees are severe.
Special Studies
Advanced im agin g is rarely necessary during the initial diagnosis of m ost SCFEs. Bone scans or MRI can be useful
for assessing fem oral head perfusion in unstable slips and
for m onitoring patients postoperatively for AVN. In addition, MRI can aid in the diagnosis of preslips,a condition
ch aracterized by inflam m ation of the physis that has yet to
displace (Fig. 11.130). CT scan s are useful for assessin g th e
severity of deform ity after initial treatm en t and for plan n ing
corrective osteotom ies (Fig. 11.131).
Figure 11.129 The slip angle is the angle between the axis of
the femoral shaft and the perpendicular to the base of the epiphysis. This angle (A) is generally compared with the contralateral,
normal side. In this case, the left side demonstrates a mild slip, so
10 degrees may be used as normative value for comparison.
D
Figure 11.130 A 12-year-old boy presented with pain in the right hip for 2 months. On further
questioning, he reported some vague, intermittent symptoms in the left hip. (A and B) Anteroposterior and frog lateral view of the pelvis show evidence of a right-sided slip, but no definitive signs
of a left slipped capital femoral epiphysis. (C) T1- and (D) T2-weighted magnetic resonance image of
the same patient demonstrate physeal widening and irregularity consistent with a pre-slip. (Reproduced with permission from Morrissy RT, Weinstein SL. Lovell and Winters Pediatric Orthopaedics.
Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
316
Treatment
O n ce th e diagn osis is m ade, th e patien t sh ould be adm itted to th e h ospital im m ediately an d placed on bed rest.
Allowin g the child to go hom e prior to definitive treatm en t in creases th e risk th at a stable SCFE will becom e
an un stable SCFE an d th at furth er displacem en t will occur. Children with atypical presentation s (youn ger than
10 years, th in body h abitus) sh ould h ave screen in g laboratory tests perform ed to rule out an un derlyin g en docrin opathy.
The goal of treatm ent is to prevent further progression
of th e slip an d to stabilize (i.e., close) th e physis. Alth ough
various form s of treatm en t have been used in the past, includin g castin g and threaded pins, the current gold standard for th e treatm en t of SCFE is in situ pin n in g with a
sin gle, large cannulated screw (Fig. 11.132). Screws are typically placed percutan eously un der fluoroscopic guidan ce.
Th e recom m en ded position for th e screw is perpen dicular
to th e physis an d in th e cen ter of th e h ead on both th e AP
an d lateral views. Gen erally, 3 to 5 th reads across th e physis
are sufficien t to ach ieve adequate fixation , but care sh ould
be taken to en sure th at th e screw h as n ot en tered th e join t
(Fig. 11.133). Because th e epiphysis is posterior an d in ferior in relation to the neck, the in itial entry poin t for the
screw becom es progressively an terior on the fem oral neck
with increasin g slip severity. Placing the screw too an terior,
however, can in crease the ch ances th at the screw head will
impin ge on th e acetabular rim . Postoperatively, m ost patien ts are allowed partial or complete weigh t-bearin g with
crutches for 4 to 6 weeks. Gradual return to norm al activities en sues, with resum ption of full activity by 4 to 6 m on th s
following h ip pin ning. Patients should be m onitored with
serial radiographs to be sure th at th e physis is closing an d
that the slip is stable. After healing from the initial stabilization , patien ts with severe deform ity m ay be can didates for
a flexion , valgus, and internal rotation proxim al fem oral
osteotomy to reduce impin gem en t an d improve ran ge of
m otion (Figs. 11.134 and 11.135).
Complications
Ch ondrolysis, th e global loss of articular cartilage with in
the hip joint, is a m ajor complication of SCFEs. With m odern treatm en t, th e in ciden ce of ch on drolysis is approxim ately 1.5%, although older studies have reported an
inciden ce as high as 10%. Patients with chondrolysis typically present 1 to 4 m onths after treatm ent with extrem e
pain an d loss of m otion ; radiograph s dem on strate severe
join t space n arrowin g (Fig. 11.137). Th e etiology of ch on drolysis is poorly un derstood. Som e auth ors h ave sh own a
correlation between tran sient penetration of the joint during surgery (by a guide pin or implant) and an increased
risk of ch on drolysis. O th er reports describe th e spon tan eous developm en t of ch on drolysis in patien ts wh o have
n ot been treated. The join t fluid of th ese patien ts dem on strates elevated levels of certain types of im m unoglobulins,
suggestin g an autoim m une etiology. The path ologic findings include hypertrophy of the synovium , degeneration
of th e articular cartilage, an d in traarticular adh esion s. Although the joint space n arrowing and range of m otion m ay
recover som ewh at, m ost of th ese h ips h ave un satisfactory
F
Figure 11.132 Proper screw locations in slips of varying severity (A and B), (C and D), and (E and
F). In all three cases, the screws enter the anterior femoral neck, are perpendicular to the physis, and
are located in the center of the femoral head. The starting point is more proximal and the screw is
angled progressively more posterior as the magnitude of slip progresses from least (A and B) to most
(E and F) severe. (Reproduced with permission from Morrissy RT, Weinstein SL. Lovell and Winters
Pediatric Orthopaedics. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
317
318
Subcapital
Femoral neck
Intertrochanteric
B
Figure 11.133 A 111/ 2 -year-old boy with hip pain for 1 month
after in situ screw fixation of a stable slipped capital femoral epiphysis. Anteroposterior radiograph (A) demonstrates what appears
to be adequate alignment of the hardware. The frog lateral view
(B), however, demonstrates penetration of the joint surface by one
screw. This case highlights the importance of keeping the screw at
least 5 mm from subchondral bone even if the hip is imaged through
the full range of motion at the time of surgery. (Reproduced with
permission from Morrissy RT, Weinstein SL. Lovell and Winters Pediatric Orthopaedics. Philadelphia, PA: Lippincott Williams & Wilkins,
2006.)
outcom es with severe degen erative arth ritis an d join t con tractures. In th e sh ort term , sym ptom s can be m an aged
with rest, gentle range-of-m otion exercises, and NSAIDs.
The second importan t com plication associated with
SCFE treatm en t is avascular n ecrosis (AVN) of th e fem oral
head. Th e underlying cause of AVN is a disruption in th e
blood supply to th e epiphysis, leadin g to devascularization
of th e fem oral h ead. It is, th erefore, n ot surprisin g th at th e
risk of osteon ecrosis varies with the stability of the slip. In
several large series, the risk of AVN after treatm en t of a
stable slip approached zero. Unstable slips, however, h ave
a 15% to 50% in ciden ce of AVN. As m en tion ed, un stable
slips should be treated in an urgent/ em ergen t fashion with
Subcapital
(Dunn
and Fish)
Femoral neck
(Kramer and
Barmada)
Intertrochanteric
(Southwick and
Imhauser)
gen tle reduction , secure fixation , an d capsular decompression to m inim ize th e ch an ces of developing AVN. The first
radiograph ic sign of osteon ecrosis is in creased sclerosis of
the epiphysis because the lack of a norm al blood supply
preven ts th e n orm al resorption of bon e from disuse. Even tually, the necrotic bone is absorbed, followed by collapse
of th e fem oral h ead (Fig. 11.138). Th is results in severe
join t pain an d restricted ran ge of m otion . Often , th e posterior portion of th e epiphysis is relatively spared. In th ese
cases, a flexion an d valgus-producing proxim al fem oral
D
Figure 11.135 A 13-year-old girl with pain on sitting and difficulty riding a bike from impingement
and external rotation of the left leg 16 months following in situ fixation of the left slipped capital
femoral epiphysis. (A) Anteroposterior (AP) pelvis and (B) lateral radiographs showing the residual
deformity after in situ fixation. (C) AP and (D) lateral views 1 year after flexionvalgusinternal rotation osteotomy of the proximal femur. The osteotomy increases the neckshaft angle, increases
the articulotrochanteric distance, and moves the metaphysis away from the joint. A downside of the
surgery is that if total hip arthroplasty is necessary in the future, distortion of the proximal femoral
anatomy will make such a replacement more difficult. (Reproduced with permission from Morrissy
RT, Weinstein SL. Lovell and Winters Pediatric Orthopaedics. Philadelphia, PA: Lippincott Williams &
Wilkins, 2006.)
B
Figure 11.136 (A) Preoperative radiograph of a left acute, unstable slipped capital femoral epiphysis. (B) Radiographs after gentle closed reduction and screw fixation with two screws. (Reproduced
with permission from Childrens Orthopaedic Center, Los Angeles, CA.)
320
D
Figure 11.137 Left hip chondrolysis in a 13-year-old body. (A and B) Normal joint space of the
left hip when the patient presented with a right slipped capital femoral epiphysis. Ten months later,
the patient developed a left-sided slip and was pinned in situ with prompt resolution of symptoms.
However, 2 months postoperatively, the patient began to have increased hip pain, difficulty walking,
and decreased hip range of motion. (C and D) Radiographs at that time reveal joint space narrowing
consistent with chondrolysis. (Reproduced with permission from Morrissy RT, Weinstein SL. Lovell
and Winters Pediatric Orthopaedics. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
situ screw fixation of an unstable slipped capital femoral epiphysis. The hardware has been removed to allow magnetic resonance
imaging.
LeggCalvePerthes
Disease
LCPD, or idiopath ic osteon ecrosis of th e fem oral h ead,
was sim ultaneously described in the literature in 1910 by
Arthur Legg in the United States, Jacques Calve in Fran ce,
an d Georg Perth es in Germ any. Henning Waldenstro m of
Sweden actually publish ed th e first description of th e con dition in 1909, but sin ce h e attributed th e cause to a m ild
form of tuberculosis, his nam e is not frequently associated
with th e disease. Sin ce its in itial description , LCPD con tinues to be on e of the m ost vexing problem s in pediatric
orth opaedics, as both th e etiology an d th e treatm en t of th is
con dition rem ain poorly understood.
Pathophysiology
Although the underlying etiology rem ains obscure, m ost
authors agree th at th e final com m on pathway in the pathogen esis of LCPD is disruption of th e vascular supply to
the fem oral epiphysis, which results in isch em ia and osteon ecrosis. Several factors in th e coagulation cascade h ave
been suggested to play a role in cludin g protein C, protein
S, an d an tith rom bin III. Deficien cies in all th ree h ave been
dem on strated in som e patien ts with LCPD, wh ich in creases
blood viscosity an d th e risk for ven ous th rom bosis. Poor
ven ous outflow leads to increased intraosseous pressure,
wh ich in turn impedes arterial in flow, causin g isch em ia
an d cell death. Although several studies support this th eory of th rom boph ilia as th e cause of vascular disruption ,
321
oth er recen t studies h ave failed to sh ow defin itive abn orm alities in th e levels of fibrin olytic factors. Altern ative th eories for the cause of LCPD in clude traum a to the lateral epiphyseal vessels an d a system ic abn orm ality in growth an d
developm en t (based on th e fin din gs th at ch ildren often
h ave delayed skeletal growth ).
Regardless of th e underlyin g etiology, the early pathologic ch an ges in th e fem oral h ead are con sisten t with
isch em ia an d n ecrosis; subsequen t ch an ges result from
the repair process. Waldenstro m origin ally separated th e
course of the disease into four stages, although several m odification s of h is system h ave been described
(Fig. 11.139). Th e in itial stage of th e disease, wh ich often
lasts 6 m on th s, is ch aracterized by syn ovitis, join t irritability, an d early n ecrosis of th e fem oral h ead. Revascularization th en leads to osteoclastic-m ediated resorption of th e
n ecrotic segm ent. The n ecrotic bone, however, is replaced
by fibrovascular tissue an d n ot n ew bon e. Th is com prom ises th e structural in tegrity of th e fem oral epiphysis. Th e
secon d stage is th e fragm entation state, which typically lasts
8 m on th s. Durin g th is stage, th e fem oral epiphysis begin s
to collapse, usually laterally, an d begin s to extrude from th e
acetabulum . Th e h ealin g stage, wh ich lasts approxim ately
4 years, begin s with n ew bon e form ation in th e subch on dral region . Reossification begin s cen trally an d expan ds in
all direction s. Th e degree of fem oral h ead deform ity depen ds on th e severity of collapse an d th e am oun t of rem odelin g th at occurs. Th e fin al stage is th e residual stage,
wh ich begin s after th e en tire head has reossified. A m ild
am oun t of rem odelin g of th e fem oral h ead still occurs un til th e ch ild reach es skeletal m aturity. LCPD often dam ages
th e proxim al fem oral physis; during this stage, relative overgrowth of the greater trochan ter can occur.
Classification
At th e presen t tim e, th ree m ajor classification system s exist for LCPD, all of which are based on radiographic assessm ent of th e in volved hip. Th e Catterall classification
system , first described in 1971, separates the disease into
four groups based on the percentage of the head involved
and the degree of collapse (Fig. 11.140). Catterall group I
includes patients with less than 25% head involvem ent,
wh ich is usually in th e an terocen tral region . Group II defines h ips with 50% head involvem ent; m ore of the anterolateral region is affected an d a cen tral sequestrum m ay
be presen t. Group III patien ts h ave up to 75% of th e epiphysis affected with large areas sequestrated. Group IV
describes total h ead in volvem en t. Widespread use of th e
Catterall classification has waned in recent years because
th e groupin gs can be difficult to defin e an d because several
studies h ave dem on strated a lower interobserver reliability
com pared with oth er classification system s.
Th e SalterTh ompson classification system is also based
on th e percen tage of subch on dral collapse. Two groups
are defined: those in group A h ave less than 50% of the
322
2 mo
14 mo
18 mo
25 mo
52 mo
disease progression by month after initial presentation. Two months, initial; 14 months, fragmentation;
18 months, early healing; 25 months, late healing; 52 months, residual stage. (Reproduced with
permission from Morrissy RT, Weinstein SL. Lovell and Winters Pediatric Orthopaedics. Philadelphia,
PA: Lippincott Williams & Wilkins, 2006.)
Presentation
Th e m ost com m on presen tin g complain t is pain or a limp.
Th e on set of symptom s is often in sidious, an d pain m ay be
referred to th e th igh or kn ee. Paren ts m ay recall a h istory of
traum a or viral illness preceding the onset of pain , an d the
severity of sym ptom s m ay wax and wane in the m onths
prior to presen tation . Ch ildren typically presen t between
4 an d 9 years of age, alth ough an adolescen t onset pattern h as been described. Boys are m ore com m on ly affected
than girls, by a 3:1 ratio. Approxim ately 10% of patients
m ay have bilateral involvem ent, although both hips rarely
presen t at th e sam e disease stage. Affected ch ildren are often
sm all in stature an d dem onstrate a delay in their bone age.
Physical Examination
Observation of a childs gait is importan t, as a subtle limp is
often th e on ly sign of early disease. Th e lim p seen in LCPD
is a com bination of an an talgic gait from hip irritability and
a Tren delen burg gait from abductor dysfun ction . Patien ts
will gen erally h ave a positive Tren delen burg sign on th e
involved side. Depen ding on the duration of symptom s,
atrophy of the proxim al m uscles can be seen. Careful assessm en t of h ip ran ge of m otion is absolutely essential in
the evaluation of any child with LCPD. Abduction is best
323
Figure 11.140 (A) Catterall group I disease shows anterior femoral head involvement with
Radiographs
Stan dard radiograph s for LCPD in clude an AP of th e pelvis
an d frog lateral views of both hips. The radiographic fin dings in LCPD parallel the stage of th e disease. Durin g the
initial stage, joint space widening an d soft tissue swellin g
can be seen . Th e ossific nucleus is usually sm aller an d
becom es m ore radioden se th an th e con tralateral side
(Fig. 11.142). Other findings in clude m etaphyseal lucen-
324
Figure 11.141 (A) Lateral pillar type A demonstrates preservation of the height of the lateral
pillar. (B) Type B has more than 50% of the height of the lateral pillar maintained. (C) Type C has
less than 50% of the lateral pillar height maintained. Recently, Herring has added a B/C subgroup
to define those patients with approximately 50% collapse of the lateral pillar. (Reproduced with
permission from Morrissy RT, Weinstein SL. Lovell and Winters Pediatric Orthopaedics. Philadelphia,
PA: Lippincott Williams & Wilkins, 2006.)
Special Studies
Although not routinely used in the evaluation of LCPD,
MRI offers several th eoretical advan tages. Because if its ability to defin e soft tissue an atomy, MRI can offer in form ation
about the sh ape of th e largely cartilaginous fem oral epiphysis and the congruity with the acetabulum . In addition,
MRI can provide early inform ation on the extent of necrosis an d th e pattern of revascularization. On e of the m ajor drawbacks with th e curren t radiograph ic classification
disease
Figure 11.143 Anteroposterior radiograph of the pelvis demonstrates a right hip in the fragmentation stage of LeggCalve
325
disease. The
overall contour of the femoral head is visible and the lucent areas
of the epiphysis are filling in with new bone.
CalvePerthes
dis-
ease of the left hip. Several Catterall at-risk signs are present,
including a Gage sign, calcification lateral to the epiphysis, metaphyseal lesions, lateral joint subluxation, and a horizontal growth
plate. (Reproduced with permission from Morrissy RT, Weinstein
SL. Lovell and Winters Pediatric Orthopaedics. Philadelphia, PA:
Lippincott Williams & Wilkins, 2006.)
Differential Diagnosis
Th e differen tial diagn osis for LCPD in cludes oth er causes of
avascular n ecrosis, in cludin g traum a, leukem ia, sickle cell
disease, an d h em oph ilia. An appropriate h istory an d physical exam ination will gen erally rule out these other condition s. Hypothyroidism can cause sim ilar radiograph ic
findings as early LCPD; however, the findings are generally bilateral and sym m etric. In con trast, bilateral involvem ent in LCPD occurs in a sequen tial rath er than sim ultan eous fashion . In un clear cases, a thyroid fun ction panel
m ay be necessary. Although radiographically sim ilar, children with MED are gen erally less sym ptom atic th an th ose
with LCPD. Th ese patien ts are sh ort in stature an d alm ost
always h ave abnorm alities in oth er epiphyses. In addition,
both h ips are affected sym m etrically. O lder ch ildren with
a h istory of DDH wh o developed iatrogenic osteon ecrosis
can resem ble patien ts with LCPD. A h istory of treatm en t
326
D
Figure 11.147 A 9-year-old boy with LeggCalvePerthes
lateral radiographs demonstrate total head involvement in the reossification stage of the disease. (C)
Arthrogram in neutral position showing considerable flattening of the head. (D) Arthrogram in abduction demonstrating hinge abduction. Note the medial dye pool. (Reproduced with permission from
Morrissy RT, Weinstein SL. Lovell and Winters Pediatric Orthopaedics. Philadelphia, PA: Lippincott
Williams & Wilkins, 2006.)
Treatment
Treatm en t of LCPD rem ain s ch allen gin g because of th e
variability in disease severity. In general, the two m ost h elpful prognostic factors are age at the tim e of disease onset
an d th e lateral pillar classification . Ch ildren youn ger th an
6 years at th e tim e of disease on set, especially th ose with
lateral pillar A an d B h ips, usually do well with n on operative treatm en t. Th is is due to th e greater rem odelin g poten tial of youn ger ch ildren an d th e h igh er percen tage of
cartilage in th e fem oral epiphysis, which helps resist collapse. On th e oth er h an d, ch ildren with delayed on set of
disease (older th an 8 years) an d lateral pillar C h ips ten d
to h ave poor lon g-term outcom es regardless of treatm en t.
Th ose ch ildren th at fall between th ese two extrem es (i.e.,
6 9 years of age, lateral pillar B or B/C h ips) m ay be th e
best can didates for early surgical in terven tion .
For n early h alf a cen tury, th e treatm en t of LCPD h as
been guided by th e prin ciple of con tain m en t. Th is prin ci-
327
B
Figure 11.148 An abduction orthosis. (Reproduced with permission from Morrissy RT, Weinstein
SL. Lovell and Winters Pediatric Orthopaedics. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
Once range of m otion has improved, containm ent options sh ould be discussed with the fam ily. It is important
to rem em ber th at to be successful, con tain m en t m ust be
instituted early while the fem oral head is still m oldable;
on ce th e h ead h as h ealed, reposition in g th e fem oral epiphysis will n ot aid rem odelin g an d m ay in fact worsen
symptom s.
Non operative con tain m en t tech n iques employ devices,
wh eth er th ey be casts or orth oses, to position th e h ips
in abduction and internal rotation (Fig. 11.148). In this
position , th e fem oral h ead is solely con tain ed with in th e
acetabulum . In 1971, Gordon Petrie reported success using
two long leg casts connected by a bar. Th e legs were placed
in at least 45 degrees of abduction and 10 degrees of intern al rotation . If n ecessary, an adductor ten otomy can be
added to increase the am ount of abduction. These Petrie
casts were chan ged every 2 m onths or so until th e fem oral
head was well into the healin g stage. Orthoses such as th e
Toronto brace and the Atlanta Scottish Rite brace are based
on th ese sam e prin ciples of con tain m en t but allow som e
degree of h ip m otion an d lim ited am bulation . Alth ough
bracin g an d castin g can be h elpful for m ain tain in g m otion ,
recen t studies h ave n ot proven th eir efficacy for improvin g
the long-term outcom e of LCPD.
Surgical con tain m en t m eth ods in clude both fem oral
an d pelvic osteotom ies. In the early stages of the disease, varus-producin g in tertroch an teric fem oral osteotomy
328
B
Figure 11.149 (A) LeggCalvePerthes
disease of the left hip. (B) Two years after varus proximal
femoral osteotomy. (Reproduced with permission from Childrens Orthopaedic Center, Los Angeles,
CA.)
Long-Term Prognosis
As m en tion ed, th e goal of containm en t is to preserve a
sph erical fem oral head sin ce th e lon g-term outcom e of
LCPD depen ds on th e sh ape of th e fem oral h ead. Th e Stulberg classification separates h ips in to five differen t categories based on th e radiograph ic appearan ce of th e h ip after skeletal m aturity. Stulberg group I h ips are essen tially
norm al, whereas group II h ips are en larged but spheri-
cal. Stulberg group III h ips are oval or m ush room -sh aped;
th ese h ips h ave an approxim ately 50% risk of developin g
osteoarth ritis in adulth ood but gen erally n ot un til after th e
age of 40. Stulberg group IV hips h ave an area of flattening
of th e fem oral h ead but are con gruous with th e acetabulum ; patien ts with group IV deform ities h ave a greater
th an 50% risk of developin g sign ifican t osteoarth ritis by
th e age of 40. Fin ally, Stulberg V h ips are ch aracterized by
a flatten ed fem oral h ead that is incongruous with the acetabulum . In on e series, up to 86% of th ese patien ts h ad
severe degen erative chan ges by the age of 40.
B
Figure 11.150 Same patient from Figure 11.148. (A) Arthrogram in adduction demonstrates improved congruity. (B) Valgus osteotomy was performed. (Reproduced with permission from Morrissy
RT, Weinstein SL. Lovell and Winters Pediatric Orthopaedics. Philadelphia, PA: Lippincott Williams &
Wilkins, 2006.)
329
volvem en t will typically dem on strate a waddlin g gait; un ilateral cases h ave an ipsilateral Tren delen burg gait. O n
ran ge-of-m otion assessm en t, abduction an d internal rotation are gen erally restricted. Because of troch an teric overgrowth, abductor strength is often decreased an d patien ts
typically h ave a positive Tren delen burg sign . Leg len gth s
sh ould be carefully assessed; m odest discrepan cies (< 3 cm )
are n ot un com m on with un ilateral coxa vara.
Pathophysiology
Con genital coxa vara m ost likely results from a prim ary
defect in th e ossification of th e m edial fem oral n eck. Th e
stress of weigh t-bearing causes fatigue failure of th is weaken ed region , resultin g in progressive varus deform ity of th e
proxim al fem ur (Fig. 11.151). As th e n eckshaft an gle decreases, the physis becom es m ore vertical, which converts
the norm al compressive forces to shear forces. The abnorm al physeal orientation and m echanical loading pattern
of a h ip with coxa vara leads to relative sh orten in g of th e
fem oral neck and overgrowth of the greater trochanter.
Presentation
Con genital coxa vara is equally com m on in m ales and fem ales. Approxim ately 25% to 33% of cases present with
bilateral in volvem en t. Patien ts with con gen ital coxa vara
typically present after walking age with a painless limp.
Fam ilies m ay also com plain of an apparent leg len gth discrepancy. In older children, abductor fatigue from the abnorm al m echanics of the h ip m ay cause pain with physical
activity.
Physical Examination
Observation of gait is extrem ely importan t in suspected
cases of congenital coxa vara. Children with bilateral in-
Radiographs
Plain radiograph s of th e proxim al fem ur are sufficien t to
m ake the diagn osis. In addition to the decreased neckshaft
angle (< 120 degrees), radiograph ic fin din gs in clude a
widen ed an d m ore vertically orien ted physis, sh orten ed
fem oral neck, and overgrowth of the greater trochanter. The
m ost characteristic radiographic sign of congenital coxa
vara is an inverted radiolucen t V in the m edial fem oral
n eck th at straddles a trian gular piece of bon e. Th e superior
and m ore horizontal arm of the V represents the capital
fem oral physis. The inferior, m ore vertical line is the area of
abnorm al ossification. In addition to the n eckshaft an gle,
th e severity of coxa vara can be graded by usin g th e Hilgen rein er epiphyseal an gle (HEA) (Fig. 11.152). Th is HEA is
form ed by the intersection of Hilgenrein er line and a lin e
drawn th rough th e capital fem oral physis. Ch ildren with a
HEA less than 45 degrees tend to h ave spontaneous resolution of their deform ity. Values greater than 60 degrees h ave
a h igh rate of progression . An gles between 45 degrees an d
60 degrees represen t a gray area; th ese ch ildren sh ould be
followed closely for signs of progression .
Differential Diagnosis
Several other conditions can cause varus deform ity of the
proxim al fem ur, in cludin g PFFD, a variety of skeletal dysplasias, an d rickets. Path ologic con dition s of bon e, in cluding OI, fibrous dysplasia, and renal osteodystrophy, can
also lead to progressive deterioration of th e n ecksh aft angle. In addition, coxa vara m ay be a long-term sequela of
infection or traum a to the proxim al fem oral physis. A careful history and physical exam ination is usually sufficient to
rule out these other diagn oses. Lim b deficiency syndrom es,
m etabolic disturbances, and conditions with path ologic
bon e gen erally affect m ore region s th an just th e h ip. Skeletal dysplasias can gen erally be distin guish ed on th e basis
of fam ily h istory an d sh ort stature. Skeletal surveys can be
extrem ely h elpful if th e diagn osis rem ain s un certain .
Treatment
For progressive cases of congen ital coxa vara, the goal of
treatm ent is n orm alization of the biom ech anics around
th e h ip, wh ich will h elp stim ulate h ealin g of th e path ologic
fem oral n eck. To do so, one m ust restore the norm al n eck
sh aft angle, improve abductor function , and increase ran ge
of m otion . As m en tion ed, surgery is recom m en ded wh en
th e HEA is greater th an 60 degrees an d wh en progression
330
Hilgenreiner line
A
Figure 11.152 Hilgenreiner epiphyseal angle (HEA). (A) The HEA is the angle between Hilgenreiner line and a line drawn parallel to the capital femoral physis. (B) An HEA angle of 68 degrees
in a patient with coxa vara; this value is associated with a progressive deformity. (Reproduced with
permission from Morrissy RT, Weinstein SL. Lovell and Winters Pediatric Orthopaedics. Philadelphia,
PA: Lippincott Williams & Wilkins, 2006.)
is docum en ted in ch ildren wh ose HEA is between 45 degrees an d 60 degrees. Valgus osteotom y of th e proxim al
fem ur is the m ost popular surgical techn ique for correctin g con gen ital coxa vara. Perform ed at eith er th e in tertroch an teric region or th e subtroch an teric region , valgus osteotomy corrects th e n eckshaft angle, lowers th e
trochan ter, improves abduction, and corrects the orientation of th e physis (Fig. 11.153). Several osteotomy techn iques h ave been described, but fixation usually consists
of a blade plate or screw an d side plate device. Correction
of th e HEA to less th an 40 degrees h as been associated with
a decreased risk of recurrence.
B
Figure 11.153 (A) Anteroposterior (AP) view of the pelvis showing bilateral congenital coxa vara.
(B) AP view of the right hip 1 year after valgus-producing intertrochanteric femoral osteotomy.
331
Osteochondritis Dissecans
OsgoodSchlatter Disease
Osgood Sch latter disease is really m ore appropriately con sidered a condition rather than a disease. This con dition is
an osteoch ondrosis of the tibial tubercle. Unlike epiphyses,
wh ich are loaded in compression , apophyses are loaded in
ten sion . In th e case of Osgood Sch latter disease, th e pull
of th e stron g quadriceps causes a traction apophysitis at
the tibial tubercle. This low-grade in flam m atory condition
results from ch ron ic m ech an ical overload an d causes localized pain and swelling.
Th e typical ch ild with Osgood Schlatter disease presents
in the preadolescent or adolescent years complaining of
anterior knee pain. These children in variably localize their
pain to th e tibial tubercle. Ch aracteristically, th e pain is
m ade worse by strenuous physical activity and stair clim bing. Although the diagn osis is rarely in question based on
the clin ical evaluation alone, m ost physicians will obtain
radiograph s of th e kn ee. Radiograph ic fin din gs in clude irregular ossification of th e tibial tubercle an d traction osteophytes.
Th e treatm en t of O sgood Sch latter disease focuses on
activity m odification since symptom s are prim arily activity related. Moderation of activity and the selection of on e
sport versus m any is usually th e m ost help. Adjunctive
therapy with icing after activity, ligh tweight knee straps or
braces, an d in term itten t NSAID adm in istration are all of
value. In severe cases in which an ossicle is presen t, surgical excision can be con sidered.
B
Figure 11.154 (A) Tunnel view of the left knee showing a loose body from a detached osteochon-
dritis dissecans (OCD) lesion. (B) Lateral view confirms the loose body. (Reproduced with permission
from Childrens Orthopaedic Center, Los Angeles, CA.)
332
B
Figure 11.155 (A) Magnetic resonance image of a knee demonstrating an OCD lesion (black
arrow) in the classical location (lateral aspect of the medial femoral condyle). The lesion appears to
be stable, with an intact articular surface. (B) Lateral image of the same knee (black arrows outline
lesion). (Reproduced with permission from Morrissy RT, Weinstein SL. Lovell and Winters Pediatric
Orthopaedics. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
Popliteal Cysts
Popliteal cysts are synovial cysts located behind the knee
join t th at are typically composed of gelatin ous m aterial. Prim ary cysts arise from th e bursa un der th e m edial h ead of
the gastrocnem ius or from the fascia of the sem im em branosus m uscle. Secon dary cysts com m un icate directly with
the knee joint and usually in dicate an intraarticular process
such as a m eniscal tear or synovitis. Whereas the m ajority
of popliteal cysts in adults are secon dary to in traarticular
disease, m ost cysts in ch ildren are a prim ary ph en om en on .
Ch ildren typically presen t with a pain less m ass beh in d
the knee. Parents m ay report that th e m ass waxes or wanes
in size. Plain radiograph s can be used to rule out oth er
conditions, but clinical exam ination and transillum ination
Discoid Meniscus
A discoid m eniscus is an abnorm ally large an d abn orm ally
sh aped m en iscus that usually occurs in the lateral h em ijoin t. Th e etiology of th e discoid m en iscus rem ain s con troversial. The theory of em bryologic delay has been popular
for m any years. Simply stated, this proposes that the norm al
C shaped m eniscus is th e result of differen tial changes
that occur in an initial hockey-puck shaped structure.
Current literature, h owever, h as suggested that this m ay not
be th e cause sin ce discoid m en isci h ave n ever been reported
in the autopsies of newborns or stillbirth s.
A discoid m en iscus can presen t anywh ere between th e
age of 3 and early adulth ood. Young children generally do
n ot complain of pain but m ay presen t with a limp, interm itten t effusion s, or a loud clun k with flexion an d rotation al
m otions of the knee. As the ch ild grows older, the m eniscus
can tear, resulting in pain, lockin g, and other m echanical
sym ptom s. Physical exam ination m ay reveal pain along the
lateral joint line and lack of term inal extension. Gait is notable for a persisten t kn ee flexion th rough stan ce ph ase.
333
Figure 11.156 Three successive sagittal magnetic resonance image cuts demonstrating contiguous anterior and posterior horns of the lateral meniscus. This finding is diagnostic of a discoid meniscus. (Reproduced with permission from Childrens Orthopaedic Center, Los Angeles, CA.)
B
Figure 11.157 (A) Complete discoid meniscus viewed from the lateral compartment. (B) Appearance of the meniscus after arthroscopic saucerization. (Reproduced with permission from Skaggs DL,
Tolo VT. Master Techniques in Orthopaedic Surgery: Pediatrics. Philadelphia, PA: Lippincott Williams
& Wilkins, 2008.)
334
Classification
As m ention ed, Blount disease is typically separated into
in fan tile an d adolescen t form s on th e basis of th e age of
on set. Th e severity of in fan tile tibia vara is described by
the Langenskio ld classification (Fig. 11.158). Th e classification is based on the radiographic appearance of th e proxim al tibia. Th e con dition of th e growth plate, th e exten t of
II
III
IV
VI
the m edial beaking, changes in the m edial tibial m etaphysis, and evidence of prem ature fusion of the growth plate
m edially are all factors in differentiating th e grades. The
stages represen t progressive m edial physeal inclination of
the proxim al tibia with physeal bar presence in stage 6. The
Lan genskio ld grade and the age of the patient are factors
in determ in ing treatm ent.
335
Imaging
Radiograph ic evaluation in cludes views of th e proxim al
tibia and a standing AP view of both hips to an kles, with
the patellas (not the feet) facing forward. The characteristic
radiograph ic fin din gs in in fan tile tibia vara in clude varus
an gulation of the proxim al tibial epiphysis/ m etaphysis,
widen in g an d irregularity of th e m edial tibial physis, a m edially sloped epiphysis, an d prom in en t beakin g of m edial
m etaphysis. Prior to the appearan ce of these findings, it can
be difficult to distin guish in fan tile Bloun t disease from severe physiologic bowing. For these cases, Levin e and Drennan described the m etaphysealdiaphyseal an gle (MDA)
to h elp predict th e likelih ood of a given lim b developin g
infantile Bloun t disease. A ch ild with an MDA of less than
9 degrees is un likely to progress to tibia vara, wh ereas th e
one with greater th an 16 degrees is at h igh risk for progression (Fig. 11.161). Unlike the infantile form , the sh ape of
the tibial physis is relatively norm al in adolescent Blount
disease. Slopin g of th e m edial epiphysis an d beakin g of th e
m etaphysis are not usually seen . The hallm ark of adolescen t tibia vara is widening of the m edial physis. Occasionally, widening of the physis can also be seen in th e lateral
side of the distal fem ur. Advan ced im agin g, such as CT scan
or MRI, is gen erally n ot n eeded to m ake th e diagn osis of
Blount disease. In certain cases, th ese studies m ay be useful
to rule out th e presen ce of a bony bar an d to evaluate th e
health of the m edial physis.
Differential Diagnosis
Th e m ost importan t diagn osis to distin guish from Bloun t
disease is physiologic gen u varum , wh ich can be a difficult
336
task in a ch ild youn ger th an 2 years. Th e lack of ch aracteristic Bloun t fin din gson radiograph s an d a low MDA is in dicative of physiologic gen u varum . In addition , th e
deform ity in physiologic gen u varum is sym m etric an d
global, often involving both th e fem ur and the tibia.
However, the presen ce of a focal deform ity or a lateral
thrust during gait is m ore suggestive of Blount disease.
O th er n onphysiologic causes of gen u varum in clude
skeletal dysplasias, rickets, traum a, an d in fection.
with closed physes, a valgus producin g proxim al tibial osteotomy with in tern al fixation is th e m ost com m on ly used
approach. Alternatively, external fixation using a circular or
m ultiaxial fram e can be used to achieve gradual correction
of th e deform ity an d to m in im ize th e risk of n eurovascular
com plication s from an acute correction .
Treatment
Treatm en t is guided by both th e age of th e patien t an d
the severity of th e condition . Observation m ay be in dicated wh en the diagnosis is still uncertain, but treatm ent
sh ould be initiated as soon as th e radiograph ic diagn osis
of in fan tile Bloun t disease is con firm ed sin ce early treatm en t h as been associated with a better progn osis. A brace,
such as a valgus-producing KAFO , can be effective in treatin g m ild to m oderate in fan tile tibia vara (Lan gen skio ld II
or better) before 3 years of age. For older ch ildren , patien ts
with m ore severe disease, and those wh o do n ot respon d to
bracin g, surgery is recom m en ded. Th e results of corrective
osteotomy are best if surgery is perform ed by 4 years of age.
Various techn iques have been described, including transverse, dom ed, an d an gled osteotom ies, but in all cases, th e
lim b sh ould be overcorrected in to valgus to m in im ize th e
risk of recurrence. The internal tibial torsion sh ould also
be corrected. In m ore severe Lan gen skio ld stages, con sideration sh ould be given to resection of th e m edial bar an d
in terposition of fat or oth er m aterial to reduce th e ch an ces
of recurren t deform ity (Fig. 11.162).
For ch ildren with adolescen t Bloun t disease an d open
physes, tem porary h em iepiphysiodesis usin g a staple or
plate or a m ore perm an en t lateral h em iepiphysiodesis
can be used to gradually correct the deform ity over tim e
(Fig. 11.163). For severe deform ities an d for th ose patien ts
337
case of anterolateral bowing and pseudarthrosis are associated with NF. Other associated con ditions include Ehler
Dan los syn drom e, fibrous dysplasia, an d am n iotic ban d
syn drom e.
Classification
Num erous classification system s of CPT h ave been described, includin g th ose of Boyd, Anderson , and Crawford. Radiographic classification of CPT as described by
Crawford is as follows: type I has anterolateral bowin g with
m edullary sclerosis and cortical thickening at the apex; type
II h as con striction or n arrowin g of th e cortical diam eter
with cortical sclerosis; type III h as a cystic-appearin g lesion ; type IV h as frank pseudarth rosis with tapered bone
en ds (Fig. 11.165). Th ese system s gen erally describe th e radiograph ic appearan ce of th e un treated bon e at th e pseudarth rosis site, th e presen ce of fracture at birth , an d th e
appearance of the fibula. However, none of these classification system s provides specific guidance for m an agem ent or
is predictive of outcom e. Also the type of CPT in th ese classification system s will change with growth. Consequently,
th e criteria th at m ay be m ost relevan t to treatm en t were
suggested by Joh nston an d are based on the presence or
Figure 11.164 (A) Anterolateral bowing of the tibia may be apparent at birth or may progress
with weight-bearing. Bowing usually occurs between the middle and distal third of the tibia. (B)
Even though this deformity was protected in a total-contact orthosis, fracture and pseudarthrosis
developed at the apex of the bow. (Reproduced with permission from Morrissy RT, Weinstein SL.
Lovell and Winters Pediatric Orthopaedics. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
338
Imaging
Differential Diagnosis
Bowing of the tibia can occur in various plan es with th e
apex of the deform ity defining the direction of bowing.
Anterolateral bowing as seen in CPT should be distinguished from posterom edial and anterom edial bowing of
the tibia. Posterom edial bowing is associated with calcan eovalgus feet and gen erally resolves with growth . Anterom edial bowin g, on th e oth er h an d, is associated with
fibular h em im elia.
Treatment
A,B
339
C,D
Figure 11.167 (A and B) Preoperative anteroposterior and lateral radiographs of the tibia demonstrating congenital pseudarthrosis and anterolateral bowing. (C and D) Postoperative radiographs
2 months after bone grafting and intramedullary fixation of the tibia and fibula. (Reproduced with
permission from Childrens Orthopaedic Center, Los Angeles, CA.)
IDIOPATHIC TOE-WALKING
Alth ough it is n ot un com m on for toddlers to toe-walk, lack
of n orm al h eel strike after 3 years of age is abn orm al. Typically, toe-walking starts as a habitual phenom en on , an d
wh en asked to m ost ch ildren , th ey are able to walk plan tigrade. O ver tim e, h owever, a con tracture of th e h eel cord
can develop, wh ich m akes th e gait disturban ce m ore difficult to con trol.
Patients typically present between 3 and 4 years of age.
Most patients are asymptom atic, but som e children m ay
com plain of fatigue or pain in th e gastroc-soleus com plex.
Idiopath ic toe-walkin g is m ore com m on in m ale ch ildren ,
and a fam ily h istory of the condition can often be elicited.
Th e toe-walkin g gait is best appreciated with th e ch ild barefoot. As m en tioned, if the ch ild con centrates, th e degree of
toe-walking can often be con trolled. If distracted or asked
to run, however, the true severity of the gait disturbance
is revealed. Ankle plantar flexion is generally norm al, but
dorsiflexion sh ould be carefully evaluated to determ in e th e
degree of h eel cord tigh tn ess. Toe-walkin g is often a sign of
m ore serious conditions such as CP, prim ary m uscle disease, an d disturban ces of th e CNS. As a result, th e diagn osis
of idiopath ic toe-walkin g sh ould be m ade on ly after th ese
oth er con dition s h ave been ruled out. Un like th ese oth er
diagn oses, ch ildren with idiopath ic toe-walkin g h ave n orm al m uscle ton e and m uscle stren gth; spasticity and clonus
are absent.
Treatm en t gen erally con sists of h eel cord stretch in g to
m aintain range of m otion and an articulated AFO with
340
a plan tar flexion stop to preven t th e toe-walkin g an d en courage norm al h eel strike gait. For patients with tight heel
cords who lack significant m otion, serial stretch ing casts
m ay be n ecessary to regain sufficien t an kle dorsiflexion . If
toe-walkin g persists in spite of m axim al con servative treatm en t, surgical len gth en in g of th e gastrocn em ius sh ould be
considered.
vex lateral border of the foot and the neutral hindfoot alignment.
(Reproduced with permission from Morrissy RT, Weinstein SL. Lovell
and Winters Pediatric Orthopaedics. Philadelphia, PA: Lippincott
Williams & Wilkins, 2006.)
that the dorsum of the foot is almost in contact with the anterior leg.
(Reproduced with permission from Morrissy RT, Weinstein SL. Lovell
and Winters Pediatric Orthopaedics. Philadelphia, PA: Lippincott
Williams & Wilkins, 2006.)
Calcaneovalgus Foot
In a calcan eovalgus foot deform ity, th e h in dfoot extern ally
rotates an d hyperdorsiflexes. In som e cases, th is causes th e
dorsum of th e foot to be in con tact with th e an terior tibia
(Fig. 11.169). The deform ity is prim arily positional and is
thought to occur from intrauterine position ing. The estim ated incidence of calcaneovalgus foot deform ity is 0.4 to
1 in 1,000 live births, although som e believe that a m ild
form can be see in up to 30% to 40% of newborn s.
Although a calcaneovalgus foot is generally con sidered
a benign condition, it is important to rule out other, m ore
path ologic con dition s. Posterom edial bowin g of th e tibia
is a condition in which the distal tibia is hypoplastic and
bowed; th is can result in an apparen t calcan eovalgus deform ity. Posterom edial bowing can generally be distin guish ed
from a true calcan eovalgus foot by determ ining th e location of th e apex of the deform ity: in posterom edial bowing,
the apex is in the distal tibia, whereas in calcaneovalgus
foot, the apex is in the joint (Fig. 11.170). Vertical talus can
som etim es present with a sim ilar, dorsiflexed appearance
of th e foot. In con trast to th e calcan eovalgus foot, a vertical
talus h as far less flexibility.
341
B
Figure 11.170 (A) In posteromedial bowing, the apex of the deformity is in the distal tibia. (B) In
a calcaneovalgus foot, the apex of the deformity is in the joint. (Reproduced with permission from
Skaggs DL, Flynn JM. Staying Out of Trouble in Pediatric Orthopaedics. Philadelphia, PA: Lippincott
Williams & Wilkins, 2006.)
342
B
Figure 11.172 Plantar flexion lateral views of an oblique (A) and vertical talus (B). In the oblique
talus, the navicular (unossified), and first metatarsal reduce on the talus. In a true congenital vertical talus, the talus remains plantar flexed in relation to the navicular (unossified) and metatarsal.
(Reproduced with permission from Childrens Orthopaedic Center, Los Angeles, CA.)
dem on strated excellen t results in term s of clin ical appearan ce, deform ity correction , an d foot fun ction .
the heel and shifting it from side to side (inverting and everting).
(Reproduced with permission from Skaggs DL, Flynn JM. Staying
Out of Trouble in Pediatric Orthopaedics. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
are flatfooted at birth as the arch does not norm ally develop
un til after 2 years of age. Up to 25% of n orm al adults will
retain som e degree of flat feet; th e vast m ajority does n ot
cause any functional lim itations.
Most ch ildren presen t because th eir caregivers are con cerned about the appearance of their feet. Pain is less often
the cause for seeking care. The foot is ch aracterized by a
collapsed arch with weight-bearing. When weight-bearing
is discontinued, the arch reconstitutes itself. The hindfoot
is usually in valgus but sh ould correct to varus when children stan d on th eir toes (Fig. 11.174). An kle ran ge of m otion and tightness of the h eel cord should be assessed by
ch ecking dorsiflexion with the h indfoot in verted an d the
knee both extended and flexed (Silfverskio ld test). Radiograph s are rarely n ecessary to m ake th e diagn osis; h owever,
lateral views of the foot will often dem onstrate a sag at the
talon avicular join t an d an in crease in Meary an gle (th e an gle between the long axis of the talus and the long axis of
the first m etatarsal).
Most ch ildren are asymptom atic, but som e m ay h ave
activity-related pain. If the child does not complain of
pain , it is best to reassure th e caregivers, explain th e ben ign natural h istory of the con dition , an d avoid expensive
orth otics. If symptom s are presen t an d th e h eel cords are
tight, a stretchin g program is indicated. Arch supports can
often be h elpful to reduce sym ptom s, but if m ore con trol
of th e h in dfoot is desired, a larger orth osis such as a UCBL
(nam ed for the University of Californ ia Biom echanics Laboratory, wh ere it was developed) or supram alleolar orth osis m ay be n ecessary. Surgery should be reserved for patients with continued pain in spite of m axim al conservative
m anagem ent. Generally, it is best to avoid foot arth rodeses as th ese procedures can increase the risk of arth ritis in
adjacent joints. The two m ost popular surgical procedures
for correction are the m edial sliding calcaneal osteotomy
343
B
Figure 11.174 (A) Patient with flatfeet and hindfoot valgus. (B) When standing on the toes, the
hindfoot goes into varus, proving that the hindfoot is mobile, and the arch elevates, thus confirming
a flexible flatfoot. (Reproduced with permission from Skaggs DL, Flynn JM. Staying Out of Trouble in
Pediatric Orthopaedics. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
Tarsal Coalition
By definition, a tarsal coalition is an abn orm al fibrous,
cartilaginous, or bony connection between two bon es of
the hindfoot or m idfoot. Th e overall prevalence of tarsal
coalitions has been reported to be 2% to 6% in the general
population . Th e true prevalen ce, h owever, is difficult to ascertain since m any patien ts are asymptom atic and do not
presen t for m edical care. Th e m ost com m on sites of coalition occur between the anterior process of the calcaneus
an d the n avicular and between the talus and the calcaneus
(through the m iddle facet of the talocalcaneal joint). Approxim ately 50% of patien ts h ave bilateral coalition s. Although m ost cases occur in isolation, tarsal coalitions have
been associated with oth er disorder such as clubfoot, fibular hem im elia, and Apert syndrom e.
Most patien ts presen t durin g adolescen ce wh en th e cartilaginous or fibrous connection s begin to ossify. Frequent
an kle sprains and achin g pain over th e m edial aspect of the
foot or the sinus tarsi are typical complaints. The m ost characteristic finding in a tarsal coalition is lim ited subtalar m otion and a valgus hindfoot. This lack of m obility is thought
to be th e source of pain as th e stress of weigh t-bearin g gets
344
A
Figure 11.175 (A) A calcaneonavicular coalition (arrow) is best seen on an oblique radiograph
of the foot. (B) Lateral radiograph demonstrating the anteater nose sign (arrows), indicating a calcaneonavicular coalition. (Reproduced with permission from Morrissy RT, Weinstein SL. Lovell and
Winters Pediatric Orthopaedics. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
after talocalcan eal coalition excision are improved if a con com itant calcaneal osteotomy is perform ed.
Clubfoot
Clubfoot or talipes equin ovarus is a con gen ital foot deform ity th at is ch aracterized by th e CAVE m n em on ic (cavus,
forefoot adductus, h in dfoot varus, an d equin us). Th e in ciden ce of th is con dition is approxim ately 1 to 2 per 1,000
birth s, an d 30% to 40% of cases occur bilaterally. Clubfeet
can have a wide spectrum of presen tations from the m ild,
postural form s to th e severe, rigid deform ities. Th e latter
are usually associated with arth rogryposis, myelom en in gocele, Larsen syndrom e, or another underlying syndrom e.
The etiology of talipes equinovarus rem ains unknown , but
talocalcaneal coalition. This represents a traction spur, not degenerative arthritis. The C-sign of Lafleur (black arrows) is a nonspecific
indication of a talocalcaneal coalition. (Reproduced with permission
from Morrissy RT, Weinstein SL. Lovell and Winters Pediatric Orthopaedics. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
345
B
Figure 11.178 (A) Simulated weight-bearing anteroposterior radiograph of a clubfoot. The talus
(small straight arrow) and calcaneus (large straight arrow) are parallel, rather than divergent. The
cuboid ossification center (curved arrow) is medially aligned on the end of the calcaneus. (B) Maximum
dorsiflexion lateral radiograph of a clubfoot. The talus and calcaneus are somewhat parallel to each
other and plantar flexed in relation to the tibia. (Reproduced with permission from Morrissy RT,
Weinstein SL. Lovell and Winters Pediatric Orthopaedics. Philadelphia, PA: Lippincott Williams &
Wilkins, 2006.)
346
Osteochondroses
O steoch on droses (local disorders of en ch on dral growth )
are a com m on cause of foot pain in growin g ch ildren .
Kohler disease is osteonecrosis of the tarsal navicular. Typically, th is is seen in 4- to 6-year-old ch ildren wh o presen t
with pain and swellin g aroun d th e arch of th e foot. Th e etiology of th e con dition is th ough t to be repetitive traum a.
Th e radiograph will dem on strate in creased den sity an d
sclerosis of th e navicular. O ccasion ally, the bone will appear flatten ed on th e lateral view. Treatm en t sh ould be
conservative. During the symptom atic ph ase, short leg castin g followed by a lon gitudin al arch support is usually adequate to con trol symptom s. With in 1 year of on set, radiograph s usually dem on strate n orm alization of th e tarsal
navicular.
Avascular necrosis of the secon d m etatarsal head,
known as Freiberg infraction, typically affects adolescents.
Th e in creased in ciden ce in fem ales suggests th at th e frequen t discrepan cy in len gth between th e first an d secon d
m etatarsal m ay be a factor. Again , repetitive m icrotraum a
has been implicated as a causative factor. The radiograph s
usually dem on strate flatten in g of th e in volved m etatarsal
head. Conservative treatm ent is best, with short-term im m obilization an d appropriate orth otic use. Activity restriction particularly from jum pin g or con tact sports m ay be
necessary. For those cases that do n ot respond to con servative m an agem en t, surgery m ay be in dicated. Tech n iques in clude excision of th e necrotic bon e with graftin g or simple
sh ortenin g of the m etatarsal to relieve the weight-bearin g
stress on the plantar surface.
Sever disease is th e m ost com m on cause of h eel pain
in children. Th e condition is an osteochondrosis of th e
calcaneal apophysis. Typically, the patient is 5 to 10 years
of age an d presen ts with h eel pain durin g or after activity. Physical findin gs generally consist of tendern ess over
the tuberosity of the os calcis; radiographs usually dem onstrate fragm entation ch anges of the apophysis that can be
m isin terpreted as path ologic. Th ese latter ch an ges reflect
the norm al irregular ossification of this secondary ossification center. Treatm ent consists of activity m odification,
judicious use of NSAIDs, h eel cups, an d h eel cord stretch in g. In jection s with lidocain e or cortisone are generally
avoided.
347
in g con gen ital scoliosis, KlippelFeil syn drom e, con gen ital
m uscular torticollis, an d ren al an d facial deform ities.
Th e treatm en t of Spren gel deform ity varies with th e
severity of th e condition . For the vast m ajority of patients
in wh om th e cosm etic deform ity is m ild an d m otion is
adequate, on ly observation is required. For m ore severe
cases, surgical correction usually consists of th e Woodward
procedure in wh ich th e om overtebral bon e is resected an d
the trapezii, rhom boids, an d levator m usculature are released from th eir spin al attach m en ts an d advan ced distally
to lower th e scapula. Resection of th e superior border of th e
scapula im proves the cosm etic outcom es. In children older
than 7 years, th e m idportion of th e clavicle should be resected an d m orselized to m inim ize the risk of traction palsy
to th e brach ial plexus as th e scapula is advan ced distally.
con dition is m ore com m on in fem ales than m ales and affects the left shoulder m ore often than th e right.
Th e clin ical features of Spren gel deform ity in clude a hypoplastic, h igh -ridin g scapula with a variable degree of gen eralized m uscular atrophy about th e en tire sh oulder girdle (Fig. 11.179). In approxim ately on e-th ird of cases, an
om overtebral bon e can be iden tified. Som e patien ts will
dem on strate decreased ran ge of m otion in th e sh oulder,
particularly in abduction ; h owever, in m any cases, th e com plain ts are prim arily cosm etic in n ature. It is essen tial for
the treating physician to recognize that Sprengel deform ity
can be associated with other congenital anom alies, includ-
Congenital pseudarthrosis of the clavicle is a rare con dition in which the m edial and lateral ossification centers
of th e clavicle fail to un ite (Fig. 11.180). Typically, in fan ts
with th is defect presen t with a palpable m ass in th e cen ter
of th e clavicle. Th e con dition alm ost always occurs on th e
righ t side, un less dextrocardia is presen t. Th e radiograph ic
appearance is often confused with a clavicle fracture, but
th e con dition is n ot pain ful. Th e diagn osis is con firm ed by
lack of callus on subsequent radiographs. The natural history of this condition is benign as virtually n o fun ctional
deficits h ave been reported. As a result, m ost ch ildren do
n ot require treatm en t. Open excision of th e pseudarth rosis site, bon e graftin g, and fixation are generally successful
for those ch ildren who report discom fort or are concerned
about th e cosm etic appearan ce of the bump.
348
Erb palsy has the left arm in the characteristic waiters tip position. (Reproduced with permission from Skaggs
DL, Flynn JM. Staying Out of Trouble in Pediatric Orthopaedics. Philadelphia, PA: Lippincott Williams & Wilkins,
2006.)
349
sifican s develop, furth er loss of function will occur. Occasion ally, an osteotomy can be useful to place the han d in
a m ore functional position. For example, a forearm fixed
in supin ation can be m ade m ore functional by being rotated in to sligh t pron ation , wh ich im proves writin g an d
keyboard use.
True Madelung deform ity is a con genital anom aly that results from arrest of th e ulnar and volar portions of the distal
radial growth plate (Fig. 11.184). As a result, a un ique carpal
deform ity results, referred to as a trian gulation defect of th e
distal radius. Th e distal radius an d uln a appear V-sh aped,
with th e carpus h avin g m igrated som ewh at cen trally. Th e
con dition is tran sm itted as an autosom al dom in an t trait, is
m ore com m on in fem ales, and frequently is bilateral.
Wh en th e an om aly is prim arily cosm etic, little or n o
treatm ent is required. In m ore severe cases, surgical options include epiphysiodesis of the rem aining distal radial
physis to m in im ize progression , osteotom y of th e distal radius to correct deform ity, resection of th e distal uln a, an d
ultim ately wrist fusion . An acquired type of Madelun g deform ity can be seen following dam age to the distal radial
physis from osteomyelitis or traum a.
Syndactyly
Webbing or fusion of two or m ore fin gers is th e m ost com m on congen ital anom aly of the hand. It results from a failure of differen tiation between adjacen t fin gers. Th e m ost
com m on con n ection occurs between th e lon g an d rin g
finger. Males are affected twice as often as fem ales, with
a fam ilial in ciden ce of 25%. It is importan t to determ in e
th e exten t of soft tissue an d bony in volvem en t. Syn dactyly
th at in volves on ly skin an d soft tissue is referred to as simple syndactyly, whereas th ose with bony fusions are referred
to as complex syndactyly (Fig. 11.185). As with radial deficien cy syn drom es, it is importan t to be sure th at th ese are
isolated phenom en a. Num erous syndrom es and anom alies h ave been associated with syndactyly, including Apert
syn drom e an d Polan d syndrom e.
Surgical separation typically im proves fin ger an d h an d
function . If left uncorrected, syn dactyly will cause the
longer of th e two fingers to deviate; th erefore, surgical interven tion is gen erally recom m en ded with in th e first year
of life.
Polydactyly
Figure 11.183 Lateral radiograph of the elbow showing a proxi-
350
B
Figure 11.184 (A) Anteroposterior view of the wrist demonstrating the characteristic Madelung
deformity from incompetence of the ulnar and volar portions of the distal radial growth plate. (B)
Postoperative radiograph after corrective osteotomy of the distal radius and ulna. (Reproduced with
permission from Morrissy RT, Weinstein SL. Lovell and Winters Pediatric Orthopaedics. Philadelphia,
PA: Lippincott Williams & Wilkins, 2006.)
B
Figure 11.185 (A and B) A 1 year-old child with complete simple third web-space syndactyly. (Reproduced with permission from Morrissy RT, Weinstein SL. Lovell and Winters Pediatric Orthopaedics.
Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
351
B
Figure 11.186 (A) Complete postaxial polydactyly with phalangeal duplication and a conjoined
metacarpal. B: Radiographs of the same patient. (Reproduced with permission from Morrissy RT,
Weinstein SL. Lovell and Winters Pediatric Orthopaedics. Philadelphia, PA: Lippincott Williams &
Wilkins, 2006.)
MISCELLANEOUS CONDITIONS
Etiology
Many differen t conditions can cause a leg length inequality. Congen ital causes such as PFFD and fibular hem im elia
h ave been previously discussed. DDH with a high
dislocation can sim ilarly cause a differen ce in lim b len gth s.
Acquired con dition s such as juven ile rh eum atoid disease,
dam age to th e physis followin g traum a or in fection s, an d
obscure etiologies such as radiation an d burn s are all capable of producin g un equal lim b len gth s. Even n eurom uscular con dition s such as CP can produce a lim b len gth
discrepan cy.
Evaluation
Th e h istory of a ch ild with lim b len gth discrepan cy sh ould
be screen ed for both con gen ital an d acquired causes. Fam ily history m ay be helpful for identifying inherited disorders. Birth h istory an d th e tim e th at th e discrepan cy was
first noted are also important: discrepancies present at birth
are alm ost certainly due to congenital hypoplasia or DDH.
On physical exam ination , absolute leg length inequality
can be determ in ed by comparin g th e len gth of th e two legs
from th e anterior superior iliac spine to the m edial m alleolus. Th is tech n ique does n ot accoun t for an gular ch an ges
or for deform ities of th e foot an d an kle. Apparen t discrepancy is m easured from the um bilicus to the m edial m alleolus; th is is also a less useful m easure sin ce it can be in fluen ced by h ip adduction con tractures, pelvic obliquity, an d
352
Ruler
X-ray film
Figure 11.187 Limb lengths can be accurately assessed by placing your fingers on the iliac crests and using blocks to level the
pelvis. (Reproduced with permission from Skaggs DL, Flynn JM.
Staying Out of Trouble in Pediatric Orthopaedics. Philadelphia, PA:
Lippincott Williams & Wilkins, 2006.)
position in g. Th e m ost accurate an d efficien t way to clin ically evaluate a leg length discrepancy is to have the child
stand on m easured blocks until the pelvis is level (as judged
by a finger placed on each iliac crest) (Fig. 11.187). This
tech n ique is th e m ost fun ction al m easure as it accoun ts for
both an gular m alalign m en t an d foot deform ity. It is also
importan t to observe th e ch ild walkin g, to look for compen satory m ovem ents and to determ in e the functional effect
of th e discrepan cy. In m ost cases, ch ildren vault over th e
lon g leg, walk with th e kn ee of th e lon g leg flexed, an d/ or
toe-walk on th e sh ort side.
Accurate radiographs, including scan ogram s and teleoroen tgen ogram s, are essen tial in th e evaluation of lim b
len gth discrepan cies. A teleoroen tgen ogram is a sin gle
AP radiograph of both lower extrem ities (including hips,
knees, and an kles) taken on top of a ruler. An advantage of
this film is visualization of th e entire lower extrem ity and
the sin gle exposure (since children often have difficulty
staying still) (Fig. 11.188). Am ajor disadvantage, especially
in larger ch ildren , is m agn ification error because th e sam e
x-ray beam strikes th e h ips, kn ees, an d an kles at differen t an gles. Scan ogram s m in im ize th is error by m ovin g a
sm aller cassette ben eath th e patient and obtain ing m ultiple orth ogon al exposures of th e h ip, kn ees, an d an kles
(Fig. 11.189). Alth ough m ore accurate, this tech nique requires th at th e patien t lay still between exposures (Fig.
11.190). In addition , scanogram s do not allow visualization of th e fem oral an d tibial diaphyses n or do th ey accoun t
for foot deform ity in the overall m easurem ent of leg len gth
discrepan cy. Both teleoroen tgen ogram s an d scan ogram s
can give false readings in children with h ip or knee contractures or rotation al m alalign m en ts. In th ese cases, CT
scan ogram s are a m ore accurate option .
Table
Figure 11.188 The teleoroentgenogram takes a single exposure of the hips to ankles and is subject to the errors of magnification. However, it is probably the best technique for children who
cannot reliably comply with instructions to remain still for multiple
exposures. (Reproduced with permission from Morrissy RT, Weinstein SL. Lovell and Winters Pediatric Orthopaedics. Philadelphia,
PA: Lippincott Williams & Wilkins, 2006.)
Ruler
X-ray film
Table
error by exposing each joint individually. The child must remain still
for each exposure. (Reproduced with permission from Morrissy RT,
Weinstein SL. Lovell and Winters Pediatric Orthopaedics. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
Management
It is importan t to rem em ber th at th e focus of treatm en t is
not the presentin g leg length discrepancy but rath er th e predicted leg len gth discrepan cy at skeletal m aturity. As a result,
proper m an agem en t of a growin g ch ild with a lim b len gth
discrepan cy depen ds on accurate prediction of th e discrepan cy at skeletal m aturity. There are four com m only used
tech n iques for predictin g lim b len gth discrepan cy, each
with a differen t level of accuracy an d complexity. Th ese in clude the arith m etic m eth od, growth-rem ainin g m ethod,
m ultiplier m ethod, an d the straight-line m ethod. Regardless of the techn ique, the poten tial accuracy of these predictive m ethods is improved by longitudinal data. Therefore,
repeated leg len gth m easurem en ts at 6- to 12-m on th in tervals provide m ore inform ation from which to base these
future prediction s.
Th e arith m etic m eth od of Men elaus, also kn own as
the rule-of-thum b m ethod, is the m ost straightforward
m ethod for predicting leg length inequality. The technique
353
TABLE 11.5
Treatment
< 2 cm
26 cm
620 cm
> 20 cm
354
100
+2 S.D.
+1 S.D.
90
Mean
1 S.D.
Boys
80
2 S.D.
70
60
50
40
30
20
10
0
1
8
9 10 11
Skeletal age (yr)
12
13
14
15
16
17
18
100
90
+2 S.D.
+1 S.D.
Girls
80
Mean
1 S.D.
70
2 S.D.
60
50
40
30
20
10
0
1
10
11
12
13
14
15
16
17
18
355
Skeletal agegirls
Reference slopes
ia
Tib
ur
m
Fe
Both
ng
o
L
g
le
prises three parts: the leg length area with the predefined line for the growth of the long leg, the areas
of sloping lines for plotting skeletal ages, and reference slopes to predict growth following epiphysiodesis. (Reproduced with permission from Morrissy
RT, Weinstein SL. Lovell and Winters Pediatric Orthopaedics. Philadelphia, PA: Lippincott Williams &
Wilkins, 2006.)
formed on the proximal tibial physis. The physis is ablated with a drill
followed by a curette. (Reproduced with permission from Morrissey
RT, Weinstein SL. Atlas of Pediatric Orthopaedic Surgery. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
356
357
TABLE 11.6
Fracture
Osteomyelitis, septic arthritis, diskitis
Juvenile rheumatoid arthritis
Lyme disease
Discoid meniscus
Foreign body in the foot
Tumor
DDH
Cerebral palsy
Leg length discrepancy
Fracture
Osteomyelitis, septic arthritis, diskitis
Juvenile rheumatoid arthritis
Lyme disease
Discoid meniscus
Transient synovitis
Tumor
DDH
Cerebral palsy
Leg length discrepancy
Osteochondritis dissecans
LeggCalvePerthes
disease
Muscular dystrophy
Slipped capital femoral epiphysis
Accessory tarsal navicular
Sever apophysitis
Fracture
Osteomyelitis, septic arthritis, diskitis
Apophysitis (e.g., OsgoodSchlatter disease)
Tumor
Cerebral palsy
Osteochondritis dissecans
LeggCalvePerthes
disease
Muscular dystrophy
Slipped capital femoral epiphysis
Tarsal coalition
Accessory tarsal navicular
Diagnostic Studies
Th e ch oice of diagn ostic studies sh ould be guided by in form ation garnered from the history and physical exam ination. Norm ally, h igh -quality plain radiographs are the
first im agin g m odality th at sh ould be obtain ed. For ch ildren wh o can localize th eir sym ptom s, orth ogon al views
sh ould be taken of the region including the join t above an d
the joint below the point of m axim al tenderness. Oblique
views, especially in the foot and ankle, are helpful to iden tify subtle fracture lin es or m inor physeal widen ing. Bone
scans are an excellent test for evaluatin g a lim pin g child
in wh om the history and physical exam in ation are unable
to localize th e an atom ic region th at is affected. Sen sitive,
but n ot specific, bon e scan s can iden tify fracture, in fection ,
or m align an cy. Ultrason ography is th e diagn ostic study of
ch oice for the evaluation of hip joint effusions. Ultrason ography is n on in vasive, does n ot require sedation , an d can be
Diagnosis
Making the diagnosis in a limping child depends on integratin g in form ation obtain ed from th e h istory, physical exam ination, and diagnostic studies. In particular, the ch ilds
age, th e presence or absence of pain, and the type of limp
are important initial clues to the diagnosis an d can help
guide the diagnostic workup. For example, a painful, antalgic limp followin g traum a in an adolescen t is m ost likely
due to fracture; plain radiograph s of th e affected extrem ity
are usually sufficient to m ake the diagn osis. In contrast, an
antalgic gait in a toddler with hip pain, fever, and m alaise
358
RECOMMENDED READINGS
Alm an BA. Duchenne m uscular dystrophy and steroids: pharm acologic treatm ent in the absence of effective gen e therapy. J Pediatr
Orthop. 2005;25(4):554 556.
Chung SM. The arterial supply of th e developing proxim al end of the
h um an fem ur. J Bone Joint Surg Am. 1976;58:961 970.
Flyn n JM, Miller F. Man agem en t of h ip disorders in patien ts with cerebral palsy. J Am Acad Orthop. 2002;10:198 209.
Flyn n JM, Widm an n RF. Th e limpin g ch ild: evaluation an d diagn osis.
J Am Acad Orthop. 2001;9(2):89 98.
Gillin gh am BL, Sanchez AA, Wen ger DR. Pelvic osteotom ies for th e
treatm en t of h ip dysplasia in ch ildren an d youn g adults. J Am Acad
Orthop. 1999;7(5):325.
Heath CH, Stah eli LT. Norm al lim its of kn ee an gle in wh ite ch ildren
gen u varum an d gen u valgum . J Pediatr Orthop. 1993;13(2):259
262.
Sectio n 2
Herrin g JA, Kim HT, Brown e R. Legg-Calve-Perthes disease, II: prospective m ulticen ter study of th e effect of treatm en t on outcom e. J Bone
Joint Surg Am. 2004;86-A(10):2121 2134.
Johnston CE. Congen ital pseudarthrosis of the tibia: results of techn ical variation s in th e Ch arn ley-William s procedure. J Bone Joint
Surg Am. 2002;84:1799 1810.
Kay RM. Lower extrem ity surgery in ch ildren with cerebral palsy. In :
Skaggs DL, Tolo VT, eds. Master Techniques in Orthopaedic Surgery.
Philadelphia, PA: Lippincott William s & Wilkins; 2008.
Lincoln TL, Suen PW. Com m on rotational variations in children. J Am
Acad Orthop. 2003;11:312 320.
Misra M, Pacaud D, Petryk A, et al. Vitam in D deficiency in children
and its m anagem ent: review of current knowledge an d recom m endations. Pediatrics. 2008;122:398 417.
Moseley CF. Assessm ent and prediction in leg-length discrepan cy. Instr
Course Lect. 1989;38:325 330.
Pon seti IV. Growth an d developm en t of th e acetabulum in th e n orm al child: an atom ical, histological, and roentgenographic studies.
J Bone Joint Surg Am. 1978;60:575.
Rauch F, Glorieux FH. Osteogenesis im perfecta. Lancet. 2004;363:
1377 1385.
Skaggs DL, Flyn n JM. Staying Out of Trouble in Pediatric Orthopaedics.
Philadelphia, PA: Lippincott William s & Wilkins; 2006.
Stout JL, Gage JR, Sch warz, et al. Distal fem oral exten sion osteotom y
and patellar tendon advancem ent to treat persisten t crouch gait in
cerebral palsy. J Bone Joint Surg Am. 2008;90:2470 2484.
Pediatric Spine
Wudbhav N. San k ar
IDIOPATHIC SCOLIOSIS
Scoliosis can be due to a n um ber of differen t etiologies, in cludin g n eurom uscular disease, con gen ital vertebral an om alies, collagen disorders, n eurofibrom atosis, an d
spin al cord injury. Idiopathic scoliosis is th e m ost com m on
form of scoliosis and is a diagnosis of exclusion, implying
that n o other underlying condition is present.
David L. Sk aggs
Pathophysiology
Scoliosis refers to coron al or fron tal plan e curvature of
the spine greater than 10 degrees. It is a complex threedim en sion al (3-D) deform ity n ot on ly in cludin g th e obvious abnorm ality in the frontal plan e but also involving alteration in sagittal plan e balance an d rotation in the
transverse plane (Fig. 11.195). This com bination of abnorm alities in three planes leads to the cosm etically apparent
aspects of the deform ity including shoulder and pelvis
asym m etry, hypokyphosis, an d rotational prom inence of
the rib or flank. Alth ough th e etiology of idiopath ic scoliosis rem ains un kn own, potential causes include abnorm alities in platelet dysfun ction, m uscle im balance, collagen
structure, growth plate m echan ics, and th e central nervous
system (CNS). Idiopath ic scoliosis is though t to be polygen etic; a history of scoliosis in a first-degree relative significantly increases an individuals risk.
Classification
Idiopath ic scoliosis can be divided in to in fan tile (youn ger
than 3 years), juvenile (3 10 years), an d adolescen t (older
than 10 years) form s. Infantile scoliosis is extrem ely rare,
m ore com m on in boys than in girls, and m ore often characterized by left th oracic curve pattern s. Juvenile scoliosis
359
lum bar, an d th oracolum bar/ lum bar with a structural th oracic curve. These patterns are then m odified on the basis
of th e deviation of th e apical lum bar vertebra from th e
m idlin e (cen tral sacral vertical lin e [CSVL]) an d th e sagittal balan ce.
Presentation
AIS occurs m ore frequen tly in girls th an in boys, by a 10:1
ratio. Patien ts are usually asymptom atic, alth ough adolescen ts m ay occasion ally com plain of m ild back pain . Pain
severe en ough to require frequent m edication or causing
m issed tim e from school should be thoroughly investigated for another etiology. Patients m ore often present
with complain ts about th eir body im age due to th eir
trunk shift or rib hump. Altern atively, trunk asym m etry
360
Figure 11.196 Synopsis of the Lenke classification for adolescent idiopathic scoliosis. SRS, Scoliosis Research Society; CSVL, central sacral vertical line. (Reproduced with permission from Lenke LG,
Betz RR, Harms J, et al. Adolescent idiopathic scoliosis: a new classification to determine the extent
of spinal arthrodesis. J Bone Joint Surg Am. 2001;83:11691181.)
361
m otor strength, lower extrem ity ton e, and deep ten don
reflexes. Babin ski sign sh ould be sough t an d th e abdom in al
reflex routin ely tested. Th is latter reflex is assessed by ligh tly
strokin g the abdom en on either side of the um bilicus with a
blun t in strum en t; a n orm al respon se con sists of a sym m etric un ilateral con traction of th e abdom in al m uscles toward
th e side bein g stim ulated. Any eviden ce of upper m otor
n euron pathology or asym m etry in fin din gs from on e leg
to th e other calls into question the diagnosis of idiopathic
scoliosis an d sh ould be in vestigated further.
Radiographs
In itial radiograph ic evaluation of a patien t with spin al deform ity consists of standin g posteroan terior (PA) and lateral views on a sin gle, lon g cassette. Gen erally, th e PA view
is preferred over the an teroposterior (AP) view to lim it
th e am oun t of radiation exposure to th e breast tissue. Th e
fron tal view is repeated at regular intervals (usually 3 6
m onths) depending on the age an d growth velocity of
th e ch ild to determ in e curve progression ; an in crease of
at least 5 degrees is gen erally accepted as evidence of curve
progression . Lateral views are im portan t in itially to assess
th e sagittal balan ce an d to look for coexistin g spon dylolysis but are n ot necessary at each follow-up visit. Bending
x-rays are h elpful for assessin g curve flexibility an d plan n in g fusion levels but are in dicated on ly as preoperative
studies (Fig. 11.199).
Figure 11.198 (A) Viewed from the back, the deformity as-
sociated with this girls scoliosis appears mild. (B) The Adams
forward bending test reveals the rotational deformity. (Reproduced with permission from Childrens Orthopaedic Center,
Los Angeles, CA.)
362
A,B
363
C7
C7 plumbline
Cobb angle
thoracic curve
CSVL
Cobb angle
lumbar curve
L5
Special Tests
Differential Diagnosis
Computed tom ography (CT) scans are generally unnecessary in idiopath ic scoliosis but are useful for oth er
diagn oses such as con gen ital scoliosis an d osteoid osteom a. Magn etic reson an ce im agin g (MRI) is th e diagn ostic
m odality of choice for all in traspinal an om alies and spinal
cord tum ors. Most surgeons obtain an MRI of the full spine
in young patients (younger than 10 years), patients with a
history of significant pain, and those ch ildren with objective fin din gs of n eurologic dysfun ction to rule out an
un derlyin g n eural axis abn orm ality. In addition , atypical
curve patterns (e.g., left thoracic curves, hyperkyphosis)
an d rapidly progressive curves should be evaluated with
an MRI.
Natural History
Th e risk of deform ity progression depen ds on th e am oun t
of growth rem ain in g an d th e size of th e curve. Durin g
364
4
5
2
1
B A
RVAD = A B
Figure 11.202 The rib vertebral angle difference (RVAD) is measured by determining the angle of the right and left ribs at the apical vertebra. The slope of the ribs relative to the transverse plane is
measured for each rib. The difference in the angle between the right
and left sides is the RVAD. (Reproduced with permission from Morrissy RT, Weinstein SL. Lovell and Winters Pediatric Orthopaedics.
Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
Treatment
In fan tile idiopath ic scoliosis with an RVAD less th an 20
degrees is typically observed, alth ough treatm en t is often
instituted if a progression beyond 30 degrees is noted. Ch ildren with progressive in fan tile scoliosis or an RVAD greater
than 20 degrees m ay be treated with serial corrective casting
un der gen eral an esth esia (Fig. 11.203). Th ese growin g ch ildren usually require cast ch an ges every 3 m on th s. Wh en
the curve has been corrected an d m aintained at less than
10 degrees, full-tim e bracin g is in stituted. In juven ile scoliosis, several studies have shown continued curve progression in spite of brace use. In certain cases, however, bracing
m ay lim it th e rate of curve progression and m ay be effective in delaying the need for surgical intervention. As a result, bracing of juven iles is often con tinued even in larger
curves to allow furth er trunk growth, recognizing that surgical treatm en t will be needed in the future. In children
with progressive in fan tile an d juven ile scoliosis th at h ave
failed n on surgical treatm en t, early lon g segm en t spin al
fusion is generally avoided because it can drastically affect
trunk heigh t and pulm onary fun ction. Instead, m ost surgeon s favor th e use of growin g in strum en tation with out
fusion, which allows serial len gthenings in the operating
room to ach ieve in creased spin al len gth (Fig. 11.204).
Th e prim ary goal of treatm en t in AIS is to con trol curve
progression an d allow ch ildren to en ter adulth ood with
a stable spine. Observation is indicated for patien ts with
sm aller curves (< 25 degrees) an d older adolescen ts (Risser
III, IV, or V) with lim ited growth rem ain in g. O bservation is also appropriate for adolescen ts with significant
curves wh o m ay have gone beyon d the suitable ran ge for
bracin g but are n ot yet can didates for surgical treatm en t.
365
366
A,B
Figure 11.205 (A) Thoracolumbosacral orthosis underarm brace. (B) Posteroanterior radiograph
demonstrates a right thoracic and left lumbar curve pattern in an adolescent with remaining growth.
(C) The in-brace radiograph demonstrates a reduction of both the thoracic and lumbar curves. (Reproduced with permission from Morrissy RT, Weinstein SL. Lovell and Winters Pediatric Orthopaedics.
Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
367
Com bined anterior fusion and posterior fusion and instrum en tation have classically been indicated for severe curves
an d in ch ildren younger than 10 years to m inim ize the risk
of cran ksh aft. Th e use of m odern pedicle screw in strum en tation allows for greater curve correction an d m ay decrease
the risk of cran kshaft with a posterior-only approach.
diographs of a 16-year-old boy with Lenke 3 adolescent idiopathic scoliosis. The thoracic curve measures 53 degrees and
the lumbar curve measures 60 degrees. (C, D) Postoperative
PA and lateral radiographs after posterior spinal instrumentation and fusion. (Reproduced with permission from Childrens
Orthopaedic Center, Los Angeles, CA.)
NEUROMUSCULAR SCOLIOSIS
A n um ber of n eurom uscular con dition s are seen in wh ich
scoliosis is com m on an d contributes significan tly to the
368
Presentation
Neurom uscular scoliosis m ay be diagn osed early in ch ildren wh o are followed for oth er orth opaedic issues related
to th eir un derlyin g con dition . Altern atively, patien ts m ay
presen t later with m ore advan ced deform ity. Th ese patien ts
gen erally com plain of difficulty sittin g due to trun cal im -
rod anterior construct used for thoracic scoliosis correction. Note the structural grafting of
the lower two levels. (B) Dual-rod constructs
are generally preferred for thoracolumbar
scoliosis. (Reproduced with permission from
Morrissy RT, Weinstein SL. Lovell and Winters
Pediatric Orthopaedics. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
balan ce an d/ or pelvic obliquity. In severe cases, isch ial ulcers can occur from asym m etric loadin g. In ch ildren with
n orm al cognition, th e ability to freely use th e upper extrem ities and function independently in a wheelchair m ay be
com prom ised by worsen in g scoliosis. Fam ilies with h igh ly
involved children often complain that transfers, positioning, and bathing are difficult. Pain m ay or m ay not be
associated with neurom uscular scoliosis and is often difficult to assess, particularly in patien ts with cerebral palsy.
369
B
Figure 11.208 Clinical (A) and radiographic (B) images of a girl with neuromuscular scoliosis due
to cerebral palsy. Note the sitting imbalance and pelvic obliquity. (Reproduced with permission from
Morrissy RT, Weinstein SL. Lovell and Winters Pediatric Orthopaedics. Philadelphia, PA: Lippincott
Williams & Wilkins, 2006.)
Radiographs
As in cases of idiopath ic scoliosis, lon g-cassette AP an d lateral radiograph s are n ecessary to evaluate n eurom uscular
spin al deform ity. Often these patients are n onam bulatory,
so radiographs m ust be perform ed in the seated position
(Fig. 11.209). This is preferred over supine radiographs,
wh ich can drastically un derestim ate th e degree of spin al
deform ity. In addition to usin g th e Cobb an gle to quan tify
th e severity of th e curve, on e sh ould assess pelvic obliquity
by m easuring the angle between the horizontal and a
lin e tangen tial to the iliac crests (Fig. 11.210). Flexibility
is best assessed with traction radiographs since bendin g
radiograph s are often difficult to obtain in th is patien t
population .
Special Tests
CT scans are usually not n ecessary unless there is a suspicion of a con gen ital vertebral an om aly. O ccasion ally, CT
scan s can be h elpful in cases of myelodysplasia to determ in e th e presen ce or absen ce of posterior elem en ts.
370
A,B
C
Figure 11.209 (A, B) Seated posteroanterior and lateral radiographs of a 10-year-old boy with
a mitochondrial disorder and neuromuscular scoliosis. Note the severe thoracolumbar scoliosis and
pelvic obliquity. (C) In these patients, traction x-rays are superior to bending x-rays to assess curve
flexibility. (Reproduced with permission from Childrens Orthopaedic Center, Los Angeles, CA.)
MRI is in dicated for n eural axis abn orm alities (e.g., syringomyelia) and for cases with m ore rapid curve progression th an would otherwise be suspected for th e particular
condition.
Differential Diagnosis
Th e differen tial diagn osis for n eurom uscular scoliosis in cludes idiopath ic scoliosis, congenital scoliosis, and spinal
deform ity due to con n ective tissue disorders (e.g., Marfan syn drom e, Eh lersDan los syn drom e). Any spin al deform ity in the presence of an underlying neurom uscular
disorder can be diagn osed as n eurom uscular scoliosis.
Treatment
Non operative treatm en t m ay in clude observation , seatin g
support system s, or bracin g. Observation is appropriate
for m ild curves without functional impairm en t. These children , h owever, sh ould be closely followed, as m ost are at
relatively h igh risk for progression . Th e risk of progression
is greatest in patien ts with spastic quadriplegia, particularly
those who are n onam bulators. Seating support system s are
extrem ely useful for m an agin g m ild to m oderate deform ities. A well-m ade support system can accom m odate pelvic
obliquity, m in im ize th e risk of skin com plication s, provide
assistan ce in sittin g balan ce, an d even assist with h ead con trol (Fig. 11.211). Bracin g is con troversial for neurom uscular spin al deform ity. It is gen erally accepted th at bracin g
is in effective for correctin g spin al deform ity. O ccasion ally,
371
Cobb angle
Pelvic obliquity
Congenital anom alous vertebrae m ay lead to the developm ent of spinal deform ities. Th ese deform ities range from
m ild to severe an d are am on g th e types of spin al deform ity that are m ost likely to lead to n eurologic impairm ent
and even paraplegia. Because of th e propensity for certain
types of congen ital spinal deform ity to progress rapidly, because of th e risk of n eurologic impairm en t an d in traspin al
anom alies, and because of th e association of congenital
spin al deform ity with congenital an om alies of other organ system s, all orthopaedic surgeons sh ould be aware of
th e im plication s of con gen ital deform ity of th e spin e wh en
recogn ized.
372
Presentation
Th e in ciden ce of con gen ital scoliosis in th e gen eral population is estim ated between 1% and 4%; congenital kyphosis
is even rarer. Most children with congenital spine deform ities present at an early age, and m ost are asymptom atic.
Youn g ch ildren m ay presen t with a m ild deform ity or with
an om alies that were found in cidentally on radiographs
taken for oth er reason s. In advan ced cases (especially severe
con genital kyphosis), patients m ay presen t with neurologic
deficits.
Defects of segmentation
Block vertebra
Unilateral bar
Unilateral
failure of
segmentation
Bilateral
failure of
segmentation
Defects of formation
Hemivertebra
Wedge vertebra
Unilateral
complete
failure of
formation
Fully segmented
Defects of
vertebral-body
segmentation
Unilateral
partial failure
of formation
Semisegmented
Incarcerated
Nonsegmented
Partial
Anterior
unsegmented bar
Posterolateral
quadrant vertebra
Butterfly vertebra
Complete
Anterior aplasia
Anterior hypoplasia
Block vertebra
Posterior hemivertebra
Wedge vertebra
Mixed anomalies
Anterolateral bar
and contralateral
quadrant vertebra
Figure 11.213 Classification of congenital scoliosis. (Reproduced with permission from Morrissy
RT, Weinstein SL. Lovell and Winters Pediatric Orthopaedics. Philadelphia, PA: Lippincott Williams &
Wilkins, 2006.)
373
374
demonstrating a L1 hemivertebra. (B) Three-dimensional computed tomography reconstruction more clearly defines the nature of the hemivertebra. (Reproduced with permission from
Childrens Orthopaedic Center, Los Angeles, CA.)
Radiographs
Th e in itial diagn ostic tests of ch oice are h igh -quality radiograph s of th e en tire spin e. Careful evaluation of th e vertebrae an d disk spaces is importan t to defin e th e area of
spin e in volvem en t an d to determ ine the specific pattern of
deform ity (Fig. 11.214). Iden tifyin g on e vertebral an om aly
sh ould prompt a search for oth er contiguous and n oncon tiguous m alform ation s. Th e overall radiograph ic balan ce
of th e spin e sh ould be assessed. For exam ple, con tralateral h em ivertebrae can result in a relatively balan ced curve
an d a stable spin e deform ity. In addition to evaluatin g th e
coronal plane deform ity, it is essential to obtain lateral radiograph s to adequately exam in e th e sagittal plan e. Kyph osis, not scoliosis, is the m ost con cern in g type of congen ital
spin al deform ity due to its h igh risk for neurologic com plications.
Special Tests
CT scan is th e diagn ostic m odality of ch oice for evaluatin g
bony an atomy an d is extrem ely useful for elucidatin g vertebral m alform ation s th at can often be difficult to defin e on
the basis of plain radiographs. In particular, CT scans with
3-D recon struction s can be very h elpful for un derstan din g
abn orm al an atomy an d plan n in g corrective surgery. MRI
is in dicated in all ch ildren with con gen ital spin al deform ity to rule out an intraspinal anom aly (Fig. 11.215). As
m en tion ed, ren al ultrasoun d an d ech ocardiogram m ay be
necessary to look for coexistin g GU or cardiac abnorm alities.
Differential Diagnosis
Th e differen tial diagn osis of isolated con gen ital scoliosis
in cludes scoliosis due to syn drom es an d idiopath ic sco-
Treatment
Treatm ent of congen ital spinal deform ity is determ ined by
the natural history of the specific anom alies present, an
assessm ent of th e potential for curve progression, and the
risk of n eurologic deterioration . McMaster an d O h tsuka,
in a large review, dem onstrated significant progression in
75% of th eir patien ts. Both th e region of th e spin e an d th e
type of anom aly impacted on the risk of progression (Table
11.7). The worst prognosis was seen in patients with a unilateral unsegm ented bar opposite a hem ivertebra, although
an isolated unilateral unsegm ented bar was also at significant risk for progression. The best prognosis was seen with
isolated hem ivertebra, particularly incarcerated, sem isegm en ted, and nonsegm ented hem ivertebrae. Defects at the
thoracolum bar junction had a higher risk of progression
than elsewh ere; h owever, because of the impact on shoulder balan ce, defects in th e upper th oracic an d cervicoth oracic spin e resulted in th e m ost readily apparen t clin ical
deform ities seen .
B
Figure 11.215 (A) Intraspinal anomalies accompanying vertebral anomalies are common. Indications for magnetic resonance imaging include planned surgical intervention, abnormalities found on
neurologic examination, and progressive curvature in the unaffected section of the spine. Diplomyelia
is visible in this computed tomography (CT) myelogram. (B) Diastematomyelia, diplomyelia, tethered
spinal cord, and other anomalies are present in this infant with multiple vertebral anomalies. (C) Tethered spinal cord with thickened filum terminale. (D) A CT scan with three-dimensional reconstruction
is helpful to understand the details of congenital vertebral anomalies. Two lumbar hemivertebrae are
readily visible here. (Reproduced with permission from Morrissy RT, Weinstein SL. Lovell and Winters
Pediatric Orthopaedics. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
375
376
TABLE 11.7
Block
Vertebra
Wedge
Vertebra
< 1 1
< 1 1
< 1 1
< 1
2
2 3
1.5 2
< 1
Hemivertebra
Single
Double
1 2
2 2.5
2 3.5
< 1 1
< 1 1.5
2 2.5
2 3
5
Unilateral
Unsegmented
Bar
2 4
5 6.5
6 9
> 5
Ch ildren with m ild spin al deform ity an d a favorable n atural h istory can be followed with serial radiograph s un til
skeletal m aturity. Th e frequen cy of radiographic evaluation
depen ds on th e risk of curve progression an d th e patien ts
age. Con genital curves are usually less flexible than idiopath ic curves; an d th erefore, bracin g is rarely effective in
controllin g th e prim ary curve. Occasion ally, bracin g can
be h elpful for m an agin g compen satory curves.
In con gen ital scoliosis, surgery is in dicated to h alt progressive deform ity an d spin al im balan ce. All surgical procedures in volve som e am oun t of spin al fusion an d can potentially decrease th e overall spin e len gth in th ese growin g
children. The risks of lim iting growth potential, however,
m ust be compared with the risks of continued asym m etric growth an d worsen in g spin al deform ity. Early, lim ited
in situ fusion can stop curve progression with relatively
low risk of complications. For younger children , a com bined an terior an d posterior arth rodesis sh ould be con sidered to m in im ize th e risk of cran ksh aft ph en om en on . In
sm aller ch ildren , postoperative im m obilization can consist
of a cast or brace. In strum en tation can be used to stabilize
th e arth rodesis an d ach ieve m ore curve correction ; h owever, th e n eurologic risks of in strum en tation are h igh er in
children with con genital scoliosis th an in children with idiopathic scoliosis. For ch ildren youn ger than 5 years with
progressive deform ity due to a fully segm en ted h em ivertebra, con vex an terior an d posterior h em iepiphysiodesis
m ay allow for continued growth on the concave side of the
curve, th ereby causin g som e gradual im provem en t of th e
deform ity. In m ore severe deform ities, h em ivertebra excision can be perform ed (Fig. 11.217). This procedure allows
for greater correction but does carry an increased risk of
n eurologic complication s.
Because of their tenden cy to progress an d th e h igh
risk for n eurologic deterioration , m ost cases of con gen ital kyph osis warran t surgery. Posterior fusion alon e can be
perform ed in ch ildren youn ger th an 5 years with curves less
th an 55 degrees, as th is can allow for som e im provem en t in
377
SCHEUERMANN KYPHOSIS
Wh ile scoliosis refers to deform ities in th e coron al plan e,
kyphosis is m easured in the sagittal plane. The norm al thoracic spin e h as sligh t kyph osis ran gin g from 20 degrees to
45 degrees (Fig. 11.218). Th e th oracolum bar spine sh ould
be relatively straigh t between T10 an d L2, an d th e lum bar
spine below L2 should have m ore lordosis th an th e th oracic spin e h as kyph osis. Abn orm al th oracic kyph osis can
be due to m ultiple etiologies, but Sch euerm an n kyph osis
is one of the m ost classic causes in an adolescent.
Pathophysiology
Th e etiology of Sch euerm an n kyph osis con tin ues to be debated. Mech an ical an d m etabolic factors h ave been suggested, an d disruption of th e cartilage rin g apophysis,
abn orm alities of the en dplates leading to Schm orl node
form ation (herniation of disk m aterial through the endplate), an d gen etic factors h ave all been im plicated. Th ese
en dplate disturban ces cause an terior wedgin g of th e vertebral bodies an d th e resultan t kyph osis.
Presentation
Sch euerm an n kyphosis occurs in 0.4% to 8.3% of the population an d is m ore com m on in boys th an in girls. Un like juvenile form s of scoliosis, Scheuerm ann kyph osis is
rarely diagn osed prior to age 10, typically presen tin g during later teenage years. Patients are usually brough t to a
surgeon because of concerns on the part of the parents
about hunched posture. Mild to m oderate thoracic back
pain is m ore com m on in m ore severe deform ities or in deform ity of th e thoracolum bar junction or upper lum bar
spin e. Natural history studies have sh own that although
affected patients seem to have m ore back pain than h ealth
con trols, th eir ability to perform activities of daily livin g or
m aintain gainful employm en t is not altered.
Physical Examination
Typical patien ts with Sch euerm an n kyph osis h ave rigid hyperkyph osis of th e m idth oracic or lower th oracic spin e.
Th ere is often compen satory hyperlordosis of th e lum bar
spin e. This rigidity distin guish es Scheuerm ann kyphosis
from m ore benign causes such as postural kyphosis and can
be assessed by position in g th e pron e patien ts on th e exam ining table and asking th em to hyperextend the back and
lift th e h ead. The sagittal profile during a forward bending
test often appears m ore sh arply an gulated compared with
th e gen tle roun dn ess of postural kyph osis (Fig. 11.219).
Associated h am strin g tigh tn ess is com m on an d sh ould be
evaluated by m easurin g th e popliteal an gles (Fig. 11.220).
378
C2
C7
T1
Normal range
of thoracic
kyphosis = 2045
Figure 11.219 In Scheuermann kyphosis, the sagittal profile appears more sharply angulated than the gentle roundness of postural kyphosis. (Reproduced with permission from Childrens Orthopaedic Center, Los Angeles, CA.)
T12
Normal lumbar
lordosis = 4060
L5
Special Tests
MRI is in dicated as a preoperative study to rule out any
spin al cord abn orm alities. In addition, MRI is useful to
evaluate th e h ealth of lum bar disks, because th e presen ce
of disk degen eration m ay be th e un derlyin g cause of th e
patien ts sym ptom s an d can alter th e exten t of fusion .
Figure 11.218 Normal sagittal alignment of the spine. (Adapted
from Abel MF. Orthopaedic Knowledge Update: Pediatrics. Rosemont, IL: American Academy of Orthopaedic Surgeons, 2006.)
Radiographs
Th e classic radiograph ic criteria for diagn osin g Sch euerm an n kyph osis are (1) wedgin g of th ree adjacen t vertebrae of 5 degrees or m ore, (2) en dplate irregularity, an d
(3) Sch m orl n ode form ation (Fig. 11.221). Many con sider
ch an ges in a sin gle vertebral body especially in th e th oracolum bar or lum bar spine to be form s of Scheuerm ann
kyph osis, even though these patients do not m eet th e strict
Differential Diagnosis
Th e differen tial diagn osis for abn orm al kyph osis in cludes
postural kyph osis, con gen ital kyph osis, an d posttraum atic
kyphosis am ong others. The m ost com m on kyphotic disorder seen by th e orth opaedist is th e adolescen t with postural
roun d back. Lon g-stan din g complain ts of poor posture
are com m on and m ay have been present in oth er m em bers of th e fam ily. An appreciation of th e ten den cy of som e
adolescents going through puberty to h abitually stand with
roun ded sh oulders m ay explain th e perceived in crease in
kyphosis. Postural roundback m ay be differentiated from
Sch euerm an n kyph osis by th e lack of ch aracteristic en dplate ch an ges on radiograph s, in creased flexibility of th e
spin e, and m ore generalized rounding in the sagittal plane
compared with th e m ore localized, an gular appearance of
379
Figure 11.221 Lateral radiograph of a patient with ScheuerFigure 11.220 The popliteal angle is measured by flexing the
hip to 90 degrees and extending the knee. The popliteal angle is
the angle formed between the leg and the vertical.
Treatment
Non operative treatm en t is classically in dicated for growin g
ch ildren with kyph osis greater than 45 degrees to 50 degrees. Physical th erapy can be useful to im prove sym ptom s
an d reduce ham string tightness but is not capable of im provin g th e deform ity. Bracin g is h elpful on ly in patien ts
with som ewh at flexible deform ities an d at least a year of
growth rem ain in g. Lon g-term results are best in curves less
than 75 degrees and when th e m ore extensive Milwaukee
brace is used. Un derarm orth oses, such as th e TLSO, are at
a m echanical disadvan tage in m ost cases of Scheuerm an n
kyphosis but m ay be utilized for curves with an apex below
T9, particularly for disease occurrin g at th e th oracolum bar
jun ction .
380
381
B
Figure 11.223 A 3-year-old boy with KlippelFeil syndrome. (A) Note the short neck and low
posterior hair line. (B) The lateral cervical spine radiograph demonstrates complete fusion of the
posterior elements of C2C3, with reduced disc height anteriorly. Note the reduced space between
C3 and C4, which most likely represents a cartilage fusion between C3 and C4 that will probably
progress to an osseous fusion later in life. (Reproduced with permission from Morrissy RT, Weinstein
SL. Lovell and Winters Pediatric Orthopaedics. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
Os Odontoideum
Os odontoideum is an anom aly of th e cervical spine in
wh ich th e n orm al odon toid process is replaced by an ossicle with sm ooth circum feren tial cortical m argin s th at h as
n o osseous con tin uity with th e body of th e axis. Th e etiology h as been debated; m any believe th at os odon toideum
results from un recogn ized traum a th at leads to n on un ion
of th e fractured den s. O th ers believe th at os odon toideum
h as a con genital origin .
On radiographic evaluation, the os is typically seen as a
hypoplastic, sclerotic ossicle th at m ay be an terior to, at, or
382
an ossicle with well-circumscribed cortical margins and open posterior ring of C1. (Reproduced with permission from Sankar WN,
Wills BP, Dormans JP, et al. Os odontoideum revisited: the case for
a multifactorial etiology. Spine. 2006;31:979984.)
383
rotatory subluxation. (A) The lateral cervical spinal radiograph demonstrating that the posterior arches fail to superimpose because of the head tilt (arrow). (B) Dynamic
computed tomography scans in a 9-year-old girl with a
fixed atlantoaxial rotatory displacement, with the head
maximally rotated to the left. (C) Her head maximally rotated to the right, in this case, does not reach the midline.
The ring of C1 is still in the exact relation to the odontoid as in B, indicating a fixed displacement. (Reproduced
with permission from Morrissy RT, Weinstein SL. Lovell and
Winters Pediatric Orthopaedics. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
Down Syndrome
sided congenital muscular torticollis. Note the tight left sternocleidomastoid muscle. (Reproduced with permission from Childrens
Orthopaedic Center, Los Angeles, CA.)
384
SPONDYLOLYSIS AND
SPONDYLOLISTHESIS
Spon dylolysis is a stress fracture of th e pars in terarticularis
of th e lum bar spin e. Spon dylolisth esis refers to th e forward
slippage of on e vertebra on another. The overall inciden ce
in adolescen ts is 5% to 6% by th e en d of skeletal growth .
Male patien ts are m ore com m on ly affected th an fem ale patien ts, by a 6:1 ratio.
is intact. Progression is com m on in this type of spondylolisthesis. Class II, or isthm ic, spondylolisthesis is the m ost
com m on type seen in ch ildren . In this case, the spondylolisthesis occurs because of a defect in th e pars in terarticularis (spon dylolysis). Approxim ately 80% to 90% of cases
involve the L5 S1 level, with 5% to 15% affectin g L4 L5.
Th e rem ain in g types of spon dylolisth esis (wh ich rarely affect children ) include degenerative, traum atic, pathologic,
an d postoperative. Progression of spondylolisthesis has
been associated with th e adolescen t growth spurt, lum bosacral kyph osis, an d greater degree of in itial slip on presentation .
Presentation
Spon dylolysis an d spon dylolisth esis are som e of th e m ost
com m on causes of back pain in the pediatric population,
an d patients present typically with pain in the low back,
occasion ally radiatin g in to th e buttocks or posterior th igh .
Th is back pain is largely m ech an ical an d is worsen ed by
activity an d improved by rest. In advanced cases of spondylolisthesis, an terior translation of the superior vertebral
body can result in foram in al sten osis of th e exitin g n erve
root an d can presen t as radiculopathy.
385
Physical Examination
In spon dylolysis, th e pain is usually aggravated by hyperexten sion an d rotation . Tigh t h am strin gs (as eviden ced by an
increased popliteal angle) are com m on. High-grade slips
can also result in the typical appearance of lum bar hyperlordosis (balancin g the lum bosacral kyphosis), crouch ed
posture, an d waddlin g gait.
Radiographs
A num ber of radiographic findings have been described
in spon dylolysis and spondylolisthesis. Most defects of the
pars in terarticularis can be seen on spot lateral radiograph s
of th e lum bosacral spin e. In som e cases, furth er defin ition
of th e defect can be seen on oblique radiograph s, wh ere
the characteristic collaron the neck of the Scotty dogis
seen (Fig. 11.228). Lateral radiograph s also allow gradin g
of spon dylolisth esis. Th e two m ost im portan t radiograph ic
m easures are the percent slip (Meyerdin g classification )
an d the slip angle. Th e Meyerding classification is based on
the percen tage of translation of th e superior vertebral body
across the inferior vertebral body. Th e superior endplate of
the inferior vertebrae is divided into quadran ts, an d the
am ount of translation is graded between I and IV. Grade
V or tran slation over 100% is term ed spondyloptosis (Fig.
11.229). Th e slip angle quan tifies the am ount of kyphosis
Slip angle
ysis (white arrows) at L3 and L5. The location of the stress fracture is the neck of the Scotty dog. (Reproduced with permission
from Weinstein SL. The Pediatric Spine. Philadelphia, PA: Lippincott
Williams & Wilkins, 2001.)
386
Special Tests
In certain cases of spon dylolysis, plain radiograph s (in cludin g obliques) are non diagnostic. Bone scan s can show
in creased uptake in patien ts with n ew spon dylolytic lesion s but m ay be cold in those who h ave had lon g-term
symptom s. CT scans are m ore sensitive th an either plain
radiographs or bone scans and allow for m ultiplanar recon struction s. Single-ph oton em ission CT (SPECT) scans h ave
greater sen sitivity an d specificity for diagn osin g spon dylolysis compared with radiograph s an d bon e scan s. MRI
is useful for rulin g out oth er causes of back pain an d for
evaluatin g sten osis as part of preoperative plan n in g.
Differential Diagnosis
Th e differen tial diagn osis for spon dylolysis an d spon dylolisth esis is sim ilar to th at of back pain (see later).
Neoplasm s, m uscular strain s, in fection s, an d psych osom atic back pain can all presen t sim ilar to spon dylolysis/
spondylolisth esis. Usually, radiograph s or advan ced im agin g tech n iques are diagn ostic.
Treatment
Many cases of spon dylolysis are foun d in ciden tally, are
asymptom atic, an d require n o treatm en t. In patien ts wh o
presen t with symptom atic spon dylolysis, th e m ain stay of
treatm en t is n on surgical. Usually th is in volves activity restriction, nonsteroidal an ti-inflam m atory drugs (NSAIDs),
an d physical th erapy focusin g on core stren gth en in g an d
ham string stretching. In patients suffering from acute
spondylolysis, bracing can be useful. It is im portant to
note that the resolution of symptom s does not necessarily correlate with h ealin g of th e pars defect. Th e goal of
treatm en t is pain resolution an d return to full activity; as
a result, patien ts sh ould be m an aged on th e basis of th eir
clinical response, n ot the radiographic findings. Patients
with spondylolysis wh o are still sym ptom atic after conservative treatm en t m ay be can didates for direct repair of the
pars defect. Various tech n iques h ave been described in cludin g wirin g, screw fixation , an d screw h ook con structs usually with autogen ous bon e graftin g. In patien ts with disk
degen eration or any degree of segm en tal in stability, posterolateral fusion with or with out in strum en tation is th e
treatm en t of ch oice.
Treatm en t of spon dylolisth esis depen ds on th e grade of
the slip and the presence or absence of symptom s. Asymptom atic patien ts with grade I spon dylolisth esis are typically
treated with observation alon e with out activity restriction ;
routin e radiograph ic follow-up is recom m en ded on an an nual basis to m onitor for slip progression. Asymptom atic
patien ts with h igh er grades of spon dylolisth esis are usually restricted from h igh -risk activities such as gym n astics
or con tact sports. Symptom atic patien ts with grade I or
387
D
Figure 11.231 (A, B) This 11-year-old girl underwent posterior decompression and instrumented
posterolateral fusion from L5 to sacrum, using autogenous iliac crest graft laterally. (C) At 5 years 6
months postoperatively, she had an excellent arthrodesis on the posteroanterior view. (D) The lateral
view shows stability at L5S1. (Reproduced with permission from Morrissy RT, Weinstein SL. Lovell
and Winters Pediatric Orthopaedics. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
BACK PAIN
Back pain in adults is so com m on th at it is alm ost a norm al
variant. Although bothersom e and at tim es incapacitating,
m ost patients and fam ily m em bers accept the fact that a
backach e is a routin e occurren ce, frequen tly difficult to diagnose, an d often resistant to treatm ent. When significant
back pain occurs in ch ildren , h owever, a certain an xiety
level is seen on the part of fam ily m em bers and referring
physician s. Most of th is con cern stem s from th e fact th at
back pain h as tradition ally been con sidered a rare fin din g
in th e pediatric population . In reality, back pain is relatively com m on in adolescen ts an d ch ildren . Recen t studies
in dicate th at m ore th an 50% of ch ildren will experien ce
back pain by age 15 an d rough ly 24% of adolescen t girls
complain of back pain m ore th an once a week. It is un clear
wh at h as caused th is apparent increase in incidence, although sedentary lifestyles, in creased sports participation,
an d backpack use h ave all been th ough t to play a role. Pediatric back pain can be caused by a variety of con dition s
388
Presentation
A careful detailed history should be obtain ed from both
the child and the parent. The age of the patient at presentation is im portan t in th e evaluation of low back pain . Th e
prevalen ce of back pain in ch ildren youn ger th an 10 years
is less com m on th an in adolescen ts an d is m ore likely to
have an organic etiology such as an in fection or a tum or.
Th e on set of symptom s sh ould be explored, in cludin g any
in citin g traum a, as well as th e location of th e pain an d sites
of radiation . Pain at rest is con cern in g an d is classically associated with neoplasm s. The severity of pain is often best
assessed by askin g about th e ch ilds ability to participate
in sports an d oth er recreation al activities. It is n ot at all
un com m on for adolescen ts to com plain of relatively m ild
back pain with n o specific cause; th is is particularly true if
the diagnosis of scoliosis has recen tly been m ade. On the
oth er h an d, pain th at is of sufficien t m agn itude to in terfere with activities such as attendin g school or participatin g in organ ized sports is m ore worrisom e. Patien ts sh ould
be question ed about n eurologic sym ptom s such as radiculopathy or paresth esias in th e legs an d recen t ch an ges in
bowel or bladder h abits. An in quiry sh ould be m ade about
the childs general m edical status, including a thorough
review of system s an d specific question in g about con stitution al symptom s (e.g., fever, ch ills). Fin ally, it is im portan t
to rem em ber th at psych ological factors can play a role in
back pain , especially in teen agers. It is th erefore im portan t
to assess th e social h istory for fam ily dysfun ction an d oth er
sources of psychological stress.
Physical Examination
Physical exam in ation is perform ed with th e patien t in an
exam in in g gown , disrobed down to un derwear with sh oes
an d socks rem oved. Skin sh ould be assessed for cafe au
lait spots, dimples, or h airy patch es. Balan ce an d posture
sh ould be evaluated in the standin g position to determ ine
thoracic kyphosis, lum bar lordosis, and overall alignm en t.
Gait sh ould be evaluated for eviden ce of weakn ess or pain .
Flexibility can be assessed by exam in in g forward ben din g,
rotation , an d exten sion pain with th e latter can be suggestive of spon dylolysis. Th e spin ous processes an d paraspin al
m uscles sh ould be palpated to determ in e th e location of
the pain. Back pain that is well localized (positive finger
testin wh ich th e patien t poin ts to on e particular spot as th e
source of pain) over bone is particularly indicative for un derlyin g path ology, wh ereas pain over a broad distribution
is likely to be stan dard m ech an ical back pain . In traabdom -
Radiographs
Adolescen ts with m echanical back pain (without any red
flags in the history an d physical exam ination) often do
n ot require radiographic evaluation . Sym ptom atic treatm en t including rest, physical therapy, and judicious use of
NSAIDs is usually sufficien t, but follow-up exam in ation s
are important to ensure improvem ent with these m easures.
Ch ildren youn ger than 10 years and any patients with persisten t sym ptom s, n ight pain , or constitutional complaints
sh ould be im aged at th e in itial visit. Plain AP and lateral
radiograph s of th e spin e sh ould be obtain ed, an d dyn am ic
film s are h elpful if in stability is suspected. O blique film s
of th e lum bosacral spin e can be obtain ed if spon dylolysis
is being considered but are not routin ely ordered. Standing views of the full spine are utilized for cases of spin al
deform ity.
Special Tests
Bon e scan s are a sen sitive but relatively n on specific m odality that will iden tify m ost spin al colum n and pelvic conditions such as tum ors, infections, an d spondylolysis. The
sensitivity and specificity can be enh anced with SPECT
scan n ing, particularly wh en the diagnosis of spondylolysis is an issue. CT scan s are the best im aging m odality
for evaluatin g bon ey anatomy, and are extrem ely useful in
cases where a bone tum or (such as osteoid osteom a) is suspected (Fig. 11.232). Th e presen ce of n eurologic fin din gs
usually warran ts an MRI of th e spin e. MRI is m ore sen sitive and specific in the diagnosis of tum or or infection and
is the im aging m odality of choice for disk abnorm alities
including h erniation and diskitis. Laboratory testing is occasion ally in dicated in the child or adolescent with back
pain an d is m ore com m on ly utilized in th is settin g th an in
the adult. Urinalysis and complete blood cell count m ay be
obtain ed, an d th e sedim en tation rate an d C-reactive protein level are good screen in g tests for n eoplasm or in fection .
Several blood tests are available to complem en t th e search
for un derlying rheum atologic disorders, but this testin g is
usually deferred to th e rh eum atologist.
389
plete collapse of the L1 vertebral body (vertebra plana) from Langerhans cell histiocytosis. (Reproduced with permission from Childrens
Orthopaedic Center, Los Angeles, CA.)
390
Figure 11.234 (A) Lateral radiograph of a 4-year-old child with diskitis demonstrating disc space
narrowing. (B) A positive bone scan with increased uptake at T11 and T12 confirms inflammatory
involvement on both sides of the disc. (Reproduced with permission from Weinstein SL. The Pediatric
Spine. Philadelphia, PA: Lippincott Williams & Wilkins, 2001.)
391
Physical Examination
Radiographs
Several factors m ake pediatric spin e in juries un ique com pared with th ose in adults. Th e h ead of a ch ild is proportionately larger than that of an adult. In addition, children
have weaker paraspin al m uscles to provide head con trol.
Th e result is an in creased relative risk of cervical spin e in jury
in children. Because of their larger head-to-body ratio, im m obilization on a standard adult spin e board will flex the
neck an d could exacerbate any cervical spine injury (Fig.
11.235). Children should therefore be im m obilized and
In itial evaluation sh ould con sist of stan dard AP an d lateral radiograph s of th e in volved area. If an in jury is iden tified, radiographs should be perform ed of the entire spin e
to rule out a noncontiguous in jury. It is importan t to be
aware th at several radiograph ic fin din gs in th e im m ature
spin e can be m isin terpreted as pathologic when in fact they
are norm al. As in other parts of the body, pediatric spine
bon es can be in completely ossified an d growth cen ters can
be m istaken for fractures. For exam ple, in th e youn g ch ild,
SPINE TRAUMA
Spin e fractures con stitute approxim ately 1% of all pediatric
fractures. The cervical spine is the m ost typical location of
injury, accounting for 60% of all pediatric spinal injuries.
Mechanisms of Injury
392
A
Figure 11.236 (A) Pseduosubluxation of C2 on C3. In flexion, the posterior element of C2 should
normally align itself with the posterior elements of C1 and C3. The relationship of the body of C2
with the body of C3 gives the appearance of subluxation; however, the alignment of the posterior
elements of C1C3 confirms pseudosubluxation. (B) True subluxation. (Reproduced with permission
from Beaty JH, Kasser JR. Rockwood and Wilkins Fractures in Children. 6th ed. Philadelphia, PA:
Lippincott Williams & Wilkins, 2006.)
cervical vertebral bodies often appear wedged with deficient an terosuperior m argins. The atlan todens interval is
often in creased compared with adults because of th e presen ce of cartilage aroun d th e im m ature odon toid process;
gen erally, an in terval less th an 5 m m is con sidered n orm al in a ch ild. Perh aps th e m ost com m on m istake is diagnosing pseudosubluxation as true cervical spine in stability.
Pseudosubluxation is th e apparen t an terior displacem en t
of C2 on C3 (or less com m on ly C3 on C4), wh ich occurs in 9% of children (Fig. 11.236). It is believed to be
facilitated by th e m ore h orizon tal orien tation of th e upper cervical facet join ts, wh ich becom e m ore vertical as
the child ages; as a result, pseudosubluxation is rarely seen
after th e age of 8 years. Pseudosubluxation can be distin guish ed from true cervical in jury by th e absen ce of a h istory
of sufficien t traum a to explain th e in jury, by spon tan eous
reduction of C2 on C3 wh en th e h ead is exten ded, an d
by alignm ent of the spin olam in ar line (Swischuks line)
(Fig. 11.237).
Treatment
Th e m ajority of pediatric spin e fractures are stable an d can
be treated with sim ple im m obilization (cervical collar or
TLSO). Displaced cervical spin e fractures th at require reduction an d upper cervical spin e in stability m ay n ecessitate
Special Tests
CT scan s are extrem ely useful in pediatric spin e traum a.
In patien ts wh o h ave in adequate radiograph s or in wh om
the diagnosis is uncertain, CT is an excellent screening tool
with a high sensitivity for boney in jury. In addition , CT is
the diagnostic m odality of ch oice to visualize the upper
cervical spine including the occipitocervical junction. MRI
is in dicated for cases of suspected soft tissue in jury such as
ligam en tous tears or h ern iated disks. MRI is also th e best
test for evaluatin g spin al cord in jury.
Figure 11.237 The spinolaminar line (Swischuks line) should remain aligned in the presence of pseudosubluxation of C2 on C3.
(Reproduced with permission from Beaty JH, Kasser JR. Rockwood
and Wilkins Fractures in Children. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
393
Occipitocervical dissociations are purely ligam entous injuries an d are associated with an extrem ely h igh m ortality rate (Fig. 11.239). Injuries can be classified as anterior,
vertical, or posterior on th e basis of the displacem ent of
th e occiput in relation to th e cervical spin e. Early diagn osis an d treatm ent are critical because patients are at a h igh
risk for n eurologic in jury or sudden death . If radiograph s
are nondiagnostic, an urgent MRI is warran ted. Reduction
sh ould be perform ed under fluoroscopic guidan ce; traction should be avoided as it can exacerbate axial displacem ent. Patients can be temporarily im m obilized in a halo
vest, but defin itive treatm ent con sists of occipitocervical
fusion with instrum entation.
Fractures of C1
Fractures of the atlas ring constitute rough ly 10% of all cervical spine injuries (Fig. 11.240). The m ech anism of in jury
is an axial load; neurologic injury is rare because, when
fractured, the ring of C1 expands, creating m ore space for
th e spin al cord. Posterior arch fractures are stable an d can
B
Figure 11.239 (A) Lateral radiograph of a patient with atlanto-occipital dislocation. Note the
increase in the facet condylar distance. (B) Lateral radiograph after occipital-C1 arthrodesis. (Reproduced with permission from Beaty JH, Kasser JR. Rockwood and Wilkins Fractures in Children. 6th
ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
Posterior arch
fracture
Burst fracture
Lateral mass
fracture
Figure 11.240 There are three common types of atlas fractures: posterior arch fractures, in which
the lateral masses do not spread; burst or Jefferson fractures, in which the lateral masses will spread
and displace laterally; and lateral mass fractures, in which displacement of the lateral mass occurs on
the fractures side. (Reproduced with permission from Jackson RS, Banit DM, Rhyne AL, et al. Upper
cervical spine injuries. J Am Acad Orthop Surg. 2002;10:271280.)
395
Atlantoaxial Injuries
Atlantoaxial injuries are alm ost always ligam en tous. Norm ally, the tran sverse ligam ent is the prim ary stabilizer of
the C1 C2 articulation , with additional stability provided
by the apical an d alar ligam ents. Rupture of th is ligam entous complex can occur from excessive flexion forces. Lateral flexion / exten sion views of th e cervical spin e are usually diagnostic (Fig. 11.241). In ch ildren, an atlan todens
interval m ore than 5 m m is con sidered abnorm al. MRI can
also be helpful to delineate the ligam entous injury. Confirm ed cases of in stability sh ould be treated with posterior
arthrodesis of C1 C2.
Odontoid Fractures
In ch ildren , a syn ch on drosis, exists at th e base of th e odon toid process, wh ich closes aroun d th e age of 5 years. Th e
m ajority of pediatric dens fractures occur through this physeal area due to a flexion m om ent to the cervical spine (Fig.
11.242). Lateral cervical radiographs are usually diagnostic
but can be in con clusive in n on displaced in juries. In th ese
cases, MRI can be helpful to m ake the definitive diagnosis.
Most fractures can be treated by reduction and halo im m obilization for 8 to 12 weeks.
Traumatic spondylolisthesis of C2
(Hangman Fracture)
Fractures th rough th e pedicle of C2 are referred to as Hangman fractures an d result from hyperexten sion in juries. Th e
diagn osis is usually apparen t on lateral cervical spin e radiograph s, as th ere is often displacem en t at th e fracture
site with som e forward subluxation of C2 on C3 (Fig.
11.243). Neurologic injury is rare because (sim ilar to C1
rin g fractures) m ore space is created for th e spin al cord
from displacem ent of the fracture. Treatm ent should be
symptom atic with im m obilization in a h alo or Minerva
cast for approxim ately 8 to 12 weeks. For n onunions and
fractures with significant angulation, posterior or anterior
arthrodesis of C2 C3 m ay be in dicated.
demonstrates an odontoid fracture through the dentocentral synchondrosis with anterior angulation and translation. (Reproduced
with permission from Morrissy RT, Weinstein SL. Lovell and Winters Pediatric Orthopaedics. Philadelphia, PA: Lippincott Williams
& Wilkins, 2006.)
scribed in th e subaxial cervical spine in cluding ligam entous disruptions, facet dislocations, compression fractures,
and burst fractures. Posterior ligam entous disruption s result from flexion or distraction m echanism s (Fig. 11.244).
Patien ts usually com plain of posterior ten dern ess at th e site
of in jury; often , th e on ly radiograph ic eviden ce of in jury
is subtle widening of the spinous processes. MRI can be
h elpful to confirm the presen ce of ligam en tous dam age.
Patien ts can be in itially m an aged with a cervical orth osis;
h owever, any sign of in stability is an in dication for posterior arth rodesis.
Sim ilar to oth er subaxial cervical spin e in juries, un ilateral an d bilateral facet dislocation s are m ore com m on in
adolescents. Diagnosis is usually apparent on lateral radiograph s. Reduction sh ould be perform ed by traction if possible or open reduction if closed m eth ods are unsuccessful. Either way, defin itive treatm ent consists of posterior
arth rodesis.
Compression fractures are the m ost com m on subaxial spine fracture in children . The m echanism of injury is
flexion an d axial loading. Lateral cervical spin e film s will
dem on strate loss of vertebral body h eigh t. Th ese in juries
are alm ost always stable and can be treated with a cervical collar for 3 to 6 weeks. Flexion / exten sion radiograph s
sh ould be obtain ed 2 to 4 weeks after injury to con firm
stability of th e cervical spine.
Burst fractures are caused by an axial load. Although
radiograph s are usually sufficien t to m ake th e diagn osis, CT
scan s are helpful in determ inin g the am ount of spinal canal
396
397
ligamentous injury. (A, B) Anteroposterior and lateral radiographs of a 14-year-old girl who sustained a high-speed motor vehicle accident. She
was a front-seat, restrained passenger. Radiographs demonstrate a probable injury at L4. (C)
Sagittal magnetic resonance imaging shows fracture through the L4 vertebral body and complete
disruption of the posterior ligamentous complex.
(D) Lateral radiograph taken after the patient was
treated with posterior spinal instrumentation and
fusion. (Reproduced with permission from Morrissy RT, Weinstein SL. Lovell and Winters Pediatric Orthopaedics. Philadelphia, PA: Lippincott
Williams & Wilkins, 2006.)
Thoracolumbar Fractures
Compression fractures occur due to an axial load with som e
degree of flexion . In th ese in juries, th e an terior vertebral
body collapses m ore th an th e posterior wall, resultin g in
anterior wedgin g of the vertebrae. Falls are the m ost com m on m echanism of in jury. Fractures can occur at single or
m ultiple levels depending on the severity of injury. Usually,
398
diagn osis is straigh tforward given th e radiograph ic fin din gs an d complain ts of localized pain . For th ose cases in
which th e acuity of in jury is un certain, MRI can be useful.
Most compression fractures are stable an d can be treated
symptom atically with a TLSO for 6 to 8 weeks. Rarely, local
kyph osis can be severe en ough (> 40 degrees) to warrant
posterior in strum en tation an d fusion .
Burst fractures occur from sim ilar m ech anism s as com pression fractures but result from h igh er-en ergy in juries.
In addition to affectin g th e an terior colum n , th e fracture
exten ds th rough th e posterior wall of th e vertebral body.
Neurologic in jury can result from spin al can al en croach m en t by retropulsed bony fragm en ts. Determ in in g th e stability of th ese fractures can be difficult but usually relies on
an in tact posterior ligam en tous complex. Stable fractures
without n eurologic im pairm en t can be treated with brace
im m obilization for 2 to 4 m on th s. Un stable fractures an d
any in juries associated with n eurologic deficits require surgical decompression an d stabilization th rough an an terior
or posterior approach .
Ch an ce fractures are ligam en tous or bony in juries th at
occur from a flexion -distraction m ech an ism . Classically,
Ch an ce fractures occur from lap belt in juries sustain ed durin g m otor veh icle acciden ts. Durin g a fron tal impact, th e
torso is driven forward an d flexes over th e restrain in g belt.
Th e axis of rotation is an terior to th e spin e resultin g in
posterior distraction in juries an d variable degrees of an terior compression ; as a result, all th ree colum n s of th e
spin e are affected. A high percentage of Ch ance fractures
are associated with in traabdom in al in juries. Th e plan e of
in jury can be en tirely th rough bon e, soft tissue, or a com bin ation of th e two (Fig. 11.245). Bony in juries are readily
diagn osed on lateral radiograph s. If th e in jury is purely
ligam en tous, h owever, th e on ly radiograph ic fin din g m ay
be subtle widen in g of th e spin ous processes. MRI is usually in dicated to assess th e spin al cord an d th e in tegrity of
the posterior ligam entous complex. Pure bony injuries can
be treated with exten sion bracin g or castin g (often with
thigh exten sion). Ch ance fractures with ligam entous com pon en ts, sign ifican t abdom in al in jury, or n eurologic im -
Sectio n 3
RECOMMENDED READINGS
Cavalier R, Herm an MJ, Cheun g EV, et al. Spondylolysis and spondylolisthesis in children an d adolescents, I: diagnosis, natural history,
and nonsurgical m anagem ent. J Am Acad Orthop. 2006;14:415
424.
Cheung EV, Herm an MJ, Cavalier R, et al. Spondylolysis and spondylolisthesis in children and adolescents, II: surgical m anagem ent.
J Am Acad Orthop. 2006;14:488 498.
Guille JT, Sh erk HH. Congenital osseous an om alies of the upper and
lower cervical spine in children. J Bone Joint Surg Am. 2002;84:277
288.
Hedequist D, Em an s J. Con gen ital scoliosis. J Am Acad Orthop. 2004;
12:266 275.
Lenke LG, Betz RR, Harm s J, et al. Adolescent idiopathic scoliosis: a
n ew classification to determ ine th e exten t of spinal arthrodesis.
J Bone Joint Surg Am. 2001;83:1169 1181.
McMaster MJ, Ohtsuka K. The natural history of congenital scoliosis:
a study of 251 patien ts. J Bone Joint Surg Am. 1982;64:1128 1147.
Newton PO, ed. Adolescent Idiopathic Scoliosis Monograph. Rosem ont,
IL: Am erican Academy of Orthopaedic Surgeons; 2004.
Skaggs DL, Flyn n JM. Staying Out of Trouble in Pediatric Orthopaedics.
Ph iladelphia, PA: Lippin cott William s & Wilkins; 2006.
Weinstein SL, Dolan LA, Spratt KF, et al. Health and fun ction of patien ts with un treated idiopath ic scoliosis: a 50-year n atural h istory
study. JAMA. 2003;289:559 567.
John M. Flynn
age because of the rapidity an d certainty of bony un ion
and the ability of the childs bones to rem odel, several specific fractures can be problem atic an d require
proper un derstan din g an d treatm en t to ach ieve an optim al
result.
399
TABLE 11.8
Adults
Skeletal maturity
Thin, less osteogenic periosteum
Inferior blood supply
Bones more brittle
Ligaments more likely to fail
Low remodeling potential
400
Figure 11.247 (A) In skeletally mature patients with closed physes, tensile failure usually occurs
across the ligament. (B) In skeletally immature patients with open physes, failure usually occurs across
the physis. (Reproduced with permission from Beaty JH, Kasser JR. Rockwood and Wilkins Fractures
in Children. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
growth slowdown could result in a lim b len gth discrepan cy. If th e arrest is partial, on e side of th e growth plate
could sh ut down and an angular deform ity m ay develop
as th e ch ild grows asym m etrically. After a physeal fracture,
follow-up radiographs should be carefully assessed for prem ature physeal closure an d divergen t ParkHarris growth
lines (Fig. 11.249). These lines appear in the m etaphysis
after temporary periods of slowed growth (e.g., traum a, illness). Resumption of norm al growth is m arked by a parallel
progression of th e ParkHarris lin e away from the physis.
II
III
IV
Figure 11.248 SalterHarris classification of physeal fractures. In SalterHarris type I fractures, the
fracture line is entirely within the physis. In SalterHarris type II fractures, the fracture line extends from
the physis into the metaphysic; in SalterHarris type III fractures, the fracture enters the epiphysis
from the physis and almost always exits the articular surface. In SalterHarris type IV injuries the
fracture extends across the physis from the articular surface and epiphysis, to exit in the margin of
the metaphysic. SalterHarris type V fractures were described by Salter and Harris as a crush injury
to the physis with initially normal radiographs with late identification of premature physeal closure.
(Reproduced with permission from Beaty JH, Kasser JR. Rockwood and Wilkins Fractures in Children.
6th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
401
of an atom ic reduction an d in tern al fixation . Physeal fractures with any con cern in g degree of displacem en t sh ould
be reduced gen tly to m in im ize traum a to th e growth plate.
Depen din g on th e an atom ic region , th e physis m ay n eed
to be stabilized with in tern al fixation . If it is n ecessary to
cross the physis with hardware to achieve adequate fixation,
sm ooth pins are usually used to m inim ize the possibility
of growth arrest.
PEDIATRIC POLYTRAUMA
Figure 11.249 Distal tibial growth arrest. (A) Distal tibial physeal
of join t m otion ) will be corrected by th is rem odelin g ph enom en on (Fig. 11.250). There is a lim it to the am oun t of
rem odelin g th at can be ach ieved; for example, rotation al
deform ities are rarely am en able to th is type of correction .
It is importan t to rem em ber th at rem odelin g depen ds on
the presence and proxim ity of an active physis; therefore,
adolescents with closing physes have decreased rem odeling
poten tial an d sh ould be treated m ore like adults.
Approxim ately 10% of all pediatric traum a patien ts adm itted to th e h ospital are victim s of m ultiple in juries. Traum a is
th e leadin g cause of death in ch ildren , accoun tin g for m ore
fatalities an d disabilities th an all oth er causes com bin ed in
children older than 1 year. Motor vehicle acciden ts involving the ch ild as a passenger, pedestrian, or bicyclist are the
m ost com m on m echan ism s of pediatric polytraum a.
An aggressive team approach for these severely in jured
children is required, including input from general surgeons,
n eurosurgeons, pediatrician s, an d em ergen cy departm ent
physician s. In itial m an agem en t con sists of en surin g th e
stan dard ABCs (airway, breathin g, an d circulation). After
com pletion of th e prim ary survey an d stabilization of th e
patien t, th e secon dary survey is con ducted in a m an n er
sim ilar to stan dard adult traum a protocols.
Certain differences in the anatomy and physiology of
pediatric patien ts can provide un ique ch allen ges. Com pared with adults, ch ildren h ave relatively large ton gues,
sm aller m ouths, and sm aller laryn xes, which can m ake intubation m ore difficult. The head of a child is proportionately larger; as a result, im m obilization on a standard adult
spin eboard will flex th e neck and could exacerbate any cervical spine injury. The protuberant abdom en in children
offers less protection to vital organ s from eith er th e rib
cage or th e pelvis, con sequen tly pediatric patien ts h ave a
h igh er in cidence of intraabdom in al in juries. Ch ildren an d
adults also have physiologic differences that impact th eir
care as polytraum a patien ts. In th e pediatric population ,
tachycardia is able to com pen sate for large in travascular
volum e losses; th erefore, decreased blood pressure is usually a late sign of hypovolem ic shock. Hypotherm ia is also
m ore prevalent in children due to the large surface area to
body weigh t ratios.
Outcom es in children can be predicted by using the
m odified injury severity scale (MISS), as described by
Mayer (Table 11.9). This has proved to be useful in predictin g m orbidity an d m ortality rates in th e pediatric age
group. Th e MISS em ploys th e Glasgow com a scale for grading th e n eurologic injury; in addition , it reviews dam age to
individual body areas, such as the face and neck, th e chest,
th e abdom en , an d th e extrem ities. Rapid evaluation of th e
pediatric polytraum a patien t can be assessed also by usin g
th e Pediatric Traum a Score (Table 11.10). Several compon en ts such as size, airway in tegrity, cen tral n ervous system
402
A,B
403
GSC 13-14
Abrasion or contusions of
ocular apparatus or lid
Vitreous or conjuctival
hemorrhage
Fractured teeth
Minor sprains
Simple fractures and
dislocations
Neural
Chest
Abdomen
Extremities and
pelvic girdle
Major abdominal-wall
contusion
Undisplaced facial-bone
fracture
Laceration of eye, disfiguring
laceration
Retinal detachment
GSC 9-12
2Moderate
GSC 9-12
GSC 5-8
4Severe,
Life-Threatening
Lacerations, tracheal
hemomediastinum
Aortic laceration
Myocardial laceration or rupture
GSC 4
5Critical, Survival
Uncertain
1Minor
Body Area
3Severe, Not
Life-Threatening
THE MODIFIED INJURY SEVERITY SCALE (MISS) FOR MULTIPLE INJURY CHILDREN
TABLE 11.9
404
TABLE 11.10
+2
+1
Weight (kg)
Airway patency
Systolic blood
pressure (mm Hg)
Neurologic
Open wound
Skeletal trauma
> 20
Normal
> 90
1020
Maintained
5090
< 10
Unmaintained
< 50
Awake
None
None
Obtunded
Minor
Closed
Comatose
Major
Open or multiple
(Reprinted with permission from Morrissy RT, Weinstein SL. Lovell and
Winters Pediatric Orthopaedics. Philadelphia, PA: Lippincott Williams &
Wilkins, 2006.)
UPPER EXTREMITY
Shoulder and Arm Injuries
Clavicle Fractures and Dislocations
Fractures of th e clavicle occur in all age groups, from th e
neonate to the adult. Birth fractures of th e clavicle are th e
m ost com m on fracture in th e n ewborn . Frequen tly, th e diagn osis can be m ade in th e n ursery wh en th e ch ild develops
pseudoparalysis of th e in volved lim b an d an asym m etric
Moro reflex. It is importan t to evaluate th e ch ild for associated brach ial plexus palsy as both condition s can result
from a difficult delivery. Treatm ent for these clavicle in juries sh ould be simple im m obilization of th e extrem ity
with a soft wrap of cast padding or stockinette. Healin g is
rapid, and lon g-term sequelae are virtually nonexistent.
In older patien ts, diaphyseal fractures are th e m ost com m on injury to th e clavicle. Typically, these fractures result
from a fall onto th e poin t of the shoulder, and the diagnosis
is straightforward: patients have ten derness along th e clavicular shaft, associated with pain on m otion of the upper
extrem ity. Stan dard treatm en t is brief im m obilization in a
slin g or figure-of-8 dressing. Rapid h ealing in 3 to 6 weeks
is expected, with restoration of full m otion, function, and
strength in m ost patients. Parents should be warn ed about
th e bum p or m ass of callus th at can form aroun d th ese
fractures. This m ass resolves with norm al growth and rem odeling. Recent concerns in adults regardin g m alunion,
n onun ion , and refracture h ave caused a tren d toward open
reduction an d in tern al fixation of m arkedly displaced m idsh aft clavicle fractures. The indications for operative fixation in adolescents are som ewh at unclear but m ay have a
role in severely displaced fractures in older adolescen ts.
Fractures of th e m edial en d of th e clavicle are quite
rare, accoun tin g for fewer th an 10% of clavicular fractures.
Equally rare are true stern oclavicular dislocation s. Th e clavicle is the first bone to ossify; however, the m edial physis
does n ot close un til approxim ately 25 years of age. As a result, m ost m edial in juries to the clavicle are actually physeal
fractures that can m im ic a sternoclavicular dislocation . In
patien ts with th ese in juries, plain radiograph s are often difficult to interpret, and computed tom ography (CT) scans
are usually needed to m ake the diagnosis. Posterior injuries
are of particular concern because they can compress the
trachea, esophagus, or great vessels (Fig. 11.251). Closed
reduction in th e operatin g room with vascular or th oracic
surgery support has traditionally been advocated for th ese
fractures. Because of concerns about recurren t in stability
after closed reduction, m any surgeons are starting to prefer
open reduction of th ese in juries. Usually th e m edial clavicle is approach ed an teriorly. Th e fracture is reduced un der
direct visualization , an d suture is used to repair th e stern oclavicular join t capsule an d ligam en ts to preserve a stable
reduction .
Fractures of th e distal en d of th e clavicle also are frequen tly physeal separation s. Th e distal physis rem ain s
open un til approxim ately 19 years of age. Th e persisten ce
of th is open physis alon g with th e presen ce of a th ick periosteal sleeve aroun d th e distal clavicle m akes physeal fractures m ore com m on than true lateral clavicular fractures.
Once the physis closes, an acrom ioclavicular separation is
th e usual in jury. Again , th e in jury typically results from
a fall on to the poin t of th e sh oulder an d sim ple radiograph s are usually adequate to m ake th e diagn osis. Sh ortterm slin g im m obilization is sufficien t for m ost of th ese
injures.
405
C
Figure 11.251 Sternoclavicular separation. This 14-
neonates, but m ost in juries occur in adolescents. Th e geom etry of th e proxim al h um eral physis is n ot plan ar but rath er
tent shaped, with the apex located posterom edially. Before closin g between the ages of 14 and 18, the proxim al
hum eral physis con tributes 80% of th e growth of th e total
hum erus. Because of th is large growth potential, a trem en dous am oun t of deform ity can be accepted an d expected
to rem odel (Fig. 11.252). Furth erm ore, th e vast ran ge of
m otion of the glenohum eral joint perm its adequate com pen sation for any residual deform ity. As a result, closed
treatm ent with sling im m obilization is recom m en ded for
alm ost all pediatric patients with either a m etaphyseal or
physeal fracture of th e proxim al h um erus. Closed reduction and percutaneous pin fixation is generally not necessary unless a child has greater th an 40 degrees of m alalign m en t and is nearing skeletal m aturity. One definite indication for open reduction and internal fixation is a biceps
ten don en trapped in th e fracture site.
Fractures of th e h um eral sh aft are un com m on in ch ildren ; wh en seen , th e ch ild is usually older th an 12 years
or youn ger th an 3 years. It is critically im portan t to recognize th e association between spiral fractures of the h um eral
sh aft an d child abuse. In children youn ger th an 3 years, an
acute torsional injury to th e upper extrem ity typically produces th is un ique spiral lesion . If th ere is an in con sisten t
history of injury, delay in presen tation for care, or associated injuries in these children, additional investigation into
possible abuse is warran ted. Hum eral sh aft fractures h ave
also been reported in neonates following difficult delivery an d, m uch like clavicle fractures, are h eralded by pseudoparalysis of th e upper extrem ity (Fig. 11.253). Because
of compen satory sh oulder an d elbow ran ge of m otion , up
to 30 to 40 degrees of m alalign m en t is acceptable. As a
result, th e vast m ajority of h um eral sh aft fractures can be
year-old boy sustained an injury to the right clavicle during a wrestling match when his shoulder was compressed
against his chest wall. He complained of shortness of
breath, especially when he extended his neck. (A) The
anteroposterior radiograph demonstrates asymmetry of
the sternal position of the clavicle. (B) The computed tomographic scan demonstrates posterior displacement of
the medial end of the right clavicle, which is near the trachea (arrow). (C) A three-dimensional reconstruction, with
a cephalic projection, demonstrates the posterior and midline displacement of the clavicle. (Reproduced with permission from Morrissy RT, Weinstein SL. Lovell and Winters Pediatric Orthopaedics. Philadelphia, PA: Lippincott
Williams & Wilkins, 2006.)
treated by closed m eth ods, such as collar an d cuff, fun ction al brace, or slin g im m obilization . Most fractures are
sticky by 4 weeks, and m obilization can occur at this
tim e. Select polytraum a victim s (usually adolescen ts) m ay
be can didates for operative treatm en t. In th ese rare cases,
both titan ium elastic n ails an d plate fixation h ave been
used with good success.
Radial n erve in juries associated with h um eral sh aft fractures are usually due to a con tusion sustain ed durin g in itial
fracture displacem ent. These palsies are classically associated with fractures at th e jun ction of th e m iddle an d distal
third (Holstein Lewis fractures). True entrapm ent of the
radial nerve in the fracture site is rare; therefore, alm ost
all ch ildren with radial n erve in juries sh ould be observed
with th e expectation of full recovery. If the radial nerve fails
to recover by 3 to 4 m on th s, electrodiagn ostic studies an d
surgical exploration are warran ted.
Elbow Injuries
No in jury gen erates as m uch an xiety for orth opaedic surgeon s un accustom ed to treatin g ch ildren as do elbow fractures. There is good reason for th is: a sm all swollen elbow
is difficult to exam ine, n eurovascular structures are often at
risk, an d radiograph s can be difficult to in terpret because
of m ultiple evolvin g ossification cen ters. Th e an atom y of
th e ch ilds elbow differs dram atically from th at of th e adult.
At birth , n o epiphyseal structures are presen t. Th e first secon dary ossification cen ter to appear is th at of th e capitellum , usually observed at 6 m onths of age. Following that,
in order of appearan ce, the ossification cen ters of the radial
h ead, m edial epicon dyle, troch lea, olecran on , an d the lateral epicon dyle are seen (Fig. 11.254). In itially, th ese are all
parts of on e large ch on droepiphysis. With rapid differen tial
406
A,B
D,E
J
Figure 11.252 Proximal humeral fracture in a 12-year-old boy. (A) the initial fracture was treated
with a sling and swathe. (B and C) Three months after injury, healing and early remodeling are evident.
(D and E) One year after injury, remodeling continues. (F and G) Four years after injury, remodeling
is complete. (HJ) The patient has recovered full range of motion but has a 1 cm arm length discrepancy. (Reproduced with permission from Morrissy RT, Weinstein SL. Lovell and Winters Pediatric
Orthopaedics. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
407
7 years of age
(59 years)
11 years of age
(813 years)
1 year of age
(126 months)
9 years of age
(713 years)
tal humerus. The average ages are specified, and the age ranges are
indicated. The ossification ranges are earlier for girls than for boys.
The lateral epicondyle, capitellum, and trochlea coalesce between
10 and 12 years of age, subsequently fusing to the distal humerus
between 13 and 16 years of age. This is about the time that the medial epicondyle fuses to the proximal humerus. (Reproduced with
permission from Morrissy RT, Weinstein SL. Lovell and Winters Pediatric Orthopaedics. Philadelphia, PA: Lippincott Williams & Wilkins,
2006.)
408
B
Figure 11.255 (A) Lateral radiograph showing an extension-type supracondylar humerus fracture.
(B) Lateral radiograph demonstrating a flexion-type fracture. (Reproduced with permission from Beaty
JH, Kasser JR. Rockwood and Wilkins Fractures in Children. 6th ed. Philadelphia, PA: Lippincott
Williams & Wilkins, 2006.)
B
Figure 11.256 (A) The typical orientation of the fracture line
displaced posterolaterally an d th ose displaced posterom edially; th e latter accoun t for approxim ately 75% of th e
total. It is importan t to n ote th e direction of displacem en t,
because it frequen tly h as an impact on m an agem en t.
A m ore recent type IV fracture has been described by
Skaggs et al., in wh ich th e periosteum h as been stripped
circum feren tially an d the fracture is, therefore, un stable in
both flexion an d exten sion .
In addition to th e Gartlan d classification , th ere are several radiograph ic m easurem en ts th at are essen tial wh en
evaluatin g a supracon dylar h um erus fracture. Th e sin gle m ost importan t m easurem ent is drawn on the lateral
view by extending a line down the anterior surface of the
h um erus th rough th e elbow join t (Fig. 11.258). If th e line
intersects any part of the capitellar ossification center, then
the reduction (at least in the sagittal plane) is deem ed acceptable. If, however, th e anterior hum eral lin e falls anterior to th e ossification cen ter, it in dicates exten sion at
the fracture site and the need for reduction. On th e AP
view, the m ost important m easurem en t is Baum ann angle,
wh ich is form ed between a lin e perpen dicular to th e axis
of th e h um erus an d a lin e parallelin g th e m etaphysis on
the lateral side of the distal hum erus (Fig. 11.259). The
n orm al an gle varies between 9 an d 26 degrees. A m easurem en t less th an th is in dicates that the fracture is in varus,
409
I fracture is nondisplaced. Often the only evidence is posterior displacement of the olecranon fat pad due to intraarticular
blood (large arrows). (B) Type II fracture. Lateral view demonstrates a displaced supracondylar fracture with the posterior
cortex intact. (C) Type III fracture is totally displaced. (Reproduced with permission from Beaty JH, Kasser JR. Rockwood
and Wilkins Fractures in Children. 6th ed. Philadelphia, PA:
Lippincott Williams & Wilkins, 2006.)
Figure 11.259 Baumann angle is formed between a line perpenFigure 11.258 In the normal elbow, the anterior humeral line
dicular to the axis of the humerus and a line paralleling the metaphysis on the lateral side of the distal humerus. The normal angle
varies between 9 and 26 degrees. (Reproduced with permission
from Skaggs DL, Flynn JM. Staying Out of Trouble in Pediatric Orthopaedics. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
410
411
Figure 11.260 (A and B) Anteroposterior and lateral radiographs of a 4-year-old boy with at type III
supracondylar humerus fracture. (C and D) Intraoperative AP and lateral view after closed reduction
and percutaneous pinning. (Reproduced with permission from Childrens Orthopaedic Center, Los
Angeles, California.)
412
Figure 11.261 The brachial artery can be tented over the sharp
causing a gunstock deformity, which is mostly cosmetic. (Reproduced with permission from Beaty JH, Kasser JR. Rockwood and
Wilkins Fractures in Children. 6th ed. Philadelphia, PA: Lippincott
Williams & Wilkins, 2006.)
supracondylar fracture of the humerus. (Reproduced with permission from Berger RA, Weiss AP. Hand Surgery. Philadelphia, PA:
Lippincott Williams & Wilkins, 2004.)
type I injury with the fracture line lateral to the trochlear groove.
(B) Milch type II fracture extending medial to the ossific nucleus of
the lateral condyle. (Reproduced with permission from Beaty JH,
Kasser JR. Rockwood and Wilkins Fractures in Children. 6th ed.
Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
413
B
A
fracture may be best visualized on the oblique radiograph. Anteroposterior (A), lateral (B), and internal
oblique (C) radiographs. (Reproduced with permission
from Morrissy RT, Weinstein SL. Lovell and Winters Pediatric Orthopaedics. Philadelphia, PA: Lippincott Williams
& Wilkins, 2006.)
414
A,B
D,E
F
Figure 11.266 The drifting lateral condyle fracture. (A and B) Anteroposterior (AP) and lateral
radiographs at presentation. This lateral condyle fracture had only approximately 2 mm of displacement on the AP view. No displacement is noted on the lateral view. The child was placed in a long arm
cast and a follow-up 1 week later was recommended. (C and D) AP and lateral radiographs taken 1
week after injury show further displacement of the lateral condyle fracture, with 5 mm of separation
of the lateral condyle from the distal humerus. Open reduction and pinning was performed. (E and
F) Radiographs taken in the cast 4 weeks after open reduction and pinning show anatomic alignment
and early healing. (Reproduced with permission from Morrissy RT, Weinstein SL. Lovell and Winters
Pediatric Orthopaedics. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
n on union and collapse of the lateral colum n. A tardy uln ar nerve palsy can develop from this deform ity and m ay
require corrective osteotomy an d uln ar n erve tran sposition .
415
B
Figure 11.267 (A) Anteroposterior view showing an elbow dislocation with an incarcerated medial
epicondyle fracture within the joint (arrow). (B) Lateral view of the same elbow demonstrates the
fragment (arrow) between the humerus and olecranon. (Reproduced with permission from Beaty JH,
Kasser JR. Rockwood and Wilkins Fractures in Children. 6th ed. Philadelphia, PA: Lippincott Williams
& Wilkins, 2006.)
less than 5 m m are generally treated by short-term im m obilization followed by early ran ge-of-m otion exercises to
m inim ize th e risk of elbow stiffness. Surgical treatm ent for
fractures displaced m ore than 5 m m is extrem ely controversial since studies have sh own that fibrous unions and
nonunions cause little fun ctional deficits. Som e surgeons
favor open reduction an d in tern al fixation for th ese fractures in those patien ts who participate in repetitive valgus
stress activities (pitching an d gym nastics). The only defin ite
indication for operative treatm ent is a displaced m edial epicon dyle fragm ent, which is in carcerated in the join t (Fig.
11.267). Surgical dissection proceeds through a m edial approach . Th e uln ar n erve is iden tified an d protected, an d th e
fragm ent is reduced by flexing the elbow. Rigid internal fixation using a compression screw is preferred to allow early
m obilization and prevent elbow flexion con tracture.
Because of its proxim ity to the fracture fragm en t, uln ar
nerve injury is relatively com m on , occurring in 10% to 16%
of cases. Som e loss of term in al exten sion is com m on after treatm en t but can be m in im ized by early m obilization .
Non un ion s m ay occur in over 50% of patien ts treated con servatively, but as previously m en tion ed, th is appears to
have little function al con sequence.
ring in children up to 12 m on th s of age, before th e appearan ce of capitellum ossification cen ter. Th ese in juries
are usually SalterHarris type I fractures and are difficult
to diagn ose because of th e lack of ossification cen ters in
the distal fragm en t. Group B fractures occur in ch ildren between 12 m on th s an d 3 years of age wh en th ere is defin ite
ossification of th e lateral con dylar epiphysis. Th ese, too,
are usually SalterHarris type I fractures. Group C fractures
occur in older ch ildren (3 7 years of age) an d are associated with a large m etaphyseal fragm en t. Group C fractures
can be distinguished from a low supracondylar fracture by
the sm ooth outline of the distal h um erus.
A distal h um eral physeal separation sh ould be con sidered in any child youn ger than 18 m onths with a swollen
elbow. Radiograph ic diagn osis can be difficult, especially
in group A, because of th e lack of ossification cen ters. On e
key con cept to rem em ber is th at in a distal h um eral physeal
fracture, the relationship of the ulna to the radius is m aintain ed but both are displaced posterom edially in relation
to th e distal h um erus (Fig. 11.268). Although these injuries
are often con fused with elbow dislocation s, it is importan t
to rem em ber th at dislocation s are exceedin gly rare in ch ildren of th is age. In an elbow dislocation , th e displacem en t
of th e proxim al radius an d uln a is alm ost always posterolateral, an d th e relation sh ip between th e proxim al radius an d
lateral con dylar epiphysis (wh en it appears) is disrupted.
If diagnosis is still uncertain , ultrasoun d or arth rography
can be used to outlin e th e epiphysis of th e hum erus.
Neon ates an d extrem ely sm all in fan ts can be treated
with closed reduction and cast im m obilization at
416
417
418
tension band technique using axial wires plus absorbable suture for
a displaced olecranon fracture. (Reproduced with permission from
Beaty JH, Kasser JR. Rockwood and Wilkins Fractures in Children.
6th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
Monteggia FractureDislocations
Monteggia fracturedislocations refer to a fracture of th e proxim al ulna with an associated dislocation of the radiocapitellar joint. The direction of th e radial head dislocation gen erally follows th e apex of th e uln ar fracture an d form s th e
basis of th e Bado classification (Fig. 11.272). Diagn osis can
often be subtle, an d for th is reason , m any Mon teggia fractures are m istakenly diagnosed as simple ulna fractures. In
the norm al forearm , a lin e drawn alon g the axis of the radius sh ould bisect th e capitellum on every radiograph ic
view (Fig. 11.273). It is, therefore, imperative that elbow
radiograph s be obtain ed in all cases of forearm fractures
so th at th is relation sh ip can be adequately assessed. If this
relation sh ip is violated in th e settin g of an uln a fracture,
then a Monteggia injury is present.
As a general principle, it is the alignm ent an d stability
of th e uln ar fracture reduction th at dictates th e stability
of th e radial h ead reduction . Th erefore, treatm en t of Mon teggia in juries is guided by th e uln ar fracture pattern . Plastic
deform ation of th e uln a an d in complete (green stick) fractures are treated with closed reduction and long arm cast
A,B
Figure 11.271 (A) Displaced radial neck fracture in an 11-year-old girl. (B) Percutaneous reduction
with a K-wire. (C) Final image showing near-anatomic reduction. (Reproduced with permission from
Skaggs DL, Flynn JM. Staying Out of Trouble in Pediatric Orthopaedics. Philadelphia, PA: Lippincott
Williams & Wilkins, 2006.)
Type I
419
Type II
Type III
Type IV
apex anterior ulna fracture with anterior dislocation of the radial head. (B) Type II: apex posterior
ulna fracture with posterior dislocation of the radial head. (C) Type III: apex lateral ulna fracture
and lateral dislocation of the radial head. (D) Type
IV: fracture of both the ulna and radius with anterior dislocation of the radial head. (Reproduced
with permission from Beaty JH, Kasser JR. Rockwood and Wilkins Fractures in Children. 6th ed.
Philadelphia, PA: Lippincott Williams & Wilkins,
2006.)
best treated with open reduction an d plate fixation . Regardless of treatm en t m ethod, it is importan t that th ese
fractures be followed closely to prevent loss of radial head
reduction .
Ch ronic Mon teggia fracturedislocation s result from
m issed diagnosis or loss of reduction after treatm en t. In
late cases, the ulna m ay h ave rem odeled sign ificantly so
th at th e on ly apparen t in jury is an isolated radial h ead
dislocation . Norm ally, th e posterior border of th e uln a
sh ould be com pletely straight. Usually, careful review of
th e forearm radiograph s will dem on strate subtle bowin g
of th e posterior uln ar border in dicatin g th e site of th e
origin al fracture (Fig. 11.274). An addition al ch allen ge is
B
Figure 11.274 Monteggia injury. (A) A 10-year-old boy with a
Figure 11.273 A line drawn down the long axis of the radius
should bisect the capitellum in any view. (Reproduced with permission from Beaty JH, Kasser JR. Rockwood and Wilkins Fractures
in Children. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins,
2006.)
420
dislocation. Note the dysplastic shape of the radial head. (Reproduced with permission from Beaty JH, Kasser JR. Rockwood and
Wilkins Fractures in Children. 6th ed. Philadelphia, PA: Lippincott
Williams & Wilkins, 2006.)
Diaphyseal Fractures
Diaphyseal forearm fractures are divided in to th ree categories based on fracture pattern : plastic deform ation ,
green stick, an d complete fractures. Plastic deform ation results wh en the forces applied to th e young childs forearm
exceed th e elastic lim it of bon e but fall sh ort of its ultim ate
stren gth. Excessive plastic deform ation (usually > 20 degrees of an gulation ) can lim it forearm rotation , so closed
reduction is in dicated for any of th ese in juries. Reduction
is obtain ed by applyin g a sustain ed th ree-poin t load over
the apex of th e deform ity until the deform ity gradually
improves (usually un der gen eral an esth esia), an d th e arm
is im m obilized in a well-m olded lon g arm cast. Green stick
fractures are in complete fractures and usually have both angular an d rotation al displacem en t. Most of th ese fractures
can also be treated with closed reduction and placem ent of
a well-m olded long arm cast. Reduction m ust correct both
componen ts of the deform ity and is perform ed according
to th e rule of th um bs. In th is m an euver, th e th um b is
B
Figure 11.276 A 12 year-old girl with complete midshaft forearm fracture. (A) AP and lateral injury
radiographs demonstrating marked displacement of both the radius and ulna. (B) Post operative
AP and Lateral films demonstrating reduction of both bones and fixation with titanium elastic nails.
(Reproduced with permission from Beaty JH, Kasser JR. Rockwood and Wilkins Fractures in Children.
6th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
421
422
Hand Injuries
Most m etacarpal an d ph alan geal fractures in ch ildren are
nondisplaced and require m in im al treatm ent. The m ajority of displaced fractures can be adequately reduced closed
an d im m obilized, usin g simple splin ts or casts. It is im portan t to im m obilize fin gers in th e position of fun ction
to preven t un n ecessary stiffn ess. As is so often th e case,
when the vast m ajority of in juries are benign, it is easy to
overlook th e problem h an d an d fin ger fractures. Th erefore,
several specific in juries are worthy of note. Condylar fractures, especially if in traarticular (in eith er th e m iddle or
proxim al ph alan x), require an atom ic reduction an d fixation . As in adults, degen erative ch an ges an d deform ity will
result if th ey are n ot treated appropriately. Physeal fractures
occur typically at th e base of th e proxim al ph alan x; th ese
are usually SalterHarris type II injuries. Because an gula-
PELVIC FRACTURES
Th e pelvis in a ch ild is far m ore flexible th an th at of th e
adult. Because of the presence of significantly m ore cartilage, the pediatric pelvis is able to absorb m ore en ergy prior
to failure. Un fortun ately, th e abdom in al con ten ts are n ot
n ecessarily as pliable; thus, with th e relative lack of protection provided by the im m ature pelvis, they are m ore likely
to be dam aged. Alth ough associated gen itourin ary in juries
an d h ead traum a are com m on, the m ortality of pelvic fractures is on ly one-third the rate reported for adults. Pelvic
traum a in children is indicative of a high energy injury an d
prim arily results from pedestrian versus m otor veh icle accidents. Lower energy avulsion in juries can be secondary
to ath letic traum a.
423
of th is physis could result in acetabular dysplasia an d progressive h ip subluxation . Late osteotom ies of th e pelvis are
usually required to treat th is un fortun ate com plication .
LOWER EXTREMITY
Fractures of the Hip and Thigh
Hip Fractures
Un like osteoporotic h ip fractures in the elderly, wh ich result from relatively low loads, hip fractures in children are
n early always th e result of h igh -en ergy traum a. Mech anism
of in jury is usually a m otor veh icle acciden t or fall from
h eigh t, an d associated in juries in clude h ead traum a, long
bon e fractures, an d visceral in juries. Th e h igh -en ergy n ature of these injuries can jeopardize the vascular anatomy
of th e h ip in th e growin g ch ild, leadin g to avascular n ecrosis (AVN) of th e fem oral head. Urgent anatom ic reduction
and stabilization is necessary to restore blood flow to the
fem oral head and decompress the fracture h em atom a.
Pediatric hip fractures are classified according the system of Delbet (Fig. 11.278). Type I fractures are tran sphyseal an d are, th erefore, sim ilar to an acute slipped capital
imal femur fractures. (A) Type I is transepiphyseal. (B) Type II is a transcervical fracture. (C)
Type III is a basicervical fracture. (D) Type IV is an
intertrochanteric fracture. (Reproduced with permission from Morrissy RT, Weinstein SL. Lovell and
Winters Pediatric Orthopaedics. Philadelphia, PA:
Lippincott Williams & Wilkins, 2006.)
424
B
Figure 11.279 (A) Approximately 5-year-old boy with a type III
femoral neck fracture. (B) Three months after anatomic open reduction and internal fixation with two screws sparing the physis.
(Reproduced with permission from Beaty JH, Kasser JR. Rockwood
and Wilkins Fractures in Children. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
425
Figure 11.280 (A) Anteroposterior radiograph taken 6 months after screw implantation. (B) Another radiograph taken after screw removal at 18 months shows avascular necrosis of the femoral
head. (Reproduced with permission from Skaggs DL, Flynn JM. Staying Out of Trouble in Pediatric
Orthopaedics. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
426
Figure 11.281 (A and B) Injury radiographs demonstrating a short oblique femoral shaft fracture
in an 8-year-old boy. (C and D) Anteroposterior and lateral radiographs 4 months after treatment with
flexible intramedullary nails. Note the abundant callus at the fracture site. (Reproduced with permission from Skaggs DL, Tolo VT. Master Techniques in Orthopaedic Surgery: Pediatrics. Philadelphia,
PA: Lippincott Williams & Wilkins, 2008.)
427
Lateral
epiphyseal a.
Lateral femoral
circumflex a.
Ligamentum
teres a.
Growth plate
Medial
circumflex a.
ANTERIOR
Femoral a.
POSTERIOR
Lateral femoral
circumflex a.
ANTERIOR
428
D
Figure 11.283 (A and B) AP and lateral radiographs of a 13-year-old boy with a SalterHarris type
II distal femoral physeal fracture. Note the size of the ThurstonHolland fragment. (C and D) Intraoperative radiographs after reduction and fixation with a 7.3-mm cannulated screw. (Reproduced with
permission from Morrissy RT, Weinstein SL. Lovell and Winters Pediatric Orthopaedics. Philadelphia,
PA: Lippincott Williams & Wilkins, 2006.)
429
Figure 11.285 Classification of tibial tuberosity fractures. (A) Type I fracture through the sec-
ondary ossification center. (B) Type II fracture located at the junction of the primary and secondary
ossification centers. (C) Type III fracture is an intraarticular fracture (SalterHarris type III). (Reproduced with permission from Morrissy RT, Weinstein SL. Lovell and Winters Pediatric Orthopaedics.
Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
mal tibial physeal fracture can cause arterial injury. (Reproduced with permission from Skaggs DL, Flynn JM. Staying
Out of Trouble in Pediatric Orthopaedics. Philadelphia, PA:
Lippincott Williams & Wilkins, 2006.)
B
Figure 11.287 (A and B) Toddler fractures are often difficult to appreciate on a single radiographic
view. The lateral view demonstrates the spiral fracture. (Reproduced with permission from Skaggs
DL, Flynn JM. Staying Out of Trouble in Pediatric Orthopaedics. Philadelphia, PA: Lippincott Williams
& Wilkins, 2006.)
Ankle Fractures
Pediatric ankle fractures are relatively com m on injuries,
an d usually affect children between 8 an d 15 years of age.
Th e m ech an ism of in jury is usually in direct traum a from a
twisting injury although direct traum a from m otor veh icle
accidents, falls, or contact sports can be respon sible. Proper
evaluation in cludes AP, lateral, an d m ortise radiograph s of
the in volved extrem ity. The m ortise view, in particular, is
important as som e pediatric physeal fractures cann ot be
readily visualized on stan dard AP an d lateral radiograph s.
Accessory ossification centers including th e os subtibiale,
os subfibulare, an d os trigon um are com m on an d can often
be con fused with acute fractures. Careful physical exam in ation, radiographs of th e contralateral extrem ity, and a bone
scan (if n ecessary) can distinguish these anatom ic varian ts
from acute injuries. ACT scan is useful in cases of suspected
intraarticular in jury. In these in stances, plain radiographs
often un derestim ate th e degree of displacem en t, an d CT
scans can be invaluable for determ in in g the need for an d
exten t of surgery.
Most in juries are physeal an d can be classified accordin g
to th e SalterHarris system . SalterHarris type I fractures of
the distal tibia or fibula are often m isdiagn osed as ankle
sprain s since there can be m inim al or no displacem ent at
the fracture site. It is important to rem em ber that in chil-
431
432
B
Figure 11.288 (A) SalterHarris type IV distal tibia fracture in a 12-year-old girl. (B) Anteroposte-
rior radiograph after open reduction and fixation with screws placed parallel to the physis. (Reproduced with permission from Beaty JH, Kasser JR. Rockwood and Wilkins Fractures in Children. 6th
ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
recon struction s are usually in dicated. Sim ilar to oth er in traarticular fractures, the goal of treatm ent is anatom ic reduction of th e join t surface. An articular step-off of m ore
th an 2 m m or fracture gap of m ore th an 2 to 3 m m is
an indication for open reduction with an arthrotomy to
visualize the articular surface. Fixation usually consists of
interfragm entary screws placed across the epiphysis from a
lateral to m edial direction and across the m etaphysis from
anterior to posterior. Sim ilar to Tillaux injuries, triplan e
fractures occur in patients nearin g skeletal m aturity; as a
result, th e risk of growth disturban ce is m in im al an d fixation m ay cross th e physis if necessary. Patients should be
placed in to a n on weigh t-bearin g cast for approxim ately
6 weeks.
433
Foot Fractures
Fractures of th e foot in ch ildren are very sim ilar, both in
m echanism and m anagem ent, to those in adults. Fractures
of th e m etatarsals an d ph alan ges are alm ost ubiquitously
m anaged nonoperatively. Excellent results are usually anticipated. On e injury unique in this age group is th e stress
fracture of the calcaneus. Frequently, the child who presents
with h eel pain is diagn osed with Sever disease. Th is osteoch ondrosis of the calcaneal apophysis is com m on in young
ch ildren . However, should the tenderness be m ore distal
in the body of the calcan eus an d the symptom s be m ore
intense, a stress fracture of the calcan eus should be considered. Abon e scan is usually adequate to m ake th e diagn osis,
in a 12-year-old girl. (A) The anteroposterior radiograph shows a SalterHarris type III fracture. (B) The
lateral radiograph shows an apparent SalterHarris
type II fracture. (C) Computed tomography through
the epiphysis helps assess the true displacement of
the fracture. (Reproduced with permission from Morrissy RT, Weinstein SL. Lovell and Winters Pediatric
Orthopaedics. Philadelphia, PA: Lippincott Williams &
Wilkins, 2006.)
because radiograph s are often n orm al. A sh ort leg cast for
3 to 4 weeks is usually an adequate treatm ent.
Child Abuse
Approxim ately 2 m illion ch ildren experien ce ch ild abuse
every year. Approxim ately 25% of th ese ch ildren are physically abused, resultin g in m ore than 1,000 deaths per year.
Half of th e ch ildren are younger than 2 years, an d 40% are
between 2 an d 5 years of age. It is widely recogn ized th at
early diagn osis is importan t. Green h as stated th at sh ould
an abused child be returned to h is or h er h om e without
appropriate in tervention, approxim ately 50% to 70% are
434
at risk for furth er in jury, an d 10% are at risk for death . Paren ts (in cludin g th e m oth er) are com m on ly at fault, as are
stepfathers and oth er m ale partners of the m oth er wh o are
not the biologic fath er.
O rth opaedic surgeon s are frequen tly called upon to
evaluate m usculoskeletal in juries an d to weigh in on th e
likelih ood th at a given fracture resulted from n on acciden tal traum a. Many large pediatric h ospitals h ave dedicated,
m ultidisciplin ary abuse team s th at are respon sible for
the evaluation of suspected cases of child abuse. In m any
situations, h owever, decisions m ust be m ade by th e treatin g physician , wh eth er it be th e pediatrician , em ergen cy
departm en t physician , or th e orth opaedic surgeon . Th e
diagn osis rests on th e fin din g of a con stellation of symptom s, th at, wh en viewed collectively, poin t to ch ild abuse.
Usually a vague or inconsisten t history is offered by th e
caregiver that does n ot explain the ch ilds injuries. Most
ch ildren are with drawn an d an xious wh ile bein g evaluated
by a doctor. Assessm ent of the skin for bruises an d burns
is essen tial as 60% of physically abused ch ildren h ave on ly
soft tissue injuries. Multiple bruises of different colors suggest th at m ultiple in juries h ave occurred at differen t poin ts
in tim e. Bruisin g on th e buttocks, trun k, an d back of legs
are all h igh ly suspicious for in ten tion al in juries. In addition , bruise pattern s from com m on objects can occur from
belt buckles an d coat h an gers an d oth er h ouseh old devices.
Multiple, sm all burn s of differen t ages suggest th e use of
cigarettes or m atch es to punish the ch ild.
Non skeletal traum a is com m on an d sh ould be evaluated by th e appropriate specialists. Retin al h em orrh ages
can occur from violent shakin g of sm all infants. Visceral injury can result from an im pact with a th ick object, such as
a wall. The m ost com m on in traabdom inal in jury is a liver
laceration ; h owever, kidn ey in juries, ruptured in testin es,
an d rectal perforation s can occur. Head in jury is th e m ost
frequent cause of death and implies a significant m echanism of injury. Skull fractures involving m ultiple sites with
complex configurations are usually nonaccidental. In particular, n onparietal skull fractures are suspicious for abuse.
Com m on skeletal in juries from ch ild abuse in clude diaphyseal lon g bon e fractures, in juries to th e m etaphysis/
epiphysis, an d rib fractures. Certain diaphyseal fractures
are h igh ly suggestive of n on acciden tal traum a in cludin g
spiral fractures of th e h um erus in children younger than
2 years. In addition, fem ur fractures in children before th e
walking age are extrem ely concerning for abuse. Metaphyseal corner fractures seen in the distal fem ur, proxim al
tibia, an d distal h um erus an d bucket-h an dle fractures in
which the entire periph eral m etaphyseal rim is avulsed are
considered characteristic abuse injuries (Fig. 11.291). Rib
fractures are very com m on an d can occur from vigorous
squeezin g of a child or following a kicking injury. Multiple rib fractures, in various stages of h ealin g, again suggest
battery.
If child abuse is suspected, hospital adm ission is m an datory. Proper m edical care sh ould be provided, an d ch ild
RECOMMENDED READINGS
Flyn n JM, Sarwark JF, Waters PM, et al. Th e operative m an agem en t
of pediatric fractures of the upper extrem ity. J Bone Joint Surg Am.
2002;84:2078 2089.
Flyn n JM, Skaggs DL, Spon seller PD, et al. Th e operative treatm en t
of pediatric fractures of the lower extrem ity. J Bone Joint Surg Am.
2002;84:2288 2300.
Kay RM, Matthys GA. Pediatric an kle fractures: evaluation an d m an agem ent. J Am Acad Orthop. 2001;9:268 279.
Kocher M, Kasser JR. The orth opaedic aspects of child abuse. J Am
Acad Orthop. 2000;8:10 20.
Om id R, Ch oi PD, Skaggs DL. Curren t con cepts review: supracon dylar
h um erus fractures in ch ildren . J Bone Joint Surg Am. 2008;90:1121
1132.
12
The Spine
W illiam Postm a St even
Sam W. W iesel
INTRODUCTION
All orthopedic surgeons need to be able to effectively evaluate and treat the patients with back or neck pain regardless
of th eir subspecialty as sym ptom s surroun din g th e spin e
represen t on e of th e m ost com m on reason s for visitin g
physician s, an d disease en tities en com passin g th e spin e often m asquerade as problem s in volvin g oth er areas of th e
body. Th is ch apter will provide an in troduction to th e m ost
com m on problem s in volvin g the adult spine. Th e chapter
will begin focusin g on traum a before m ovin g on to degen erative disorders and other associated entities in cluding adult
scoliosis. Finally, a brief discussion on spine pathology, including tum or and infection, will en sue. The purpose of
this chapter is to provide the reader with a broad, solid
basis for un derstan din g an d treatin g spin al con dition s.
SPINE TRAUMA
Spinal Cord Injury
Spin al cord in jury (SCI) is with out a doubt th e m ost devastatin g con dition en coun tered by th e orth opedic surgeon .
No oth er in jury or con dition is as disruptive physically,
em otion ally, or econ om ically or h as such a h igh rate of
prem ature death an d associated complication s. Described
origin ally in th e tim e of Ph araoh s, th ere is a lon g an d pessim istic h istory of th e response of SCI to treatm en t. Labeled
by ancient Egyptian physicians as an ailm ent not to be
treated,it is only in the latter half of the twentieth cen tury,
with th e evolution of special SCI un its, th at an improvem en t in the functional progn osis of SCI patien ts h as been
reported.
Th e tragedy of SCI is h igh ligh ted by its predilection for
young, healthy individuals. Th e incidence of SCI is between
30 an d 50 cases per m illion people per year with little
436
Evaluation
Evaluation of th ese patien ts begin s with evaluation an d stabilization of th e en tire m edical con dition followin g th e advanced traum a life support (ATLS) guidelines. The details
of ATLS are beyon d th e scope of th is article. Any patien t
that has suffered a significant traum a should be assum ed
to h ave a spin al in jury un til proven oth erwise. Th erefore,
all polytraum a patients at the m inim um sh ould receive lateral radiograph s of th e cervical spin e with visualization of
the superior end plate of T1.
Wh en possible, a detailed h istory sh ould be obtained
eith er from th e patien t or any observers presen t focusin g
on th e m ech an ism of in jury as well as any tran sien t loss
of n eurologic fun ction at th e tim e of th e in jury. A con vin cing history of transient loss of m otor or sen sory function
m ay suggest the occurrence of an incomplete SCI that has
resolved rapidly an d m ay affect treatm en t decision m akin g
if a fracture is identified.
Regardin g th e spin e physical exam in ation , th e en tire
spin e m ust be in spected and palpated with the patient logrolled wh ile m ain tain in g in -lin e traction of th e n eck. Ecchym osis, tenderness, or a palpable gap between spinous
processes suggests in jury to th e posterior elem en ts, an d
supplem en tal radiographic inform ation m ust therefore be
obtain ed. Neurologic exam in ation m ust be detailed, system atic, an d docum en ted. It sh ould be repeated at regular intervals. Most SCI centers utilize the Am erican Spinal
In jury Association (ASIA) guidelin es for classification an d
docum en tation , wh ich is th en en tered in th e patien ts ch art,
facilitatin g accurate iden tification of n eurologic status,
progn ostication , an d in m any cases treatm en t. Th e Fran kel
gradin g system or a m odification of it is also utilized to
classify the extent of function following neurologic injury:
is also important, when perform ing the neurologic exam ination, to diligently search for eviden ce of sacral sparing,
such as retained toe flexion , perianal sensation , and so on .
Rectal exam ination and evaluation of the bulbocavernosus
reflex are routin ely carried out as described earlier.
Radiograph ic assessm en t begin s with a routin e lateral
cervical view and proceeds as in dicated per physical exam in ation findings. If the lateral cervical view is negative,
an d th e patient is awake and alert without any neck pain
subjectively or on physical exam ination, no other views
are necessary. If the patient has neck pain, but the lateral
view is negative, additional film s include an AP, oblique
views, and an open -m outh odontoid view. Of note, 80%
of in juries can be iden tified on th e lateral view. Flexion an d
exten sion views can be obtain ed in th e n eurologically n orm al patien t under physician supervision, but these have
largely been supplan ted by computed tom ography (CT)
scannin g th at can be obtain ed quickly in m ost em ergency
departm en ts. CT can be used if T1 is n ot visualized on plain
film , to look for an in jury n ot presen t on plain film , or to
further evaluate a fracture/ dislocation that is apparent on
plain film . It offers better defin ition of bony in jury an d can
m ore accurately assess canal comprom ise. Magnetic resonance im agin g (MRI) is utilized to assess for in trinsic cord
dam age, to evaluate possible cases of posterior ligam en tous in jury, or to assess th e presen ce of a h ern iated disk
in a patient with a subluxation or dislocation. The m ajor
disadvan tage of MRI is logistic, in cludin g difficulty in troducin g an in tubated patien t or a patien t with ton gs in to th e
scanner, as well as th e tim e it takes to scan with an MRI as
opposed to th e CT scan .
Th e iden tification of any fracture or dislocation of the
spine m andates AP an d lateral radiographs of th e en tire
spine (or CT scan) due to the high inciden ce of associated
noncontiguous injuries, which is as high as 20%. As alluded
to earlier, th e iden tification of a fracture in th e cervical, th oracic, or lum bar spin e is typically followed by CT scan n in g
of th e area to better defin e bony disruption an d determ in e
the presence and extent of spin al canal comprom ise. MRI
scannin g is less com m on ly utilized but is m ost helpful for
identifying injury to the posterior ligam entous complex to
better ascertain stability.
Management
As soon as the possibility exists for an SCI injury, the patient should be im m obilized with a backboard. It m ust
be em ph asized th at th e backboard or spin e board sh ould
be used for tran sportation purposes on ly, an d th e patien t
sh ould be safely tran sferred to a bed while protectin g th e
spine an d m aintaining im m obilization as soon as th e patient arrives at the hospital. Aside from protecting the spin e
from further injury, m anagem ent of the patient with SCI
begin s with m edical stabilization . Th is is usually accom plish ed with th e h elp of a gen eral surgery traum a team , an
intensive care unit team , an d an orth opedic traum a team
followin g th e ATLS algorithm an d protocols as m entioned
437
438
An ongoing federally sponsored system of SCI rehabilitation cen ters based on Guttm an n s guidelin es was begun
in the United States in 1970 and has without a doubt greatly
improved patientsfunctional an d em otional outcom es.
SPINAL STABILITY
When decidin g upon treatm en t for particular injuries to the
vertebral colum n , on e n eeds to un derstan d th e stability of
439
Deniss three-column model. (Reproduced with permission from Chapman MW. Chapmans Orthopaedic
Surgery, 2nd ed. Philadelphia, Lippincott Williams &
Wilkins, 1993.)
440
Figure 12.2 Upper cervical spine ligamentous anatomy. Illustration depicting the ligamentous
anatomy in the occipitocervical region from posterior, anterior, sagittal, and superior views. (Reproduced with permission from Frymoyer JW, Wiesel SW, An HS, et al. The Adult and Pediatric Spine,
3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2003.)
vertebral bodies h ave a sligh tly oval sh ape with th e coronal distance larger than the sagittal distance. Th e pedicles
project from th e body in a posterolateral direction with th e
facets subsequen tly arisin g from th e posterior portion s of
the pedicles. Th e superior facets of th e inferior segm ent
articulate with th e in ferior facets of th e superior vertebral
segm en t, comprising the diarthrodial facet joints. The superior facets face posteriorly an d lie an terior to th e in ferior
facets, wh ereas th e in ferior facets face an teriorly an d lie
posterior to th e superior facets. In th e cervical spin e, th ere
is a 45-degree in clin ation of th e facet join t, wh ile th ere is
no facet an gulation in the coronal plane (the facets face
directly an terior/ posterior).
The area of bone between the superior and inferior facets
in a sin gle segm en t is referred to as th e lateral m ass, an d th e
lam in a subsequen tly arise from th ese structures. Th e lam inae are oriented posterom edially and com bin e to close th e
posterior rin g of th e spin al can al an d con tin ue posteriorly
form ing the spinous processes. Typically, th e spinous processes of C2 C6 are bifid, differen tiatin g th em selves from
C7 an d th e rem ain in g spin ous processes th at h ave a sin gle
projection .
The transverse processes of the subaxial cervical spine
are un ique in th at th ey h ave a foram en th at allows passage
of th e vertebral artery. Th e vertebral artery typically en ters
into th e transverse processes above C7 and thus the foram ens of C6 C1 tran sm it passage th rough th e n eck. Classically, th e C7 foram en does n ot h ouse th e vertebral artery
but on e of th e vertebral vein s.
Th ere are several soft-tissue structures in th e subaxial
cervical spin e, wh ich h elp m ain tain stability an d dissipate
forces. The importan t elem ents anteriorly are the an terior
longitudinal ligam ent, th e PLL, and the intervertebral disk
th at lies between th e an terior an d PLLs. Th e lon gitudin al
ligam ents lie an terior and posterior to the vertebral bodies
th e en tire len gth of th e spin al colum n . Posterior stability is
m aintained by the ligam entum flavum , facet joint capsule,
interspinous ligam en ts, and supraspin ous ligam ents, also
known as the ligam entum nuchae in the cervical region.
Th ese structures provide stability m ain ly with flexion .
Fin ally, it is im portan t to un derstan d th e cervical n erve
roots an d h ow th ey are n um bered in relation to th e vertebral level as th is is th e basis for un derstan din g an d locatin g cervical root path ology. Th e roots are n um bered for
th e vertebral level below th em in th e cervical spin e as th ey
exit. Th erefore, th e C5 n erve root exits between C4 an d C5.
Un like th e lum bar spin e, in the cervical spine, a hern iated
disk or disk path ology im pin ges on th e exitin g n erve root
th e vast m ajority of th e tim e. Th erefore, a h ern iated disk
between C4 an d C5 im pin ges on th e C5 n erve root, th e
441
442
Wackenheim's line
C1-C3
Spinolaminar line
6 mm
LADI within + 2 mm
Joint "spaces"
1-2 mm
2-3 mm
PAL-B: < 4 mm
< 12 mm
DBI
< 12 mm
No overhang
< 15% Normals
D
C
Figure 12.4 Upper cervical spine lines. (A) Prevertebral shadow at C2C3 should not exceed
6 mm in a healthy patient without an endotracheal tube in place. (B) Bony screening lines and dens
angulation. The anterior cortex of the odontoid should parallel the posterior cortex of the anterior
ring of the atlas. Any deviation should be viewed with suspicion for an odontoid fracture or injury
the TAL. Wackenheims line is drawn as a continuation of the clivus caudally. The tip of the odontoid
should fall within 1 to 2 mm of this line. The C1C3 spinolaminar lines should fall within 2 mm of one
another. (C) Ligamentous injury reference lines. The ADI should be less than 3 mm in adults. The SAC
is measured as the distance from the posterior cortex of the odontoid tip to the anterior cortex of
the posterior arch of the atlas and should measure greater than 13 mm typically. The dens-basion
interval (DBI) is the distance between the odontoid tip and the basion. It should be less than 12 mm
in the adult. The posterior axis line (PAL-B) should not be more than 4 mm anterior and less than
12 mm posterior to the basion. (D) Bony screening lines. The left and right lateral atlantodens interval
(LADIs) should be symmetric to one another (within 2 mm of deviation). The bony components of
the atlanto-occipital joints should be symmetric and should not be spaced more than 2 mm apart
on AP images. The combined lateral overhang of the lateral masses should also not exceed 7 mm.
(Reproduced with permission from Bucholz RW, Heckman JD, Court-Brown C, et al. Rockwood and
Greens Fractures in Adults, 6th ed. Philadelphia, Lippincott Williams & Wilkins, 2005.)
distan ce sh ould be less th an 3 m m . Fractures of th e odon toid an d C1 C2 dislocation / subluxation can cause th is distan ce to be greater. Th e SAC represen ts th e region from th e
posterior aspect of th e den s or th e posterior aspect of th e
vertebral bodies to th e an terior aspect of th e posterior arch .
In th e cervical spin e, th is distan ce will typically be greater
than 13 m m in the average adult. The an terior spinal lam inar line is an im aginary line from th e opisth ion alon g th e
an terior aspect of th e posterior arch of C1 an d th e lam inae of C2, C3, an d the rem aining subaxial cervical spine
as m en tion ed earlier. Th is lin e sh ould rem ain sm ooth an d
curvilinear. Any deviation from the norm of the relationsh ips described earlier sh ould alert th e physician to probable fracture or dislocation an d furth er evaluation sh ould be
don e. Fin ally, th e Powers ratio is th e ratio of th e distan ce
443
of in jury results from m otor veh icle acciden ts. For patien ts
wh o do survive, th ey m ay have subtle or no neurologic
deficits because a dissociation resultin g in n eurologic com prom ise essen tially results in death . Th ese patien ts h ave a
h ighly un stable in jury despite th eir preserved n eurologic
function, and thus a h igh degree of suspicion and prompt
recogn ition of th e in jury is essen tial as n eurologic fun ction
can decline rapidly if th ese patients are not im m obilized.
It m ust be noted that ch ildren , particularly th ose under
the age of 8, are predisposed to these injuries secondary
to th eir relative ligam en tous laxity an d larger h ead size. As
these injuries are purely ligam entous in nature, th ere will
be n o fracture seen on plain film s, so on e n eeds to look for
m ore subtle radiograph ic fin din gs, in cludin g prevertebral
soft-tissue swelling (should not exceed 6 m m in adults),
in creased Powers ratio, an d abn orm ality of Wacken h eim s
lin e. Followin g recogn ition of th is in jury or if th e in jury is
suspected, im m ediate im m obilization in a halo vest should
be con sidered prior to furth er im agin g studies.
Once the diagnosis is establish ed prompt, aggressive
treatm en t is in dicated. Typically a cran iocervical fusion will
be perform ed after in itial h alo-vest im m obilization . Non operative treatm en t will alm ost always result in persisten t
in stability as th e in jury is usually a purely soft-tissue in jury.
444
Figure 12.6 Jefferson Fracture (A) The open-mouth odontoid view shows bilateral overhang
of the C1 lateral masses relative to the C2 facets, with combined lateral displacement measuring
13 mm. (B) Axial CT image shows a true Jefferson fracture in the form of a four-part burst fracture
of the atlas. This fracture is unstable secondary to the associated TAL disruption. (Reproduced with
permission from Bucholz RW, Heckman JD, Court-Brown C, et al. Rockwood and Greens Fractures
in Adults, 6th ed. Philadelphia, Lippincott Williams & Wilkins, 2005.)
Fractures of th e rin g of C1 m ay occur an teriorly, posteriorly, an d/ or laterally an d m ay con sist of on e to four fracture lin es. Th e classic m ech an ism of in jury is a direct h it to
the top of th e h ead producin g a pure axial load compressing C1, resulting in the well-known eponym , the Jefferson
fracture,wh ich classically describes a burst fracture resulting in disruption of both th e anterior and posterior arches
producin g four differen t fractures. Th ere are several oth er
fracture patterns dependin g on the degree and direction
of flexion / exten sion of th e n eck an d resultan t vector of th e
force producing the fracture. For example, a hyperextended
neck with a concom itant posterior load can cause a posterior arch fracture alon e or vice versa for a hyperflexed n eck
resultin g in an isolated an terior arch fracture. Th e degree
of force applied dictates wh eth er th e TAL will be disrupted,
wh ich is th e key to th e stability of th e fracture.
When evaluatin g th ese fractures radiographically, routin e radiograph s of th e cervical spin e often reveal n o evidence of fractures even in th e case of m ultiple fractures. It is
therefore essential to obtain an open-m outh odontoid view
to look for spread of th e lateral m asses of C1, wh ich is evidence for C1 rin g disruption . Spen ce et al. foun d th at com bined extrusion of both lateral m asses of 7 m m or m ore
to be con sisten t with TAL disruption . Furth er evaluation
of th ese in juries sh ould be don e usin g a CT scan with fin e
cuts to visualize the full extent of the injury an d help with
decision m akin g regardin g th e treatm en t (Fig. 12.6).
Non operative treatm en t is in dicated for th e vast m ajority
of th ese fractures an d patien ts gen erally do well, as dem on strated by th e series of patients of Levine an d Edwards. Min im ally displaced fractures can be treated in either a cervical
orth osis or a h alo vest, depen din g on th e in jury, for a period
of aroun d 3 m on th s. Displaced fractures require reduction
with traction or prolon ged traction followed by h alo vest.
Cases treated n onoperatively need to be followed up reg-
Odontoid Fractures
Odontoid fractures accoun t for 15% to 20% of all cervical
spin e fractures an d are th e m ost com m on fracture of the
axis. These fractures are particularly com m on in the very
young and th e elderly, ages in which failure to recognize
the injury, always a com m on problem , is even m ore likely.
Th e m ost com m on m ech an ism of in jury depen ds on th e
population in volved with falls accoun tin g for th e m ajority
of th e cases in th e elderly an d pediatric population , an d
MVAs accounting for the vast m ajority in young adults and
m iddle-aged population .
Th e bony, ligam en tous, an d vascular an atomy surroun ding th e odontoid (dens) is unique an d pertin ent for understan din g th e m ech an ism of in jury, m an agem en t, an d
complications of these fractures. The odontoid consists of
a broad base with a tooth like projection exten ding from the
body of th e axis th at articulates with th e posterior portion
of th e an terior arch of th e atlas providin g in h eren t bony
stability through th is configuration. The intricate ligam entous complex en compassin g th e odon toid greatly en h an ces
stability. Th e TAL of th e cruciate complex (Fig. 12.2) form s
a slin g aroun d th e posterior portion of th e den s an d serves
as the prim ary restraint to anterior translation of C1 on
C2 and the prim ary stabilizer of atlantoaxial m otion. Secon dary stabilizers in clude th e apical an d alar ligam en ts
origin atin g from th e base of th e skull an d in sertin g on th e
tip of the dens. Because of these in sertions on th e dens,
Type I
Type II
Type III
C
Figure 12.7 Anderson and DAlonzo odontoid fracture clas-
445
446
B
Figure 12.8 Odontiod fracture treated with anterior screw fixations. (A) Saggital CT scan image
demonstrating a Type II odontiod fracture sustained in a fall. (B) Post-operative films demonstrating
fixation with a single anterior screw.
spondylolisthesis of the axis (Hangmans fracture). (A) Type Inondisplaced fracture of the pars interarticularis. (B) Type IIdisplaced fracture of the pars interarticularis. (C) Type IIa-displaced
fracture of the pars with disruption of the C2C3 discoligamentous complex. (D) Type III-dislocation of the C2C3 facets with fracture of the C2 pars interarticularis. (Reproduced with permission
from Bucholz RW, Heckman JD, Court-Brown C, et al. Rockwood
and Greens Fractures in Adults, 6th ed. Philadelphia, Lippincott
Williams & Wilkins, 2005.)
447
448
fracture). Lateral cervical spine film demonstrates angulation predominating over translation (black lines), which is pathognomonic
for Type IIa C2 arch fractures. The causative flexiondistraction
mechanism is thought to result in progressive tensile failure of
the posterior atlantoaxial membrane (white arrow), the posterior longitudinal ligament (PLL), posterior annulus, and intervertebral disk. The anterior annulus and anterior longitudinal ligament
(ALL) are thought to remain intact. (Reproduced with permission
from Bucholz RW, Heckman JD, Court-Brown C, et al. Rockwood
and Greens Fractures in Adults, 6th ed. Philadelphia, Lippincott
Williams & Wilkins, 2005.)
449
450
D
Figure 12.12 C3 burst fracture. (A) Preoperative lateral view. (B) Preoperative axial CT scan.
(C) CT reconstruction. (D) Healing after anterior corpectomy and plating. (Reproduced with permission from Frymoyer JW, Wiesel SW, An HS, et al. The Adult and Pediatric Spine, 3rd ed. Philadelphia:
Lippincott Williams & Wilkins, 2003.)
be treated operatively, with lesser degrees perh aps un dergoing nonoperative m anagem ent (provided that the patient
is neurologically intact). MRI can provide further inform ation if necessary, exam ining th e cord itself as well as the
posterior elem en ts. MRI sh ould n ot be ordered un less it
will provide addition al in form ation to guide decision m aking. If one decides upon nonoperative m anagem ent, typical
treatm ent in volves a h alo vest, or occasionally a rigid cervical orth osis. Regardless of the type of im m obilization,
close follow-up is necessary to ensure that the fracture is
adequately stabilized.
Th e in fam ous teardropvarian t of compression (Allen
an d Ferguson compressive flexion Type III) fractures needs
to be discussed briefly as th ere is such a h igh in ciden ce of
neurologic in jury with th is fracture, an d surgery is alm ost
always indicated. The m echanism of injury is the sam e as
discussed earlier with compression fracture, but th ere is
such a high degree of flexion with compression that an an terior fragm en t of bon e separates from th e rem ain der of th e
body (an terior extrusion of a fragm en t from th e an terior
lip of th e body) often with retrolisthesis of the rem ain der of th e posterior body or posterior displacem en t of th e
posteroin ferior corn er of th e in volved vertebral body. Th e
com m onality of neurologic injury results from the posterior displacem en t of eith er th e body or th e posteroin ferior corn er, an d as such surgery is gen erally in dicated. In
the case of n eurologically intact patients, surgical decision
m akin g follows th e sam e algorithm as with other types of
compression fractures with close atten tion to any evidence
of posterior in stability.
451
452
B
Figure 12.13 Bilateral facet subluxation. (A) Lateral plain film. (B) Postreduction MRI shows a
herniated disk present. (Reproduced with permission from Bucholz RW, Heckman JD, Court-Brown
C, et al. Rockwood and Greens Fractures in Adults, 6th ed. Philadelphia, Lippincott Williams & Wilkins,
2005.)
paradoxical m otion of th e subaxial vertebral bodies. Because of th e risk of redisplacem en t, even un ilateral dislocation s are gen erally treated by operative m ean s as th ere is
n ot a good m ethod of adequately im m obilizin g th e injury
n onoperatively.
Bilateral facet dislocation s com m on ly occur in conjunction with significant disruption of the interspinous ligam ent, ligam entum flavum , and often the PLL and are
th erefore h igh ly un stable. Ligam en tous disruption with
un ilateral facet dislocation is gen erally less severe, with th e
PLLspared m uch m ore com m on ly. Th is con stitutes th e reason why som e surgeon s attempt to treat unilateral dislocations nonoperatively. Our preferen ce for either injury is surgical stabilization due to the in consistent results following
n onoperative m anagem en t an d th e un stable n ature of the
injuries. With operative m an agem ent, the neurologically
n orm al patien t is return ed m uch m ore quickly to norm al
activity with m in im al risk of long-term sequelae, while the
n eurologically impaired patien t is ready to aggressively un dergo reh abilitation followin g surgery with out th e n eed for
prolon ged extern al im m obilization . O perative treatm en t
involves stabilization and fusion, which can be done anteriorly, posteriorly or with a com bin ed approach an d depen ds on associated in juries (i.e., herniated disk treated
with discectomy an d an terior fusion , gen erally). With n o
n eurologic in jury or n o n eed for rem oval of elem ents from
th e can al, a posterior approach is gen erally used.
Thoracolumbar Trauma
Th oracolum bar in juries en compass in juries from T1 to L5
an d range in severity from m ild to life threatening. The initial m anagem ent has been covered in th e previous sections
Compression Fractures
Compression fractures m ake up the m ajority of traum atic
injuries to th e thoracic and lum bar spin e, even after
path ologic fractures th rough osteoporotic bon e h ave been
excluded. Th e m ech an ism of in jury in volves axial com pression com bin ed with m ild degrees of forward flexion
producin g com pressive failure of th e an terior aspect of th e
vertebral body (Deniss anterior colum n). By definition ,
a compression fracture involves only the an terior colum n
with preservation of th e m iddle an d posterior colum n s. Th e
isolated involvem ent of the an terior colum n differentiates
them from burst fractures, which result in compression of
the m iddle colum n as well. Compression fractures generally result from low-en ergy traum a in th e elderly but can
be secon dary to m uch h igh er-en ergy m ech an ism s in th e
younger population . True compression fractures represent
stable in juries; however, m any tim es it is difficult to differen tiate a com pression fracture from its m ore serious coun terpart, th e burst fractures, or even a flexion distraction
injury, involving ten sion failure, or distraction, of the posterior elem en ts.
Differen tiation of th ese in juries is im portan t as m ore
serious injuries often require surgical intervention, while
453
compression fractures can generally be treated non operatively. Th e differen tiation lies in th e radiograph ic exam in ation . On th e lateral view, loss of h eigh t of th e an terior colum n an d th e degree of kyph osis sh ould be assessed with
true com pression fractures h avin g less th an 40% loss of
h eight, an d less th an 30 degrees of kyph osis, m aking th em
stable (Fig. 12.14). Many still consider fractures with loss
of h eigh t greater th an 50% to be compression fractures if
on ly th e an terior colum n is in volved; h owever, with th is
am oun t of loss of h eigh t, it can be argued th at th e posterior colum n is disrupted and by definition sh ould be considered a flexion distraction in jury. Addition ally, kyph osis greater th an 30 degrees represents an unstable fracture
with likely disruption of the posterior elem ents to som e
exten t. Of n ote, an addition al fin din g on th e lateral film
that is suggestive of a burst fracture rather than a compression fracture is an in crease to greater than 100-degree an gle
between th e superior en d plate an d th e posterior cortical
lin e at th e posterosuperior corn er of th e vertebral body. In crease in th is an gle indicates probable loss of height in the
m iddle colum n . On th e AP view, an in crease in in terpedicular distan ce suggests disruption of th e posterior cortex,
splayin g of th e pedicles, and the presen ce of a burst fracture. If th ere is any question regardin g th e differen tiation , a
CT scan sh ould be obtain ed as th ere can be disastrous con sequen ces for m isdiagnosis and subsequent m istreatm ent.
Ballock an d colleagues reported a m isdiagn osis rate of 25%
in attemptin g on plain radiography to differen tiate com pression fractures from burst fractures an d recom m en ded
the routine use of CT scannin g in the case of compression
fractures to avoid this error. If after physical exam ination,
plain film s, an d CT scan n in g, on e is still un certain of posterior ligam entous stability, an MRI can be obtained to evaluate th e soft tissue stability of th e posterior colum n . Of
n ote, physical exam in ation fin din gs suggestive of tension
failure of the posterior colum ns, and by defin ition, not a
simple compression fracture (rather a flexion distraction
in jury), in clude m arked m idlin e ten dern ess at fracture site,
ecchym osis, or a palpable gap between spin ous processes
as in th e cervical spin e.
Most compression fractures do not result in n eurologic
in jury. However, compression fractures, particularly in th e
upper th oracic spin e between T2 an d T10, can result in
n eurologic comprom ise. Alth ough th e rib cage and stern um provide an added degree of stability to fractures in
this region, th eir presence should be un derstood to imply
an even greater degree of en ergy required to produce th e
in jury. Th is factor, in addition to th e relatively low spin al
canalspin al cord ratio in the m idth oracic spin e, as well
as th e sen sitivity of th e spin al cord to m in or traum a, all
contribute to a sign ifican t risk of in jury at this level.
As m en tion ed previously, com pression fractures can
generally be treated nonoperatively, as they are by Deniss
defin ition stable because on ly on e colum n is disrupted.
Non operative treatm en t gen erally con sists of an extern al
orth osis prescribed for 2 to 3 m on th s for m ost patien ts
454
Burst Fractures
Sir Fran k Holdsworth was th e first to use th e term burst
fracture to describe what is today recognized as one of
the m ost com m on injuries to the thoracolum bar spine
an d on e wh ose treatm en t con tin ues to be h otly debated.
Part of the reason for the con fusion surrounding the treatm en t of burst fractures stem s from differen ces in defin ition s am on g various auth ors. Most reports are con sisten t
with Holdsworth s origin al description of a fracture that results from th e ceph alad disk exploding through th e upper
en d plate in to th e vertebral body, causin g a fracture of both
the anterior an d posterior cortices. Therefore, with burst
fractures one observes compression of both the anterior
an d m iddle colum n , as opposed to compression fractures
in wh ich on ly th e an terior colum n is disrupted. Secon dary
to th e m ech an ism an d usual h igh -en ergy in jury, th ere is
typically a retropulsed burst fragm en t extruded in to th e
can al at the level of th e pedicles, often causin g n eural el-
455
Figure 12.15 Burst Fx L1. This patient was a 19-year-old female who sustained a burst fracture
of L1 following an MVA. (A,B) The fracture on CT scan was judged to compromise about 60% of the
canal diameter. (C,D) Notice the large fragment seen on the CT scan at L2. By proper examination
and sagittal reconstruction via CT scanning, this fragment was noted to still be in continuity with
L1 and as such did not have to be removed during surgery as it reduced to L1 with height restoration. (Reproduced with permission from Chapman MW. Chapmans Orthopaedic Surgery, 2nd ed.
Philadelphia, Lippincott Williams & Wilkins, 1993.)
ligam en tous complex (wh ich m any auth ors feel would exclude such an in jury from classification as a burst fracture),
acute kyph osis greater th an 20 degrees with a n eurologic
deficit, 50% loss of vertebral h eigh t in th e presen ce of facet
join t subluxation , an d/ or th e presen ce of retropulsed bon e
causing neural elem ent comprom ise in association with an
in complete n eurologic in jury. Bradford an d McBride h ave
stressed, on th e other h and, the importance of a neurologic
456
deficit as a clin ical in dicator of in stability at least as it pertain s to th e appropriaten ess of surgical stabilization .
Though there rem ain s a great deal of con troversy surroun din g th e appropriate m an agem en t, m ost auth ors favor surgical decompression an d fusion for th e patien t wh o
is n eurologically impaired, an d all would agree on surgical
in terven tion for th e patien t with an in complete n eurologic
in jury as decompression h as been sh own to h ave favorable
results with n eurologic improvem en t. Patien ts with com plete n eurologic in jury are com m on ly treated surgically to
facilitate early return to reh abilitation . In gen eral, patien ts
requirin g decompression are treated with an an terior approach to adequately decompress th e cord followed gen erally by strut graftin g, stabilization (gen erally an teriorly),
an d fusion . Lam in ectomy alon e does n ot con tribute to decompression of the cord or cauda equine in the presence
of a burst fracture.
Surgery is n ot reserved on ly for th ose with a n eurologic
deficit, h owever. In th e patien t wh o is n eurologically in tact,
on e m akes th e decision of surgical in terven tion on radiograph ic fin din gs th at suggest structural in stability. As alluded to earlier, th ere are n o con crete rules statin g wh en
to operate an d wh en n ot to operate. However, we will provide som e gen eral radiograph ic fin din gs th at would sway
m ost surgeon s toward operative in terven tion in th e patien t
who is neurologically in tact. Th ese include acute kyph otic
an gulation of 25 to 30 degrees or greater th an th e n orm
at a particular level, greater th an 50% loss of vertebral
height, greater than 50% comprom ise of the spin al can al
by retropulsed bony fragm ent(s), and tension failure of the
posterior ligam en tous complex. Th e n eurologically n orm al
patien t wh o un dergoes surgery for poten tial in stability is
usually treated posteriorly with posterior in strum en tation
an d fusion . In gen eral, th e posterior approach is less m orbid th an th e an terior approach with fewer serious com plications. However, posterior in strum entation provides less
support th an anterior instrum entation as it is un able to
recon stitute th e an terior support. Th erefore, posterior in strum entation is m ore likely to fail with increasing kyph osis/com pression, especially in fractures with severe kyphosis and/ or loss of height. Success rates h ave been sim ilar
when comparing an terior an d posterior instrum entation s
an d fusion for burst fractures.
Followin g th e tren d with th e treatm en t of burst fractures,
the num ber of levels fused varies from surgeon to surgeon.
Prior to pedicle screw fixation , Harrin gton rod in strum en tation was m ostly used with in strum en tation an d fusion
three levels above and two or three levels below the fractured vertebrae. As th is requires a fairly exten sive fusion , th e
adven t of pedicle screw fixation h as allowed better th reepoin t fixation , an d h en ce less levels n eeded for fusion . Curren tly, m ost surgeon s advocate pedicle screw fixation an d
fusion either one or two levels (our personal preference)
above an d on e or two levels below th e compression fracture
depen din g on th e severity of th e fracture an d associated
ligam en tous disruption . An oth er option is addin g an terior
Chance Injuries
In 1948, G.Q . Ch an ce provided th e first description of an
injury to the lum bar spine involving flexion and distraction
of th e posterior elem en ts, wh at we kn ow today as Ch an ce
fractures or in juries. The m ost com m on cause of flexion
distraction in juries today are lap belt in juries from MVAs,
even th ough Ch an ces origin al description predated th e use
of lap belts. Th e lap belt scen ario, alth ough n ot always th e
cause, helps on e to visualize and un derstand the m echan ism of injury an d th e forces in volved. Followin g an MVA,
the individual sitting in the back seat is wearin g a lap belt
an d the sudden deceleration injury forces the patient forward over the lap belt. The lap belt causes blunt traum a
to th e abdom in al viscera in its course to th e spin e as th e
victim continues to m ove forward. Th e belt essentially acts
as a fulcrum over which the spine rotates around an axis
of rotation cen tered on th e an terior cortex or an terior lon gitudinal ligam en t of the spin e. The classic description is
a pure flexion distraction in jury, but th ere often is a rotational component to it as well. As one would im agine, there
is a very high rate of associated abdom inal in juries, quoted
around 50%, which one needs to keep in m ind when evaluatin g lap belt in juries from eith er th e orth opedic or th e
traum a surgery standpoint. Patients will typically present
with th e seatbelt sign with a ban d of ecchym osis across
the abdom en wh ere the patient hinged over the belt during
deceleration .
Th e stan dard Ch an ce in jury m ay be a pure bony in jury,
exten din g th rough th e spin ous process, lam in a, pedicle,
an d vertebral body; a pure soft-tissue in jury, exten ding
through the in terspin ous ligam ent, ligam en tum flavum ,
facet join t capsule, an d disk; or m ixed, with variable in volvem ent of bon e and soft tissue (Fig. 12.16). Th e com m on finding am ong all three is the m arked distraction of
the posterior elem ents, m oderate distraction of the m iddle
colum n , an d classically a neutral appearance of the far anterior colum n , reflectin g an in stan tan eous axis of rotation
in or about the ALL (Fig. 12.17). It is not uncom m on to see
m ild-to-m oderate wedging of the vertebral body reflecting
an elem ent of axial loading in addition to pure flexion.
Burst-type fractures of th e vertebral body m ay also be seen ,
reflectin g a m ech an ism of in jury th at ch an ges from axial
loading to sudden flexion such as in a fall from a height.
Neurologic in jury is un com m on but n ot rare in in juries
of th is type. As with oth er areas of th e spin e, th e presen ce
of a n eurologic in jury is in itially treated with realign m en t
eith er th rough an operative or n on operative approach , followed by stabilization. Reduction involves various hyperexten sion m an euvers. If th e patien t recovers n eurologic status
followin g reduction, the treatm ent can then be operative or
n on operative, but in th at situation , m ost surgeon s would
likely elect operative intervention for reliable stability. If
Figure 12.17 Radiographic characteristics of Chance injury. (A) Lateral radiograph of a severe
flexiondistraction injury status post MVA. (B) AP radiograph shows wide spacing between spinous
processes at the level of the injury. (C) MRI confirms extensive soft-tissue disruption. (Reproduced
with permission from Frymoyer JW, Wiesel SW, An HS, et al. The Adult and Pediatric Spine, 3rd ed.
Philadelphia: Lippincott Williams & Wilkins, 2003.)
458
459
paid to th e serious associated in juries with fracture dislocations includin g traum a to the thorax, m ediastinum , an d
abdom en, as well as blunt traum a to the aorta. Neurologic
injury is the norm that un fortun ately is frequently complete
or n ear-com plete resultin g in paraplegia. Dural tears occur
around half of the tim e as well. Careful evaluation of sacral
sparing should be carried out. Radiographic evaluation begins with stan dard AP an d lateral radiographs followed by
CT scann ing with sagittal and coronal reconstructions and
MRI evaluation once th e injury is iden tified.
As stressed earlier, recognition of this very serious injury
stem s from recogn izing the radiograph ic hallm ark, tran slation. Once the diagn osis is m ade, all of these fractures
require operative stabilization as all th ree colum n s are disrupted an d thus the only stability th at is m ain tained is
by the ALL if it is intact. These represen t the m ost unstable of all spin e in juries, an d patien t m obilization for im proved pulm on ary fun ction an d gen eral m edical care in
these patients sh ould be deferred until definitive treatm ent
of th e spin e is perform ed. Th erefore, th ese in juries sh ould
be defin itively stabilized as soon as possible, preferably
in th e first 48 h ours after in jury. Because of th e in h eren t in stability of th ese in juries, it is importan t to accept
that rigid segm ental instrum entation should be employed
an d strategies design ed to m in im ize th e n um ber of levels
fused that are used with other injuries are generally inappropriate for th ese cases. Most advocate lon g fusion s exten din g th ree levels above an d at least two, if n ot th ree
levels below th e fracture with pedicle screw in strum en tation . Th ere are reports of less aggressive fusion with good
results; h owever, lon g fusion is still recom m en ded. Oth er
m eth ods aside from pedicle screw fixation an d in strum en tation in clude sublam in ar wirin g, in terspin ous wirin g, an d
segm ental an d n on -segm ental hook fixation. These m ethods are often com bin ed with an terior in strum en tation to
obtain even m ore stability.
Reduction sh ould be obtained in all cases, even in
complete n eurologic injury, as anatom ic reduction restores
significant in h erent stability an d thus lessens the stress on
surgical im plan ts and m ay contribute to a lesser degree
of postoperative pain . Addition ally, th ere still exists th e
rem ote possibility of som e degree of n eurologic recovery.
460
DEGENERATIVE DISORDERS OF
THE SPINE
CERVICAL SPINE
461
After careful focus in th e upper extrem ities, th e lower extrem ities n eed to be exam in ed as well because cervical spin e
myelopathy usually h as positive findings in the upper an d
lower extrem ities. Specifically, th e patien ts gait sh ould be
observed, wh ich is classically described as a wide, broadbased gait with myelopathy. Addition ally, stren gth an d reflex testing sh ould be exam ined. The m ost com m on abnorm al lower extrem ity myelopath ic sign s are weakn ess, spasticity, an d hyperreflexia. O n e m ay fin d a positive Babin skis
sign as well with myelopathy. Finally, atrophy can be observed in the lower extrem ities but is less com m on and den otes a m uch longer stan din g problem . As will be discussed
in th e n ext section s, myelopathy ten ds to affect th e upper
an d lower extrem ities, wh ile radiculopathy on ly affects th e
upper extrem ities; th us, th e lower extrem ity exam in ation
sh ould be n orm al in th e face of a pure radiculopathy.
Cervical Radiculopathy
Cervical radiculopathy is defined as pain or symptom atology in th e distribution of on e of th e cervical roots. Th is
is typically radiatin g pain from the n eck into the arm , alth ough th e classic derm atom al distribution is n ot always
seen. It is caused by compression of a cervical nerve root,
gen erally as it exits from th e spin al cord, wh ich can be secon dary to a variety of reason s ran gin g from h ern iated disks
to degenerative changes. It is th e compression of the nerve
itself that differen tiates radiculopathy from myelopathy,
wh ich is compression of th e cord as a wh ole rath er th an of
an individual nerve root.
History
Patien ts will gen erally presen t secon dary to pain in th e n eck
region th at radiates in to th e arm . Th is radiatin g pain from
th e n eck in to th e arm is th e h allm ark of radicular pain . Th e
patien t typically describes th e pain as sh ootin g, burn in g,
or a deep ach e. Many tim es, th ey will describe paresth esias
down th e arm as well. It m ust be n oted, h owever, th at th ere
are radiculopathies that radiate no further th an the shoulder, an d th e predom in atin g com plain t of patien ts will be
sh oulder pain rath er than the classic presen tation.
Physical Examination
Wh en dealin g with th e physical exam in ation for a suspected radiculopathy, th e typical exam in ation of th e cervical spine should be done as previously discussed, with
specific atten tion on certain parts of the physical exam ination. As m entioned earlier, the un derlying abnorm ality is
irritation on the affected root from a site of compression.
Keepin g th is in m in d, th ere are m an euvers described th at
further irritate the nerve to elicit the patients symptom s.
Th e classic test is Spurlin gs sign . In th is test, th e patien ts
h ead is flexed laterally, sligh tly rotated toward th e symptom atic side, an d then compressed to elicit reproduction
or aggravation of th e radicular sym ptom s. An oth er test described th at h as the opposite effect is the abduction relief
462
TABLE 12.1
CERVICAL RADICULOPATHY
C2C3 Disk: C3 Nerve Root
Pain: Back of neck, mastoid
process, pinna of ear
Sensation: Back of neck,
mastoid process, pinna of
ear
Motor: None
Reflex: None
Diagnostic Studies
It m ust be emph asized th at th e core of th e in form ation
obtain ed sh ould be from th e h istory an d physical exam ination, and diagnostic studies should be used to con firm
the clin ical impression. Many of th ese studies are overly
sen sitive and relatively nonspecific and th erefore should
not be used for screen in g purposes. Wh en in terpreting th e
in form ation gain ed from th ese studies, th e clin ical picture
needs to be correlated with the fin din gs in the study, an d
the studies should n ever be interpreted in isolation.
Plain Radiographs
As discussed previously, the typical plain film s of the cervical spine should include AP, lateral, oblique, and odontoid views. Plain film s provide importan t in form ation regarding degenerative changes an d can suggest th e specific
level of the cervical spine involved. The generally accepted
radiograph ic sign s of cervical disk disease in clude loss
of h eigh t of th e disk space, osteophyte form ation , secon dary en croach m en t of th e in tervertebral foram in a, an d
osteoarth ritic ch an ges in th e apophyseal join ts. Align m en t
an d listh esis (slippin g) of one vertebral body on another
sh ould be exam in ed as well.
It m ust be stressed th at th e iden tification of som e
path ology on plain cervical film s does n ot n ecessarily in dicate th e cause of th e patien ts sym ptom s as several studies have sh own th at a large percentage of asymptom atic
individuals have radiographic evidence of degenerative
ch anges on x-ray.
MRI
MRI is currently the study of choice when evaluating root
compression (or cord compression in the case of myelopathy). MRI is excellent at clearly visualizing the cord and
roots an d sten osis or compression of both . It is best at iden tifying soft tissues, so herniated intervertebral disks (soft
disks) (Fig. 12.19) causin g root com pression are better visualized th an osteophytes (hard disks) causing compression,
but both can be appreciated. Foram in al sten osis is also well
visualized. Additionally, MRI is safe (does not use ionizing
radiation an d rarely uses con trast agen ts) an d is curren tly
becom in g ch eaper, alth ough it is still a m uch m ore expen sive test than CT. The only caution is the prevalence of
fin din gs in asym ptom atic patien ts is very h igh (19%), an d
results sh ould th erefore be strictly correlated with th e h istory an d physical exam in ation .
CT
Th e use of CT scan n in g in th e spin e, as with any oth er place
in the body, visualizes the bony anatomy m uch better than
the soft tissues an d is thus lim ited in detecting soft-tissue
path ology causin g im pin gem en t. However, CT does visualize bony causes of impingem ent better th an MRI. In general, it is used for th ose patien ts wh o can n ot un dergo MRI
or in th ose in wh ich th e MRI is equivocal. Th e addition of
myelography (in jection of dye in to th e spin al can al prior to
im aging) m ay be necessary if surgical treatm ent is considered. In gen eral, CT with or with out myelography is used as
a backup test to MRI in the evaluation of a radiculopathy.
Electromyography
Electromyography (EMG) is an electrical test th at con firm s
the interaction of nerve to m uscle. It is perform ed by placing needles into specific m uscles to determ ine if there is an
intact nerve supply to that m uscle. EMG is particularly useful in localizing a specific abnorm al nerve root. However, it
463
Natural History
Gen erally speakin g, th e n atural h istory of cervical radiculopathy is favorable with the m ajority resolving with nonoperative treatm en t. Lees an d Turn er studied th e n atural h istory in 51 patien ts an d sh owed th at 45% h ad on ly
1 episode with resolution , while 25% reported persistent
sym ptom s. The rem ain der had m ild symptom s, and no patient progressed to myelopathic symptom s. Therefore, nonoperative m an agem en t is th e in itial treatm en t of ch oice.
Th e question rem ain s as to wh eth er m eth ods of n on operative treatm ent actually improve the course of th e disease
or wh eth er n on operative treatm en t provides symptom atic
relief on ly. Th ere is lim ited in form ation comparin g n on operative treatm en ts, an d it rem ain s surgeon preferen ce as to
wh ich m eth od to use. Th e differen t m eth ods of treatm en t
are discussed in the individual sections on th e pathologies causing radiculopathy (i.e., herniated disk, cervical
spon dylosis) as well as in the treatm ent algorithm for cervical path ology.
Cervical Myelopathy
Cervical Myelopathy is defined as compression of the
spin al cord, wh ich is usually due to degenerative changes.
Th e compression occurs on th e cord itself, wh ich differen tiates it from radiculopathy, where compression is on the
individual root.
B
Figure 12.19 Disk herniation. Midsagittal (A) and axial (B) T2-
History
Myelopathy typically presen ts in those over the age of
50 with m ales predom in atin g over fem ales. Th e on set is
gen erally in sidious with sym ptom s worsen in g over tim e.
Com m on presentin g symptom s in clude n um bness and
paresth esias in th e h an ds, clum sin ess of th e fin gers, weakn ess (greatest in the lower extrem ities), an d gait/ balance
disturban ces. Abn orm alities of m icturition can occur an d
indicate m ore severe or progressed cord in volvem en t. Sensory abn orm alities are also com m on and m ay show a
patchy distribution . Spin oth alam ic tract (pain an d tem perature) deficits can be seen through out an d are classically
described as bein g in a stockin g or glove distribution . Posterior colum n deficits (vibration an d proprioception ) also
com m on ly occur in th e h an ds an d feet. Th e patien t typically
com plain s of globally dim in ish ed appreciation of touch or
464
Physical Examination
Th e myelopath ic physical exam in ation will gen erally h ave
nonspecific findin gs in addition to fin din gs specific to
cord compression. One non specific but important findin g is lim ited n eck exten sion on exam in ation secon dary to
pain from th e n arrowed can al. Especially im portan t with
myelopathy is a full neurologic exam in ation with particular
atten tion paid to weakn ess, m uscle atrophy, an d clum sin ess
in both th e upper an d lower extrem ities. Th ere are various
specific m aneuvers described for han d/ finger clum sin ess
in cludin g rapidly open in g an d closin g th e h an ds, wh ich is
often slowed. In th e lower extrem ities, th e usual fin din gs
are spasticity an d weakn ess, in addition to atrophy (pyram idal tract sign s).
O n th e reflex exam in ation , hyperreflexia, clon us, an d a
positive Babin skis sign are often positive in th e lower extrem ities, wh ile hyperreflexia an d a positive Hoffm an s sign
m ay be observed in th e upper extrem ities. Sen sory exam in ation sh ould be docum en ted but is m uch less sen sitive.
Usually there is no gross sensory dysfunction but rather a
patchy decrease in ligh t touch an d pin prick. Th e sen sory
exam in ation does n ot m ake th e diagn osis but can support
the diagn osis.
Fin ally, it is importan t to assess th e patien ts gait. Th e
classic myelopathic gait is described as a wide-based gait
an d furth er testin g m ay sh ow difficulty with toe walkin g, h eel walkin g, an d/or h eeltoe gait. Addition ally, th e
Rom bergs test can be positive, dem on stratin g a disturban ce in balan ce secon dary to dysfun ction in th e posterior
colum n.
Diagnostic Studies
Again , it m ust be emphasized that th e core of the inform ation obtain ed sh ould be from th e h istory an d physical exam in ation , an d diagn ostic studies sh ould be used
to con firm th e clin ical impression . Many of th ese studies
are overly sen sitive an d relatively n on specific an d th erefore should not be used for screen ing purposes as they can
iden tify path ology in asymptom atic in dividuals for wh ich
no treatm ent is necessary. Th erefore, when in terpretin g th e
in form ation gain ed from th ese studies, th e clin ical picture
needs to be correlated with the fin din gs in the study, an d
the studies should n ever be interpreted in isolation.
Plain Films
Radiograph s of th e cervical spin e in myelopath ic patien ts
typically sh ow ch an ges con sisten t with advan ced degen erative disease. Fin din gs in clude disk-space n arrowin g, en d
plate sclerosis, facet join t arth rosis, osteophytosis with
spin al canal narrowing/ foram inal n arrowing, an d in stability. Con gen ital cervical sten osis, defin ed as a can al less th an
MRI
In a patien t with a physical exam in ation con sisten t with
myelopathy, an MRI is th e n ext step after plain film s. Th e
MRI findings can be very impressive as it im ages the cord/
soft tissue extrem ely well, thereby allowing one to visualize
cord impin gem en t closely (Fig. 12.20). The typical findings
are cord compression at m ultiple levels, disk herniation ,
facet hypertrophy, bucklin g/ hypertrophy of th e ligam en tum flavum , and soft-tissue changes. It m ust be stressed
again to correlate findings with th e physical exam ination
as MRI is often positive in asymptom atic in dividuals.
Natural History
Th e n atural h istory for cervical myelopathy is n ot as favorable as for radiculopathy, but it is not an absolute indication for surgery. Patien ts typically experien ce plateau
periods followed by exacerbation s of th e disease. It differs
from radiculopathy in the sense that generally speaking it is
progressive. Th e rapidity of progression varies from patien t
to patien t with m ost even tually requirin g surgery.
Management
Th ere rem ain s a lim ited role for n on operative treatm en t in itially, but on ce further deterioration is observed, surgery
is clearly indicated. Conservative m anagem ent involves
im m obilization and rest with a cervical orthosis. To our
knowledge, there are no good clinical trials indicating that
465
466
is m aintained, possibly dim inish ing the am ount of segm en tal disease at the levels above and below the fusion
site.
Cervical Spondylosis
Once com m on ly referred to as cervical degenerative disk
disease, cervical spon dylosis is a ch ron ic process defin ed
as the developm en t of osteophytes an d other stigm ata of
degen erative arth ritis as a con sequen ce of age-related disk
disease. Th is process m ay produce a wide array of sym ptom s from n eck pain to symptom s of a radiculopathy
an d/or myelopathy.
Th e process begin s with disk degen eration from agerelated ch an ges resultin g in a ch an ge in th e proteoglycan
an d collagen conten t of the disk as well as loss of water
con tent. Ultim ately, these changes lead to desiccation of
the n ucleus pulposus, loss of annular elasticity, an d narrowin g of th e disk space with or with out disk protrusion
or rupture. Th e ch an ges with in th e disk an d th e loss of disk
height disrupt the biom ech anics in th e vertebral colum n ,
resultin g in progressive degen eration an d m otion between
segm en ts. Increased m otion between segm ents results in
overridin g facets, facet hypertrophy, in flam m ation of th e
syn ovium , osteophyte form ation, hypertrophy of th e ligam en tum flavum and/ or PLL, and even m icrofractures. Depen din g on th e location of th ese ch an ges with in th e spin e,
a variety of clin ical syndrom es can occur including spon dylosis, ankylosis, central or foram inal spinal stenosis, radiculopathy, myelopathy, or spinal segm ental instability.
Th e typical patien t with spon dylosis alon e (i.e., with out
radiculopathy an d/ or myelopathy) is over th e age of 40
with a prim ary complain t of n eck pain . Not in frequen tly,
however, these patien ts will h ave little neck pain and will
presen t with referred pain pattern s: occipital h eadach es or
as pain in the sh oulder, suboccipital, interscapular areas,
an d/or the anterior ch est wall. In patients with predom inantly referred pain, a previous history of neck pain is
usually obtain ed. Th ese patien ts h ave n on specific physical
exam in ation fin din gs.
Th e patien t with spon dylosis an d radiculopathy an d/ or
myelopathy will often h ave little n eck pain but rath er
presen t m ain ly with radicular an d/ or m yelopath ic sym ptom s. Radiculopathy results from irritation of th e n erve
root from a bony protuberan ce (osteophytes, facet join t
hypertrophy) or less com m on ly soft disk h ern iation as th e
nerve root is exiting the canal. This is com m only referred to
as foram inal sten osis. Myelopathy can result from a sim ilar
process; h owever, th e cord is impin ged from cen tral rath er
than foram inal stenosis. Central sten osis occurs from disk
bulgin g (less com m on ), un covertebral hypertrophy, vertebral en d plate osteophytes, an d/ or ligam en tum flavum
hypertrophy. Posterior osteophytes causin g cord im pin gem en t are com m only referred to as hard disks that delineates th em from in tervertebral disk h ern iation , soft disks.
Com m on ly, radiculopathy and myelopathy will coexist in
these patients, referred to as myeloradiculopathy.
467
468
C
Figure 12.21 Spondylosis with myelopathy. A 78-year-old woman presenting with myelopathy
including myelopathic hand, broad-based gait, and positive Hoffmans sign on left. (A) AP radiograph
demonstrates severe uncovertebral joint narrowing (arrows) and sclerosis characteristic of advanced
osteolysis. (B) Lateral radiograph demonstrates anterolisthesis of C4 on C5 (open arrow) with severe
disk space narrowing of C5C6, C6C7, and C7T1 (closed arrows). Note also the anterior osteophytes
(small arrows) and concomitant loss of the normal cervical lordosis. (C) Transaxial CT scan at the C5
C6 disk level demonstrates a large posterior hard disk (arrow) protruding into the spinal canal with
associated uncovertebral joint osteophytes. (Reproduced with permission from Frymoyer JW, Wiesel
SW, An HS, et al. The Adult and Pediatric Spine, 3rd ed. Philadelphia: Lippincott Williams & Wilkins,
2003.)
goals of surgery in th e myelopath ic patien t are decompression of th e spinal cord an d preven tion of furth er neurologic deterioration . ACDF is used in th e m ajority of cases,
alth ough with m ultilevel disease, lam in oplasty m ay be
in dicated.
Rheumatoid Arthritis
Rh eum atoid arth ritis (RA) is an autoim m un e in flam m atory arth ropathy affectin g aroun d 2% of th e population
with cervical spine in volvem en t becom ing symptom atic in
aroun d 60% of rh eum atoid patien ts an d radiograph ic in -
469
categories: (1) atlantoaxial instability, (2) basilar in vagination, and (3) subaxial instability (Fig. 12.22). Atlantoaxial
instability is the m ost com m on form of instability accounting for approxim ately 70% of the cases. In flam m ation and
pan n us form ation lead to weaken in g of th e ligam en tous
structures about C1 and C2, eventually resultin g in an terior
subluxation of C1 on C2. Subluxation results in cord im pin gem en t as th e SAC decreases. Basilar in vagin ation refers
to th e ceph alad m igration of th e odon toid secon dary to in volvem ent of the atlan toaxial and atlanto-occipital joints,
resultin g in impaction of th e odon toid on th e brain stem
with severity depen din g on th e am oun t of m igration . Th is
is the least com m on yet m ost feared complication of RA of
the cervical spine as severe neurologic deficits can occur,
an d death from compression on the respiratory center at
the brainstem is possible. Subaxial instability occurs in approxim ately 25% of th e cases, resultin g in decreased SAC
via the sam e m echanism as in atlantoaxial instability.
Sym ptom atic patien ts with cervical spin e in volvem en t
typically complain of neck pain in th e m iddle, posterior
neck, and occipital area with varying complaints of weakness about the neck itself and/ or in the extrem ities. Physical
exam in ation sh ould start with a careful n eurologic exam ination, which often can be difficult with the associated
ch anges in the appendicular skeleton. Range of m otion of
the neck is often decreased an d crepitus or a feeling of in stability m ay be elicited.
Plain radiograph s are th e first step after th e physical exam in ation with AP, lateral, odontoid, and lateral flexion/
exten sion views obtain ed. Certain radiograph ic param eters
are critical in evaluating the rheum atoid cervical spine. On
the lateral view, these include the anterior atlan todents in terval (aADI), th e posterior atlan toden tal in terval (pADI),
odon toid m igration in relation to McGregors lin e, an d th e
spinolam inar line (Fig. 12.4). An aADI 3 m m or greater
is significant for atlantoaxial in stability, while a pADI less
than 14 m m signifies a decreased SAC with an indication
for surgical fixation . Basilar invagination is defined as m igration of th e odon toid tip m ore th an 4.5-m m ceph alad to
McGregors line (line from hard palate to caudal surface of
the basiocciput). Subaxial instability appears as a stepladder appearan ce of th e spin olam in ar lin e kn own as stepladdervertebrae. Flexion / exten sion views are obtain ed to an alyze the extent of atlantoaxial instability as the patient can
exh ibit an in creased aADI an d a decreased pADI on th e
flexion view in comparison to th e extension view, as well as
toid. This is a 55-year-old female with rheumatoid arthritis with atlantoaxial instability with an MRI showing large pannus formation
(arrow) at the odontoid.
470
Conservative Treatment
Th e prim ary m ode of th erapy in both acute an d ch ron ic cervical spine disease is im m obilization. In acute neck injuries,
im m obilization allows for healin g of torn and attenuated
soft tissues, wh ereas in chronic conditions im m obilization
is aim ed at reduction of inflam m ation in the supporting
soft tissues an d around th e nerve roots of the cervical spine.
Im m obilization is best ach ieved by th e use of a soft collar. It needs to be properly fitted and com fortable on the
patien t. In itially, th e collar is worn 24 h ours a day. Th e patient m ust understand that during sleep the neck is totally
unprotected from awkward position s an d m ovem en ts, an d
therefore collar wear is m ost important.
Drug th erapy is th e oth er m ain stay of in itial treatm en t.
It is directed at reducin g in flam m ation , especially in th e
soft tissues. A variety of anti-inflam m atory m edications are
471
NECK PAIN
(BRACHIALGIA)
MYELOPATHY
(PROGRESSIVE WEAKNESS ATAXIA,
LONG TRACT SIGNS)
YES
MYELOGRAM/
MRI
SURGERY
NO
ANTI-INFLAMMATORY
MEDICATIONS.
REST, AND COLLAR
UP TO 3 WEEKS.
YES
ISOMETRIC
EXERCISES
NO
BEDREST, PO STEROIDS,
AND/OR TRIGGER-POINT
INJECTION
FULL ACTIVITY
YES
NO
BRACHIALGIA
NECK PAIN
(INTERSCAPULAR
RADIATION)
ADSONS
TEST
PLAIN
X-RAYS AND/OR
MOTION FLIMS
YES
VASCULAR
STUDIES
AND EMG
YES
APPROPRIATE Rx
FOR THORASIC
OUTLET SYNDROME
NO
YES
INSTABILITY
YES
PLAIN X-RAYS
TO INCLUDE
CHEST AND
SHOULDER
NO
DEGENERATIVE DISEASE
YES
APPROPRIATE Rx
NO
YES
YES
BRACE AND
PERIODIC
REEVALUATION
EMG
ISOMETRIC
EXERCISES
AND
PERIODIC
REEVALUATION
MEDICAL
EVALUATION
AND
BONE SCAN
YES
NO
LIMITED
ACTIVITY
APPROPRIATE
Rx
NERVE
COMPRESSION
SYNDROME
YES
RADICULOPATHY
NO
MYELOGRAM/MRI
FUSION
YES
PSYCHOLOGICAL
EVALUATION
CHRONIC PAIN Rx
NO
SURGERY
(NERVE ROOT DECOMPRESSION)
ANTIDEPRESSANTS, EDUCATION,
PAIN CLINIC, AND PERIODIC
REEVALUATION; STOP NARCOTICS
NERVE
DECOMPRESSION
472
LUMBAR SPINE
Low-back pain occurs m uch m ore com m only than neck
pain . Th e lifetim e in ciden ce of low-back pain is estim ated
to be 65%. Every physician will be eith er person ally affected
or profession ally ch allen ged by th is problem .
History
A gen eral m edical review, especially in th e older patien t, is
imperative. Metabolic, in fectious, and m alignant disorders
m ay in itially present to the physician as low-back pain.
473
Physical Examination
Th e physical exam in ation is directed at fin din g th e location of th e pain and any associated n eurologic findings.
All patien ts with low-back pain can h ave n on specific fin dings that vary in degree, depending on the severity of the
con dition . Th ese fin din gs in clude a list to on e side, ten dern ess to palpation an d percussion , an d a decreased range
of m otion of th e lum bar spin e an d can be presen t in both
radiculopath ic an d referred pain patien ts. Th eir presen ce
den otes th at th ere is a problem but does n ot iden tify th e
etiology or level of th e problem .
Th e n eurologic exam in ation m ay yield objective evidence of n erve root compression. If such evidence is
presen t, a th orough n eurologic evaluation of th e lower extrem ities should be conducted, particularly to ch eck the reflexes and m otor fin din gs. Sen sory ch an ges m ay or m ay not
be presen t, but because of th e overlap in th e derm atom es
of spin al n erves, it is difficult to iden tify specific root in volvem en t.
In patien ts with radiculopath ies, th ere are several m an euvers that tighten the sciatic n erve an d in so doing, furth er com press an in flam ed lum bar root again st a h ern iated
disk or bony spur. Th ese m an euvers are gen erally term ed
ten sion sign s or a straigh t leg raisin g test (SLRT). The
con ven tion al SLRT is perform ed with th e patien t supin e.
Th e exam in er slowly elevates th e leg by th e h eel with th e
knee kept straight. This test is positive when the leg pain
474
Herniated Disk
A h ern iated disk can be defin ed as th e protrusion of th e
n ucleus pulposus th rough th e torn fibers of th e annulus
fibrosus. Most disk h ern iation s occur durin g th e th ird an d
fourth decades of life while the nucleus pulposus is still
gelatin ous. Th e perforation s usually arise th rough a defect
just lateral to th e posterior m idlin e wh ere th e PLL is weakest. Th e two m ost com m on levels for disk h ern iation are
L4 L5 and L5 S1, accoun tin g togeth er for 95% of all lum bar disk h ern iation s.
Because disk h erniation s are gen erally posterolateral as
discussed earlier, th e h ern iation gen erally affects th e n erve
traversing the region rather th an th e exiting nerve root. The
spin al cord ends aroun d L1/ L2, so th e nerve roots of the
lum bar spine exit th e cord well above th at level where they
exit th e can al. Th ey, th erefore, h ave a lon g way to travel
before exitin g th rough th e foram en , un like in th e cervical spin e. Th e nerves begin m oving laterally and in feriorly
from a proxim al direction rather than exitin g alm ost in a
straigh t lateral direction like the cervical spine. For this reason , by th e tim e th e nerve root reaches its exiting level, it
is already so far lateral from its descent that a hern iated
disk at th e level wh ere th e n erve root exits will n ot disrupt
it unless the herniation is the m uch less com m on far lateral type. Th erefore, a h ern iated disk will im pin ge upon th e
traversing nerve th at exits at th e n ext level down, rath er than
the exiting nerve, which differs from a cervical disk herniation that impinges upon the exiting nerve root. However,
because th e n erves in th e lum bar spin e exit below th eir respective vertebra, th e sam e rule applies for the likely nerve
impinged, which is the nerve nam ed for th e lowest vertebral
475
TABLE 12.2
476
physician an d a well-in form ed patien t. If a patien t h as in sight in to the rationale for the prescribed treatm en t an d
follows instructions, the chances for success are greatly increased.
O n e of th e m ost importan t elem en ts in n on operative
treatm en t is con trolled physical activity. Patien ts sh ould
m arkedly decrease th eir activity in th e acute stages. Th is
will occasionally require bed rest and in m ost cases can be
accomplish ed at h om e. An acute h ern iation usually takes
about 2 weeks of rest before th e pain substan tially eases.
Drug th erapy is an oth er importan t part of th e treatm en t, an d th ree categories of ph arm acologic agen ts are
com m only used: anti-in flam m atory drugs, analgesics, an d
m uscle relaxan ts. In asm uch as th e symptom s of low-back
pain an d sciatica result from an in flam m atory reaction as
well as a m echanical compression , the auth ors feel that
an ti-in flam m atory m edication in th e form of aspirin or
NSAIDs taken regularly sh ould be in cluded with rest. We
prefer n aproxen 500 m g twice daily, alth ough we h ave h ad
success with aspirin or oth er NSAIDs as well. For those with
GI in toleran ce, celecoxib or a bufferin g agen t can be used.
Analgesic m edication is rarely needed if the patien t truly
follows th e nonoperative protocol of resting. Occasionally,
narcotics will be n eeded to overcom e the in itial hump, although it sh ould be m ade clear th at narcotics will not be
used lon g term an d are n ot th e an swer to th e problem .
Rarely, a patien t m ay n eed to be adm itted to th e h ospital
for pain con trol with IV narcotics.
There is som e question as to whether there actually is a
m uscle relaxan t; all drugs th at are design ated as such probably act to som e degree as tran quilizers. If on e is required,
Spinal Stenosis
Spin al sten osis can be defin ed as a n arrowin g of th e spin al
canal secondary to degen erative, developm ental, or congen ital con dition s. Th e degree of m ech an ical pressure on
the neural elem ents within the canal depends directly upon
the degree of n arrowing. It m ust be realized that every person will h ave som e degree of narrowing with age secon dary
to osteoarth ritis; h owever, n ot everyon e will h ave symptom s.
Th e m ost com m on form of spin al sten osis is degen erative stenosis secondary to the effects of osteoarth ritis on
the aging spine. The stenosis is due to a com bination of
ch anges in osseous anatomy as well as soft-tissue hypertrophy. Th e typical sequen ce of even ts results from disk degen eration due to loss of water con ten t th at leads to segm en tal
instability as loss of disk height results in m otion within the
spinal colum n secondary to a disruption of th e biom ech anics. Segm ental instability, or m otion between vertebral levels, leads to overridin g facets, facet join t hypertrophy, osteophyte form ation , hypertrophy of th e ligam en tum flavum
an d oth er ligam entous structures, and/ or m icrofractures.
Th e ultim ate result is n arrowin g of th e cord secon dary to
osteophytes an d/ or soft-tissue hypertrophy. Th is usually results in nerve root im pin gem en t or sym ptom atic stenosis
at the lateral recess, th ough less com m only impingem ent
can occur in th e neural foram en an d centrally.
Spin al sten osis affects aroun d 2% to 10% of th e population. The typical patient with lum bar stenosis is over the
age of 50 when they first experien ce symptom s beginning
with vague pain s in th e lower back, wh ich slowly progress
to dysesth esias an d paresth esias down th e legs durin g am bulation . Th e sym ptom s gradually in crease in n ature with
worsen in g pain an d/ or pain after m in im al walkin g to pain
wh ile stan din g. Th ese n eurogen ic claudication symptom s
will abate wh en th e patien t sits or lies down , th ough th e
pain usually takes m ore tim e to abate th an claudication
secon dary to peripheral vascular disease. Am bulation and
stan ding typically exacerbate th e symptom s because th ose
actions result in hyperextension of the lum bar spine, which
further narrows an already diseased region . Sittin g or lying
supine results in a m ore kyphotic lum bar spine and th us
relieves th e pressure by en largin g th e sten otic region s. For
this reason, m any of these patients will walk with their
sh oulder h un ched forward over or anterior to th e pelvis,
thereby increasing kyph osis.
With m aturation of th e syn drom e, sym ptom s m ay even
occur at rest. Muscle weakn ess, atrophy, an d asym m etric reflex ch an ges m ay th en appear; h owever, as lon g as
the symptom s are on ly aggravated dynam ically, neurologic
ch anges will occur only after the patient is stressed. For th is
reason , m ost of th ese patien ts will h ave an absen t SLRT as
opposed to patien ts with an acute h ern iated disk. Th e physical exam ination of these patients will therefore be un rem arkable other than n onspecific fin dings in the m ajority of
cases. The following stress test can be used in an outpatient
clinic; after a neurologic exam in ation has been perform ed
on th e patien t, h e/ sh e is asked to walk up an d down th e
corridor un til symptom s occur or the patient h as walked
300 feet. A repeat exam in ation is th en don e, an d in m any
cases, th e second exam ination will be positive for a focal
neurologic deficit when the first was negative. While h elpful if positive, this test does not rule out sten osis if negative.
Plain x-rays sh ould be obtain ed wh en on e suspects
spinal stenosis and generally are h elpful in visualizin g
stenosis, especially if it is degen erative. Th e typical findings are intervertebral disk degeneration or loss of h eigh t,
decreased in terpedicular distan ce, a decreased sagittal can al
diam eter, an d facet degen eration . Th ese are also visualized
well on CT scan (Fig. 12.26). If a patien t fails con servative treatm en t and becom es a surgical can didate, the location and degree of neurologic compression can be assessed with MRI and/ or CTscan, depen ding on wh ether th e
477
Spondylolisthesis
Spondylolisthesis refers to the forward displacem ent of on e
vertebra on another. It can occur from a variety of causes
and th us can be classified as congenital, isthm ic, degen erative, traum atic, pathologic, and postoperative. The m ost
frequent causes are degen erative and isthm ic, though degen erative m ost com m on ly occurs in adulth ood. Isth m ic
spon dylolisthesis, on th e other hand, begins in childhood
and adolescen ce, although m any tim es it will not present
un til adulth ood.
Isth m ic spon dylolisth esis occurs secon dary to spon dylolysis, which m eans a defect in the area of the vertebra
known as the pars interarticularis. Approxim ately 5% to 6%
of th e population h as a defect in th e pars. Th e reason for th is
is not completely understood, although it is believed to result from a fatigue-type fracture that develops in childhood.
Som e of these patients will rem ain asymptom atic, though
som e will progress to develop spondylolisthesis secondary
to a degree of instability from the pars defect with subsequen t subluxation or an terior displacem en t (listh esis) of
on e vertebra on to an oth er. Th e m ost com m on areas affected are L5 S1, followed by L4 L5, and L3 L4. As alluded
to earlier, spondylolysis occurs in childhood, while the
even tual developm en t an d m an ifestation s of spon dylolisth esis can occur in ch ildh ood, adolescen ce, or adulth ood.
Th e correlation between spon dylolysis or spon dylolisth esis an d back pain is n ot clear, an d th ere are con flictin g
findings in the literature. Sarasate et al. found radiographic
eviden ce of disk degen eration an d a slip of greater th an
10 m m correlated positively with sym ptom s as did a low
lum bar index, increased lum bar lordosis, and spondylolysis at L4. It is important to be aware when evaluating th e patient with back pain and radiographic evidence
of spon dylolisth esis, h owever, th at th is con dition m ay
be n on -pain ful an d th at th ere are m any oth er poten tial
sources of pain . Leapin g to the conclusion that spondylolisthesis, as seen on plain film s, is the source of th e patients pain m ay lead to unsuccessful treatm ent. Pain in the
adult patient with spon dylolisthesis h as several potential
sources, an d each sh ould be con sidered before determ ining th at the pain is secondary to th e slip.
478
D
Figure 12.26 Spinal stenosis. (A) Axial CT scan showing the central region (A), lateral recess (B),
and foraminal regions (C). (B) Axial CT scan showing facet degeneration with hypertrophy and resultant lateral recess stenosis. (C) Normal sagittal CT scan showing foraminal dimensions. (D) Sagittal CT
scan showing foraminal encroachment due to degenerative changes. (Reproduced with permission
from Frymoyer JW, Wiesel SW, An HS, et al. The Adult and Pediatric Spine, 3rd ed. Philadelphia:
Lippincott Williams & Wilkins, 2003.)
479
lumbar radiographs demonstrating instability at L4L5 with approximately 30% slip of L4 anteriorly on L5. (Reproduced with permission from Chapman MW. Chapmans Orthopaedic Surgery, 2nd ed.
Philadelphia, Lippincott Williams & Wilkins, 1993.)
480
481
POLYMYALGIA
RHEUMATICA
NO
NO
FIBROSITIS
YES
ESR
YES
MUSCLE
PAIN STIFFNESS
NO
MEDICAL
EVALUATION
NO
BONE
SCAN
NO
PSYCHO
SOCAL
EVALUATION
NO
LOW BACK
SCHOOL
YES
TUMOR
INFECTION
YES
YES
DEGENERAT
TREATMENT AS
INDICATED
PLB
INSTABILITY
SURGERY
MYELOGRAM +
NO
EPIDURAL
STEROIDS
SURGERY
NO
SUPPORT
YES
CAT/MRI
SCAN
NO
LOCAL
INJECTION
POSTERIOR
THIGH PAIN
FULL
ACTIVITY
EXERCISE
YES
NO
YES
YES
BACK STRAIN
PROTOCOL
(SONOGRAM)
CAT SCAN
NO
NO
IVP
NO
YES
SUPPORT
CT/MRI OR
MYELOGRAM
ANTERIOR
THIGH PAIN
YES
YES
CONTROLLED PHYSICAL
ACTIVITY (UP TO 6 WEEKS)
MEDICATIONS
NO
ACUTE
CONSTITUTIONAL
SYMPTOMS
CEC
(PROGRESSIVE
WEAKNESS)
ISOLATED STENOSIS
L3-4 OR L4-5
YES
FULL
ACTIVITY
BACK STRAIN
PROTOCOL
FULL
ACTIVITY
EXERCISE
SPONDYLOLISTHESIS
CPPD
OR
OCHRONOSIS SEGMENTAL INSTABILITY
YES
PLAIN X-RAY
(MOTION
STUDIES)
PREDOMINANT
CALCIFICATION
DISC
OSTEOARTHRITIS
ACROMEGALY
FULL
ACTIVITY
FULL
ACTIVITY
EXERCISE
YES
LOCAL INJECTION
AND/OR SUPPORT
BACK STRAIN
PERIODIC
REEVALUATION
NO
THERAPEOTIC
INTERVENTION
DIAGNOSTIC
TEST
SYMPTON
OR SIGN
LBP
(SCIATICA)
ABDOMINAL
ANEURISM
KIDNEY
DISORDER
ARTHRITIS
HERNIA
EXERCISE
MEDICAL
EVALUATION
NO
MYELOGRAM +
NO
HNP
INVASIVE
PROCEDURE:
SURGERY/
CHEMONUCLEOLYSIS
YES
SCAT
CAT/MRI +
NEURO/
TENSION
SIGNS +
NO
EPIDURAL STEROIDS
YES
FULL
ACTIVITY
LEG PAIN
BELOW KNEE
PREDOMINANT
YES
EXERCISE
SURGERY
SURGERY
SPINAL
STENOSIS
MYELOGRAM +
CAT
SCAN +
PLAIN XRAYS +
STRESS
TEST +
NEURO/
TENSION
SIGNS
FULL
ACTIVITY
482
Conservative Treatment
Th e vast m ajority in th is in itial group h ave n on radiatin g
low-back pain , term ed lum bago or back strain . Th e etiology of back strain is n ot clear. Th ere are several possibilities, in cludin g ligam en tous or m uscular strain , con tin uous
m ech an ical stress from poor posture, facet join t irritation ,
or a sm all tear in th e an n ulus fibrosis. Patien ts usually com plain of pain in th e low back, often localized to a sin gle area.
O n physical exam in ation , th ey dem on strate a decreased
range of lum bar spine m otion, tenderness to palpation
over th e in volved area, an d paraspin al m uscle spasm . Th eir
roen tgen ograph ic exam in ation s are usually n orm al, but if
therapy is n ot successful, film s should be obtained to rule
out oth er possible etiologic factors. Two exception s to th is
rule are patients youn ger than 20 years and patients over
60 years; x-rays are important early in the diagnostic process for th ese patients because they are m ore likely to h ave
a diagnosis other than back strain (tum or or infection).
O th er situation s warran tin g x-rays soon er rath er th an later
in clude a h istory of serious traum a, kn own can cer, un explain ed weigh t loss, or fever.
The early stage of treatm ent of low-back pain (with or
without leg pain ) is a waitin g gam e. Th e passage of tim e,
the use of an ti-inflam m atory m edication, and controlled
physical activity are th e m odalities th at h ave proved safest
an d m ost effective. Th e vast m ajority of th ese patien ts will
respon d to th is approach with in th e first 10 days, alth ough
a sm all percentage will not. In todays society with its em ph asis on quick solution s an d h igh tech n ology, m any
patien ts are push ed too rapidly toward m ore complex (i.e.,
in vasive) m an agem en t. Th is quick fix approach h as n o
place in th e treatm en t of low-back pain . Th e physician
treats th e patien t con servatively an d waits up to 6 weeks for
a respon se. As already stated, m ost of th ese patien ts will
improve with in 10 days, alth ough a few will take lon ger.
O n ce th e patien ts h ave ach ieved approxim ately 80%
relief, th ey sh ould be m obilized with th e h elp of a
ligh tweigh t, flexible corset. After th ey becom e m ore com fortable and have in creased their activity level, they should
begin a program of isom etric lum bar exercises an d return
to th eir n orm al lifestyles. Th e path way alon g th is section of
the algorithm is a two-way street; should regression occur
with exacerbation of sym ptom s, th e physician can resort
to m ore strin gen t con servative m easures. Th e patien t m ay
require furth er bed rest. Most acute low-back pain patien ts
will proceed along th is pathway, returning to a norm al life
pattern with in 2 m on th s of th e on set of sym ptom s.
If the in itial conservative regim en fails and 6 weeks h ave
passed, sym ptom atic patien ts are sorted in to four groups.
Th e first group comprises th ose with low-back pain predom in atin g. Th e secon d group com plain s m ain ly of leg
pain , defin ed as pain radiatin g below th e kn ee an d com -
483
484
ADULT SCOLIOSIS
Scoliosis is described as a coron al plan e curvature occurrin g m ost com m on ly in th e th oracic, th oracolum bar, an d
lum bar spine. Although the frontal curve is th e m ost com m on ly recognized aspect of the deform ity, scoliosis is a
three-dim ensional abnorm ality with alterations not only
in the frontal plan e but also in th e sagittal an d axial planes,
all contributing sign ifican tly to the cosm etic deform ity and
m orbidity seen with this con dition. Adult scoliosis refers to
scoliosis in th e skeletally m ature individual, in m ost series,
beyon d th e age of 20.
Th e prevalen ce of scoliosis, as well as th e severity of
the curves identified, increases with increasin g age. Kostuik
an d Bentivoglio reported on 5,000 patien ts undergoing
IV pyelography, n otin g 3.9% of th ese in dividuals to h ave
thoracolum bar or lum bar curves greater than 10 degrees.
Th ey also n oted th at th e overall prevalen ce was probably
som ewhat h igher, but chest radiographs were n ot included.
Many authors have noted th e potential for de novo developm en t of scoliosis in m iddle-aged an d older patien ts secon dary to degen erative ch an ges, as well as th e ten den cy for
m ild-to-m oderate curves in adolescence to progress slowly
durin g adulth ood, leadin g to in creasin g prevalen ce an d
severity as older patients are surveyed.
Wh en treatin g an adult patien t with scoliosis, th e etiology of th e curve is frequen tly related to th e age of th e
patien ts. Youn g an d m iddle-aged adults frequen tly presen t
with idiopath ic scoliosis th at m ay h ave been diagn osed in
adolescence or m ay be newly identified. Older patients will
be m ore likely to h ave n ewly diagn osed scoliosis secon dary
to degenerative disease. In fact, the m ost com m on form of
scoliosis is degenerative in nature.
Patient presentation again varies with adult scoliosis,
and often depends on the type of scoliosis, that is, idiopath ic versus degen erative. Som e patien ts h ave n o com plain ts, an d scoliosis is discovered as an in ciden tal fin din g,
for example, on a chest x-ray. The m ost com m on presenting
complain t for th e adult patien t with idiopath ic scoliosis is
back pain , an d it is in cum ben t on th e physician to clearly
identify the location of the pain, in particular whether it is
related to th e curve or is th e m ore typical low-back pain . It
is important to recognize that there is n o clear-cut correlation between th e presence of idiopathic scoliosis and back
pain . Th e vast m ajority of th e pediatric population with
idiopathic scoliosis present with painless deform ity. A certain percen tage of adults with idiopath ic scoliosis will develop persistent, at tim es worsenin g pain that is clearly
related to th eir curve an d are good can didates for eith er
nonsurgical or surgical treatm en t. On the oth er hand, m any
patien ts with scoliosis presen t with n on specific low-back
pain . In th ese in dividuals, treatm en t directed at th e curve,
especially surgical treatm en t, is un likely to be effective.
Curve progression m ay occur even in adulthood and is
m ore likely in curves that are greater than 50 degrees at the
tim e of skeletal m aturity, particularly right thoracic curves.
Slow progression is seen , so it is important to compare
curve m easurem en ts over a period of 5 or even 10 years
to accurately identify possible curve progression. Although
pulm on ary sym ptom s, an d even respiratory failure, h ave
been reported in scoliosis, th e in ciden ce of objective respiratory in sufficien cy is really quite low. Fin ally, cosm esis is
a sign ifican t con cern of m any patien ts with idiopath ic scoliosis. Th is is particularly true in the adult, although m any
patien ts are reluctan t to iden tify th is to th e physician as a
reason for seekin g treatm en t.
Th e secon d an d m ore exten sive group of patien ts
presen ts with degen erative scoliosis. Th ese patien ts are typically older and have only recently been diagnosed with
scoliosis. The etiology of degenerative scoliosis is un certain, but it probably related to preexistin g sm all curves th at
progress as a respon se to asym m etric degen eration an d collapse in the posterior facets and anterior disk thereby essentially destabilizin g the colum n . Significant spon dylotic
changes are seen with associated rotation, coronal plane
curvature, an d frequen tly loss of lum bar lordosis. Cen tral,
lateral recess, and foram in al sten osis are com m on , th ereby
leading to possible nerve root compression in the concavity of either th e prim ary lum bar or the lum bosacral fractional curve (opposite the prim ary curve). Th ese patients
th erefore usually h ave a h istory of lon g stan din g, gradually
485
Evaluation
Evaluation of th e patien t with scoliosis in cludes h istory,
physical exam in ation , an d radiograph ic studies. Th e h istory should focus on determ ining the chief complaint of
th e patien t, wh eth er it is back pain , n eurogen ic claudication, loss of balance, or deform ity. If pain is the presen ting
com plain t, on e m ust obtain a clear, detailed description of
th e exact location of th e pain as well as radiation . Eviden ce
of curve progression , such as loss of h eigh t or a n otable
change, over the last few years, in the fit of clothing, is
importan t. It is also important to ask about the patients
subjective sense of balance.
Physical exam in ation sh ould follow th e typical spin e
physical exam in ation with focus on gait, balan ce, an d ran ge
of m otion . Th e presen ce of a rotation al rib, flan k deform ity, or a leg length discrepancy should be noted. Neurologic testing seeking both upper and lower m otor neuron
findings is carried out; it sh ould be noted that idiopathic
scoliosis, as opposed to degen erative scoliosis, never results
in spinal cord compression or paraplegia, and the presence
of upper m otor n euron fin din gs such as clon us or a positive Babinskis sign should trigger a search for intraspin al
path ology.
Radiograph ic evaluation in cludes stan din g PA (Fig.
12.29) an d lateral radiograph s of th e full spin e, ben din g
film s when surgery is contemplated, and m ay include
supin e views of th e lum bar region to better define degen erative ch an ges. Th e Cobb an gle is used to m easure
curve severity an d docum en t progression . MRI sh ould be
obtain ed in cases of rapid progression , any upper m otor
n euron fin din g, or a h istory suggestive of lum bar stenosis.
It sh ould be n oted th at th e abn orm al th ree-dim en sion al
anatomy seen in scoliosis secondary to rotation an d curvature superimposed on the spondylotic changes present
with degen erative scoliosis m ay m ake accurate diagn osis of
th e site an d severity of sten osis difficult on MRI. Th erefore,
CT is often obtained as well to better delineate the bony
anatomy.
Treatment
Many patients with scoliosis presen t for evaluation and
treatm ent of their backs, but only rarely is surgical
treatm ent necessary. Accurate identification of the patien ts
m ajor source of concern will in m any cases lead to observation as th e appropriate form of m anagem ent. When
treatm ent is in dicated, m any patients either have low-back
pain , leadin g to n on operative m an agem en t in m ost cases,
or h ave m ild-to-m oderate curve-related pain , wh ich will
frequently respond to nonoperative treatm ent as well.
Non operative treatm en t for low-back pain related to scoliosis essentially follows th e treatm ent protocol outlined
earlier. Usually a program of weigh t reduction , aerobic
486
487
488
Osteoid Osteoma/Osteoblastoma
O steoid osteom a an d osteoblastom a are tum ors of bony
origin th at com m on ly arise in th e spin e, alm ost exclusively in the posterior elem ents. Th ese tum ors can be
differen tiated from each oth er on th e basis of size, with
osteoid osteom a con sistin g of a n idus less th an 2 cm an d osteoblastom a bein g greater th an 2 cm . Approxim ately 40%
of osteoid osteom a an d 30% of osteoblastom as occur in
the spin e, with both occurring m ost com m only in the secon d an d th ird decades. Both presen t as back pain , usually
un related to activity. Osteoid osteom as occur m ost com m on ly in th e lum bar spin e, wh ile osteoblastom as occur
m ost com m on ly in th e cervical spin e, th ough both can be
found through out the spine. Radiograph ic dem onstration,
particularly with th e sm aller osteoid osteom a, is difficult
an d x-rays often appear n orm al. Wh en th is lesion is suspected an d film s are n orm al, tech n etium bon e scan n in g
en ables localization of th e lesion th at is th en better defin ed by CT (Fig. 12.30). Both of th ese lesion s can result
in pain ful scoliosis, wh ich is usually rapidly progressive
an d rigid, an d th ese sh ould be con sidered wh en pain is
the presenting complaint in a patien t with a spinal deform ity. O steoid osteom a m ore com m on ly results in scoliosis
than osteoblastom a. As m entioned earlier, back pain is th e
m ost com m on complain t with 30% of th ese patien ts experiencing th e pain at night. Classically, the pain in osteoid
osteom a is relieved with aspirin or NSAIDs, th ough th is
occurs on ly about 30% of th e tim e in th e spin e.
Excision is the preferred treatm ent for both of these lesion s, though asymptom atic patients with osteoid osteom a
can be m onitored. Intralesional curettage and bone graftin g as n eeded result in excellen t pain relief with sm all recurrence rates in osteoid osteom a, while recurrence rates
489
Osteosarcoma
Th e spin e is a rare site for prim ary osteogen ic sarcom a (on ly
3% of all prim ary osteosarcom as), an d th e treatm en t of osteosarcom a in th is location represen ts a particularly ch allenging un dertaking with a poor prognosis. Most patients
presen t with pain , alth ough n eurologic deficits are presen t
over 50% of th e tim e as well. Most cases arise in th e vertebral body, usually with exten sive soft-tissue m asses or
extra-com partm en tal disease at th e tim e of diagn osis. A variety of radiograph ic appearan ces m ay be seen from blastic
to lytic or a com bination, both generally involvin g cortical destruction . CT is useful to sh ow th e path ologic bony
anatomy, while MRI is useful in delineatin g the soft-tissue
path ology. Alth ough progn osis is poor, an aggressive attempt at ch em oth erapy prior to en bloc excision an d recon struction followed by adjuvan t radioth erapy is gen erally recom m ended.
Ewings Sarcoma
As with osteosarcom a, Ewin gs sarcom a rarely presen ts in
th e spin e, accoun tin g for approxim ately 5% of all cases. It
also has a predilection for the vertebral body and is m ost
com m on in th e sacrum (50% of th e tim e). Again , patien ts
presen t m ost com m on ly with pain , alth ough n eurologic
490
deficits are com m on with Ewin gs sarcom a. Secon dary softtissue exten sion is typical, an d it is com m on ly presen t at th e
tim e of diagn osis. Th ese tum ors are gen erally lytic in n ature with eviden ce of soft-tissue exten sion on MRI. Diagn osis is gen erally not m ade until after biopsy showin g sm all
roun d blue cells. Th e radiosen sitivity of Ewin gs sarcom a
m akes h igh -dose radioth erapy with adjuvan t ch em oth erapy th e treatm en t of ch oice for m ost lesion s. Surgery is un dertaken for path ologic fracture with in stability or n eurologic comprom ise. Alth ough better th an for osteosarcom a,
the prognosis for patients with Ewings sarcom a of the spine
is worse th an for extrem ity disease, an d 5-year survival rates
are aroun d 30% with proper treatm en t.
Chordoma
Ch ordom a is a slow growin g m align an cy arisin g from th e
residual n otoch ord in th e m idlin e of th e spin e an d skull
base. Th ese tum ors are m ost com m on in th e sacrum an d
one level above and one level below. (A) Sagittal MRI shows epidural extension into adjacent
bodies. (B) Axial MRI shows canal compromise.
(C) CT scan showing bone destruction. (Reproduced with permission from Frymoyer JW,
Wiesel SW, An HS, et al. The Adult and Pediatric
Spine, 3rd ed. Philadelphia: Lippincott Williams
& Wilkins, 2003.)
491
B
Figure 12.32 Metastatic disease. (A) Sagittal MRI scan of a 58-year-old man with isolated colon
adenocarcinoma metastasis to L5 with low-back pain. (B) Sagittal CT reconstruction showing mixed
blastic and lytic regions within L5. (Reproduced with permission from Frymoyer JW, Wiesel SW, An
HS, et al. The Adult and Pediatric Spine, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2003.)
492
is highly predictable for pain relief, restoration an d protection of n eurologic function, and an acceptably low complication rate.
SPINE INFECTIONS
In fection s of th e spin e occupy a perversely importan t place
in the history of orthopedic surgery in general and spine
surgery in particular. Percival Potts description of tuberculosis (TB) and associated paralysis gave rise to the endurin g eponym Potts paraplegia. Many of th is cen turys
sem in al advances in spin e surgery including the developm en t of posterior fusion of the spine by Hibbs and Albee
related to th e treatm en t of tuberculous spon dylitis. Hodgson pioneered an terior surgery of th e spine, curren tly in
widespread use for n um erous con dition s, as th e treatm en t
for spinal TB. We now see infections of the spine in num erous settings and caused by a variety of organism s, but
despite sign ifican t tech n ologic an d m edical advan ces in our
treatm ent, the underlyin g prin ciples of the treatm en t of infection of the spine are still largely based on lesson s learned
from TB.
Pyogenic Infection
Th e in ciden ce of pyogen ic vertebral osteomyelitis appears
to be in creasin g with an in crease in m edical an d social con dition s th at lead to im m un osuppression . Th e spin e is th e
site for up to 7% of all cases of osteomyelitis and certainly
is the area with the greatest poten tial for m orbidity. Prior to
the current an tibiotic era, the m ortality secondary to vertebral osteomyelitis reach ed 20% to 25%. With th e adven t
of curren t an tibiotic treatm en t an d advan ces in spin al surgical techniques, the m ortality rate is less than 10%, with a
significant drop in m orbidity as well, but the consequences
can still be devastating.
Th e path ophysiology of vertebral osteomyelitis arises
from three potential sources: direct in oculation, con tiguous spread from an oth er source, an d th e m ost com m on ,
hem atogenous spread. Direct in oculation can occur via
pen etratin g traum a or from iatrogen ic in oculation th rough
procedures ran gin g from surgical in terven tion to percutaneous procedures. Con tiguous spread as the n am e implies
occurs from an oth er in fection in th e region of th e affected
area, generally a retroperitoneal abscess or possibly from
the spinal canal itself. The vast m ajority of cases are th e
result of h em atogen ous spread from a distan t source, with
the m ost com m on locations being the genitourin ary tract,
the skin and soft tissues, and the upper respiratory tract.
Approxim ately 50% of patients with an in fection of the
spine will give a h istory of a preceding in fection elsewh ere.
Th e in fection seeds th e m etaphyseal region of th e vertebral
body th rough th e rich an astom otic n etwork in th e area.
Once the infection reaches the vertebral body, it locally
493
494
495
B
Figure 12.33 Vertebral osteomyelitis. A 78-year-old male on hemodialysis presented with back
pain, fevers, and progressive paraplegia, though incomplete. (A) Sagittal T1 gadolinium MRI demonstrating enhanced signal within T7 and part of T8 and an anterior epidural mass compressing the
cord. (B) Sagittal reconstruction CT scan shows advanced destruction of T7 and part of T8. Sclerotic
changes in the infected vertebrae are noted. (Reproduced with permission from Frymoyer JW, Wiesel
SW, An HS, et al. The Adult and Pediatric Spine, 3rd ed. Philadelphia: Lippincott Williams & Wilkins,
2003.)
496
As noted, we believe strongly in th e need for a bacteriologic diagn osis wh en ever possible, an d wh en m in im ally
in vasive tech n iques fail, we prefer defin itive surgical treatm en t as a m ean s of obtain in g tissue rath er th an a lim ited
open tech n ique.
The extent of bony destruction or deform ity leadin g to
the need for surgical treatm en t has not been clearly defin ed; it is importan t wh en evaluatin g th e patien t with a
possible n eurologic deficit to recogn ize th e exten t to wh ich
kyph osis can contribute to compression of th e spinal cord
an d cauda equin a. Progressive kyph osis with retropulsion
of disk or bon e will n ot respon d to bracin g or an tibiotics
an d sh ould be promptly recogn ized an d treated surgically.
Failure of m edical m anagem ent requires the correlation of
a n um ber of factors. In th e patien t with m in im al an terior
colum n destruction who is neurologically intact without
eviden ce of abscess form ation , we favor a m in im um of 4
weeks of antibiotic treatm ent alon g with rest and bracing.
At th at tim e, the absence of a significant decrease in the patien ts pain as well as th e absen ce of a sign ifican t declin e in
the ESR/ CRP would lead to consideration of either repeat
biopsy to en sure th at th e proper organ ism is bein g treated,
or defin itive surgical treatm en t.
The significance of the radiographic appearance of abscess form ation should be m entioned. The presence of a
soft-tissue m ass in th e paraspinal or epidural space is usually n ot, in our experien ce, eviden ce of pus un der pressure. Although frequently a large paraspinal or epidural
m ass is presen t in a patien t with sign ifican t destruction or
neurologic comprom ise, in the absen ce of these m ore con crete surgical indication s we typically prefer to undertake
nonoperative m anagem ent and closely follow the patien t.
Awaren ess of th e previously described risk factors for n eurologic in jury, in cludin g in creasin g age, im m un osuppression , an d involvem en t of th e cervical spin e facilitates appropriate decision m akin g in th is settin g.
Vertebral osteomyelitis is prim arily a disease of the anterior colum n , an d bein g such , it is axiom atic th at surgical treatm ent should approach this disease directly from
an an terior approach . Th e an terior approach to th e spin e
was pioneered by Hodgson for the treatm en t of tuberculous spon dylitis an d is still favored in th e vast m ajority of
cases. With the exception of lim ited posterior or posterolateral approach es for biopsy, th ere is little advan tage of
an isolated posterior approach as th orough debridem en t
is rarely possible an d lam in ectomy for decompression h as
been dem on strated to destabilize an in fected spin e.
The anterior approach lends itself ideally to th orough
surgical debridem en t, decompression of the spin e or cauda
equin a, an d stabilization of th e spin e. O n ce debridem en t
of th e in fection is carried out, an d bleedin g bon e above an d
below th e in volved area is seen , autogen ous strut graftin g
has been dem onstrated to be safe and effective. As an altern ative, in recen t years, th e use of titan ium surgical m esh
with autogenous bone graft has been used with success as
well, though long-term follow-up is lacking.
Anterior stabilization alone followed by casting or bracing is usually sufficient for single-level involvem ent in
wh ich th e kyph otic deform ity can be m ostly corrected. A
com bin ed approach with posterior stabilization is gen erally reserved for cases of m ultilevel disease or cases with
residual kyph osis of 20 degrees or greater. Th is m ost typically occurs in lon g-stan din g in fection s at th e th oracolum bar jun ction . Wh en posterior stabilization is un dertaken ,
m ost authors believe th at the risk of secondary in fection of
th e orth opedic im plan ts posteriorly is acceptable, an d th is
h as certainly been our experien ce.
Th e improvem en t in outcom es seen followin g m edical
and surgical m anagem ent of pyogenic vertebral osteomyelitis is striking. Nonoperative treatm en t is successful in the
m ajority of patients particularly in those that are not im m unocomprom ised, an d surgical treatm ent has a success
rate of over 90% to 95% in term s of obtain in g solid bony
fusion and pain relief. In short, m odern surgical and m edical techniques have alm ost completely elim inated the risk
of death , in th e absen ce of failure of oth er organ system s,
lead to predictably good rates of healing of the spine with
good relief of pain, and lead to predictable improvem en t
in neurologic function when impaired.
Epidural Abscess
Abscess form ation in the epidural space occurs alm ost exclusively in adults and, with increasing num bers of elderly
an d im m unosuppressed patients, appears to be in creasing in frequen cy. Although epidural abscess can occur secon dary to spread from a focus of vertebral osteomyelitis, a
distin ct en tity of epidural abscess arisin g from h em atogen ous spread from a rem ote source of in fection or from direct in oculation is also seen . It is importan t to distin guish
prim ary epidural abscess from a secon dary abscess associated with vertebral osteomyelitis; prim ary in fection of the
epidural space is n ot associated with destruction or in stability of th e spin e, is frequen tly seen posterior to th e cord
an d cauda equina, and therefore has significantly different
treatm ent implications. It is by all accounts a m edical an d
surgical em ergen cy.
A h igh in dex of suspicion is m an datory wh en approach ing the patient with a potential epidural abscess. The initial diagnosis is m issed in approxim ately 50% of cases, an d
there are various m odes of presentation . Therefore, one
m ust keep in m ind th e risk factors that are the sam e as
for pyogenic infection. Symptom s m ay be short lived, of
less th an 1 to 2 weeks duration, or chronic exten ding over
several m on th s. Th e m ost com m on findings with acute
epidural abscess are fever, back pain , an d localized ten dern ess, but on e or all of th ese m ay be absen t with a m ore
ch ronic presen tation. An om inous progression of the disease h as been described. Pain in th e m idlin e of th e back
or n eck persists for a variable period of tim e, followed by
radicular pain , possibly weakn ess, an d fin ally paraparesis
an d paralysis. The tim ing of this progression varies, and
497
498
A
Figure 12.34 Tuberculosis of the spine. (A) Sagittal T2 MRI scan demonstrates involvement of
upper thoracic vertebral body with soft-tissue mass extending anteriorly and posteriorly into the
spinal canal, causing cord compression. Note relative preservation of disks at this stage of disease,
which is frequently the case with tuberculous versus pyogenic spondylitis. (B) T1 axial MRI of same
patient shows extensive soft-tissue mass in the left foraminal and extraforaminal regions. (Reproduced
with permission from Frymoyer JW, Wiesel SW, An HS, et al. The Adult and Pediatric Spine, 3rd ed.
Philadelphia: Lippincott Williams & Wilkins, 2003.)
CONCLUSIONS
Disorders of th e spin e en com pass a wide spectrum from
m inor problem s such as neck strain to disabling conditions
such as severe degen erative spinal stenosis. Most conditions
can be treated successfully with conservative m anagem en t
followin g the algorithm s outlined in the article. The success of treatm ent revolves around a good doctorpatien t
499
RECOMMENDED READINGS
Cousin s JP, Haughton VM. Magnetic reson an ce im aging of the spine.
J Am Acad Orthop Surg. 2009;17:22 30.
Daniels AH, et al. Adverse events associated with anterior cervical spine
surgery. J Am Acad Orthop Surg. 2008;16:729 738.
Heck AH, et al. Ven ous th rom boem bolism in spine surgery. J Am Acad
Orthop Surg. 2008;16:656 664.
Reilly CW. Pediatric spin e traum a. J Bone Joint Surg. 2007;89:98 107.
Rih n JA, et al. Th e use of bon e m orph ogen ic protein in lum bar spin e
surgery. J Bone Joint Surg. 2008;90:2014 2025.
13
The Shoulder
Bren t B. W iesel
Gerald R. W illiam s
Th e prim ary purpose of th e sh oulder is to position th e upper extrem ity in space an d provide a stable platform for
hand and elbow function . It is also th e m ajor power generator of th e upper extrem ity. O ften th ough t of as a sin gle joint, it is m ore appropriately described as the shoulder
complex, con sistin g of m ultiple bon es, articulation s, an d
m uscleten don un its. Wh en all of th ese elem en ts are working correctly, the complex is able to obtain a rem arkable
ran ge of m otion (ROM) an d gen erate sign ifican t power.
Unfortunately, th e com plexity of th e in teraction m akes th e
sh oulder complex susceptible to a n um ber to traum atic
an d atraum atic conditions that can lead to dysfunction and
pain . Several of th ese con dition s h ave quite sim ilar presen tation s, an d a th orough un derstan din g of each disorder is
essen tial in m akin g th e correct diagn osis an d ren derin g effective treatm ent. This chapter reviews th e shoulders functional an atomy, outlines a basic approach to th e evaluation
of sh oulder problem s, an d describes th e evaluation an d
m anagem ent of several of th e com m on pathologic conditions affectin g the shoulder complex.
FUNCTIONAL ANATOMY
Th e sh oulder complex con sists of five articulation s working in synch rony to obtain a trem endous ROM. The prim ary articulation is th e glen ohum eral (GH) joint, in which
the round hum eral head articulates with the oval glen oid.
Th e rem ain in g articulation s are th e stern oclavicular (SC)
join t, th e acrom ioclavicular (AC) join t, th e scapuloth oracic articulation , an d th e subacrom ial space (Fig. 13.1).
Of these five articulations, on ly the GH, SC, and AC joints
are true diarth rodial joints with a joint capsule containing syn ovial fluid separating opposing articular surfaces.
Th e rem ain in g two articulation s are con tact areas between
two m obile surfaces with an intervening bursa to facilitate
m otion.
Wh en con siderin g m otion about th e sh oulder it is im portan t to realize th at alm ost any activity represen ts a com plex pattern of coordin ated m ovem en t at each of th e five
articulation s. For example, elevation of th e arm gen erally
consists of two-thirds m ovem ent at th e GH joint and onethird at th e scapulothoracic articulation, accompan ied by
rotation an d tran slation at th e SC an d AC join ts. Furth erm ore, wh en path ology affects on e of th e articulation s it
will often induce secondary path ology at the other articulation s. If m ovem en t at th e GH join t is lim ited by adh esive capsulitis, patien ts will often attempt to compensate
by increasing m otion at the scapulothoracic articulation ,
leadin g to fatigue in th e m uscles respon sible for scapular
m otion an d periscapular pain .
Osteology
Th e clavicle is an S-sh aped bon e th at serves as a strut to
m aintain th e norm al relationship of the shoulder girdle
to the body (Fig. 13.2). On the m edial side, the strut is
attached to the sternum and the first rib at the SC joint,
wh ereas on th e lateral en d, th e clavicle articulates with th e
acrom ion via the AC joint. Fractures of th e clavicle m ost
com m on ly occur th rough th e m idportion , wh ich is th e
th in n est an d n arrowest portion of th e bon e an d th erefore
m echan ically weakest.
Th e proxim al h um erus con sists of th e n early roun d
h um eral h ead, which is approxim ately on e th ird to one
h alf of a sph ere, an d th e greater an d lesser tuberosities
(Fig. 13.3). Th e jun ction between the articular surface and
th e tuberosities form s th e an atom ic n eck of th e h um erus,
wh ereas th e jun ction of th e tuberosities to th e sh aft is referred to as the surgical neck. The articular surface is angled
superiorly, with a neck sh aft an gle of 135 degrees (angle between th e hum eral shaft and a line drawn perpendicular to
th e an atom ic n eck) an d in 30 degrees of retroversion wh en
com pared to th e tran sepicon dylar axis of th e elbow. Th e
502
glenohumeral, (2) scapulothoracic, (3) acromioclavicular, (4) sternoclavicular, and (5) subacromial. (From Chapman MW, Szabo RM,
Marder RA, et al. Chapmans orthopaedic surgery. Philadelphia, Lippincott Williams & Wilkins, 2001, with permission.)
Spine of scapula
Supraspinous
fossa
Scapula
Acromion
Coracoid
process
Clavicle
Shaft
Acromial end
of clavicle
Acromioclavicular
joint
Sternal end
of clavicle
that serves as a strut to maintain the normal relationship of the shoulder girdle to the body. (From
Oatis CA. Kinesiology. The mechanics and pathomechanics of human movement. Baltimore: Lippincott Williams & Wilkins, 2003, with permission.)
503
Anatomic neck
Greater
tuberosity
Bicipital
groove
Lesser
tuberosity
135
30 retroversion
Figure 13.3 The proximal humerus consist of the humeral head and the greater and lesser tuberosities. The highest point of the humeral head is 510 mm above the top of the greater tuberosity. The
articular surface is angled superiorly 135 degrees and is in 30 degrees of retroversion when compared
to the transepicondylar axis of the elbow.
Glenohumeral Joint
Th e GH join t h as th e largest RO M of any join t in th e body.
Th is extrem e ROM com es at th e cost of stability, an d th e GH
Figure 13.4 The primary blood supply of the humeral head is the
504
Coracoid
Coracoid
Anterior
Posterior
Acromion
Glenoid fossa
Figure 13.5 Anterior and posterior view of the scapula demonstrating the multiple muscle attach-
ments as well as the glenoid, coracoid, and acromion. (From Iannotti JP, Williams GR. Disorders of
the Shoulder: Diagnosis and Management, 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2007,
with permission.)
TABLE 13.1
Acromioclavicular Joint
Th e AC join t con sists of a fibrocartilagin ous disk in terposed
between th e distal clavicle an d th e acrom ion . With agin g,
n atural degen eration of th is disk occurs, often leading to
arthritis of the AC joint. Fortunately, this arthritis is often
asymptom atic. Stability is provided by the join t capsule,
wh ich surroun ds th e join t circum feren tially. Th e superior
an d posterior aspects of the capsule are the m ost important
h orizon tal stabilizers of th e AC join t, wh ereas th e coracoclavicular (CC) ligam ents are the m ost importan t vertical
stabilizers. These ligam en ts run between the coracoid process and the distal clavicle and consist of the m edial conoid
an d lateral trapezoid ligam ent (Fig. 13.10).
Sternoclavicular Joint
Th e SC join t is th e m edial articulation between th e clavicle
an d the m an ubrium of the sternum . Th is joint is supported
505
Scapulothoracic Articulation
Th e an terior aspect of th e scapula is covered by th e subscapularis m uscles, wh ose an terior side articulates with
area of the glenoid socket, which improves stability of the glenohumeral joint. (From Iannotti JP, Williams GR. Disorders of the Shoulder: Diagnosis and Management, 2nd ed. Philadelphia: Lippincott
Williams & Wilkins, 2007, with permission.)
506
Biceps tendon
Superior glenohumeral
ligament
Posterior
capsule
An t e r io r
P o s t e r io r
Middle glenohumeral
ligament
Posterior
band
Anterior band
Axillary pouch
Inferior glenohumeral
ligament complex
Figure
13.9 Capsuloligamentous
anatomy
viewed from the side with the anterior aspect
to the right and the posterior aspect to the left.
The humeral head has been removed, leaving the
glenoid. The superior glenohumeral ligament and
middle glenohumeral ligament are labeled. The
inferior glenohumeral ligament complex consists of
an anterior band, posterior band, and interposed
axillary pouch. The posterior capsule is the area
above the posterior band. The biceps is also
labeled. (Adapted from OBrien SJ, Neves MC,
Arnoczky SP, et al. The anatomy and histology of
the inferior glenohumeral ligament complex of the
shoulder. Am J Sports Med 1990;18:449456, with
permission.)
Figure 13.10 The acromioclavicular joint is stabilized by the joint capsule and the coracoclavicular
ligaments, while the sternoclavicular joint is stabilized by the costoclavicular and sternoclavicular
ligaments. (From Iannotti JP, Williams GR. Disorders of the Shoulder: Diagnosis and Management,
2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2007, with permission.)
507
Subacromial Space
Th e subacrom ial space is located between th e superior aspect of th e superior rotator cuff ten don s an d th e in ferior
aspect of the acrom ion. With in th is space, the subacrom ial
bursa h elps to facilitate m otion between th e two opposin g
surfaces (Fig. 13.12). In flam m ation of this bursa, narrowing of the space, or degeneration of the rotator cuff ten don s
with in th e space is a com m on source of sh oulder pain , as
discussed in th e section on rotator path ology.
Figure 13.12 The subacromial bursa is between the rotator cuff and the overlying acromion.
When a full-thickness rotator cuff tear is present, this bursa communicates with the glenohumeral
joint. (From Agur AMR, Dalley AF. Grants Atlas of Anatomy, 11th ed. Philadelphia: Lippincott Williams
& Wilkins, 2005.)
508
Figure 13.13 The four rotator cuff muscles originate on the scapula and insert on the greater and
lesser tuberosities of the proximal humerus. The long head of the biceps tendon runs in a groove
between the two tuberosities. (From Agur AMR. Grants Atlas of Anatomy, 9th ed. Philadelphia:
Williams and Wilkins, 1991.)
509
Figure 13.14 A: Contraction of the anterior and posterior rotator cuff muscles provides a com-
pressive force that keeps the humeral head centered in the glenoid during rotation of the arm. B:
During elevation of the arm, the inferior and medially directed force generated by the rotator cuff
keeps the humeral head centered in the glenoid and allows the force generated by the deltoid
to rotate humeral head. (From Iannotti JP, Williams GR. Disorders of the Shoulder: Diagnosis and
Management, 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2007.)
in depressin g th e h um eral h ead, especially wh en a deficiency of the rotator cuff is presen t. Others believe that
its fun ction al purpose is in con sequen tial an d th at it is a
significant source of pain. The tendon originates from th e
supraglen oid tubercule an d superior glenoid labrum and
runs laterally through the GH joint to exit out the bicipital groove (Figs. 13.9 an d 13.13). Tears of th e subscapularis m uscles are often associated with m edial in stability of
the LHBT. Given its close anatom ic proxim ity, pathology
of th e supraspin atus is often associated with ten din osis of
the LHBT within the GH joint.
Glenohumeral Movers
Th e prim ary m uscles respon sible for gen eratin g m otion
and power about the GH joint are the deltoid, pectoralis
m ajor, latissim us dorsi, and teres m ajor (Fig. 13.15). The
deltoid is th e largest m uscle of th e sh oulder girdle, with an
anterior head arising from the m id to lateral clavicle, a m iddle h ead arisin g from th e lateral acrom ion , an d a posterior
h ead that arises from th e scapular spin e. All th ree h eads
coalesce to in sert on th e deltoid tuberosity of th e proxim al
h um erus. Inn ervation is via th e axillary n erve, wh ich passes
posteriorly th rough th e quadran gular space an d th en wraps
back aroun d th e arm an teriorly on th e deep surface of th e
deltoid m uscle (Fig. 13.16). The n erve travels 5 cm below
th e tip of th e lateral acrom ion as it passes in an an terior
direction from th e m iddle to th e an terior deltoid. Wh en
splittin g the deltoid between th e anterior an d lateral heads
to access the rotator cuff, it is important that the split does
n ot exten d greater th an 5 cm below th e lateral acrom ion in
order to avoid in jurin g th e n erve an d dein n ervatin g th e an terior deltoid. Th e prim ary action of th e deltoid is elevation
510
B
Figure 13.15 Anterior (A) and posterior (B) views of the primary movers of the glenohumeral joint,
which are the deltoid, pectoralis major, latissimus dorsi, and teres major. (From Moore KL. Clinically
Oriented Anatomy, 3rd ed. Baltimore: Williams & Wilkins, 1992, with permission.)
511
Figure 13.16 The axillary nerve passes posteriorly through the quadrangular space and then
wraps back around the humerus anteriorly on the undersurface of the deltoid muscle. (From Moore
KL. Clinically Oriented Anatomy, 3rd ed. Baltimore: Williams & Wilkins, 1992, with permission.)
Scapular Movers
In everyday life, th e m ajority of m ovem en ts about th e
sh oulder complex consist of composite m otion at both th e
GH an d scapuloth oracic articulation . Because th e scapulas
on ly bon ey articulation with th e axial skeleton is via th e
AC joint, a group of large m uscles is required not only to
m ove the scapula but to stabilize it on the posterior aspect
of th e th orax. Th e m uscles respon sible for scapular m ovem en t an d stability include the trapezius, levator scapulae,
rh om boids, an d serratus an terior (Fig. 13.17).
512
Trapezius
(upper
portion)
Rhomboid
minor
Rhomboid
major
Trapezius
(lower
portion)
Serratus
anterior
Latissimus
dorsi
Figure 13.17 The scapular rotators. A: The trapezius and serratus anterior are the primary upward rotators of the scapula. B: The rhomboids, levator scapula, and latissimus dorsi are responsible
for downward rotation. (From Iannotti JP, Williams GR. Disorders of the Shoulder: Diagnosis and
Management, 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2007, with permission.)
Neurovascular Structures
Although the blood supply to th e proxim al hum erus
an d in n ervation of th e various m uscles surroun din g th e
sh oulder h as been previously discussed, it is extrem ely im portan t to keep in m in d th e close proxim ity of th e m ajor n eurovascular structures of th e upper extrem ity to th e
sh oulder girdle. Th e axillary artery and vein, surrounded
by the brachial plexus, typically lie m edially and distally
to th e coracoid process (Fig. 13.19). Dam age to th ese vital
structures followin g traum atic injuries to the shoulder region is uncom m on but certainly can occur. Missing such
dam age, especially wh en it in volves th e vasculature, can
h ave catastroph ic con sequen ces.
History
Figure 13.18 Weakness of the serratus anterior or trapezius
muscles can lead to scapular winging. (From Krishnan SG, Hawkins
RJ, Warren RF. The Shoulder and the Overhead Athlete. Philadelphia: Lippincott Williams & Wilkins, 2004, with permission.)
For all patien ts presen tin g with upper extrem ity com plain ts,
the history should begin with their age, dom inant hand,
an d occupation. Age is particularly importan t when evaluatin g sh oulder problem s, because m any of th e com m on pathologies affecting the shoulder have a m arked
513
Figure 13.19 The axillary vessels and brachial plexus lie medial and distal to the coracoid process.
(From Chapman MW, Szabo RM, Marder RA, et al. Chapmans Orthopaedic Surgery. Philadelphia:
Lippincott Williams & Wilkins, 2001, with permission.)
514
Physical Examination
Th e physical exam in ation of th e sh oulder in volves th e sam e
basic elem en ts as exam in ation of th e oth er join ts in th e
m usculoskeletal system in cludin g in spection , palpation ,
ROM, stren gth testin g, an d n eurovascular exam in ation . Addition ally, several special tests are useful in th e evaluation of
specific pathologic con ditions (Table 13.2). Each of th ese
tests n eed n ot be perform ed on every patien t. In stead, on ly
those m an euvers related to suspected pathology, as determ in ed by th e h istory an d basic elem en ts of th e physical
exam in ation , sh ould be perform ed. Th is section describes
the basic elem en ts of the physical exam ination; the specific
tests are described in th e physical exam in ation section s of
the conditions that th ey evaluate.
TABLE 13.2
Condition Examined
Impingement
Impingement
Rotator cuff weakness, impingement
Infraspinatus weakness
Infraspinatus and teres minor weakness
Subscapularis weakness
Subscapularis weakness
Glenohumeral instability
Glenohumeral instability
Glenohumeral laxity
Inferior glenohumeral laxity
SLAP tear
SLAP tear
Inspection
Th e patien t m ust be appropriately gown ed to allow in spection of both shoulders and the neck. Exam ination
begin s with in spection of th e sh oulders for asym m etry,
m asses, swelling, erythem a, ecchym oses, and m uscle atrophy. Th e location an d con dition of any previous surgical in cisions should be noted. As with all elem ents of the shoulder exam in ation , com parison of th e two sides is essen tial.
Ecchym oses m ay be presen t in a n um ber of traum atic
sh oulder con dition s in cluding fractures, dislocations, m uscle ruptures, and large, acute rotator cuff tears. Prom inence
of th e distal clavicle at th e AC join t is a com m on fin din g
after AC separation or osteophyte form ation with AC arthritis. Atrophy of the m uscles about the shoulder can occur
with disuse secon dary to pain , ten don rupture, or following de-innervation . When longstandin g rotator cuff tears
lead to m uscle atrophy, hollowing often occurs over the
supraspinatus an d in fraspinatus fossa. Atrophy of the deltoid m uscle, especially followin g traum atic in jury or previous surgery, sh ould raise con cern for in jury to th e axillary
n erve.
In spection of th e position of th e scapula on th e posterior
ch est wall is important. Winging of the scapula can indicate
weakn ess of th e serratus an terior or trapezius (Fig. 13.18).
Wh ile viewed posteriorly, th e patien t sh ould be asked to
raise both h an ds overh ead wh ile th e exam in er in spects
for scapulothoracic rhythm , which sh ould be sm ooth and
sym m etric. Abn orm alities can be due to scapulothoracic
bursitis or scapular win gin g. Th ey m ay also be secon dary
as th e patient attempts to compensate for stiffness or pain
in other aspects of th e shoulder complex.
Palpation
Palpation begins m edially at the SC join ts and contin ues
laterally alon g the clavicle, AC joint, coracoid, acrom ion,
an d scapular spine. Patients with SC or AC joint pathology
will gen erally be ten der directly over th ose join ts. Th e in sertion of th e rotator cuff tendons on the greater tuberosity can be palpated through th e deltoid m uscle lateral to
the acrom ion and is often tender in patients with impingem en t or rotator cuff tears. Tenderness to palpation over
the trapezius is often seen with cervical spin e pathology or
with m uscle spasm durin g scapuloth oracic compen sation
for GH abn orm alities.
Range of Motion
In th e traum atized or obviously fractured or dislocated
sh oulder, ROM assessm ent should be con sidered only after
515
Figure 13.21 External rotation with the arm at the side is as-
sessed by asking the patient to place her elbow at the side of the
body and flex it 90 degrees. The patient is then asked to externally
rotate the forearm while maintaining the elbow at her side.
Figure 13.20 Forward elevation is assessed by asking the patient to raise her hands directly overhead.
to put her hand behind her back and touch as high as possible. The
relationship of the thumb to the spinous processes of the vertebral
bodies is used as a reference for measurement. This patient has
internal rotation to the T5 level.
516
Figure 13.23 AC: For rotation with the arm at 90 degrees of ab-
Strength Testing
Stren gth testin g about th e sh oulder focuses on evaluation
of th e rotator cuff. Th e supraspin atus is best evaluated by
testin g resisted abduction in th e plan e of th e scapula of th e
exten ded, in tern ally rotated arm . Th is is kn own as th e Jobe
test or th e empty can sign . Th e patien t is asked to resist
down ward pressure from th e exam in er with th e sh oulder
abducted 90 degrees, th e elbow exten ded, an d th e th um b
poin tin g down ward toward th e floor (Fig. 13.24). Weakness with this m aneuver can be indicative of supraspin atus
dysfun ction , alth ough it can be difficult to distin guish true
weakness from weakness secondary to pain. Furth erm ore,
som e patients with full-thickness tears of the supraspin atus ten don will exh ibit m in im al stren gth deficits with th is
test.
The posterior rotator cuff m uscles (infraspin atus an d
teres m in or) are evaluated by testin g extern al rotation
stren gth of the arm with th e elbow at the side (Fig. 13.25).
Sign ifican t weakn ess in extern al rotation sh ould be evaluated with lag sign s. With th e elbow flexed 90 degrees an d at
517
Neurovascular Assessment
Th e m ajority of th e n eurologic exam in ation h as already
been com pleted by evaluation of th e stren gth of th e m uscles about th e sh oulder. Motor fun ction of th e rem ain in g
m ajor nerves to the arm can be tested by resisted elbow
flexion (m usculocutan eous), elbow exten sion (radial), finger flexion (m edian ), fin ger abduction (uln ar), an d th um b
abduction (posterior interosseous). Sensation is evaluated
by assessing ligh t touch over th e lateral deltoid (axillary),
B
Figure 13.26 A lag between maximal passive and active external rotation with the arm at the side
constitutes a positive external rotation lag signs and is associated with infraspinatus weakness. (From
Iannotti JP, Williams GR. Disorders of the Shoulder: Diagnosis and Management, 2nd ed. Philadelphia:
Lippincott Williams & Wilkins, 2007, with permission.)
518
B
Figure 13.27 An inability to keep the arm in maximal external rotation at 90 degrees of abduction
constitutes a positive Hornblower sign and is associated with weakness of the infraspinatus and teres
minor. (From Iannotti JP, Williams GR. Disorders of the Shoulder: Diagnosis and Management, 2nd
ed. Philadelphia: Lippincott Williams & Wilkins, 2007, with permission.)
lateral forearm (m usculocutan eous), th um b web space (radial), radial aspect of th e in dex fin ger (m edian ), an d lateral
aspect of th e little fin ger (uln ar). For patien ts with suspected n eurologic path ology, a m ore detailed n eurologic
exam in cludin g reflex evaluation is n ecessary. Vascular in tegrity sh ould be evaluated by palpatin g th e radial pulse
an d m easurin g th e capillary refill tim e for th e fin gers.
Imaging
Multiple im agin g m odalities are available for th e evaluation of disorders of th e sh oulder com plex. A stan dard set
of plain radiograph s sh ould be obtain ed in all patien ts presen ting with shoulder complain ts. Addition al views and
m ore advan ced im agin g tech n iques are th en ordered based
Radiographs
Th e stan dard radiograph ic exam in ation of th e sh oulder in cludes th e anteriorposterior (AP), scapular Y, an d axillary
lateral views. To evaluate the GH joint, it is important to
obtain a true AP view of th e sh oulder, n ot of th e ch est.
Because th e scapula is an gled an teriorly on th e th orax, the
x-ray beam m ust an gled 30 to 45 degrees laterally, so th at
the beam is perpendicular to the GH joint (Figs. 13.30 32).
Th e Zan ca view, described below un der th e evaluation of
AC sprains, is used to evaluate the AC joint. A variety of
Figure 13.29 A patient with subscapularis weakness will be unFigure 13.28 The lift-off test is used to evaluated subscapularis
strength. (From Krishnan SG, Hawkins RJ, Warren RF. The Shoulder and the Overhead Athlete. Philadelphia: Lippincott Williams &
Wilkins, 2004, with permission.)
able to keep his elbow in front of the plane of the body when asked
to press down on his belly. This patients elbow remains forward
on the normal left side, whereas on the right side, the elbow falls
posterior making the belly-press test positive. (From Krishnan SG,
Hawkins RJ, Warren RF. The Shoulder and the Overhead Athlete.
Philadelphia: Lippincott Williams & Wilkins, 2004, with permission.)
519
45
B
Figure 13.30 A: The true anteriorposterior (AP) view of the glenohumeral joint is obtained by
angling the beam 30 to 45 degrees from the sagittal plane. B: The true AP shows the glenohumeral
joint without overlap of the proximal humerus on the glenoid, as occurs on an AP of the chest. (From
(A) Buholz RW, Heckman JD, Court-Brown CM. Rockwood and Greens Fractures in Adults, 6th ed.
Philadelphia: Lippincott Williams & Wilkins, 2006; and (B) Iannotti JP, Williams GR. Disorders of the
Shoulder: Diagnosis and Management, 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2007, with
permission.)
Ultrasound
Ultrasoun d evaluation is rapidly gain in g popularity for th e
evaluation of soft tissue path ology about th e sh oulder, especially disorders of th e rotator cuff. Compared to MRI
scan s, ultrasound h as th e advantage of being quicker, less
expen sive, an d better tolerated by patien ts, an d it allows
for dynam ic as well as static exam ination s. O n the downside, th e accuracy is highly operator-dependent an d associated m uscle atrophy an d in tra-articular path ology is n ot
well visualized. For th ese reason s, MRI rem ain s th e im agin g
520
Arthrography
Arthrography involves th e in jection of radiopaque con trast
m aterial into the GH join t followed by radiographic evaluation of the shoulder to determ ine the distribution pattern
of th e dye. In patien ts with full-th ickn ess tears of th e rotator
cuff, the dye will leak through the cuff defect into the subacrom ial space. Although extrem ely accurate in th e detection of full-thickn ess rotator cuff tears, the use of arthrography h as been supplan ted by MRI an d ultrasoun d exam in ation due to their less in vasive n ature an d ability to better
detect partial-th ickn ess cuff tears an d ten don itis. Th is study
is now reserved for patients un able to undergo an MRI scan
in locations where ultrasound is not available.
Clavicle Fractures
Th e clavicle is th e m ost frequen tly fractured bon e in th e
sh oulder com plex. Alth ough the m ajority of these fractures
h eal un eventfully with n on operative treatm en t, recent eviden ce suggests th at th e in ciden ce of n on un ion an d th e disability associated with m alunion is m ore significant than
was previously thought.
Classification
Fractures are classified accordin g to th eir an atom ic location into m edial, m iddle, and lateral thirds. The m ajority
of fractures (80%) occur in th e m iddle th ird, wh ere th e
bon e is biom ech an ically weakest an d less soft tissue protection is presen t. Fractures of th e lateral th ird are furth er
divided accordin g to th e relation sh ip of th e fracture pattern
to th e CC ligam en ts an d th e AC join t (Fig. 13.33). Medial
fractures are m uch less com m on, accountin g for only 5%
of all clavicle fractures.
Mechanism of Injury
Th e m ost com m on cause of clavicle fractures is a fall on th e
involved shoulder. Direct impact to th e clavicle and a fall on
an outstretch ed hand are other, less com m on, m echanism s
of in jury.
B
Figure 13.31 A: The Y view is obtained by shooting the x-ray
beam parallel to the scapular spine. B: This view visualizes the shape
of the acromion and the subacromial space. (From (A) Buholz RW,
Heckman JD, Court-Brown CM. Rockwood and Greens Fractures
in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006,
with permission.)
Presentation
Patients usually presen t with localized pain, swelling, and
deform ity over th e clavicle followin g a traum atic in jury.
Th e affected arm is often adducted across th e body an d
supported by th e opposite hand in an effort to decrease
the deform ing forces across the fracture site.
Physical Findings
Visible deform ity and ecchym osis at the fracture site are
com m on. Th e m edial fragm ent can tent the skin, occasion ally leadin g to a com plete puncture an d an open fracture. It is important to look for, and docum ent, any open
woun ds, as th eir presen ce could h ave a sign ifican t im pact
on treatm en t. A th orough n eurovascular exam in ation is
521
B
Figure 13.32 A: The axillary lateral is obtained by aiming the x-ray beam into the axilla with the
plate on the superior shoulder. B: The axillary view demonstrates the relation of the humeral head
to the glenoid articular surface in the anterior and posterior plane. (From (A) Buholz RW, Heckman
JD, Court-Brown CM. Rockwood and Greens Fractures in Adults, 6th ed. Philadelphia: Lippincott
Williams & Wilkins, 2006; and (B) Iannotti JP, Williams GR. Disorders of the Shoulder: Diagnosis and
Management, 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2007, with permission.)
necessary, especially in patients with a high-en ergy m ech anism of in jury. Th e brachial plexus and axillary artery lie in
close proxim ity to the inferior surface of the bone and are
vulnerable to injury, especially with fractures of the m edial
third. The ch est should be auscultated for bilateral breath
sounds to rule out a pneum othorax.
Radiographic Evaluation
Two views of th e clavicle are n eeded. For m edial clavicle
fractures, an AP and an AP with 40 degrees of ceph alic tilt
are used. Lateral fractures are better evaluated with an AP,
a Zanca view (Fig. 13.34), an d an axillary lateral of the
sh oulder.
Figure 13.33 Fractures of the distal clavicle are divided into three types. Type I fractures are
lateral to the cricoclavicular (CC) ligaments. Type II fractures are medial to the CC ligaments or lead
to rupture of the ligaments from the medial clavicle. Type III fractures are lateral to the CC ligaments
with extension into the acromioclavicular joint. (From Chapman MW, Szabo RM, Marder RA, et al.
Chapmans Orthopaedic Surgery. Philadelphia: Lippincott Williams & Wilkins, 2001, with permission.)
522
10
X-ray
A
Figure 13.34 A: The Zanca view is obtained by shooting an anterior-posterior view with 10 de-
grees of cephalic tilt and half of the normal kV. B: The view provides excellent visualization of the
acromioclavicular joint and the cricoclavicular space. (From (A) Rockwood CA, Young DC. Disorders
of the acromioclavicular joint. In: Rockwood CA, Matsen F III, eds. The Shoulder. Philadelphia: WB
Saunders, 1990; and (B) Buholz RW, Heckman JD, Court-Brown CM. Rockwood and Greens Fractures
in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006, with permission.)
Special Tests
Special tests are rarely n eeded. If th ere is difficulty un derstanding the fracture pattern , CT scan can be helpful. Th is
is especially true for m edial th ird fractures. If, based on th e
physical exam in ation , th ere is con cern for vascular in jury,
an arteriogram is n eeded. For patien ts with a n eurologic
deficit, an electromyograph (EMG) is useful for diagn ostic
an d progn ostic purposes but n ot un til 3 to 4 weeks after
the in jury.
Differential Diagnosis
Clavicle fractures m ust be differen tiated from oth er traum atic in juries about th e sh oulder. Th is is easily accom plish ed by physical exam in ation an d radiograph . Wh en
evaluatin g in juries about th e AC an d SC join ts in youn ger
patien ts, it is im portan t to rem em ber th at th e m edial an d
lateral physes often do n ot fuse un til th e late teen s or early
twen ties. Suspected AC an d SC dislocation s in th is patien t
population are often Salter Harris type I fractures of th e
clavicle through th e physis. A CT scan is helpful in m aking
this distinction.
Treatment
Historically, alm ost all m idshaft clavicle fractures were
treated n on operatively an d th ough t to h eal with a very low
incidence of nonunion an d residual disability. Nonoperative m anagem ent consists of sling im m obilization for 4 to
6 weeks, followed by a gradual return to activity. Stiffn ess of
th e sh oulder is gen erally n ot a problem because th e in jury
does n ot in volve th e GH join t. Several recen t studies h ave
dem on strated th at, in adults, th e in ciden ce of n on un ion
following displaced or com m in uted fractures of the m iddle th ird m ay be as h igh as 20%. Furth erm ore, patien ts wh o
h eal with m ore than 1.5 to 2 cm of sh orten in g often have
som e residual loss of sh oulder function. These studies have
led to an increased interest in operative fixation, either with
plates an d screws or in tram edullary pin s, for fractures with
greater th at 100% displacem en t, com m in ution , or greater
th an 2 cm of sh orten in g (Fig. 13.35). Th e absolute in dications for operative m anagem ent of m iddle-third fractures
con tin ue to be open fractures, fractures associated with
a n eurovascular in jury, an d fractures in polytraum a patients who need rapid use of the upper extrem ity for weight
bearin g.
For lateral clavicle fractures, types I an d III are stabilized by the in tact CC ligam ents, so th ey are generally
treated nonoperatively. If symptom s persist, they can be
treated with excision of the distal clavicle. Because th e CC
ligam ents are either disrupted or attached to the lateral
piece, type II factures are in h eren tly un stable an d associated
523
B
Figure 13.35 A: A comminuted fracture of the middle third of the clavicle. Recent evidence
suggests that this type of fracture is more prone to nonunion than previously thought. B: The fracture
was treated with open reduction and internal fixation using a plate and screws. (From Buholz RW,
Heckman JD, Court-Brown CM. Rockwood and Greens Fractures in Adults, 6th ed. Philadelphia:
Lippincott Williams & Wilkins, 2006, with permission.)
Classification
Th e m ost useful an d com m on ly used classification of
proxim al h um erus fractures is th e Neer classification (Fig.
13.36). The sch em e is based upon dividing th e proxim al
hum erus into four segm en ts, as described by Codm an (Fig.
13.37). In order for a segm en t to be con sidered a fracture
part, it m ust be displaced at least 1 cm or an gulated 45 degrees. Fractures are th en described based on th e n um ber
of parts. In a on e-part fracture, n on e of th e com pon en ts
is sufficiently displaced to qualify as a part, regardless
of th e n um ber of fracture lin es. Two-part fractures in volve displacem ent of either the articular surface (th rough
the an atom ic neck), the entire head (through the surgical neck), the greater tuberosity, or th e lesser tuberosity.
In th ree-part fractures, th ere is displacem en t of eith er th e
lesser or greater tuberosity, as well as the head through the
surgical neck. Four-part fractures in volved displacem en t of
Mechanism of Injury
In th e elderly, th e m ajority of proxim al h um erus fractures are the result of falls onto an outstretched h and.
Youn ger patien ts are m ore frequen tly th e victim s of sign ifican t traum a, such as a m otor veh icle collision or a fall
from a sign ifican t height.
Presentation
Th e typical presen tation is th at of pain , swellin g, an d sh oulder deform ity followin g a traum atic in jury. Th e patien t typically holds th e arm at th e side and complains of sign ifican t
pain with any m ovem en t of th e sh oulder. If th e fracture is
m ore than 6 to 12 h ours old, ecchym oses extending from
th e axilla to below th e elbow an d swellin g of th e extrem ity
all the way to the h and is not uncom m on.
Physical Examination
As with all fractures, it is im portan t to m ake sure th at th e
overlyin g skin is in tact, alth ough open fractures of th e proxim al h um erus are rare. Given the close proxim ity of the
524
Radiographic Examination
Radiograph ic evaluation m ust in clude an AP view of th e
GH join t, a scapular Y view, an d an axillary lateral view.
Th e axillary view is especially importan t in evaluatin g for
the presence of a dislocation of the GH joint.
Figure 13.37 The Neer classification is based on dividing the
Special Tests
Even experien ced clin ician s can h ave difficulty describing th e exact fracture pattern based on plain radiographs.
In m ost displaced fractures, CT scan s are useful to better
525
B
Figure 13.38 A: Anterior-posterior radiograph demonstrating a three-part fracture of the proxi-
mal humerus. The fracture lines separate the greater tuberosity, humeral shaft, and head fragment.
The lesser tuberosity remains attached to the head fragment. B: Open reduction and internal fixation
was obtained using a plate and screws. (From Chapman MW, Szabo RM, Marder RA, et al. Chapmans
Orthopaedic Surgery. Philadelphia: Lippincott Williams & Wilkins, 2001, with permission.)
visualize and understand the injury pattern and aid in treatm en t decision m aking. For patients with neurologic deficits
or th ose with an un expectedly prolon ged recovery, n eurodiagn ostic testin g is valuable in detectin g an d classifyin g
neurologic injury.
Differential Diagnosis
Th e differen tial diagn osis in cludes oth er traum atic in juries to th e sh oulder region . In th e patien t wh o presen ts
with con siderable sh oulder pain followin g a fall, but h as
negative radiograph s, con sideration sh ould be given to a
nondisplaced proxim al hum eral fracture or acute rotator
cuff tear. Both entities can be seen on an MRI scan.
Treatment
Greater th an 70% of proxim al h um erus fractures are
nondisplaced and do well with nonoperative treatm en t
con sisting of 4 to 6 weeks of im m obilization in a sling.
Given th e in tra-articular n ature of th e in jury, stiffn ess is a
significant concern. If the fracture pieces m ove as a sin gle
un it with m otion of th e arm , th e patien t is asked to rem ove
his sling several tim es a day and perform gen tle pen dulum
exercises. Un stable fractures sh ould be reevaluated weekly
an d started on m otion exercises as soon as the pieces m ove
as a unit.
Two-part and som e three-part fractures with out significant displacem en t, especially in elderly patien ts, can
be treated n on operatively, as described earlier. For fractures with sign ifican t displacem en t, especially in youn ger,
h igher-dem an d patien ts, operative fixation usin g a variety
of fixation tech n iques is preferred. Alth ough several tech n iques h ave been described, th e goal of surgery is always
to ach ieve an an atom ic reduction with en ough stability to
perm it early m otion (Fig. 13.38).
In four-part fractures, avascular n ecrosis is a particular
concern because the fragm ent containing the articular surface is generally separated from its soft tissue attachm ents
an d blood supply. In youn ger patien ts, attempts at ORIF
sh ould be m ade wh en possible, wh ereas older individuals are gen erally treated with h em iarth roplasty. Alth ough
h em iarthroplasty for th e treatm en t of proxim al hum erus
fractures is often effective in relieving patients pain, function al results are h igh ly variable, with a sign ifican t n um ber
of patien ts failin g to ach ieve m ore th an 90 degrees of forward elevation .
526
Classification
Sprain s of th e AC join t are classified based on th e degree
of ligam en t disruption an d th e am oun t an d direction of
clavicular displacem ent, as described by Rockwood (Fig.
13.39). Type I in juries are a sprain of th e AC ligam en t with
no displacem ent of the joint. In type II injuries, the AC
ligam ents are torn and th ere is a sprain of the CC ligam ents.
Type III sprain s in volve disruption of both th e AC an d CC
ligam ents, with up to 100% superior displacem ent of the
distal clavicle from th e acrom ial join t surface. Separation
types IV through VI involve complete disruption of the AC
and CC ligam ents and wide displacem ent of the clavicle.
Type II
Type I
Type IV
Type III
Conjoined tendon of
biceps and coracobrachialis
Type V
Type VI
Figure 13.39 A: The Rockwood classification of injuries to the acromioclavicular joint (see text for
detail explanation). (From Bucholz RW, Heckman JD, Court-Brown C, et al. Rockwood and Greens
Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006, with permission.)
527
Radiographic Examination
An AP view an d axillary lateral are n eeded for evaluation of
AC joint traum a. The Zanca view is preferred over a standard
AP radiograph . Th is view is obtain ed by an glin g th e x-ray
beam 10 degrees toward th e h ead an d decreasin g th e kV by
h alf in order to better visualize th e AC join t (Fig. 13.34).
Alth ough th is view will dem on strate step-off at th e AC join t,
th e degree of superior displacem en t of th e distal clavicle
can best be described by comparin g th e CC distan ce in
each sh oulder. In type III sprain s, th is distan ce is typically
increased 25% to 100%, whereas in type V injuries it is
increased 100% to 300%. The axillary view is important
for rulin g out an associated GH dislocation an d posterior
displacem en t of th e clavicle, as seen in type IV in juries.
Mechanism of Injury
Acrom ioclavicular injury is the result of direct traum a to
the lateral aspect of shoulder. Most com m on ly, this occurs
as a fall onto the tip of the shoulder during a sporting activity (Fig. 13.40). The traum atic load applies an in feriorly
directed force on th e acrom ion relative to th e clavicle. Depen din g on th e degree of th e force, th ere is progressive
disruption first of th e AC ligam en ts an d th en of th e CC
ligam ents.
Presentation
Patients with acute AC sprains present with pain localized
to th e AC join t followin g direct traum a to th e sh oulder.
Occasion ally, these patients will present in a delayed m anner, in which case they m ay have m ilder symptom s over the
AC joints accompanied by fatigue and cramping around the
sh oulder and scapula worsened by overh ead activity.
Physical Examination
Patients with AC joint injuries will typically have pain an d
ten dern ess directly over th e AC join t. With in creased severity of injury, there will also be in creased step-off and deform ity across the joint. Although pain is often present with
active m otion of the shoulder, especially with higher-grade
Special Tests
No special tests are n ecessary for th e evaluation of AC in juries. If th ere is question as to th e degree of separation ,
stress views can be obtained by takin g Zanca views of each
sh oulder with 5 to 10 pounds of weight suspended from
each wrist. In type II separation s, th e CC distan ce sh ould rem ain unchan ged, whereas type III sprains will dem on strate
an increase in the distance from the additional stress caused
by the weights. Clinically, stress views are rarely needed because if a type III separation is n ot apparen t on stan dard
radiograph s, it is likely to respon d well to con servative treatm ent.
Differential Diagnosis
Acrom ioclavicular join t sprain s m ust be distin guish ed from
distal clavicle fractures, wh ich can be accom plish ed with
radiograph s. Degen erative con dition s of th e distal clavicle,
such as AC join t arth ritis and distal clavicle osteolysis, can
also cause pain over the AC joint. These conditions have a
m ore insidious onset and lack both the characteristic isolated traum atic even t to the lateral shoulder, as well as an
increase in the CC distance on plain film .
Treatment
Th e in itial treatm en t for all AC join t in juries is supportive care with the use of a slin g, ice, and nonsteroidal antiinflam m atory drugs (NSAIDs). Type I an d II injuries are
treated conservatively, with a gradual return to activity as
sym ptom s decrease. Ath letes with type I injuries will generally be able to return to th eir sport with in a few days,
wh ereas type II in juries often require several weeks before
a substantial improvem ent in symptom s occurs.
Th e treatm en t for type III in juries is con troversial. Th e
m ajority of patien ts do well with conservative treatm en t. It
is important to advise patients that the step-off across the
528
Glenohumeral Instability
As previously m ention ed, the shoulder h as the largest ROM
of any join t in th e body. Un fortun ately, th is m obility com es
at th e expen se of stability: Th e GH join t is also th e m ost frequen tly dislocated m ajor join t. Wh en discussin g in stability
of th e GH join t, it is importan t to keep th e defin ition of
four key term s in m in d. Laxity is asymptom atic tran slation
of th e h um eral h ead on th e glen oid. Laxity is required for
norm al GH m otion, h as a large variation between individuals, an d ten ds to decrease with in creasin g age. Instability is a
path ologic con dition ch aracterized by pain associated with
excessive tran slation of th e h um eral h ead on th e glen oid.
If th e in stability leads to complete separation of th e articular surfaces, it is referred to as a dislocation. Typically, a
reduction m an euver perform ed by th e patien t or an oth er
in dividual is required to restore th e alignm en t of th e joint.
Wh en th e in creased tran slation of th e h um eral h ead results in partial separation of the articular surfaces, and th e
GH relation sh ip spon tan eously return s to n orm al followin g rem oval of th e deform ing force, the even t is term ed a
subluxation.
Classification
Several factors m ust be con sidered wh en classifyin g GH
in stability, th e m ost importan t of wh ich is presen ce of a
traum atic even t leadin g to th e in itial episode of in stability. Th om as an d Matsen divided GH in stability in to two
broad categories with th e m n em on ics TUBS an d AMBRI.
Traumatic unidirectional Bankart surgery (TUBS) refers to th e
fact th at traum atic in stability of th e sh oulder is gen erally
un idirection al, associated with a Ban kart lesion s (see th e
section Mechanism of Injury), an d respon ds well to surgical treatm ent. Atraumatic multidirectional bilateral rehabilitation inferior capsular shift (AMBRI) describes atraum atic
in stability th at ten ds to occur bilaterally an d respon ds to
reh abilitation , or if th at fails, an in ferior capsular sh ift.
Although these m n em onics oversimplify this complex con-
TABLE 13.3
529
Mechanism of Injury
A traum atic blow to a m axim ally abducted, externally rotated arm is th e m ost com m on m ech an ism of in jury for an
acute anterior shoulder dislocation. With the arm in this
provocative position , GH stability is provided prim arily by
the anterior ban d of th e in ferior glenohum eral ligam ent
(AIGHL). Further external rotation of th e arm , an anterior
directed force applied to th e posterior sh oulder, or a posterior force directed toward th e h an d or elbow levers th e
hum eral head away from the glenoid an d results in an an terior dislocation . Th ese in juries frequen tly occur durin g a
wide variety of ath letic activities an d are m ore com m on in
m ales than fem ales.
Th e an terior dislocation of th e h um eral h ead results
in the disruption of th e anterior stabilizin g structures, especially th e AIGHL an d an terior in ferior glen oid labrum .
Th is was classically described as an avulsion of th ese structures from the anterior inferior glenoid rim and term ed
the Bankart lesion (Fig. 13.41). It is n ow clear th at th ese
restrain in g structures can fail anywh ere alon g th eir len gth ,
in cluding at th e glenoid rim (Bankart lesion), as a m idsubstance rupture or stretch, an d at their hum eral attachm en t
(referred to as a hum eral avulsion of the glenohum eral ligam en t or HAGL lesion ). Con traction of th e sh oulder girdle
m usculature on ce th e h um eral h ead h as slipped forward
over th e glen oid rim can lead to an impaction fracture of
the posterior lateral h um eral head, called a Hill-Sachs lesion
(Fig. 13.42).
Acute posterior instability typically occurs following a
posteriorly directed force tran sm itted th rough a flexed, ad-
Presentation
Patien ts with acute dislocation s will presen t with a sudden
on set of pain an d deform ity of th e sh oulder followin g a
traum atic event. The patient will keep the arm splinted at
th e side, often supportin g th e wrist with th e opposite h an d.
Any rotation th rough th e GH join t will lead to severe pain .
Wh en recurren t, th e sh oulder m ay dislocate with little or no traum a and, especially as th e capsular structures
are stretched with an increasing num ber of dislocations,
th e patien t is often able to relocate th e join t with out assistan ce. In these patien ts, it is important to determ in e th e
n ature of th e in jury at th e tim e of th e first dislocation, h ow
it was initially treated, th e num ber of recurrences, and the
specific activities or positions that now cause instability.
Patients with subluxation or m ultidirectional instability
will presen t with complain ts of pain wh en th e join t sh ifts
out of place with provocative position in g of th e arm . In
athletes with subtle instability, the presenting complaint is
often sh oulder pain an d a decrease in ath letic perform an ce.
Th is pain often occurs on ly wh en th ey are participatin g in
athletics and m ay or m ay not be associated with a sensation
of in stability or loss of stren gth in th e arm .
Physical Examination
With an acute anterior dislocation, prom inence of the
h um eral h ead an teriorly will be presen t, with n oticeable
flatten ing of the n orm al roun ded con tour of th e posterior
sh oulder. The sh oulder is globally pain ful and prereduction
exam in ation is gen erally lim ited to th e assessm en t of th e
n eurovascular status. As with proxim al h um erus fractures,
th e axillary n erve is at particular risk for in jury with sh oulder dislocation , as it passes alon g th e in ferior sh oulder
capsule to transverse th e quadrangular space (Fig. 13.16).
Assessm en t an d docum en tation of deltoid m uscle m otor
function is important prior to attempting any reduction
m aneuvers.
With posterior dislocation s, th e arm will be h eld in tern ally rotated at th e side, an d any attem pts at external rotation will cause sign ifican t pain . Th ere m ay be som e an terior flatten in g an d posterior prom in en ce alth ough th is
is often difficult to appreciate because of the increased
530
B
Figure 13.42 Impaction of the posterior superior humeral head on the glenoid rim leads to a
Hill-Sachs lesion of the humeral head. A: An axillary radiograph demonstrating an anterior dislocation with a Hill-Sachs lesion. B: A post-reduction computed tomography scan further demonstrating
the impaction fracture. (From Iannotti JP, Williams GR. Disorders of the Shoulder: Diagnosis and
Management, 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2007, with permission.)
531
B
Figure 13.43 The apprehension (A) and relocation (B) tests for anterior instability. (From Ian-
notti JP, Williams GR. Disorders of the Shoulder: Diagnosis and Management, 2nd ed. Philadelphia:
Lippincott Williams & Wilkins, 2007, with permission.)
Radiographs
Any patien t with a possible sh oulder dislocation sh ould be
evaluated with AP, scapular Y, an d axillary radiograph s. O f
th e th ree views, th e axillary lateral is by far th e m ost im portan t. Radiology tech n ologists will often sh oot a th ree-view
sh oulder series consisting of an AP in in ternal and extern al
the load and shift test. (From Iannotti JP, Williams GR. Disorders
of the Shoulder: Diagnosis and Management, 2nd ed. Philadelphia:
Lippincott Williams & Wilkins, 2007, with permission.)
(From Krishnan SG, Hawkins RJ, Warren RF. The Shoulder and
the Overhead Athlete. Philadelphia: Lippincott Williams & Wilkins,
2004, with permission.)
532
or pain an d a physical exam in ation suggestive of in stability, MRI scannin g is a useful tool. Th is study can be used to
evaluate th e soft tissue restrain ts to in stability an d also to
rule out other path ologic conditions about the shoulder.
Th e use of in tra-articular con trast to obtain an MRI arth rogram in creases th e accuracy in evaluatin g in th e labrum
and capsular structures.
Differential Diagnosis
Th e differen tial diagn osis of acute sh oulder dislocation s
in patien ts with severe pain after traum a injury includes
AC separations and fractures about the shoulder complex.
Th ese can be easily distin guish ed by physical an d radiograph ic exam in ation .
For patien ts, especially ath letes, with subtle in stability
presen tin g prim arily as pain , th e differen tial diagn osis in cludes several other shoulder disorders such as rotator cuff
path ology, SLAP tears, AC join t arth ritis, an d scapuloth oracic m otion abn orm alities.
tient lean backward 30 degrees over the cassette with his arm in
the sling. The beam is then directed superior to inferior through
the shoulder. This view provides a magnified axillary view in patients who cannot tolerate abduction of the arm. (From Iannotti
JP, Williams GR. Disorders of the Shoulder: Diagnosis and Management, 2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2007,
with permission.)
Treatment
Followin g clin ical an d x-ray evaluation , th e in itial treatm en t for acute anterior dislocations involves closed reduction under con scious sedation. This can be accomplish ed
by a variety of m an euvers that gen erally involve traction
coun ter traction across the joint (Fig. 13.47). Following reduction , th e arm is placed in a slin g, th e n eurovascular status is rechecked, and postm anipulation film s are obtain ed
to con firm th e reduction .
Special Studies
Followin g a sim ple dislocation an d reduction , n o addition al studies are n eeded if n o bon ey abn orm alities are
suspected on the pre- an d postreduction radiograph s. If
there is concern regardin g the size of Hill-Sachs lesions or
bon e defects about th e an terior glen oid rim , th en a CT scan
is useful. For patien ts with an un clear h istory of in stability
533
Classification
Superior labrum an terior to posterior tears were originally
described by An drews in 1985, an d furth er defin ed an d
classified in to four types by Snyder in 1990 (Fig. 13.48).
Type I tears in volve frayin g or degen eration of th e superior
labrum without detachm ent of the labrum or the biceps
anchor. In type II tears, there is detachm en t of the superior labrum an d biceps an ch or from th e glen oid rim . Type
III tears are ch aracterized by a bucket-h an dle tear of a
portion of th e superior labrum , with th e rem ain in g superior labrum an d biceps an ch or still firm ly attach ed to th e
glenoid rim . The type IV SLAP involves a bucket-h andle
tear of th e superior labrum th at exten ds in to th e biceps
ten don . Sin ce Snyders origin al classification , several addition al types of SLAP tears h ave been described. Th ese
involve exten sion of the tear into varying portions of the
anterior or posterior labrum and m ay be associated with
sh oulder in stability.
Mechanism of Injury
Superior labrum an terior to posterior lesions are typically
caused by traction or com pression in juries to th e sh oulder.
Th e m ost com m on m ech an ism is a fall on an abducted,
forwardly flexed arm , which leads to a direct compressive
force on the superior labrum . Reflex contraction of the biceps m uscle m ay provide addition al traction on th e biceps
anchor durin g the fall.
Superior labrum an terior to posterior tears are frequen tly foun d to occur in overh ead ath letes. In th ese patients, it is believed that the lesions are due to m icrotraum a
from repeated traction transm itted through the biceps tendon durin g th e th rowin g m otion . Th is population also
ten ds to h ave hypertrophy of th eir posterior in ferior capsular structures, which causes a posterior superior shift of
th e con tact poin t between th e h um eral h ead an d glen oid
wh en th e arm is placed in abduction an d extern al rotation
(as in the late cockin g phase of the throwing m otion ). This
sh ift can lead to dam aging sh eer and compressive forces
across the superior labrum .
534
Presentation
Th e presen tation of patien ts with SLAP lesion s can be quite
variable, and the diagnosis should be considered in all patien ts youn ger th at 40 with pain com in g from with in th e
sh oulder joint. The m ost com m on presentation is a youn g,
active patien t with activity-related pain deep with in th e
sh oulder following a traum atic even t. Th e inciting injury
typically in volves a fall on an outstretch ed h an d, weigh t
liftin g, autom obile acciden ts, or traction on th e exten ded
arm . In overh ead ath letes, rarely is a sin gle traum atic even t
the cause; rather, the player will complain of shoulder pain
an d a loss of stren gth an d power with th rowin g or overh ead
activities.
Physical Examination
Patien ts with SLAP lesions will typically have full ran ge of
m otion an d good stren gth about th e sh oulder, especially of
the rotator cuff m uscles. The exception is overhead athletes
535
anterior to posterior tears. For a positive test, the patient will have
pain when resistance is applied to the internally rotated arm that
is not present when resistance is applied to the externally rotated
arm. (From Krishnan SG, Hawkins RJ, Warren RF. The Shoulder and
the Overhead Athlete. Philadelphia: Lippincott Williams & Wilkins,
2004, with permission.)
Radiographic Findings
Stan dard radiograph s are un rem arkable in patien ts with a
SLAP tear.
Special Studies
Magn etic resonance im aging is th e m ost useful im aging
m odality for the diagnosis of labral pathology. Th e diagnosis is m ade when fluid is visualized between th e superior glen oid rim an d th e labrum on th e oblique coron al
im ages (Fig. 13.50). The specificity and sensitivity of MRI
in detecting SLAP tears can be m arkedly improved th rough
the use of an MRI arthrogram , wh ich involves the injection
of con trast m aterial in to th e GH join t prior to th e MRI exam ination. Magnetic resonan ce im aging is also useful for
identifying other path ology, such as partial articular-sided
rotator cuff tears an d Ban kart lesion s th at can lead to sh oulder pain in youn ger patien ts.
Differential Diagnosis
Th e differen tial diagn osis for SLAP tears in cludes any en tity that can cause shoulder pain in young patients. For
patien ts wh o h ave experien ced a compression or traction
injury to the shoulder, GH instability, AC joint injuries, rotator cuff tears, bursitis, an d adh esive capsulitis m ust be excluded based on h istory, physical exam in ation , an d im aging studies. In overhead ath letes, subtle anterior instability,
articular-sided rotator cuff tears, and isolated deficits of GH
internal rotation can lead to a loss of stren gth and perform ance and m ust be differentiated from SLAP tears. Patients
over th e age of 40 com m on ly h ave som e degen eration or
even fran k tearin g of th eir superior labrum th at m ay be an
asymptom atic part of n orm al aging. Th erefore, in this population , oth er con dition s, especially rotator cuff related
path ology, are m uch m ore likely to be respon sible for th at
patien ts symptom s.
Treatment
Superior labrum anterior to posterior tears generally do
n ot respon d well to con servative treatm en t. In young
536
injuries can occur in patients of any age, are often associated with significant weakness, and tend to require surgical
treatm ent.
Presentation
Th e m ost com m on presen tation of rotator cuff disease is
a late m iddle-aged patien t with th e gradual on set of dull
pain over th e an terior lateral sh oulder. Th e pain often radiates to deltoid in sertion on th e lateral arm , awaken s th e
patien t from sleep (especially wh en lyin g or rollin g on to
the affected side), an d is exacerbated by overhead activities
or reach in g beh in d th e back (as wh en puttin g a wallet in
the back pocket of pants or h ooking a bra). Alternately, the
pain m ay begin followin g in creased use of th e arm , such
as paintin g a room or playing several sets of tennis.
O ccasion ally, th e pain m ay follow a traum atic even t.
Th is is m ore com m on in youn ger patien ts, an d th ese patients are m ore likely to complain of weakness in addition
to pain . As described in th e section on GH in stability, it is
important to suspect a rotator cuff tear in any patient over
the age of 40 with a dislocation of the GH joint.
Physical Examination
Patients with longstanding rotator cuff tears m ay have atrophy of th e posterior sh oulder over th e supra- or in fraspin atus fossa. They will often have tenderness to palpation
about the cuff insertion on the greater tuberosity. With the
exception of th ose with full-th ickn ess tears, full active forward elevation is generally norm al, alth ough it is often accompanied with significant discom fort in the impingem ent
zon e between 70 an d 120 degrees. It is n ot un com m on for
patien ts with cuff path ology to lack several levels of in ternal rotation when m easured with th e arm beh ind the back.
Placin g th e arm in th is position in creases th e con tact between th e an terior superior rotator cuff and CA arch and is
often provocative of th e patien ts pain .
Th e evaluation of rotator cuff stren gth is especially im portan t in th e exam in ation of patien ts presen tin g with rotator cuff disease. In patien ts with in flam m ation of th e
subacrom ial bursa, it can be difficult to distin guish between true weakness and weakn ess secondary to pain,
although with proper instruction, m ost patients with an
intact cuff are able to m ain tain at least 4+ / 5 stren gth . Significant weakn ess on strength evaluation , especially positive lag signs, belly-press, or lift-off tests, is concerning for
complete tears of the cuff tendons.
Several addition al tests h ave been described for th e evaluation of rotator cuff path ology. Best kn own for th e n am e
of th e exam in er wh o origin ally described th em , th ese tests
attempt to reproduce the patients symptom s by m anipulating the arm to increase impingem ent within the subacrom ial space. Unfortunately, although sensitive for th e detec-
537
Radiographic Findings
Th e AP radiograph m ay dem on strate sclerosis of th e un dersurface of th e acrom ion an d cyst form ation in the greater
tuberosity. In elderly patien ts, it is important to carefully
evaluate th e film s for GH an d AC join t arth ritis. With lon gstan ding disease, th e h um eral head m ay be riding superiorly on th e glen oid, with decrease in th e acrom ioh um eral
interval. This is an important finding as it indicates a large,
and often irreparable, tear of the cuff (Fig. 13.53).
Th e axillary view is useful for dem on stratin g abn orm al
ossification cen ters with in th e acrom ion . Th ese are kn own
as os acromiale and, when present, m ay contribute to pain
an d impingem ent.
A m odified scapular Yview, called th e outlet view, is used
to evaluate th e m orph ology of th e acrom ion an d th e space
available un der th e CA arch . Th e radiograph is obtain ed by
orien tin g th e beam parallel to th e spin e of th e scapula an d
then an gling it 10 to 30 degrees caudally. Biglian i classified
the acrom ion according to its shape on th is view. Type I involves a straigh t, sm ooth acrom ion. In a type II acrom ion,
there is a gentle inferior curve anteriorly, whereas a type III
acrom ion involves an anterior hook (Fig. 13.54). Type III
acrom ion are m ore com m on in patients with full-thickn ess
tears, but th e exact relation sh ip between acrom ial m orph ology an d rotator cuff disease rem ain s un clear.
Special Tests
Magnetic resonance im aging scans are the im aging m odality of choice in evaluating disorders of the rotator cuff. Fulland partial-thickness tears are best seen on the T2 weigh ted
coron al oblique im ages (Fig. 13.55). Any associated
538
A
Figure 13.52 A: The Neer impingement sign. B: Hawkins impingement test. (From Iannotti JP,
Williams GR. Disorders of the Shoulder: Diagnosis and Management, 2nd ed. Philadelphia: Lippincott
Williams & Wilkins, 2007, with permission.)
the humeral head indicates a large, full-thickness tear of the rotator cuff. (From Johnson DH, Pedowitz RA. Practical Orthopaedic
Sports Medicine and Arthroscopy. Philadelphia: Lippincott Williams
& Wilkins, 2007, with permission.)
Differential Diagnosis
Th e differen tial diagn osis of rotator cuff disease is agedepen den t. In older patien ts, it in cludes cervical spin e
path ology, GH arth ritis, m etastatic disease an d referred
sources of sh oulder pain such as cardiac disease. Impingem en t and cuff path ology is m uch less frequent in younger
patien ts, an d m ore com m on sources of sh oulder pain
539
type I, flat; type II, curved; type III, hooked. This is evaluated on the
supraspinatus outlet view. (From Iannotti JP, Williams GR. Disorders
of the Shoulder: Diagnosis and Management, 2nd ed. Philadelphia:
Lippincott Williams & Wilkins, 2007, with permission.)
Treatment
Th e treatm en t of rotator cuff disease depen ds on th e
path ology an d th e age of th e patien t. If th ere is n o suggestion of a full-th ickn ess cuff tear on th e h istory, physical exam ination, and radiograph s, then th e presumptive
diagn osis is cuff ten don itis or bursitis, an d th e in itial treatm en t is nonoperative. At first, this consists of rest and education . Th is is followed by a progressive physical th erapy program to regain m otion, strengthen th e cuff, and
restore n orm al scapuloth oracic stren gth an d rhyth m . Specific exercises to strengthen the cuff m uscles help to keep
the hum eral head centered in the glenoid during m otion ,
thereby creating m ore space for the tendons in the subacrom ial space. The speed of the patients improvem ent
can be enhanced through the use of subacrom ial corticos-
540
Calcific Tendonitis
Calcific tendonitis is a com m on disorder in m iddle-aged
patien ts in wh om calcification occurs with in th e ten don s
of th e rotator cuff, especially th e supraspin atus.
541
Physical Examination
In th e precalcifyin g an d calcifyin g stages, physical exam in ation fin dings are sim ilar to subacrom ial impingem ent, with
a m ild decrease in ROM an d positive impingem en t signs.
Durin g th e resorptive ph ase, th e patien t m ay h ave severely
lim ited active and passive m otion accompanied by in tense
pain .
Radiographic Findings
Radiograph s are diagn ostic for th is disorder an d will
dem on strate calcification with in th e rotator cuff ten don
(Fig. 13.57). A single AP view m ay m iss th e calcification if
overlyin g bon e is presen t, so addition al AP radiograph s in
intern al and external rotation can be h elpful. The scapular
Y an d axillary views are useful for visualizing calcification
with th e subscapularis or posterior cuff m uscles.
Special Tests
Radiograph s are diagn ostic of calcific ten don itis, so n o further tests are n ecessary.
Differential Diagnosis
Calcific tendonitis is differentiated from other disorders of
the rotator cuff by the presence of calcification within the
ten don on plain radiograph s. In patien ts presen tin g with
acute pain characteristic of the resorptive phase, consideration m ust be given to septic arthritis. If the patient has any
system ic sign s of infection or underlyin g m edical problem s
m akin g h im m ore prone to in fection, the disorders can be
distin guish ed by aspiration of th e join t.
Treatment
Th e vast m ajority of patien ts with calcific ten don itis respond well to nonoperative treatm en t. Patients presenting with severe pain in the resorptive phase will benefit
Pathophysiology
Acrom ioclavicular join t arth ritis can occur as a con sequen ce of several disease processes. Th e th ree m ost com m on are prim ary osteoarthritis, posttraum atic arthritis,
and osteolysis of the distal clavicle. As in oth er joints, prim ary osteoarthritis in volves progressive cartilage loss resultin g in join t space narrowing, sclerosis, and osteophyte
form ation. O steoarth ritis of the AC join t is ubiquitous, with
intrinsic degeneration of the in tra-articular disk in m ost in dividuals by age 40. Som e radiograph ic eviden ce of arth ritis is present in the m ajority of adults over the age of 50;
h owever, the m ajority of th ese patien ts are asym ptom atic.
Sym ptom atic posttraum atic arth ritis is com m on , occurrin g in approxim ately 10% to 15% of th ose in dividuals with
grade I or grade II AC separation s. Ah istory of traum a from
a previous fall or in jury durin g a con tact sport is com m on .
Iden tifyin g th e subset of patien ts with a h istory of traum a
is important because, in these individuals, an elem ent of
AC instability m ay contribute to their pain .
Patients with osteolysis of th e distal clavicle are generally
younger and typically involved in repetitive weight-lifting
activities. The etiology of this condition is thought to be due
to stress fractures of th e subchondral bone and secondary
join t breakdown . Th ey com plain of pain over th e AC join t,
particularly with ben ch pressin g, dips, flies, an d push -ups.
Presentation
Patien ts typically presen t with pain over th e top of th e
sh oulder, occasion ally with radiation up into the trapezius
or down th e sh oulder. Th e pain is often a m ild ach e, worsen ed with specific activities, especially reach in g across th e
body. Symptom s can be worse at n igh t, an d lyin g or rollin g
on to th e in volved side m ay awaken th e patien t from sleep.
Physical Examination
In spection m ay reveal prom in en ce due to previous traum a
with som e residual separation or hypertrophy of th e distal clavicle. Palpation yields ten dern ess directly over th e
AC joint. The joint is compressed by having the patient
place th e arm in adduction across th e body at th e level of
th e sh oulder. In sym ptom atic patien ts, th is m an euver will
542
reproduce th eir pain . In stability is exam in ed by graspin g th e distal clavicle an d attemptin g to tran slate it in an
an teriorposterior or superiorin ferior direction while the
opposite h an d stabilizes th e acrom ion .
Radiographic Findings
As described in the section on AC sprains, the AC joint is
best visualized in th e AP plan e usin g th e Zan ca view. With
AC arth ritis, th ere will be join t space n arrowin g, sclerosis,
juxtacortical cysts, an d osteophyte form ation (Fig. 13.58).
Th e axillary view provides furth er visualization of th e join t
space as well as any an terior or posterior tran slation of th e
distal clavicle. In osteolysis, th e distal clavicle is en larged
an d appears radiolucen t. In th is con dition , th e join t space
m ay actually appear in creased.
Special Tests
Additional studies are generally not necessary in the diagnosis of AC arthritis. Rarely, stress radiographs can be used
to evaluate th e con tribution of in stability to th e patien ts
complaints. In complex cases, an injection of 1% lidocaine
in to th e AC join t followed by repeat exam in ation can be
used to con firm th e AC join t as th e source of th e patien ts
pain . Assum in g th e m edication is correctly placed in th e
join t space, pain from AC arth ritis sh ould be tem porarily
elim in ated by th e in jection .
Differential Diagnosis
Acrom ioclavicular joint pain m ay be due to a n um ber of entities oth er th an degen erative arth ritis. Th ese in clude acute
AC join t separation , ch ron ic pain or in stability followin g
Treatment
Th e treatm en t of prim ary osteoarth ritis, posttraum atic
arthritis, and osteolysis is sim ilar. It is important to rem em ber th at AC arth ritis is a com m on radiograph ic fin din g,
an d only th ose patients wh o are symptom atic warrant treatm en t. In itial treatm en t involves activity m odification an d
NSAIDs. In m ildly sym ptom atic patien ts, th is is often effective in reducing their acute inflam m ation, and they can
gradually return to th eir n orm al activities with out a return
of pain . In th e weigh t-liftin g ath lete with osteolysis, ch an ging the grip distan ce or elim in ating bench presses and dips
from the workout routine m ay elim in ate symptom s. If pain
persists, an in jection of corticosteroid in to th e join t often
provides dram atic if n ot perm an en t relief. Up to th ree in jection s can be perform ed for recurren t sym ptom s.
Surgical treatm en t with join t debridem en t an d rem oval
of th e distal en d of th e clavicle is curative in m ost patien ts.
Th is can be don e with eith er an open or arth roscopic procedure. Care is taken to keep the resection lateral to the CC
ligam ents in order to avoid destabilizing th e distal clavicle.
In patien ts with symptom atic AC join ts wh o are un dergoing surgery for the treatm ent of rotator cuff pathology,
con servative treatm en t is generally bypassed and excision
of th e distal clavicle is perform ed at th e tim e of th e cuff
procedure.
Glenohumeral Arthritis
Although less com m on th an arthritis of the hip and knee,
degen erative arth ritis of th e GH join t is still relatively com m on . As in any join t in the body, the characteristic fin ding of GH arthritis is destruction of the articular cartilage,
an d a num ber of different pathologic en tities can lead to
this destruction. Given the importan ce of the periarticular
soft tissues in shoulder function, the effect of arthritis on
these structures is particularly important in determ ining
the symptom atic effects an d treatm ent of th e disease.
543
B
Figure 13.59 Anterior-posterior (A) and axillary (B) radiographs demonstrating moderately se-
vere glenohumeral arthritis. Osteophytes along the inferior humeral neck are pathognomonic of osteoarthritis. (From Iannotti JP, Williams GR. Disorders of the Shoulder: Diagnosis and Management,
2nd ed. Philadelphia: Lippincott Williams & Wilkins, 2007, with permission.)
capsule, leading to hypertrophy of this structure and a characteristic decrease in external rotation. Disease progression
leads to a preferential posterior wear of the glenoid eventually resulting in posterior subluxation of th e h um eral h ead.
Th e disease process appears relatively protective of th e rotator cuff, wh ich is in tact in 90% of th ese patien ts.
A secon d m ajor cause of GH arth ritis is in flam m atory
arthritis, especially rheum atoid arthritis. In these patients,
the initiatin g event in cartilage destruction is a proliferative,
inflam m atory process of the synovium . Unfortunately, th e
destructive process is n ot lim ited to th e articular cartilage
but also in volves th e surroun din g soft tissue, leadin g to
attenuation and rupture of capsular restraints and rotator
cuff. On radiographs, the osteophytes and sclerosis of osteoarth ritis are absen t, replaced by diffuse osteopen ia an d
periarticular erosion s in areas wh ere th e syn ovium h as access to the bone (Fig. 13.60). Glenoid wear tends to be
sym m etrical, and patients do n ot have th e dram atic loss of
extern al rotation seen in osteoarth ritis.
End-stage rotator cuff disease can lead to a un ique
form of arth ritis term ed cuff tear arthropathy. With m assive,
ch ronic rotator cuff tears, the hum eral head can m igrate
superiorly, leading it to articulate with th e superior m argin
of th e glen oid an d th e un dersurface of th e acrom ion (Fig.
13.61). Th is leads to destruction of th e articular surface
an d, if loss of the CAligam ent occurs, can result in anterior
superior subluxation of th e hum eral head with attem pted
abduction of the arm . These patients often have significant
pain an d complete fun ction al loss or pseudoparalysis of
the shoulder.
A n um ber of oth er disease processes, in cludin g osteon ecrosis, GH dislocation s, an d posttraum atic articular
incongruity, can lead to destruction of th e GH articular surfaces. In m ost cases, th is results in secon dary osteoarth ritis
with join t destruction an d symptom s sim ilar to prim ary
B
Figure 13.60 Anterior-posterior (A) and axillary (B) radiographs
544
Presentation
Patien ts with GH osteoarthritis generally present with a
ch ief com plain t of pain . Typically, th e pain h as an in sidious
on set, is progressive, an d in ten sifies with use. Patien ts m ay
also n otice som e lim itation of m otion , especially extern al
rotation . Th e pain often in terferes with sleep, especially if
the patient rolls or lies on the involved side.
The presentation of other form s of GH arthritis depen ds
on th e un derlyin g disease. Patien ts with rh eum atoid arth ritis m ay already kn ow th eir diagn osis or presen t with pain
an d effusion s in m ultiple join ts. In cuff tear arth ropathy,
the pain is typically accompan ied by the in ability to raise
the affected arm and weakness typical of m assive rotator
cuff tears.
Physical Examination
In prim ary osteoarth ritis, atrophy about th e sh oulder girdle m ay be presen t secon dary to disuse. Palpation of th e
join t often dem on strates crepitan s with m otion as th e in con gruous surfaces slide past each other. Posterior joint
line tenderness m ay be present. Active m otion is typically
lim ited by pain , whereas passive m otion is decreased secon dary to capsular con tracture. Th e m ost dram atic fin din g
is often a significant loss of external rotation . With the arm
at the side, these patients often have zero degrees of, or
even n egative, extern al rotation . Th ey typically h ave sign ifican t pain with stretch of the an terior capsule, which can be
dem on strated be placin g th e arm in m axim al extern al rotation an d th en gen tly applyin g a m ild extern al rotation al
force. Alth ough the lim ited ROM can m ake the evaluation
of th e rotator cuff difficult, it is im portan t to evaluate, as
cuff integrity can have a significan t impact on treatm ent if
the decision is m ade to proceed with arth roplasty.
Patien ts with inflam m atory arthritis are likely to h ave a
relatively preserved ROM but m ay lack stren gth secon dary
to rotator cuff tears. In patien ts with cuff tear arth ropathy,
sign ificant h ollowin g about the scapula is often present,
secon dary to atrophy of the cuff m uscles. If the patien t has
an teriorsuperior subluxation, the hum eral head will be
visible anterior to the acrom ion.
Radiographic Findings
True AP and axillary radiographs will dem onstrate joint
space narrowin g in all patients with arthritis. Once th e
545
Special Tests
In th e straigh tforward presen tation of osteoarth ritis, n o
special studies are n eeded. In patien ts bein g considered for
sh oulder arthroplasty, CT scans are useful to furth er defin e
posterior glen oid wear. Wh en th ere are question s regarding the integrity of th e rotator cuff, especially in patients
with in flam m atory arth ritis, MRI con tin ues to be th e study
of ch oice. Early in th e course of som e secon dary causes
of osteoarth ritis, such as osteon ecrosis, MRI is also useful in dem onstrating ch anges that m ay not be apparent on
plain radiograph s. Patien ts with radiograph ic fin din gs of
inflam m atory arthritis with out a diagnosis of a system ic in flam m atory process (rheum atoid arthritis, lupus, spondyloarthropathy) should be referred to a rheum atologist for
further clinical and laboratory evaluation.
Differential Diagnosis
Th e differen tial diagn osis of GH arth ritis con sists of any
con dition that can presen t with a stiff, painful sh oulder.
Th e m ost com m on en tities to presen t in a sim ilar m an n er
are adhesive capsulitis and rotator cuff disease. Th e distinction can generally be easily accomplished through history,
physical exam in ation , an d radiograph ic studies. It is im portan t to rem em ber th at m ore th an on e of th ese en tities
can exist in a given shoulder. Generally, if significant loss
of th e join t space h as occurred, arth ritis is respon sible for
the patients symptom s.
Treatment
Th e treatm en t of arth ritis depen ds on th e patien ts discom fort and ability to function. For patients with m inor or m oderate pain an d preserved fun ction , n on operative treatm en t
con sisting of activity m odification and anti-inflam m atory
m edications is utilized. Physical therapy m ay be useful in
m ain tain ing the ROM, but it can also aggravate the patients
symptom s. For patien ts with m ore significant pain an d a
decreasin g ability to perform th e activities th ey wan t or
need to do, shoulder replacem ent is an excellent treatm en t
option .
Total sh oulder arth roplasty (TSA) in volves replacem en t
of th e h um eral h ead with a m etal sph ere an d replacem en t
of th e glen oid surface with an ultra-h igh -m olecular-weigh t
polyethylen e disc (Fig. 13.63). In m ost curren t design s, th e
hum eral compon ent is placed in press-fit m ann er while
the glenoid component is held in place by bone cem ent.
Patien ts often ach ieve dram atic, lastin g pain relief an d 85%
to 90% good to excellent results h ave been reported at 10 to
15 year follow-up. Return to m ost activities, in cludin g golf,
is perm itted, although the patien t is generally advised not
to repetitively lift m ore than 25 pounds with the involved
extrem ity. Con troversy exists over th e n eed to resurface th e
glenoid, but recent evidence suggests that, in patients with
an intact rotator cuff, TSA provides superior fun ction and
pain relief wh en com pared to h em iarth roplasty.
Total sh oulder arth roplasty is a resurfacin g procedure
and relies on the integrity of surrounding soft tissue structures to provide stability and proper fun ction of the join t.
Improper position in g or sizin g of th e compon en ts or loss
of in tegrity or fun ction of th e rotator cuff can lead to sign ifican t decreases in th e postoperative fun ction an d early
failure of th e prosth esis.
Given th e propen sity for posterior glen oid wear with GH
osteoarth ritis, it is importan t to carefully evaluate th e exten t of glen oid bon e loss on th e preoperative axillary radiograph s an d CT scan . Occasion ally, th e am oun t of posterior
bon e loss will preclude th e placem en t of a glen oid com pon en t, in wh ich case th e glen oid can be ream ed to create
a sm ooth surface with placem en t of a h em iarth roplasty
546
Adhesive Capsulitis
Adhesive capsulitis, or frozen shoulder, is a painful con dition ch aracterized by th e loss of both active an d passive
Radiographic Findings
Radiograph s of patien ts with adh esive capsulitis are gen erally un rem arkable. Th ey are importan t to rule out oth er
con ditions th at can lead to restricted ROM, especially GH
arthritis.
Special Tests
Frozen sh oulder is diagn osed on th e basis of h istory an d
physical exam in ation fin din gs, an d n o special tests are
needed. In rare circum stan ces, arth rography can be used to
con firm the diagnosis. The n orm al sh oulder will accom m odate 15 to 30 m L of contrast fluid, whereas the contracted capsule of the typical frozen shoulder will hold less
than 10 m L. Postcontrast radiographs will also dem onstrate
a sm all, blun ted axillary fold. O ccasion ally, MRI exam ination is warranted to rule out other soft tissue disorders
about the shoulder that can lead to pain and secondary
adh esive capsulitis.
Differential Diagnosis
Durin g th e early ph ases of adh esive capsulitis, it can be
extrem ely difficult to differen tiate th e con dition from rotator cuff disease. Both groups of patien ts will presen t with
pain th at is very sim ilar in n ature. It is n ot un com m on
for patien ts with adh esive capsulitis to presen t having selfdiagn osed th em selves with im pin gem en t syn drom e. Patients with cuff path ology will often have sm all decreases
in th e range of active m otion, especially internal rotation.
Furth er com plicatin g th e issue, patien ts with frozen sh oulder will often experien ce som e degree of secon dary im pin gem en t syn drom e as th eir tigh t posterior in ferior capsule leads to an terior superior translation of the hum eral
head toward the acrom ion with elevation of the arm . Th e
distin ction is best accomplish ed over tim e. Both sets of patients can be started on an initial therapy program th at
emph asizes capsular stretch in g an d stren gth en in g of th e
rotator cuff m uscles outside of th e impin gem en t zon e. In
the compliant patient, reexam ination in 1 m onth will gen erally reveal an im provem en t in th e RO M in patien ts with
cuff disease. In patients in the early stages of adhesive capsulitis, further decrease in th e ROM will often occur despite
the stretching program .
Glen oh um eral arth ritis an d m issed traum atic in juries to
the shoulder, especially posterior GH dislocations, can lead
to decreased ROM. Th ese disorders can be easily differen tiated on plain radiographs.
Treatment
Th e m ost importan t aspect of treatm en t of th e patien t with
adh esive capsulitis is educatin g the patien t regarding the
self-lim ited nature of th e disease. The variable tim e course
an d generally slow restoration of m otion can m ake the
treatm ent of this condition extrem ely frustrating for both
547
patien t an d physician . Durin g th e freezin g ph ase, th e patien t is started on a passive stretch in g program in an attempt to m ain tain as m uch m otion as possible. Alth ough
supervision of th e program by a therapist is often helpful,
in order to be effective, th e stretch in g m ust be perform ed
by the patient at hom e, a m inim um of four to five tim es
a day. For patien ts with sign ifican t pain , NSAIDs or an
in tra-articular cortison e in jection are h elpful in relievin g
the patients symptom s, so that they can participate in the
therapy program . The stretching is contin ued during the
frozen and thawin g ph ases in an attempt to restore m otion
as quickly as possible. Th e m ajority of patien ts are left with
som e sm all lim itation s in GH m otion following adhesive
capsulitis; h owever, these deficits rarely result in any fun ction al lim itation s.
For patients with no improvem ent or a decrease in their
ROM despite 3 to 6 m on th s of aggressive th erapy, operative in terven tion is a con sideration . Tradition ally, m an ipulation un der an esthesia h as been th e procedure of
ch oice, alth ough fractures of th e proxim al h um erus are
a significant risk. More recently, an arthroscopic capsular release h as been favored. Alth ough m ore in vasive, th is
procedure allows con trolled section in g of th e con tracted
capsular structures. Regardless of wh ich surgical option is
utilized, aggressive postoperative th erapy is crucial to m ain tain in g th e in creased ROM ach ieved in th e operatin g room .
CONCLUSION
Wh en h ealthy, th e sh oulder complex is able to ach ieve a
rem arkable ROM wh ile gen eratin g sign ifican t power for
th e fun ction al activities of th e upper extrem ity. In order
to achieve these fun ctions, it relies on a complex interaction between m ultiple bones, joints, and m uscles, m aking
it susceptible to a wide range of pathologic processes. Sign ifican t advances in our un derstan din g of th e fun ction of
th e various elem en ts of th e complex, as well as advan ces in
open an d arth roscopic surgical tech n iques, h ave led to an
en h an ced ability to diagn ose an d treat dysfun ction about
th e sh oulder. Disorders of th e sh oulder com plex rem ain an
area of active orth opaedic research, an d future findin gs will
con tin ue to advan ce our un derstan din g of th ese con dition s
and our ability to diagnose and treat them .
RECOMMENDED READINGS
Ten n en t DT, Beach WR, Meyers JF. A review of special test associated
with shoulder exam in ation. Part I: The rotator cuff tests. Am J Sports
Med 2003;31(1):154 160.
A detailed description of each of th e various special tests used in
the evaluation of rotator cuff disease.
Ten n en t DT, Beach WR, Meyers JF. A review of special tests associated
with shoulder exam in ation. Part II: Laxity, instability, and superior labral an terior an d posterior (SLAP) lesion s. Am J Sports Med
2003;31(2):301 307.
A detailed description of th e m any of th e special tests used in th e
evaluation of several com m on disorders of th e glen oh um eral join t.
548
Ian notti JP, Ram sey ML, William s GR, et al. Nonprosthetic m anagem ent of proxim al hum eral fractures. Am J Bone Joint Surg 2003;85A(8):1578 1593.
This reprint of an Instruction Course Lecture describes th e m ultiple
options available for the surgical treatm ent of proxim al hum erus
factures.
Robin son CM, Dobson RJ. An terior in stability of th e sh oulder after
traum a. Br J Bone Joint Surg 2004;86-B(4):469 479.
An excellent review of the epidem iology, pathoanatomy, and results of open an d arth roscopic treatm en t of traum atic an terior
shoulder instability.
William s GR, Rockwood Jr. CA, Biglian i LU, et al. Rotator cuff tears:
Why do we repair th em ? Am J Bone Joint Surg 2004;86-A(12):2764
2776.
Th is article provides a th orough review of both n on operative an d
operative m anagem ent of rotator cuff tears.
Boileau P, Sin n erton RJ, Ch uin ard C, et al. Arth roplasty of th e sh oulder.
Br J Bone Joint Surg 2006;88-B(5):562 575.
A comprehen sive discussion regarding th e design rationale beh in d
the current generation of im plants available for sh oulder replacem ent, as well as a review of factors influencing th e success of shoulder arthroplasty.
14
The Elbow
Brian Magovern
INTRODUCTION
Wh ile th e sh oulder allows placem en t of th e upper extrem ity throughout a large sphere of m otion, the elbow allows
fin e-tun ed m otion s with in th at sph ere. Th rough its th ree
articulations and a complex interplay of m uscles and ligam ents, the elbow is capable of both fine m otion s an d
great power. Th e elbow h as a very un ique an atom ical an d
biom ech an ical profile, wh ich adds to th e com plexity wh en
evaluatin g an d treatin g disorders of th is region . Traum atic
an d atraum atic elbow conditions can have a dram atic influence on a patients ability to fun ction during work,
recreation , or activities of daily livin g. Th is ch apter describes th e anatomy, biom echanics, evaluation , an d m anagem ent of th e m ost com m on pathologic con ditions of th e
elbow.
FUNCTIONAL ANATOMY
Th e elbow is a h igh ly con strain ed h in ge join t (troch ogin glym oid) that is m ade up of th ree articulations. Th e th ree
join t surfaces con sist of hyalin e cartilage an d are foun d
with in on e sh ared join t capsule. Th e uln oh um eral join t
is the prim ary articulation of the elbow. It allows flexion
an d extension and provides a large degree of elbow stability. The other two articulations are the radiocapitellar an d
proxim al radiouln ar join ts, wh ich allow for supin ation an d
pron ation . Path ologic con dition s th at in terfere with th ese
important joint surfaces, such as rheum atoid arthritis (RA),
will lead to pain ful loss of m otion an d poor fun ction .
Several im portan t structures are vital to th e n orm al fun ction of these articulations. They con sist of bon es, ligam en ts, and m uscles, which provide static and dyn am ic stability as well as m otion an d power. Con dition s th at disrupt
these structures lead to a breakdown in the complex chain
necessary for fluid and powerful elbow m otion .
Osteology
Th e distal h um erus is a trian gular-sh aped lon g bon e th at
flatten s in th e coronal plan e as it n ears th e elbow join t
(Fig. 14.1). Distally, it flares m edially and laterally into two
strong bony colum n s, leaving a very thin segm en t of in terven in g bon e. Th e two colum n s en d as th e m edial an d
lateral epicondyles, respectively, which serve as important
attachm ent sites for the ligam ents and m uscles th at cross
th e elbow. At th e level of th e join t, th e h um eral colum n s
are separated by two m ain articular segm ents. Medially, th e
spool-shaped troch lea m akes up the m ajority of the ulnoh um eral articulation . Lateral to th e troch lea lies th e capitellum , a convex projection of the distal hum eral joint surface,
wh ich articulates with th e con cave radial h ead to form th e
radiocapitellar join t. In th e coron al plan e, th e troch lea h as
a 6 to 8 degree valgus alignm ent, which gives th e elbow its
carryin g an gle. Com m on ly, wom en h ave a larger carryin g
angle than do m en. In th e sagittal plan e, the capitellum is
angled 30 degrees relative to th e h um eral shaft, which m ay
be h elpful in th e evaluation of fractures.
Th e proxim al uln a is a saddle-sh aped articulation th at
closely m atch es th e sh ape of th e troch lea on th e h um eral
side of the join t. Th e elbow, unlike the sh oulder, has an
inheren t bony stability prim arily because of th e congruity
of th ese two irregular surfaces. Th e uln a is also m ade up of
th e an terior coron oid process an d th e posterior olecran on
process, wh ich act as im portan t ten don , ligam en t, an d capsular attachm en t sites. Th e coronoid is an important buttress to prevent anterior dislocation of the elbow joint. The
distal h um erus h as two correspon din g con cavities kn own
as the coronoid and olecranon fossae. The coronoid process en gages its fossa at greater th an 120 degrees of flexion
and the olecran on process at less than 20 degrees of flexion
(Fig. 14.2). Bony stability is the m ost prevalen t during these
en d ran ges of m otion . Th e proxim al uln a also articulates
with th e proxim al radius at th e area kn own as th e lesser
sigm oid n otch .
550
Lateral
supraepicondylar ridge
Radial fossa
Olecranon fossa
Coronoid fossa
Medial epicondyle
(common flexor orgin)
Lateral epicondyle
(common extensor orgin)
Trochlea
Capitulum
Medial Flexors
epicondyle
for Ulnar nerve
Extensors
Anconeus
Trochlea
Trochlear notch
Olecranon
Radial notch
Head
Neck
Tuberosity for
Subtendinous
bursa
Biceps brachii
Tubercle on
coronoid process
Lateral
epicondyle for
Cutaneous
triangular
for olecranon
bursa
Head
Neck
Tuberosity of ulna
Supinator crest
Tuberosity
Supinator fossa
Posterior border
Posterior
oblique line
A.
Anterior View
B.
Posterior View
Figure 14.1 Osteology. (Reproduced with permission from Agur AMR, Dalley AF. Grants Atlas of
Anatomy. 11th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2004.)
Ligaments
Figure 14.2 The coronoid and olecranon process engage at terminal flexion and extension so bony stability of the ulnohumeral
joint is greatest at these end ranges of motion. (Reproduced with
permission from Bucholz RW, Heckman JD, Court-Brown C, et al.
Rockwood and Greens Fractures in Adults. 6th ed. Philadelphia,
PA: Lippincott Williams & Wilkins, 2005.)
551
Humerus
Biceps brachii tendon
Anular ligament
of radius
Oblique cord
Interosseous membrane
Medial epicondyle
Radius
Anterior band
Posterior band
Oblique band
Olecranon
Ulna
Figure 14.3 Medial ulnar collateral ligament complex. (Reproduced with permission from Agur
AMR, Dalley AF. Grants Atlas of Anatomy. 11th ed. Philadelphia, PA: Lippincott Williams & Wilkins,
2004.)
Muscles
Th e elbow join t is powered by several m ajor m uscles. Th ese
m uscles can be divided into groups based on the elbow
m otion th at they perform . There are also m any important
m uscles that cross the elbow joint providing m otor function to th e wrist and hand.
Elbow extension is prim arily perform ed by th e triceps
m uscle (Fig. 14.5). It is m ade up of three heads proxim ally
that form one ten don that attaches to the olecranon process distally. It is innervated by th e radial nerve. Flexion of
the elbow is driven by the structures of the anterior arm
compartm ent (Fig. 14.6). The brachialis originates from
the anterior hum erus and inserts just distal to the tip of
the coronoid process along the anterior slope. It is the prim ary flexor of the elbow and has a dual inn ervation. Th e
lateral fibers are innervated by the radial nerve, whereas
552
Figure 14.4 Lateral ulnar collateral ligament complex. (Reprinted with permission from ODriscoll
SW, Horii E, Morrey BF, et al. Anatomy of the ulnar part of the lateral collateral ligament of the elbow.
Clin Anat. 1992;5:296303.)
Neurovascular Structures
Th e elbow is surroun ded by m ajor n eurovascular structures
all with in close proxim ity to on e an oth er. Kn owledge of
the relationship between structures in the elbow is crucial
durin g surgical dissection as th ere is little room for error.
The brachial artery runs along the m edial arm an d
crosses anterior to the elbow joint as it bifurcates in to the
radial and ulnar arteries underneath the bicipital apon eurosis (Fig. 14.7). Th e radial artery run s alon g th e m edial
aspect of th e biceps ten don an d in to th e radial forearm .
Th e uln ar artery con tin ues alon g th e uln ar side of th e
forearm .
The m edian nerve courses along with the brachial
artery, passin g un der th e bicipital apon eurosis m edial to
the artery. It then con tinues between th e FDS and FDP
in to th e forearm . It supplies th e PT an d th e rem ain der of th e flexorpron ator m ass. Th e uln ar n erve also
travels alon g th e m edial arm , passin g in to th e posterior
compartm en t th rough the interm uscular septum proxim al
to the elbow joint. It th en runs under the m edial epicon dyle in to th e cubital tun n el. Th e posterior bun dle of
th e uln ar collateral ligam en t m akes up th e floor of th e
cubital tun n el wh ile th e an terior bun dle lies an terior to
th e n erve run n in g parallel to it. Th e n erve passes between the two heads of th e PT and runs alon g th e uln ar aspect of the forearm in to th e h an d. Th e m usculocutaneous nerve enters the anterior arm from undern eath th e coracoid process wh ere it supplies the coracobrach ialis, th e biceps, an d th e m edial two-th irds of
th e brach ialis. It th en exits th e arm between th e biceps
and brachialis m uscles proxim al to the elbow joint, form ing the lateral antebrachial cutan eous nerve. It pierces
th e an terior fascia of th e forearm , becom in g subcutan eous an d is in dan ger durin g surgical approach es to th e
anterior forearm , such as those used for distal biceps tendon repair. Th e radial n erve en ters th e arm from th e posterior cord of th e brach ial plexus an d passes posterior to
th e h um erus in th e spiral groove. Th e n erve th en en ters th e
anterior compartm ent of the arm between the brach ialis
and the brachioradialis m uscles. It travels in close proxim ity to the an terior elbow capsule and bifurcates distal
to th e elbow joint. Th e superficial branch runs on the
553
2
Triceps tendon (2)
Brachioradialis (3)
Extensor carpi
radialis longus (4)
Medial epicondyle
Ulnar nerve
Posterior ulnar
recurrent artery
Common extensor
tendon
Olecranon (1)
Anconeus (6 )
Anconeus
A. Posterior View
B. Posterior View
Figure 14.5 Posterior elbow muscles. (Reproduced with permission from Agur AMR, Dalley AF.
Grants Atlas of Anatomy. 11th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2004.)
un dersurface of th e brach ioradialis an d provides sen sation to the radial forearm and first dorsal webspace of the
hand. The deep bran ch becom es th e posterior in terosseous
nerve (PIN) as it passes un der th e arcade of Struth ers
an d into the supinator m uscle. The PIN th en travels alon g
the radius and along th e interosseous m em brane, giving
important branches to th e wrist an d digital extensors. It
sh ould be noted th at th e PIN runs on th e opposite side of
the bicipital tuberosity, wh ich sh ould be rem em bered during surgical approaches to the proxim al radius. Pronation
ten ds to brin g th e n erve m edially, wh ile supin ation ten ds to
put th e n erve in a m ore lateral position . Th erefore, durin g
554
Biceps brachii
Musculocutaneous nerve
Brachialis
Inferior ulnar collateral artery
Radial nerve
Ulnar nerve
Brachial artery
Brachioradialis
Median nerve
Biceps brachii tendon
Extensor carpi radialis longus
Deep branch of radial nerve
Radial recurrent artery
Extensor carpi radialis brevis
Superficial branch of radial nerve
Radial artery
Anterior View
Figure 14.6 Anterior elbow muscles. (Reproduced with permission from Agur AMR, Dalley AF.
Grants Atlas of Anatomy. 11th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2004.)
th en be tailored for each patien t. If th e m ech an ism of in jury is traum atic, m ake n ote of th e type of traum a an d th e
position of th e arm at th e tim e of in jury. Ask th e patien t
wh eth er th ere was a sen se of subluxation or wh eth er any
reduction m an euver was required. If th e patien t presen ts
555
556
Supinator
Supinator
Anconeus
Posterior
interosseous n.
Arcade of
Frohse
Radial n.
Pronation
Physical Examination
Th e physical exam in ation of th e elbow will often con firm
the diagn osis after the h istory has narrowed down th e
differen tial. A system atic approach will en sure th at a com plete exam in ation is perform ed an d n o path ology is overlooked. Th e basic components of th e physical exam ination
include inspection, palpation, range-of-m otion, stability,
and a neurovascular evaluation. The contralateral lim b m ay
be used as a n orm al com parison if it is asym ptom atic. Furth er testin g for specific disorders is added to th e exam in ation depending on clinical suspicion. These tests will be
further discussed in the section s on the path ologic entities
th at th ey detect.
As previously stated, there is significant overlap between
cervical spin e an d upper extrem ity disorders, an d th ey can
frequently occur sim ultaneously. Prior to exam ination of
th e extrem ity, a com plete cervical spin e exam in ation is
n ecessary. Ran ge of m otion , ten dern ess, an d th e presence
of a Spurlin g or Leh rm ite sign are n oted. In addition , a
com plete sh oulder exam in ation will h elp iden tify coexisting pathology.
Inspection
Th e physical exam in ation begin s with a th orough circum ferential inspection. The location and character of traum atic woun ds, such as bruisin g or lacerations, are recorded.
557
An elbow joint effusion , indicative of intraarticular pathology, m ay be seen on th e lateral side of th e elbow between
the radial h ead and the olecranon. Any asym m etric m uscle atrophy should raise the con cern of chronic denervation. The presence and location of any prior surgical incisions is also important. O pen woun ds, drainin g sin uses,
an d warm th and erythem a should be considered as possible eviden ce of in fection. Elbow align m en t is also evaluated. Th e carryin g an gle, form ed between th e h um erus
an d forearm , should be 5 to 7 degrees of valgus. Asym m etry is m ost com m on ly seen following pediatric traum a to
the supracon dylar h um erus (Fig. 14.9).
Palpation
Careful palpation of all structures is perform ed. The
elbow offers an advan tage durin g physical exam in ation in
that m any structures are subcutaneous and readily palpable even in obese patien ts. Th is is a diagn ostic exam in ation and should be conducted circum ferentially so as not
to m iss any poten tial problem areas. Begin n in g on th e lateral side, palpate th e lateral epicon dyle. Ten dern ess is in dicative of lateral epicon dylitis. Th e radial h ead is palpated
an d can be felt rotating un derneath the skin with forearm
pron ation an d supin ation . An effusion m ay be palpated in
the triangular area between the lateral epicon dyle, radial
head, and proxim al tip of th e uln a. The lateral collateral
Range of Motion
Th e elbow is capable of flexion , exten sion , pron ation , an d
supin ation. Th e functional range of m otion has been determ in ed to be a flexion exten sion arc of 30 to 130 degrees an d pron ation an d supin ation of 50 degrees each .
Th e passive an d active ran ge of all four m otion s is exam in ed
and recorded. The contralateral elbow, if uninvolved, can
be used as a com parison . Any crepitus, clickin g, or grin ding during range of m otion should be noted. If lim itations
in m otion exist, the firm ness of th e endpoint should be
n oted. A soft endpoin t m ay be m ore in dicative of soft tissue con tracture that m ay improve with stretching, whereas
a m ore firm en dpoin t m ay in dicate a process less likely to
resolve with n on operative treatm en t, such as a syn ostosis.
Th e presen ce of pain durin g ran ge-of-m otion exam in ation
can also be in form ative. Pain durin g th e m idran ge as opposed to th e en d ran ge of m otion m ay in dicate abn orm ality of the joint surface in stead of surrounding soft tissue
path ology.
Stability
Assessm en t of stability of th e elbow is often difficult for
two reasons. One, instability is often very painful and patients will guard against attempts at recreating the unstable
scen ario. Secon d, sh oulder m otion m ust be controlled so
th at varus an d valgus stressin g of th e elbow is n ot falsely
positive sim ply because th e h um erus is rotatin g. Th ere are
specific tests for differen t types of instability, wh ich will be
discussed in th eir respective section s later.
Neurovascular Assessment
A th orough neurovascular exam in ation is un dertaken. Th e
radial, m edian , uln ar, an d several cutan eous n erves cross
th e elbow an d m ay be subject to traum atic or surgical in jury or atraum atic n europathy from compression . Neural exam in ation sh ould in clude m uscle stren gth testin g
and sensory exam ination. Strength testin g sh ould be conducted m eth odically an d sh ould in clude all four m otion s
of th e elbow. Sen sory testin g sh ould in clude ligh t touch an d
two-point discrim ination for greater accuracy. Knowledge
of cervical root in n ervation an d periph eral n erve in n ervation is crucial for delineating the location of potential
lesions. For example, elbow extension by the triceps in in n ervated by th e radial n erve periph erally an d th e seventh
558
Imaging
Radiography
Plain radiograph s rem ain th e in itial im agin g study for
virtually all disorders of th e elbow. A stan dard series in cludes anteroposterior (AP), lateral, an d oblique views
(Fig. 14.10). Addition al radiograph s such as radiocapitellar, traction , or stress views are obtain ed, depen din g on
the condition under investigation . Radiographs are relatively in expen sive an d n on in vasive an d can provide a large
am oun t of in form ation . Astan dard radiograph ic series will
often give m ore in form ation about con dition s such as fractures, arth ritis, an d an gular deform ities th an any advan ced
im agin g m odality. Radiograph s m ust be scrutin ized for th e
presen ce of osseous lesion s or soft tissue swellin g con sisten t with a n eoplastic process. Th ey also m ust be scrutinized for m ultiple injuries. It is easy to m ake the m istake
of iden tifyin g th e prim ary abn orm ality on th e radiograph
an d th en m issin g an addition al in jury th at m ay n ot be as
obvious.
Additional Imaging
Additional im aging m ay be added to the diagnostic arsenal dependin g on the pathology in question . CT scan will
Classification
Fractures of th e h um eral sh aft are gen erally classified by location and fracture type. The location is described as m idsh aft, junction of th e m iddle and distal third, or junction
of th e proxim al an d m iddle th ird. Th e fracture type is described as transverse, oblique, spiral, or com m inuted. The
presen ce of a butterfly fragm en t or a segm en tal compon en t
is also noted.
Mechanism of Injury
Th e m ech an ism of in jury of h um eral sh aft fractures m ay
vary widely. A young patien t with good bon e stock will
often presen t followin g h igh -velocity traum a. Altern atively,
activities that place high torsional force on the arm , such as
Figure
559
560
Physical Findings
Th e skin will often display eviden ce of traum a, such as
bruisin g an d ecchym oses, particularly in h igh er en ergy in juries. Open h um eral sh aft fractures are relatively un com m on , secon dary to th e large soft tissue en velope, but th e
skin m ust be thoroughly exam ined such that an open injury is n ot m issed. A careful n eurovascular exam in ation
sh ould be perform ed and docum en ted, with specific atten tion placed on distal exam in ation of th e radial n erve.
Th e n erve run s alon g th e posterior h um eral sh aft in th e
spiral groove and m ay be injured durin g or after fracture.
Radiographic Evaluation
Radiograph s of th e h um eral sh aft m ust in clude two orthogon al views th at are taken 90 degrees to one another.
Th e radiological tech n ologist will often attempt to take
two orth ogon al views by takin g two AP views, on e with
the hum erus in ternally rotated an d one externally rotated
(Fig. 14.11). Th is will on ly lead to m otion th rough th e fracture site an d in adequate radiograph s. Atran sth oracic lateral
is an altern ative m eth od to obtain a view th at is orth ogon al
to th e AP. It is also crucial th at th e radiograph s in clude th e
elbow an d sh oulder to iden tify th e presen ce of any articular
exten sion or addition al in jury to th ese adjacen t structures.
Special Studies
Furth er studies are rarely required for th e evaluation of
hum eral sh aft fractures. A CT scan m ay help determ in e
the presence an d degree of involvem ent of the shoulder
or elbow join t if th ere is a con cern for articular exten sion .
Irregularity at th e fracture site th at suggests path ologic fracture should be further evaluated with advanced im aging
such as MRI or bon e scan. An electromyogram (EMG)/
n erve conduction velocity (NCV) m ay be ordered if th ere is
a neurologic deficit but is rarely helpful until several weeks
following the injury.
Differential Diagnosis
Th e diagn osis of a h um eral sh aft fracture is rarely in question after the history, physical exam in ation, and radiograph s. Adjacen t join t in volvem en t an d path ologic lesion s
sh ould be carefully elim inated from the differential diagn osis.
Treatment
Th e vast m ajority of h um eral sh aft fractures can be treated
n onoperatively with predictably h igh rates of h ealing an d
little residual deform ity. Initially, a coaptation splin t is applied from th e axilla to th e base of th e n eck, with a gen tle
valgus m old (Fig. 14.12). When patien t com fort allows,
th e splin t is con verted to a clam sh ell orth osis an d sh oulder an d elbow m otion is in itiated. At 6 to 8 weeks, th e
orth osis m ay be discon tin ued if th e physical exam in ation
and radiographs dem onstrate healing. Up to 30 degrees of
varus angulation and 3 cm of shortening is acceptable. Relative indications for surgical treatm ent include an inability
to m aintain a closed reduction secondary to body habitus
or th e presen ce of polytraum a with th e n eed for im m ediate use of th e extrem ity. Absolute in dication s for operative fixation include open fractures and those with vascular
561
B
Figure 14.12 The majority of humeral shaft fractures are initially treated with a coaptation splint.
This is converted to a clamshell orthosis once the discomfort for the initial injury subsides.
562
A,B
C
Figure 14.13 (A) Preoperative radiograph of a displaced humeral shaft fracture. (B and C) Postoperative radiographs demonstrating open reduction and internal fixation with a plate and screws.
C1
C2
C3
Figure 14.14 Orthopaedic Trauma Association classification of distal humerus fractures. (Reproduced with permission from Bucholz RW, Heckman JD, Court-Brown C, et al. Rockwood and Greens
Fractures in Adults. 6th ed. Philadelphia, PA; Lippincott Williams & Wilkins, 2005.)
563
Differential Diagnosis
Th e diagn osis of distal h um eral fractures is typically obvious on plain radiograph s. In the absence of fracture on
radiograph , soft tissue in juries such as an elbow dislocation or ligam en t rupture m ust be con sidered. Fractures in
oth er areas of th e elbow, such as th e olecran on , sh ould also
be con sidered in th e differen tial diagn osis.
essen tially n on displaced fractures wh o can with stan d gen tle early m otion and those with m edical com orbidities
th at place th em at excessive surgical risk. O perative treatm ent is favored in m ost patients. In younger patients, open
reduction an d in tern al fixation (ORIF) is recom m en ded
(Fig. 14.16). The goals of surgery are to restore the articular
con gruity an d obtain stable in tern al fixation th at will allow
early m otion . Failure to restore th e join t surface m ay lead
to posttraum atic arthrosis, which is difficult to treat in the
younger population. Osteotomy of the olecranon m ay be
n ecessary for improved exposure of th e join t surface, in the
presen ce of com m in ution . Stiffn ess an d h eterotopic ossification (HO ) form ation are com m on complications following ORIF. Elderly patients with osteoporosis will often
h ave sign ifican t fracture com m in ution an d a low-dem and
lifestyle. Obtaining stable intern al fixation m ay not be possible. Wh en ever possible, ORIF is the preferred treatm ent
for distal hum erus fractures in the elderly. However, if poor
bon e quality preven ts prim ary O RIF, acute total elbow
arth roplasty (TEA) is the preferred treatm en t. The m ost
con cern in g com plication of TEA is th e developm en t of in fection. Because of the lim ited soft tissue envelope around
th e elbow, in fection rates reach as h igh as 5%, substan tially
h igh er th an other joint arth roplasties.
Treatment
Th e treatm en t of distal h um erus fractures depen ds on
m any factors. The elbow joint is prone to stiffn ess and
im m obilization m ust be kept to a m inim um . Nonsurgical treatm ent, therefore, is indicated only for patients with
Radiographic Evaluation
Th e stan dard series of plain radiograph s in cludes AP, lateral, an d oblique views of th e elbow. If th ere is sh orten in g
of th e bon es with overlappin g segm en ts, gen tle traction can
be applied to th e elbow wh ile radiograph s are taken .
Special Studies
In a simple fracture pattern , plain radiograph s m ay be sufficient for diagnosis, classification , and treatm ent. A CT scan
is a very useful additional study and should be obtain ed
if there is any question as to th e location of the fracture
fragm ents or degree of complexity (Fig. 14.15).
Classification
Radial h ead fractures are classified accordin g to Mason
(Fig. 14.17). Type I fractures are n ondisplaced. Type II fractures have a m arginal fracture or impaction but have a portion of the head that is not fractured. Type III fractures
are com m inuted and involve th e entire radial head. A type
IV fracture was later added to th e classification to in clude
radial h ead fractures with an associated elbow dislocation .
Mechanism of Injury
Fractures of th e radial head usually occur followin g a
fall on to th e outstretch ed h an d. Th e force is tran sm itted
th rough th e forearm in to th e elbow. Wh en an elbow dislocation has occurred, the radial head m ay be fractured by
th e distal h um erus as it exits th e join t.
Presentation
Patien ts presen t with variable degrees of pain depen din g
on th e exten t of in jury. Min im ally displaced fractures m ay
cause little pain with ran ge of m otion an d presen t m uch
like a bruise or sprain. More displaced fractures will cause
sign ificant pain , an d the patient will be reluctan t to m ove
th e elbow.
564
D
Figure 14.16 Pre- (A and B) and postoperative (C and D) radiographs of a distal humerus fracture
treated with open reduction and internal fixation. An olecranon osteotomy was performed to improve
visualization of the articular surface during reduction. This was repaired with a precontoured proximal
ulna plate.
Physical Findings
Th e radial h ead is con sisten tly palpable alon g th e lateral
aspect of th e elbow, even in obese patien ts. Th e exam in er
can feel for tenderness over the radial head as it is rotated
with forearm pronation an d supination. An effusion m ay
be palpable in th is area as well. Ran ge of m otion is a crucial
565
n um ber an d location of fragm en ts. It m ay also h elp diagn ose oth er path ology, such as coron oid fractures, n ot seen
on plain radiograph .
Differential Diagnosis
Displaced radial h ead fractures will be seen on plain radiograph . Non displaced fractures, h owever, m ay dem on strate
on ly a posterior fat pad sign , or an effusion , on radiograph s. Oth er causes of in traarticular path ology, such as
occult fracture or ligam en tous in jury, m ust be ruled out in
th is in stan ce. A careful physical exam in ation is perform ed
and radiographs and advanced im aging are scrutinized for
th e presen ce of th ese oth er in juries.
Figure 14.17 The Mason classification of radial head fractures.
(Reproduced with permission from Koval KJ, Zuckerman JD. Handbook of Fractures. 3rd ed. Philadelphia, PA: Lippincott Williams &
Wilkins, 2006.)
Treatment
Fractures with less than 2 m m of displacem ent are treated
n on operatively. Th e elbow is im m obilized briefly in a sling
for com fort, and early m otion is begun when the patient is
able to tolerate it. The elbow should n ot be used for strenuous activities un til 6 weeks after in jury wh en a gradual
increase in weight-bearing is allowed. Fractures with m ore
sign ificant articular displacem ent or an osseous block to
m otion are treated with ORIF or radial head replacem ent.
Youn ger patien ts with sim pler fracture pattern s are treated
with ORIF (Fig. 14.19). Older, seden tary patien ts or th ose
with com m in uted fractures are treated with radial h ead replacem en t. Postoperative early m otion is again critical to
reduce stiffn ess. Associated in juries m ust be assessed such
th at early m otion is lim ited to a safe an d stable zon e. Partial or complete radial head excision m ay be considered in
rare circum stan ces but m ust n ot be perform ed if an Essex
Lopresti lesion is presen t. In gen eral, a radial h ead replacem ent is favored to prevent proxim al m igration of the radius.
Figure 14.18 The elbow can be aspirated via the lateral soft
Mechanism of Injury
Fractures of th e olecranon typically occur through two different m echan ism s. O ne type of fracture is an avulsion
of th e triceps m ech an ism , wh ich is typically a tran sverse
Figure 14.19 (A) Pre- and (B) postoperative radiographs of open reduction and internal fixation of a radial head fracture.
566
567
B
Figure 14.21 Tension band wiring of an olecranon fracture. (Reproduced with permission from
Bucholz RW, Heckman JD, Court-Brown C, et al. Rockwood and Greens Fractures in Adults. 6th ed.
Philadelphia, PA: Lippincott Williams & Wilkins, 2005.)
568
tures. (Reprinted with permission from Regan W, Morrey BF. Fractures of coronoid process of the ulna. J Bone Joint Surg Am.
1989;71:13481354.)
Tip
Anteromedial
Basal
Figure 14.23 ODriscoll classification of coronoid fractures. (Reproduced with permission from Bucholz RW, Heckman JD, CourtBrown C, et al. Rockwood and Greens Fractures in Adults. 6th ed.
Philadelphia, PA: Lippincott Williams & Wilkins, 2005.)
Presentation
Th e patien ts h istory will often give clues to th e diagn osis. Patien ts m ay describe a subluxation of the elbow that
self-reduced. If th e patient reports that a closed reduction
was required, a coronoid fracture sh ould be considered. Patients will have diffuse pain and swelling and be reluctant
to m ove th e elbow.
Physical Findings
After a careful neurovascular exam in ation an d close evaluation of th e skin in tegrity, a ran ge-of-m otion an d stability exam ination is perform ed. Stability is often difficult to
evaluate secon dary to pain an d guardin g. An exam in ation
un der an esth esia is con sidered if furth er in form ation is
n eeded.
Radiographic Evaluation
Plain radiograph s con sistin g of th ree views of th e elbow are
obtain ed in itially (Fig. 14.24). Fractures of th e coron oid
m ay be very sm all and the radiographs m ust be closely
scrutin ized. While fran k dislocations will be obvious, subtle subluxation m ust not be overlooked.
Special Studies
Coronoid fractures m ay be difficult to appreciate on plain
radiograph s secon dary to overlap of th e radial h ead an d
oth er bony structures. CT scan s are very h elpful in th ese
cases where the size and configuration of th e fracture rem ain s in question (Fig. 14.25).
Differential Diagnosis
Th e differen tial diagn osis of coron oid fractures in cludes
oth er osseous an d soft tissue in juries of th e elbow. Dislocation of th e elbow, radial head fracture, and olecranon
fracture m ust be considered.
Treatment
Th e m an agem en t of coron oid fractures depen ds on m ultiple factors. Fractures of th e tip of th e coron oid h ave traditionally been considered capsular avulsions from an elbow
dislocation . In reality, th e tip of th e coron oid is in traarticular and th e capsule inserts m ore distal so these likely represent sheer in juries. Th ese isolated fractures can be m anaged
n on operatively as lon g as a con cen tric reduction of the elbow can be m ain tain ed durin g early con trolled m otion an d
associated injury to th e radial head does not require surgical m an agem ent. If repair is required, the fragm ent is often
too sm all for ORIF an d suture repair of th e overlyin g capsule down to the ulna is perform ed. Larger fractures will
con tribute m ore to elbow stability and m ay require ORIF.
569
Figure 14.24 Plain lateral (A) and oblique (B) radiographs of a Type II coronoid fracture.
Instability
Elbow Dislocation
Dislocation of th e elbow is a relatively com m on in jury,
m aking up as m any as 25% of all elbow injuries. They typically occur in youn ger patien ts, often durin g con tact sports
or activities. Associated in juries are com m on an d play a
m ajor role in th e m anagem ent of elbow dislocations.
A
Figure 14.25 Lateral (A) and three-dimensional (B) computed tomography scan reconstructions of a coronoid fracture.
570
Classification
Elbow dislocation s are classified first accordin g to the direction of th e dislocation (Fig. 14.27). Stan dard orth opaedic
nom enclature describes a dislocation based on the location of th e distal segm en t in relation to th e proxim al segm en t. A posterior elbow dislocation , for example, implies
that the forearm lies posterior to the hum erus. They are
further classified on the basis of th e presence of associated in juries. Simple elbow dislocation s do n ot h ave any
Presentation
Patients will presen t with acute pain, deform ity, and inability to ran ge the elbow. Th ey will typically hold the arm at
the side with the elbow partially flexed.
Physical Findings
A careful n eurovascular exam in ation prior to any reduction m aneuver is critical in th e initial evaluation. The exam in ation m ust be repeated followin g reduction, as n erve
en trapm en t with in th e join t h as been reported. Alth ough
rare, compartm en t syn drom e does occur an d m ust be diagnosed an d em ergently treated.
Radiographic Evaluation
Plain radiograph s will clearly dem on strate a dislocated
elbow. Th e presen ce of associated fractures m ay n ot be as
obvious. Postreduction radiograph s m ay be m ore h elpful
in the diagn osis of oth er injuries. Th ey should be evaluated to en sure that there is not an in carcerated fragm ent of
bon e with in th e join t. Any residual subluxation m ust be
identified and treated accordin gly.
Special Studies
As stated earlier, a CTscan is obtained if a coronoid or radial
h ead fracture requires furth er evaluation . Rarely, an MRI
m ay be useful in determ ining the extent of ligam entous
injury.
Differential Diagnosis
Th e differen tial diagn osis of elbow dislocation s in cludes
fractures of the distal hum erus, olecranon, and radial head.
Plain radiograph s will rule out th ese oth er in juries.
Treatment
Simple Elbow Dislocation. Th e in itial m an agem en t of an
with permission from Browner BD, Jupiter JB, Levine AM, eds.
Skeletal Trauma. Philadelphia, PA: WB Saunders, 1992:1142.)
571
early m otion . If th e elbow is un stable m ovin g in to th e exten ded position , a h in ged brace is utilized. Th e brace is
set to lim it exten sion within stable lim its for the first few
weeks. It is gradually open ed an d discon tin ued between
3 an d 6 weeks, depen din g on th e stability exam ination . In
elbows th at are m ore un stable an d can n ot be treated closed,
open repair is in dicated. Operative treatm en t begin s with
repair of th e LUCL. Stability is reevaluated an d if in stability
persists, repair of th e MUCL is con sidered. Last, a h in ged
extern al fixator m ay be placed if residual in stability exists.
Mechanism of Injury
Th ere are two prim ary m ech an ism s of in jury to th e MUCL.
A sin gle even t such as an elbow dislocation or acute valgus
load m ay rupture th e ligam en t. Th e force across th e elbow
durin g a pitch far exceeds th e stren gth of th e ligam en t. More
com m only, repetitive traum a from overh ead activities will
lead to atten uation an d ligam en t in sufficien cy.
Figure 14.28 The milking maneuver for evaluation of the medial ulnar
collateral ligament. (Reproduced with
permission from Morrey BF. Master
Techniques in Orthopaedic Surgery:
The Elbow. 2nd ed. Philadelphia, PA:
Lippincott Williams & Wilkins, 2002.)
Classification
In juries to th e MUCL are classified as acute versus ch ron ic
ruptures. Th ey are further classified into m idsubstance
tears an d bony avulsion s.
Presentation
Th e h istory will often reveal th e m ech an ism of in jury. Patien ts presen t with m edial-sided elbow pain followin g an
in jury or with certain activities. Som e patien ts will also
complain of pain, num bness, and weakn ess in th e uln ar n erve distribution. Uln ar n erve symptom s are typically
tran sien t occurrin g with th rowin g an d im prove on ce th rowin g is discon tin ued.
Physical Findings
Th e MUCL is exam in ed for ten dern ess to palpation . The
m ilkin g m an euver places a valgus stress across th e elbow
(Fig. 14.28). Th e m ovin g valgus stress test is a dyn am ic test
572
that places a valgus stress across th e elbow while sim ulatin g a th rowin g m otion . Pain with eith er test is eviden ce of
MUCL in sufficien cy. Th e uln ar n erve m ust be closely exam in ed for subluxation an d any sign of n erve dysfun ction .
Th e lateral side of th e elbow m ust be exam in ed closely as
well, as attenuation of th e MUCL m ay lead to h igher com pressive forces across th e radiocapitellar join t an d diseases
such as osteochondritis dissecan s.
Radiographic Evaluation
A standard elbow series is obtained initially and m ay reveal
a bony avulsion of the ligam ent. Valgus stress radiographs
m ay dem on strate widen in g of th e m edial join t space.
Special Studies
An MRI arth rogram is the m ost sensitive and specific test
for MUCL rupture. Concom itant path ology can also be
diagn osed by MRI. Ultrason ography h as recen tly sh own
prom ise in th e diagn osis of MUCL in jury, th rough n on in vasive m eans.
Differential Diagnosis
MUCL insufficien cy m ust be distin guish ed from other
causes of m edial-sided elbow pain . Medial epicon dylitis,
cubital tun n el syn drom e, an d m edial epicon dyle fractures can present with symptom s sim ilar to MUCL injury.
In skeletally im m ature ath letes, Little League elbow sh ould
be con sidered. Radiograph s an d a careful physical exam in ation are usually sufficien t to m ake th e diagn osis.
Treatment
In itial treatm en t is typically con servative. Rest from in citing activities for up to 3 m onths is appropriate. Elbow
ran ge of m otion an d stren gth en in g of th e flexorpron ator
m usculature are also initiated. On ce symptom s subside,
th e patien t is gradually allowed to return to th rowin g. If
th e patien t does n ot respon d to con servative treatm en t,
surgical reconstruction is in dicated. Multiple reconstructive tech niques using different grafts and fixation m ethods
h ave been described. Classically, autograft ten don is woven
th rough bon e tun n els in th e h um erus an d uln a (Fig. 14.29).
Use of allograft tissue an d fixation with in terferen ce screws
C
Figure 14.29 Medial ulnar collateral ligament reconstruction. (Reproduced with permission from
Morrey BF. Master Techniques in Orthopaedic Surgery: The Elbow. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2002.)
has been described m ore recen tly. An ulnar n erve tran sposition is n ot typically required wh en th e n erve sym ptom s
are transient with activity. However, when the ulnar neuropathy is m ore profoun d, tran sposition m ay be required.
Postoperatively, valgus stresses m ust be avoided. Early
ran ge of m otion is in itiated in a h in ged brace. At 3 m on th s,
early stren gth en in g is begun . Ligh t pitch in g from flat
groun d begin s at 6 m on th s an d off th e m oun d pitch in g
begin s at 9 to 12 m on th s.
573
Treatment
Acute elbow dislocation m ay be in itially treated n on operatively, as stated earlier. In th e case of contin ued instability,
acute ligam en t repair is usually sufficient to stabilize the
elbow. However, ch ron ically un stable elbows require ligam ent reconstruction, not repair. Th e LUCL is reconstructed
with autograft or allograft ten don . It is placed between th e
574
A1
B1
A2
B2
A3
B3
Figure 14.31 The pivot shift maneuver for evaluation of the lateral ulnar collateral ligament.
(Reproduced with permission from Morrey BF. Master Techniques in Orthopaedic Surgery: The Elbow.
2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2002.)
lateral epicon dyle an d th e supin ator crest on th e uln a. Various fixation tech n iques h ave been described. Postoperative
care includes early m otion in a safe range determ ined at
surgery. Extension and supination are avoided. Varus stress
across th e repair is also avoided, m ost com m on ly by keepin g th e arm at th e side. By 6 weeks, full m otion is allowed
an d stretch in g is employed. Gradual in creased use of th e
arm is perm itted over th e n ext 12 weeks an d stren gth en in g
is added to th e postoperative regim en . Patien ts are allowed
full activity at 6 m onths after surgery.
Classification
Distal biceps ten don ruptures m ay be partial or com plete.
Complete ruptures are broadly classified into acute and
ch ronic injuries. The definition of an acute rupture is arbitrary an d varies from less th an 2 to 6 weeks after in jury
but gen erally is con sidered acute if th e in jury is less th an
4 weeks old.
Mechanism of Injury
Th e m ech an ism of in jury is typically an eccen tric load forcefully extendin g an actively flexing elbow.
Presentation
Ruptures of the distal biceps tendon prim arily occur in m en
in their 50s. There have been a few reports of wom en sustain in g th is in jury. O th er risk factors in clude weigh tliftin g,
steroid use, and sm oking. Patien ts m ay describe a tearin g
sen sation and pain in the anterior elbow following an injury. Som e patien ts n ote a secon d distin ct tear th at represen ts failure of the bicipital apon eurosis.
Physical Findings
Patients with an acute rupture will have swellin g, ten derness, and ecchym oses around the proxim al m edial forearm .
Th e biceps ten don will n ot be palpable alon g th e an terior
elbow. Proxim al m igration of th e m uscle belly with supin ation m ay help confirm the diagn osis but m ay n ot occur if
the lacertus fibrosis rem ains intact (Fig. 14.32).
575
Radiographic Evaluation
Plain radiograph s are usually n orm al but sh ould be scrutin ized for any abn orm alities of th e bicipital tuberosity.
Special Studies
MRI an d US h ave been used for con firm ation of th e rupture
an d m ay dem on strate th e degree of proxim al m igration
(Fig. 14.33). A special MRI view of th e biceps is obtain ed
with the patient placed prone with the elbow flexed to
90 degrees, the shoulder abducted, and the forearm
supin ated (FABS view). This view provides a longitudinal
view of th e biceps ten don
Differential Diagnosis
Although rare, m uscleten don jun ction tears m ay occur
an d will h ave a sim ilar presen tation . Oth er sources of
path ology to con sider are partial ten don ruptures, cubital
bursitis, an d lateral an tebrach ial n erve compression .
Treatment
Direct ten don repair to th e bicipital tuberosity is in dicated in active individuals to restore supination and flexion stren gth an d en duran ce. Non operative treatm en t is reserved for low-dem and patien ts or those who are m edically
un fit for surgery. Multiple fixation m eth ods usin g eith er
a one-incision or a two-in cision approach have been described. Historically, the one-incision technique had a high
rate of radial nerve injury, leading to the developm ent of
the two-incision repair. Recent advan ces in fixation using
suture an chors an d fixation buttons have led to a renewed
B
Figure 14.32 Clinical photographs demonstrating the right biceps with an intact tendon (A) and
the left biceps where there is a distal biceps rupture (B).
576
Rheumatoid Arthritis
With th e recen t adven t of disease-m odifyin g an tirh eum atic
drugs, severe destructive elbow arth ritis is becom in g less
com m on. RA, however, rem ains the m ost com m on cause
of elbow join t arth ritis an d can be severely debilitatin g.
Pathophysiology and Classification
Autoim m une complexes form and incite a painful inflam m atory response in the synovial linin g of the joint.
Presentation
Patien ts with early-stage disease will presen t with a pain ful
ran ge of m otion an d join t effusion . In later stages, th ey will
com plain of in creasin g loss of m otion an d varyin g degrees
of join t deform ity. Patien ts h ave usually been diagn osed
with RA prior to orth opaedic con sultation an d will often
h ave adjacent joint or cervical spin e in volvem en t. Occasion ally, however, patien ts will present prior to diagnosis,
and a proper workup or referral is imperative.
Physical Examination
An in itial in spection sh ould n ote any soft tissue swellin g,
join t effusion , an d deform ity. Th e elbow is th en taken
th rough a ran ge of m otion , n otin g any crepitus, grin din g,
or in stability. Th e cervical spin e, sh oulder an d wrist are
exam in ed, as well, for th e presen ce of any dysfun ction or
deform ity.
Radiographic Findings
Th e radiograph ic fin din gs in rh eum atoid disease dem on strate the classic chan ges of inflam m atory arthritis. Periarticular osteopenia is seen in early stages. Sym m etric joint
space n arrowin g and periarticular bone erosion follow. Ultim ately, bon e loss and soft tissue attenuation lead to loss
of join t stability an d arch itecture. In con trast to OA, very
few osteophytes are typically presen t.
Special Tests
Gen erally, th e plain radiograph s are sufficien t for diagn osis. CT scan s or MRI m ay be helpful if the degree of bone
loss or soft tissue attenuation is in question . Laboratory
workup for RA, such as rh eum atoid factor an d oth er in flam m atory m arkers, is con sidered if a diagn osis h as n ot
yet been m ade.
Differential Diagnosis
RA is a form of inflam m atory arthritis, which can typically be distin guish ed from oth er form s of DJD by radiograph s. Oth er causes of in flam m atory arth ritis sh ould be
con sidered, such as h em oph ilic arth ropathy an d psoriatic
577
B
Figure 14.34 (A) Preoperative radiograph of an elbow with advanced rheumatoid arthritis.
(B) Postoperative image following treatment with a total elbow arthroplasty.
Osteoarthritis
OAis relatively un com m on in th e elbow join t. Non eth eless,
th e pain an d stiffn ess th at occur can greatly affect a patien ts
livelihood.
578
Posttraumatic Arthritis
Posttraum atic arthritis is an extrem ely difficult condition
to treat. Because patien ts ten d to be youn ger, arth roplasty
with lifelon g activity restriction s is an un realistic treatm en t
option . Patien ts typically h ave a h igh -dem an d lifestyle an d
require a fun ction in g elbow for th eir livelih ood.
Figure 14.35 Lateral radiograph of elbow osteoarthritis demonstrating significant periarticular osteophytes with preservation of
the chondral surfaces.
Physical Examination
Ran ge of m otion is th e m ost importan t compon en t of th e
exam in ation of th e osteoarth ritic elbow. Th e overall ran ge
is recorded first. Next, th e presen ce of pain durin g th e exam in ation is carefully evaluated. As stated earlier, th e presen ce
of m idran ge pain im plies in volvem en t of th e join t surface
which m ay sign ifican tly affect treatm ent.
Radiographic Findings
Plain radiograph s will reveal th e ch an ges of OA. In particular, periarticular osteophytes are often very impressive
an d explain th e lack of m otion seen on physical exam in ation (Fig. 14.35). Join t space n arrowin g is typically
not seen initially. The deform ity and instability seen with
in flam m atory arth ritis is usually n ot seen with OA.
Special Tests
Th e plain radiograph s m ay be difficult to in terpret in two
dim en sion s. A th ree-dim en sion al study, such as a CT scan ,
will better define th e size and location of the osteophytes
an d m ay be useful for preoperative plan n in g.
Differential Diagnosis
OA of th e elbow is typically diagn osed by plain radiograph s. It m ust be distin guish ed from oth er form s of elbow
DJD. In th e presen ce of n orm al radiograph s, soft tissue
contracture m ay cause sim ilar pain and loss of m otion .
Treatment
In itial treatm en t is con servative, con sistin g of an tiin flam m atory m edication s an d activity m odification . Later
stages m ay respond to arthroscopic debridem ent, capsular release, an d rem oval of osteophytes. Care m ust be
taken n ot to destabilize th e elbow join t with overaggressive
Special Tests
A m ajor con cern in th e posttraum atic elbow is th e possibility of in fection. Laboratory workup including WBC, ESR,
an d CRP will offer evidence for or against the presence of
infection. Joint aspiration can also aid in the diagn osis. CT
scan is helpful in determ in in g such factors as the location
of HO, th e presen ce of n on un ited segm en ts, an d areas of
bon e loss.
Differential Diagnosis
Th e m ain difficulty is th e diagn osis of posttraum atic arth ritis is the evaluation of the joint surface. In the presence
of traum a, m any oth er factors besides cartilage loss can
cause symptom s. HO, soft tissue con tracture, in fection, and
nonunion m ay all contribute to painful loss of m otion in
the elbow. Treated separately, these con ditions m ay relieve
a great deal of th e patien ts complain ts, with out requirin g
interven tion at the joint surface.
Treatment
Th e treatm en t of posttraum atic arth ritis varies on th e basis of th e presenting com plaints an d m ust be tailored
to each in dividual. Con servative m easures in clude an tiinflam m atory m edications and activity restriction. Any
suspicion for infection should be diagnosed an d treated
accordingly. Operative treatm ent is chosen on th e basis of
the patients needs. Hardware rem oval, contracture release,
an d repair of nonunited segm en ts can relieve m any symptom s. Addressin g articular surface degen eration is m ore
ch allenging. Arthrodesis of the elbow is less successful than
it is in other joints, leaving patien ts very disabled. TEA requires lifelon g activity restriction an d con version to a lowdem an d lifestyle. Th is is often n ot possible for a youn g,
active patient who m ust use the elbow for work. Interposition arthroplasty, using fascial tissue, has been used with
success but is a tech n ically dem an ding procedure with results th at m ay be unpredictable.
579
580
Olecranon Bursitis
Th e olecran on bursa lies on th e dorsal aspect of th e proxim al uln a as a protective tissue between th e skin an d bon e.
It is a frequen t area of in flam m ation an d a com m on cause
of elbow pain .
581
a pulsatile m ass. Weakn ess m ay exist when testing in trinsic m uscles. Patients m ay compen sate for the loss of finger
abduction with fin ger hyperexten sion . Th e first dorsal in terosseous m uscle is easily palpated in th e first webspace,
with attempted in dex finger abduction. Decreased sensation m ay be presen t alon g th e little fin ger an d uln ar side of
the ring finger.
Radiographic Findings
Plain radiograph s of th e elbow are obtain ed an d are usually
n orm al. They m ay dem on strate posttraum atic deform ity or
callus with in the area of th e cubital tunnel. An epicon dylar
view m ay be added to obtain a clear im age of th e groove an d
evaluate for th e presen ce of osteophytes or oth er lesion s.
Radiograph s of oth er areas of th e body, such as th e cervical spin e, chest, an d wrist are taken, depending on clin ical
suspicion followin g th e physical exam ination.
Special Tests
Advanced im agin g is rarely helpful in th e diagnosis of cubital tun n el syn drom e. MRI can be obtain ed if con cern exists for a space-occupyin g lesion . Electrodiagn ostic studies,
such as EMG an d NCV, help to confirm the diagnosis and
localize th e compression in equivocal situation s. False n egatives do occur an d treatm en t for cubital tun n el syn drom e
sh ould proceed accordin gly if the clinical exam ination is
clear, despite a norm al EMG/NCV.
Differential Diagnosis
As stated earlier, the differential diagnosis is extensive.
Many con dition s h ave overlappin g symptom s, an d differen t con dition s m ay occur sim ultan eously. Th e differen tial diagn osis begin s with cervical n erve root com pression .
Travelin g down th e arm , brach ial plexus com pression from
thoracic outlet syndrom e or a Pancoast tum or is considered. At th e elbow, MUCL in sufficien cy an d m edial epicondylitis are evaluated. At the wrist, ulnar nerve compression at Guyon canal, aroun d the hook of the ham ate, or
secon dary to ulnar artery aneurysm is also considered. Last,
system ic abnorm alities that m ay produce peripheral neuropathy, such as vitam in deficien cy, h eavy m etal in toxication , an d alcoh olism , are all in cluded in th e differen tial
diagn osis.
Treatment
In itial treatm ent is con servative. Splin tin g is effective in reducin g th e am oun t of elbow flexion , particularly at n igh t.
Nigh ttim e 45-degree splin ts relieve a sign ifican t portion of
in volun tary compression . Daytim e flexion is avoided, an d
full-tim e splinting m ay be considered in severe cases. Antiin flam m atory m edication s an d th erapy m odalities m ay
also be added. In refractory cases, surgical treatm en t is
in dicated. Th ere is con troversy in th e various treatm en t
m easures available. In all cases, h owever, all areas of com pression or poten tial compression m ust be addressed. Surgical tech n iques vary from simple decompression to n erve
582
Figure 14.37 Ulnar nerve transposition. (Reproduced with permission from Morrey BF. Master
Techniques in Orthopaedic Surgery: The Elbow. 2nd ed. Philadelphia, PA: Lippincott Williams &
Wilkins, 2002.)
RECOMMENDED READINGS
CONCLUSION
For n orm al elbow fun ction , a delicate in terplay of bon es,
ligam en ts, an d m uscles m ust exist. Traum atic an d atraum atic disorders disrupt th is delicate in terplay in m ultiple differen t ways. Th ey all lead to a com m on en dpoin t,
15
Jon as L. Matzon
ANATOMY
Anatomy of the h and is m ore intricate than perhaps any
oth er area of th e m usculoskeletal system . Kn owin g th e
an atomy is fundam ental to un derstanding the basic han d
function and to diagnosing dysfun ction when evaluating a
patien t with a h an d in jury in th e clin ic or em ergen cy departm en t settin g.
584
with permission from Doyle JR, Botte MJ. Surgical Anatomy of the
Hand and Upper Extremity. Philadelphia, PA: Lippincott Williams &
Wilkins, 2003.)
Th e m etacarpus is th e skeletal region of th e h an d, bordered by th e distal carpal row proxim ally an d th e ph alanges distally. It consists of five elon gated bon es with a
h ead, neck, body, an d base area. Th e TM differs sligh tly
from th e others in that its epiphysis is located proxim ally
instead of distally, and its base is saddle-shaped, which increases overall m obility. All th e MC heads are cam -shaped,
m eaning that their diam eter from palm ar to dorsal is larger
than from the distal head to neck junction . Th e m etacarpoph alan geal (MCP) join ts are stabilized m edially an d laterally by radial an d uln ar collateral ligam en ts. Th ese ligam ents start dorsally on the MC h ead and attach volarly
on th e proxim al ph alan x. Because of th e cam sh ape of
the MC heads, th e collateral ligam ents are taut in flexion and lax in extension (Fig. 15.5). In addition, th e volar
surface of th e MCP join t contain s fibrous thickenings of
the joint capsule, collectively referred to as volar plates,
wh ich add stability to th e join t an d serve as restrain ts to
hyperexten sion .
Th e ph alan ges articulate directly with th e MC h eads.
Each digit is com posed of th ree ph alan ges (proxim al, m iddle, an d distal) with th e exception of th e th um b, wh ich
h as only a proxim al an d distal ph alan x. Th e ph alan ges decrease in size as one m oves from proxim al to distal. Th eir
h eads are bicon dylar in sh ape, un like th ose of th e aforem en tioned MCs. They are stabilized laterally and m edially
by collateral ligam ents, which sh are the sam e orientation
as those in the MCs.
585
B
Figure 15.2 (A) Volar radiocarpal ligaments. (B) Dorsal radiocarpal ligaments. (Reprinted with permission from Doyle JR and Botte MJ. Surgical Anatomy of the Hand and Upper Extremity. Philadelphia:
Lippincott Williams & Wilkins, 2003.)
Figure 15.3 The normal volar tilt of the distal radius av-
586
ECU, extensor carpi ulnaris. (Reprinted with permission from Doyle JR, Botte MJ. Surgical Anatomy of the
Hand and Upper Extremity. Philadelphia, PA: Lippincott
Williams & Wilkins, 2003.)
the tendons to the lon g and ring fingers are m ore superficial than those to the index and sm all at the level of the
carpal tunn el. The FDP originates off the anterior ulna and
in terosseous m em bran e an d run s th rough th e carpal tun nel on its way to in serting on the distal ph alan ges of th e
in dex th rough sm all fin ger. It allows flexion of th e distal in -
A
B
MC
PH
MC
PH
Figure 15.5 The cam shape of the metacarpal heads causes the collateral ligaments to be more taut
in flexion than extension. MC, metacarpal; PH phalanx. (Reprinted with permission from Bucholz RW,
Heckman JD, Court-Brown CM, et al. Rockwood and Greens Fractures in Adults. 6th ed. Philadelphia,
PA: Lippincott Williams & Wilkins, 2006.)
Bicipita l
a pone uros is
P rona tor te re s
Ra dia l a rte ry
587
Extrinsic Extensors
Fle xor
pollicis
longus
P rona tor
qua dra tus
P a lma r
ca rpa l
bra nch
P a lma r
ra dioca rpa l
bra nch
S upe rficia l
pa lma r
bra nch
(B)
TABLE 15.1
1.
2.
3.
4.
5.
6.
588
Collateral ligament
Distal interphalangeal joint
Accessory ligament
Collateral ligament
Metacarpal phalangeal joint
Proximal interphalangeal joint
Rexor digitorum
profundus
C3 pulley
Rexor digitorum
superficialis
A2 pulley
A4 pulley
C2 pulley
A3 pulley
C1 pulley
A1 pulley
Figure 15.7 The pulley system of the finger. (Adapted with permission from Hoppenfeld S, deBoer
P. Surgical Exposures in Orthopaedics: The Anatomic Approach. 3rd ed. Philadelphia, PA: Lippincott
Williams & Wilkins, 2003.)
589
La te ra l
mus cle s
Exte ns or ca rpi
ra dia lis bre vis
Exte ns or digitorum
Exte ns or digiti minimi
Abductor pollicis
longus
Exte ns or indicis
Exte ns or pollicis
bre vis
Outcropping
mus cle s
of the thumb
Exte ns or pollicis
longus
Exte ns or re tina culum
Common fibrous s he a th of
a bductor pollicis longus a nd
e xte ns or pollicis bre vis
Ra dia l a rte ry in the
a na tomica l s nuff box
Dors a l ca rpa l bra nch
of ra dia l a rte ry
Dors a le s pollicis a rte rie s
Dors a lis indicis a rte ry
Dors a l digita l
a rte rie s
as th eir volar counterparts. However, th ey are all bipen nate m uscles an d assist in digit abduction . Both groups of
interossei are innervated by the ulnar nerve. In addition,
they both help the lum bricals with MCP flexion and IP
exten sion .
Th e th en ar m uscles are composed of th e abductor pollicis brevis (APB), flexor pollicis brevis (FPB), and opponens pollicis (OP). The APB originates on the scaphoid an d
590
Figure 15.9 The extensor mechanism of the finger. (Reprinted with permission from Doyle JR and
Botte MJ: Surgical Anatomy of the Hand and Upper Extremity. Philadelphia: Lippincott Williams &
Wilkins, 2003.)
Ancone us
591
De e p bra nch of
the ra dia l ne rve
Bra chiora dia lis
Exte ns or ca rpi
ra dia lis longus
P la n e o f s e c tio n fo r (B)
Exte ns or ca rpi
ra dia lis bre vis
P os te rior inte ros s e ous
ne rve a nd a rte ry
Exte ns or
digitorum
Exte ns or digiti
minimi
Ra dius
Exte ns or pollicis
bre vis
Ou tc ro p p in g
m u s c le s o f th u m b
Exte ns or pollicis
longus
Ra d ia l a rte ry
(in a na tomica l
s nuff box)
Dors a lis pollicis
a rte rie s
VASCULAR
Th e m ain blood supply to wrist an d h an d is via th e radial an d uln ar arteries, wh ich are term in al bran ch es of
the brachial artery (Fig. 15.12). Th e ulnar artery, which
is slightly larger than its radial counterpart, starts in proxim al forearm , runn ing on top of FDP and beneath both
FDS an d FCU. As it travels m ore distal, th e uln ar artery is
located just radial to uln ar nerve. After traversing the TCL,
P rope r pa lma r
digita l a rte rie s
P rope r pa lma r
digita l ne rve s
Fibrous digita l s he a th
Fle xor digitorum
s upe rficia lis
Common pa lma r digita l a rte rie s
a nd ne rve s
2nd lumbrica l
Abductor
Digiti
minimi
1s t lumbrica l
Te ndon of
fle xor pollicis longus
Fle xor pollicis bre vis
Communica ting
Bra nche s of
ulna r ne rve
S upe rficia l
Oppone ns pollicis
De e p
P is iform
Fle xor re tina culum
(tra ns ve rs e ca rpa l
liga me nt)
Ulna r ne rve a nd a rte ry
B
Figure 15.11 The superficial (A) and deep (B) intrinsic hand muscles. (Reprinted with permission
from Moore KL, Dalley AF. Clinically Oriented Anatomy. 4th ed. Philadelphia, PA: Lippincott Williams
& Wilkins, 1999.)
593
forearm and hand. (Reprinted with permission from Doyle JR, Botte MJ. Surgical Anatomy of the Hand and Upper
Extremity. Philadelphia, PA: Lippincott
Williams & Wilkins, 2003.)
carpal branch, and a superficial palm ar branch. The superficial palm ar bran ch an astom oses with th e uln ar artery
to complete th e superficial palm ar arch . Th e radial artery
con tinues dorsally under the APL and EPB tendons as it
en ters th e an atom ic sn uffbox. After passin g th rough th e
sn uffbox, it dives between the heads of the first dorsal in terosseus m uscle an d gives off two addition al bran ch es: th e
prin ceps pollicis, wh ich supplies th e th um b, an d th e radialis in dicis artery, wh ich supplies th e radial in dex fin ger.
Th e rem ainder of th e radial artery term in ates in to th e deep
palm ar arch .
Th e deep arch gives off th ree palm ar MC arteries an d
the superficial arch gives off three com m on palm ar digital
arteries. Th e palm ar MC arteries join th e com m on palm ar
594
P a lma r digita l
a rte rie s a nd
ne rve s
Fibrous digita l
s he a th
Fibrous digita l s he a th
P a lma r
a pone uros is
P a lm a r
Hypothe na r
fa s cia
The na r
fa s cia
P a lma ris
bre vis
Fle xor
re tina culum
(tra ns ve rs e
ca rpa l
liga me nt)
P a lma ris
longus
te ndon
P a lm a r vie w
P a lma r
digita l
Cuta ne ous
liga me nt
Dors a l (e xte ns or)
e xpa ns ion
Do rs a l
Figure 15.13 Cross section of a finger showing the relationships between the tendons and surrounding neurovascular structures. (Reprinted with permission from Moore KL, Dalley AF. Clinically
Oriented Anatomy. 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 1999.)
NERVE ANATOMY
Th e th ree m ain n erves th at supply th e h an d are th e uln ar,
m edian , an d radial. Th e uln ar n erve en ters th e forearm after
em ergin g from th e m edial epicon dylar groove an d piercin g
the two h eads of the FCU. It runs down the length of the
forearm , just radial to the ulnar artery. Before reaching the
radiocarpal joint, it gives off dorsal and palm ar sensory
bran ch es. After en terin g th e Guyon can al, it divides in to a
superficial and deep branch . Th e superficial branch turns
in to th e proper digital n erves to th e sm all fin ger an d uln ar
595
m ore superficially a few centim eters proxim al to the exten sor retin aculum . Th e superficial radial n erve is purely
sen sory in fun ction and provides sensation to the dorsum
of both th e wrist an d th e proxim al h alf of th e followin g
digits: th um b, in dex, lon g fin ger, an d radial h alf of th e rin g
fin ger.
Th e digital n erves lie volarly an d at th e periph ery of th e
digits. As m en tion ed previously, th ey are superficial to th e
digital arteries. Th e n eurovascular bun dle is protected by
two thickened ligam entsGrayson and Cleland ligaments
wh ich are located volarly an d dorsally, respectively. Th e
digital arteries an d n erves are protected by th ese ligam en ts
(see Figs. 15.13 and 15.14).
PATIENT EVALUATION
History
Th e key to diagn osin g any h an d path ology begin s with
a well-taken history. O ne should begin by obtainin g the
patien ts age, h an dedn ess, m ode of em ploym en t, an d
explorin g h is or h er ch ief complain t. Typically, a patien t
will complain of pain in a specific area of th e h an d. A good
Physical Examination
As in any m edical field, th e physical exam in ation of th e
h an d sh ould begin with in spection . On ce in spection is
com plete, on e sh ould proceed with palpation an d ran ge
of m otion of all join ts of th e h an d, especially th e area of
596
Radiographic Evaluation
Radiograph ically, th e in itial in vestigation begin s with plain
radiographs showing th ree views of the hand and/or finger
(an teroposterior or posteroan terior [PA], lateral, oblique)
depen din g on th e circum stan ces. Occasion ally, a special
view m ay be requested depen din g on th e patien ts symptom atology an d th e suspected diagn osis. For example, if th e
clinician is worried about a h ook of the ham ate fracture,
he or sh e m ight request a carpal tunnel view, wh ich provides
a better view of th e h ook itself. An oth er importan t addition al view is th e scaphoid view, wh ich is sh ot with th e wrist
in uln ar deviation . Uln ar deviation causes scaph oid to exten d, wh ich places it in th e plan e of th e radius, m akin g it
easier to evaluate for fracture.
More soph isticated im agin g m ay be n ecessary for certain types of suspected in juries. For example, a patien t with
un explain ed an atom ic sn uffbox ten dern ess 2 weeks after
a fall on to an outstretch ed h an d m igh t m erit a m agn etic
reson an ce im agin g (MRI) scan to rule out a scaph oid fracture. MRI can also be useful for evaluation of TFCC tears,
scapholunate ligam ent disruption , or suspected avascular
necrosis of a carpal bone. CT scan can be useful for evaluatin g bon e in juries such as in traarticular distal radius fractures or h ook of th e h am ate fractures.
Classification
Distal ph alan x fractures are classified on th e basis of location , in to th ree types: tuft, sh aft, an d in traarticular.
Mechanism of Injury
Fractures of th e distal ph alan x are gen erally th e result of a
crush injury.
597
Mechanism of Injury
Th e typical m ech an ism s are crush in jury an d axial load.
Phalangeal Dislocations
E
Figure 15.16 (AE) Technique of extension block pinning.
(Reprinted with permission from Bucholz RW, Heckman JD, CourtBrown CM, et al. Rockwood and Greens Fractures in Adults. 6th
ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
ten don is attach ed to th e avulsed fragm en t, th e in jury is often referred to as a bony mallet finger. Th is in jury frequen tly
requires closed reduction an d percutan eous pin n in g, especially if greater th an 50% of the joint surface is in volved
or there is DIP joint subluxation (Fig. 15.16). The m ajority
of in juries th at in volve an FDP avulsion fracture h ave to be
repaired surgically to restore th e flexion m ech an ism of th e
fin ger.
Classification
Fractures of th e proxim al an d m iddle ph alan x can be divided into the following types based on anatom ic location:
base, sh aft, n eck, an d con dylar (Fig. 15.17)
Classification
Ph alan geal dislocation s are classified as dorsal, volar, rotatory, or lateral.
Mechanism of Injury
Th ese in juries are com m on ly th e result of an axial load to
an extended digit.
Presentation and Physical Examination
Th e patien t will often complain of pain an d difficulty m oving th e involved joint.
Th e patien t will h ave ten dern ess over affected join t, an
obvious deform ity, an d reduced active an d passive m otion
of th e join t.
Radiographic Findings/Special Studies
Plain an teroposterior, lateral, an d oblique radiograph s of
th e in volved fin ger will dem on strate dorsal, volar, or lateral
dislocation of th e m ore distal ph alan x relative to th e m ore
proxim al ph alan x (or MC).
Treatment
DIP dislocation s are com m on ly dorsal an d easily reduced.
PIP dislocation s can be volar, dorsal, or lateral an d are also
easily reduced, usually with a m an euver con sistin g of gen tle
traction and volar or dorsal pressure on the m iddle phalanx
(Fig. 15.18). Rotational PIP dislocations can be irreducible
by closed m ethods and m ay require surgical intervention.
598
Metacarpal Fractures
Th e MCs are com m on sites of in jury in th e h an d. Th ey are
often in jured durin g physical altercation s wh en on e in dividual attempts to pun ch another person or object with a
closed fist.
B
Figure 15.18 (A) Dorsal proximal interphalangeal dislocation and (B) subsequent reduction.
(Reprinted with permission from Bucholz RW, Heckman JD, Court-Brown CM, et al. Rockwood and
Greens Fractures in Adults. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
Figure 15.19 Oblique fracture of metacarpal shaft with shortening. (Reprinted with permission from Bucholz RW, Heckman JD,
Court-Brown CM, et al. Rockwood and Greens Fractures in Adults.
6th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
Classification
MC fractures are classified on th e basis of anatom ic location
as h ead, neck, shaft, an d base (Fig. 15.19).
Mechanism of Injury
Th e fractures are typically th e result of eith er a crush in jury
or an axial load to th e MC (e.g., wh en pun ch in g an object
with a clen ch ed fist).
Presentation and Physical Examination
Patients typically complain of pain an d swelling over the
affected MC after an in jury. Patients typically dem onstrate
ten dern ess an d swellin g over th e affected MC. Th e MC h ead
m ay be depressed, giving the appearance of a m issing
knuckle.
Radiographic Findings/Special Studies
Plain PA, lateral, an d oblique radiograph s of th e h an d will
dem on strate a visible fracture lin e. A Brewerton view can
be h elpful to evaluate for collateral ligam en t avulsion fractures. It is taken with the MP joints flexed 60 to 70 degrees,
the dorsal surfaces of th e digits placed flat on the x-ray
cassette, and the beam angled 15 degrees radial.
599
Treatment
MC h ead fractures are relatively uncom m on but when they
occur, th ey are often difficult to treat an d gen erally require operative stabilization . A simple fracture pattern can
be m an aged effectively with eith er closed reduction an d
percutan eous pin n in g or open reduction in tern al fixation
(ORIF). Com m inuted fractures can be m anaged sim ilarly
but h ave poorer outcom es an d m ay require future arth roplasty.
Fractures of th e MC n eck are relatively frequen t. Th ey
carry th e eponym boxers fracturesbecause of th eir m ech anism , wh ich is an axial load across a clenched fist. MC
n eck fractures generally assum e an apex dorsal an gulation
deform ity. Th ey m ay also exh ibit rotation al deform ity,
wh ich is importan t to n ote as it m ay m erit reduction even
if angulation is m in im al. Criteria for acceptable an gulation
varies dependin g on the source, but m any surgeons use the
10 20 30 40 rule in wh ich 10 degrees is acceptable for th e
index finger, 20 for the long, 30 for the ring, and 40 for
th e sm all. Th ere is little eviden ce in th e literature regarding what acceptable angulation is, and there are som e
biom ech an ical data for th e sm all fin ger MC th at suggest
th at an gulation of m ore th an 30 degrees leads to sign ifican t
dysfun ction of th e flexor system . If displacem en t is greater
th an th e accepted degree for a particular fin ger, a closed
reduction is warran ted. A com m on ly applied tech n ique is
th e Jahss maneuver, in wh ich th e affected digit is volar flexed
to 90 degrees and a volar to dorsal force is applied through
th e proxim al ph alan x so as to restore th e n orm al align m en t
of th e MC n eck (Fig. 15.20). Any rotation al deform ity can
also be corrected while perform ing th is m aneuver. Aplaster
spin t or cast sh ould be applied to m aintain this reduction
with th e affected digit in a 90 degree volar flexed position ,
wh ich serves to m ain tain reduction an d preven t th e MC
h ead collateral ligam ents from sh orten in g. As reduction is
often difficult to m ain tain in a splin t or cast, th ese fractures
m ay require a repeat reduction with percutan eous pinning
in the operating room setting.
As noted earlier, MC shaft fractures are typically the result of eith er an axial load or a crush injury. Th ey generally
create an apex dorsal an gulation deform ity due to th e vector of pull of th e interosseus m uscles, wh ich is volar (Fig.
15.21). Most clin ician s consider n onoperative treatm en t in
a spint or cast if sagittal plane deform ity is less than 30 degrees an d th ere is n o sign ifican t rotation al m alalign m en t.
In gen eral, un stable MC sh aft fractures require operative
fixation, which consists of percutaneous pinning versus
ORIF with plates and/ or screws. It is important to be aware
th at m ultiple MC sh aft fractures in th e sam e h an d can result in a com partm ent syn drom e, in which the patient will
presen t with a very swollen pain ful h an d h eld in th e intrinsic minus (MP join t exten sion an d IP join t flexion ) position .
Fractures of th e MC base are less com m on th an in th e
n eck but can be m ore problem atic, particularly when in traarticular. The often involve the thum b an d sm all finger.
600
(Reprinted with permission from Bucholz RW, Heckman JD, CourtBrown CM, et al. Rockwood and Greens Fractures in Adults. 6th
ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
An in traarticular fracture at the base of the thum b MC is often referred to as a Bennett fracture (Fig. 15.22). Th is in jury
is typically caused by axial load to flexed thum b. Deform ity
an d difficulty with h ealin g is th e result of th e fact th at th e
APL pulls the thum b MC shaft radially an d dorsally while
the deep volar oblique (beak ligament) rem ains attached to
the ulnar-sided fragm ent. Of note, the eponym Rolando
fractureis used when there is com m inution at the thum b
MC base an d both an uln ar an d radial fragm en t are visible.
Last, a baby Bennettis the term used for an intraarticular
fracture at the base of the sm all fin ger MC. In this scenario,
B
Figure 15.21 Ring and small finger metacarpal fracture (A) status post open reduction internal
fixation (B). (Reprinted with permission from Bucholz RW, Heckman JD, Court-Brown CM, et al.
Rockwood and Greens Fractures in Adults. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins,
2006.)
601
the ECU pulls the sm all finger MC sh aft uln arly, m akin g
healing difficult. Each of th ese intraarticular MC base fractures generally require percutaneous pinning versus O RIF.
Gamekeepers Thumb
Ligam entous in jury involving the MCs occurs quite frequen tly, with th e MCP join t of th e th um b bein g th e
m ost vuln erable due to its hyperm obility. Classically, gamekeepers thumb refers to ch ron ic atten uation of th e uln ar collateral ligam ent, while skiers thumb refers to acute rupture
of th e ligam en t.
Mechanism of Injury
Radial-directed stress on th e th um b MCP join t can dam age
the uln ar collateral ligam en t, resulting in a gam ekeepers
thum b.
Presentation and Physical Examination
Th e patien t typically complain s of pain an d in stability at
the thum b MCP joint.
O n exam in ation , th e patien t will h ave ten dern ess to palpation at th e uln ar aspect of th e th um b MCP join t an d will
have gapping at the joint with radial stress. The joint sh ould
be stressed in full exten sion an d in 30 degrees of flexion .
Compared with th e con tralateral side, greater than 35 degrees of in creased an gulation in exten sion or greater th an
15 degrees of increased angulation in flexion is diagnostic.
Radiographic Findings
Stan dard an teroposterior, lateral, an d oblique radiograph s
of th e th um b m ay dem on strate a bony fleck in th e region
of th e th um b MCP represen tin g th e avulsion of th e uln ar
collateral ligam en t.
Special Studies
Stress radiograph s of th e th um b with a radial-directed force
m ay reveal gapping at th e MCP join t. Ultrasonography and
MRI can also h elp in establishing the diagnosis.
Treatment
Patients who dem on strate m inim al gapping with radial
stress are likely to h ave only a partial uln ar collateral ligam en t rupture, which can be treated with th um b spica casting for 6 weeks. However, gapping with radial stress greater
than 35 degrees in extension or greater than 15 degrees in
30 degrees of flexion suggests a com plete rupture. In com plete tears, th e ligam en t can becom e lodged beh in d AP
aponeurosis, which prevents healing (known as a Stener lesion) (Fig. 15.23). Th erefore, early surgery is advocated for
complete tears.
CARPUS
Scaphoid Fractures
Th e scaph oid is th e m ost frequen tly fractured bon e in th e
carpus and the slowest to heal. Scaphoid fractures are fre-
quen tly m issed sin ce th ey often can n ot be visualized on in itial radiographs and require close follow-up for detection.
All scaph oid fractures can be problem atic but fractures
of th e proxim al pole are th e m ost worrisom e. Sin ce th e
scaph oid h as a retrograde blood supply from the radial
artery, which enters m ainly on its dorsal ridge, the proxim al pole is particularly susceptible to avascular necrosis
wh en fractured.
Classification
Fractures of scaphoid are often described on th e basis of
anatom ic location as tubercle, proxim al pole, waist, or distal pole (Fig. 15.24).
Mechanism of Injury
Th e scaph oid is typically in jured by a fall on to an outstretch ed h and.
Presentation and Physical Examination
Th e patien t will typically complain of pain over th e region
of th e an atom ical sn uffbox after a fall. Th e patien t often
h as radial-sided swellin g an d pain with m ovem en t. Frequen tly, th ere is ten dern ess to palpation dorsally over th e
anatom ical snuffbox or volarly over the scaph oid tubercle.
Radiographic Findings
Standard radiographic evaluation of the scaphoid begin s
with th ree plain radiograph views of th e wrist, wh ich in clude a PA, lateral, an d oblique.
602
Tuberosity
fracture
Waist fracture
Proximal
fracture pole
Special Studies
To better visualize th e scaph oid, on e can request a
scaphoid view of the wrist, which is a PA shot with approxim ately 20 degrees of uln ar deviation . Uln ar deviation
rotates th e scaph oid in to th e sam e axis as th e radius an d
m in im izes overlap between th e waist an d tubercle, allowin g on e to visualize th e scaph oid alon g its en tire len gth
(Fig. 15.25).
Sin ce scaph oid fractures m ay n ot sh ow up on in itial radiograph s, any patien t wh o com plain s of an atom ic sn uffbox pain after traum a to th e h an d/ wrist sh ould be placed
in th um b spica splin t an d sh ould be followed up for repeat
radiographs in 2 to 3 weeks (Fig. 15.26). At that tim e, bone
Radial deviation
Neutral
Ulnar deviation
Normal synchronous
flexion/extension
Extension
Neutral
Flexion
imal carpal row during radial/ulnar deviation and flexion/extension. (Reprinted with
permission from Bucholz RW, Heckman JD,
Court-Brown CM, et al. Rockwood and
Greens Fractures in Adults. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
603
B
Figure 15.27 A clear scaphoid fracture on magnetic resonance imaging (A), which is difficult to
see on plain radiograph (B). (Reprinted with permission from Bucholz RW, Heckman JD, Court-Brown
CM, et al. Rockwood and Greens Fractures in Adults. 6th ed. Philadelphia, PA: Lippincott Williams &
Wilkins, 2006.)
Treatment
As note earlier, scaphoid fractures com e in four varieties:
tubercle, proxim al pole, waist, and distal pole. In general,
scaphoid fractures are treated on th e basis of displacem en t;
however, som e surgeons choose to surgically fix all proxim al pole fractures to m inim ize the ch ances of avascular necrosis. Nondisplaced fractures can be treated with a
thum b spica cast. Som e surgeons place patients in a long
arm thum b spica for 6 weeks, after which they are placed
in a short arm thum b spica until the fracture has healed.
Th ese fractures can take from 3 to 6 m on th s to h eal. Waist
fractures average approxim ately 12 weeks to heal, whereas
proxim al pole fractures gen erally take approxim ately 20 to
25 weeks. Because of th ese prolon ged h ealin g tim es, patients m ay be given a choice of surgical fixation even for
nondisplaced injuries.
Displaced scaph oid fractures require operative fixation ,
usually with a h eadless compression screw. O th er criteria
for fixation include scapholunate angle of greater than 60
degrees an d radiolun ate an gle of greater th an 15 degrees.
Th e procedure can be don e eith er percutan eously or open .
If don e open , m ost surgeon s advocate a volar approach for
waist to distal pole fractures and dorsal approach for waist
to proxim al pole (Fig. 15.28).
604
Fin ally, fractures of th e proxim al pole or th ose dem on stratin g avascular necrosis m ay require vascularized bon e
grafts. Th e m ost com m on ly used is th e distal radius vascularized bon e graft based on th e 1,2 intercompartm en tal supraretin acular artery, wh ich h as dem on strated un ion
rates of approxim ately 70%. More recently, som e centers
have attempted free vascularized grafts from the m edial
fem oral condyle.
Lunate Fractures
Th e lun ate is th e fourth m ost com m on ly fractured bon e in
the carpus. Sim ilar to th e scaph oid, it has a tenuous blood
supply th at can be disrupted when a fracture occurs.
Classification
Th ere are five types of lun ate fractures: palm ar pole, osteoch on dral ch ip, dorsal pole, sagittal oblique, an d coron al
split.
Mechanism of Injury
Th e typical m ech an ism is a fall on to an outstretch ed, hyperexten ded wrist.
Presentation and Physical Examination
Patien ts often complains of central wrist pain and/ or pain
with wrist m ovem en t after a fall. Physical findin gs in clude
ten dern ess to palpation in th e cen ter of th e wrist an d pain
with wrist range of m otion .
sclerosis of th e lun ate. Stage III involves sclerosis and fragm entation of th e lunate and is divided into A and B based
on eith er th e absen ce (A) or presen ce (B) of fixed scaph oid
rotation . Stage IV is degen erative arth ritis of th e adjacen t
intercarpal join ts.
In term s of treatm en t, Stage I can be treated with im m obilization, whereas stages II through IIIA m ay require
revascularization an d joint leveling procedures (e.g., uln ar len gth enin g, radial sh orten in g) or even carpal fusion s,
wh ich h elp to un load th e lun ate. With fixed rotation of th e
scaphoid, a proxim al row carpectomy (PRC) or intercarpal
fusion m ay be indicated. Finally, with stage IV disease, a
total wrist fusion or PRC is recom m ended.
Triquetral Fractures
Triquetral fractures are the second m ost com m on type of
carpal fracture behin d fractures of the scaphoid.
Classification
Th ere are two types of triquetral fractures: dorsal rim ch ip
fractures, which are the m ost com m on, and body fractures.
Mechanism of Injury
Wrist hyperflexion with radial deviation is a com m on cause
of dorsal ch ip fractures, wh ereas triquetral body fractures
are often caused by direct traum a.
Radiographic Findings
Stan dard PA, lateral, an d oblique radiograph s of th e h an d
m ay be n egative.
Special Studies
CT of th e wrist m ay h elp to delin eate a lun ate fracture if
plain radiograph s are n egative. MRI is in dicated if Kien bock
disease (osteon ecrosis of th e lun ate) is suspected.
Treatment
In gen eral, m in im ally displaced lun ate fractures can be
treated with 4 to 6 weeks of im m obilization in a sh ort or
lon g arm cast. Fractures associated with in traarticular in congruity or instability are gen erally treated with ORIF.
Treatment
Sm all dorsal ch ip triquetral fractures an d m in im ally displaced body fractures can typically be treated with 4 to
6 weeks of cast im m obilization . If the fragm ent is sizable, it
results in in stability, or if it is sign ifican tly displaced, O RIF
m ay be indicated.
Complications
O f n ote, on e of th e poten tial an d m ore devastatin g com plications of lunate traum a is Kienbock disease. It is believed
that traum a, which can be acute or ch ronic from repetitive stress (e.g., as in patients with negative uln ar varian ce,
which causes in creased stress on th e lunate), disrupts the
ten uous blood supply of th e lun ate, leadin g to avascular
necrosis. MRI or bon e scan should be obtained if there is
any suspicion . Th is disease an d its severity can be ch aracterized by th e Lichtman classification system. Th is system is
based on plain radiograph appearan ce an d divides Kien bock disease in to four stages. Stage I represen ts n o visible
ch an ges in th e lun ate on plain film , on ly MRI. Stage II is
Trapezium Fractures
Trapezial fractures are the third m ost com m on carpal
fracture.
Classification
Th ere are five types of trapezium fractures: vertical tran sarticular, horizon tal, dorsoradial tuberosity, anterom edial
ridge, an d com m in uted.
Mechanism of Injury
Th e m ost com m on m ech an ism is an axial load to th e TM.
605
Capitate Fractures
Capitate fractures are rather rare but often have poor outcom es.
Classification
Th ere are four types: tran sverse body, tran sverse proxim al
pole, coron al oblique, an d parasagittal.
malunion. (Reprinted with permission from Doyle JR, Tornetta P, Einhorn TA. Orthopaedic Surgery Essentials: Hand and Wrist. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
Mechanism of Injury
Th e m ost com m on m ech an ism of in jury is an axial load
on a hyperexten ded wrist.
Classification
Ham ate fractures can in volve either the body or hook, the
latter of which is exceedingly m ore com m on.
Mechanism of Injury
Ham ate fractures can result from a direct blow to the h am ate or from chronic repetitive impact (Fig. 15.30).
Hamate Fractures
Hook of h am ate fractures are m ost frequently seen in th ose
wh o en gage in stick or racquet sports, such as golfers an d
baseball players. Th ese fractures can be difficult to h eal an d
606
Treatment
Non displaced h am ate body fractures can be treated with
cast im m obilization , whereas displaced or unstable fractures m ay require excision of th e fractured h ook, or rarely
O RIF. It is gen erally recom m en ded th at displaced fractures
or n on un ion s of th e h ook be excised.
Pisiform Fractures
Pisiform fractures are rath er un com m on in juries seen in
the carpus.
Classification
A variety of classification system s exist, in cluding the Frykm an and Melon e, but there is no gen eral con sensus as to
wh ich on e sh ould be used (Fig. 15.31). In gen eral, distal
radius fractures are referred to by certain eponym s, wh ich
include Colles (dorsal displacem ent), Sm ith (volar displacem en t), Barton (radial rim fracture with eith er volar or
dorsal displacem en t of th e carpus), or Ch auffeur fractures
Classification
Th ere are four types: tran sverse (m ost com m on ), parasagittal, com m in uted, an d pisotriquetral impaction .
Mechanism of Injury
Th e typical m ech an ism is direct traum a to th e pisiform .
Type I
Type IIA
Type IIB
3
3
1
2
4
1
4
Type III
Type IV
Type V
3
1
4
Figure 15.31 The Melone classification for distal radius fractures. (Reprinted with permission from
Bucholz RW, Heckman JD, Court-Brown CM, et al. Rockwood and Greens Fractures in Adults. 6th
ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
Mechanism of Injury
Th ese gen erally occur by a fall on to an outstretch ed h an d.
Presentation and Physical Examination
Th e patien t complain s of pain an d swellin g over th e wrist
after a fall. On exam ination, the patient will exhibit tendern ess over th e wrist with lim ited ran ge of m otion . A detailed n eurovascular exam in ation m ust be perform ed, with
special attention given to the m edian nerve. Patients wh o
presen t with n um bn ess in th e m edian n erve distribution
often h ave im proved symptom s after fracture reduction .
However, on occasion , patients develop progressive deterioration of m edian n erve fun ction , wh ich is suggestive of
acute carpal tunnel syndrom e (CTS). In these situations,
any restrictive dressings, splin ts, and/ or casts should be rem oved, and the wrist should be placed in a neutral position. If the symptom s do not improve, the patient should be
taken to th e operatin g room for an em ergen t carpal tun n el
release.
Radiographic Findings/Special Studies
Stan dard an teroposterior, lateral, an d oblique views of th e
wrist are in itially obtain ed. In cases in wh ich th e fracture is
com m inuted or intraarticular, a CT scan can be obtained
to assist with preoperative plan n in g.
Treatment
Treatm ent options for distal radius fractures differ depen ding on several variables, such as a patien ts age, activity level,
an d occupation. However, the degree of displacem ent is the
m ost important factor that influen ces m anagm ent. Recall
from th e anatomy section th at the distal radius is tilted
volarly at an angle of approxim ately 11 degrees. Its angle of
radial in clin ation is rough ly 22 degrees wh ile its h eigh t radially is approxim ately 11 m m relative to its m ost uln ar surface. Th ese n um bers are importan t in determ in in g wh eth er
a reduction, open or closed, is n ecessary. However, even after reduction , fractures h ave a ten den cy to return to th eir
initial displacem en t. Alth ough n o consensus exists, m ost
would con sider acceptable align m en t in a h ealthy, active
patien t to be up to 10 degrees of dorsal tilt (20 degrees from
norm al), less than 2 m m of in traarticular step-off at radiocarpal joint, less than 5 m m of radial shortenin g, a congruen t DRUJ, an d m ore th an 15 degrees of radial in clin ation .
If closed reduction is warran ted, th e reduction m an euver m ay vary depending on the nature of the fracture. The
gen eral prin ciple is to recreate th e m ech an ism th at caused
the deform ity. For example, a Colles fracture occurs via
a wrist hyperextension m echanism ; th erefore, when reducing these fractures, one sh ould not simply pull lon gitudinal
traction on the wrist but hyperextend it so as to lever the
dorsally displaced fragm en t back in to position . Con versely,
for a Sm ith fracture, a wrist hyperflexion reduction m aneu-
607
Figure 15.32 A volar distal radius plate. Note that the more dis-
tal the plate placement, the more likely a screw will penetrate the
articular surface. (Reprinted with permission from Bucholz RW,
Heckman JD, Court-Brown CM, et al. Rockwood and Greens Fractures in Adults. 6th ed. Philadelphia, PA: Lippincott Williams &
Wilkins, 2006.)
608
O f n ote, a related fracture pattern seen in th e distal forearm is the Galeazzi fracture, in wh ich a distal radial sh aft
fracture occurs in com bination with a DRUJ dislocation.
Th is in jury requires ORIF of radial sh aft with possible percutaneous pinning of the DRUJ, depen ding on the stability
of th e DRUJ after closed reduction .
609
Mechanism of Injury
Th e TFCC is susceptible to in jury, eith er from gen eral wrist
overuse or from acute traum a. Th e specific m ech an ism is
an extension or pronation force to an axially loaded wrist.
Presentation and Physical Examination
Patien ts with TFCC tears typically presen t with uln ar-sided
wrist pain an d m ay complain of a clickin g sen sation in th eir
wrist with certain m ovem en ts. Patien ts usually experien ce
ten dern ess to palpation over th e fovea, wh ich is th e area
between th e FCU an d ECU. Also, th e TFCC com pression
test, wh ich in volves axial loadin g an d uln ar-deviatin g th e
wrist, can often exacerbate pain .
Differential Diagnosis
Other causes of ulnar-sided wrist pain should be in cluded
in the differential diagnosis for a TFCC tear, in cluding both
ECU an d FCU ten don itis, uln ocarpal abutm en t, lun otriquetral in stability, uln ar styloid fracture, triquetrum fracture, and pisiform fracture.
Classification
TFCC tears h ave been divided by Palm er in to two classes:
traum atic (Class I) and degenerative (class II). Class IAtears
are central perforation s of the articular disc. Class IBlesion s
are ulnar-sided avulsion s that m ay or m ay not be associated
with an uln ar styloid fracture. Th ese lesion s can destabilize
the DRUJ. Class IC lesion s are distal avulsions of eith er the
uln olun ate or uln otriquetral ligam en ts. Class ID lesion s
involve radial-sided avulsions of either the dorsal or volar
radiocarpal ligam en ts.
Class II lesion s are degen erative an d are often th e result of uln ocarpal abutm ent syndrom eexcessive loadin g
of th e uln ocarpal join t secon dary to positive uln ar varian ce.
Class IIA lesions involve TFCC thinnin g, while class IIB involves thinnin g plus lunate an d/or ulnar ch on drom alacia.
Class IIC is the addition of perforation to th e TFCC while
Treatment
Alth ough certain types of TFCC tears m ay require surgical
treatm ent, all TFCC tears warrant an initial trial of conservative therapy, which includes splinting, anti-inflam m atory
m edication, and activity m odification for 6 weeks. On ly if
sym ptom s persist sh ould arthroscopic or open surgery be
con sidered.
Class IA tears involve a relatively avascular zone and,
th erefore, can n ot be repaired. In stead, arth roscopic debridem en t is th e treatm en t of ch oice. Class IB lesion s can
destabilize th e DRUJ. Sin ce th ey occur in th e m ore vascular
periph ery of th e articular disc, th ey are am en able to repair.
Associated uln ar styloid fractures sh ould un dergo ORIF or
closed reduction an d pin n in g. Class IC lesion s often require open repair. For class ID lesion s, direct repair (eith er
open or arth roscopic) is advocated.
Class IIA through IID can be m an aged with ulnar shorten in g, eith er at th e h ead (wafer procedure) or diaphysis.
Th e goal is to m ake th e uln ar varian ce n egative. Class IIE
lesions should be m anaged with either a SuaveKapandji
(DRUJ arthrodesis with uln ar neck resection) or Darrach
procedure (distal ulna resection ).
610
Carpal Instability
Carpal in stability is a com m on ly en coun tered problem in
hand surgery; however, it rem ains difficult to both diagn ose
an d treat.
Classification
Although m any system s pervade the literature, th e Mayo
clinic classification system appears the m ost widely used.
It divides carpal in stability in to four m ajor categories: carpal
in stability dissociative (CID), carpal in stability n on dissociative (CIND), com plex in stabilities (dissociative and
nondissociative), an d longitudinal or axial loading in stabilities.
CID in volves disruption of intrinsic in terosseous ligam en ts of th e proxim al carpal row, in con trast to n on dissociative instability, which results from disruption of the
extrinsic radiocarpal ligam en ts with in tact in trin sic ligam en ts. With in th e CID category are two importan t subgroups of in stability: dorsal in tercalated segm en t in stability
(DISI) an d volar in tercalated segm en t in stability (VISI). Th e
DISI deform ity, wh ich describes a palm ar-flexed scaph oid
in com bin ation with a dorsiflexed lun atetriquetram , is a
result from eith er a scaph olun ate ligam en t disruption or
un stable scaph oid fracture. Th e VISI deform ity, wh ich describes a palm ar-flexed scaph oid lun ate in com bin ation
with a dorsiflexed triquetram , usually results from lun otriquetral ligam en t disruption . Th e reason for th ese deform ities relates to th e biom ech an ics of th e wrist, wh ich are
such that th e scaphoid gen erally wan ts to assum e a palm arflexed position while th e triquetrum wants to extend dorsally. When the lun ate loses its teth er to th e scaph oid
from a SL ligam ent disruption or scaph oid fracture, th e
lun ate m oves with th e triquetrum , assum in g a dorsiflexed
position . Con versely, wh en th e lun ate loses its teth er to
the triquetram from a LT ligam ent disruption, the lun ate
m oves with th e scaph oid, assum in g a volar-flexed position . In DISI, PA radiograph s of th e wrist m ay dem on strate
the Terry-Thomas sign, wh ich is SL widen in g greater th an
3 m m , and/ or the cortical ring sign, wh ich represen ts th e appearan ce of tubercle of th e scaph oid wh en palm ar-flexed
(Fig. 15.34). In VISI, PA radiographs of the wrist m ay show
widen in g of th e LT in terval. Lateral radiograph s of th e wrist
will sh ow SL an gle greater th an 60 degrees in DISI or less
than 30 degrees in VISI.
The second category is CIND, which involves disruption
of th e extrinsic radiocarpal ligam ents with intact intrinsic
ligam ents and results in instability at the radiocarpal joint
an d m idcarpal rows. Th is category is furth er subdivided
in to three types: radiocarpal instability, m idcarpal in stability, an d uln ar tran slation . In radiocarpal in stability, disruption of either the dorsal or volar radiocarpal ligam en ts
results in carpal drift. Midcarpal in stability, th e secon d subtype, in volves in stability between th e proxim al an d distal
carpal row. A capitolunate angle of greater than 15 degrees
or less th an 0 degrees on a true lateral radiograph is ch ar-
(Reprinted with permission from Bucholz RW, Heckman JD, CourtBrown CM, et al. Rockwood and Greens Fractures in Adults. 6th
ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
III
611
II
I
IV
(Reprinted with permission from Bucholz RW, Heckman JD, CourtBrown CM, et al. Rockwood and Greens Fractures in Adults. 6th
ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
Mechanism of Injury
Mechanism s of injury range from a fall onto an outstretched h an d to a h igh -en ergy axial load to the wrist, as
m ay occur during a m otor vehicle accident.
Presentation
Th e patien t m ay presen t with vague symptom s of wrist pain
anywh ere in the carpal region depen ding on where the disruption h as occurred. They m ay also report a clunking sen sation with certain m ovem en ts of the wrist.
Physical Examination
Physical exam in ation for carpal in stability in clude th e
scaphoid shift an d lunatotriquetral shear tests. Th e scaph oid
sh ift test was design ed to evaluate th e com petency of the
scapholunate ligam ent (Fig. 15.36). Durin g th is test, th e
exam in er ran ges th e wrist from uln ar to radial deviation
wh ile m ain tain in g con stan t pressure on th e scaph oid tubercle. Un der n orm al con dition s, th e scaph oid sh ould
palm ar-flex; h owever, if th e scaph olun ate ligam en t is disrupted, the direct pressure on the scaph oid tubercle can
subluxate the scaph oid, causin g the patient considerable
612
B
Figure 15.37 (A, B) Gilula lines. (Reprinted with permission from Bucholz RW, Heckman JD, Court-
Brown CM, et al. Rockwood and Greens Fractures in Adults. 6th ed. Philadelphia, PA: Lippincott
Williams & Wilkins, 2006.)
Treatment
Treatm en t for SL in stability with DISI deform ity is varied
an d depen ds on th e recon structability of th e SL ligam en t.
For acute SLligam en t tears treated with in th e first 6 m on th s,
m any advocate open reduction an d prim ary ligam en t repair. Th e repair m ay be augm en ted by a Blatt dorsal capsulodesis. If th e ligam en t is n ot repairable but th e in stability
is reducible, recon struction of th e ligam en t with ten don
or bon eligam ent bon e autograft or capsulodesis is recom m en ded. If th e in stability is n ot reducible, a scaph o
trapezialtrapezoidal (STT) or scaph ocapitate (SC) fusion
m ay be in dicated. Wh en ch ron ic in stability is presen t, a
pattern of arth ritis kn own as scapholunate advanced collapse
(SLAC) can result. Th is pattern is discussed in detail in th e
arth ritis portion of th e ch apter. Th e secon d subgroup of
CID is th e VISI deform ity, in wh ich th e lun ate assum es a
palm ar-flexed position wh ile th e triquetrum rem ain s in exten sion . Acute in stability can be treated with pin fixation
while fusion of th e LTin terval is n eed for chron ic instability.
For CIND with m idcarpal in stability, n on operative
m an agem en t with im m obilization sh ould be attempted
in itially. If th at treatm en t fails, a m idcarpal fusion m ay be
in dicated. Treatm en t for CIND with uln ar tran slation in cludes im m ediate open repair, reduction, an d pin fixation.
CIC in juries are typically treated with O RIF, with focus
on restorin g th e n orm al SL gap. A prolon ged period of castin g (8 12 weeks) typically follows. Last, for lon gitudin al or
axial loadin g in stabilities, O RIF is th e m ain stay of treatm en t.
Classification
Th ere is n o specific classification system for isolated skin
an d nail traum a. Th ese injuries can be characterized by the
exten t of n ail bed in volvem en t, location of th e in jury, an d
the type of laceration (linear, stellate, etc.).
Presentation and Physical Examination
Patients usually present with th e injured region wrapped.
Because each in jury to th e skin an d/ or n ail is different,
there is no unifying presentation . The patient should be
exam in ed closely. Much in form ation regardin g associated
injuries can be obtained by simply inspecting the hand.
A subungual hem atom a often indicates a nail bed disruption with an intact nail plate. Flexor and extensor tendon
injuries can often be diagnosed by the posture of th e h and.
If th e h an d is n ot in th e usual restin g cascade, a ten don
injury m ust be excluded (Fig. 15.38). Vascular injuries can
be diagn osed by th e color of th e distal digits. Followin g in spection , a full neurovascular exam ination sh ould be perform ed, and the function of all tendons sh ould be tested.
Radiographic Findings/Special Studies
Radiograph s are useful in diagn osin g associated fractures
an d/or identifying foreign bodies. Orthogonal views are
Treatment
On presentation, it is imperative that the patients tetan us
status is up to date. If n ot, a booster shot should be given .
Th e appropriate treatm en t of n ail traum a is depen den t on
the size of the injury. If a subungual hem atom a occupies
less than 25% of th e nail, then treatm ent consists of symptom atic care. If a subun gual h em atom a in volves 25% to
50% of th e n ail, th en a sm all perforation can be m ade in
the nail to relieve the fluid pressure, wh ich decreases pain.
If greater th an 50% of th e n ail is in volved, som e h an d surgeon s recom m en d rem ovin g th e n ail an d explorin g th e n ail
bed, alth ough th is rem ain s con troversial. Laceration s can
be repaired by usin g fin e absorbable sutures (6 0 chrom ic),
although skin glue can be used for simpler injuries. After
the repair, th e rem oved n ail or another type of stent sh ould
be replaced un der th e n ail fold to preven t it from scarrin g
down on th e n ail bed.
While woun ds sh ould be closely exam ined, th ey sh ould
not be extensively explored in the em ergen cy departm en t
settin g. Bleeding should be stopped by direct pressure, and
on e sh ould avoid blin dly clampin g any bleedin g vessels,
given the proxim ity of the digital nerves to the digital vessels. If evaluation indicates no injuries to th e deeper structures, the laceration should be copiously irrigated an d then
loosely closed with simple 4 0 or 5 0 nylon sutures. In
ch ildren , absorbable sutures, such as chrom ic gut, m ay be
preferred to avoid th e n eed for rem ovin g th e sutures in th e
office. An tibiotics sh ould be given depen din g on th e size
an d contam ination of th e wound.
If th ere is an amputation of th e distal part of th e fin ger, treatm en t is depen den t on location . Distal in juries can
often be treated with isolated debridem en t an d composite grafting by using the amputated part. Even if this graft
613
fails, th e fin ger tip can frequen tly h eal by secon dary in ten tion in sm all wounds (< 1 cm ). If bon e is exposed, it can
be debrided back proxim al to th e skin defect to allow for
prim ary closure. Wh en th is is don e, it is importan t n ot to
advance the n ail bed distally as this will lead to a hooked
nail deformity. More sign ifican t soft tissue defects can be
treated in a variety of ways. Skin grafts are used for areas
with skin loss but adequate deep soft tissue coverage. Split
th ickn ess skin grafts can cover large areas an d are prim arily used for the dorsal surface of the han d. Full-th ickness
skin grafts are m ore cosm etic and are preferred for palmar
defects. Wh en bon e is exposed, local advan cem en t flaps
are ideal for obtaining coverage. Distal finger amputation s
can often be treated by eith er a volar or lateral VYflaps (Fig.
15.39). For amputation s th rough th e tip of th e th um b, th e
Moberg advancem ent flap is preferred (Fig. 15.40). This flap
can cover defects up to 2.5 cm , but it risks a th um b IP flexion contracture. Th ese local flaps provide sensate soft tissue
coverage for th e fin gertip in sm all cen tral defects. Larger defects require regional flaps. The cross-finger flap is useful for
volar fin ger defects an d is based on the dorsal aspect of the
m iddle phalanx (Fig. 15.41). The donor site requires skin
graftin g. Th e thenar flap is in dicated for loss of skin an d pulp
of th e lon g or rin g fin gers (Fig. 15.42). Th is flap can cause
PIP join t con tractures but rem ain s useful in youn g patien ts.
Other flaps, such as the neurovascular island flap and the
first dorsal MC artery flap, are available for m ore proxim al
coverage, but th ese are m ore tech n ically dem an din g.
614
A,B
Figure 15.40 (AG) The Moberg advancement flap. (Reprinted with permission from Moran
SL, Cooney WP. Master Techniques in Orthopaedic Surgery: Soft Tissue Surgery. Philadelphia, PA:
Lippincott Williams & Wilkins, 2009.)
Pathophysiology
Ten don h ealin g occurs by a com bin ation of in trin sic an d
extrin sic m ech an ism s. Th e in itial in flam m atory ph ase be-
615
B
Figure 15.41 (A, B) The cross-finger flap. (Reprinted with permission from Moran SL, Cooney WP.
Master Techniques in Orthopaedic Surgery: Soft Tissue Surgery. Philadelphia, PA: Lippincott Williams
& Wilkins, 2009.)
Zone I
Zone II
Zone TI
Zone TII
Zone III
Zone IV
Zone TIII
Zone V
Figure 15.42 The thenar flap. (Reprinted with permission from
Figure 15.43 The flexor zones of the hand. (Reprinted with permission from Doyle JR, Tornetta P, Einhorn TA. Orthopaedic Surgery
Essentials: Hand and Wrist. Philadelphia, PA: Lippincott Williams &
Wilkins, 2006.)
616
Radiographic Findings
Radiograph s are un n ecessary in diagn osin g flexor ten don
ruptures. However, th ey provide som e utility if there is concern regarding con com itant fractures.
Special Studies
Flexor ten don rupture can usually be diagn osed on th e basis of h istory an d physical exam ination. If the diagnosis is
un clear, MRI or ultrasoun d can be used to con firm th e diagnosis. These m odalities also help to identify partial flexor
ten don ruptures.
Differential Diagnosis
Th e differen tial of flexor ten don in juries in clude n erve in juries th at cause m uscle paralysis an d un derlyin g n eurological conditions, such as polio or spinal m uscular atrophy.
A h istory of traum a gen erally distin guish es flexor ten don
injuries from these other conditions.
Treatment
Complete flexor ten don ruptures should be repaired surgically. Partial tendon lacerations are difficult to diagnose,
but laceration s greater th an 60% sh ould be repaired to preven t triggering or subsequent rupture.
In flexor ten don repair, several factors affect outcom e.
First, prim ary ten don repair sh ould be perform ed early.
No differen ce in results h as been foun d between em ergen t
an d delayed early repairs, but worse outcom es m ay occur if
B
Figure 15.45 Note the loss of the normal cascade (A) and inability to flex the distal interphalangeal
joint (B). (Reprinted with permission from Doyle JR, Tornetta P, Einhorn TA. Orthopaedic Surgery
Essentials: Hand and Wrist. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
617
Figure 15.46 Recommended skin incisions for extension of traumatic hand wounds. Dotted
lines represent the safe extensions of these wounds. (Reprinted with permission from Doyle JR,
Tornetta P, Einhorn TA. Orthopaedic Surgery Essentials: Hand and Wrist. Philadelphia, PA: Lippincott
Williams & Wilkins, 2006.)
Classification
Sim ilar to flexor tendon injuries, zones can be used to define the location of exten sor tendon injuries. Nine zones
h ave been defin ed an atom ically, with th e odd zon es occurrin g over join ts an d th e even zon es occurrin g over bon es
(Fig. 15.50). Zon e I is over the DIP join t and involves
th e disruption of th e term in al ten don , wh ich leads to DIP
flexion . These in juries are com m on ly referred to as mallet
fingers (Fig. 15.51). Zone II in juries occur over the m iddle
ph alan x. Zon e III in juries are directly over th e PIP join t an d
involve disruption of the cen tral slip of the extensor m ech anism . Th e PIP joint goes into flexion , and chronic injuries
618
F
Figure 15.47 (AF) Flexor tendon repair. (Reprinted with permission from Strickland JW, Graham
TJ. Master Techniques in Orthopaedic Surgery: The Hand. Philadelphia, PA: Lippincott Williams &
Wilkins, 2005.)
Presentation/Mechanism of Injury
Extensor tendon injuries usually occur via traum a. Com m on m ech an ism s are altercation s, sh arp laceration s, or
jam m in g of a fin ger. Presen tation an d deform ity is depen den t on th e location of th e exten sor ten don disruption
(Fig. 15.53).
Physical Examination
As with the flexor tendons, extensor tendon injury is relatively straightforward to diagn ose. Inspection will often
reveal exten sor lag, an d exam in ation reveals th e in ability
to actively exten d th e fin ger. Each fin ger sh ould be tested
in isolation with the adjacent fingers flexed at th e MP joints.
619
B
Figure 15.48 (A, B) Repair of the flexor digitorum profundus tendon. (Reprinted with permission
from Strickland JW, Graham TJ. Master Techniques in Orthopaedic Surgery: The Hand. Philadelphia,
PA: Lippincott Williams & Wilkins, 2005.)
Th is position elim in ates th e pull of th e jun cturae ten dinae (fibrous connections between th e tendons), which
can m ask isolated extensor tendon disruption . Also, active
exten sor stren gth sh ould be tested at each join t or zon e.
Th e Elson test is a specific test for diagn osin g an acute
bouton n iere deform ity in a patien t with a cen tral slip in jury (Fig. 15.54). It is perform ed with th e fin ger flexed 90
degrees over a table at th e PIP join t. In th is position , th e patient attempts to extend the PIP joint. With an intact central
slip, there sh ould be extension pressure through th e m iddle
ph alan x wh ile th e distal ph alan x is flail. With a disrupted
cen tral slip, the m iddle phalanx is lax, whereas the distal
ph alan x is rigid th rough th e DIP join t.
Radiographic Findings
Radiograph s are m an datory durin g evaluation to rule out
fractures and foreign bodies such as teeth.
Special Studies
It is rare th at advan ced im agin g is n ecessary in th e diagn osis
or treatm en t of exten sor ten don in juries.
B
A
(Reprinted with permission from Strickland JW, Graham TJ. Master Techniques in Orthopaedic Surgery: The Hand. Philadelphia, PA:
Lippincott Williams & Wilkins, 2005.)
620
Treatment
In m an agin g th ese in juries, several gen eral prin ciples
sh ould be kept in m ind. First, open injuries sh ould gen erally be treated in an open m an n er with surgery, wh ereas
closed injuries sh ould be initially treated closed with splin t-
ing. Surgical repair should be perform ed with a nonabsorbable m aterial and a core suture. Partial open ten don
injuries sh ould be repaired if greater than 50% of the tendon width is lacerated.
Zon e I in juries can be treated with exten sion splinting for 6 weeks with a Stack splint and then subsequen t
n igh ttim e splin tin g for an addition al 6 weeks (Fig. 15.55).
Splin tin g is th e prim ary treatm en t also in fin gers presen ting up to 6 m onths after injury. Untreated zon e I in juries
will lead to a swan -n eck deform ity with DIP flexion an d
PIP hyperexten sion secon dary to dorsal m igration of th e
lateral ban ds. This deform ity requires significant surgical
recon struction to be corrected. Mallet fin gers can also occur with an avulsion fracture of the distal phalanx. Treatm en t rem ains the sam e unless there is DIP subluxation or
the fracture fragm ent is greater th an 50% of the articular
surface.
Zon e II injuries require suture repair if greater than 50%
of th e ten don is disrupted. Again , n on absorbable suture is
preferred an d core sutures sh ould be used.
Sim ilar to m allet fin gers, zon e III in juries are usually
treated nonoperatively with extension splin ting of the PIP
join t for 6 weeks. Patien t com plian ce is im portan t because
recon struction of ch ron ic bouton n iere deform ities (i.e., th e
Fowler procedure) is difficult.
Zon es IV through IX in juries all require prim ary repair.
In zon e V in juries, urgen t surgical irrigation an d debridem en t is necessary if the join t capsule h as been violated.
A com m only associated injury is sagittal band rupture.
Most often, the radial sagittal band of th e lon g finger is
ruptured, which leads to ulnar subluxation of th e exten sor m ech an ism . Closed injuries can be treated with extension splin tin g for 4 to 6 weeks, but open injuries sh ould be
repaired.
Nerve Injury
Nerve in juries from laceration s or crush in juries to th e h an d
are relatively com m on .
Pathophysiology/Classification
Th e classification was origin ally described by Seddon an d
subsequently m odified by Sunderland (Table 15.2). Type I
(neuropraxia) is a conduction block with axon continuity
preserved. Type II (axon otom esis) in volves axon al dam age
but th e en don eurium is preserved. Type III (axon otom esis)
describes axon al dam age but th e perin eurium is preserved.
Type IV (axon otom esis) in volves axon al dam age with on ly
the epineurium intact. Fin ally, type V is a complete nerve
transection.
Figure 15.51 Mallet finger. (Reprinted with permission from
Doyle JR, Tornetta P, Einhorn TA. Orthopaedic Surgery Essentials:
Hand and Wrist. Philadelphia, PA: Lippincott Williams & Wilkins,
2006.)
Presentation/Physical Examination
Presen tation varies an d is depen den t on th e specific n erve
involved. Physical exam ination will yield deficits in th e distribution of the n erve involved.
621
deformity. EDC, extensor digitorum communis; MP; PIP, proximal interphalangeal; DIP,
distal interphalangeal. (Reprinted with permission from Strickland JW, Graham TJ. Master Techniques in Orthopaedic Surgery: The
Hand. Philadelphia, PA: Lippincott Williams &
Wilkins, 2005.)
TABLE 15.2
Descriptive Term
Nature of Injury/Neuropathology
Sunderland
Seddon
Seddon Sunderland
First-degree injury
Neurapraxia
Second-degree injury (axonotmesis)
Sunderland Seddon
Sunderland
Fourth-degree injury
Sunderland
Fifth-degree injury
Distal degeneration of the injured axon but with almost always complete
regeneration due to intact endoneurium
Sunderland third-degree injury is less severe than the neurotmesis
category of Seddon since the perineurial layer is intact. Regeneration
occurs but is incomplete due to endoneurial scarring and loss of
end-organ specificity within the fascicle
Axon, endoneurium, and perineurium are disrupted with extensive
scarring that blocks axonal regeneration and often results in a
neuroma-in-continuity
Severed nerve trunk without possibility of spontaneous regeneration
(Reprinted with permission from Doyle JR, Tornetta P, Einhorn TA. Orthopaedic Surgery Essentials: Hand and Wrist.
Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
622
to prevent neurom a form ation . Prim ary nerve repair is favored, but nerve grafts should be considered if a tensionfree nerve repair cannot be achieved. Com m on nerve grafts
include the sural nerve, the anterior branch of the m edial
antebrachial cutaneous nerve, the lateral antebrachial cutan eous n erve, an d th e term in al bran ch of th e posterior in terosseous n erve. Recen tly, autogen ous vein con duits an d
synth etic n erve grafts h ave been used with som e success.
After appropriate align m en t of th e n erve, epin eurial repair
is currently preferred because grouped fasicular repair h as
n ot been sh own to be superior (Fig. 15.56). Suture size is
depen den t on th e size of th e n erve bein g repaired. In ch ildren , fibrin glue h as been used successfully in place of a
suture. After nerve repair, occupational therapy is importan t to provide m otor an d sen sory reeducation .
Replantation
Advances in m icrosurgical techn iques and instrum entation
in the late 1950s and the early 1960s led to the ability to
replan t detach ed lim bs. Malt an d McKh an n perform ed th e
first successful arm replan tation in Boston in 1962, an d
Kom atsu and Tam ai perform ed the first successful digital
replan tation in 1968. Today, th e survival rates for digital
replan ts are greater th an 90% if perform ed for appropriate
indications.
Figure 15.53 Deformities secondary to extensor mechanism injury. (Reprinted with permission from Doyle JR, Botte MJ. Surgical
Anatomy of the Hand and Upper Extremity. Philadelphia, PA: Lippincott Williams & Wilkins, 2003.)
Radiographic Findings
Radiograph s are un n ecessary in n erve in juries un less associated bon e injury is suspected.
Differential Diagnosis
Th e differen tial diagn osis in cludes ten don disruption s th at
m ay m im ic n erve in juries. Th ese two diagn oses can be distin guish ed by th e use of th e ten odesis effect, wh ich sh ould
be presen t on ly in patien ts with n erve in juries but absen t if
there is a ten don injury. The tenodesis effect refers to spon tan eous flexion of th e digits wh en th e wrist is passively
exten ded an d im plies con tin uity of th e extrin sic ten don s.
Also, underlying neurological con ditions, such as polio or
spin al m uscular atrophy, m ust be excluded.
Treatment
When a lacerated n erve is foun d, m icrosurgical repair
sh ould be perform ed to facilitate nerve regen eration an d
Classification
No specific classification sch em e exists. In juries are described by location of amputation and the quality of soft
tissue.
Mechanism of Injury
Th ere are m any differen t m ech an ism s th at cause upper extrem ity amputations. Com m on causes include lawn m owers, sn owblowers, in dustrial m ach in es, an d m otor veh icle
collisions.
Physical Examination
Th e m ost importan t aspect of th e physical exam in ation is
inspection of the amputated site and residual part. It is vital
to assess th e quality of th e soft tissues an d to determ in e
wh eth er replan tation h as a ch an ce to be successful. Most
often , th is is depen den t on wh eth er th e am putation was a
sh arp or a crush injury.
Radiographic Findings
Radiograph s of both th e amputated part an d th e residual
lim b are necessary to assess th e bone stock and to determ ine the best m ode of bone fixation .
Treatment
Wh en ever a part of th e h an d or upper extrem ity is amputated, th e part sh ould be wrapped in salin e-soaked gauze
623
624
with permission from Doyle JR, Tornetta P, and Einhorn TA: Orthopaedic Surgery Essentials: Hand and Wrist. Philadelphia: Lippincott Williams & Wilkins, 2006.)
laxis. The amputation site and part should then be evaluated to determ ine whether replantation is possible.
Th e curren tly accepted in dication s for replan tation are
any thum b amputation, m ultiple digit amputations, any
amputation in a child, and partial hand amputation s
th rough th e palm , wrist, or forearm (Table 15.3). Th e duration of isch em ia tim e is also extrem ely im portan t. Warm
ischem ia tim e of m ore than 12 hours for digital amputation or m ore than 6 hours for amputations proxim al to th e
carpus leads to poor outcom es Coolin g of parts gives an addition al isch em ia tim e of 24 h ours for digits an d 12 h ours
for m ajor lim bs. Acceptable ischem ia tim e is less for m ore
proxim al am putation because m uscle can tolerate less
ischem ia than tendon. The type of injury is also extrem ely
importan t. Sharp amputation s do significantly better than
crush or deglovin g in juries. Fin ally, patien t factors play a
role in decidin g wh eth er replan tation sh ould be attempted.
Youn ger patien ts h ave better outcom es. Preexistin g con ditions such as diabetes, peripheral vascular disease, hypercoagulopathy, n icotin e depen den ce, an d severe psych iatric
con dition s decrease success rates. Patien ts m ust also be able
and willing to comply with the long postoperative rehabilitation program .
Wh en replan tation is attempted, a stan dard operative
sequen ce is used. After identification of structures and debridem en t of n ecrotic tissues, th e bon e is sh orten ed an d
fixed to allow decreased tension on the neurovascular structures. Next, the extensor tendons, th e flexor ten don s, the
arteries, the nerves, and the veins are repaired in that order.
All repairs m ust be perform ed usin g careful m icrovascular
tech n ique. In m ultiple digital amputation s, repair of th e
sam e an atom ic structure in each digit improves operative
efficien cy. In m ajor lim b replan tation , arterial sh un tin g is
th e first step to lim it isch em ic tim e.
Postoperatively, patients m ust be m onitored closely
to prevent unn ecessary failure. Dressings and protective
splin ts should be applied carefully to avoid compression.
Th e extrem ity sh ould be elevated h igh en ough to preven t
TABLE 15.3
Controversial Indications
Single-digit amputation at a level proximal to the
insertion of the flexor digitorum superficialis tendon
Ring avulsion injuries
Severe contamination
Contraindications
Amputated parts that are severely
crushed or damaged
Multiple-level amputations
Significant associated trauma and/or
medical conditions
(Reprinted with permission from Moran SL, Cooney WP. Master Techniques in Orthopaedic Surgery: Soft
Tissue Surgery. Philadelphia, PA: Lippincott Williams & Wilkins, 2009.)
625
C
D
(Reprinted with permission from Moran SL, Cooney WP. Master Techniques in Orthopaedic Surgery: Soft Tissue Surgery. Philadelphia, PA:
Lippincott Williams & Wilkins, 2009.)
626
The gen eral assessm ent of a patien t in wh om a com pressive n europathy is suspected sh ould in volve a careful
history and physical exam in ation. The h istory should evaluate predisposin g factors such as system ic or in flam m atory con dition s in cludin g diabetes, hyperthyroidism , RA,
an d infection. Also, the history should draw out con ditions
that alter fluid balance, such as pregn ancy and hem odialysis. On exam ination, on e should focus on finding objective sign s of m otor or sen sory ch an ges an d tryin g to isolate
the exact level at which the compression is present. Motor
strength is graded on the standard scale of 1 to 5. Sen sory exam ination consists of both thresh old (ligh t touch )
an d innervation den sity (2-point discrim ination ) testing.
Sem m esWein stein testin g with m onofilam ents is h elpful in diagnosin g early sen sory change. The concept of a
double crush ph en om en on , with en trapm en t at two levels,
m ust always be considered because both sites of compression m ay require release.
Pathophysiology
CTS is compression of th e m edian n erve as it passes un dern eath th e TCL in th e wrist (Fig. 15.58). Poten tial causes
in clude an atom ic abn orm alities (such as proxim al lum brical m uscles), fluid im balances (pregnan cy, hem odialysis),
traum a (h em atom a, distal radius fractures), an d position al
factors.
Presentation/Mechanism of Injury
CTS usually presen ts with decreased sen sation over th e palm ar aspect of radial th ree fin gers an d th e radial side of th e
ring fin ger. The num bn ess is typically worse at night. As
the syndrom e progresses, patients complain of weakness
an d pain th at can radiate in to th e volar forearm . If left un treated, CTS can lead to th en ar atrophy.
Physical Examination
Physical exam in ation in cludes Tin el test (tappin g over th e
TCL, which elicits electric-like shocks th at radiate into the
fin gers), Ph alen test (m an ual volar flexion of th e wrist,
which reproduces the patients sym ptom s), an d th e carpal
tun n el com pression test (reproduction of th e patien ts
symptom s from direct compression over the volar aspect
of th e carpal tun n el) (Table 15.4). Each of th ese tests h as
varying degrees of sen sitivity an d specificity, but com bined
with a h istory an d electrom yography (EMG), a reliable diagn osis can usually be obtain ed.
Special Studies
EMG and n erve conduction studies (NCSs) are useful tests
to h elp con firm th e diagn osis of CTS. Ch an ges con sisten t
with a diagn osis of CTS in clude distal m otor latency greater
Treatment
Once diagnosed, CTS can be treated nonoperatively or
operatively. In itial treatm en t usually focuses on n igh ttim e
wrist splin tin g in a n eutral position , oral an ti-in flam m atory
m edications to decrease syn ovitis and edem a, and m anagem en t of underlying m edical problem s. Corticosteroid in jection s can be perform ed directly in to th e carpal tun n el.
Although injection s provide transient relief to 80% of patients, only 22% of patients have con tinued symptom atic
relief at 1 year. Alth ough relief m ay be on ly tran sien t, it is
a good prognostic sign for surgical release.
Surgical treatm en t can be don e eith er open or en doscopically. Although debate still exists over which is the optim al
procedure, data con tin ue to sh ow m in im al differen ces between the two procedures. Endoscopic carpal tunnel release
m ay result in less pillar pain and earlier return to work, but
there is a slightly increased risk of in complete release. Success after either procedure results in improved pain an d
decreased n um bn ess, wh ich is proportion al to th e am oun t
of preoperative EMG dysfun ction .
Pronator Syndrome
Pathophysiology
Pron ator syn drom e in volves proxim al compression of
the m edian nerve. Potential compression sites include a
supracon dylar process of the hum erus with an associated ligam en t of Struthers, the lacertus fibrosis or bicipital
aponeurosis, the pronator teres origin, and the origin of
the FDS (Fig. 15.59).
Presentation
Th e prim ary presen tin g symptom s are n um bn ess in th e
radial th ree fin gers an d th e radial side of th e rin g fin ger,
as well as forearm pain. Pron ator syndrom e rarely presen ts
with m otor weakn ess.
Physical Examination
Pron ator syn drom e is clin ically differen tiated from CTS by
n um bn ess in th e palm ar cutan eous bran ch distribution,
pain with resisted wrist flexion an d forearm pron ation , an d
a n egative Phalen and carpal compression tests.
Special Studies
EMG is usually n ecessary to defin itively distin guish pron ator syn drom e from CTS, alth ough th e accuracy of th e study
for this con dition can be variable.
Differential Diagnosis
Pron ator syn drom e m ust be differen tiated from th e m ore
com m on CTS.
Plamaris
longus
Common digital
branches of median n.
Sensory digital
branches of
ulnar n.
Superficial radial a.
Flexor pollicis brevis
Hypothenar muscles
Volar carpal ligament
(roof of Tunnel of Guyon)
Flexor carpi
ulnaris
Palmaris longus
Flexor digitorum
superficialis
Radial a.
Ulnar n. and a.
Ulnar a.
Hook of hamate
Transverse
carpal ligament
Ulnar n.
Volar carpal ligament
(roof of Tunnel of Guyon)
Pisiform
Pisohamate
ligament
Flexor carpi
ulnaris
Triquetrum
Scaphoid
Lunate
Figure 15.58 The carpal and ulnar tunnels. (Adapted with permission from Hoppenfeld S, deBoer
P. Surgical Exposures in Orthopaedics: The Anatomic Approach. 3rd ed. Philadelphia, PA: Lippincott
Williams & Wilkins, 2003.)
627
628
TABLE 15.4
Test
How to Perform
Condition Tested
Phalen test
Paresthesia in response to
position
Site of nerve lesion
Numbness or tingling on
radial digits within 60 s
Electric tingling
response in fingers
Paresthesia in response to
compression
Paresthesia within 30 s
Patients perception of
symptoms
Hydrostatic compression
is felt to be probable
cause of CTS
Determine minimum
separation of two
distinct points when
applied to palmar
fingertip
As mentioned earlier, with
movement of the points
Innervation density of
slow-adapting fibers
Resting pressure 25
mm Hg or more
(variable and technique
related)
Failure to determine
separation of at least
5 mm
Advanced nerve
dysfunction
Vibrometer placed on
palmar side of digit,
amplitude set to
120 Hz, and increase to
threshold of perception;
compare median and
ulnar bilaterally
Monofilaments of
increasing diameter
touched to palmar side
of digit until patient can
determine which digit is
touched
Orthodromic stimulus and
recording across wrist
Threshold of fast-adapting
fibers
Failure to determine
separation of at least
4 mm
Asymmetry compared
with contralateral hand
or median to ulnar in
ipsilateral hand
Threshold of slowly
adapting fibers
Latency, conduction of
sensory fibers
Probable CTS
Latency, conduction
velocity of motor fibers
of median nerve
Denervation of thenar
muscles
Percussion test
(Tinel sign)
Carpal tunnel
compression test
(Durkan)
Hand diagram
Hand volume stress
test
Direct
measurement of
carpal tunnel
pressure
Static two-point
discrimination
Moving two-point
discrimination
Vibrometry
SemmesWeinstein
monofilaments
Distal sensory
latency and
conduction
velocity
Distal motor
latency and
conduction
velocity
Electromyography
Hand volume
Hydrostatic pressure in
resting and provocative
positioning
Innervation density of
fast-adapting fibers
Positive Result
Probable CTS (sens 0.75,
spec 0.47)
Probable CTS if positive at
the wrist (sens 0.60,
spec 0.67)
Probable CTS (sens 0.87,
spec 0.90)
Advanced nerve
dysfunction
Probable CTS
629
Physical Examination
Physical exam in ation can dem on strate th e in ability to
m ake an O sign with the index fin ger and th e thum b.
No sen sory deficit sh ould be eviden t.
Special Studies
EMG is n ecessary to m ake th e diagn osis. Delayed con duction should be seen across the site of compression.
Differential Diagnosis
Th e differen tial diagn osis of th is rare con dition in cludes
ten don ruptures an d Parson ageTurn er syn drom e (viral
brach ial n euritis).
Treatment
In itial treatm en t in volves 3 to 6 m on th s of observation . If
sym ptom s do not resolve, surgical decompression or tendon tran sfers can be con sidered.
Figure 15.59 Sites of median nerve compression include (A) ligament of Struthers from supracondylar process, (B) pronator teres,
(C) lacertus fibrosis, and (D) fibrous arch of flexor digitorum superficialis. (Reprinted with permission from Doyle JR, Tornetta P, Einhorn
TA.Orthopaedic Surgery Essentials: Hand and Wrist. Philadelphia,
PA: Lippincott Williams & Wilkins, 2006.)
Treatment
If th e diagn osis is m ade, in itial m an agem en t is n on operative with activity m odification to decrease repetitive
flexion and pronation. Splinting an d nonsteroidal an tiinflam m atory drugs (NSAIDs) are occasionally helpful.
Operative treatm ent, wh ich involves releasing all four poten tial compression sites, is con sidered on ly after a m in im um of 6 m onths of conservative treatm ent.
Pathophysiology/Classification
Cubital tunnel syndrom e involves ulnar n erve compression
around the elbow, and there are five com m on sites of com pression . Th e arcade of Struth ers is a ban d of fascia th at
con n ects th e m edial in term uscular septum to th e m edial
h ead of the triceps an d is located approxim ately 8 cm proxim al to the m edial epicondyle (Fig. 15.60). Th is fascia, alon g
with th e in term uscular septum an d a hypertroph ied m edial
h ead of th e triceps, can com press th e uln ar n erve. Moving distally, the m edial epicon dyle can compress th e ulnar
n erve, especially during elbow flexion . Beyon d th e m edial
epicon dyle, th e n erve is at risk as it passes un der th e arcuate ligam ent, which connects the m edial epicondyle to the
olecran on an d serves as th e roof of th e cubital tun n el. Osborn e fascia, wh ich is a fascial ban d between th e two h eads
of th e FCU, is an oth er site of poten tial compression . Fin ally,
630
Figure 15.60 (A) The arcade of Struthers. (Reprinted with permission from Doyle JR, Botte MJ.
Surgical Anatomy of the Hand and Upper Extremity. Philadelphia, PA: Lippincott Williams & Wilkins,
2003.)
Presentation
Cubital tun n el syn drom e usually presen ts with n um bn ess
or paresth esias in th e uln ar on e an d a h alf fin gers. Oth er
signs an d symptom s include elbow pain , intrin sic weakness, and hand clum siness. Symptom s are usually exacerbated by elbow flexion because th is alters th e sh ape of th e
cubital tunnel from an oval to a slit, thereby decreasing its
volum e by 50%.
Physical Examination
Beyond standard m otor and sensory testin g, several
provocative physical exam in ation sign s m ay h elp in th e
diagn osis. O ften , tappin g over th e cubital tun n el (Tin el
sign) an d full-elbow flexion will reproduce the patien ts
symptom s. A From ent sign is weakness during pinch . Patien ts are asked to pin ch a sh eet of paper between th eir
thum b and index finger. Patients with cubital tunn el syndrom e h ave weakn ess in th um b adduction (uln ar n erve)
Special Studies
EMG an d NCS are h elpful in con firm in g th e diagn osis. A
n erve conduction velocity of less th an 50 m / s or a drop
in conduction velocity of greater than 10 m / s around th e
elbow is con sidered abn orm al.
Differential Diagnosis
Differen tial diagn osis in cludes radiculopathy of C8 T1,
Pancoast tum or, and thoracic outlet syn drom e.
Treatment
In itial treatm en t in volves NSAIDs an d n igh ttim e exten sion
splin ting. If n on operative treatm ent fails or intrin sic atrophy occurs, surgery is in dicated. In situ decompression is
the least invasive option but does n ot address the poten tial
traction phenom en on that the nerve experiences as the elbow flexes. In gen eral, an terior tran sposition of th e uln ar
n erve is th e m ost com m on ly used surgical tech n ique for
treating cubital tunn el syn drom e. Although dissection of
the nerve risks devascularization, the entire length of the
n erve can be freed from com pression . By m ovin g the nerve
an terior to the axis of m otion at the elbow, traction on the
n erve is also reduced. Two differen t tech n iques h ave been
described for th e tran sposition : subm uscular an d subcutan eous. Subcutan eous tran sposition s are tech n ically easier
an d preserve the integrity of the flexorpron ator m uscle
631
Differential Diagnosis
In tact wrist exten sion is importan t in differen tiatin g posterior in terosseous syn drom e from a m ore proxim al radial
n erve palsy. The other differen tial diagn osis is extensor tendon rupture, wh ich can be differen tiated from posterior in terosseus syn drom e by th e presen ce of th e ten odesis effect
(passive finger extension with wrist flexion).
Pathophysiology
Ulnar tunnel syndrom e is compression of the uln ar nerve
at th e Guyon canal in the wrist. The borders of the Guyon
canal are defined by th e flexor retinaculum (floor), the
pisiform (uln ar border), th e h ook of th e h am ate (radial
border), an d th e volar carpal ligam en t (roof). In th is area,
the ulnar nerve bifurcates into the deep m otor branch and
the superficial sensory bran ch. Compression is m ost usually secondary to ganglion cysts but can be associated with
hook of the ham ate fractures, ulnar artery th rom bosis, an d
repetitive traum a.
Special Studies
EMG an d NCS are useful for diagn osin g posterior in terosseous syn drom e.
Treatment
Once the diagnosis has been m ade, initial treatm ent involves activity m odification and splinting. If this fails, surgical release or tendon transfers m ay be in dicated.
Presentation/Physical Examination
Ulnar tun nel syndrom e can be differentiated from cubital
tun nel syndrom e by intact sensation over the dorsal uln ar
aspect of the hand, wh ich is in nervated by the dorsal sensory nerve.
Special Studies
EMG an d NCS are im portan t in con firm in g th e location of
compression .
Presentation
Th e ch ief complain t is pain in th e proxim al radial forearm ,
and it is usually related to repetitive work activities.
Differential Diagnosis
Th e prim ary diagn oses th at n eed to be excluded are com pression of th e uln ar n erve at th e elbow or m ore proxim al
nerve compression, especially in the cervical spine.
Physical Examination
On physical exam ination, tenderness over the radial nerve
distal to th e lateral epicon dyle is on e of th e h allm ark fin dings, and provocative m aneuvers include pain with resisted
m iddle finger exten sion. However, both of these findings
lack sensitivity and specificity.
Treatment
Treatm ent is based on etiology. Sim ilar to other compression n europath ies, splin tin g, NSAIDs, an d activity m odification are attempted prior to surgical decompression.
Pathophysiology
Radial tun n el syn drom e is a pain syn drom e th at is n ot associated with m otor or sensory deficits.
Special Studies
EMG an d NCS usually h ave n orm al results.
Differential Diagnosis
Th e oth er m ajor diagn osis in th e differen tial is lateral epicon dylitis. O n e m eth od to differen tiate th ese two con ditions is selective injection of local anesthetic in to the region of the posterior interosseous nerve. If this leads to
pain relief wh ile also causin g a temporary, complete radial
n erve palsy, it is con sidered diagn ostic for radial tun nel syndrom e. Un fortun ately, lateral epicon dylitis an d radial tun n el syn drom e can coexist in up to 5% to 10% of patien ts.
Treatment
Treatm ent is based on extended nonoperative m odalities,
such as splinting, activity m odification, and NSAIDs. If
sym ptom s persist despite 6 to 9 m onths of con servative
treatm ent, surgical decompression can be considered.
632
Brachialis
Sensory branch,
radial nerve
Hueters
line
E
Radial recurrent
artery
PIN
Hook on
ECRB
Wartenberg Syndrome
Pathophysiology
Warten berg syndrom e (also kn own as cheiralgia paresthetica) is compression of th e superficial radial n erve, wh ich is
a purely sen sory n erve th at run s in th e forearm un dern eath
the brach ioradialis and exits dorsally between the tendons
of th e brach ioradialis an d ECRL. Com pression occurs secon dary to scissorin g of th e brach ioradialis an d th e ECRL.
Handcuffs, tight casts, tight watch bands, an d direct blows
have been im plicated in its etiology.
Presentation
Sym ptom s are paresth esias on th e dorsal radial aspect of
the hand; wrist flexion, ulnar deviation, and pronation m ay
exacerbate sym ptom s.
Physical Examination
A positive Tin el sign over th e superficial radial n erve is diagn ostic.
Special Studies
EMG and NCS are not indicated.
Treatment
Treatm ent is alm ost always n onoperative and is based on
the rem oval of th e inciting agent.
Physical Examination
Adson test is specific for thoracic outlet syndrom e and involves obliteration of the radial pulse with slight abduction of the shoulder in the coronal plane and rotation of
the n eck to the affected side. Roos test is another useful
physical exam in ation for m akin g th e diagn osis. Th e test is
positive wh en th ere is n um bn ess or tin glin g of th e uln arsided digits with 90 degrees of abduction of the shoulder,
90 degrees of extern al rotation , an d open in g an d closin g
the hands rapidly for up to 3 m inutes.
Radiographic Findings
Radiograph s of th e n eck an d ch est sh ould be obtain ed to
ch eck for cervical ribs, Pancost tum ors, and other chest
diseases or an om alies.
Special Studies
EMG an d NCS can be h elpful in m akin g a diagn osis if a
proxim al site of com pression can be iden tified.
Differential Diagnosis
Cervical radiculopathy and cubital tunnel syndrom e are
am ong the chief conditions in the differential diagn osis.
Treatment
Th is con dition sh ould be treated n on operatively for an exten ded period un less th ere is an un derlyin g structural abnorm ality, such as a cervical rib, th at is found durin g th e
initial evaluation. Initial m anagem ent includes stren gthening of the upper extrem ity, trapezius, an d neck m uscles as
well as stretch in g of th e n eck an d sh oulder. Weigh t loss an d
oth er physical th erapy m odalities can be h elpful. If th ese
fail, surgical option s in clude an terior scalen otomy, exploration an d resection of any an om alous fibrous ban ds, or
first rib resection th rough an axillary approach .
Degenerative Arthritis
Pathophysiology
In th e h an d, degen erative arth ritis occurs in diarth rodial
join ts th at are subjected to abn orm al loadin g con dition s
or th at h ave abn orm al cartilage. It ten ds to be a progressive
con dition and is classified as eith er prim ary, when there
is n o underlyin g cause, or secon dary, when it is attributed
to un derlyin g factors, such as traum a, avascular n ecrosis,
developm en tal dysplasia, or oth er disease.
Presentation/Physical Examination
Com m on ly, patien ts present with pain localized to the involved joint, decreased range of m otion, and a progressive
deform ity.
Radiographic Findings
Th e diagn osis can usually be m ade with radiograph s, wh ich
dem on strate four ch aracteristic ch an ges: join t space n arrowin g secon dary to cartilage destruction , periph eral os-
633
teophyte form ation , subch on dral sclerosis, an d subch on dral cyst form ation .
Special Studies
Radiograph s are usually sufficien t to m ake th e diagn osis
of degen erative arth ritis. O ccasion ally, an MRI scan is useful for the diagnosis of early arthritis, and CT scans can
poten tially be h elpful in surgical plan n in g.
Differential Diagnosis
Th e prim ary differen tial diagn osis is in flam m atory
arth ritis.
Treatment
In itial treatm en t is n on operative an d in cludes activity m odification, splinting, and NSAIDs. The second line of n onoperative treatm en t often in cludes in traarticular corticosteroid in jection s th at can provide excellen t symptom atic
relief. Surgical in terven tion is con sidered on ly wh en th e patient has deform ity or instability that interferes with function or pain that is refractory to n onoperative treatm ent.
Any joint in th e hand an d wrist can be involved, but
arth ritis m ost com m only affects th e IP joints, th e first CMC
join t, an d th e STT join t. Specific surgical m an agem en t is
depen den t on th e patien t an d join t in volved.
DIP Joint
Th e DIP join t is on e of th e m ost frequen tly in volved join ts.
Presen tin g sym ptom s in clude pain , swellin g, decreased
ran ge of m otion , an d deform ity. Heberden n odes are th e
characteristic en largem ents of the joint secon dary to th e
un derlyin g osteoarth ritis. Mucous cysts, wh ich are gan glion cysts associated with a joint osteophyte, can com m only be seen. Surgical treatm en t is dependent on the stage
of th e disease. Mucous cysts can often be m an aged by cyst
excision with rem oval of th e un derlyin g osteophyte. More
exten sive arth ritis is typically treated with DIP arth rodesis. Fusion is a simpler procedure and has been shown to
h ave at least equal results to arth roplasty (Fig. 15.62). The
join t is fused in a position of sligh t flexion (5 degrees to
10 degrees) to h elp with fun ction . Multiple tech n iques, in cludin g th e use of K-wires an d com pression screws, h ave
been described.
PIP Joint
Th e PIP join t is also frequen tly in volved in osteoarth ritis.
Arth ritic disease presen ts sim ilarly in th e PIP join t, except
th at dorsal join t prom in en ces are called Bouchard nodes. The
prim ary differen ce between DIP an d PIP arth ritis is th e
preferred form of treatm en t. In th e PIP join t, th e prim ary surgical options are arthroplasty and arthrodesis.
Arth roplasty with silicon e or pyrocarbon implan ts can give
an approxim ately 60-degree arc of m otion, although im plan t durability an d lon g-term results rem ain question able. Arthrodesis in approxim ately 40 degrees of flexion
634
Figure 15.62 (A) Radiograph and (B) schematic of DIP fusion. DIP, distal interphalangeal.
(Reprinted with permission from Strickland JW, Graham TJ. Master Techniques in Orthopaedic
Surgery: The Hand. Philadelphia, PA: Lippincott Williams & Wilkins, 2005.)
MP Joint
MP join t arth ritis is sign ifican tly less com m on th an eith er
DIP or PIP arth ritis. Disease at th is location is usually secon dary to traum a. Treatm en t is sim ilar to th at at th e PIP
join t, with arth roplasty bein g th e preferred surgical option .
Classification
Eaton an d Littler categorized TM arth ritis in to four stages
(Fig. 15.63). Stage 1 involves a norm al TM join t with
possible join t widen in g secon dary to syn ovitis. Stage 2 is
635
D
Figure 15.63 (AD) Stages IIV of thumb carpometacarpal arthritis. (Reprinted with permission from Lotke PA, Abboud JA, Ende J. Lippincotts Primary Care Orthopaedics. Philadelphia, PA:
Lippincott Williams & Wilkins, 2008.)
636
ch aracterized by m ild join t space n arrowin g with osteophytes sm aller th an 2 m m . Stage 3 dem on strates join t space
narrowing with osteophytes larger than 2 m m . Stage 4 in volves pan trapezial arth rosis. Th ese stages are im portan t in
determ in in g treatm en t.
Presentation/Physical Examination
Patien ts usually present with pain at the base of th e thum b.
Th ey com m on ly h ave a positive CMC grin d test, wh ich is
axial load an d rotation of th e th um b. Careful evaluation of
the thum b MP joint m otion m ust be perform ed to assess
for MP hyperextension.
Radiographic Findings
Radiograph ic evaluation in cludes a PA stress view, a lateral
view, an d a Robert view (a pron ated an teroposterior view).
O n e m ust keep in m in d th at th e radiograph ic severity of th e
disease does n ot always correlate with clin ical symptom s.
Differential Diagnosis
It is imperative to rule out oth er con com itan t diagn oses,
such as de Q uervain tenosyn ovitis, stenosin g ten osyn ovitis,
CTS, MCP in stability, or oth er wrist arth ridities.
Treatment
As with arthritis at any other location in the hand and wrist,
in itial treatm en t is con servative with activity m odification ,
thum b spica splinting, and NSAIDs. If nonoperative treatm en t is un successful, surgical treatm en t can be con sidered.
Stage 1 disease can be treated with arth roscopic debridem en t an d syn ovectomy, MC exten sion osteotomy to redirect th e MC force dorsally, an d ligam en t recon struction to
improve join t laxity. Th e success of any of th ese treatm en ts
hinges on the correct staging of the TM arthritis. Stages 2
through 4 imply m ore advanced TM joint degeneration and
usually require m ore exten sive procedures. Ligam en t reconstruction tendon interposition (LTRI) arthroplasty was
in itially described by Burton an d Pellegrin i an d rem ain s
the gold standard for en d-stage pantrapezial arth ritis (Fig.
15.64). Th is procedure involves trapezium excision, palm ar
(beak) ligam en t recon struction usin g th e FCR, an d FCR in terposition between th e scaph oid an d first MC. Lon g-term
results h ave sh own excellen t pain relief an d predictable in creases in both grip and pinch strength. Hem atom a or distraction arth roplasty is gain in g popularity but risks in clude
subsiden ce an d loss of pinch strength . Arthroplasty has
dem on strated h igh rates of loosen in g. Trapeziom etacarpal
arth rodesis in 30 degrees to 40 degrees of palm ar abduction , 35 degrees of radial abduction , an d 15 degrees of
pron ation is favored for youn g laborers. Syn th etic spacers, such as Artelon , h ave recen tly been in troduced an d but
lack lon g-term follow-up. Fin ally, with any of th ese procedures, it is im portan t to address any th um b MCP deform ity.
Hyperextension of th e th um b MP joint is a characteristic
respon se to CMC arth ritis an d m ust be corrected to preven t early failure of a CMC recon struction . Hyperexten -
STT Joint
Wh ile th e scaph otrapezialtrapezoidal join t is a com m on
site of arth ritis, it rarely occurs in isolation. Usually this
join t is in volved in pan trapezial arth rosis, wh ich is treated
with ligam en t recon struction with ten don in terposition
(LRTI) arthroplasty, or in SLAC wrist, where treatm ent is
depen den t on th e stage of collapse. However, if th e arth ritis
is lim ited to th e STTjoint, STTarth rodesis is a viable option.
SLAC/SNAC Wrist
Scaph olun ate advan ced collapse (SLAC) an d scaph oid
n on union advan ce collapse (SNAC) are two com m on
form s of posttraum atic wrist arthritis.
Pathophysiology
SLAC occurs secon dary to disruption of th e scaph olun ate
ligam ent and subsequent scaphoid flexion, whereas SNAC
results from a scaph oid n on un ion .
Classification
Watson was th e first to describe th e reproducible pattern
of radiocarpal an d in tercarpal degen eration th at occurs in
a SLAC wrist. Stage I arth rosis is lim ited to the distal aspect
of th e scaph oid an d th e radial styloid. Stage II arth rosis
involves the entire radioscaphoid joint. Stage III arthrosis
affects the entire radioscaphoid joint and the capitolunate
join t.
SNAC wrist is less com m on th an SLAC wrist an d h as a
differen t pattern of progression . Stage I arth rosis is lim ited
to th e distal scaph oid an d radial styloid. Stage II arth rosis
is stage I arth rosis plus scaphocapitate arth rosis. Stage III
arthrosis is periscaph oid arthrosis.
637
Presentation
Patients usually present with a rem ote history of a fall
on an outstretch ed h an d. In itially, patien ts com plain of
wrist pain an d swellin g th at resolves with tim e. Even tually,
however, patients develop decreased wrist m otion an d decreased grip/ pinch strength .
Physical Examination
Physical exam in ation is depen den t on th e stage of disease, but patien ts usually h ave ten dern ess over th e radioscaph oid articulation . Patien ts with an early SLAC wrist
m ay have a positive Watson test, as described earlier.
Radiographic Findings
Radiograph s are imperative in th e diagn osis, stagin g, an d
treatm ent of these posttraum atic form s of arth ritis.
Differential Diagnosis
Th e diagn osis of posttraum atic arth ritis is gen erally
straightforward, but SLAC and SNAC m ust be differentiated from each other.
Treatment
As with other form s of arthritis, conservative m an agem ent
in the form of activity restriction, simple splinting, and oral
an ti-inflam m atory m edications should be attempted first.
For th ose patien ts wh o h ave recalcitran t symptom s, surgical
m anagem ent of symptom atic patients is based on the stage
of disease. Stage I is best treated with radial styloidectomy
an d scaphoid stabilization. If th e scaphoid can be reduced,
it should be stabilized with a soft tissue procedure, such
as a dorsal capsulodesis or scapholunate recon struction. If
638
wrist arth rodesis is an excellent procedure in young laborers, in wh om it reliably decreases pain an d provides a rapid
return of grip stren gth . Total wrist arth roplasty is gain in g
som e popularity but does not have adequate lon g-term results to com pare with total wrist arthrodesis.
Treatm en t of SNAC is sim ilar to th at of SLAC, except
that surgery for stage I involves radial styloidectomy and
fixation of scaph oid n on un ion with som e form of bon e
graft.
INFLAMMATORY ARTHRITIS
Pathophysiology
Th e true etiology of RA is un kn own , but it is th ough t to be
a com bination of genetic an d en viron m ental factors. Over
tim e, RA leads to synovial proliferation within join ts an d
around ten dons. Progressive destruction of these tissues results in secondary antibody reactions followed by lysozym e
release from wh ite blood cells, oxygen free radical form ation, and collagenase release from the synovium . Cartilage,
ligam ent, and tendons are eventually affected, leading to
join t pain , in stability, deform ity, an d ten don rupture.
Pathophysiology/Classification
DRUJ arth ritis can be posttraum atic or degen erative.
Presentation
Sym ptom s in clude pain , swellin g, stiffn ess, an d decreased
grip stren gth .
Physical Examination
O n physical exam in ation , pain in located over th e uln ar
head and th e DRUJ, an d it is often exacerbated by forearm
rotation .
Radiographic Findings/Special Studies
Radiograph s will sh ow stan dard degen erative ch an ges of
the DRUJ. MRI is som etim es helpful in evaluating the
TFCC for poten tial tears an d th e lun ate for uln ar impaction
syn drom e.
Differential Diagnosis
Differen tial diagn oses in clude uln ar im paction syn drom e
an d TFCC tears.
Treatment
Surgical treatm en t is in dicated on ly after con servative
treatm en t h as failed. For advan ced arth ritis, m ultiple
procedures exist th at elim in ate th e distal uln a an d radius
articulation , an d each h as its advan tages an d disadvantages. Bowers distal uln a hem iresection an d ten don
in terposition preserves th e TFCC in sertion but is con train dicated in uln ar-positive in dividuals, wh o m ay h ave
residual uln ocarpal impaction . Darrach distal uln ar resection an d stabilization with ECU suspen sionplasty h as h ad
good results in th e low dem an d, elderly population , but
has had problem s with stum p in stability and subsequen t
weakness in younger patien ts. Th e SauveKapandji procedure retains the distal ulna, fuses the ulnar head to the
sigm oid notch, and creates a pseudoarthrosis of the uln ar
neck. Th e procedure provides better support for th e carpus
than th e distal ulna resection, but complications include
proxim al uln ar in stability an d uln ar regen eration with
loss of m otion . Fin ally, DRUJ arth roplasty is becom in g
in creasin gly popular, but few lon g-term studies exist to
accurately assess its outcom es.
Rheumatoid Arthritis
RA is a system ic inflam m atory autoim m une disease th at
initially affects the soft tissues and secondarily affects the
bon e. Approxim ately 1% of th e population is affected, with
a fem ale:m ale ratio of 2.5:1. O n set is usually between ages
40 an d 70, an d th e disease h as a progressive course. Han d
an d wrist involvem ent is extrem ely com m on.
Classification
RA can be classified by stage of join t involvem ent; accurate classification h elps guide treatm en t. Stage 1 is syn ovitis
with out deform ity an d can be treated n on operatively. Stage
2 is syn ovitis with passively correctable deform ity. Th is
stage is initially treated nonoperatively, but if symptom s
persist, ten osyn ovectom y m ay be n ecessary. Stage 3 is fixed
deform ity with out join t ch an ges an d is best treated with
surgical reconstruction. Stage 4 is articular destruction; salvage surgery such as arthrodesis or arthroplasty is required.
Presentation/Physical Examination
Th e diagn osis of RA requires th at at least four of th e seven
followin g criteria be present: periarticular m orn ing stiffn ess lastin g for at least 1 h our per day for at least 6 weeks,
sim ultan eous arthritis an d synovitis in three or m ore joints
for at least 6 weeks, arthritis of the hand joints for at least 6
weeks, sym m etric arth ritis presen t for at least 6 weeks, presen ce of rh eum atoid n odules, elevated rh eum atoid factor
titer, and radiographic evidence of subchondral erosions
or osteopen ia adjacen t to in volved join ts.
Ten don ruptures are com m on in patien ts with RA. Etiologies in clude syn ovitis, attrition al wear from osteophytes,
an d traum atic or iatrogenic causes. The Vaughn Jackson
lesion results from a subluxated, osteophytic, and sharp
uln ar h ead th at causes EDM an d EDC ten don ruptures. A
Mannerfelt lesion is a scaph otrapezial joint osteophyte that
causes FPL rupture. The diagnosis of ten don rupture is relatively straightforward: patients will have norm al passive
m otion but will be unable to actively m ove the joint. In
addition, there is a loss of the tenodesis effect.
Deform ity results wh en MP join ts drift in to uln ar deviation . This instability is secondary to synovitis, which atten uates th e radial exten sor h ood sagittal fibers an d causes
639
Psoriatic Arthritis
Psoriatic arth ritis is a relatively un com m on arth ritis an d
presen ts on ly in 5% to 10% of patien ts with psoriasis.
Pathophysiology
Synovial disease in the hand leads to either osteolysis or
ankylosis and autofusion. Osteolysis m ost com m only involves the DIP joint with erosion of the m iddle phalangeal
con dyles in to a spike, creatin g th e classic pen cil-in -cup
deform ity. Spon tan eous fusion occurs m ain ly at th e DIP
join t an d occasion ally at th e PIP join ts.
Presentation/Physical Examination
Patien ts usually h ave classic fin din gs of psoriasis, such as
th e scaly eryth em atous rash , before developin g join t sym ptom s. Early findings include nail pitting an d sausage digits.
However, once sign ifican t arthritis develops, it can affect
all finger joints and cause severe deform ity, which is often
referred to as arthritis mutilans. Fin ger telescoping can also
occur, wh ich gives a ch aracteristic appearan ce called opera
glass han d.
Radiographic Findings
As previously described, radiograph s frequen tly sh ow PIP
fusions, MP erosions, and wrist autofusions. The classic
deform ity seen on radiograph s is th e DIP pen cil-in -cup
deform ity.
Differential Diagnosis
In itially, RA m ust be distin guish ed from osteoarth ritis an d
oth er form s of in flam m atory arth ritis. O n ce th is is don e,
m ore specific clinical diagnoses have to be m ade. For instan ce, tendon ruptures m ust be differentiated from tendon
subluxation and peripheral neuropathy.
Differential Diagnosis
Psoriatic arth ritis m ust be differen tiated from osteoarth ritis, RA, an d other inflam m atory arth opathies. This usually
can be accom plish ed with a th orough h istory an d a search
for the characteristic nonm usculoskeletal fin dings.
Treatment
In itial treatm en t of acute flares is based on rest an d activity m odification. However, th e current m ainstay of treatm en t is early an d aggressive use of disease-m odifyin g an tirh eum atic drugs (DMARDs). These drugs, such as TNF-
inh ibitors, have had a dram atic effect on symptom s an d disease progression . By doin g so, th ey h ave m arkedly reduced
the need for surgical treatm ent of RA patients. However,
surgical intervention is still n ecessary in m anaging certain
aspects of th e disease.
Persistent tenosynovitis is best m anaged by complete
syn ovectom y. Ten don ruptures are treated by resection of
the offen ding bony prom in en ce, ten osynovectomy, and recon struction via tendon tran sfers. Later stages of RA, which
usually exh ibit n ear-com plete articular destruction , are best
treated by arthrodesis or arthroplasty. The choice between
Treatment
Medical treatm ent is sim ilar to that used for RA. Operative
treatm ent prim arily involves arthroplasty or arthodesis of
arth ritic joints.
Crystalline Arthropathy
Gout an d pseudogout are th e m ost com m on crystallin e
arth ropathies.
Pathophysiology/Classification
Gout can be separated in to prim ary gout, wh ich is idiopath ic, an d secon dary gout, wh ich results from an im balance in uric acid m etabolism Pseudogout or calcium pyroph osph ate deposition disease is th ough t to be due to
increased level of calcium or pyroph osph ate in cartilage.
640
Presentation/Physical Examination
Gouty attacks presen t with th e sudden on set of a warm ,
swollen, eryth em atous, and painful joint. Pseudogout can
presen t sim ilarly, but usually th e attack is less severe. Arth ritis an d ten don ruptures can occur secon dary to ch ron ic
in flam m atory ch an ges.
Radiographic Findings/Special Studies
Radiograph in gout can dem on strate soft tissue den sities
(toph i) an d articular erosion . Pseudogout appears as calcification s in th e cartilage, m ost com m on ly seen in th e TFCC.
For both con dition s, th e diagn osis is m ade on th e basis of
join t fluid aspiration an d an alysis. Uric acid crystals in gout
are n egatively birefrin gen t an d n eedle-like un der polarized
m icroscopy, wh ereas calcium pyroph osph ate crystals from
pseudogout are weakly positively birefrin gen t an d rh om boid sh aped.
Hand Stiffness
Hand stiffn ess is a com m on problem that has m any etiologies. To appropriately treat the stiffness, the correct diagn osis m ust first be m ade.
Differential Diagnosis
In fection can often be con fused with crystallin e
arth ropath ies sin ce both presen t as h ot, swollen join ts.
Th e diagn osis of in fection can usually be excluded on th e
basis of an alysis of th e join t fluid cell coun t an d of th e
Gram stain .
Classification
Stiffn ess can be due to eith er extrin sic or in trin sic causes.
Extrin sic stiffn ess in volves ten don s th at origin ate proxim al
to th e wrist, wh ereas th e source of in trin sic tigh tn ess originates at or distal to the wrist. Extrinsic exten sor tightness
m anifests as lim ited IP joint flexion when the MP joint is
h eld in flexion. Wh en th e MP join t is exten ded, m otion
is improved. Sim ilarly, extrinsic flexor tightn ess m anifests
as lim ited IP joint extension when the MP join t is held in
exten sion ; th is is im proved with MP join t flexion . O n th e
oth er h an d, in trin sic tigh tn ess results in a positive Bun n ell
intrinsic tigh tness test (Fig. 15.68), which dem onstrates less
IP join t flexion with th e MP join t in exten sion compared
with wh en th e MP join t is in flexion .
Treatment
Acute gout attacks are treated with colchicin e and/ or indom eth acin . In between flares, allopurin ol h elps m etabolize uric acid an d preven t future attacks. Pseudogout is
m ain ly treated symptom atically with NSAIDs an d im m o-
Presentation/Physical Examination
History sh ould address th e onset of symptom s, the progression of symptom s, an d any associated traum a. Exam ination
sh ould in clude in spection for deform ity and swelling, evaluation of active an d passive ran ge of m otion , an d testin g
Figure
Pathophysiology
Th e exact etiology or m ech an ism of CRPS is un kn own . It
has been hypothesized to occur from a positive feedback cycle in which peripheral nocicepter activation causes a spinal
cord m ediated reflex, which in turn activates the efferent
sympathetic system . Another hypoth esis is that CRPS is
caused by exaggeration of the peripheral neural inflam m atory respon se to tissue in jury.
Classification
Th ere are two types of CRPS. Type I, wh ich correspon ds
to th e classic RSD, is pain out of proportion to th e in itial
noxious even t that cannot be linked to any path ologic process. Type II, which corresponds to causalgia, is pain out
of proportion to th e in itial n oxious even t th at is associated
with an iden tifiable n erve lesion .
Presentation/Physical Examination
CRPS develops after an initial painful or noxious event,
an d often is associated with traum a. Subsequently, patients
complain of pain with light tough (allodynia), in creased
641
sen sitivity to touch (hyperesthesia), pain at rest (hyperpath ia), burn in g pain , an d various extrem ity ch an ges correspon din g to th e stage of disease. Specifically, th ree stages
h ave been described. Stage I in volves sign ifican t extrem ity swellin g an d edem a, with hyperh idrosis. Stage II is th e
dystroph ic ph ase ch aracterized by m arked stiffn ess. In th is
stage, skin ch an ges such as loss of creases, loss of hair, and
decreased m oisture are eviden t. Stage III is th e atroph ic
stage, durin g wh ich th e lim b becom es h ardly usable.
Dupuytren Disease
Dupuytren disease is a con dition th at is ch aracterized by
n odule an d cord form ation in previously n orm al fascial
tissues of the han d, with progressive flexion contractures
of th e MP an d/ or PIP join ts. It prim arily affects 40- to 60year-old m en of Northern European an cestry. Although it
can be in h erited as an autosom al dom in an t con dition with
variable penetrance, it is m ost frequently sporadic. It h as
been lin ked to alcoh ol, diabetes, HIV, an d sm okin g.
Pathophysiology
Th e exact etiology of Dupuytren disease is un kn own , but
m any factors have been proposed. Th ese include oxygen
free radical form ation secondary to hypoxia and dysfun ction of m ultiple growth factors including PDGF and TGFB1. The cell respon sible for th e disease h as been identified
as the myofibroblast, which has features of both sm ooth
m uscle cells and fibroblasts. These cells are responsible
for the three stages of the disease. The proliferative stage
is a vascular stage when the num ber of myofibroblasts
increases. Th e involutional stage involves alignin g of the
642
ral cord, th e retrovascular cord, th e lateral cord, th e n atatory cord, an d th e first webs in tercom m issural cord (Fig.
15.70). The central cord has no fascial precursor but is a
con tinuation of the pretendinous band. Th e spiral cord
arises from four structures: the pretendinous band, the spiral ban ds, th e lateral digital sh eath s, an d Grayson ligam en t.
Th is cord passes ben eath th e n eurovascular bun dle an d
brin gs it m ore superficial.
Presentation
Patients usually presen t with sin gle or m ultiple nodules
an d/or cords in th e palm ar fascia of the h and (Fig. 15.71).
Although these n odules are often pain less, they can cause
skin dim pling, flexion con tractures of th e MP and PIP
join ts, an d web space con tractures. Th ese con tractures often
lim it fun ction and usually progress over tim e. Eventually,
patien ts com plain of difficulty with fin e m otor m ovem en t.
Physical Examination
Physical exam in ation varies depen din g on th e severity of
the disease. Range of m otion of th e involved joints should
be accurately assessed. Distal n eurovascular fun ction m ust
be con firm ed, especially if operative in terven tion is bein g
con sidered.
Radiographic Findings
Radiograph s are usually un n ecessary to m ake th e
diagn osis.
cia. (Reprinted with permission from Doyle JR, Botte MJ. Surgical Anatomy of the Hand and Upper Extremity. Philadelphia, PA:
Lippincott Williams & Wilkins, 2003.)
Treatment
Treatm ent is based on the severity of the disease. Nonoperative treatm en t is useful in th e early stages of th e disease
wh en th e patien t h as n o pain an d n o fun ction al lim itation s.
However, as th e disease progresses, surgical treatm ent is indicated for MP join t con tractures greater th an 30 degrees
an d any PIP joint contracture. Surgical options include
palm ar fasciotom ies, partial palm ar fasciectom ies, an d
complete palm ar fasciectom ies. Fasciotom ies allow joint
con tracture release but have higher rates of recurrence an d
increased in cidence of n eurovascular injuries. Complete fasciectom ies have fallen out of favor due to the in creased
risk of complication s such as n eurovascular in jury an d in fection. Partial fasciectom ies are a comprom ise between
the oth er two procedures. With any procedure, careful dissection m ust be perform ed to prevent injury to th e neurovascular bun dle. Th e skin is often left open to preven t
h em atom a form ation , wh ich h as been im plicated in flair
reaction an d RSD. O verall, th e results of th e procedures are
relatively good, but th e recurren ce rate rem ain s approxim ately 10% per year.
Recen tly, en zym atic fasciotomy with clostridial collagen ase in jections h as sh own som e prom isin g results. On e
ran dom ized con trolled trial sh owed a 90% success rate,
with low recurren ce rate. However, lon g-term results are
pen din g.
643
Figure 15.70 Changes in palmar and digital fascia seen in Dupuytren disease. (Reprinted with
permission from Doyle JR, Botte MJ. Surgical Anatomy of the Hand and Upper Extremity. Philadelphia,
PA: Lippincott Williams & Wilkins, 2003.)
B
Figure 15.71 (A, B) Dupuytren cords. (Reprinted with permission from Lotke PA, Abboud JA, Ende
J. Lippincotts Primary Care Orthopaedics. Philadelphia, PA: Lippincott Williams & Wilkins, 2008.)
644
TENDINOPATHIES
Ten din opath ies are com m on con dition s of th e h an d an d
wrist. Th e flexor/exten sor tendons are restrained from displacin g forces by th e flexor retin aculum , th e exten sor retinaculum , an d the digital fibro-osseous pulleys. If th ere
is th icken in g of th ese restrain ts or of th eir con ten ts, th e
ten don s becom e compressed an d th e ten osyn ovium can
becom e in flam ed. Motion of th e ten don is altered, an d a
vicious cycle of worsen in g pain an d decreased ran ge of m otion results.
Trigger Finger
Trigger fin ger or sten osin g ten osyn ovitis is a com m on problem th at is ch aracterized by th e in ability to flex or exten d
a digit. Norm ally, th e flexor ten don s can glide sm ooth ly
through the fibro-osseous flexor pulley system . However,
in trigger digits, a discrepan cy exists between th e size of th e
flexor ten don and of the tendon sh eath, and this leads to
m ech an ical impin gem en t.
Pathophysiology/Classification
Trigger fin ger exists in two form s. Nodular ten osyn ovitis
is caused by th icken in g of th e flexor ten don on th e distal
edge of th e A1 pulley an d h as a distin ct n odule. Diffuse
ten osyn ovitis is caused by diffuse th icken in g of th e flexor
ten osyn ovium .
Presentation
Idiopath ic trigger fin ger often occurs in m iddle-aged
wom en , wh ereas secon dary trigger fin ger is com m on ly seen
in patien ts with diabetes, hypothyroidism , RA, ch ron ic renal disease, or other inflam m atory disease. All of th ese patien ts usually com plain of palm ar pain an d stiffn ess of th e
in volved fin ger. Depen din g on th e severity, patien ts m ay
also sen se crepitus, catch in g, or lockin g of th e fin ger.
Physical Examination
O n exam in ation , a palpable n odule can often be felt over
the A1 pulley. Patien ts are tender to palpation over the nodule. Visible catch in g or lockin g can usually be seen with
active ran ge of m otion .
Radiographic Findings
Radiograph s are usually un n ecessary to m ake th e
diagn osis.
Differential Diagnosis
Differen tial diagn oses in clude lockin g secon dary to im pin gem en t of th e collateral ligam en ts on a prom in en t MC
head condyle, FDP avulsion or rupture, MP dislocation ,
an d exten sor ten don rupture.
Treatment
Treatm en t is based on th e severity of disease. In itially, m ost
patien ts are treated n on operatively. Th is usually in volves
Figure 15.72 Trigger finger injection. (Reprinted with permission from Lotke PA, Abboud JA, Ende J. Lippincotts Primary
Care Orthopaedics. Philadelphia, PA: Lippincott Williams & Wilkins,
2008.)
de Quervain Tenosynovitis
Pathophysiology
de Quervain ten osyn ovitis is ten osyn ovitis of th e first dorsal com partm ent of th e wrist. Com m on causes include
repetitive use, in flam m atory arth ritis, an d traum a. New
m others often are diagnosed with de Quervain tenosynovitis as a result of liftin g th eir ch ildren with radial/ uln ar
deviation of th e wrists.
Presentation
de Quervain ten osyn ovitis occurs prim arily in m iddle-aged
patien ts an d presen ts with radial-sided wrist pain . Th e pain
is exacerbated by thum b m ovem ents and m ay radiate distally or proxim ally.
Physical Examination
On exam ination, patien ts are tender over the first dorsal
compartm ent of the wrist. Most patients have a positive
Fin kelstein test, wh ich is pain with forced uln ar deviation
of th e wrist with th e th um b in side a clen ch ed fist.
645
B
Figure 15.73 (A, B) Operative pictures of a trigger finger release. (Reprinted with permission from
Lotke PA, Abboud JA, Ende J. Lippincotts Primary Care Orthopaedics. Philadelphia, PA: Lippincott
Williams & Wilkins, 2008.)
Radiographic Findings
Radiograph s are un n ecessary in m akin g th e diagn osis but
m ay be helpful to rule out oth er conditions.
Differential Diagnosis
It is importan t to exclude oth er causes of radial-sided
wrist pain , such as CMC arth ritis, in tersection syn drom e,
Warten berg syn drom e, an d scaph oid fracture.
Treatment
In itial treatm en t is n on operative with th um b spica splin ting and oral NSAIDs. A corticosteroid injection can also
be perform ed to decrease in flam m ation an d is successful
approxim ately 60% of the tim e. If conservative treatm ent
fails, surgery con sistin g of release of th e first dorsal com partm en t is in dicated. Given th at th e APL often h as several
slips, great care m ust be taken to release all tendon sh eaths
of both th e APL an d EPB. Th e ten don sh eath s sh ould be
released on th eir uln ar aspect to preven t radial subluxation
of th e compartm en t. Th e sen sory bran ch es of th e radial
nerve have to be protected to avoid neurom a form ation
(Fig. 15.74).
Intersection Syndrome
Pathophysiology
In tersection syn drom e is in flam m ation of th e secon d dorsal exten sor compartm ent secondary to overuse. It is ch aracteristically seen in rowers.
Presentation/Physical Examination
Patients usually present with pain approxim ately 4 cm
proxim al to th e wrist (Fig. 15.75). On exam in ation , th e
secon d dorsal compartm ent is boggy and crepitation can
be felt.
646
ECRL
ECRB
APL
EPB
4 cm
Site of physical
findings
Site of
tenosynovitis
Radiographic Findings
Radiograph s are un n ecessary to diagn ose in tersection syn drom e.
Pathophysiology
Th e h an d is con stan tly exposed to both m in or an d m ajor traum a, wh ich can disrupt th e skin an d allow in oculation of bacteria. On ce bacteria have penetrated the skin,
the progression of infection is dependent on several factors,
including the location, the virulence of the organ ism , an d
the im m une status of the host. The m ost com m on organism s involved in h and infections are Staphylococcus aureus
an d Streptococcus, but others are encountered.
Presentation
As with oth er locations in the body, hand infections present
with pain , warm th , eryth em a, an d swellin g. In fection s th at
becom e system ic can cause fevers, ch ills, an d n igh t sweats.
Often, inflam m atory m arkers, such as C-reactive protein
(CRP), erythrocyte sedim entation rate (ESR), and white
blood cell (WBC) coun t are elevated.
History/Physical Examination
A complete history is vital to appropriately treating infections. Key components of the history are m ode of inoculation , duration of symptom s, ch an ge in sym ptom s,
previous treatm en ts, en viron m en tal exposures, occupation
travel h istory, an d im m une status. On exam ination, it is im portan t to determ in e th e exact location of th e in fection . For
instance, cellulitis is a superficial tissue infection and does
n ot in volve any deep loculated areas of purulen ce. On the
oth er h an d, septic arth ritis affects join ts cause m icrom otion pain and can lead to deep, fluctuant abscesses.
Radiographic Findings
Radiograph ic fin din gs in osteomyelitis in clude osteopen ia,
bony erosion s, lytic lesion s. For oth er soft tissue in fection s,
radiograph s are less h elpful but can som etim es dem on strate soft tissue swelling or subcutaneous air.
Differential Diagnosis
Th e differen tial diagn osis is sim ilar to th at of de Q uervain
syn drom e.
Special Studies
MRIs and ultrasounds are the best m odalities for accurately localizin g and diagnosin g deep infections. For
septic join ts, aspiration an d fluid analysis is diagnostic.
Nuclear m edicin e testin g m ay be ben eficial in diagn osin g
osteomyelitis.
Treatment
Th e m ain stays of treatm en t are activity m odification , wrist
splinting, and oral NSAIDs. Corticosteroid in jections are
used if th ese m odalities fail. Surgery, wh ich in volves com plete release of th e secon d com partm en t, is in dicated after
failure of n on operative m an agem en t.
Differential Diagnosis
Tum ors and crystalline arth ropathies can often present
sim ilar to in fection . Another com m on condition that can
presen t like in fection is pyogen ic gran ulom a. Th ese lesion s
form secondary to penetratin g traum a an d present as a red,
friable m ass; treatm ent con sists of cauterization.
HAND INFECTIONS
Although the hand is well perfused, frequent breaks in the
skin and exposure to outside pathogen s m akes it a frequent
site of infection.
Treatment
In gen eral, all in fection s of th e h an d are treated sim ilarly
with im m obilization , elevation , an tibiotics, an d operative
debridem en t if n ecessary. Th e specifics of treatm en t are
based on th e severity of th e path ogen an d th e location
of th e in fection . Em piric an tibiotics, wh ich sh ould be used
647
Nail plate
Matrix cells
Area of chronic paronychia
Paronychia
Pathophysiology
Paronychia is an infection un der the eponych ial fold, and
it usually occurs secondary to m an icures, hang nails, or
nail biting. The m ost com m on path ogen responsible is
S. aureus.
Presentation/Physical Examination
Paronychia usually presen t with pain , swelling, an d redness along the nail fold. Spontaneous drainage of purulen t
m aterial can also be seen.
Radiographic Findings
Radiograph s can evaluate th e distal ph alan x for osteomyelitis.
Differential Diagnosis
Severe paronych ias can progress to felon s.
Treatment
Th e treatm en t of paronych ia is based on th e stage of th e
infection. Early stages can be treated with warm water
soaks an d oral antibiotics. As the infection progresses, an
irrigation and debridem en t (I&D) m ust be perform ed to
decom press th e pus. Th is can usually be perform ed in th e
em ergen cy departm en t settin g, un der digital block. Th e
eponych ial fold is separated from th e n ail, an d often
the involved portion of the nail is rem oved. After irrigation,
the fold should be stented open with gauze to allow con tinued drain age. Ch ron ic paronych ia is usually caused by Candida albicans, is m ore resistan t to treatm en t, an d m ay require
m arsupialization for complete eradication (Fig. 15.76).
Felon
Pathophysiology
A felon is an abscess of th e fin ger pulp overlying the distal
ph alan x, an d it usually occurs secon dary to m in or traum a
or exten sion of a paronych ia. Sim ilar to paronych ia, felon s
are m ost frequently caused by S. aureus.
Presentation/Physical Examination
Th ese in fection s presen t with ten se swellin g, warm th , redness, an d pain localized to the finger pulp.
Radiographic Findings
Radiograph s are ben eficial in excludin g osteomyelitis of
the underlying distal phalanx in severe infections.
Differential Diagnosis
Severe infection can progress to adjacent structures. Therefore, osteomyelitis of the distal phalanx, septic arth ritis of
th e PIP join t, an d pyogen ic flexor ten osyn ovitis m ust be
excluded.
Treatment
Early cases can be treated with elevation , warm soaks, an d
antibiotics. However, the m ajority of felons require surgical decom pression of all th e pulps m ultiple compartm en ts.
Th e procedure can usually be perform ed in th e em ergen cy
departm en t settin g, un der digital block. Wh ile m any in cision s h ave been described, th e m ost com m on approach
is through a m idaxial, longitudinal incision. To avoid scar
sensitivity, the in cision should be placed on th e ulnar side
of th e in dex fin ger, lon g fin ger, an d rin g fin ger, but on
th e radial sides of th e th um b an d sm all fin ger. Th e digital
n eurovascular bun dle m ust be avoided, an d th en scissors
or clamps are used to decompress all th e sm all com partm ents. The wound is packed, and twice-a-day soaks are
started after 24 hours. Empiric antibiotics covering gram positive cocci are started un til culture results are fin alized.
Herpetic Whitlow
Pathophysiology
Herpetic whitlow is a fin ger infection caused by the herpes
sim plex virus. Most com m only, it is transm itted by oral
secretion s; an d th erefore, ch ildren and health care workers
are at risk.
Presentation/Physical Examination
Th e in fection presen ts as a sin gle or a group of pain ful
vesicles over the fingertips or other regions of th e hand
(Fig. 15.77). Th e pain m ay precede the appearan ce of th e
vesicles.
648
Pathophysiology
In fection of th e ten don sh eath usually results from direct
inoculation or from the spread from adjacent infection. If
treatm ent is inadequate or delayed, infection can spread to
adjacent tendon sheaths or to the radial/ulna bursa. Th e
radial an d uln a bursa can th eoretically com m un icate
through Parona space in th e wrist, form ing what is kn own
as a horseshoe abscess.
Presentation/Physical Examination
Diagn osis is usually based on th e Kan avel four cardin al
signs, which are severe pain to passive exten sion, fusiform
swellin g of th e involved digit (sausage digit), tenderness
along th e flexor tendon sheath , an d partial flexed resting
posture of th e fin ger
Differential Diagnosis
Th e differen tial diagn osis for pyogen ic ten osyn ovitis in cludes gout, other deep infections of th e hand, an d inflam m atory arthropathy.
Treatment
Treatm ent is based on tim e to presentation. Early stages
of th e disease (< 24 h ours) can som etim es be m an aged
with elevation , im m obilization , in traven ous an tibiotics,
an d close observation. However, if the infection worsens
or if th e patien t presen ts beyon d 24 h ours, irrigation an d
debridem en t of th e flexor ten don sh eath is m an datory. Th is
can be accomplished via an open Brunner zigzag incision
or a m idaxial in cision . Altern atively, it can be perform ed
closed via a proxim al and a distal incision into the ten don sh eath , followed by irrigation of th e sh eath usin g an
an giocath eter (Fig. 15.78).
Abscesses
Th e h an d con tain s m any deep spaces wh ere abscesses can
occur. Th ese in clude th e subcutan eous space, th e dorsal
subaponeurotic space, th e then ar space, the hypoth enar
space, an d th e interdigital web spaces.
Pathophysiology
Most abscesses occur from a penetrating traum a or from
con tiguous in fection of an adjacent area. However, a collar
button abscess is an abscess of th e web space th at assum es
649
a volar to dorsal hourglass configuration due to th e superficial transverse MC ligam en t. This abscess often form s in
laborers from a palm ar blister, callus, or fissure.
Presentation/Physical Examination
Patien ts usually presen t with pain , eryth em a, warm th , an d
swellin g. Th e swellin g m ay be diffuse or localized. For example, m id palm ar abscesses h ave a loss of the norm al
palm ar con cavity. Also, patien ts m ay h ave lim ited, pain ful
finger m otion depending on the location of the abscess.
Radiographic Findings/Special Studies
If a patien t presen ts with diffuse swellin g, an MRI is useful
in differentiatin g cellulitis from an abscess.
Differential Diagnosis
Abscesses can m im ic any adjacen t in fection . Tum or m ust
also be excluded.
Treatment
All abscesses are treated with irrigation an d debridem en t,
but specific tech n iques are depen den t on th e exact location of the infection . Certain infections, such as a collar
button abscess or a th en ar space abscess, m ay require two
incisions. The wounds should be packed open, an d soaks
sh ould be in itiated 1 to 2 days after surgery. Following
surgery, appropriate in travenous antibiotics, elevation, an d
im m obilization are critical for a successful outcom e.
Septic Arthritis
Pathophysiology
Septic arth ritis is infection of the join t, an d it can be caused
by direct inoculation from traum a or by secondary spread.
Once there is infection in the joint, cartilage destruction will
occur from th e in flam m atory process. Th e m ost com m on ly
involved pathogens are S. aureus an d Streptococcus.
Presentation/Physical Examination
Patien ts with septic arth ritis com plain of eryth em a,
swellin g, an d sign ifican t joint pain th at causes pain even
with m icrom otion of th e join t.
mission from Strickland JW, Graham TJ. Master Techniques in Orthopaedic Surgery: The Hand. Philadelphia, PA: Lippincott Williams
& Wilkins, 2005.)
650
Differential Diagnosis
In flam m atory arth ritis can m im ic septic arth ritis but gen erally dem on strates lower WBC coun ts an d lower percen tages
of n eutroph ils.
Treatment
O n ce th e diagn osis of septic arth ritis is m ade, th e treatm en t is irrigation an d debridem en t of th e join t, followed
by lon g-term oral or intravenous an tibiotics. Th e one exception is septic arthritis caused by Neisseria gonorrhoeae,
which can usually be treated non operatively by intraven ous
ceftriaxone.
Osteomyelitis
Pathophysiology
O steom yelitis, or an in fection of th e bon e, is typically
caused by an open fracture or by spread of infection from
adjacen t sites. Th e risk of osteomyelitis is in creased in im m un ocomprom ised patien ts, especially th ose wh o h ave
diabetes.
Presentation/Physical Examination
Patien ts usually present with pain, swelling, eryth em a, and
possible drain age. In flam m atory m arkers, such as CRP
level an d ESR, are elevated.
Radiographic Findings/Special Studies
In itial radiograph s are often n egative. However, after several weeks of osteomyelitis, radiograph s will dem on strate
osteopen ia an d periosteal reaction . Sequestra, wh ich is
dead bon e with surroun din g gran ulation tissue, an d in volucrum , wh ich is periosteal n ew bon e, can also be seen .
When radiograph s are n egative, MRI and nuclear m edicin e
studies are invaluable in m akin g the diagnosis.
Differential Diagnosis
Th e differen tial diagn osis for osteomyelitis in cludes septic arth ritis, crystallin e arth ropathy, traum a, an d deep soft
tissue in fection .
Treatment
Antibiotics are the first lin e of treatm en t an d are contin ued for 4 to 6 weeks. If con servative treatm en t fails, an
associated abscess is presen t, or n ecrotic bon e is seen , th en
surgical debridem ent is required.
Bite Wounds
Pathophysiology
Both hum an and an im al bite wounds are a com m on source
of in fection in th e h an d. Hum an bites usually occur durin g
an altercation wh en on e person strikes an oth er person in
Presentation/Physical Examination
Patients usually present with a wound on the h and. If the
patien t presen ts with a dorsal woun d over th e MP join t after
an altercation, careful physical exam ination is warran ted to
be sure th at th is figh t bite does n ot com m un icate with th e
join t.
Radiographic Findings/ Special Studies
Radiograph s are n ecessary to screen for fractures an d foreign bodies, especially with figh t bites.
Treatment
Most inoculated wounds should be copiously irrigated,
left open, and treated with broad-spectrum an tibiotics,
such as ampicillin sulbactam (Unasyn) or am oxicillin
clavulanate (Augm entin). If a wound is grossly infected or
if the joint is infected, form al irrigation an d debridem ent
sh ould be perform ed in th e operating room . Rabies prophylaxis sh ould be con sidered if th e in volved an im al was
a bat, fox, skunk, raccoon, unknown dom estic anim al, or a
dom estic an im al dem on stratin g features of rabies.
Necrotizing Fasciitis
Pathophysiology
Necrotizin g fasciitis is a rapidly progressive an d poten tially
life-threatening in fection of th e soft tissues. It usually stem s
from relatively m inor traum a to the extrem ity. The m ost
com m on organism responsible is group A -hem olytic
streptococcus, but S. aureus an d an aerobes m ay be presen t.
It is seen m ore com m on ly in diabetic patien ts.
Presentation/Physical Examination
Patients presen t with rapidly spreading, painful erythem a
that is accompan ied by induration and swelling. Inflam m atory m arkers, such as CRP and ESR, and WBC count are
usually extrem ely elevated. As th e in fection progresses, th e
patien t m ay becom e h em odyn am ically un stable.
Radiographic Findings/Special Studies
Radiograph s will sh ow sign ifican t soft tissue swellin g an d
poten tially subcutan eous air. If th e patien t is stable an d th e
diagn osis is un clear, an MRI can be perform ed, wh ich will
sh ow edem a and swellin g of the fascial planes.
Differential Diagnosis
Th e prim ary differen tial diagn osis is cellulitis, wh ich
presen ts with less severe symptom s, stable vitals sign s,
slower disease course.
Treatment
Mortality rates of been described between 10% and 30%.
Th erefore, early an d aggressive surgical debridem en t alon g
with empiric, broad-spectrum an tibiotics is warran ted.
Antibiotics m ust include coverage for gram -positive organism s (cephalosporins), gram -negative organism s (gentam icin), and anaerobes (penicillin). In the operating room ,
watery, foul-sm elling fluid (dishwasher pus) is usually
found along the fascial planes. Multiple debridem ents are
usually required, an d amputation is occasion ally n ecessary.
If th e lim b can be salvaged, soft tissue coverage is often
even tually required.
Atypical Infections
Besides com m on bacterial infections, atypical infections
from mycobacterial species an d fungi can be seen in the
hand.
Embryology
Th e em bryon ic developm en t of th e upper lim b occurs
in a surprisingly consistent an d reproducible pattern . On
rough ly day 26, th e upper lim b buds appear. At th is tim e,
lim b growth is controlled by the apical epidermal ridge. All
growth in th e lim bs proceeds from proxim al to distal. By
day 33, prim itive arm s an d h an ds h ave form ed. At 6 weeks,
ch ondrification of the bones has begun. By 8 weeks, apoptosis (program m ed cell death ) h as separated out th e in dividual fingers.
Incidence and Etiology
Upper extrem ity anom alies are present in approxim ately 1
out of every 626 live birth s. However, on ly 10% of th ese
an om alies cause any significant functional or cosm etic
deficit. Th e root cause of h alf of th ese con gen ital defects
is unknown, wh ereas the rest are believed to be either genetic or environm en tal in etiology. Wh en an upper extrem ity congenital anom aly is en countered, it is important to
evaluate th e ch ild for an om alies of oth er organ system s,
such as cardiac, gastroin testin al, or ren al.
651
Classification
Swanson h as divided anom alies of the upper lim b into 7
m ajor categories, which are outlined below:
I.
II.
III.
IV.
V.
VI.
VII.
652
Failure of Differentiation
Failure of differen tiation occurs when the norm al m ech anism s of apoptosis are disrupted an d structures th at n orm ally are separate rem ain join ed. Syn dactyly is th e m ost
represen tative con dition in wh ich digits fail to separate.
Syn dactyly is discussed furth er in Ch apter 11.
RECOMMENDED READINGS
Duplication
Duplication refers to th e presen ce of an extra structure in th e
hand, usually a finger or a thum b. Preaxial duplication, or
polydactyly, refers to duplication s of the thum b or the radial
16
Charles L. Nelson
INTRODUCTION
Th e h ip join t is th e m ost proxim al join t of th e lower extrem ity and plays an integral role in gait an d balan ced locom otion. The hip is designed for strength and m obility, and thus
the bony architecture, soft-tissue structures, and surrounding m usculature are geared toward conferring constraint
an d joint stability while allowing for a m ultitude of m aneuvers and range of m otion (ROM). Path ologic processes
affecting th e hip are com m on and include soft-tissue in juries such as labrum an d cartilage defects, bony in juries
such as fractures about the acetabulum and fem ur, vascular insults such osteonecrosis of the fem oral head, and
degen eration of th e join t as seen in post-traum atic arth ritis
an d osteoarthritis (OA). Hip pathology has a significant
impact on a patients m obility and thus m ay result in a
significant degree of m orbidity and dysfun ction with out
adequate treatm ent.
Th is ch apter will focus on a brief overview of th e em bryology an d developm en t of th e h ip, th e osteology an d
m usculature surrounding the h ip joint, contribution of the
hip to lower extrem ity gait and biom echan ics, as well as
a series of soft-tissue and bony path ologies with an em ph asis on clin ical diagn osis, radiograph ic diagn osis, an d
indications for surgical treatm ent.
ANATOMY
Embryology of the Hip
Th e h ip is defin ed as a ball an d socket-type join t. Th e
fem oral h ead is situated within the confin es of th e acetabulum th at con fers bony stability to th e join t. Th e structural
acetabulum is a result of a fusion between three separate
pelvic bon es: th e ilium , isch ium , an d pubis (Fig. 16.1).
Th ese th ree bon es are con fluen t at th e tri-irradiate car-
654
Figure 16.1 Hemipelvis depicting the three components of the innominate bone. (Reprinted
with permission from Tile M, Helfet DL, Kellam JF. Fractures of the Pelvis and Acetabulum. 3rd ed.
Philadelphia, PA: Lippincott Williams & Wilkins, 2003.)
Figure
655
16.3 Anteroposterior
Posteriorly, th e sacrospinous (from th e sacrum to the ischial spine) and sacrotuberous (from the sacrum to the ischial tuberosity) ligam en ts define the borders of the greater
and lesser sciatic foram en or notches, respectively. The piriform is m uscle is a key landm ark with regards to all structures posterior to the hip join t. Using this m uscle as a referen ce, th e superior gluteal artery an d n erve lie superior
to the piriform is. Th e followin g structures lie deep to the
656
B
Figure 16.5 (A) The normal neck-to-shaft angle (angle of inclination of the femoral neck to the
shaft in the frontal plane) is approximately 125 degrees. The condition in which this angle is less than
125 degrees is called coxa vara. If the angle is greater than 125 degrees, the condition is called coxa
valga. (B) Top view of the left femur showing the angle of anteversion formed by the intersection of
the long axis of the femoral head and the transverse axis of the femoral condyles. The angle averages
approximately 12 degrees in adults. (Reprinted with permission from Nordin M, Frankel FH. Basic
Biomechanics of the Musculoskeletal System. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins,
2001.)
Figure 16.6 (A) Anterior and (B) Posterior views of the hip. Illustration of the three pericapsular
hip ligaments. (Reprinted with permission from Callaghan JJ, Rosenberg AG, Rubash HE. The Adult
Hip. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2007.)
657
Figure 16.7 Origin and insertion of the major muscles surrounding the hip joint. (Reprinted with
permission from Callaghan JJ, Rosenberg AG, Rubash HE. The Adult Hip. 2nd ed. Philadelphia, PA:
Lippincott Williams & Wilkins, 2007.)
piriform is: (a) puden dal n erve, (b) n erve to obturator in tern us, (c) posterior fem oral cutan eous n erve, (d) sciatic
nerve, (e) inferior gluteal nerve, and (f) nerve to quadratus fem oris. All of these structures, includin g the piriform is
m uscle, exit the pelvis through the greater sciatic foram en.
However, both the puden dal nerve and the n erve to th e obturator internus reenter the pelvis through the lesser sciatic
foram en (Figs. 16.1 and 16.2). Clinically, the greater sciatic foram en or notch is a key landm ark for identifying th e
location of th e superior gluteal artery. Inadverten t injury
to th is artery in th is location durin g surgery m ay result in
significant bleedin g and retraction of the dam aged artery
into the pelvis, m aking hem ostasis difficult to achieve.
Sciatic Nerve
Cruciate Anastomosis
658
Figure 16.8 Illustration of arterial supply surrounding the hip joint. (Reprinted with permission
from Clemente CD. Clementes. Anatomy Dissector. 3rd ed. Philadelphia, PA: Lippincott Williams &
Wilkins, 2011.)
Obturator artery
Femoral artery
Medial and
lateral circumflex arteries
Profunda femoris artery
Nutrient artery
659
Figure 16.9 The vascular supply to the femoral head arises from
the medial and lateral circumflex vessels, which create a ring giving
rise to the cervical vessels. A minor contribution comes from the
obturator artery via the ligamentum teres. From Bucholz RW, MD
and Heckman JD, MD. Rockwood & Greens Fractures in Adults,
5th ed. Lippincott, Williams & Wilkins, 2001.
PATIENT EVALUATION
Clinical History
Th e evaluation of a patien t presen tin g with h ip pain requires a th orough an d detailed h istory. Th is h istory is com plim en ted by physical exam in ation an d wh en n ecessary
im aging studies, including plain radiographs, m agnetic reson an ce im agin g (MRI), an d com puted tom ography (CT).
Several key elem en ts are in corporated in to obtain in g a
th orough patien t h istory. Th e h istory sh ould first focus on
th e exact location of th e pain . It is im portan t to determ in e
wh eth er th e patien t suffers from poin t ten dern ess versus
diffuse pain en circlin g th e h ip. Wh en possible, try to h ave
th e patien t poin t with on e fin ger to th e location of m axim al
discom fort. In tra-articular h ip pain typically m an ifests as
groin pain with h ip RO M, wh ereas referred pain to th e h ip
from th e lum bar spine presents as diffuse pain over th e
PSIS an d buttock. Th igh pain typically is in dicative of eith er
h ip or fem oral pathology, especially wh en th e patien t h as
previously un dergon e total h ip arth roplasty.
Next, th e tem poral n ature of th e pain sh ould be determ ined. What has been th e duration of this pain? Has the
pain been th ere for 3 days, 2 weeks, or 1 year? Un derstan ding the chronicity of th e complaint is critical in assessin g
wh eth er th e patien t is likely to n eed surgical in terven tion .
Relating the onset of the pain to a specific event is also critical in determ inin g the etiology. If the patien ts state that
th eir h ip pain started after a fall, it is im portan t to obtain
details surroun din g th e even t to fin d a correlation between
th e m ech an ism of in jury an d th e un derlyin g path ology.
After un derstan din g th e even ts leadin g up to th e on set of
h ip pain, h ave the patien t rate th e pain on a scale of 1 to
10 to objectively docum en t th e degree of pain .
Ask the patient regarding rem itting and exacerbatin g factors associated with their pain what m akes the pain worse
and what m akes it better? Are there specific m otion s that
recreate th e pain ? Is th e pain alleviated by th e use of any
660
Obturator
artery
Subsynovial
intracapsular
arterial ring
Ascending
cervical arteries
Medial femoral
circumflex artery
Descending
branch LFC
Femoral artery
Profunda
femoris artery
Lateral
femoral
circumflex
artery
Foveal
artery
Subsynovial intracapsular
arterial ring
Ascending
cervical arteries
Extracapsular
arterial ring
Retinacula of Weitbrecht
Medial femoral
circumflex artery
Femoral artery
Profunda
femoris artery
First perforator
femoral head and neck. (Top) Anterior aspect. (Bottom) Posterior aspect. LFC: lateral femoral circumflex artery (Reprinted
with permission from Bucholz RW, Heckman
JD, Court-Brown CM, et al. Rockwood and
Greens Fractures in Adults. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
for any length of tim e. Has the patien t been wh eelchairboun d over th e past 2 years? In form ation of th is n ature is
importan t in determ ining the contribution of com orbidities (e.g., cerebrovascular accident) to the patients condition and its effect on potential surgical treatm en t. Attention
sh ould also be given to the patients history of m edications
(e.g., corticosteroids m ay lead to osteonecrosis) an d social
h istory (EtOH abuse is also associated with osteon ecrosis).
It is imperative to question th e patien t regardin g symptom s th at m ay indicate concom itant lum bar spin e involvem ent. Pain originating in the hip m ay radiate to the knee
Physical Examination
Wh en con ductin g a physical exam in ation of th e pain ful
hip, it is im portan t to em ploy a th orough system atic approach . Gait an alysis is th e m ost im portan t fun ction al evaluation of th e lower extrem ity. O bservin g a patien t walkin g
into the office can reveal a great deal about the patients
hip pathology an d overall function al capacity. Typically,
patien ts with a pain ful h ip will spen d a sh orter tim e in
stan ce ph ase on the involved lower extrem ity and lean over
the affected hip when weight-bearing to reduce th e joint
reaction forces. Th is type of gait is term ed as Trendelenburg
gait an d m ay also be seen with a weak abductor complex.
661
Th e m eth od by wh ich to con duct th e physical exam in ation of th e h ip follows th e sam e prin ciples used to exam in e
any organ system . Th e exam in ation sh ould adh ere to th e
following sequence: (a) inspection, (b) palpation, (c) active an d passive RO M, (d) m an ual m uscle/ stren gth testin g,
(e) n eurologic exam in ation , (f) vascular exam in ation , an d
(g) special tests based on th e differen tial diagn osis developed from th e h istory.
To inspect the h ip properly, it is recom m ended to disrobe th e patien t. In spect th e h ip for eviden ce of any skin
discoloration , abrasion s, ecchym osis, open woun ds, drain in g sin us tracts, swellin g, fluid collection (h em atom a or
abscess), as well as any previous in cision s. Asym m etry existin g between h ips sh ould be n oted. In addition , use th e
position s of th e ASIS to determ in e if pelvic obliquity exists
an d th en assess for leg len gth discrepan cy.
Bony palpation surroun din g th e h ip sh ould flow system atically from an terior to posterior. Th e an terior structures th at sh ould be palpated in clude th e ASIS, iliac crests,
an d pubic tubercles. Next, atten tion sh ould be focused on
the greater trochanters. The posterior edge of the greater
troch an ter is relatively un covered an d is easily palpable in
a th in patien t. Th is is th e region th at is typically pain ful in
patien ts with troch an teric bursitis. Con tin uin g posteriorly,
the PSIS an d the ischial tuberosities should be palpated.
Patients with referred pain from th e lum bosacral spine typically are diffusely ten der across th e PSIS an d sacrum .
Th e h ip ROM sh ould be docum en ted. Norm al h ip flexion an d exten sion are 130 an d 20 degrees, respectively,
wh ile intern al and extern al rotation of th e hip is 30 and
70 degrees, respectively. Th ese m an euvers are best tested
with th e patient in the supine position. In the lateral decubitus position (patient on their side), hip abduction and
adduction can be tested an d typically dem on strate 40 an d
30 degrees, respectively. Passive ROM of the hip sh ould be
correlated to pain; patients with osteonecrosis of th e hip
typically m ain tain h ip ROM but h ave pain ful in tern al rotation . In addition , all h ip ROM m an euvers m ust be don e
with stabilization of th e pelvis to avoid artificially inflated
degrees of m otion .
Th e n eurovascular exam in ation begin s with m an ual
m uscle testin g. Muscle stren gth is graded on a scale from 0
to 5: 0 is complete absen ce of m uscle fun ction ; 1 dem on strates m uscle fasciculations without any lim b m ovem ent;
2 represents th e ability to fire th e m uscle an d m ove th e
lim b, but n ot again st gravity; 3 allows firin g of th e m uscle
an d m ovem en t of th e lim b, but again st gravity on ly; 4 is
firin g of th e m uscle again st som e resistan ceth is grade is
subdivided into a 4 and 4+ on th e basis of th e degree of
resistan ce th at th e patien t can coun ter; an d 5 is full m uscle
function. In general, the lower extrem ity m uscles m ust n ot
be able to be m an ually overcom e to be given a grade of 5.
A detailed n eurologic exam in ation of th e en tire lower
extrem ity as well as provocative spin e m an euvers sh ould
be docum en ted. Fun ction of th e m ajor n am ed n erves (e.g.,
fem oral, tibial, deep, and superficial peron eal) should be
662
tested. In addition , sen sation to ligh t touch sh ould be determ in ed in th e derm atom al distribution of th e lower extrem ity. Adetailed sen sory n eurologic exam in ation is m ore
importan t in diabetic patien ts wh o m ay suffer from diabetic
neuropathy.
Every patient should also undergo a vascular exam ination th at starts with palpation of th e dorsalis pedis an d posterior tibial arteries. In patien ts wh o do n ot h ave palpable
pulses, a form al vascular con sultation sh ould be ordered
to determ in e th e vascular status of th e in volved lower extrem ity. Vascular com prom ise m ay im pede woun d h ealin g
or m ay result in a vascular crisis in th e early postoperative
period followin g an elective h ip procedure.
While obtain in g a detailed h istory and perform ing a basic physical exam in ation , th e surgeon should form ulate a
differen tial diagn osis. On th e basis of th is differen tial diagnosis, special tests are perform ed to recreate patien t sym ptom atology an d con firm a diagn osis prior to employin g
im agin g m odalities.
Patients suffering from long standing hip pain, especially pain secondary to OA, m ay present with a hip flexion
contracture due to con tracture of soft-tissue structures surroun din g th e h ip join t. Th e an terior capsule, h ip capsule,
is m ost frequen tly in volved, resultin g in decreased h ip exten sion . Th e Th om as test aids in diagn osin g th e presen ce
of a h ip flexion con tracture. Th e patien t is placed supin e
on th e exam in in g table wh ile m axim ally flexin g th e con tralateral h ip an d kn ee by brin gin g th e kn ee in toward th e
ch est. As th e exam in er, m ake sure to place your h an ds
on th e ASISto en sure th at th e pelvis is stable an d flat again st
the exam ining table. If th ere is a flexion contracture about
the hip, the involved extrem ity will not rest flat on the table
(Fig. 16.12). If th e pelvis is n ot flat on th e table, patien ts
m ay be able to reposition th eir pelvis an d in crease th e degree of lum bar lordosis to com pen sate an d dem on strate
full extension of th e involved hip.
Patients with a tight iliotibial (IT) band m ay also com plain of lateral h ip pain . Th e Obers test dem on strates th e
Radiographic Evaluation
Stan dard radiograph s used to evaluate a patien t with h ip
pain in clude a stan ding AP pelvis (Fig. 16.13), and a standing AP of the in volved hip with the hip internally rotated
15 degrees. A frog leg lateral or shoot-through lateral of th e
involved h ip should also be obtained. These views provide
Figure 16.12 Thomas test. After simultaneous flexion of both hips, each hip may be extended
separately to record the arc from the horizontal to the femoral shaft. This indicated the degree
of passive flexion contracture of the hip. (Adapted from Steinberg M. The Hip and its Disorders.
Philadelphia, PA, WB Saunders, 1991.)
663
A,B
Figure 16.13 (A) AP radiograph of the left hemipelvis. (B) Diagram demonstrating the anatomic
landmarks seen on the AP radiograph. (C) The major landmarks identified by various lines are as
follows: diagonal dashes, the iliopectineal line (anterior column); straight dashes, the ilioischial line
(posterior column); and solid line, the anterior lip of the acetabulum. The same identifying lines are
used in Figures 16.14 and 16.15. (Used with permission from Tile M. Fractures of the Pelvis and
Acetabulum. Baltimore, MD: Williams and Wilkins Co, 1984.)
664
D
Figure 16.14 (A) Obturator oblique radiographic view of the left hemipelvis. (B) This view is taken
by elevating the affected hip 45 degrees to the horizontal by means of a wedge and directing the
beam through the hip joint with a 15-degree upward tilt. (C) Diagram demonstrating the anatomy
of the pelvis on the obturators oblique view. (D) Diagram demonstrating the important anatomic
landmarks by various lines (described in Fig. 16.13). In this view, note particularly the pelvic brim,
indicating the border of the anterior column and the posterior lip of the acetabulum. (Used with
permission from Tile M. Fractures of the Pelvis and Acetabulum. Baltimore, MD: Williams and Wilkins
Co, 1984.)
Figure 16.15 (A) Iliac oblique radiographic view of the left hemipelvis. This view is taken placing
the patient in 45 degrees of external rotation by elevating the uninjured side on a wedge, as shown
in (B). (C) Diagram demonstrating the anatomic landmarks of the left hemipelvis on the iliac oblique
view, further clarified in (D) by the various lines described in Figure 16.13. This best demonstrated
the posterior column of the acetabulum. (Used with permission from Tile M. Fractures of the Pelvis
and Acetabulum. Baltimore, MD: Williams and Wilkins Co, 1984.)
665
666
Classification
Hip dislocations are in itially classified as anterior or posterior according to the relationsh ip of the fem oral head to the
acetabulum . Th ompson an d Epstein first proposed a classification system for both an terior an d posterior dislocation s
an d in corporated associated fractures of th e fem oral h ead
an d acetabulum (Table 16.1). Stewart an d Milford proposed a sim ilar classification sch em e th at in cluded postreduction stability. Both of th ese classification s h ave been
com m only employed over th e years an d have been sh own
to predict outcom e.
More recen tly, Levin in troduced a compreh en sive classification system that is useful for both anterior an d pos-
TABLE 16.1
terior h ip dislocation s (Table 16.2). Th is classification system attempts to guide treatm en t on th e basis of th e pre- an d
postreduction physical fin din gs, associated fractures, an d
diagn ostic in form ation gain ed from radiograph s as well as
CT scan.
Mechanism of Injury
Th e vast m ajority of h ip dislocation s are posterior an d occur
secon dary to h igh-energy m echanism s such as m otor veh icle accidents. Th ey are due to a posteriorly directed force
on a flexed kn ee. Th ese in juries are com m on ly referred to
as dashboard injuries. Other com m on m echanism s in clude falls, pedestrians struck by autom obiles, and sports
injuries.
Th e position of th e h ip, th e direction of th e force vector, an d th e patien ts an atomy will determ in e th e direction
TABLE 16.2
Reprinted with permission from Browner BD, Levine AM, Jupiter JB,
et al. Skeletal Trauma: Expert Consult. 4th ed. Saunders, 2008.
of th e dislocation an d wh eth er an associated fracture occurs. More than 85% of hip dislocations are posterior. It
has been shown that increasing degrees of adduction an d
flexion at th e tim e of impact m ake pure dislocation m ore
likely. Conversely, less hip adduction and flexion typically
leads to fractures of the posterior wall of the acetabulum or
sh ear fractures of th e fem oral h ead. Additionally, in creased
fem oral anteversion h as been shown to decrease th e risk of
posterior wall acetabular fracture in posterior dislocation s.
Anterior dislocations occur m uch less frequently than
posterior dislocation s. Th e h ip m ust be in a position of abduction an d extern al rotation at th e tim e of im pact, as is
often th e case in m otorcycle acciden ts, for an an terior dislocation to occur. The degree of flexion of the hip determ ines
if the fem oral head com es to rest in a suprapubic or obturator location . However, th is an atom ic distin ction does n ot
affect treatm en t or outcom e. Associated fem oral head fractures occur m ore com m on ly in anterior dislocations and
typically are impaction-type fractures.
Presentation
Patients with h ip dislocations typically presen t with severe
pain an d are un able to bear weigh t or m ove th e affected
hip. They m ay also complain of num bn ess in the sciatic or
fem oral nerve distributions. Often patients will have m ultiple injuries at presentation and m ay be obtunded or uncon scious.
Physical Examination
In itially, th e physical exam in ation sh ould be directed by th e
guidelines of th e Advan ced Traum a and Life Support System . Followin g a th orough traum a evaluation , exam in ation
of th e patien t sh ould begin with observation of th e position
of th e lim b. Posterior h ip dislocation s cause th e lim b to be
fixed in flexion , adduction , an d in tern al rotation . On th e
con trary, m arked abduction and external rotation are eviden ce of an an terior dislocation . However, associated fractures of the fem oral neck or sh aft will obscure these findings. Because of th e typical dashboard m echanism causing
m ost hip dislocations, associated injuries should be anticipated. In spection an d palpation m ust in clude th e spin e,
pelvis, an d th e en tire in jured extrem ity. Close atten tion
sh ould be given to exam in ation of th e knee as kn ee injuries, such as patella fractures, ligam en tous in juries, an d
dislocations, are especially com m on (Table 16.3).
Followin g careful in spection of th e in jured extrem ity, a
detailed n eurovascular exam in ation sh ould en sue. Sciatic
nerve injury occurs in up to 20% of posterior dislocation s,
an d it is important to m ake the diagn osis prior to reduction. Pulses should be palpated an d compared with th e
con tralateral extrem ity. Rarely, an an terior dislocation m ay
lead to fem oral vessel comprom ise, wh ile posterior dislocations m ay have associated occult knee dislocations with
injury to the popliteal artery. Th e n eurovascular exam ination should be repeated im m ediately after reduction of th e
hip as the sciatic nerve can becom e incarcerated.
667
TABLE 16.3
Radiographic Examination
Radiograph ic evaluation begin s with careful an d system atic
inspection of the AP pelvis radiograph. In a posterior dislocation , th e affected fem oral h ead will appear sm aller th an
th e un affected h ip, an d th ere will be loss of con gruen ce between th e fem oral h ead and acetabulum (Fig. 16.16). With
anterior dislocations, the fem oral head will appear larger
th an th e con tralateral fem oral h ead. Rotation can be assessed th rough inspection of the relative positions of the
lesser trochanters. It is very important to clearly visualize
th e fem oral n eck for eviden ce of fracture prior to attempted
reduction . Fem oral h ead fractures, pelvic rin g in juries, an d
acetabular fractures should also be noted.
Followin g reduction , th e five stan dard views of th e
pelvis (AP, in let, outlet, obturator oblique, an d iliac
oblique) an d a CT scan sh ould be obtain ed. Th ese studies
668
fragment of bone interposed between the femoral head and posterior articular surface that requires removal (Reprinted with permission from Bucholz RW, Heckman JD, Court-Brown CM, et al.
Rockwood and Greens Fractures in Adults. 6th ed. Philadelphia,
PA: Lippincott Williams & Wilkins, 2006.)
Special Tests
Bone scan or MRI m ay reveal vascular ch anges associated
with AVN of th e fem oral h ead prior to evidence on plain
radiographs. Additionally, MRI m ay be useful in the diagnosis of a labral tear. However, th ese studies have no curren t
role in th e acute m an agem en t of h ip dislocation s.
Differential Diagnosis
Th e differen tial diagn osis is lim ited an d in cludes fractures
of th e pelvis, acetabulum , an d proxim al fem ur.
Treatment
Hip dislocation constitutes an orthopedic em ergen cy. Th e
goal of in itial treatm en t is to ach ieve reduction of th e
fem oral h ead within in 6 hours of the injury. AVN of th e
fem oral h ead h as been reported to occur in up to 40%
of dislocation s; h owever, sign ifican tly lower rates of AVN
occur for h ips reduced with in 6 h ours of dislocation . Addition ally, prom pt reduction relieves pressure on th e sciatic
nerve.
In the absen ce of a concurren t fracture of the fem ur
neck, closed reduction with con scious sedation or general an esth esia sh ould be attem pted. Closed reduction of a
posterior dislocation is m ost often ach ieved with th e Allis
669
TABLE 16.4
Complications
Th e lon g-term outcom e of a h ip dislocation is variable
and is often dependen t on the complications encountered
(Table 16.4). Posttraum atic arthritis is th e m ost com m on
com plication , occurrin g in up to 70% of cases. Its developm ent is likely m ultifactorial and m ay be related to cartilage
dam age at th e tim e of in jury, th ird body wear, or m alreduction of associated fractures.
AVN of the fem oral head is a dreaded complication
wh ose in ciden ce is dim in ish ed with em ergen t reduction .
However, it m ay still occur in up to 10% of patien ts despite reduction within 6 hours of the injury. Its developm ent is believed to be prim arily related to ischem ia induced by kin kin g an d spasm of th e ascen din g cervical an d
circum flex fem oral vessels. Th us, reduction is th ough t to
relieve vasospasm allowin g for resumption of perfusion to
th e fem oral h ead.
Sciatic n erve in jury m ay complicate up to 20% of posterior dislocation s an d can lead to severe fun ction al deficits.
Th e in jury is typically in complete with th e peron eal division of the nerve m ost com m only affected. Recovery of
n erve fun ction is often unpredictable an d m ay be evaluated
at 3 m onths with an electromyogram (EMG).
Heterotopic ossification is not uncom m on after open
reduction of a posterior h ip dislocation an d is m ore com m only associated with an anterior approach . Prophylaxis
with in dom eth acin or radiation m ay reduce th e developm ent of clinically significant heterotopic ossification.
670
A
B
D
Figure 16.20 The Pipkins classification of femoral head fractures. (A) Type Ifracture inferior
to the fovea. (B) Type IIfracture superior to the fovea. (C) Type IIIfemoral head fracture with
associated fracture of the femoral neck. (D) Type IVfemoral head fracture with associated fracture
of the acetabular rim. (Reprinted with permission from Bucholz RW, Heckman JD, Court-Brown CM,
et al. Rockwood and Greens Fractures in Adults. 6th ed. Philadelphia, PA: Lippincott Williams &
Wilkins, 2006.)
Classification
Th e m ost com m on ly utilized classification sch em e is proposed by Pipkin (Fig. 16.20). Th is relatively sim ple classification system is useful for com m un ication an d correlates
with progn osis. Type I and Type II fractures are distin guish ed by th e location of th e fracture lin e in relation to
the fovea. In Type I fractures, th e fracture line is in ferior to
the fovea, while in Type II fractures, the fracture extends
superior to th e fovea into the weigh t-bearing portion of
the fem oral h ead. Th is important distinction often directs
treatm en t an d correlates with outcom e as Type I fractures
typically perform better th an Type II fractures. As on e m igh t
expect, fem oral h ead fractures with an associated fracture
of th e fem oral n eck (Type III fracture) h ave th e worst progn osis overall.
Brum beck et al. an d Th e Orth opaedic Traum a Association have each proposed m ore comprehensive classification system s that apply to both an terior an d posterior dislocations. Th ese classification system s also h ave prognostic
value but have not gained widespread use in clinical practice.
Mechanism of Injury
As stated previously, nearly all fem oral head fractures
are due to traum atic h ip dislocation s. As such, fem oral
h ead fractures are typically secon dary to h igh -energy
Presentation
Patients with fem oral head fractures usually have an accompanying hip dislocation. They will present with severe pain with inability to m ove the affected hip or bear
weigh t. Th ey m ay also com plain of n um bn ess in th e sciatic or fem oral nerve distribution s. Often patients will have
m ultiple injuries at presentation and m ay be obtunded or
un con scious.
Physical Examination
Th e physical exam in ation sh ould in itially be directed by th e
guidelines of th e Advan ced Traum a and Life Support System . Followin g a th orough traum a evaluation , exam in ation
of th e in jured extrem ity sh ould begin with observation of
the position of the lim b as this will give clues to the direction of the hip dislocation an d the potential type of fem oral
head fracture present. Posterior hip dislocations cause th e
671
lim b to be fixed in flexion , adduction , an d in tern al rotation . On th e con trary, m arked abduction an d extern al rotation are eviden ce of an an terior dislocation . However,
with a fem oral head fracture or associated fracture of the
fem ur or acetabulum , these signs m ay n ot be present. In spection an d palpation should include th e en tire extrem ity
with emph asis on exam in ation of the knee as these in juries
are com m on with posterior h ip dislocation s. Addition ally,
a careful n eurovascular exam in ation sh ould be perform ed
an d repeated after h ip reduction .
Radiographic Examination
Evaluation begin s with careful an d system atic review of th e
AP pelvis radiograph (Fig. 16.21A). Dislocation is typically
apparent with disruption of Sh enton s line and incongruen cy between th e fem oral h ead an d acetabulum . Often th e
fractured portion of the fem oral head will rem ain in the acetabulum , h eld th ere by an in tact ligam en tum teres. Furth er
inspection m ay reveal associated fractures of the acetabulum and fem oral neck.
Followin g closed reduction or in th e even t of an irreducible dislocation , th e five stan dard views of th e pelvis
(AP, inlet, outlet, obturator oblique, an d iliac oblique) and
a CT scan sh ould be obtain ed. Th ese studies will allow
for the assessm ent of the con gruency of reduction as well
as identify in tra-articular loose bodies and associated fractures (Fig. 16.21B). Additionally, the CT scan will accurately
localize the fracture plane in the fem oral head, which is
useful in plan n in g th e surgical approach .
Special Tests
Bon e scan or MRI m ay reveal vascular ch an ges associated
with AVN of th e fem oral h ead prior to eviden ce on plain
B
Figure 16.21 (A) Anteroposterior radiograph of the pelvis depicting a posterior hip dislocation
with femoral head fracture. Note the portion of the femoral head remaining within the acetabulum (arrow) and the fracture of the posterior wall of the acetabulum (arrow head). (B) Coronal CT
reconstruction in the same patient.
672
radiographs but have no current role in the acute m an agem en t of fem oral h ead fractures.
Differential Diagnosis
Th e differen tial diagn osis is lim ited an d in cludes fractures
of th e pelvis, acetabulum , an d proxim al fem ur.
Treatment
Hip dislocation with fem oral h ead fracture is an orth opedic em ergen cy. Th e goal of in itial treatm en t is to ach ieve
reduction of th e fem oral h ead with in 6 h ours of th e in jury
as th is h as been sh own to decrease th e rate of AVN.
O ccasion ally, a h ip dislocation with fem oral h ead fracture is irreducible. Often th is is due to th e blockage by
fem oral head fracture fragm ents. In this case, em ergent
open reduction is in dicated. If a substan tial delay is n ot
an ticipated, a CT scan sh ould be obtain ed prior to open
reduction to accurately iden tify th e fracture fragm en ts an d
aid in operative plan n in g.
O n ce reduction of th e fem oral h ead is ach ieved, defin itive m an agem en t of th e fem oral h ead fracture depen ds on
a n um ber of variables in cludin g th e stability of th e h ip reduction , size of th e fragm en t, location of th e fracture in
relation sh ip to th e weigh t-bearin g surface, an d th e quality
of fracture reduction . Non surgical m an agem en t sh ould be
considered for dislocation s in which a congruent an d stable reduction is ach ieved with associated fractures th at h ave
less th an 2 m m of step off or do n ot in volve th e weigh tbearin g portion of th e fem oral h ead.
Surgical treatm en t is in dicated for fem oral h ead fractures in wh ich th e h ip rem ain s un stable or in con gruen t,
in tra-articular loose bodies are en trapped in th e join t or
fracture reduction that is nonanatom ic. Simple excision is
appropriate for loose bodies or fracture fragm en ts th at are
com m inuted or do not involve th e weigh t-bearing portion
of th e fem oral h ead. Large fracture fragm en ts, especially
those th at involve the superior weigh t-bearing dom e of the
fem oral h ead, sh ould undergo open reduction with stable
in tern al fixation .
For fractures m an aged n on operatively or with open reduction an d in tern al fixation , weigh t-bearin g is typically
protected for 8 weeks to en sure fracture h ealin g. For th ose
fractures in which fragm ents are simply excised, full weightbearin g m ay begin wh en tolerated. Regardless of treatm en t,
early h ip m otion sh ould be en couraged to m in im ize stiffness and adhesions. However, extrem es in ROM sh ould be
avoided un til the join t capsule has fully h ealed.
Outcomes and Complications
Historically, fem oral head fractures have resulted in relatively poor fun ction al outcom es. Modern surgical tech niques and em ergent hip reduction have led to som ewhat
improved results. However, as with h ip dislocation s, th e
overall outcom e from a fem oral h ead fracture is often depen den t on th e com plication s en coun tered such as posttraum atic arth ritis, AVN of th e fem oral h ead, sciatic n erve
Classification
Fem oral n eck fractures are often classified accordin g to th e
an atom ic location of th e fracture lin e. Th is includes basicervical fractures occurring at the base of the neck, transcervical fractures th rough the m id-portion of th e neck, and
subcapital fractures at th e base of the h ead. However, it is
often difficult to precisely defin e th e exact location of th e
fracture line with plain radiography, and thus, this classification m eth od h as lim ited utility.
Th e m ost com m on ly used classification sch em e is th at
proposed by Garden (Fig. 16.22). Th is classification system
is based on the degree of displacem en t observed on plain
radiograph s. Garden I fractures are in com plete or impacted.
Garden II fractures are complete fractures with out displacem en t. Garden III fractures are complete fractures with partial displacem en t, while Garden IVfractures are completely
displaced. However, distin ction between Garden I an d II or
between Garden III an d IV does n ot affect treatm en t. Th us,
there has been a trend toward simply classifying these fractures as nondisplaced or displaced since this improves both
interobserver an d intraobserver reliability and has greater
relevan ce to treatm en t an d progn osis.
Fem oral n eck fractures h ave also been classified by
Pauwel according to th e angle at which the fracture line
m akes with the h orizon tal (Fig. 16.23). Type I fractures are
30 degrees from th e h orizon tal; Type II, 50 degrees from th e
h orizon tal; and Type III, 70 degrees from th e h orizontal.
Th is classification was based on th e hypoth esis th at vertically oriented fracture lin es are m ore unstable and lead
to greater complication s. However, furth er research h as
dem on strated th at it is often difficult to accurately m easure
the angle of the fracture on prereduction radiographs and
that the fracture angle does not correlate with nonun ion or
AVN. Th us, this classification is not com m only used today.
Additionally, th e Orthopaedic Traum a Association h as
proposed a compreh en sive classification system . Th is
673
Garden type I
classification schem e is based on fracture location an d displacem en t an d is m ost useful for research purposes.
Mechanism of Injury
In th e elderly, a fracture of th e fem oral n eck is alm ost always an insufficiency fracture through osteoporotic bone.
Th e m ech an ism m ay be a low-en ergy fall directly on to th e
greater troch an ter causin g in im paction fracture or an extern al rotation force th at causes th e fem oral n eck to lever
an d buckle off of th e posterior acetabulum , leading to com m inution of the posterior neck.
In youn ger patien ts, h igh -en ergy traum a, such as a m otor veh icle acciden t or a fall from a h eigh t, is usually required to gen erate a fracture of th e fem oral n eck. Typically,
the m echanism is an axial force along the fem oral shaft
Garden type II
Presentation
Th e clin ical presen tation of a patien t with a fem oral n eck
fracture can vary widely. Patients generally present with
groin pain an d an in ability to bear weigh t; h owever, stress
fractures and nondisplaced fractures m ay present with no
obvious clin ical deform ity an d on ly sligh t groin pain . Typically, there is noticeable shortening an d external rotation
of th e in volved extrem ity. Elderly patien ts wh o live alon e
m ay be discovered hours to days after a fall and present with
674
Garden type IV
Physical Examination
For h igh -en ergy m ech an ism s an d obtun ded elderly patien ts, th e in itial exam in ation sh ould be directed by th e
guidelines of the Advanced Traum a an d Life Support System . Followin g a th orough traum a evaluation , exam in ation
of th e in jured extrem ity sh ould begin with close in spection
of th e skin for sign s of an open fracture. Sh orten in g an d
extern al rotation of th e affected leg sh ould be n oted. ROM
of th e h ip sh ould be avoided as it m ay lead to furth er fracture displacem ent. In high-en ergy m echanism s, a detailed
exam in ation of th e en tire in jured extrem ity is im portan t
with special atten tion to th e exam in ation of th e kn ee. Elderly patien ts sh ould be evaluated for con com itan t fragility
Type II
30
50
675
Type III
70
femoral neck fractures. (Reprinted with permission from Bucholz RW, Heckman JD, Court-Brown
CM, et al. Rockwood and Greens Fractures
in Adults. 6th ed. Philadelphia, PA: Lippincott
Williams & Wilkins, 2006.)
fractures such as distal radius an d proxim al hum erus fractures. While nerve or vessel injury is uncom m on, a careful neurovascular exam ination should be perform ed in all
patien ts.
Radiographic Examination
Radiograph ic evaluation begin s with careful scrutiny of th e
AP pelvis radiograph as well as the AP and cross-table lateral
views of the affected hip. An AP view of the h ip in 10 to
15 degrees of intern al rotation is often h elpful as it offsets the fem oral anteversion and provides a true AP of the
fem oral n eck. Fracture displacem ent, the degree of osteoporosis, an d presen ce of posterior com m in ution sh ould be
noted as these factors will affect the treatm ent.
Reduction can be assessed radiograph ically via two
m ethods. Lowell described the radiographic appearance
of th e fem oral h ead neck junction (Fig. 16.24). An atom ic
alignm ent sh ould reveal the convex fem oral head m eeting the concave fem oral neck, thus form ing an S-curve on
both of th e visualized cortices. Malreduction will cause a Csh aped curve on one cortex and a sh arp apex on the oth er.
A second m ethod of assessing reduction is th rough th e
Garden Alignm ent In dex (Fig. 16.25). Th is m ethod m ea-
Special Tests
MRI and bone scan are helpful in diagnosing stress fractures
or occult n on displaced fem oral n eck fractures for th ose patients with groin pain and inconclusive radiographs. Bone
scan sh ould be delayed until 48 hours post injury to decrease th e rate of false n egatives; h owever, MRI will reveal
fractures im m ediately. Additionally, MRI is appropriate for
suspected path ologic fractures. While CT scans can be used
to confirm a fem oral n eck fracture, they are not adequate
to rule out a nondisplaced fracture and therefore have m inim al utility in the assessm ent of th ese patients.
Differential Diagnosis
Th e differen tial diagn osis in cludes in tertroch an teric fem ur
fracture, fractures of the pubic ram i, acetabular fracture,
Figure 16.24 (A) The cortices of an anatomically reduced femoral neck fracture will from an S- or
reverse S-shaped curve on both radiographic views. (B) Malreduction will cause a C-shaped curve on
one side and a sharp apex on the opposite. (Reprinted with permission from Bucholz RW, Heckman
JD, Court-Brown CM, et al. Rockwood and Greens Fractures in Adults. 6th ed. Philadelphia, PA:
Lippincott Williams & Wilkins, 2006.)
676
160
140
180
150
(AP)
(Lat)
Treatment
Fractures of th e fem oral n eck are best treated with operative m an agem en t th at allows for early m obilization an d
full weight-bearing. Because of the significant m orbidity
an d risks associated with prolon ged recum ben cy, n on operative treatm en t sh ould on ly be con sidered in patien ts wh o
are extrem ely poor surgical can didates or in n on am bulatory patien ts wh o h ave m in im al discom fort. In eith er case,
early bed-to-ch air m obilization sh ould be in stituted with
knowledge that m alunion will occur.
In elderly patien ts, the presence of fracture displacem en t, preexistin g OA, an d th e fun ction al dem an ds of th e
patien t are im portan t factors in determ in in g th e appropriate m eth od of surgical treatm en t. Fracture displacem en t
has important implication s regarding th e viability of the
fem oral head. In nondisplaced fractures, rates of AVN have
been reported to be 13% to 20%, compared with rates as
high as 25% to 40% for displaced fractures. This discrepan cy is believed to be due to differin g degrees of dam age
to th e ascen din g cervical vessels. Th ese vessels travel with in
the joint capsule to supply a large portion of the fem oral
head and are thought to partially rem ain in tact in n ondisplaced fractures. Th us, n on displaced fractures (Garden I
an d II) are gen erally treated with an atom ic reduction an d
in tern al fixation utilizin g parallel lag screws with th e expectation of low rates of fem oral h ead collapse from AVN
(Fig. 16.26).
O n th e oth er h an d, displaced fractures (Garden III an d
IV) are typically treated with prosth etic replacem en t due
to th e h igh probability of fem oral h ead n ecrosis an d subsequen t collapse. Prosthetic replacem ent m ay con sist of
hem iarthroplasty in which a fem oral stem with a m etallic h ead is used to replace th e fem oral h ead an d n eck (Fig.
16.27). Altern atively, a total h ip arth roplasty m ay be used,
in wh ich th e acetabulum is resurfaced in addition to pros-
Figure
th etic replacem en t of th e fem oral h ead an d n eck. Th e decision to em ploy a h em iarth roplasty versus a total h ip arth roplasty is depen den t on th e presen ce of preexistin g h ip pain ,
th e degree of OA with in th e acetabulum , an d th e activity
level of the patient. Preexisting hip pain, significant degen erative ch an ges with in th e acetabulum , or a h igh ly active
patien t would likely lead to progressive acetabular erosion
and pain with hem iarthroplasty. In these cases, total hip
arth roplasty is often th e preferred option. However, the
strating anatomic fixation of a femoral neck fracture with three parallel lag screws.
677
TABLE 16.5
tients due to dim inished functional capacity and upper extrem ity weakness. In younger patients, weight-bearin g status will depend on the stability of the reduction but if often
delayed for 6 weeks.
Complications
Treatm ent of fem oral neck fractures m ay be complicated
by loss of fixation, non un ion, m alunion, pain, dislocation, deep vein throm bosis, infection, AVN, and death
(Table 16.5). Early fixation failure is uncom m on an d is
associated with fracture com m inution and varus reduction. The rates of non un ion and AVN are related to fracture displacem ent with h igh er rates occurring for displaced
fractures. Historically, nonunion rates for nondisplaced
fractures have ranged from 0% to 5%, while nonunion
rates as h igh as 35% h ave been reported for displaced
fractures. However, rates of n onunion appear to be im provin g with m odern treatm en t m eth ods. More recen tly,
n on union rates in youn g patien ts are typically less than
10% an d are likely related to im proved fixation an d tim ely
surgical treatm ent. AVN with collapse complicates 11%
of n on displaced fractures an d up to 27% of displaced
fractures.
678
Classification
Historically, in tertrochanteric fractures h ave been classified accordin g to th e system in troduced by Evan s (Fig.
16.28). Evan s recogn ized th at th e posterom edial cortex was
the key to fracture stability. Subsequently, he divided intertroch an teric fractures in to two groups (stable an d un stable) on the basis of the integrity of the posterom edial
cortex. In stable fractures, the posterom edial cortex is intact
or h as m in im al com m in ution . Un stable fractures h ave a
com m inuted posterom edial cortex or have a reverse obliquity fracture pattern . Evan s recogn ized th at reverse obliquity fractures are in h eren tly un stable with a ten den cy toward m edial m igration of the fem oral sh aft. He also n oted
that som e unstable fractures can be converted to stable
fractures through restoration of th e posterom edial cortex.
Th is fracture classification is importan t n ot on ly because it
defin es th e stability of th e fracture but because it also guides
treatm en t th rough defin ition of a stable reduction . However, despite th e importan t con tribution s of th is classification , it h as been plagued by poor in terobserver reliability.
Th us, today th e un derlyin g prin ciples of th e Evan s classification are utilized to facilitate com m un ication an d guide
treatm en t by simply describin g in tertroch an teric fractures
as stable or un stable.
tertrochanteric hip fractures. (A) Stable with intact posteromedial cortex. (B) Stable with minimal
comminution of posteromedial cortex. (C) Unstable with comminuted posteromedial cortex. (D) Unstable with global comminution. (E) Unstable with
reverse obliquity fracture pattern. (Reprinted with
permission from Bucholz RW, Heckman JD, CourtBrown CM, et al. Rockwood and Greens Fractures in Adults. 6th ed. Philadelphia, PA: Lippincott
Williams & Wilkins, 2006.)
Mechanism of Injury
Th e vast m ajority of in tertroch an teric fractures are fragility
fractures in the elderly secondary to low-energy m echan ism s. Approxim ately 90% result from a sim ple fall, m ost
often directly on to th e lateral h ip wh ere th ere is little soft
tissue to cushion th e blow. In younger patients, h igh-en ergy
traum a is required to fracture the intertrochanteric region
of th e fem ur. Motor veh icle acciden ts or a fall from a h eigh t
causin g a direct blow to th e lateral hip or a rotational force
to th e leg are th e m ost com m on m ech an ism s.
Presentation
Th e clin ical presen tation of an in tertroch an teric fracture
can vary widely. Patients with displaced fractures will com plain of severe groin pain an d will be un able to stan d or
bear weigh t. However, som e n on displaced fractures will
cause slight groin pain and will lack th e typical sh ortened
an d externally rotated posture present in displaced fractures. Thus, th e diagnosis of a hip fracture should be con sidered for any patient complaining of groin pain. Elderly
patien ts wh o live alon e m ay be discovered h ours to days
after a fall and m ay present with dehydration , decubitus
ulcers, or con fusion . In youn ger patien ts, th ere m ay be associated injuries as well as signs and symptom s of shock.
Physical Examination
For h igh -en ergy m ech an ism s an d obtun ded elderly patients, the initial exam ination should be directed by the
guidelines of th e Advan ced Traum a and Life Support System . Followin g a th orough traum a evaluation , exam in ation
of th e in jured extrem ity sh ould begin with close in spection of the skin for sign s of open fracture. Shortening an d
679
Radiographic Findings
Radiograph ic evaluation begin s with careful scrutiny of th e
AP pelvis radiograph as well as the AP and cross-table lateral views of th e affected h ip. An AP view of th e h ip in 10 to
15 degrees of intern al rotation is often helpful as it offsets
the fem oral anteversion and provides a true AP of th e proxim al fem ur. Fracture displacem ent, the degree of osteoporosis, and presence of posterom edial com m in ution should be
noted as th ese factors will affect th e treatm en t. Radiographs
of th e con tralateral h ip m ay be h elpful for preoperative
plan n in g.
Special Tests
In patien ts with groin pain an d in con clusive radiograph s,
MRI and bone scan are helpful in diagnosing occult n on displaced fractures of th e proxim al fem ur. Bon e scan sh ould
be delayed un til 48 h ours post in jury to decrease th e rate
of false n egatives; h owever, MRI will reveal fractures im m ediately. Addition ally, MRI is appropriate for suspected
path ologic fractures.
Differential Diagnosis
Th e differen tial diagn osis in cludes fem oral n eck fracture,
fractures of the pubic ram i, acetabular fracture, sacral insufficien cy fracture, OA, AVN, tum or, or lum bar spine
path ology.
Treatment
In tertroch an teric fem ur fractures are best treated with operative m an agem en t th at provides for early m obilization
an d full weigh t-bearing. Because of the significant m orbidity and risks associated with prolon ged recum ben cy, nonoperative treatm en t sh ould on ly be con sidered in patien ts
wh o are extrem ely poor surgical can didates or in n on am bulatory patien ts wh o h ave m in im al discom fort. In eith er
case, early bed-to-chair m obilization sh ould be instituted
with kn owledge th at m alun ion will occur.
Today, in tertroch an teric fem ur fractures are typically
treated with either a sliding screw plate device or a
ceph alom edullary device that incorporates a lag screw into
the fem oral head through an intram edullary nail. The appropriate ch oice of implan t depen ds on th e fracture pattern
an d stability. Cephalom edullary devices have gen erally
been foun d to be m ost appropriate for very un stable fractures and reverse obliquity pattern s. Regardless of the
Figure 16.29 Anteroposterior radiograph of the hip, demonstrating the use of a sliding screw plate device.
680
X ap
D true = known diameter of the lag screw
TAD = (X ap x
D
D true
) + ( X lat x true
D lat
D ap
Dap
D lat
X lat
the lag screw. Despite these theoretical advan tages, studies have shown that there is no difference in the outcom e
compared with the sliding screw plate devices for m ost
intertrochanteric fractures; however, m ore frequent com plication s h ave been reported with th e ceph alom edullary
n ails.
Treatm en t of h igh ly un stable fracture pattern s sh ould be
approach ed m ore cautiously and are worth special m en tion. Th ese fracture patterns in clude highly com m inuted
fractures, fractures with subtrochanteric exten sion, an d the
reverse obliquity fracture. O ften occurrin g in youn ger patients secondary to high-energy traum a, these fractures are
n otorious for excessive collapse, n on un ion , an d implan t
failure, especially wh en a slidin g screw plate device is em ployed. Th us, h igh ly un stable fractures are best treated with
long cephalom edullary implan ts.
Postoperatively, patients should be m obilized im m ediately. It has been shown that the elderly will self-regulate
weigh t-bearin g an d th us sh ould be allowed to weigh t bear
as tolerated in m ost instances to prom ote early m obilization. In youn ger patients, weight-bearing status will depen d
on th e stability of th e reduction .
Complications
Treatm ent of in tertrochanteric fractures is m ost com m only
complicated by loss of fixation and lag screw cutout, occurrin g in up to 20% of cases. Close atten tion to th e tip apex
distan ce an d avoidin g th e use of th e slidin g screw plate device for highly un stable fracture patterns should m inim ize
these complications. Because of the extracapsular location
of th ese fractures an d th e rich vascular supply, n on un ion
occurs in less th an 2% of th ese fractures. Fin ally, careful
scrutiny of th e reduction is necessary to avoid rotational
m alunion.
however, proxim al involvem en t of the in tertrochanteric region is not uncom m on. The m edial an d posterom edial cortices of the subtrochanteric fem ur experience the highest
compressive stresses in the body, while the lateral cortex
is under a high degree of tensile stress. The action of the
iliopsoas, the h ip abductors (gluteus m edius an d gluteus
m inim us), and short external rotators cause the proxim al
fragm ent to flex, abduct, and externally rotate, respectively,
wh ile th e pull of th e adductors lead th e distal fragm en t
to adduct (Fig. 16.32). Because of th ese powerful m uscle
forces and th e trem en dous stresses on the bone, fracture
reduction an d m ain ten an ce of th e reduction can be quite
ch allenging.
Classification
Num erous classification sch em es h ave been proposed for
subtrochanteric fractures. Th e Fieldings classification is an
an atom ic classification based on the distance of the m ajor
fracture lin e from th e lesser trochanter an d is rarely used today. Th e Sein sh eim ers classification factors in th e in tegrity
of th e posterom edial cortex to predict fracture stability
681
Mechanism of Injury
In youn g patien ts, subtroch an teric fractures are typically
th e result of h igh -en ergy blun t traum a or gun sh ot woun ds.
A low-en ergy m ech an ism in a youn g patien t sh ould raise
th e suspicion of a path ologic fracture. In th e elderly, th ese
fractures typically occur through osteoporotic bone after
a low-en ergy fall. Rarely, a subtroch an teric fracture m ay
result from treatm en t of a fem oral n eck fracture with can n ulated screws. If th e startin g poin t for th e screws on the
lateral fem oral cortex is distal to the lesser trochanter, a
stress riser is created and there is a risk of fracture.
Presentation
Patien ts typically presen t un able to am bulate due to sign ificant pain. Typically, there is obvious shortening and extern al rotation of the leg with m arked swellin g of th e proxim al
th igh . As th ese fractures are often secon dary to h igh -en ergy
traum a, the patient m ay presen t with associated injuries as
well as sign s an d sym ptom s of sh ock.
Physical Examination
In itially, th e physical exam in ation sh ould be directed by
th e guidelin es of th e Advan ced Traum a an d Life Support
System as these are often high-energy fractures and m ay
h ave associated in juries. Followin g a th orough traum a evaluation , exam in ation of th e in jured extrem ity sh ould begin
with close in spection of th e skin for sign s of open fracture.
Th e en tire lim b sh ould th en be in spected an d palpated for
eviden ce of ipsilateral extrem ity traum a. Careful atten tion
sh ould be given to th e kn ee for signs of effusion, which m ay
be in dicative of ligam en tous in jury. Alth ough n eurovascular injuries are rare with subtroch anteric fem ur fractures, a
detailed n eurovascular exam in ation sh ould be perform ed.
Radiographic Examination
Radiograph ic evaluation in volves detailed an d system atic
review of th e AP radiograph of th e pelvis as well as an
682
Type II
A
1
1
2
2
Type III
A
2
2
3
Type IV
Type V
3
4
Special Tests
Plain radiograph s are typically sufficien t for diagn osis an d
preoperative plan n in g; h owever, MRI is in dicated if th ere
is con cern for path ologic fracture.
Differential Diagnosis
Th e differen tial diagn osis is lim ited an d in cludes h ip dislocation, fem oral neck fracture, and peritrochanteric fracture.
Treatment
Subtroch an teric fem ur fractures are best treated with surgical fixation. Because of the significant m orbidity and risks
associated with prolon ged recum ben cy, n on operative treatm en t sh ould on ly be con sidered for patien ts wh o are ex-
683
I-B
I-A
II-A
II-B
Figure 16.34 The RussellTaylors classification of subtrochanteric fractures. (Reprinted with permission from Bucholz RW, Heckman JD, Court-Brown CM, et al. Rockwood and Greens Fractures in
Adults. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
the patients pain has subsided. Often these fractures require 8 to 12 weeks for h ealin g. Failure of th e fracture to
un ite m ay be related to in fection , th e n utrition al state of th e
patien t, com orbid h ealth con dition s, exten sive soft-tissue
strippin g, or in adequate fixation.
Classification
Often for inform al com m unication, these fractures are classified descriptively on th e basis of the location (proxim al, m iddle, or distal third) and fracture m orphology
(transverse, oblique, spiral, com m inuted, or segm en tal).
684
B
Figure 16.35 (A) Subtrochanteric femur fracture. (B) Anatomic stabilization with a cephalomedullary device.
tion. Today, it is rare to consider the treatm ent with an in tram edullary nail without employing in terlockin g screws.
Neverth eless, th is classification sch em e rem ain s useful, h as
progn ostic sign ifican ce, an d aids in operative plan n in g. Addition ally, a com preh en sive classification proposed by th e
II
III
IV
685
Mechanism of Injury
Fem oral sh aft fractures are alm ost always due to h igh en ergy m ech an ism s such as m otor veh icle acciden ts, falls,
gunsh ots, or pedestrian injuries. Pathologic fracture should
be suspected for any patien t presen tin g with a fem oral sh aft
fracture in the absence of high-energy traum a.
Sin ce th e fem oral sh aft is essen tially a cylin der, th e exact m ech anism of injury can often be extrapolated from
the fracture pattern. Transverse fractures are the result of a
ben din g force. Torque applied to th e fem ur causes a spiral fracture. An elem en t of compression com bin ed with a
ben din g force creates an oblique fracture or a butterfly fragm en t. For com m inuted fractures, it is th e degree of energy
an d not the direction of force that determ ines th is pattern.
Presentation
Typically, th ese patien ts presen t un able to am bulate, in a
trem endous am ount of pain and with obvious deform ity
of th e th igh . In cases of associated traum a, patien ts m ay
presen t obtun ded, un con scious, or in sh ock.
Physical Examination
Th e in itial physical exam in ation sh ould be directed by th e
guidelines of th e Advan ced Traum a and Life Support System as th ese are often h igh -en ergy fracture an d m ay h ave
associated in juries. Even in isolated fractures of the fem oral
shaft, blood loss of greater th an 2.0 L into the th igh can be
significant and results in hem odynam ic instability.
Followin g a th orough traum a evaluation , exam in ation
of th e in jured extrem ity sh ould begin with close in spection of the skin for signs of open fracture. Next, the en tire
lim b should be inspected and palpated for evidence of ipsilateral extrem ity traum a. Careful attention should be paid
to th e kn ee for sign s of effusion , wh ich m ay be in dicative
of ligam en tous in jury or fracture. A detailed n eurovascular
exam in ation m ust be perform ed in each patien t wh o h as
sustain ed a fem ur fracture. Finally, th e compartm en ts of
the thigh should be assessed for evidence of compartm ent
syn drom e, and if warranted, form al compartm ent pressure
m easurem en t should be un dertaken.
Radiographic Examination
Radiograph ic assessm en t sh ould begin with careful evaluation of full-length AP and lateral views of th e fem ur for
fracture pattern, bon e quality, and length (Fig. 16.37). Fulllength radiographs of the contralateral fem ur are useful
in com m in uted fractures for assessing the patients norm al len gth and an atom ic bow. Alternatively, a CT scout
view that includes both fem urs m ay give useful inform ation on fem oral length. Measurem en t of th e size of the
fem oral can al will guide preoperative planning for the intram edullary n ail diam eter. Additionally, it is imperative to
carefully scrutinize high-quality internal rotation AP and
lateral views of the ipsilateral hip for eviden ce of fem oral
Special Tests
MRI is indicated for evaluation of suspected path ologic
fractures.
Differential Diagnosis
Th e differen tial diagn osis is lim ited an d in cludes oth er fractures of the fem ur.
Treatment
Th e in itial goal of th e treatm en t for fem oral sh aft fractures
is to expeditiously restore length, alignm en t, and rotation.
Skeletal traction an d external fixation are frequently used
for this purpose in a temporary capacity. They serve to alleviate pain and m inim ize bleeding through a reduction
in the volum e of the thigh. Today, however, skeletal traction and extern al fixation have lim ited utility as defin itive
treatm ent of fem oral shaft fractures due to frequent m alun ion , pin site in fection , an d kn ee stiffn ess. Addition ally,
skeletal traction requires prolon ged recum ben cy leading to
increased pulm onary complications an d greater risk of decubitus ulcers. Th us, th ese m eth ods sh ould on ly be con sidered as defin itive stabilization in patien ts wh o are extrem ely
poor surgical can didates.
686
Figure 16.38 Anteroposterior radiographs of intramedullary nail fixation of midshaft femur fracture (A & B).
bearin g as tolerated. Com plication s are relatively in frequen t an d in clude in fection , n on un ion , m alun ion , device
failure, an d th igh compartm en t syn drom e.
687
TABLE 16.6
Inflammatory Arthritis
Subchondral cyst
Osteophyte formation
688
Osteotomies
Osteotom ies or bony procedures around the hip joint m ay
be classified on th e basis of location , pelvis, or proxim al
fem ur, or by purpose, reconstructive, or salvage. Reconstructive osteotom ies are geared toward the treatm ent of
a preexistin g h ip deform ity such th at th e procedure will
preven t degen erative ch an ges from occurrin g prem aturely.
Salvage option s rely upon operative correction of a preexisting degenerative hip pathology to reduce the patients
sym ptom s an d delay th e need for possible arthroplasty.
Th e gen eral goal of a h ip osteotomy is to redirect forces
across the h ip joint from a degenerative area to a healthier
region , preven tin g disease progression an d preservin g th e
rem ain in g viable articular cartilage. A detailed discussion
of th e differen t h ip osteotom ies is beyon d th e scope of th is
textbook.
Tensor
fasciae latae
689
Ilium
Gluteus
medius
Gluteus
minimus
Anterior
joint capsule
Rectus
femoris
690
Greater trochanter
Short rotators
from Hoppenfeld S, deBoer P. Surgical Exposures in Orthopaedics: The Anatomic Approach. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2003.)
in cluded th e adven t of vacuum m ixin g to decrease porosity, pressurization of th e cem en t upon in troduction in to th e
fem oral canal, and th e use of a centralizer to en sure a uniform cem ent m antle. These improvem ents are referred to as
third-generation cem ent techn ique and are currently used
today.
Despite th ese tech n ological an d m eth odological advances in cem ent techn ique, cem entless implantation of
both compon en ts h as gain ed popularity with widen in g
surgical indications and youn ger, m ore active patien ts requirin g THA. Today, m ost THA compon en ts are im plan ted
usin g cem en tless fixation . Th e bon e on -growth or in growth an d rem odelin g poten tial associated with un cem en ted compon en ts is dyn am ic an d life lastin g. In th e settin g of revision THA, cem en tless fixation is preferred if th ere
is adequate rem ain in g bon e stock.
There are two differen t techniques for cem entless im plan t fixation : press fit an d lin e-to-lin e. In press fit, the im plan t is sligh tly larger th an th e ream ed size, creatin g com pression h oop stresses for tem porary fixation . In line-to-line
fit, th e sam e diam eter im plan t as th e ream er is used an d
exten sive porous coatin g provides th e in itial in terferen ce fit
between th e prosth esis an d th e h ost bon e. Screws provide
in itial fixation of th e acetabular cup in th e lin e-to-lin e fit
but m ay also be required for adequate com pon en t stability
when usin g th e press fit tech nique. Safe acetabular screw
placem en t is en sured by usin g quadran ts on th e basis of
the ASIS and cen ter of the acetabulum : posteriorsuperior
is th e safe zon e; posteriorinferior is safe for screws less
than 20 m m (sciatic nerve); an teriorin ferior m ay in jure
691
Abdominal
aorta
Line A
Aortic
bifurcation
Asis
Common iliac
Posterior
superior
Anterior
superior
External
italic vein
Posterior
inferior
Obturator
vein
Line B
Anterior
inferior
Figure 16.42 Acetabular quadrant system for screw placement (Reprinted with permission from
Wasieleski RC, et al. Acetabular anatomy and the transacetabular fixation of screws in THA. J Bone
Joint Surg. 1990;72A:501508.)
692
cement mantle.
gle), and 10 to 15 degrees of fem oral stem anteversion. Im proper align m en t can lead to an terior in stability (in creased
acetabular anteversion), posterior instability (retroverted
cup or stem ), troch an teric impin gem en t (decreased th eta),
or superior instability (increased theta angle) (Table 16.7).
Th e en d poin t of in stability is dislocation an d stability of
th e con struct is typically con firm ed on th e operatin g room
table prior to com pletion of th e procedure.
On e of the m ajor contributors to hip stability and hip
ROM is the ratio between the diam eters of the implant
h ead an d implant neck, kn own as th e h ead-to-n eck ratio.
Th e prim ary arc of m otion of th e h ip depen ds on th is ratio. The greater the head-to-neck ratio, th e greater the ROM
th e fem oral com pon en t can un dergo prior to n eck im pin gem ent on the acetabular shell.
Another determ inan t of hip stability is the excursion
distan ce. Excursion distan ce is defin ed as th e distan ce th e
h ead m ust travel to lever out of th e acetabular lin er once the
n eck impinges on th e acetabular sh ell an d is typically half
th e diam eter of th e h ead. Alarger diam eter h ead h as a larger
excursion distan ce an d th us con fers greater h ip stability. In
gen eral, th e largest h ead th at can be im plan ted safely is
recom m en ded.
Th e soft tissues surroun din g th e h ip are also of critical
importan ce in attaining hip stability following THA. The
h ip abductor complex (gluteus m edius an d m in im us) tension m ust be m ain tain ed for optim al h ip stability. When
th ere is sign ifican t abductor complex laxity (i.e., wh en th e
implanted components leave the lim b short), the lack of
ten sion results in in stability of th e implan ted devices. Th e
abductor tension is also affected by the degree of lateral
offset of th e compon en ts utilized (th e m ore th e lateral offset, the greater the abductor ten sion). Optim al soft-tissue
balan cin g is determ in ed in traoperatively with implan t stability determ in in g th e degree of ten sion required. Any process th at in terferes with proper soft-tissue fun ction (th e distan ce between th e cen ter of th e fem oral h ead an d th e tip
of th e greater troch an ter) or coordin ation , such as stroke,
dem en tia, delirium , or cerebellar dysfun ction , can in crease
th e risk of postoperative h ip in stability.
On e of the m ajor problem s facin g THA today is osteolysis secon dary to the gen eration of m icroscopic wear particles gen erated at th e articulatin g surface. Tradition al articular bearin g surfaces were h ard on soft (i.e., cobalt-ch rom e
m etal on polyethylene plastic). The high wear rates and particle generation associated with hard on soft bearings has
led to the developm ent of alternative bearing articulation s
th at are h ard on h ard (m etal on m etal or ceram ic on ceram ic). Th ese h ard-on -h ard bearin gs h ave greatly im proved
wear properties an d h ave been developed to improve im plan t lon gevity for th e in creasin g n um ber of youn g, active
patien ts requirin g THA.
Complications
Complications associated with total hip arthroplasty can be
classified as in traoperative, early, and late postoperative.
693
TABLE 16.7
> 25
Position of
Compromise
Anterior
ABDUCTION
VERSION
Retroverted
< 15
Posterior
Vertical
> 50
Superior/ Lateral
Horizontal
< 40
Inferior
Extension
External Rotation
Flexion
Internal Rotation
Reduction
Maneuver
Longitudinal traction
Hip extension
Abduction
Hip IR/ ER
Anterior traction
Hip flexion > 90
Adduction
Hip IR/ ER
Adductin
Longitudinal traction
Adduction
Hip IR/ ER
Abduction
Longitudiral traction
Greater trochanter Abduction
Hip IR/ ER
impingement
694
TABLE 16.8
Fracture Location
Subtype
Trochanteric region
AG (greater trochanter)
AL (lesser trochanter)
B1 (stable prosthesis)
B2 (unstable prosthesis)
B3 (inadequate bone stock)
modalities used to minimize the risk for infection in primary total hip arthroplasty. (Reprinted with permission from Callaghan JJ,
Rosenberg AG, Rubash HE. The Adult Hip. 2nd ed. Philadelphia,
PA: Lippincott Williams & Wilkins, 2007.)
B
Figure 16.46 Periprosthetic fracture around a hip arthroplasty (A) preoperative x-ray, demonstrating a spiral fracture around a hemiarthroplasty and (B) postoperative radiograph. The fracture
was treated with removal of the implant, cerclage of the fracture with two cables, and reimplantation
of a total hip arthroplasty.
Osteonecrosis
Osteonecrosis, also referred to as AVN, is defined as death
of periarticular bon e from an etiology oth er th an in fection ,
with th e fem oral h ead bein g th e m ost com m on ly affected
area in th e body. The in cidence is approxim ately 20,000
new cases in the Untied States an nually, and osteonecrosis
comprises the original diagnosis for nearly 10% of all total h ip arth roplasties perform ed each year. Osteon ecrosis
typically results from a disruption of the blood supply either secondary to traum a or other causes such as system ic
steroid use, alcohol abuse, blood dyscrasias such as sickle
cell disease, coagulopathies (protein C or S deficiency or
low lipoprotein level), caisson disease, excessive radiation
therapy, an d m etabolic storage diseases such Gauchers
disease. Cases of idiopath ic fem oral h ead osteon ecrosis is
695
TABLE 16.9
II
III
IV
.
V
VI
696
hip. MRI can be utilized to detect early cases with very h igh
sen sitivity and specificity. Nuclear m edicin e bone scan s can
also be used for early diagn osis, dem on stratin g in creased
uptake in areas of bon e rem odelin g.
Several classification s system s h ave been h istorically
used to defin e th e severity of in volvem en t of th e fem oral
head as well as patient progn osis. The University of Penn sylvania System for Staging Avascular Necrosis evaluates
both th e radiograph ic appearan ce of th e lesion as well as
the size of the lesion (Table 16.9). Th is classification determ in es th e likelih ood of success wh en usin g join t-preservin g
procedures such as core decom pression .
Treatm en t for osteon ecrosis of th e h ip ran ge from con servative symptom atic therapy with a focus on m ain tainin g h ip ROM to join t-preservin g altern atives for early AVN
to h em iarth roplasty or THA for en d-stage AVN. Join tpreservin g altern atives in clude core decom pression , vascularized fibular graftin g, an d proxim al fem oral osteotomy.
Core decompression in volves drillin g a 6 to 10 m m wh ole
up th e fem oral n eck in to th e area of n ecrotic bon e in
RECOMMENDED READINGS
Lorich DG, Geller DS, Nielson JH. Osteoporotic pertroch an teric hip
fractures: m anagem en t and current controversies. J Bone Joint Surg
Am. 2004;86:398 410.
Lieberm an JR, Berry DJ, Mon tv MA, et al. Osteon ecrosis of the hip:
m anagem ent in the twenty-first cen tury. J Bone Joint Surg Am.
2002;84:834 853.
Sierra RJ, Trousdale RT, Gan z R, Leun ig M. Hip disease in th e youn g,
active patient: evaluation and nonarthroplasty surgical options
J Am Acad Orthop Surg. 2008;16:689 703.
Barrack RL. Dislocation after total hip arthroplasty: im plant design
and orientation. J Am Acad Ortho Surg. 2003;11:89 99.
17
Freddie Fu
INTRODUCTION
Pain or injury about the knee and leg is one the m ost
frequent condition s prompting a patient to seek evaluation by an orth opaedist. The purpose of this chapter is
to review th e fun ction al an atomy an d evaluation of th e
knee an d leg and to describe the presentation an d treatm en t of the m ost com m on traum atic and atraum atic injuries to th is area. Kn ee arth ritis an d arth roplasty, in cludin g
periprosth etic fractures about th e kn ee, will be discussed in
Ch apter 18.
FUNCTIONAL ANATOMY
Th e kn ee is composed of th ree separate articulation s: th e
tibiofem oral, patellofem oral, and the proxim al tibiofibular joints. The joint m ost com m only referred to when describing the knee jointis th e tibiofem oral joint. Th e kn ee
is also divided into th ree compartm ents: m edial, lateral,
an d patellofem oral. Th e m edial an d lateral compartm ents
comprise the tibiofem oral articulations (Fig. 17.1). Th e distal fem ur is composed of m edial an d lateral con dyles with
the slightly larger and distal m edial condyle accountin g
for the valgus orientation of the n orm al knee joint. Th e
patellofem oral com partm en t lies in th e an terior kn ee an d
con tains the patellofem oral articulation (Fig. 17.2). The sulcus between th e fem oral condyles is called the trochlear
groove. The patella tracks within this groove as the kn ee
is ranged through flexion and extension. At th e distal en d
of th e fem ur between th e fem oral con dyles, th ere is an in tercon dylar n otch . Th e cruciate ligam en ts of th e kn ee are
found within this intercondylar notch. O n the m edial aspect of th e distal fem ur is th e m edial epicon dyle, wh ich
serves as th e insertion of the adductor m agn us and th e
origin of th e m edial collateral ligam en t (MCL). Th e lateral
epicon dyle on th e lateral aspect of th e distal fem ur serves
as the origin of the lateral collateral ligam ent (LCL).
698
permission from Johnson DH and Pedowitz RA: Practical Orthopaedic Sports Medicine and Arthroscopy. Philadelphia: Lippincott Williams & Wilkins, 2006.)
sh own in creases in contact pressures up to 300% following m eniscus rem oval. The m edial m en iscus transm its 50%
of th e join t force an d th e lateral m en iscus tran sm its up to
70% of th e join t force across th e kn ee. Addition al fun ction s
of th e m en iscus in clude im proved join t stability, im pact
absorption, an d articular n ourish m ent.
Th e bon e of th e distal fem ur an d proxim al tibia is covered by a h igh ly organ ized structure of hyalin e cartilage.
Th e articular cartilage th ickn ess varies with location . Th e
patella h as th e th ickest articular cartilage in th e h um an
body, an d it is 8 to 10 m m th ick. Th e cartilage is com posed
of type II collagen , wh ose structure allows it to absorb im pact an d accom m odate to th e variable forces of com pression , tension , an d sh eer seen in this joint.
Although joint congruen ce through the bone an d
m en iscal anatomy provides som e inherent stability, m ost
join t security is con ferred by th e surroun din g soft tissue
structures, includin g th e joint capsule and ligam ents. Th e
capsule of th e knee is a variably th ick structure lined by
syn ovium . This layer is responsible for th e syn ovial fluid
production th at accoun ts for th e kn ees low coefficien t of
friction . Perh aps the m ost important m acrom olecule synthesized by the synovium is hyaluronic acid, which serves
to lubricate th e join t surfaces. Extern al to th e syn ovium is
the fibrous capsular en velope of the kn ee, which varies in
699
Figure 17.4 Superior surface of tibia with superimposed medial and lateral menisci. (After Helfet
AJ. The Management of Internal Derangements
of the Knee. Philadelphia: JB Lippincott, 1963.
Reproduced with permission from Chapman MW,
Szabo RM, Marder R, et al.: Chapmans Orthopaedic
Surgery, 3rd ed. Philadelphia: Lippincott Williams &
Wilkins, 2001.)
Figure 17.5 The two bundles of the anterior cruciate ligament (ACL). (Reproduced with permission from Johnson DH, Pedowitz RA. Practical Orthopaedic Sports Medicine and Arthroscopy.
Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
700
ment (PCL). (Reproduced with permission from Johnson DH, Pedowitz RA. Practical Orthopaedic Sports Medicine and Arthroscopy.
Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
Figure 17.7 The structures of the medial side of the knee. (Re-
produced with permission from Johnson DH, Pedowitz RA. Practical Orthopaedic Sports Medicine and Arthroscopy. Philadelphia,
PA: Lippincott Williams & Wilkins, 2006.)
701
retinacular fibers, which are the conjoined layers I and II. B: The
conjoined layer-II and -III fibers posterior to the medial collateral
ligament. (Redrawn from Warren LF, Marshall JL. The Supporting
Structures of the Medial Side of the Knee. J Bone Joint Surg 1979;
61-A:56. Reproduced with permission from Chapman MW, Szabo
RM, Marder R, et al.: Chapmans Orthopaedic Surgery, 3rd ed.
Philadelphia: Lippincott Williams & Wilkins, 2001.)
Figure 17.8 The structures of the lateral side of the knee. (Re-
produced with permission from Johnson DH, Pedowitz RA. Practical Orthopaedic Sports Medicine and Arthroscopy. Philadelphia,
PA: Lippincott Williams & Wilkins, 2006.)
an d fibula. Medially, the sem im em branosus and sem iten din osus in sert at th e proxim al tibia an d posterom edial
capsule. Laterally, the biceps fem oris in serts along the fibular head. Branches of the sciatic nerve inn ervate the ham strin g m uscles. The ham strings are th e prim ary flexors of
the knee.
Th e ten don s of th e gracilis, sem iten din osus, an d sartorius are foun d m edially (Fig. 17.9). Th ese ten don s arise
from th e pubis, ischial tuberosity, and anterior superior iliac spin e (ASIS), respectively, and insert over the anterom edial aspect of th e proxim al tibia superficial to th e MCL. Th e
appearance of these three structures led Greek observers to
describe th em structure as a pes anserine in its sim ilarity
to a ducks webbed foot. Clin ically, th is structure is respon sible for symptom s wh en its un derlyin g bursa becom e irritated (pes bursitis) an d is a popular source of autograft
ten don s durin g recon structive surgery.
Laterally, the IT band is a strong broad flat ban d that
origin ates at th e iliac crest, receives in sertion s of th e gluteus m axim us an d ten sor fascia lata, an d travels in feriorly
to in sert at Gerdys tubercle on th e proxim al an terolateral
tibia (Fig. 17.10). From 0 to 30 degrees, the IT band con tributes to knee extension. Beyond 30 degrees, the IT band
con tributes to kn ee flexion . Th e IT ban d is clin ically relevan t in causing a friction syndrom e over the lateral aspect
of th e kn ee, kn own as runners or cyclists knee. The IT band
is also th ought to be m echan ically responsible for the pivot
sh ift m an euver seen in ACL deficiency.
Posteriorly, there are several other m uscle groups of
importance, including the m edial an d lateral gastrocnem ii, which originate from their respective posterior fem oral
con dyles alon g with an in direct slip from th e join t capsule.
Th e gastrocn em ii com bin e with th e soleus to from th e triceps surae m uscle, wh ose ten din ous portion is kn own as
the Ach illes tendon. Deep to th e gastrocnem ii, origin ating
from the m idpoint of the posterior proxim al tibia, is the
popliteus m uscle. Th e popliteus travels superolaterally an d
en ters th e kn ee join t capsule directly posterior to th e lateral
m eniscus and exits again to attach just inferior to the lateral epicon dyle. Th e in sertion of th e popliteus is an terior
an d distal to th e LCL origin. This structure is important in
con tributin g to n orm al kn ee fun ction by un lockin g th e tibial plateau via internal rotation of the tibia at th e beginn ing
of kn ee flexion .
Th ere are a n um ber of bursae in th e kn ee, in cludin g
the prepatellar, pes, IT, an d sem im em branosus bursae.
All of th ese bursae are syn ovial-lin ed poten tial sacs th at
serve as lubricated interfaces between adjacent m oving surfaces. Th e prepatellar bursa is detected on ly wh en it becom es sym ptom atic an d in flates in respon se to traum a or
irritation, m ost com m only in patients with direct traum a
to th e an terior aspect of th eir kn ee. Repetitive or direct
traum a leads to inflam m ation, occasional th ickening, and
702
Quadriceps tendon
Vastus lateralis m.
Iliotibial band
Patella
Biceps femoris m.
Lateral patellar
retinaculum
Patellar ligament
Common peroneal n.
Lateral head of
gastrocnemius m.
Peroneus longus m.
Illiotibial band
(insertion site at
Gerdys tubercle)
Tibial tubercle
Soleus m.
Tibialis anterior m.
Extensor digitorum
longus m.
Lateral
Compartment
703
facilitates a tailored exam ination in th e con text of the differen tial diagnosis.
Th e exam in er sh ould always take advan tage of th e
bodys sym m etry. Th e opposite kn ee an d leg serve as an
excellen t con trol th at can h elp distin guish a n orm al from
an abn orm al exam in ation with respect to atrophy, swellin g,
m otion , stren gth , an d stability. Because of n orm al variability with in th e population , th e use of th e patien ts opposite
lim b can m ake diagn ostic evaluation m ore accurate.
Finally, it is important for the physician to rem em ber
that kn ee symptom s can be caused by pathology elsewh ere. Com m on sources of referred pain in adults are the
spin e an d hip, an d in children, kn ee pain is considered hip
path ology un til proven oth erwise.
History
Deep Posterior
Compartment
Superficial Posterior
Compartment
with permission from Bucholz RW, Heckman JD, Court-Brown C, Tornetta P. Rockwood and Greens Fractures in Adults, 6th Ed. Philadelphia: Lippincott Williams & Wilkins, 2005.)
Patien ts can gen erally localize th eir pain to a specific pain generator. Th e location of the pain can
h elp lim it th e in jury to a specific com partm en t of
the knee. Anterior knee pain is typical of patella
disorders. Medial or lateral join t lin e pain is gen erally a ch on dral in jury or a m en iscus in jury.
3. Wh at is th e n ature of th e pain ?
Patella disorders are typically a dull ache. Meniscus
injuries are typically a sharp, catching pain.
4. Wh at m akes th e pain worse?
Most kn ee in juries are worse with activity. Patella
disorders are worse with ascen din g or descen ding stairs and sitting for prolonged periods in a
chair. Meniscus injuries are worse with twisting,
turn ing, or squatting m ovem ents. Cycling or rowing m ay exacerbate IT band syndrom e.
5. When did the knee first swell, an d does it continue to
swell?
704
Physical Examination
Th e physical exam in ation of th e kn ee sh ould in clude a basic kn ee exam in ation com bin ed with special tests based
on th e differen tial diagn osis establish ed from th e h istory.
A basic knee exam ination sh ould include inspection , palpation , ran ge-of-m otion , an d stability testin g. Th e basic exam in ation is done first, followed by the appropriate special
tests.
Inspection
Both lower extrem ities should be un dressed com pletely for
exam in ation to allow comparison between th e two extrem ities. Observe patientsgait as they walk down the hallway
at their norm al caden ce. Note any evidence of pain th at
Palpation
Knee palpation should be system atic so that you do n ot
overlook areas of poten tial pain gen erators. First, th e soft
tissues and skin should be evaluated for swelling, turgor,
integrity, tenderness, or crepitus. If swelling is detected, it
m ust be determ ined wh ether th e swelling is in the subcutaneous tissues or a knee join t effusion. A join t effusion can
be detected by th e ballottem en t test or th e fluid wave test.
Th e ballottem en t test is perform ed with th e kn ee exten ded,
first on e h an d m ilks fluid from th e suprapatellar pouch in feriorly into th e knee joint. Then the other hand applies
a posterior force to th e an terior aspect of th e patella. Th is
force compresses the patella in to the fluid of the knee effusion, and wh en the pressure is released, the patella boun ces
back an teriorly. Wh en swellin g is presen t over th e an terior
patella an d seem s circum scribed but is n ot ballotable, a
prepatellar effusion is presen t an d n ot a join t effusion .
Th e fluid wave test can detect a sm aller kn ee join t effusion. In the test, one han d m ilks fluid from th e suprapatellar pouch while th e other h and is positioned so that th e
index finger is placed on one side of the patella and the
thum b is placed on the other side. Then the thum b is used
to apply pressure wh ile th e in dex fin ger is used to detect
the transm ission of a fluid wave on th e other side of the
join t. Th e fluid wave test is subtle an d requires practice.
Next, palpate th e kn ee for soft tissue in tegrity an d th e
presen ce of any soft tissue defect. Th is in cludes th e presen ce
of an exten sor m ech an ism disruption . Palpate th e quadriceps tendon superior to the superior pole of the patella for
defects an d th en palpate th e patellar ten don in ferior to th e
inferior pole of the patella for defects.
Th en palpate th e kn ee for ten dern ess. Th is is th e m ost
fam iliar part of th e kn ee exam in ation an d requires exact
knowledge of the anatomy of the knee and attention to
detail. Th e kn ee sh ould be palpated from proxim ally to
distally in a system atic m an n er to en sure com pleten ess. Diagnostic accuracy and patient com fort can be improved by
exam in in g less sym ptom atic areas first for reassuran ce an d
dem on stration of in ten ded gen tlen ess of th e exam in ation .
705
Exam ination of the patien ts countenance durin g the exam in ation will often improve th e exam in ation reliability.
An teriorly, palpate th e exten sor m ech an ism , in cludin g
the rectus fem oris, vastus lateralis, vastus m edialis, the retin aculum , patella, patella ten don , an d th e tibial tubercle.
Medially, palpate th e m edial epicon dyle, m edial join t lin e,
course of the superficial MCL, MCL insertion, pes tendons,
an d pes in sertion . Laterally, palpate th e lateral epicon dyle,
lateral join t lin e, course of th e LCL, LCL in sertion , fibular h ead, an d Gerdy tubercle. Palpate both join t lin es from
an terior to posterior. Palpate th e m edial an d lateral patella
facets by subluxing the patella to the m edial or lateral side
to facilitate palpation of its deep surface. Palpate posteriorly
in th e popliteal fossa for ten dern ess or a m ass.
Last, palpate the knee for crepitus. Crepitus refers to
a gratin g sensation that is felt by placing on es hand
over th e patellofem oral join t wh ile th e patien t actively
exten ds th e kn ee. Alth ough crepitus is n ot n ecessarily
path ologic, th e presen ce of crepitus sh ould be com pared
with th e opposite side. Crepitus can be suggestive of
patellofem oral arth ritis.
Range of Motion
Th e n orm al ran ge of m otion of th e kn ee in flexion an d
exten sion is 0 to 140 degrees, but 5 to 10 degrees of hyperexten sion is often possible. Wh en th e kn ee is flexed at 90
degrees, passive rotation of th e tibia on th e fem ur can be
dem on strated up to 25 or 30 degrees. Th e degree of passive rotation varies from patient to patient. However, the
am ount of internal rotation always exceeds that of extern al rotation . Wh en the knee is fully exten ded, n o rotation
is possible. Sagittal displacem ent of the tibia on th e fixed
fem ur is detectable in both the anterior and posterior directions when the kn ee is flexed. Th e norm al exten t of sagittal
displacem en t sh ould n ot exceed 3 to 5 m m . Wh en th e kn ee
is extended, lateral (abduction adduction ) m otion at th e
knee join t occurs to a lim ited exten t and should not exceed
6 to 8 degrees. With th e kn ee hyperexten ded, n o lateral m otion sh ould be present. With the kn ee flexed, lateral m otion
is possible but should n ot exceed 15 degrees.
Th e ran ge of m otion of th e kn ee join t sh ould be com pared with th at of th e opposite, un in jured kn ee. Ran ge of
m otion of the knee should be evaluated both actively and
passively. Loss of flexion is n on specific, an d it is seen in
n early every situation wh ere th e kn ee is pain ful. It is im portan t to pay careful atten tion to th e loss of exten sion as
it can h elp narrow th e differen tial. The different degrees of
active and passive m otion can in dicate possible pathology.
1. Decreased active an d passive m otion
Th is m otion is likely due to som e type of m ech an ical
block with in th e kn ee. Mech an ical blocks with in
the kn ee can include a joint effusion, a displaced
bucket h an dle m en iscus tear, an ACL stum p (cyclops lesion), and a loose body (ch ondral fragm en t). Pain can also lim it both active an d passive
706
m otion. In degenerative arth ritis, a flexion contracture can form as the knee loses both active
an d passive extension. The loss of extension in the
arthritic knee occurs from both pain an d recurrent
effusion th at even tually results in tigh ten in g of th e
posterior capsule.
2. Decreased active but norm al passive m otion
Th is m otion is likely due to path ology in volvin g th e
exten sor m ech an ism such as quadriceps ten don
rupture, patella fracture, or patella tendon rupture.
In addition , in jury to th e kn ee can cause reflex
quadriceps in h ibition , causin g an in ability of th e
quadriceps to actively con tract with m ain tain ed
passive m otion . Quadriceps in h ibition gen erally
resolves with tim e or with resolution of th e join t
effusion . A fem oral n erve lesion would also preven t quadriceps con traction and decrease active
m otion with n orm al passive m otion.
One way to compare lack of extension is with heel height
differen ce. Th e patien t is placed pron e, an d th e h eigh t differen ce of the affected heel is compared with th e un affected
contralateral heel. Each cen tim eter of h eigh t difference is
rough ly equivalen t to 1 degree of loss of exten sion . Th e degree of extension can also be m easured with a goniom eter
an d compared between th e kn ees.
Ligament Evaluation
Th e exam in ation of th e kn ee ligam en ts can be on e of th e
m ost difficult aspects of th e kn ee physical exam in ation . It is
importan t to evaluate th e un in volved kn ee for comparison
as th is can be con sidered th e n orm al degree of laxity for
the patient in m ost cases. In general, ligam ent evaluation
in volves stressin g th e join t in th e direction th at is usually
protected by th e specific ligam en t in question . In addition ,
the ligam ents origin, m idsubstance, and insertion should
be palpated if possible. Th e four m ajor kn ee ligam en ts are
the MCL, ACL, PCL, and LCL.
Ligam en t in juries are graded accordin g to I-to-III (m ild,
m oderate, severe) classification scale. Atype I (m ild) sprain
in volves ligam en t in jury with out detectable laxity an d a
solid endpoint. A type II (m oderate) sprain involves m inim al laxity with a soft en dpoin t an d represen ts a partial
disruption . A type III (severe) sprain in volves com plete
disruption of th e ligam en t with out an en dpoin t. In jury is
determ in ed by th e followin g:
1. Th e am ount of opening compared with the opposite
side, m easured in either degrees or m illim eters.
2. Th e abn orm al quality of th e en dpoin t with a soft feel
upon application of stress rath er th an a firm or discrete
en dpoin t.
3. Th e reproduction of sym ptom s, usually pain with stress
testin g.
707
708
Strength
Stren gth assessm en t sh ould be con ducted to determ in e
m uscle or n erve in jury. Ask th e patien t to perform a straigh t
leg raise, liftin g th e leg off of th e exam in ation table. He or
sh e m ay not be able to do this owin g to pain, swellin g,
an d appreh en sion , but th e ability to do so con firm s fun ction of th e fem oral n erve an d th e exten sor m ech an ism . If
addition al abn orm alities are suspected, th en a th orough
neurom uscular exam ination of the lower extrem ity sh ould
be perform ed.
Patellofemoral Joint Assessment
Exam ination of the patellofem oral joint begins with inspection, n oting the dynam ic gait, including the feet for
pron ation . Th e presen ce of pron ation is a com m on accompanim ent of patellofem oral pain syndrom e. The exam in er th en in spects for atrophy with particular atten tion
to quadriceps developm en t. Th e vastus m edialis obliquis
(VMO) at th e superom edial border of th e patella stron gly
in fluen ces patellar trackin g. Havin g th e patien t try to push
the back of the kn ee in to the exam ination table while lyin g supin e allows for observation of VMO developm en t.
Next, m alalign m en t is assessed. Patellofem oral pain due
to m alalign m en t an d th at due to patellar in stability are
two frequen t clin ical problem s in wh ich abn orm al patella
position in g or trackin g plays a role. Th e quadriceps an gle
(Q an gle) is m easured; th is an gle is m ade by a lin e from
the ASIS to th e m idpatella, intersectin g a line from the m idpatella to th e patella ten don in sertion at th e tibial tubercle.
Th e n orm al an gle is approxim ately 15 degrees but is gen derdepen den t, with fem ales h avin g a greater an gle th an do
m ales. Q an gles greater th at 15 degrees con tribute to patella
m altrackin g an d m alalign m en t (Fig. 17.15).
The exten sor m echan ism is palpated for tenderness, in tegrity, an d crepitus. Palpation sh ould in clude th e m edial
an d lateral patellar facets an d retin aculum . Iden tifyin g th e
709
lift the lateral facet of the patella more than 15 degrees (or to neutral) and indicates a tight lateral retinaculum. (Reproduced with permission from Johnson DH and Pedowitz RA: Practical Orthopaedic
Sports Medicine and Arthroscopy. Philadelphia: Lippincott Williams
& Wilkins, 2006.)
Patellar in stability assessm en t sh ould also in clude an exam in ation for appreh en sion . Th e patella appreh en sion test
is perform ed with th e patien t supin e an d relaxed. Gen tle
pressure is applied to th e patella to laterally tran slate th e
patella wh ile observin g th e patien ts coun ten an ce. Th e patient m ay becom e an xious an d/ or actually implore th e exam in er to discon tin ue th e m an ipulation because of th e
feeling of impending instability.
Radiographic Analysis
Plain Radiography
Radiograph s are h elpful as an adjun ct to a kn ee exam in ation, particularly in the traum atized patient. In the absence
of traum a, patien ts do n ot always require radiograph ic
evaluation , particularly wh en th e diagn osis is clin ically
apparent. Patients with persistent symptom s unresponsive
to treatm ent, those with a h istory of acute or traum atic on set, an d th ose with physical exam ination fin dings suggestive of m echan ical or structural pathology (m alalign m ent,
crepitus, restricted m otion , an d loss of in tegrity) deserve
radiograph ic evaluation .
710
Computed Tomography
Computed tom ography (CT) scan s are routin ely used to
evaluate patien ts with distal fem ur or proxim al tibia fractures as an adjun ct to radiograph s. Fin e-cut (2 m m ) CT
scan s with sagittal an d coronal reconstruction s provide excellen t bony detail of the joint surfaces and allow dem onstration of the degree of articular in volvem en t and displacem en t. CT scan s can also be of use in cases of patellofem oral
m alalign m en t to better visualize th e bony articulation of
the patellofem oral joint. CT scan s are preferred over MRI
for evaluation of bone. They are less helpful in the evaluation of kn ee soft tissue path ology.
Magnetic Resonance Imaging
MRI scan s are un n ecessary in th e evaluation of m ost kn ee
in juries. However, wh en in dicated, th ey are h igh ly sen sitive an d specific for th e diagn osis of soft tissue in juries of
the kn ee. Most com m only, they are used to diagnose or
confirm the diagnosis of knee ligam entous and m eniscus
in juries. Kn ee MRI h as been sh own to be 90% to 100% sen sitive an d specific for th ese indications. MRI is also useful
in detectin g tibial stress fractures an d n eoplasm s. MRI is
highly sensitive and specific for knee path ology; however,
Bone Scan
Som e con dition s are n ot visible usin g con ven tion al plain
radiograph s. Th ree-ph ase tech n etium bon e scan s are used
to detect areas of in creased vascularization an d bon e
turnover. However, bone scans are nonspecific. They are
used to evaluate patien ts with sh in splin ts. In creased focal
uptake con firm s th e presen ce of a stress fracture, wh ereas
diffuse uptake suggests m edial tibial stress syn drom e with out fracture. Bon e scan is ch eaper th an MRI; but it is less
specific an d requires contrast injection.
Arthroscopy
Th e gold stan dard for diagn osis of in traarticular path ology
is knee joint arthroscopy. Introduced for clinical applications in the late 1970s, this m odality has developed into a
tool for diagn osis an d im m ediate treatm en t for th e m ajority
knee pathology. Arthroscopy is a m inim ally invasive techn ique th at is perform ed through two or th ree sm all, 1-cm ,
incisions. A fiber optic cam era is placed within the kn ee,
allowing visualization of the entire knee join t. Intraarticular pathology can be diagnosed, and th en m iniature instrum en ts can be used to perform im m ediate treatm ent. Studies
h ave sh own decreased m orbidity (pain , stiffn ess, infection ,
n erve injury) when compared with open arth rotom y. In addition , th e m agn ification afforded by th e fiber optic len s
tech n ology allows for superior visualization of th e kn ee
join t compared with con ven tion al open tech n iques. Diagn ostic arthroscopy is expen sive an d in vasive an d, therefore,
sh ould be utilized on ly wh en oth er m ore conservative m easures of diagnosis an d treatm ent h ave failed.
Classification
Several classification system s exist, of wh ich perh aps th e
m ost used is the AO/ ASIF classification. It divides the fractures according to whether they are intraarticular or extraarticular. Type A is extraarticular, B is unicondylar, and C is
intraarticular. In addition , there are several subtypes that
are beyon d th e scope of this chapter.
Mechanism of Injury
Most fractures occur as a consequence of direct traum a. As
m en tion ed previously, there is a bim odal age distribution
based on th e m ech an ism of in jury. Youn ger patien ts h ave
complex, intraarticular fractures as a result of h igh -energy
traum a, often, a m otor vehicle accident or a fall from height.
Older, osteoporotic patients frequently have m ore simple
extraarticular fractures th at result from a m in or fall from
stan ding on to a flexed knee.
Presentation
Patients generally present with localized pain, deform ity,
an d inability to bear weight. Approxim ately 5% to 10% of
all distal fem ur fractures are open injuries.
Relevant Anatomy
Th e gastrocn em ius m uscle origin ates on th e m ost distal
portion of th e fem oral con dyles. Th e pull of th e gastrocn em ius m uscle on the distal piece causes the usual posterior
displacem en t an d an gulation at th e fracture site. Th e pull of
the quadriceps and ham strin gs m uscles lead to shorten ing
at the fracture site.
Physical Examination
Pain ful swellin g an d deform ity present over the distal fem ur, often accompan ied by false m otion at the fracture
site. Th e proxim ity of neurovascular structures to th e fracture site m andates prompt assessm ent of the neurovascular
status of the lim b. Fullness in the popliteal space accom pan ied with weak distal pulses suggests vascular in jury.
711
Radiographic Examination
Radiograph s sh ould in clude AP, lateral, an d two oblique
projection s of th e kn ee. In addition , two views of th e h ip
sh ould be obtain ed to evaluate the fem oral neck.
Special Tests
CT scans are gen erally perform ed to evaluate the am ount
of in traarticular in volvem en t an d displacem en t.
Differential Diagnosis
Th e diagn osis is easily m ade if deform ity is presen t an d
good radiographs are obtained. Th e differential includes
fem oral shaft fracture, tibial plateau fracture, an d kn ee dislocation.
Treatment
Non operative treatm en t is possible in extraarticular an d
n on displaced in traarticular fractures. Non operative treatm ent consists of fracture reduction an d casting or functional bracin g. For displaced fractures, traction is gen erally
n eeded to obtain and m ain tain reduction . Non operative
treatm ent of these fractures often requires traction for 6
to 12 weeks, so m ost displaced distal fem ur fractures are
treated operatively with or without in itial tibial pin traction .
Articular compon en ts of th e fracture are repaired with in terfragm entary screws. Th e fractures are then fixed stabilized
with a lateral plate an d screws, in tram edullary (IM) n ail, or
extern al fixator. Lateral plates can be in serted with con ven tional open m ethods or via newer, m inim ally in vasive tech n iques (Fig. 17.17). Th e plates can be 95-degree con dylar
712
plates, dyn am ic con dylar screw plates, or con toured periarticular plates with lockin g or n on lockin g screws. IM n ails
are lim ited to extraarticular distal fem ur fractures, with th e
fracture at least 5 cm superior to the joint line. The m ain
lim itation of IM n ails is ach ievin g adequate fixation of th e
distal fragm en t. IM n ails can be in serted an terograde or retrograde. Retrograde IM n ails h ave improved distal fixation
with m ultiple distal interlockin g screws at m ultiple an gles.
External fixation devices are generally used as a part of
dam age con trol orth opaedics with distal fem ur fractures;
however, hybrid fram es using fine-wire fixation distally an d
half-pin fixation proxim ally can be used for definitive treatm en t. Postoperatively, weigh t-bearin g is in itially delayed,
but early ran ge of m otion of th e kn ee is en couraged to
decrease stiffn ess. Weigh t-bearin g is advan ced with radiograph ic eviden ce of h ealin g at 6 to 12 weeks.
Complications
Th e m ost com m on complication of distal fem ur fractures
is kn ee stiffn ess, an d th erefore, ran ge-of-m otion exercises
are started early. Non un ion is rare, given th e rich vascular
supply of th e cancellous bone of the distal fem ur. Varus
m alun ion is th e m ost com m on deform ity. Posttraum atic
osteoarth ritis results from failure to restore articular con gruity an d altered kn ee biom ech an ics, as well as ch on dral
dam age at th e tim e of th e in jury. In fection is greater with a
high-energy m echan ism and open injuries.
Classification
Th ere are several classification system s, th e on e th at is m ost
utilized is th e Sch atzker classification , wh ich divides th e
plateau fractures accordin g to th eir pattern , location , an d
level of traum a (Fig. 17.18). In type I, there is a split frac-
Mechanism of Injury
Th e m ech an ism of in jury is a varus or valgus load about
the knee coupled with an axial load. Motor vehicle acciden ts accoun t for th e m ajority of in juries in youn ger patients; however, in older patients, this injury m ay occur
with a simple fall. Th e quality of th e patien ts bon e an d
the degree of force applied determ ine the type of fracture
an d the presence of associated ligam entous injuries. With
a h igh -en ergy varus or valgus load to th e kn ee, eith er th e
collateral ligam ent will tear or the plateau will fracture. Th e
weaker structure will fail. In youn ger patien ts with stron g,
rigid bon e, th ere is a h igh in ciden ce of split-type fractures
an d a h igh rate of associated ligam ent injuries. In older patients, with bone that is weaker, there is a higher incidence
of depression -type fractures an d a lower in ciden ce of ligam ent injuries. Type V bicondylar split fractures involve a
h igh -en ergy axial load applied to an exten ded kn ee.
Presentation
Patients present with severe kn ee pain an d swelling following m ajor traum a to th e kn ee due to a m otor vehicle, industrial, or ath letic accident. The patient typically cannot bear
weigh t on th e extrem ity. Tradition ally, th ese in juries were
called bumper injuries to describe the com m on m echan ism of th e fracture occurrin g to th e kn ee of patien ts who
stepped out into traffic and their knee was struck by a cars
bumper.
Figure 17.18 Schatzkers classification of tibial plateau fractures is shown. Types I to IV are defined
as follows: I: A split fracture of the lateral tibial plateau. II: A pure depression fracture of the lateral
tibial plateau. III: A split-depression fracture of the lateral tibial plateau. IV: A fracture of the medial
tibial plateau. V: A bicondylar fracture of the tibial plateau. VI: A fracture of the tibial plateau with
metaphyseal-diaphyseal dissociation. (Reproduced with permission from Chapman MW: Chapmans
Orthopaedic Surgery, 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2001.)
Relevant Anatomy
Th e tibial plateau is composed of m edial an d lateral
con dyles. The m edial condyle is larger and concave from
an terior to posterior an d m edial to lateral. The lateral
plateau is sm aller in size an d con vex in sh ape. Th e plateaus
are separated by an intercondylar em inence that serves as
an attachm ent for the ACL. Because the m edial articular
surface and its associated condyle is stronger th an the lateral plateau, an d because of th e n orm al valgus an gle of th e
knee, fractures involving the lateral compartm ent are m ore
com m on. Adjacen t soft tissue an d n eurovascular structures
are at risk in these in juries, particularly those that involve
exten sive com m in ution an d a h igh er-en ergy in jury. Th e
popliteal vessel trifurcates just below th e kn ee an d is at risk
with proxim al tibial fractures. Laterally, th e peron eal n erve
is at risk as it winds around the n eck of the fibula.
Physical Examination
Swellin g an d ecchym oses are frequen tly presen t an d m ay
be severe. Neurovascular assessm en t is critical, particularly
in cases of high-energy traum a. Evaluation for stability is an
important component in determ in ing the treatm ent. This
involves the application of gen tle stresses to the knee to determ in e th e degree of stability. With th e kn ee in exten sion ,
a varus or valgus force is applied, depending on the com partm en t in volved, an d th e ten den cy for th e join t lin e to
open upis determ ined. Sim ilarly an an terior or posterior
force m ay be gently applied to determ in e the presence of
associated cruciate ligam ent in jury. Pain often precludes a
satisfactory evaluation , which requires intraarticular local
an esth etic or general anesthesia.
Radiographic Examination
AP, lateral, and oblique radiograph s of the knee are required.
Special Tests
Varus and valgus stress radiographs are som etim es helpful to establish the stability of an injury an d assess for
associated ligam entous dam age. This som etim es requires
an esth esia an d can be perform ed under fluoroscopy. CT
scans are helpful to determ ine th e degree of intraarticular
displacem en t. Because m an agem en t often h in ges on th e
am ount of fracture displacem ent, CT scans are com m only
indicated in the workup of tibial plateau fractures.
Differential Diagnosis
Because knee dislocations m ay be accom panied by a tibial
plateau fracture, on e m ust con sider th e possibility wh en
evaluatin g any patien t with distal fem oral or proxim al tibial
traum a. The relatively h igh percentage of vascular injuries
m andates the consideration in any knee traum a. There are
a n um ber of com m on ly associated in juries accompanyin g
fractures of the tibial plateau. Th ese include m eniscus tears
in up to 50% and associated ligam ent injury in up to 30%.
713
Treatment
Non operative treatm en t m ay be sufficien t for n on - or m in im ally displaced fractures and th ose th at are stable.Treatm ent m ost com m on ly involves non weigh t-bearing in a
fracture brace for up to 3 m onths. Operative intervention
is reserved for displaced (usually greater than 5 m m articular incongruity), unstable, or open fractures. Surgical treatm ent m ost com m only consists of open reduction and intern al fixation (ORIF) with a con toured proxim al tibia locking
plate or an extern al fixator in patien ts with severe swellin g
and fracture blisters. Vascular injuries usually require repair.
Nerve in juries are usually n europraxias. Wh en treatin g an
open in jury or perform in g an ORIF, n erve exploration m ay
be warran ted. A h igh in dex of suspicion for th e developm ent of compartm ent syn drom e should be m aintained.
Complications
Complications include stiffness, m alunion, nonunion,
posttraum atic osteoarth ritis, in fection , compartm en t syn drom e, an d n erve in jury.
Patella Fractures
Fractures of the patella are relatively com m on, accountin g
for 1% of all skeletal injuries. They are m ore com m on in
m en than in wom en (2:1). They can occur in all age groups,
but th e m ost com m on age group is 20 to 50 years of age.
Classification
Patella fractures are divided in to n on displaced an d displaced pattern s. In addition , th ey can be described on th e
basis of fracture location an d pattern : stellate, com m in uted, tran sverse, vertical, polar (superior or in ferior), or
osteoch on dral (Fig. 17.19).
Undisplaced
Transverse
Multifragmented
displaced
Lower or
upper pole
Vertical
Multifragmented
undisplaced
Osteochondral
714
Mechanism of Injury
Th e m ost com m on m ech an ism is in direct, from a forced eccentric con traction of th e quadriceps as the knee is flexed.
Th e in trin sic stren gth of th e patella is exceeded by th e pull
of th e exten sor m ech an ism . Th e facture is gen erally tran sverse with variable in ferior pole com m in ution . Th e degree of displacem en t is based on th e degree of retin acular
disruption . Patella fractures can also occur th rough direct
traum a from a fall directly on th e patella. Direct traum a
results in a stellate or com m in uted fracture pattern with
preservation of th e retin aculum .
Presentation
Patien ts present with acute anterior knee pain accompan ied
by localized tenderness and swelling.
Relevant Anatomy
Th e patella is th e largest sesam oid bon e in th e body.
Th e patella in creases th e m ech an ical m om en t arm of th e
quadriceps an d protects th e fem oral con dyles from direct
traum a. Th e articular cartilage of th e patella is th e th ickest
in th e body an d can be up to 10 m m th ick. Th e m edial an d
lateral exten sor retin acula are stron g lon gitudin al expan sion s of the quadriceps an d insert directly on to th e tibia.
If th ese rem ain in tact, active exten sion m ay be preserved in
the setting of a patella fracture.
Physical Examination
Patien ts have a tender, swollen, ecchym otic anterior knee.
Th e physician m ust evaluate for active exten sion or th e ability to do a straigh t leg raise to determ in e th e in tegrity of
retin acula.
Radiographic Examination
AP, lateral, and sunrise views of the knee are required.
Special Tests
Special tests are n ot n ecessary.
Differential Diagnosis
A bipartite patella, in which an ossification center persists,
is occasion ally m istaken for a fracture. A bipartite patella
alm ost always h as sm ooth superolateral m argin s, an d 50%
are bilateral. If a bipartite patella is suspected, con sider
im agin g th e con tralateral patella. Quadriceps ten don rupture an d patella ten don rupture sh ould be ruled out by
physical exam in ation an d radiograph s.
Treatment
Non operative treatm en t with eith er a cylin der cast or a
knee im m obilizer is reserved for nondisplaced or m in im ally displaced fractures with an in tact exten sor m ech an ism . O perative treatm en t con sists of O RIF or patellectomy. For th e m ost com m on tran sverse fracture pattern ,
O RIF is perform ed with K-wires or screws placed lon gitudin ally th rough th e patella followed by an an terior
or circum feren tial ten sion ban d wire (Fig. 17.20). Com m inution is either excised or fixed with interfragm entary
screws. Partial patellectomy is perform ed for com m inuted
polar fragm en ts with reattach m en t of th e patellar ten don .
Total patellectomy is reserved for severe, unrepairable com m inution and is rarely indicated. The retinaculum should
be repaired with any type of treatm en t. Postoperatively, th e
patien t is weigh t-bearin g as tolerated in a kn ee im m obilizer
or cylin der cast for 6 weeks.
Complications
Knee stiffness, extensor lag of approxim ately 5 degrees, and
exten sor weakn ess are th e m ost com m on com plication s.
Posttraum atic osteoarthritis has been shown to occur in
up to 50% of patien ts in lon g-term studies. Symptom atic
h ardware is com m on an d m ay n ecessitate rem oval after the
h ealin g h as occurred. Non un ion an d in fection are rare. Osteon ecrosis occurs with in creasin g com m in ution , but th e
m ajority of patients can be treated with observation with
spon tan eous revascularization in 2 years.
715
Classification
Quadriceps ten don injuries are known as quadriceps strains.
Th ey are classified from m ild to severe or grade I to III.
A grade III rupture is a complete tear. Th e m ost com m on
classification is an incomplete or complete rupture based
on th e patien ts ability to perform a straigh t leg raise or
actively exten d th e knee.
Mechanism of Injury
Th e m ech an ism is th e sam e as th at for an in direct patella
fracture, an eccentric load of the quadriceps. In th e case
of a quadriceps rupture, th e quadriceps ten don is gen erally
weaken ed th rough a degen erative process (ten din osis); an d
therefore, it is weaker than the patella an d th us ruptures.
Presentation
Patients present after experien cing sharp, acute pain after a stum ble or trip. Most are un able to walk because of
pain an d in competen ce of th eir exten sor m ech an ism . Th is
injury com m on ly occurs in patients 40 to 70 years old,
wh ereas patella ten don ruptures are m ore com m on in patients younger th an 40 years.
Figure 17.21 Quadriceps tendon repair technique. (Repro-
Relevant Anatomy
As discussed in the knee anatomy section, the four quadriceps m uscles becom e tendinous, and coalesce to form the
quadriceps ten don . Th ey th en en velop th e patella an d attach distally at th e tibial tubercle as th e patella ten don . Lon gitudin al extensions, the retin acula, run m edial and lateral
to th e exten sor m ech an ism an d attach directly on to th e
tibia. If retinacula are intact, a patient with a quadriceps
rupture m ay still be able to perform active knee exten sion .
Physical Examination
Th e patien t will h ave swollen , ten der, an terior kn ee. Th e
ten dern ess is greatest at th e superior pole of th e patella. A
palpable defect is often presen t superior to th e patella. Th e
vast m ajority of patients are unable to actively exten d the
leg or perform a straight leg raise.
Treatment
Non operative treatm en t is reserved for in com plete tears
in which active, full-knee exten sion is preserved. Operative treatm ent consists of prim ary repair of the quadriceps
ten don to th e superior pole of th e patella. Stron g n on absorbable suture is placed in to the quadriceps tendon with
a locked, run ning stitch. The tendon is then reapproxim ated to th e patella through bone tunnels and secured
(Fig. 17.21). For chronic ruptures, a quadriceps turndown ,
Scuderi tech nique, can be utilized for the repair. Postoperatively, the patient is weigh t-bearing as tolerated in a kn ee
im m obilizer or cylinder cast for 3 to 4 weeks. At th at point,
m otion is started and slowly advanced over the next 6 to
8 weeks with a h in ged kn ee brace.
Radiographic Examination
AP and lateral radiographs of th e knee dem onstrate an in tact patella with th e presen ce of patella baja or a low-ridin g
patella.
Complications
Kn ee stiffn ess, exten sor lag, an d exten sor weakn ess are th e
m ost com m on complication s. Rerupture rates are low for
acute, prim ary repair.
Special Tests
MRI can confirm the tear but is unn ecessary with a positive
physical exam in ation . MRI or ultrasoun d can be utilized
in inconclusive cases or cases wh ere patient body habitus
lim its the physical exam ination.
Differential Diagnosis
Th e differen tial in cludes th e two oth er in juries to th e exten sor m echan ism : patella ten don rupture an d patella fracture.
716
Classification
Patella tendon ruptures can be classified by location of the
rupture: proxim al in sertion , m idsubstance, or distal in sertion . Th e proxim al in sertion , at th e in ferior pole of th e
patella, is th e m ost com m on location of rupture. In addition , patella ten don ruptures can be classified by th e tim in g
between th e in jury an d surgery. Acute repair is perform ed
within 2 weeks, an d delayed repair is perform ed after
6 weeks. Repair during the acute period is the m ost im portan t progn ostic factor.
Mechanism of Injury
Th e in jury occurs by th e sam e m ech an ism as in direct
patella fractures an d quadriceps ruptures, an eccen tric load
of th e exten sor m ech an ism . In th ese youn ger patien ts, th e
quadriceps ten don h as n ot un dergon e degen eration ; an d
therefore, the patella tendon is the weakest compon ent of
the extensor m echanism .
Presentation
Patien ts present after experiencing sharp, acute pain after a
stum ble or a trip. Most are unable to walk because of pain
an d in competen ce of th eir exten sor m ech an ism .
Relevant Anatomy
Th e patella ten don run s from th e in ferior pole of th e patella
to th e tibial tubercle. Th e greatest forces th rough th e patella
ten don occur at 60 degrees of kn ee flexion , an d th ese forces
can be as h igh as 3 to 4 tim es the body weight wh en clim bin g stairs.
Physical Examination
Th e patien t h as a swollen , ten der, an terior kn ee. Th e ten derness is greatest at th e in ferior pole of th e patella. A palpable
defect is presen t in ferior to th e patella. Th e vast m ajority of
patien ts are un able to actively exten d or perform a straigh t
leg raise.
Radiographic Examination
AP and lateral knee radiographs reveal an in tact patella with
patella alta, or a h igh -ridin g patella (Fig. 17.22).
Special Tests
MRI or ultrasoun d can be used in cases wh ere th e physical
exam in ation is in con clusive.
Differential Diagnosis
Th e differen tial diagn osis in cludes quadriceps ten don rupture, patella fracture, or tibial tubercle avulsion .
Treatment
Non operative treatm en t is reserved for in complete tears,
in wh ich active, full-kn ee exten sion is preserved. O perative treatm en t con sists of prim ary repair of th e patella ten don to th e in ferior pole of th e patella. Acute repair, with in
2 weeks, has better outcom es than delayed repair due to
patella ten don scarrin g an d quadriceps con traction . Stron g
Complications
Knee stiffness, extensor lag, extensor weakness, and patella
baja are th e m ost com m on com plication s. Rerupture rates
are low for acute, prim ary repair an d h igher for delayed
repairs.
Patella Dislocation
Patella dislocation is relatively com m on and accounts for
m ost patients complaining of a knee dislocation. The dislocation is always in th e lateral direction. It is m ore com m on in wom en, owing to physiologic laxity, an d patients
with hyperm obility an d con n ective tissue diseases, such as
Eh lersDan los an d Marfan syn drom e.
Classification
Patellar instability can occur in th e form of frank dislocation or subluxation. In a subluxation, there rem ains a
portion of articular con tact between th e patella an d th e
fem ur. Patella dislocations can be classified as acute or
ch ronic.
Mechanism of Injury
Patella dislocation s usually occur durin g a m aneuver in
wh ich th e kn ee is sligh tly flexed an d rotated. In such a
position , th e patella m ay be poorly en gaged in its groove
an d vulnerable to lateral subluxation or dislocation. Predisposition to lateral dislocation of th e patella falls in to
the m ain categories of hypoplasia or dysplasia, m alalignm en t, and contracture or laxity. Hypoplasia of the lateral
fem oral condyle, patella alta, a shallow trochlea, dysplasia
of th e patella, an d hypoplasia of th e vastus m edialis decrease the forces that keep the patella within the trochlea
grove an d in crease th e risk of dislocation . An in creased
Q angle, fem oral anteversion, genu valgum , external tibial rotation, and lateralization of th e tibial tubercle predispose to in stability by in creasin g th e laterally directed forces
on th e patella. Laxity of th e m edial retin aculum , tigh tn ess
of th e lateral retin aculum , an d gen eralized ligam en tous laxity also predispose the patient to patellar dislocations.
Presentation
Patients present with acute pain following an incident
wh ere th e kn ee wen t out of place. Th e patien t m ay be
un able to exten d th e kn ee if th e patella is un reduced.
Relevant Anatomy
Th e Q angle is defined as the angle form ed by a lin e from th e
ASIS to the m idpatella and a line from the m idpatella to the
tibial tubercle. Th e n orm al ran ge is 8 to 12 degrees, with a
high Q angle being greater than 15 degrees. Patella trackin g
through th e trochlear groove is balan ced by the Q angle,
the lateral retinaculum , the m edial retinaculum , the m edial
patellofem oral ligam en t (MPFL, th e m ajor m edial restrain t
to lateral displacem en t of th e patella), an d th e VMO. Maltrackin g or lateral subluxation / dislocation can occur if any
of th e followin g th ree compon en ts are presen t: th e Q an gle is too great, the lateral retinaculum is too tight, or the
VMO is too weak. When the patella dislocates, the m edial
retin aculum is torn an d th e MPFL is torn or stretch ed
Physical Examination
Wh en th e patella is dislocated, th e con tour of th e kn ee is
abn orm al and displays a prom inence laterally and a void
an teriorly where th e patella is usually located. Most patellar dislocations, however, are seen after either spontan eous
or m an ipulated reduction , in wh ich physical exam in ation
fin din gs are n on specific an d in clude swellin g, ten dern ess,
an d ecchym oses. Ten derness is often present over the lateral aspect of th e kn ee, specifically over th e lateral fem oral
con dyle, and m edially over the m edial facet of the patella
an d th e m edial retin aculum .
Radiographic Examination
AP, lateral, and sun rise views of the kn ee are required. The
lateral or sunrise views should be in spected for evidence of
an osteochondral fragm ent.
717
Special Tests
Special tests are generally unnecessary. If the diagn osis is
doubtful, MRI can be h elpful to visualize retin acular an d
chon dral injury as well as loose bodies.
Differential Diagnosis
Kn ee dislocation sh ould be ruled out by physical exam in ation. Additional differential diagn oses are patellofem oral
pain syn drom e, patella subluxation , MCL sprain , ACL tear,
and m eniscus tear. Each of these can typically be ruled out
by physical exam ination, with the patient occasion ally requirin g an MRI.
Treatment
Th e treatm en t of patella dislocation s sh ould be based on
th e acuity of th e in jury an d th e patien ts sym ptom s. Patien ts
with in itial dislocation s are treated differen tly th an patien ts
with ch ron ic in stability.
Initial Dislocation
Th e patien t with an acute prim ary dislocation of th e patella
is m anaged with prompt reduction and evaluation to rule
out associated displaced osteoch on dral fractures. Osteochon dral fracture generally occurs as the patella is relocated an d th e m edial facet of th e patella impacts th e lateral
fem oral condyle. Therefore, the m edial patella facet an d lateral fem oral con dyle are th e typical location s of osteoch on dral fracture. O ccasion ally, aspiration of th e h em arth rosis
m ay be perform ed for com fort. If there is no osteochondral
fracture, the patients knee should be im m obilized in either
a kn ee im m obilizer or a cylin der cast for 3 to 4 weeks. Operative treatm en t is reserved for th e presen ce of displaced
osteoch on dral fragm en ts or recurren t in stability. On ce im m obilization is discontinued, the patient is started on an
aggressive quadriceps-strengthen ing physical th erapy program focusin g on VMO stren gth en in g.
Chronic Instability
Th e patien t with ch ron ic patellar in stability an d patellofem oral pain h as differen t surgical option s depending
on th e exact etiology of th e in stability an d pain . Th e m ajor causes of patellofem oral pain are patella ch on drom alacia, m alalign m en t, m altrackin g, an d retin acular im balan ce.
Th ese etiologies can presen t separately or togeth er, an d it is
importan t that the surgical approach to the patien t address
all of the etiologies to be successful.
1. Arth roscopic debridem en t an d a ch on dral procedure
Patien ts with patella ch on drom alacia can h ave partialor full-thickness dam age to the patella chondral surface. Th is ch on dral dam age can be th e source of th eir
patellofem oral pain. The first step in treating these patien ts is to arthroscopically debride (chondroplasty) the
un stable cartilage. A procedure to either stim ulate cartilage growth or transplant cartilage tissue to th e dam aged
area can then be perform ed. The purpose of this procedure is to replace th e dam aged cartilage with a n ew
718
2.
3.
4.
5.
Complications
Recurrent dislocation is m ore com m on in patients with a
prim ary dislocation at an age youn ger th an 20 years. Recurren t dislocation is an in dication for surgical in terven tion .
Knee stiffness m ay result from prolonged im m obilization
or postsurgical arth rofibrosis. Patellofem oral pain can result from ch on dral in jury at the tim e of the dislocation or
from retinacular injury that results in m altracking an d subsequent chon dral dam age. Overall, 50% of patients with a
prim ary patellar dislocation will improve with n on operative treatm en t; however, th e other 50% will have recurrent
instability or patellofem oral pain .
Knee Dislocation
Dislocation of th e kn ee is an un com m on but serious orthopaedic in jury that m ay be lim b-threaten ing and should
be treated as an orth opaedic em ergen cy. Tibiofem oral
(kn ee) dislocation is m uch less com m on than patellar dislocation and is a m uch m ore serious injury. Th e true in ciden ce is probably un derestim ated as 30% to 50% of dislocations spontaneously reduce before presentation.
Classification
Knee dislocations are classified according to the displacem en t of the tibia relative to the fem ur (Fig. 17.23). The
m ost com m on dislocation is anterior due to kn ee hyperexten sion , accoun tin g for 30% to 50% of kn ee dislocation s.
Posterior dislocations are the next m ost frequent on es due
to a posteriorly directed force to th e proxim al tibia, m ost
com m only from the dashboard of a car. Medial, lateral, and
rotation al dislocation s are less com m on an d result from a
com bin ation of m echan ism s involving sagittal an d coron al and rotation al m ovem en ts. Kn ee dislocation s can also
be described by th e ligam en ts th at are in volved. Most com m on ly, the ACL and PCL are involved along with at least
on e of th e collateral ligam en ts.
Mechanism of Injury
Knee dislocations occur after substantial traum a to the
knee. High-energy injuries usually occur as the result of
719
Figure 17.23 Classification of knee dislocations. (Reproduced with permission from Chapman
MW, Szabo RM, Marder R, et al. Chapmans Orthopaedic Surgery. 3rd ed. Philadelphia, PA: Lippincott
Williams & Wilkins, 2001.)
Presentation
Patients with h igh -energy traum atic m echanism s can have
m ultiple traum atic injuries. Lower-en ergy injuries are m ore
com m only isolated. Patients will complain of severe pain
an d swelling and will be unable to bear weight. Patien ts or
em ergen cy person el m ay describe an awkward position of
the knee that reduced while stabilizing the lim b.
Relevant Anatomy
Tibiofem oral join t stability is provided predom in an tly by
soft tissue restraints. For a kn ee dislocation to occur three
of th e four m ain con strain in g ligam en ts m ust be torn . Most
com m only, the ACL and PCL are involved along with either the MCL or LCL. Th e posterior vascular structures of
the knee, including the popliteal artery and vein, the tibial
nerve, and the com m on peron eal nerve, can be dam aged
with a kn ee dislocation an d cause a lim b-th reaten in g in jury. Th e popliteal n eurovascular bun dle courses th rough a
fibrous tun n el at th e level of th e adductor h iatus. With in th e
popliteal fossa, m ultiple bran ch es arise from th e popliteal
artery, including the superior m edial and lateral geniculate
arteries, the m iddle geniculate artery, and the inferior m edial an d lateral gen iculate arteries. Th e popliteal artery th en
run s through another fibrous tunnel deep to the soleus.
Th ese bran ch es an d th e fibroosseous tun n els teth er th e
popliteal artery to th e popliteal space. Th erefore, wh en a
knee dislocation occurs, the popliteal artery is at great risk
for kinkin g, tenting, or, rarely, tearing.
Physical Examination
Th e exam in ation fin din gs vary with th e type of dislocation and the tim ing of the evaluation . The knee will
Radiographic Examination
AP, lateral, an d oblique radiograph s of th e kn ee before an d
after reduction are perform ed. Joint space widenin g m ay indicate in complete reduction . Ligam en tous or capsular avulsion fractures can often be visualized on radiograph s.
Special Tests
Th e h igh in ciden ce of vascular in jury m an dates a vascular
surgery con sultation an d possible arteriography in every
knee dislocation. Generally, if the initial ABI is norm al, serial ABIs can be used in lieu of an arteriogram , alth ough
th is decision sh ould ultim ately be m ade by th e vascular surgeon. MRI is helpful to assess the exten t of ligam entous injury an d form ulate a reconstructive approach
(Fig. 17.24).
720
B
Figure 17.24 T2-weighted magnetic resonance images showing (A) PCL tear and (B) ACL avulsion
following a knee dislocation. (Reproduced with permission from Chapman MW, Szabo RM, Marder R,
et al. Chapmans Orthopaedic Surgery. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2001.)
Differential Diagnosis
Th e differen tial diagn osis in cludes distal fem ur, patella,
an d tibial plateau fractures. In addition , isolated ligam en tous in jury with out dislocation sh ould be in cluded.
MCL Sprain
Treatment
In itially, a prompt reduction , after n eurovascular assessm en t, sh ould be perform ed, followed by a repeat n eurovascular assessm ent an d postreduction radiographs. Concern
for lim b ischem ia m andates im m ediate vascular consult
an d likely in terven tion . Closed reduction is gen erally successful, alth ough som e dislocation s are irreducible as a result of button-holingof the bon e through the soft tissues.
In dication s for im m ediate open m an agem en t in clude open
in jury, in ability to ach ieve a closed reduction , associated
residual soft tissue in terposition , an d vascular in jury.
The definitive treatm ent is debated. The debate surroun ds th e tim in g of ligam en t repair an d recon struction .
Som e orth opaedists recom m en d im m ediate repair an d reconstruction , whereas others recom m end delayed repair
or, m ore often , recon struction . Th e cruciate ligam en ts gen erally require recon struction , wh ereas th e collateral ligam en ts m ay be am en able to repair wh en addressed acutely
(with in 2 to 3 weeks of in jury) but require recon struction
in m ore ch ron ic cases. O utcom e studies h ave been m ixed
with outcom es of persisten t pain , stiffn ess, and instability
following both im m ediate and delayed treatm ent.
Classification
MCL sprains are graded from I to III, with severity increasing from I to III. In grade I (m ild) in juries, there is m inor
injury to the ligam ent without a full-thickness tear. There is
n o detectable laxity with grade I sprain s. In grade II (m oderate) sprains, th ere is m ore significant in jury to the ligam ent,
with stretch in g an d partial tearin g. Th ere is m in im al laxity
presen t on exam in ation . In grade III sprain s, th e MCL is
completely disrupted. There is laxity on physical exam ination without a detectable endpoint.
Complications
In itial complication s in clude n eurovascular in juries. Delayed complication s in clude pain an d stiffn ess.
Relevant Anatomy
Th e MCL h as both superficial an d deep layers. Th e superficial MCL originates on the m edial epicondyle of th e fem ur
Mechanism of Injury
MCL sprains occur when a valgus stress is applied to th e
knee. Th is frequently occurs when a player is tackled or
tripped from th e side during soccer or as a contact injury
in football. If the injury involves m ore of a twisting m echan ism , the MCL, the ACL, and the m edial m eniscus can
also be torn; this is called th e unhappy triad of the knee. MCL
injuries m ay also occur in the setting of a knee dislocation.
Presentation
Patients with MCL sprain s generally present with acute m edial kn ee pain followin g a traum atic in jury to th e kn ee.
Physical Examination
Th e specific physical exam in ation elem en ts of a kn ee with
an MCL tear should include palpation of the m edial knee
an d valgus stress testing. Palpation of the m edial knee
sh ould in clude th e entire length of th e MCL: its origin on
the m edial epicondyle (the m ost com m on location of a
tear), its m idsubstan ce at th e m edial join t lin e, an d its in sertion on the anterom edial proxim al tibia. Valgus stress
testin g sh ould be tested at both 30 degrees of flexion an d
full extension. Valgus tress testing at 30 degrees of flexion
is specific for th e MCL, and at full extension, it tests the
MCL, posterom edial corner, an d cruciate ligam ents. Valgus laxity at 30 degrees in a n orm al knee ranges from 0 to
10 degrees of open in g with a solid en dpoin t an d n o ten derness. Physical exam in ation fin dings differentiate between
grades I to III in juries. In grade I in juries, th ere is m in im al
ecchym oses, swellin g, an d ten dern ess. Valgus stress testin g
in grade I sprains elicits tenderness without m edial joint
space opening and a solid endpoin t. In grade II sprains,
there is increased ecchym oses, swellin g, and tenderness.
Valgus stress testing at 30 degrees of flexion elicits tenderness and open ing from 10 to 15 degrees with th e presen ce
of an en dpoin t. Valgus stress testin g at full exten sion will
be stable. In grade III in juries, th ere is com plete tearin g of
the MCL with m ore severe ecchym oses, swelling, an d tendern ess. Th ere is open in g beyon d 15 degrees with out an
en dpoin t with valgus stress testin g at 30 degrees of flexion
an d instability can also be present at full extension depending on the severity of the injury.
Radiographic Examination
AP and lateral radiographs are generally negative. With
ch ronic MCL tears, calcification can be seen at the origin
of th e MCL at th e m edial epicon dyle, an d th is is called th e
PellegriniStieda sign.
Special Tests
MRI is rarely n ecessary with an isolated MCL sprain; however, it is used com m on ly with m ultiligam en t kn ee in juries
an d/or knee dislocation s. MRI is helpful in patien ts in
wh om an addition al kn ee in jury is suspected. It can con firm addition al kn ee ligam en t in juries or m en iscus in juries
that m ay require surgical treatm en t. Stress radiographs can
also be perform ed by placing valgus stress about the knee
wh ile an AP radiograph is taken . Stress radiograph s are
especially h elpful in th e pediatric population to differen tiate physeal fractures from ligam ent sprains
721
Differential Diagnosis
Th e m ost importan t differen tial diagn osis is th at of a distal
fem oral physeal fracture in skeletally im m ature patien ts.
Other differen tial or concom itant injuries in clude ACL
tears, m en iscus tears, patella subluxation or dislocation , pes
ten don itis, an d ch on dral in juries. Medial m en iscus tears
can be differen tiated on physical exam in ation by th e presen ce of in stability with valgus stress testin g in patien ts with
MCL tears. In addition , patien ts with MCL tears are generally ten der at the m edial epicondyle, wh ereas patients with
m eniscus tears are tender at the m edial joint line. The differen tial diagn osis for ten dern ess at th e m edial epicon dyle is
MCL tear and patellar dislocation or subluxation. In patellar dislocation, th e MPFL tears off the m edial epicondyle,
resultin g in ten dern ess.
Treatment
Treatm ent is nonoperative and involves im m obilization for
a duration that is dependent on the degree of injury and associated in juries. Grade I sprains are treated with early range
of m otion as tolerated an d early return to activity with out
im m obilization. Grade II sprains require a short period of
im m obilization with return to activity when the pain allows with a protective hin ged knee brace at 3 to 4 weeks.
Grade III in juries are im m obilized with a cast or kn ee im m obilizer at full exten sion for 2 to 4 weeks, followed by
physical th erapy to return -to-n orm al stren gth , with full return to activity by 6 to 8 weeks with a hin ged knee brace. Associated injuries sh ould be treated accordin gly an d at tim es
warrant repair of grade III injuries. Protective, hin ged knee
braces are com m on ly used prophylactically to preven t MCL
injuries in football linem an, with m ixed results.
Complications
Th e m ain complication is recurren t valgus in stability an d
pain th at can result from early return to activity with out
brace protection .
ACL Sprain
ACL sprains or tears are th e second m ost com m on knee
ligam ent injury. Th ey occur in an estim ated 250,000 people
ann ually.
Classification
ACL ligam ent injuries are graded from I to III, sim ilar to
oth er ligam en t in juries. It is difficult to distin guish between
grade I an d grade II in juries; h owever, th e distin ction between partial (I or II) and complete (III) is the m ost importan t for progn ostic an d th erapeutic reason s.
Mechanism of Injury
ACL sprains are th e result of a single traum atic even t and
are not due to overuse injuries. The exact m echan ism
varies according to the sport involved, but m ost injuries involve a twisting or pivoting m echanism of an extended knee
722
on a plan ted foot. ACL in juries can also occur with hyperexten sion . ACL in juries com m on ly occur in con tact sports,
but th ey m ost com m on ly occur as a result of a n on con tact
m ech an ism . ACL in juries are com m on in soccer, football,
basketball, an d skiin g.
Presentation
Th e classic presen tation is th e acute on set of pain an d
swelling after a traum atic event in which th e patient lan ded
awkwardly or twisted th e kn ee an d h eard a pop.Th e ath lete is rarely able to con tin ue activity.
Relevant Anatomy
Th e ACL is th e m ost an terior of th e two cruciate ligam en ts.
Th e ACL arises from th e an terom edial tibia, run s in th e
in tercon dylar n otch , an d in serts posterom edially on th e
lateral fem oral con dyle. Th e ACL is in traarticular an d covered by a th in syn ovial m em bran e. Th e m iddle gen iculate
artery supplies th e ACL an d PCL. Th e ACL provides sagittal an d rotary stability to th e kn ee. It preven ts rotation
an d an terior displacem en t of th e tibia on th e fem ur. Th e
ACL m ost com m on ly tears off of its fem oral in sertion .
Physical Examination
Acute injuries of the ACL presen t with a tender hem arthrosis of th e knee with difficulty bearing weight. The patient
m ay n ot be able to fully exten d th e kn ee due to th e effusion /
hem arthrosis. The am oun t of swelling and tenderness m ay
preven t an accurate exam in ation of th e ACL. Ch ron ic in juries of th e ACL presen t with a ben ign kn ee with n o effusion and asymptom atic weight-bearing. The patien t m ay
not be able to fully extend th e knee due to a cyclops lesion .
A cyclops lesion results wh en the scarred down torn ACL
rem n an t preven ts full exten sion by obstructin g th e fem oral
notch The tests for ACL in juries in clude th e Lachm an test,
the anterior drawer test, an d the pivot shift test. These tests
are described in th e physical exam in ation section of th is
ch apter. Th e Lach m an test is th e m ost sen sitive, an d th e
pivot sh ift test is th e m ost specific. It is im portan t to perform a full-knee exam in ation in a patien t with a suspected
ACL tear to evaluate for addition al ligam en t or m en iscus
in jury. All physical exam in ation fin din gs sh ould be com pared with th e un in jured con tralateral side.
Radiographic Examination
Radiograph s are gen erally n orm al with an ACL tear. O ccasion ally, a sm all capsular avulsion fracture off of the lateral
tibia can be presen t with an ACL tear; th is is called a Segund
sign (Fig. 17.25). Rarely, the ACL can avulse off of its origin
at th e tibial em in en ce, an d th e tibial em in en ce avulsion
fracture fragm ent can be seen radiographically. ACL avulsion occurs m ost com m on ly in th e adolescent population .
Special Tests
MRI is h igh ly sen sitive an d specific for ACLtears an d m en iscus injuries. However, in a patient with obvious physical
a Segond fracture, which is pathognomonic of anterior cruciate ligament injury. (Reproduced with permission from Chapman MW,
Szabo RM, Marder R, et al. Chapmans Orthopaedic Surgery.
3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2001.)
exam in ation fin din gs for an ACL tear, MRI adds little to
the diagnosis an d does not influence treatm ent. Another
special test for ACL injuries is the KT-1000. The KT-1000
is a device that evaluates and quan tifies anterior laxity of
the tibia on the fem ur. It is n ot com m on ly used in clinical
practice but is com m on ly used in research settin gs.
Differential Diagnosis
Th e differen tial diagn osis of an ACL tear in volves th e differential diagnosis for an acute knee hem arthrosis. This in cludes ACL tear, patellar dislocation, osteochondral in jury,
an d a peripheral m eniscus tear. If patients presen t acutely,
the pain and effusion often prevent an appropriate exam in ation of th e kn ee. In th ese patien ts, an MRI is very h elpful
at differentiating between these diagnoses. Meniscus tears
occur with approxim ately 50% of ACL tears. Lateral m en iscus tears occur m ost com m on ly with acute ACL tears, and
m edial m eniscus tears occur m ost com m only with chronic
ACL tears.
Treatment
Th e option s for an ACLtear in volve n on operative treatm en t
with physical th erapy or operative ACL recon struction . Th e
ACL has poor h ealing potential due to its in traarticular location and lim ited blood supply. The natural history of
the ACL-deficient knee in volves recurrent in stability, progressive m en iscus in jury, progressive ch on dral dam age,
an d eventual sports disability and arthritis. Interestingly,
Complications
Th e m ost com m on tech n ical error in ACL recon struction
surgery is inappropriate tun nel placem ent that can result
in recurrent laxity and lim ited flexion. The goal of ACL
recon struction is an an atom ic recon struction . Som e studies
have sh own that arthrofibrosis (knee stiffness) can occur
m ore com m only with acute ACL reconstruction (< 2 weeks
after injury).
PCL Sprain
In jury to th e PCL is m uch less com m on th an th e ACL.
Th e relative in frequen cy h as led to a poorer un derstan din g
of th e n atural h istory of th e in jury. PCL in juries are m ost
com m only associated with knee dislocations.
Classification
PCL in juries are graded from I to III, sim ilar to oth er ligam en ts. Grade III injuries represent complete tears. Associated ligam ent injury to the posterolateral corner (PLC) m ay
cause a greater degree of laxity th an isolated PCL in juries.
723
Mechanism of Injury
Th e m ech an ism varies, but th e m ost com m on m ech an ism
involves a direct blow to the an terior aspect of a flexed knee
with th e an kle plan tar flexed. In th is position , th e m ajority
of th e posterior force is absorbed by th e PCL in stead of
th e patella. Th e PCL is usually torn in its m idportion . PCL
injuries can also occur with hyperexten sion.
Presentation
Th e patien t presen ts with a pain ful swollen kn ee. Th e degree of symptom s depen ds on th e degree of traum a an d th e
associated injuries. PCL injuries can be m issed in a patient
with distractin g in juries, th e m ost com m on is a posterior
h ip dislocation or posterior wall acetabular fracture in a
patien t presen tin g after a m otor veh icle acciden t. In th is
patien t th e sam e force th at dislocated th e h ip also caused
th e PCL in jury. Associated in juries with a PCL in clude ACL,
MCL, LCL, PLC, and m eniscus injuries.
Relevant Anatomy
Th e PCL provides approxim ately 95% of th e prim ary restraint to posterior tibial translation on the fem ur. The
PCL origin ates from th e cen ter of th e posterior tibia just
distal to th e articular surface, travels th rough th e in tercon dylar n otch , an d in serts on th e lateral aspect of th e
m edial fem oral condyle. Its fibers are stout and stronger
th an th e ACL. Directly an terior an d posterior to th e fem oral
insertion of the PCL lie the m eniscofem oral ligam en ts
of Humph rey an d Wrisberg, respectively, wh ich serve as
attachm ents of the PCL to the posterior horn of the lateral
m eniscus.
Physical Examination
Th e prim ary test for th e PCL is th e posterior drawer test.
Th e posterior drawer test is perform ed on a supin e patien t
with th e kn ee flexed 90 degrees. Th e exam in er sits on th e
patien ts foot an d push es posteriorly on th e tibia to detect
th e am oun t of posterior displacem en t. Before perform in g
th e test, it is importan t to take n ote of th e position of th e
proxim al tibia to th e distal fem ur in relation sh ip to th e un injured side to detect any degree of posterior subluxation
before perform in g th e exam in ation . Th e posterior sag sign
is the test to determ ine the degree of posterior subluxation
at rest, if the tibia is less than 1 cm anterior to th e fem ur
and also less than the unaffected side it is a positive. The
quadriceps active test is perform ed in th e sam e position
as th e sag sign, by asking th e patien t to con tract quadriceps, takin g n ote of th e reduction of th e sag sign wh en
th e quadriceps are con tracted. Th e degree of kn ee ten dern ess, swellin g, an d ecchym oses on physical exam ination
increases with increasing grade of PCL injury from grade
I to III. A grade I in jury h as m ild swellin g an d ten dern ess
with n o detectable posterior laxity. Grade II in juries h ave
som e posterior laxity with an endpoint and m ay have a positive sag sign. Grade III injuries have increased subluxation
with out an en dpoin t an d a positive sag sign .
724
Radiographic Examination
Radiograph s are usually n orm al in PCL in juries. Ch ron ic
PCL in juries m ay exh ibit degen erative ch an ges in th e
patellofem oral an d m edial com partm en ts.
LCL Sprain
Special Tests
MRI is h igh ly sen sitive an d specific for PCL in juries. MRI is
perform ed wh en m ultiligam en tous in jury an d/ or kn ee dislocation is suspected. Stress radiograph s can be perform ed
with a posterior force applied to th e anterior tibia wh ile a
lateral radiograph is taken .
Classification
LCL in juries are graded from I to III, sim ilar to th ose of
oth er ligam en ts. Grade III in juries represen t com plete tears.
Associated ligam en t injuries to the PLC m ay cause a greater
degree of laxity th an isolated LCL in juries.
Differential Diagnosis
Th e differen tial diagn osis in cludes all of th e kn ee ligam en tous in juries an d kn ee dislocation . Th e PCL m ust be
considered injured until proven otherwise with a kn ee dislocation . Th e m ost importan t differen tial is to determ in e
an isolated PCL in jury from th at associated with in jury to
the PLC. The an atom ic description of the postero-PLC has
been in con sisten t an d in cludes th e LCL, popliteus, an d th e
popliteofibular ligam en t. With in jury to th e PLC in addition to th e PCL th e kn ee will be in creasin gly un stable. In
addition , PLC in juries h ave been m et with poorer results if
they are not repaired acutely prim arily. The prim ary physical exam in ation m aneuvers for PLC injuries are the posterolateral drawer an d th e dial test. Th e posterolateral drawer
test in volves applyin g a posterolaterally directed force wh ile
the patient is in the sam e position as the posterior drawer
test. Th e dial test is perform ed on a relaxed, pron e patien t.
Th e patien ts kn ees are flexed to 30 an d 90 degrees an d th e
am oun t of extern al rotation of th e feet is determ in ed. Adifference of greater than 10 degrees from the uninjured side
is a positive test. In creased extern al rotation at 30 degrees
of flexion but n ot 90 degrees suggests an isolated PLC in jury, wh ereas in creases at both 30 an d 90 degrees suggest
a com bin ed PLC an d PCL in jury.
Treatment
Treatm en t is gen erally n on operative for isolated PCL in juries. Th is in cludes h in ged bracin g an d physical th erapy to
regain th e ran ge of m otion an d stren gth . Th e n atural h istory
of th e PCL-deficien t kn ee is variable with som e patien ts
functionin g well an d other developing progressive instability. Surgical recon struction is reserved for patien ts wh o fail
nonoperative treatm ent, patients with kn ee dislocations,
or patien ts with grade III in juries with excessive posterior
in stability. Recon struction in volves open or arth roscopic
autograft or allograft ligam en t recon struction . Lon g-term
results h ave n ot approach ed th e success seen followin g ACL
recon struction .
Complications
Complication s in clude kn ee stiffn ess an d recurren t or
ch ron ic in stability. PCL deficien t kn ees are at in creased risk
for patellofem oral and m edial compartm ent degeneration.
Mechanism of Injury
An acute varus stress is responsible for the injury as the
LCLis th e prim ary restrain t of varus m otion about th e kn ee.
With m ultiligam entous kn ee injuries, injury to the LCL can
result from a twistin g m ech an ism of th e kn ee.
Presentation
Th e presen tation is th at of a sign ifican tly traum atized kn ee
with pain , swellin g, an d an in ability to bear weigh t.
Relevant Anatomy
Th e LCL is a distin ct collagen ous structure travelin g from
the lateral epicondyle of the fem ur to attach to th e fibular
h ead. Other structures of im portan ce on th e lateral side
include the arcuate ligam ent complex composed of th e
thicken ing of the posterolateral capsule, the biceps tendon,
the IT band, and the popliteus tendon. The peroneal nerve
courses around the fibular neck an d dives into the anterior
compartm ent as the deep peroneal nerve while sendin g a
bran ch in to th e lateral com partm en t as th e superficial peron eal n erve. Th e n erve is vuln erable durin g in jury to th e
lateral side of the knee. Tears of the LCL are variable but
are typically m idsubstance or off its distal insertion on the
fibular h ead.
Physical Examination
Pain, swelling, ecchym oses, and tenderness over th e lateral
side of th e knee are com m on. Exam ination for associated
n erve in jury is importan t due to th e peron eal n erves proxim ity of the LCL. Ligam ent integrity can be palpated with
the kn ee in the figure-of-four position and tested by applying a varus stress with the kn ee in sligh t flexion. Associated
injury to the PLC is suggested if there is increased external
rotation or posterior tran slation of th e tibia at 30 degrees
of kn ee flexion . Lateral open in g with varus stress in full exten sion suggests addition al in jury to th e ACL an d/ or PCL.
Radiographic Examination
AP and lateral radiographs of the knee should be perform ed to evaluate for avulsion fractures and to rule out
additional fractures or injuries.
Special Tests
MRI can confirm the injury and exclude or include additional ligam entous, m en iscus, or chondral injuries.
725
Differential Diagnosis
Associated ligam entous in juries should be included in the
differen tial diagn osis, especially th e PLC, ACL, PCL, an d
the possibility of knee dislocation.
Treatment
Treatm ent of isolated LCL injuries is usually nonoperative,
with im m obilization with a cast or kn ee im m obilizer for
6 weeks followed by a reh abilitation program . For patients
with associated PLC in juries, early prim ary repair is recom m en ded, as outcom es with prim ary repair are better
than with secondary reconstruction. In patients with varus
m alalignm ent, corrective valgus osteotomy should be considered prior to LCL repair to decrease th e varus stress on
the LCL and decrease th e risk of recurren t instability.
Complications
Complications include knee stiffn ess and recurren t or
ch ronic instability.
NONTRAUMATIC INJURIES
OF THE KNEE
Meniscus Tears
Men iscus tears are one of the m ost com m on problem s seen
in th e knee and account for the m ost com m on indication
for knee arthroscopy. In younger patien ts, they are generally traum atic in origin , whereas they are m ore com m only
degen erative in patien ts older th an 40 or 50 years.
Classification
Men iscus tears are classified by their configuration and
location (Fig. 17.26).
Th e m ain tear con figuration s are as follows:
Mechanism of Injury
Traum a can be respon sible for m eniscus tearing, although
with age, th e fibrocartilagin ous m en isci stiffen , degen erate,
and tear with little traum a. Simple sheer or rotational stress
can be sufficien t to cause a tear.
with permission from Johnson DH and Pedowitz RA: Practical Orthopaedic Sports Medicine and Arthroscopy. Philadelphia: Lippincott Williams & Wilkins, 2006.)
726
Presentation
Acute or insidious on set of pain or achin g m ay herald a tear
of th e m edial or lateral m en iscus. O ccasion ally, in addition
to pain , th ere m ay be a h istory of h avin g h eard a pop at th e
tim e of in jury, usually wh en th e patien t twisted, squatted,
or cam e down on th e leg in an awkward m an n er. In older
patien ts, sym ptom on set is usually related to a low-en ergy
activity, such as steppin g off a curb or gettin g out of a car.
Th ere m ay or m ay n ot be a h istory of swellin g associated
with the pain. Occasionally, there m ay be a history of m ech an ical lockin g in wh ich th e kn ee is tem porarily stuck in
a flexed position .
Relevant Anatomy
Th e m en isci are th e fibrocartilagin ous sem ilun ar-sh aped
disks th at occupy th e m edial an d lateral com partm en ts
of th e kn ee. Th ey provide con gruen cy between th e con vex fem oral con dyles an d th e flat tibial plateau. Th eir
predom in an t fun ction is th at of load distribution with a
secondary contribution to stability, sh ock absorption, an d
cartilage nutrition. The m edial m eniscus is circum ferentially attach ed to th e capsule an d h as little m obility. In
contrast, the lateral m eniscus has no capsular attachm ent
posterolaterally at th e popliteal h iatus, accoun tin g for its
significantly greater m obility. Th e differential in m obility
contributes to the fact that symptom atic m edial m eniscus
tears outn um ber lateral m en iscus tears by an average of 4 to
1. The blood supply to the m en isci com e from the inferior
m edial an d lateral gen iculate arteries. As described earlier,
the peripheral portion of the m eniscus is relatively vascular
an d th e cen tral portion is avascular.
Physical Examination
Th e kn ee exam in ation in cludes an exam in ation for quadriceps atrophy, knee effusion, and restricted ran ge of m otion.
Th e m ost sen sitive fin din g is join t lin e ten dern ess th at reproduces th e patien ts pain . Th e McMurray test, in wh ich
in tern al an d extern al rotation of th e kn ee from full flexion
to 90 degrees of flexion causes a palpable click, is specific
for a m en iscus tear. The palpable click reflects an interm itten tly en trapped an d freed m en iscus fragm en t in th e join t
lin e.
Radiographic Examination
Stan dard views of th e kn ee (weigh t-bearin g AP, lateral, an d
sun rise views) should be taken to evaluated for osteoarth ritis. Th ey are gen erally n egative in th e youn ger population .
In patien ts wh o h ave un dergon e complete m en iscectomy (surgical resection of th e m en iscus), early arth ritis
with Fairbanks classic radiograph ic ch an ges will often be
presen t. Fairban ks ch an ges are join t space n arrowin g, osteophyte form ation , subch on dral sclerosis, an d subch on dral cysts.
Special Tests
MRI is highly sen sitive (90% 95%) and specific (90%
95%) for m en iscus tears. However, as patien ts age, th e likelihood of finding an asymptom atic m eniscus tear on MRI
is relatively high . Therefore, MRI should be utilized in cases
wh en th e diagn osis is un certain to m axim ize th e utility of
the MRI.
Differential Diagnosis
Th e differen tial diagn osis in cludes articular cartilage in jury
(osteoarthritis, chondral, or osteochondral fracture), syn ovial disorders, or ligam en tous in jury.
Treatment
Men iscus tears are often successfully treated with nonoperative treatm en t in cludin g NSAIDs, activity m odification ,
an d a quadriceps-strengthening physical th erapy program .
A large portion of proven m en iscus tears, especially in
older, m ore seden tary patien ts, will im prove with a sign ificant duration of non operative treatm ent (1 2 m on th s). In dication s for surgical treatm en t in clude failed con servative
treatm ent, a locked knee in which the m eniscus is m echan ically blocking knee extension, and m eniscus pathology
diagn osed durin g ligam en t surgery.
Historically, surgical treatm ent in volved openin g the
knee joint (arth rotomy) and rem oving the en tire m eniscus
(m eniscectomy), which predictably led to arthritis in the
involved compartm en t. Currently, with th e developm ent
of kn ee arth roscopy, m en iscus tears are treated with eith er
m en iscus repair or partial m eniscectomy. Efforts are m ade
to preserve as m uch of th e m en iscus as possible to preven t
the developm ent of degenerative arth ritis. Un fortunately,
despite such efforts, m any studies sh ow th at even partial
m en iscectomy can lead to degenerative changes with tim e.
Certain m en iscus tears can be repaired. The gold standard
is an inside-outm eniscus repair, during which sutures are
threaded th rough the m eniscus from inside the knee and
a knot is tied outside of the capsule to secure the repair.
Outside-in and all-inside m eniscal repairs can also be
perform ed. Repairable m en iscus tears are lon gitudin al in
con figuration and in th e peripheral aspect of the m eniscus. The periph eral tears exist in th e vascular portion of th e
m en iscus an d are therefore capable of healing. Only approxim ately 5% of m en iscus tears are repairable. Men iscus
tears th at are repaired at th e sam e tim e as ACL recon struction have the highest success rate of healing. Greater success
h as been attributed to return in g stability to th e kn ee and
the fact th at a hem arth rosis occurs secondary to the ACLrecon struction in the knee. Lateral m eniscus tears occur m ore
com m only with acute ACL tears, whereas m edial m eniscus
tears occur m ore com m on ly in ch ron ically ACL deficien t
knees.
Th e fin al surgical treatm en t for m en iscus tears in patients who rem ain symptom atic after m eniscal rem oval
with out arth ritic in volvem en t is m en iscus replacem en t.
Complications
Th e m ain complication of m en iscus tears is degen erative
arthritis as previously described.
727
Relevant Anatomy
Th e patella fun ction s to effectively len gth en th e lever arm
of th e quadriceps m uscle. In full exten sion , stan din g or
supin e, th e patella lies superior to the troch lear groove. As
th e kn ee is flexed, th e patella begin s articulatin g with th e
trochlear groove, with progressively increasing contact with
knee flexion.
Physical Examination
First, the patien ts overall alignm ent is evaluated. Passive
m alalignm en t is evaluated by notin g th e Q angle. The
Q an gle is th e an gle form ed from a lin e drawn from th e
ASIS to th e patella an d a lin e drawn from th e patella to th e
tibial tubercle (Fig. 17.28). The norm al Q angle is approxim ately 10 degrees an d is slightly greater in wom en. The Q
angle should n ot exceed 15 degrees. As the patient stands
Classification
Th ere is n o specific classification system for patellofem oral
pain syn drom e. Patellofem oral pain syn drom e is a broad
classification that includes m ultiple etiologies includin g
traum a, overuse, instability, and idiopathic causes.
Mechanism of Injury
Most patients with patellofem oral symptom s have underlying patellar m alalignm ent. Abn orm al patella tracking leads
to abn orm al pressure on th e articular cartilage. Alth ough
the articular cartilage is without sensory nerve en dings, the
un derlyin g subch on dral bon e is n ot, an d th e abn orm al
forces from asym m etrical loadin g are perceived as pain.
Rarely is th ere actual structural in jury to th e patella articular
surface, whose thickness of 8 to 10 m m is th e th ickest hyaline cartilage in th e body. When such soften ing does occur,
it is known as chondromalacia. Th e term s chondromalacia and
patellofemoral pain syndrome are not synonym s. Chondrom alacia specifically refers to the condition in which there is
path ologic soften in g of th e cartilage surface.
Presentation
Patients present with vague pain in the front of th e knee,
often bilaterally, an d usually with n o h istory of specific
injury. Pain is exacerbated by activities in which the knee
is flexed, such as rising from a chair, stair clim bing, and
squatting. Descendin g stairs m ay be the m ost painful activity because the stress felt at the patellofem oral joint with
descen din g stairs is 6 tim es th e body weigh t, versus 3 tim es
the body weight with ascending stairs. Un like other m e-
728
Radiographic Examination
Radiograph s sh ould in clude AP an d lateral views of th e
knee an d a view tangen tial to the patellofem oral joint.
A tangential view (sunrise, Merch ant, Laurin) helps evaluate patellofem oral con gruen cy, trackin g, an d arth ritis
(Fig. 17.29).
Special Tests
Th ere are n o special tests n ecessary to con firm th e diagnosis of patellofem oral pain syndrom e. Som e clinician s
have found tangential radiographs at different an gles of
knee flexion helpful to better evaluate the relation ship of
the patella to the trochlear groove. However, such tests are
static and do not take in to account dyn am ic forces of m uscle pull during activity. This lim its th e usefuln ess not only
of radiograph s but also of CT an d MRI.
Differential Diagnosis
In ch ildren , an terior kn ee pain is presum ed h ip path ology
un til proven oth erwise. Wh en ten dern ess is localized to th e
tibial tubercle, th e con dition m ay be Osgood Sch latter syn drom e, a con sequen ce of repetitive traction stresses to th e
vuln erable tibial tubercle apophysis. Local ten dern ess an d
radiographic changes with fragm en tation and en largem ent
of th e tibial tubercle apophysis con firm th e diagn osis. In
eral patella tilt. (Reproduced with permission from Johnson DH, Pedowitz RA. Practical Orthopaedic Sports Medicine and Arthroscopy.
Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
Treatment
It is importan t to rem em ber th at m ost patien ts with
patellofem oral pain syn drom e h ave n o actual articular cartilage dam age. The m ainstay of treatm ent is to identify an d
correct m alalignm ent or m altracking. Physical therapy em ph asizes quadriceps-stren gth en in g, specifically th e VMO ,
through short-arc quadriceps exercises. Som e patients benefit from McCon n ell tapin g of th e patella in to a corrected
tracking position .
Surgical treatm en t is reserved for patien ts wh o are un respon sive to con servative treatm en t, h ave a suspected articular cartilage lesion, or have significant m alalignm en t.
Surgical treatm en t in volves appropriate treatm en t of th e articular cartilage lesion an d treatm en t of the m alalignm ent
as detailed in the patella instability section of this ch apter.
An arthroscopy is perform ed to evaluate the articular surface. If an articular lesion is presen t, th e patien t is treated
with ch on droplasty, m icrofracture, or possibly ACI. Th en
the m alalignm en t is addressed. If the patient has a positive
patella tilt test an d arth roscopically th e patella is tilted in
the trochlear groove, a lateral release of the lateral retinaculum can be perform ed. Th e lateral release weaken s th e
lateral constraints of the patella to decrease the am ount
of lateral m altrackin g. If th e patien t h as a large Q an gle, a
distal realign m en t procedure can be perform ed. Th e m ost
Complications
Complications include recurrent pain, patellar instability,
nonunion, and patellofem oral arth ritis.
IT Band Syndrome
IT ban d syn drom e is an overuse in jury of th e lateral kn ee.
It is also called cyclists or runners knee.
Presentation
Th e patien t will presen t with pain alon g th e lateral kn ee
that usually relates to run ning or cycling. Symptom s are
often preceded by a ch an ge in train in g regim en , such as an
increase in m ileage, intensity, terrain surface, or chan ged
sh oe wear.
Mechanism of Injury
IT ban d syn drom e is a friction syn drom e over th e lateral
part of th e leg. Repetitive m otion of th e ten se IT ban d over
the lateral epicondyle is though t to cause a bursitis between
the tendon and th e lateral epicondyle.
Relevant Anatomy
Th e ITban d origin ates on th e gluteus m axim us as th e ten sor
fascia lata an d in serts at Gerdy tubercle on th e an terolateral
aspect of the tibia. As it travels to th e knee, it runs over the
greater troch an ter of th e h ip an d th e lateral epicon dyle of
the fem ur. A friction syndrom e involving th e IT band can
develop at th e greater troch an ter as troch an teric bursitis,
the fem oral epicondyle, or Gerdy tubercle. Fem ale patients
have a wider pelvis and greater valgus alignm ent of th eir
knees, wh ich predispose them to IT band syndrom e.
Physical Examination
Th e patien t will h ave focal ten dern ess over th e lateral epicon dyle. Occasionally, th e Ober test will be positive. The
Ober test is perform ed by lying the patien t laterally on
the un involved side. Then the h ip is adducted and the knee
is flexed 90 degrees; the hip is then gently extended, abducted, an d th e kn ee is exten ded. Tigh tn ess an d irritation
over th e IT ban d will result in pain , wh ich is a positive Ober
test.
729
Differential Diagnosis
Th e differen tial diagn osis for lateral kn ee pain in cludes lateral m en iscus tear, LCL sprain , lateral com partm en t arth ritis, proxim al tibiofibular joint pathology, peroneal n erve
path ology, or IT ban d syn drom e.
Treatment
Treatm ent is nonoperative for th e vast m ajority of patients
and in cludes activity m odification, NSAIDs, and physical
th erapy to in clude a th orough stretch in g program of th e
IT ban d, h am strin gs, an d glutei. A compression strap worn
above th e lateral epicon dyle during activity m ay improve
sym ptom s. Most patien ts are able to return to their previous
level of activity. Rarely, corticosteroid injection s or surgical
release are n eeded.
Osteochondritis Dissecans
Alth ough ch on dral or osteoch on dral in juries can be caused
by acute traum a, a m ore com m on cause is O CD. In this
con dition , a portion of th e n orm al articular cartilage is
dissected away from its un derlyin g subch on dral bed. Th e
m ost com m on location in the kn ee is the lateral aspect of
th e m edial fem oral con dyle, in m ore th an 80% of cases.
Classification
Osteoch ondral injuries have been classified on the basis of
th e fragm en ts relation sh ip to th e bon e from wh ich it arises.
Agrade I lesion is in com plete with out actual complete fracture line extending from the underlyin g subchondral bone
into the joint. In a grade II lesion , there is a complete fracture line exten ding from the subch ondral bone to the joint,
but th e fragm en t is still with in th e bed an d m in im ally displaced. In a grade III lesion , th e fragm en t is loose with a
fracture plane around the lesion, which loosely lies in its
bed. In a grade IV lesion , th e fragm en t h as becom e detach ed an d is free with in th e join t.
Mechanism of Injury
Th is con dition h as been attributed to a vascular in sult of
th e growin g epiphysis of skeletally im m ature patien ts. Th e
con dition is m ost frequen tly seen in th e lateral aspect of th e
m edial fem oral con dyle of th e knee; however, it has been
described in th e elbow on th e capitellum an d th e an kle on
th e talus.
Radiographic Examination
Stan dard radiograph ic views of th e kn ee are n egative.
Presentation
Th e m ost com m on presen tation is th at of an adolescen t
or youn g adult with kn ee join t sym ptom s of in term itten t
pain , swellin g, or catch in g related to kn ee activities.
Special Tests
Rarely, an MRI is obtain ed an d can sh ow in creased sign al
at Gerdy tubercle or the lateral epicondyle.
Physical Examination
Physical fin din gs are usually n on specific, an d th e diagn osis
is afforded by im aging studies.
730
Baker cyst
Described by Baker in the late 1800s, this condition
is a well-known accompan im en t of several knee disorders. Rath er th an a discrete en tity, it is actually a n orm al
an atom ic structure that becom es prom inent in response to
knee path ology.
Presentation
Most Baker cysts com e to the physicians attention when
discovered by MRI. Occasion ally, th e patien t will n ote a
prom in en ce in th e popliteal area. Less com m on ly, patien ts
m ay presen t with acute pain and swelling in their proxim al calf as a consequence of cyst rupture, with spillin g of
the synovial contents in to the posterior compartm ents of
the leg.
signal behind osteochondral fragment, indicating an unstable fragment. (Reproduced with permission from El Attrache NS, Harner
CD, Mirzayan R, Sekiya JK: Surgical Techniques in Sports Medicine.
Philadelphia: Lippincott Williams & Wilkins, 2006.)
Radiographic Examination
Stan dard radiograph s of th e kn ee sh ow a localized area of
radiolucen cy (decreased density) in the area of th e OCD.
O ften , th e osteoch on dral fragm en t is sclerotic (in creasin gly
den se) an d m ay be partially or com pletely detach ed from
its un derlyin g bed.
Special Tests
MRI is useful to localize th e lesion an d determ in e its size
an d stability. Un stable lesion s h ave fluid beh in d th e lesion
that can be seen on T2-weighted MRI im ages (Fig. 17.30).
Treatment
Treatm en t varies accordin g to th e lesion s size, location ,
stage, an d the patients age. In skeletally im m ature patien ts, n on displaced osteoch on dral fragm en ts are th ough t
to h ave h ealin g poten tial with im m obilization . Con versely,
in older adolescen ts or youn g adults, particularly wh en
there is evidence of fragm ent displacem ent, definitive treatm en t in volves debridem en t an d, if possible, fixation of
the fragm ent with h eadless screws. A num ber of strategies
have been devised for treating the defect left behind followin g debridem en t of an OCD. Th ese in clude m icrofracture,
OATS, an d ACI, as discussed previously in th e patellar in stability section of this ch apter.
Complications
Th e m ajor complication is th e developm en t of degen erative
arth ritis in th e in volved compartm en t.
Relevant Anatomy
Th is structure is a n orm al bursa of th e sem im em bran osus
an d is present in an estim ated 35% to 50% of patients.
Syn ovial fluid gen erated with in th e kn ee in respon se to
m en iscal, ch ondral, or synovial path ology can lead to bursa
disten tion due to direct com m un ication with th e join t.
Physical Examination
Baker cysts are alm ost always located posterom edially in
the kn ee. Usually, there is an indistinct area of tenderness
in the popliteal fossa.
Radiographic Examination
Radiograph s are usually n egative, alth ough occasion ally
osteoch on dral fragm en ts can be seen posterom edially.
Special Tests
Special test are un n ecessary in patien ts with a typical h istory. Im agin g by MRI dem on strates th e cyst an d oth er in traarticular pathology and is the diagnostic test of choice.
Aspiration of the m ass yields golden-yellow viscous synovial fluid. Its viscosity m an dates th e use of a large-bore
n eedle, such as an 18-gauge, to en sure successful aspiration.
Differential Diagnosis
Th e presen ce of a n eoplasm m ust be con sidered in th e patient presenting with fullness or a palpable m ass in the
popliteal fossa. Im agin g is alm ost always con ducted to rule
out th is possibility. In th e patien t with acute pain an d
swellin g of the proxim al calf, consideration m ust be given
to a deep vein th rom bosis. Men iscal cysts are differen tiated
in th eir size and location. They are very discrete grape-like
structures th at occur directly along the joint line and are
m ost com m only associated with m eniscus tears.
Treatment
Baker cysts are often diagn osed as an in ciden tal finding
on MRI perform ed for kn ee symptom s. Most cysts will
resolve on defin itive treatm en t of th e in traarticular path ology, such as partial m en iscectom y. Occasion ally, th e cyst
itself produces symptom s due to its size. Aspiration, followed by corticosteroid injection, is an alternative but, if
un successful, surgical excision is often curative
Classification
Fractures are described by fracture pattern type: tran sverse,
spiral, oblique, an d com m inuted; th e location: proxim al,
m iddle, and distal; and the type an d degree of displacem en t. The presence of associated soft tissue injuries are also
ch aracterized according to the Gustilo and An derson classification of open fractures. Grade I fractures are clean, with
a wound less th an 1 cm . Grade II fractures have m ore extensive soft tissue dam age and a wound generally greater th an
1 cm and less than 10 cm . Grade IIIA fractures are complex
fracture patterns or crush in juries with extensive soft tissue
dam age. Grade IIIB are exten sive in juries with periosteal
stripping requiring soft tissue flap coverage. Grade IIIC are
fractures with associated vascular injuries requiring repair.
Mechanism of Injury
Th ere are th ree com m on m ech an ism s of in jury. Direct
traum a can be from high-en ergy injury, such as a m otor
veh icle accident, or a low-energy direct blow, such as during a sportin g event. In direct traum a can occur when the
foot is fixed and the leg is torqued, as can occur in sporting events or a fall from a short height. Finally, fractures
can occur as a result of penetrating injury such as gunsh ot
woun ds.
Presentation
Patients present with acute leg pain accompanied with deform ity and swelling followin g a traum atic in jury.
Relevant Anatomy
Th e tibia an d fibula are lon g bon es, with th e tibia dem on stratin g a triangular sh ape when viewed in axial cross section. Its an terior border is rather sharp, subcutaneous, and
quite vuln erable to traum a. Th e fibula is join ed proxim ally to the posterolateral proxim al tibia at the proxim al tibiofibular join t. Distally, the fibula articulates with
the distal tibia laterally at the ankle m ortise. Four distinct
compartm ents contain the soft tissue an d neurovascular
components of the leg and include the anterior, lateral,
superficial posterior, and deep posterior com partm ents
(Fig. 17.11). The blood supply is alm ost entirely from th e
731
Physical Examination
Physical exam in ation sh ould focus on close in spection to
rule out open fracture. In addition, a thorough secon dary
survey sh ould be perform ed to rule out associated injury.
Compartm ent syndrom e is a consideration with all tibia
fractures with pain severe with passive dorsiflexion or th e
foot or toes one of the earliest physical findings.
Radiographic Examination
Radiograph s sh ould in clude AP an d lateral views of th e full
length of th e tibia and fibula; AP and lateral views of the
knee; and AP, lateral, and m ortise views of the ankle.
Special Tests
Further radiographs are obtained depending on the clinical
suspicion of associated injuries. If the fracture line extends
into the knee or ankle join ts, CTscans of these join ts should
be con sidered. Doppler evaluation an d an klebrach ial in dices sh ould be used to evaluate vascular status in th e setting of a possible injury. An arteriogram is the definitive
test for suspected vascular in jury.
Differential Diagnosis
Th ere is little in th e differen tial diagn osis; h owever, correct
and prompt diagn osis of associated neurovascular injury
includin g compartm ent syndrom e should be m ade. A high
index of suspicion for the developm ent of compartm ent
syn drom e sh ould be m aintained before and after defin itive
treatm ent of these fractures.
Compartm ent syndrom e is a clinical diagnosis based on
ten dern ess with passive stretch of th e in volved compartm ent, pain out of proportion to exam in ation, and a tense
com partm en t. If th e diagn osis is question ed, th e com partm ent pressure can be directly m easured. This is obtain ed
with a h an d-h eld m on om eter or arterial lin e th at is placed
directly in to th e compartm en t. Com partm en t syn drom e is
a cyclic process started wh en th e compartm en t pressure
exceeds th e ven ous outflow pressure of th e com partm en t.
Th is results in ven ous stasis, resultan t in creased pressure
and eventual isch em ia. Interven tion needs to occur before the process starts so the cutoff of the compartm ent
pressure above wh ich a fasciotom y sh ould be preform ed is
30 m m Hg or with in 30 m m Hg of ven ous pressure. Th e
treatm ent for compartm ent syndrom e is fasciotomy.
732
Treatment
Treatm en t depen ds on th e type of fracture. For closed
fractures, nonoperative treatm ent is often acceptable, with
closed reduction an d long leg cast application. General
guidelin es for acceptable reduction in clude less th an 5 degrees of varus an d valgus an gulation , less th an 10 degrees
of rotation al deform ity, less th an 1 cm of sh orten in g, less
than 5 m m of distraction, and m ore than 50% cortical contact. Wh en treated n on operatively, a lon g leg cast is placed
with initial n on weigh t-bearin g tran sition in g to progressive weigh t-bearing as the fracture begin s to heal. Healin g
averages 16 weeks and th e risk of displacem en t warrants
frequent follow-up evaluation to ensure m aintenance of reduction . Closed treatm en t is m ost effective for low-en ergy
fractures with little displacem ent, with healing rates as high
as 97%.
Un stable fractures, th ose in wh ich reduction cann ot be
ach ieved or m ain tain ed, are usually can didates for IM n ail
fixation . Plates an d screws can be utilized for proxim al or
distal fractures an d in traarticular fractures. Th e IM n ail h as
becom e th e stan dard of care for extraarticular m idsh aft
tibia fractures. Th e IM n ail allows for im m ediate weigh tbearin g, low n on un ion rates, an d low in fection rates.
O pen fractures m ust be treated with atten tion to woun d
m an agem en t an d fracture stability. An tibiotics sh ould be
in stituted im m ediately in th e em ergen cy departm en t alon g
with tetanus prophylaxis. Open wounds sh ould be sterilely
covered, splinted, and treated as a surgical em ergency with
prom pt surgical irrigation an d debridem en t an d fracture
fixation . Repeat debridem en t an d flap coverage or vascular
repair m ay be required. Th e option s for fracture fixation in clude IM n ails or external fixation devices. For grade I and
som e grade II fractures, an IM nail can often be placed at th e
tim e of th e in itial debridem en t. For h igh er grade in juries,
an extern al fixator is applied un til th e woun d is stable an d
then the external fixation device is often rem oved and an
IM n ail is placed for defin itive fracture treatm en t. Con version from an extern al fixator to a nail is perform ed only
within the first 3 weeks to decrease the risk of spreading
osteomyelitis to th e tibial can al from in fection aroun d th e
extern al fixator pin s.
Complications
Complication s are n um erous, th e m ost com m on complication s are soft tissue related, in cludin g in fection . Oth er com plication s in clude delayed un ion , n on un ion , m alun ion ,
knee or ankle stiffness, throm boem bolic disease, compartm en t syn drom e, an d lim b loss.
Mechanism of Injury
A stress fracture occurs wh en repetitive loads exceedin g the
rem odelin g capability of th e in volved bon e are applied.
Cyclic loading above the level of norm al bone rem odeling causes osteoclastic to exceed osteoblastic activity. This
results in weaken in g of th e bon e an d fracture.
Presentation
Tibial stress fractures are con sidered overuse in juries. Th ey
are m ost com m only seen with rapid increases in frequency,
duration , or in ten sity of ath letic activity. Pain is th e m ost
com m on symptom associated with tibia stress fractures. It
is generally located in the anterior leg at the m idaspect of
the tibia. Pain is worse with activity such as jumping.
Relevant Anatomy
Th e tibia h as a n orm al bow th at h as its aspect alon g th e an terior m idsh aft. Th e m ost com m on location for tibia sh aft
fractures is the anterior m idshaft of the tibia. As a result
of th e an terior tibia bow th e an terior aspect of th e tibia is
un der ten sile load an d th e posterior aspect of th e tibia is
un der com pressive load.
Physical Examination
Physical exam in ation reveals a poin t ten der area alon g th e
an terior m idsh aft of the tibia. Th ere m ay be an irregular thickening palpable at the tender aspect of the anterior tibia. In addition , axial compression to th e tibia
exacerbates th e pain .
Radiographic Examination
AP and lateral radiograph s of the tibia m ay reveal signs of a
stress fracture. Cortical hypertrophy m ay be present at th e
stress fracture. In addition a dreaded black linecan occur
in the cortex. This is an infraction line th at is con sidered
the sign of an impen ding fracture (Fig. 17.31).
Special Tests
Radiograph s can be n egative for as lon g as 3 weeks after
the onset of symptom s. If radiographs are n egative, MRI
or bon e scan can be perform ed. In creased T2 in ten sity on
MRI or increased uptake on bone scan are the signs of stress
fracture.
Differential Diagnosis
Th e differen tial diagn osis is m edial tibial stress syn drom e
an d exertional compartm ent syndrom e. This can generally
be distin guish ed from tibial stress fracture by h istory an d
physical exam in ation .
733
A,B
Treatment
Most tibial stress fractures improve with activity m odification by avoiding impact loading activities for 4 to 8 weeks.
Th is is ach ieved with crutch es an d with or with out casting. Tibial stress fractures can result in nonunion because
of th eir location on th e ten sile aspect of th e tibia, wh ich results in fracture distraction and the relative hypovascularity
of th e tibia. A difficult tibial stress fracture can be treated
with an extern al bon e stim ulator an d a patella ten don bearing cast. If the patient continues to be symptom atic after 4
to 6 m on th s of n on operative treatm en t, th en surgical treatm en t with an IM rod is indicated.
Complications
Complications of tibial stress fractures include non union
an d overt fracture of the m idshaft of the tibia.
C,D
Presentation
Th e presen tation is in dicative of its n am e. Pain over th e sh in
and posterom edial tibia occurs, usually as a consequence of
run n ing, often on h ard, flat terrain. Discom fort is usually
durin g activity, but with con tin ued run n in g, it can lead to
pain even with walkin g.
Relevant Anatomy
Medial tibial stress syndrom e occurs over the posterior m id
to distal th ird of the tibia.
Physical Examination
Diffuse ten dern ess to palpation is usually presen t over th e
posterom edial m id to distal th ird of th e tibia.
Radiographic Examination
Radiograph s are n egative.
Mechanism of Injury
Th e path ophysiology of th is con dition is n ot well un derstood. Historically, this con dition was th ough t to be a consequen ce of one of several entities, in cluding periostitis,
posterior tibial ten don itis, soleus ten don itis, or early stress
reaction in th e bon e. Th ere is n o absolute con sen sus on
the etiology of this condition, although there is wide agree-
Special Tests
An um ber of special tests have been described, in cluding injection in to adjacen t soft tissue with local an esth etic. However, relief does n ot com pletely con firm th e diagn osis or
defin itively exclude th e possibility of a stress fracture. Bon e
scan s dem onstrate diffuse uptake of the tracer along the
distal th ird of th e tibia.
734
Differential Diagnosis
Th e m ain differen tial to con sider is th at of a tibial stress
fracture, which is well dem onstrated on the bone scan as
a focal hot spot in comparison with the m ore diffuse dye
take-up in tibial stress syn drom e.
Treatment
Defin itive treatm en t is rest. Usually, activity m odification
results in n ear-im m ediate improvem en t. Wh en ath letes can
return to th eir run n in g depen ds upon th e severity, in ten sity, duration , and goals of individual patients. Ice m assage
several tim es a day over the painful area com bin ed with
the use of NSAIDs can improve symptom s. Som e studies
have suggested that the use of arch supports m ay help th ose
with m arked pronation. Heel cord stretch ing m ay also be
useful in som e patien ts. Cross-train in g to m ain tain con dition in g th rough swim m in g, cyclin g, an d even run n in g with
a weighted vest in a pool are en couraged until th e condition
resolves. Importan tly, preven tion of th is con dition is possible th rough correctin g any iden tified train in g errors such as
excessive m ileage, h ard surfaces, an d in adequate sh oe wear.
Mechanism of Injury
Exertion al compartm ent syndrom e occurs as a consequen ce of progressive in creased compartm en tal pressure
due to activity, m ost com m on ly occurrin g in th e leg wh ile
run ning. Progressive m uscle hypertrophy and swellin g durin g activity comprom ises th e n orm al blood supply, leadin g
to poten tial isch em ia an d pain .
Presentation
Unlike stress reactions or shin splints, where pain is bearable an d th e patien t can con tin ue run n in g with th e pain ,
pain with exertion al com partm en t syn drom e is severe
en ough to force th e ath lete to stop run n in g. Un like stress
reaction s or fractures, th e symptom s promptly van ish after
cessation of activity.
Physical Examination
Physical exam in ation is un rem arkable. Th ere is n o particular focal ten dern ess or n eurologic abn orm ality.
Radiographic Examination
Radiograph s are n egative.
Special Tests
Th e diagn osis of exertion al compartm en t syn drom e is
establish ed by com partm en t pressure m easurem en ts at
rest an d followin g activity. Usin g a sm all n eedle attach ed
to a pressure m an om eter setup, each of th e four com partm en ts are m easured in both th e legs an d recorded.
Th e ath lete run s on a treadm ill un til symptom atic an d
then compartm ent pressures are m easured again and com pared to preexercise levels. Th e exact criteria n ecessary for
diagn osin g compartm en t syn drom e are som ewh at variable, but in general, pressure m easurem en ts in excess of
15 m m Hg at rest or m ore th an 20 m m Hg 5 to 15 m inutes postexercise are suggestive of exertion al com partm en t
syn drom e.
Differential Diagnosis
In th e patien t with equivocal in tracompartm en tal pressure
readin gs an d th e presen ce of bon e ten dern ess, m edial tibial
stress syn drom e is a m ore likely diagnosis.
Treatment
Ath letes can either m odify th eir activity (i.e., give up
run n in g) or h ave the affected compartm ent(s) surgically
decom pressed. Th is surgical procedure in volves a sm all
incision over th e affected compartm ent, followed by an
incision of the surrounding fascial envelope. Th e outcom e
is predictably good.
Complications
Th e m ajor risks with compartm en t release are superficial
peron eal n erve in jury an d in adequate release.
RECOMMENDED READINGS
Albert MJ. Supracondylar fractures of the fem ur. JAm Acad Orthop Surg.
1997;5:163 171.
Berkson EM, Virkus WW. High -energy tibial plateau fractures. J Am
Acad Orthop Surg. 2006;14:20 31.
Brown e JE, Bran ch TP. Surgical alternatives for treatm en t of articular
cartilage lesion s. J Am Acad Orthop Surg. 2000;8:180 189.
Greis PE, Bardana DD, Holm strom MC, et al. Meniscus injury, I:
basic science and evaluation . J Am Acad Orthop Surg. 2002;10:168
176.
Greis PE, Holm strom MC, Bardana DD, et al. Men iscus injury, II: m anagem ent. J Am Acad Orthop Surg. 2002;10:177 187.
Pell RF IV, Khanuja HS, Cooley GR. Leg pain in th e run n in g ath lete.
J Am Acad Orthop Surg. 2004;12:396 404.
Post WR. An terior knee pain: diagn osis an d treatm en t. J Am Acad
Orthop Surg. 2005;13:534 543.
Rih n JA, Ch a PS, Groff YJ, et al. Th e acutely dislocated kn ee: evaluation and m anagem ent. J Am Acad Orthop Surg. 2004;12:334
346.
Knee Arthroplasty
John A. Johansen
18
Brian G. Evans
INTRODUCTION
Osteoarthritis (OA) of the knee is a degenerative condition
that affects a large n um ber of people during the aging process and is by far th e m ost com m on cause of kn ee pain in
those older than 50 years. Pain tends to be progressive and
is often debilitatin g, th us leading to a sign ifican t decline in
the quality of life in these individuals. Wh ile there are m any
nonoperative treatm ent options and joint-sparing procedures available for th e m an agem en t of early OA, th e gold
stan dard for treatm ent of end-stage OA is total knee arth roplasty (TKA). Curren tly, th ere are approxim ately 200,000
total kn ee replacem en ts don e in th e Un ited States an n ually,
an d this num ber can be expected to increase substantially
as the population ages. This chapter will serve as a com preh en sive review of th e diagn osis an d treatm en t of OA of
the knee and th e expected outcom es and complications of
TKA.
ANATOMY
Th e osseous an atomy of th e kn ee con sists of th e proxim al tibia, distal fem ur, and the patella, which com bin e to
form three compartm ents in the knee: m edial, lateral, an d
patellofem oral. (Fig. 18.1)
Th e m edial compartm en t of th e kn ee is form ed by th e
articulation between the m edial fem oral condyle and the
m edial tibial plateau, wh ereas the lateral compartm en t is
form ed by the lateral fem oral condyle and the lateral tibial
plateau. Th e m edial an d lateral m en isci are attach ed to th e
proxim al tibia in th e respective com partm en ts an d fun ction m ainly to increase the surface area for weigh t-bearing
(Fig. 18.2). By decreasing the stress transm itted to the articular surface on both the distal fem ur an d proxim al tibia,
these m enisci help preserve the joint surface. Biom echan ical studies h ave indicated th at there is approxim ately a
300% in crease in con tact pressures on th e articular cartilage following m eniscal rem oval.
Th e patellofem oral compartm en t is form ed by th e articulation between th e troch lea, wh ich is located on th e
an terior aspect of th e distal fem ur, an d th e patella. Th e
patella is a sesam oid bon e located with in th e ten don of
the quadriceps m echanism and is composed of m edial and
lateral facets. Th e lateral facet is typically broader, wh ereas
the m edial facet is m ore acutely oriented in relation to the
troch lea (Fig. 18.3). Th e un dersurface of the patella contain s th e th ickest layer of articular cartilage in th e h um an
body. Th e troch lear groove is located between th e con dyles
an teriorly on th e distal fem ur an d h as both a m edial an d
a lateral rim . The lateral rim is frequently m ore prom in ent,
allowin g for proper patellar trackin g with flexion an d exten sion of th e kn ee.
BIOMECHANICS
Th e m ech an ical axis of th e lower extrem ity exten ds from
th e cen ter of rotation of th e h ip to th e cen ter of th e an kle joint an d norm ally crosses the knee joint in the lateral
th ird of th e m edial tibial plateau. However, th e an atom ic
axis is in 5 to 7 degrees of valgus, as the fem oral shaft exten ds m ore laterally th an th e cen ter of th e fem oral h ead
(Fig. 18.4). Wh en th e kn ee is loaded, the m edial compartm ent experiences 60% of the weight-bearin g stress, whereas
th e lateral compartm en t experien ces 40%. Th is differen ce
in the applied load in the n orm al knee is th e reason the
m edial tibial plateau an d the m edial fem oral con dyle are
larger th an the lateral side. Patien ts with sign ificant an gular
deform ity in th e kn ee h ave altered weigh t-bearin g, wh ich
results in in creased stress in th e m edial (with varus or bowlegged deform ity) or lateral (with valgus or knock-knee
deform ity) compartm en t. Th e in creased stress frequen tly
results in early arth ritis in th e affected compartm en t.
Th e h igh est join t forces, h owever, are foun d in th e
patellofem oral articulation , as forces up to 5 to 8 tim es body
weigh t can be n oted for activities such as stair clim bin g an d
jumpin g. Th e fun ction of th e patella is predom in an tly to
736
Lateral
collateral
ligament
Ant. cruciate
ligament
Post. cruciate
ligament
Medial collateral
ligament
Medial meniscus
Lateral
meniscus
Figure 18.1 Diagram of the knee joint with the patella and cap-
sule removed. The medial compartment contains the medial meniscus, the lateral compartment contains the lateral meniscus, and the
patellofemoral compartment is anterior to the distal femur. (Reproduced with permission from Koopman WJ, Moreland LW. Arthritis and Allied Conditions: A Textbook of Rheumatology. 15th ed.
Philadelphia, PA: Lippincott Williams & Wilkins, 2005.)
Figure 18.3 Bilateral axial views of the patella. Note the broad
to 15% of people older th an 60 years. Th is tran slates to approxim ately 26 m illion people in th e Un ited States alon e,
with m ore th an 200,000 total kn ee replacem en ts bein g perform ed annually in this country and m ore than 500,000
worldwide. OA causes a substan tial physical burden on th e
population as approxim ately 80% of th ese patien ts h ave
som e degree of m ovem ent lim itation, with up to 25% having difficulty perform ing routine daily activities. It also
leads to significant reduction in job productivity with reports in dicatin g th at patien ts with kn ee arth ritis m issed up
to 2 weeks per year of work because of th eir con dition . Th e
econ om ic burden of th e disease is also quite rem arkable.
Wh en in cludin g OA of all join ts, it is estim ated th at th e
cost in the Un ited States is $60 billion per year, whereas
job productivity lost costs anywh ere from $3 billion to
$10 billion . In fact, OA is secon d on ly to isch em ic h eart
disease as a cause of work disability.
Risk Factors
OA OF THE KNEE
OA, or degen erative join t disease, of th e kn ee is an extrem ely com m on con dition th at affects approxim ately 10%
superimposed medial and lateral menisci. (Reproduced with permission from Chapman MW,
Szabo RM, Marder R, et al. Chapmans Orthopaedic Surgery. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2001.)
Figure 18.4 Mechanical and anatomic axes of the knee. The me-
chanical axis goes from the center of the femoral head to the center of the ankle. The anatomic axis is along the femoral and tibial
shafts and forms approximately a 7-degree angle to the mechanical
axis. (Reproduced with permission from Chapman MW, Szabo RM,
Marder R, et al. Chapmans Orthopaedic Surgery. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2001.)
737
Pathophysiology
Kn ee OA is felt to occur because of repetitive stresses placed
on th e join t over tim e, wh ich gradually leads to a breakdown of th e articular cartilage. Th is process begin s as a
sim ple softenin g of th e chondral surface and is followed
by fraying, which will eventually lead to enough articular cartilage destruction to expose the subchondral bone.
Once the subchon dral bone is directly experiencing the
weigh t-bearin g stresses, m icrofractures begin to appear in
738
its surface, wh ich in turn lead to th e developm en t of subch on dral cysts. Th in n in g of th e cartilage also m an ifests itself as a narrowing of the joint space, which in turn leads
to a subtle degree of in stability in th e kn ee. Th e bon es response to this phenom enon is to form osteophytes, which
are simply areas of reactive bon e form ation th at act to stabilize th e join t. Th e clin ical effect of ch on dral wear is th e
developm en t of pain in addition to possible m alalign m en t
an d loss of m otion . Malalign m en t is th e result of asym m etric wear, m ost com m on ly in th e m edial compartm en t,
thus causing a varus deform ity, whereas m otion loss results
from capsular contracture, which typically occurs posterior
an d appears clin ically as a loss of term in al exten sion .
PATIENT EVALUATION
Clinical Presentation/History
Patien ts with OA can present in a variety of ways, but m ost
com m only, they complain of kn ee pain that has been insidious in onset, often over th e course of m any years. Frequen tly, th is is associated with stiffn ess an d in term itten t
swelling of the knee th at is typically worse with activity
an d relieved with rest. Patien ts will also com m on ly state
that they have been getting progressively m ore bowlegged
over th e course of tim e.
When a youn ger patien t presen ts with com plain ts th at
seem consistent with degenerative knee pain, it is also im portan t to take a th orough h istory to determ in e th e probable cause. First, th e physician sh ould con sider poten tial
sources of referred pain, wh ich can in clude either th e lum bar spin e or th e h ip. Lum bar disc disease can frequen tly
cause radicular symptom s that m an ifest as knee pain, while
hip pathology can also be referred to the kn ee along th e
course of the obturator n erve. A history of injuries or surgeries on th e kn ee, such as in traarticular fractures, ligam en tous or m en iscal tears, or prior kn ee surgery, is importan t
as th ese are poten tial risk factors. As previously m en tion ed,
gen etics also plays a prom in en t role in th e developm en t of
OA, so fam ily h istory of early-on set arth ritis sh ould be determ in ed. On e sh ould also take a complete m edical h istory
as oth er con dition s such as gout, rh eum atic diseases, recen t
in fection , an d h em oph ilia can cause kn ee pain an d lead to
arth ritic ch an ges.
Physical Examination
Th e physical exam in ation sh ould always begin with in spection , an d th ere are several im portan t th in gs to look for in
the degenerative kn ee. First, the static longitudinal alignm en t of th e lower extrem ity sh ould be observed in th e
standing patien t. Th e norm al alignm en t of the lower extrem ity is approxim ately 5 to 7 degrees of valgus, an d degen erative ch an ges can cause eith er varus or valgus m alalign m en t, with varus m alalign m en t bein g m ore com m on
Figure 18.5 This patient is seen to have significant varus alignment of the left lower extremity when observed in the standing position. (Reproduced with permission from Chapman MW, Szabo RM,
Marder R, et al. Chapmans Orthopaedic Surgery. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2001.)
(Fig 18.5). The exam iner should also observe the patients
gait, which is frequently seen to be antalgic, m eaning that
there is a shortened stance phase on the affected extrem ity.
A lateral th rust is also com m on ly seen due to th e attenuation of the lateral collateral ligam ent (LCL). This typically
occurs in patien ts with a lon g-stan din g varus deform ity
of th e kn ee (Fig. 18.6). Medial th rusts can also be seen
with valgus deform ity but are m uch less com m on in th e
osteoarth ritic patien t.
Palpation will often reveal the presence of an effusion,
wh ich is presen t durin g an exacerbation , or an arth ritic
flare.Medial an d lateral joint line ten derness is com m only
presen t, with m edial ten dern ess bein g m ore often associated with varus deform ity. Range of m otion should also
be assessed an d is frequen tly lim ited. A flexion con tracture
(loss of passive extension) is seen early, an d as th e con dition progresses, a loss of flexion is also appreciated. During
the range of m otion, patellofem oral crepitus is com m only
observed.
Imaging
Plain radiograph s are th e on ly im agin g study n ecessary
for the diagn osis of OA, with the classic findings being joint space narrowing, osteophyte form ation, subch ondral cysts, and subch ondral sclerosis (Fig. 18.7). The
739
evaluation sh ould start with a weigh t-bearin g an teroposterior (AP), lateral, an d sun rise view of th e kn ee. Th e
n eed for weigh t-bearin g radiograph s can n ot be overem ph asized, as th ey m ore accurately sh ow th e con dition of
th e join t wh en placed un der a load. It is n ot un com m on for significant varus align m ent and m edial join t space
n arrowin g to be m issed on n on weigh t-bearin g radiographs (Fig. 18.8). Lateral views show both the tibiofem oral
and patellofem oral joints, whereas the sun rise view m ore
th orough ly im ages th e patellofem oral join t. O ften with
early arth ritis th e weigh t-bearin g AP view will fail to sh ow
any sign ifican t changes as th is loads only the anterior and
m iddle weight-bearing portions of the tibial fem oral joint.
A 30- to 45-degree weight-bearing posteroanterior flexion
view can be used to m ore accurately assess the m iddle and
posterior aspects of th e fem oral con dyles. Th is study will
frequently sh ow a m ore significant arthritis th an what was
visualized on the stan dard AP view (Fig. 18.9).
Figure 18.6 A lateral thrust is seen in the stance phase of gait
Differential Diagnosis
Th e differen tial diagn osis for OA in cludes oth er con dition s
th at can lead to kn ee pain an d swellin g. Th ese in clude in flam m atory arth ritis, crystallin e arth ropathy, septic arthritis, and osteonecrosis.
Th e m ain con dition s to con sider are th e in flam m atory
arth ritides, the m ost com m on of which is rheum atoid
arth ritis. However, oth er con ditions include lupus, ankylosing spondylitis, Reiters syn drom e, psoriatic arthritis,
and arthritis associated with inflam m atory bowel disease.
Th ese con dition s can all presen t sim ilarly with an in sidious on set an d lon g duration of kn ee pain . However, th ere
are several important differences. First, m any of these patients will have involvem ent of m ultiple joints, and they
classically h ave pain th at is worse with rest an d relieved by
activity. Bilateral knee involvem ent can certainly be seen
with OA, but it is n orm al in th ose with rh eum atoid disease. O n e m ust also be cogn izan t of th e review of system s,
as inflam m atory arthritis can be associated with conditions
involving the eyes, skin , an d gastrointestinal tract and m ay
also be associated with a fam ily history. Physical exam in ation is important for distin guish in flam m atory arthritis,
as again, m ultiple joints are frequently involved. In addition, soft tissue bogginess an d swelling is m ore com m on
th an a true effusion . Valgus align m en t of th e kn ee is also
associated with inflam m atory arthritis, although it can be
seen in th e osteoarth ritic patien t. Radiograph ic changes are
also different, as the classic changes in rheum atic disease
include sym m etric joint space narrowing, osteopenia, and
periarticular erosion s, alon g with th e absen ce of osteophyte
form ation (Fig. 18.10). The con servative treatm ent options
between th ese two con dition s are sign ifican tly differen t, alth ough th e gold stan dard for en d-stage disease is total kn ee
replacem en t in both in stan ces.
Crystalline arthropathies, such as gout and pseudogout, m ust also be considered, particularly in those who
740
B
Figure 18.8 (A) Supine anteroposterior in a patient presenting with knee pain. (B) Weight-bearing
radiograph of the same patient taken a short time later. Note the medial joint space narrowing and the
obvious varus alignment, thus confirming the diagnosis of osteoarthritis. (Reproduced with permission
from Koopman WJ, Moreland LW. Arthritis and Allied Conditions: A Textbook of Rheumatology.
15th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2005.)
weight-bearing radiograph of the knee. (Reproduced with permission from Chapman MW, Szabo RM, Marder R, et al. Chapmans
Orthopaedic Surgery. 3rd ed. Philadelphia, PA: Lippincott Williams
& Wilkins, 2001.)
subchondral cysts, symmetric joint space narrowing, and the generalized osteopenia. There is also a complete absence of osteophytes. (Reproduced with permission from Koopman WJ, Moreland
LW. Arthritis and Allied Conditions: A Textbook of Rheumatology.
15th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2005.)
741
the typical punctate and linear deposits of calcium in both the medial
and lateral menisci. (Reproduced
with permission from Koopman WJ,
Moreland LW. Arthritis and Allied
Conditions: A Textbook of Rheumatology. 15th ed. Philadelphia, PA:
Lippincott Williams & Wilkins, 2005.)
NONOPERATIVE TREATMENT
Treatm ent of OA of the knee is sim ilar to the m anagem en t
of OA in oth er join ts, so th ere are m ultiple n on surgical
option s available. Th e first-lin e th erapy is typically n on steroidal an ti-inflam m atory drugs (NSAIDs), which fun ction by reducin g pain and swellin g associated with the knee.
Although all NSAIDs function in a sim ilar fashion , there
is a wide variation to patient response to each individual
m edication. Th erefore, at m in im um , two to three differen t NSAIDs sh ould be attem pted before aban don in g th is
treatm ent option. One m ust also be cognizant of the gastrointestinal side effects, as patients with a history of ulcers and gastroesoph ageal reflux should not be given these
m edications without consultation from the their prim ary
caregivers. Other oral m edication s that have been tried
include the recently popularized over-the-counter supplem en ts glucosam in e an d ch on droitin sulfate. Th ese
substances are part of the building blocks of articular cartilage an d work th eoretically by in testin al absorption of th e
substances, followed by their incorporation in to the articular cartilage of th e dam aged join t. A recen t large clin ical
trial con ducted at th e Nation al In stitutes of Health in dicated that there was no clin ical ben efit to using th ese products, but th ere is certain ly an ecdotal eviden ce th at th ey lead
to symptom atic improvem en t in som e patien ts. With th at
said, th ere does n ot appear to be any h arm , other th an cost,
to usin g th ese products, so th ey are certain ly worth tryin g
in th ose wh o h ave been un able to get symptom atic relief
via oth er m eth ods.
Th e secon d-lin e treatm en t is th e use of in tra-articular
corticosteroid injections, which are m ainly used for controllin g th e acute exacerbation s of pain . Th ese m edication s
function as strong anti-inflam m atory agents and are used
to quiet down patien tspain in an effort to restore th em to
their baselin e level of discom fort. However, wh en overutilized, cortison e h as actually been sh own to accelerate degeneration of the articular cartilage. Therefore, steroid injection s sh ould n ot be used to con trol baselin e pain an d
typically sh ould n ot be given m ore th an th ree tim es over th e
course of a year. If a patien t is requiring m ore th an th is,
oth er treatm en t option s sh ould be explored. Asecon d form
of in jection s th at are used in clude th e hyaluron ic acid
derivatives. Hyaluron ic acid is th e substan ce th at provides
the lubricating fun ction in norm al syn ovial fluid and is
often deficien t in th e arth ritic kn ee. Th ese in jection s are
theoretically used to decrease the coefficien t of friction between th e opposin g ch on dral surfaces, th us leadin g to less
degen eration of th e cartilage. Th is h as sh own som e clin ical
efficacy in certain trials, alth ough basic scien ce proof of
its m ech an ism is lackin g. However, th ese in jection s h ave
also been sh own to cause m in im al h arm , oth er th an th e
sm all risk of in fection, so they are a reasonable option in
the patient who is attempting to delay surgery.
Physical th erapy can be very h elpful in th e treatm en t
of arth ritis of th e kn ee. Th e soft tissue sleeve is im portan t to kn ee fun ction , so its optim ization can dim in ish th e
symptom s of osteoarth ritis. Therapy should be directed at
742
m ain tain in g th e ran ge of m otion of th e kn ee an d stren gth en in g th e quadriceps an d h am strin g m uscles. However, in
the late stages of degenerative disease, therapy can worsen
the symptom s and sh ould be lim ited only to the patients
toleran ce.
Assistive devices such as a cane, crutch, or walker m ay
also be h elpful in th e m an agem en t of OA. Th ese aids can
lim it th e stress across th e pain ful kn ee an d improve th e
patien ts walkin g toleran ce. Last, if all else fail, patien ts m ay
m odify th eir activities. Th is in cludes elim in atin g activities
that overload the joint, som e of which include run ning or
playin g ten n is, an d ch an gin g to less dem an din g activities
such as swim m in g. Patien ts with degen erative join t disease
are also frequen tly overweigh t, so weigh t loss can be an
effective m eth od to reduce sym ptom s by reducin g th e stress
experien ced by th e join t.
SURGICAL TREATMENT
Non operative m an agem en t can in clude som e or all of th e
therapies previously m entioned; h owever, as pain con tinues to progress, lim itation of activities will in crease. Wh en
the patient is unable to obtain acceptable symptom atic relief with n on operative care, surgical treatm en ts sh ould be
discussed. Th ese can be broken down in to procedures th at
spare the patien ts native articular cartilage and those that
rem ove or replace it. Th e tim in g of th e surgery depen ds on
the patients situation . In the younger patient with un icom partm en tal disease, an early in terven tion m ay be n ecessary
to preven t rapid progression of th e disease. However, in th e
patien t older th an 60 years with tricom partm en tal disease,
there is little chan ge in the complexity or the outcom e of
a total kn ee replacem en t with advan ced disease, so tim in g
sh ould be based on the patien ts symptom s.
Arthroscopy
Arthroscopy of the kn ee is by far the simplest operative treatm en t th at can be ch osen for m an agem en t of th e
arth ritic kn ee. Th is is an outpatien t procedure th at can gen erally be com pleted in less th an 30 m in utes, an d th e com plete recovery tim e is often less th an 2 weeks. However, its
effectiven ess is con troversial. Th e procedure is don e sim ply to clean out th e kn ee by rem ovin g any loose ch on dral flaps, debris in th e join t, or torn or frayed m en iscus.
Arthroscopy cannot be used to off-load or replace any of
the diseased cartilage and exists only to delay the need for
m ore in vasive in terven tion . Several well design ed studies
have indicated that th ere is no ben efit to arthroscopy in th e
degen erative kn ee, in dicatin g th at som e patien ts m ay even
get worse, wh ereas oth ers h ave sh own th at it is an effective
way to postpone a knee replacem ent by up to several years.
Th e actual results are likely som ewh ere in between th ese extrem es. Th ere is good eviden ce th at doin g an arth roscopic
debridem en t on patien ts with advan ced OA is un likely to
Osteotomy
Angular deform ities of the knee com m on ly occur in patients with OA. This m alalignm ent causes an asym m etrical loadin g between the m edial and lateral compartm ents,
thus leading to accelerated degenerative changes on the
overloaded side. Varus deform ity is th e m ost com m on in
OA, an d it can lead to in creased stress on th e m edial com partm en t. Wh en th is occurs th ere are ben efits to addressing just the diseased compartm ent with surgical intervention. However, it is importan t to recognize th at the vast
m ajority of patients presenting with a varus deform ity in an
arthritic knee have disease that also involves the other com partm en ts. With th at said, ch on dral-sparin g procedures
are frequently indicated in younger patients as th ey can
be used to delay th e n eed for total kn ee replacem en t. Th e
best option for treatin g un icom partm en tal m edial disease
in th e younger patient (< 60 years) is by high tibial osteotomy (HTO). HTO is don e to off-load th e diseased m edial com partm en t by correctin g, an d in fact overcorrectin g,
the m alalignm ent of the lower extrem ity by placing it back
into valgus (Figs. 18.12 and 18.13).
Th e prim ary ben efit of doin g an HTO as opposed to a
TKA is th at it preserves patien ts n ative articular cartilage,
thus elim inating the concern about m aterial wear seen with
TKA. Th is leaves patien ts with n o activity restriction s following un ion of the osteotomy site, which is particularly im portan t in youn ger active patien ts wh o are likely to quickly
wear out a prosth etic join t. Th e two prin cipal drawbacks
to HTO are th at it sh ould be used on ly in th ose with un icompartm ental disease and that the results of the procedure progressively deteriorate with tim e. HTO fun ction s
by transferrin g the weight-bearing load over to the lateral
compartm ent, so it is important to determ ine the condition of th e lateral side preoperatively. If there are already
degen erative ch an ges th ere, it is likely th at th e procedure
will fail because of in creased lateral-sided pain . Regardin g
longevity, n ew instrum entation h as in creased th e average
survival rates of th is procedure to approxim ately 10 years,
but th is is n owh ere n ear th e proven lon g-term results th at
are seen with TKA. For this reason, HTO is generally discouraged in older patien ts with a m ore sedentary lifestyle
in which TKA is m ore likely to give them m ore complete
an d endurin g success.
Valgus producing osteotom ies (for varus deform ity) are
perform ed as eith er m edial open in g wedge or lateral closing wedge procedures. Lateral closing wedge osteotom ies
were described first an d are don e by takin g a wedge of
bon e out of th e lateral border of th e proxim al tibia. Th e
gap is then closed and typically held with intern al fixation
(Fig. 18.12). However, m edial open ing wedge osteotom ies
are currently used m ore frequently as they allow for easier
743
Figure 18.13 Medial opening wedge high tibial osteotomy following correction with placement of internal fixation. Bone graft
substitute has been used to fill in the osteotomy site.
B
Figure 18.12 High tibial lateral closing wedge valgus osteotomy: (A) after the bone wedge is removed and (B) following
closing of the wedge and internal fixation to correct a varus deformity. (Reproduced with permission from Chapman MW, Szabo RM,
Marder R, et al. Chapmans Orthopaedic Surgery. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2001.)
adjustm ent at the osteotomy site (Fig. 18.13). With open ing wedge procedures, on ly one saw cut is m ade, and the
bon e is levered open wh ile keepin g th e lateral cortex in tact.
Th is osteotomy is also typically h eld in place with in tern al
fixation devices.
Valgus deform ities can also be corrected with a varusproducin g osteotomy, alth ough th is is m uch less com m on .
Th e tech n ique of ch oice is typically a distal fem oral osteotomy an d can be eith er a lateral open in g wedge or a
m edial closing wedge procedure.
744
Knee Arthrodesis
Arthrodesis, or fusion, of the knee is another seldom -used
option for the osteoarth ritic kn ee (Fig. 18.15). This procedure is very effective for pain relief, but because it does so by
completely elim inatin g all knee m otion, it is an un appealin g option . It does allow for full weigh t-bearin g an d am bulation , alth ough th e resultan t gait pattern is sign ifican tly
abn orm al. At th is tim e, fusion is con sidered on ly in youn g
active patien ts, particularly in physical laborers, or in th ose
with failed and non salvageable prior join t replacem en t.
Indications
Th e m ajor in dication for TKA is th e presen ce of persisten t
m echanical knee pain that can no longer be con trolled by
oth er n on surgical or surgical m ean s. Th e pain is m ost typically caused by OA, either prim ary or posttraum atic, but
it can also be from rheum atoid arth ritis or other inflam m atory disorders. Patients will benefit from a course of
con servative m anagem ent, but the progressive nature of
the disease eventually results in m any patients requiring a
surgical treatm en t.
Total kn ee replacem en t is an elective procedure, so th e
decision for wh en to proceed with th e operation is left up to
745
Figure 18.16 Postoperative radiograph of a patient who had bilateral total knee arthroplasties.
Surgical Procedure
Th e kn ee join t is approach ed th rough an an terior m idlin e
incision, followed by a m edial parapatellar arthrotomy. The
patella can th en be everted, wh ich in turn exposes th e en tirety of the knee joint. At that point, the proxim al tibia is cut
perpen dicular to th e lon g axis of th e sh aft of th e tibia an d
the fem oral articular surface is cut by using specific guides
to rem ove th e fem oral troch lea an d th e distal an d posterior
fem oral con dyles. Th e patella is norm ally resurfaced as well
by resecting th e articular surface with a cut parallel with its
an terior surface. The ACL is rem oved, wh ereas the m edial
collateral ligam ent (MCL) an d the LCL are retain ed and
carefully balanced. The posterior cruciate ligam ent (PCL)
can be either resected or retained, depen ding on the design of the implant ch osen. This allows for a classification
of kn ee design s in to two types: posterior cruciate retain ing and posterior cruciate substituting designs. Use of the
746
When the knee goes into flexion, posterior translation of the tibia
is blocked by the polyethylene post abutting the distal femur. (Reproduced with permission from Chapman MW, Szabo RM, Marder
R, et al. Chapmans Orthopaedic Surgery. 3rd ed. Philadelphia, PA:
Lippincott Williams & Wilkins, 2001.)
where th e h igh est force on the com pon ents fixation is experienced due to the shear stress that felt during knee flexion.
Th erefore, if n on cem en ted compon en ts are ch osen , th ey
sh ould be lim ited to th e fem oral side of th e arth roplasty.
Postoperative Recovery
Th e patien t is m obilized in to a ch air on th e first postoperative day, an d full weigh t-bearin g m ay be allowed im m ediately. However, a kn ee im m obilizer sh ould be used
to protect th e kn ee from acute flexion wh ile walkin g, an d
this is contin ued until th e quadriceps function returns. The
critical elem ent of the postoperative therapy is the restoration of m otion . If th e m otion is n ot restored with in th e
first 3 to 6 weeks, m aturation of th e scar tissue will preven t m ajor gain s in m otion . Many surgeon s elect to use a
continuous passive m otion (CPM) m ach ine in the im m ediate postoperative period to en courage m otion , alth ough
it h as n ot been sh own to h ave any substan tial impact in
the long term . Total h ospital tim e postoperatively in m ost
centers averages between 3 and 4 days, an d m ost patients require h om e physical th erapy to con tin ue work on ran ge of
Outcomes
Th e ultim ate goal of all total kn ee replacem en t surgeries is
pain relief, an d in m ost cases, it is successful. Th e lon g-term
outcom es of th e procedure h ave been well docum en ted in
the literature and have repeatedly shown excellent results.
Survivorsh ip n um bers for m odern prosth eses are cited as
bein g as h igh as 95% at 10 years, 90% at 15 years, an d up to
80% at 20 years. Lon gevity is im proved in th ose older th an
70 years, wom en , an d th ose with an un derlyin g diagn osis
of in flam m atory arth ropathy. Youn ger m ale patien ts, h owever, ten d to put m ore stress on th e prosth esis, wh ich leads
to earlier an d h igh er rates of compon en t wear an d loosen ing. In addition to impressive longevity of these implants,
it m ust also be noted th at in the m ajority of cases, these
patien ts will h ave n ear-complete pain relief in addition to
sign ificant fun ction al benefits from th e procedure.
Complications
Th e m ajority of total kn ee replacem en ts are successful operation s, but there are several com m on and significant com plication s th at n eed to be discussed. Particularly wh en con siderin g th e large volum e of kn ee replacem en ts done, it is
important to be fam iliar with the causes of continued pain
Postoperative Pain
Con tinued pain after TKA is seen in less than 10% of patients, and the m ajority of these complaints are from the
patellofem oral join t. Th is can be th e result of poor soft tissue align m ent at the tim e of arthroplasty and m ay lead to
pain ful subluxation or dislocation of th e patellar com ponent. If inadequate bone is resected from the patella at th e
tim e of resurfacing, a m arked increase in th e patellofem oral
stress can be noted, an d this m ay lead to pain. Several
authors have advocated not resurfacin g the patella for
this reason, but studies now dem onstrate a higher rate of
patellofem oral com plain ts after TKAwith out patellar resurfacin g. If sign ifican t patellofem oral arth ritis exists at th e
tim e of arthroplasty, patients with weigh t m ore than 60 kg
an d height m ore than 160 cm will h ave m ore pain postoperatively if th e patella is n ot resurfaced.
When evaluatin g th e patien t with pain following TKA, it
is important to do a th orough investigation of th e possible
causes, and infection m ust always be ruled out. If infection
is n ot presen t, then one m ust search for other sources of
pain , an d in m any cases, th ere is n ot on e th at is iden tifiable.
In th ese in stan ces, th e surgeon sh ould be h esitan t to return
to th e operatin g room for revision surgery, as th e success
rates are m uch h igh er in th e settin g of a problem th at h as
been clearly iden tified preoperatively an d is correctable.
Thromboembolic Disease
Th e m ost com m on complication after TKA is th rom boem bolic disease, wh ich can ran ge from deep ven ous th rom bosis (DVT) to fatal pulm onary em bolism (PE). At the presen t
tim e, th e rate of DVT identified by ultrasoun d in th e postoperative settin g is approxim ately 5% in patien ts wh o com plain of calf pain . However, studies usin g ven ography in all
postoperative patien ts h ave reported rates of DVT ran gin g
from 25% to 50%. PE is reported to occur in approxim ately
1% of patien ts, an d th is can poten tially be fatal, alth ough
the m ortality risk is only approxim ately 0.01%.
In an effort to preven t th ese occurren ces, all patien ts
sh ould be given lower extrem ity compressive devices for
m echanical prophylaxis and be m obilized on postoperative day 1. Both th ese intervention s have been shown to significantly reduce the n um ber of th rom boem bolic even ts.
Th e stan dard of care is for ch em ical prophylaxis to be given
as well. At present, there are a variety of m edications from
wh ich to ch oose an d th ere is con flictin g eviden ce regardin g
their risks and effectiveness. Warfarin (Coum adin) given
for 6 weeks postoperatively has the greatest volum e of literature to support its use, alth ough th e in tern ation al n orm alized ratio (INR) needs to be closely m onitored. While
Coum adin is undoubtedly effective when the INR is kept at
a safe range, it can be difficult to con trol in the outpatient
settin g, an d dangerous elevation s of th e INR are a distin ct
747
Infection
Th e m ost devastatin g complication after TKA is deep sepsis, which is estim ated to occur in approxim ately 1% of
patien ts. Th e m ost com m on organ ism s are skin flora, prim arily Staphylococcus aureus and S. epidermidis. These organism s often gain entran ce via the relatively thin soft tissue
en velope at th e in ferior aspect of th e woun d, wh ich m ust
be m on itored in th e early postoperative period. Any area of
skin breakdown after TKA should be treated aggressively to
preven t deep in fection , particularly in patien ts with prior
incisions and in those with diabetes or significant vascular disease. Diagn osis is m ade by history and physical exam ination com bined with laboratory and im aging studies.
Patien ts wh o presen t with pain in a previously wellfunction ing arthroplasty should always be worked up
for infection, which includes eryth rocyte sedim en tation
rate, C-reactive protein level, an d join t aspiration . Radiograph s sh ould be evaluated for th e presen ce of compon en t
loosenin g.
Early postoperative in fection is less com m on th an late
infection, but recognition is critical for optim al treatm ent.
If detected with in th e first 3 weeks postoperatively, aggressive open debridem en t, synovectomy, and polyethylen e exchange com bined with intravenous an tibiotics can be successful. However, if th e in fection recurs after debridem en t
or if it is detected beyon d 3 weeks, treatm en t m ust in clude
rem oval of th e prosth etic compon en ts an d all cem en t. An
antibiotic-impregnated cem ent spacer should be placed at
th e tim e of debridem en t, wh ich serves as a local depot of
antibiotic at the site of the infection and also provides stability to soft tissues durin g treatm en t. After com pletion of
a m in im um of 6 weeks of in traven ous an tibiotic th erapy,
repeat laboratory studies an d repeat aspiration sh ould be
748
B
Figure 18.19 (A) Anteroposterior and (B) lateral radiographs showing radiolucent lines around
both the tibial and femoral components indicative of loosening of this total knee arthroplasty. (Reproduced with permission from Lotke PA, Lonner JH. Master Techniques in Orthopaedic Surgery:
Knee Arthroplasty. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2003.)
completed, and if these studies are negative, on e m ay proceed with revision total knee replacem ent. However, as a
result of th e in evitable scarrin g an d probable bon e loss,
the clinical result is comprom ised to som e degree, and
the infection rate following revision surgery is significantly
higher than th at seen followin g prim ary arth roplasty.
Loosening/Wear
While current implan ts h ave sign ifican tly im proved durability, th e lon g-term effect of placin g prosth etic components into the knee joint is the generation of wear particles
from th e implan ts. Th is is m ore pron ounced in patients
who place m ore stress on th e im plan t, particularly those
who are youn ger, m ore active, or obese. In TKA, aseptic
loosen in g of th e compon en ts occurs at a low rate, but over
the expected survivorship of an implant, it eventually becom es significant. Loosening of components will lead to
knee pain, so th e m ost com m on presentation is that of
a patient with a well-functionin g implant for m any years
who th en develops th e gradual onset of pain , especially
with activity. Of n ote, any com ponen t loosen ing prior to
5 years postoperatively should be considered infected until proven oth erwise. Th e diagn osis of loosen in g is m ade
radiographically, as areas of implan t loosening will appear
as radiolucen t lin es aroun d th e compon en ts (Fig. 18.19).
Serial radiograph s will sh ow progression of th e radiolucen t
areas an d possibly m igration of th e compon en t. O n ce th e
symptom s are severe en ough, revision surgery is gen erally
required to provide a stable implan t.
Wear in TKA has other sign ifican t effects, particularly
in regard to th e polyethylene compon en t (Fig. 18.20). The
bearin g surface in TKA is m etal on polyethylen e, an d th e
result of repeated loadin g of th e join t is particulate debris origin atin g from th e polyethylen e. Th e m icroscopic
polyethylen e particles are released in to th e local tissues
wh ere th ey are in gested by m acroph ages, wh ich attempt
to digest the particles with catabolic enzym es and superoxides. Th e debris accum ulates in th e cell, wh ich even tually breaks down and releases the polyethylen e and th e
en zym es back in to th e local en viron m en t. Th e release of
th e catabolic en zym es in to th e tissue causes osteolysis of
th e bon e, wh ich can h ave severe con sequen ces (Fig. 18.21).
Loss of bone support can lead not only to prosthetic loosen in g an d clin ical failure but also to sign ifican t weakn ess of
been in place for 6 years. Note the delamination of the polyethylene both medially and laterally. (Reproduced with permission from
Lotke PA, Lonner JH. Master Techniques in Orthopaedic Surgery:
Knee Arthroplasty. 2nd ed. Philadelphia, PA: Lippincott Williams &
Wilkins, 2003.)
749
Instability
that has been in place for 6 years. Note the extensive osteolysis
of the distal femur shown by the arrows. (Reproduced with permission from Lotke PA, Lonner JH. Master Techniques in Orthopaedic
Surgery: Knee Arthroplasty. 2nd ed. Philadelphia, PA: Lippincott
Williams & Wilkins, 2003.)
Stiffness/Arthrofibrosis
Patients pre-operative range of m otion is th e best indicator of postoperative ran ge of m otion of th e kn ee, m ean in g
that those with good m otion before surgery will h ave th e
best m otion after surgery. However, in som e cases, ran ge
of m otion followin g TKA does n ot reach optim al levels.
Approxim ately 100 degrees of knee flexion is needed for
activities of daily living, an d failure to reach this can have
m any possible causes, including poor patient compliance
with reh abilitation , excessive postoperative swellin g an d
pain , or poorly im plan ted com pon en ts. CPM is used in th e
postoperative period to en courage m otion , but in som e
cases, patients do not reach their goals. If patients are less
than 2 to 6 weeks from the tim e of surgery, m anipulation
of th e kn ee un der a gen eral an esth esia can be don e in an
Periprosthetic Fracture
Periprosth etic fracture following TKA is seen in approxim ately 2% of patients, an d of these, supracondylar fem ur
fractures are th e m ost com m on (Fig. 18.23). Th ey are generally secon dary to m in or traum a, an d risk factors in clude
osteoporotic bon e, lim ited ran ge of m otion in flexion , an d
n otch in g of th e distal fem ur. Lim ited ran ge of m otion is im portan t because wh en on e falls on to th e leg with a flexed
knee, th e force is typically absorbed by increasing the flexion of the knee. However, if flexion is lim ited, the force is
dissipated elsewh ere, wh ich in m ost cases is to th e distal
fem ur. Notch ing occurs when the anterior fem oral shaft is
cut wh ile preparin g th e fem ur an d is a risk factor for fracture
(Fig. 18.24).
750
fall. (Reproduced with permission from Lotke PA, Lonner JH. Master
Techniques in Orthopaedic Surgery: Knee Arthroplasty. 2nd ed.
Philadelphia, PA: Lippincott Williams & Wilkins, 2003.)
Treatm en t of periprosth etic distal fem ur fractures depends on th e degree of displacem en t an d th e status of th e
arthroplasty. If the fem oral compon ent is already loose,
then revision should be undertaken in addition to treatm en t of th e fracture. When th e fem oral component is well
fixed, th e fracture can be treated eith er operatively or n on operatively. Non displaced an d m in im ally displaced fractures are gen erally treated n on operatively, wh ich con sists
of non weigh t-bearin g in eith er a lon g leg cast or a brace
for 6 to 8 weeks. Displaced fractures should be treated operatively, th e option s for wh ich m ost com m on ly in clude
open reduction in tern al fixation (ORIF) or retrograde in tram edullary n ailin g. O RIF is typically accom plish ed with
a plate-and-screw construct placed on the lateral fem ur and
is frequently done with a locking plate, wh ich adds stability
751
periprosthetic proximal tibia fracture. (Reproduced with permission from Lotke PA, Lonner JH. Master Techniques in Orthopaedic
Surgery: Knee Arthroplasty. 2nd ed. Philadelphia, PA: Lippincott
Williams & Wilkins, 2003.)
Figure 18.26 Retrograde intramedullary nailing of a periprosthetic distal femur fracture. (Reproduced with permission from
Lotke PA, Lonner JH. Master Techniques in Orthopaedic Surgery:
Knee Arthroplasty. 2nd ed. Philadelphia, PA: Lippincott Williams &
Wilkins, 2003.)
SUMMARY
OA of th e kn ee is a sign ifican t problem th at is experien ced by a large proportion of th e agin g population . Th ere
are m any options for con servative treatm ent of OA, but
752
RECOMMENDED READINGS
Buckwalter JA, Saltzm an C, Brown T. The im pact of osteoarthritis:
implications for research. Clin Orthop Relat Res. 2004;427(suppl):
S6 S15.
Dixon MC, Brown RR, Parsch D, Scott RD. Modular fixed-bearin g total
knee arthroplasty with retention of th e posterior cruciate ligam ent:
a study of patien ts followed for a m in im um of fifteen years. J Bone
Joint Surg Am. 2005;87(3):598 603.
Gonzalez MH, Mekhail AO. The failed total knee arthroplasty: evaluation an d etiology. J Am Acad Orthop Surg. 2004;12(6):436 446.
Naudie, DD, Am m een DJ, En gh GA, Rorabeck CH. Wear an d osteolysis around total knee arthroplasty. J Am Acad Orthop Surg.
2007;15(1):53 64.
Rand JA, Trousdale RT, Ilstrup DM, Harm sen WS. Factors affecting the
durability of prim ary total knee prostheses. J Bone Joint Surg Am.
2003;85A(2):259 265.
Win dsor RE, Bon o JV. In fected total kn ee replacem en ts. J Am Acad
Orthop Surg. 1994;2(1):44 53.
19
FUNCTIONAL ANATOMY
Osteology
Th e tibia is a trian gular lon g bon e th at expan ds proxim ally
to form th e plateau at th e kn ee an d distally to form th e
plafon d an d m edial m alleolus. Th e fibula is also trian gular
an d is oriented sligh tly posterior and lateral to the tibia. Th e
distal flare form s th e lateral m alleolus. Th ese two bon es
articulate both proxim ally an d distally in arthrodial joints,
allowing for slight translational and rotational m ovem ents.
Distally, th e tibia an d fibula form th e an kle join t.
Th e join t is secured th rough m ultiple ligam en tous con n ection sth e in terosseous m em bran e, th e an terior in ferior
tibiofibular ligam ent, and the posterior inferior tibiofibular
ligam ent. Together, the tibia and fibula create th e m ortise
of th e an kle, wh ich articulates with th e dom e of th e talus,
allowing for dorsiflexion and plantarflexion.
Th e foot is divided in to th ree separate region sth e h in dfoot, m idfoot and forefoot, and three groups of bones: the
tarsus, m etatarsus, an d ph alan ges. Th e h in dfoot in cludes
the talus and calcaneus. The m idfoot is composed of th e
navicular, cuboid, and the th ree cuneiform s. Th e forefoot
region in corporates th e m etatarsals an d th e ph alan ges.
Th e an atomy of th e talus is critical to un derstan din g th e
hin dfoot. More than 60% of the talus is covered with hyaline cartilage. It consists of a head, neck, and body and has
no m uscle or tendon attach m en ts. Stability is depen den t on
bon e articulation s, join t capsules, an d ligam en ts. Th e body
of th e talus h as a un ique trapezoidal sh ape, bein g wider an teriorly. Th is provides extra stability to th e an kle m ortise in
754
anastomotic sling that originates from the artery of the tarsal sinus
(A) laterally and the artery of the tarsal canal (B) medially. Additional blood vessels enter dorsally through the neck and medial
body (C). (Reproduced with permission from Rockwood CA, Green
DP, Bucholz RW. Rockwood and Greens Fractures in Adults. 6th ed.
Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
lates with two sesam oid bon es that are encased by the flexor
h allucis brevis (FHB) ten don . Th ese sesam oids provide a
m echanical advantage by increasing the level arm for flexion, m uch like the patella for knee extension. Th e second
m etatarsal is usually the longest and is recessed proxim ally
between th e cun eiform s. Mobility of th e secon d m etatarsal
is sacrificed for th is extra stability. The third, fourth, and
fifth m etatarsals are successively sh orter, creatin g a curved
appearance of the foot. The fifth m etatarsal has a prom in en ce at its base for in sertion of th e peron eus brevis tendon . Th e lesser four m etatarsals bear two-th irds of th e body
weigh t equally.
Th e ph alan ges of th e foot are sim ilar to th ose in th e
h an d. Th e proxim al aspect of th e proxim al ph alanges is
con cave to allow articulation with the convex head of th e
m etatarsals. The distal ends h ave m ore of a trochlear shape
that articulates with the correspon ding m iddle ph alanx.
Each distal ph alan x term in ates in a tuft of bon e to serve as
an anchor for the toe pad.
Ankle Joint
Th e m ortise form ed by th e tibia an d fibula is dyn am ic but
stable due th e bon e an atomy, thick posterior capsule, and
ligam entous structures. As the foot dorsiflexes, th e fibula
m oves proxim ally, posteriorly, and externally and rotates
to provide room for th e trapezoid-sh aped talus, wh ich is
wider an teriorly. Th e axis of th e an kle join t is n ot perpen dicular to th e m alleoli, such th at th e foot extern ally rotates
15 degrees with dorsiflexion an d internally rotates 15 degrees with plan tarflexion .
Th e m edial deltoid complex an d th e lateral ligam en ts
provide added stability. Th e deltoid is fan -sh aped ligam en t with deep and superficial components (Fig. 19.4).
Th e superficial compon en ts in clude th e posterior tibiotalar, tibiocalcaneal, and the tibion avicular ligam ents. The
an terior tibiotalar ligam ent form s th e deep component an d
is importan t to m aintaining the m edial joint space. The
lateral complex consists of the posterior talofibular ligam en t (PTFL), th e calcaneofibular ligam ent (CFL), and the
755
Ca lc a n e u s
La te ra l tube rcle
Me dia l
tube rcle
For tra ns ve rs e
tibiofibula r liga me nt
For tibia
For me dia l
ma lle olus
Exte ns or digitorum
bre vis
Ta lu s
Cu b o id
Groove for fibula ris
(pe rone us ) longus
Th re e
c u n e ifo rm s
5
4
Five
m e ta ta rs a ls
P h a la n g e s
Exte ns or ha llucis
bre vis
Exte ns or
e xpa ns ion
Me dia n
ba nd
La te ra l
ba nds
Do rs a l Vie w
Deep
anterior talotibial
Superficial
talotibial
Exte ns or ha llucis
longus
Calcaneotibial
B
Deep
posterior talotibial
Naviculotibial
Superficial deltoid ligament
756
Subtalar Joint
Anterior
tibiofibular
ligament
Anterior
talofibular
ligament
Posterior
talofibular
ligament
Calcaneofibular
ligament
Midfoot Joints
Th e m idfoot join ts are stabilized by m ultiple ligam en ts
an d by the intrinsic bony architecture of th e wedge-shaped
cun eiform bon es. Th is section of the foot is prim arily a
IOL
PITFL
AITFL
ITL
Anterior
AITFL
Posterior
AITFL
Figure 19.6 The syndesmosis is composed of the anterior inferior tibiofibular (AITFL), the posterior
inferior tibiofibular (PITFL), inferior transverse ligament (ITL), and the interosseous membrane (IOM).
(Reproduced with permission from Rockwood CA, Green DP, Bucholz RW. Rockwood and Greens
Fractures in Adults. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
PITFL
Lateral
757
Tarsometatarsal Joints
Metatarsophalangeal Joints
Th e MTP join ts of th e lesser toes are stabilized by th e
bony sh ape, th e fibrocartilagin ous plan tar plates origin ating from th e m etatarsal heads an d inserting on the bases
of th e proxim al ph alan ges, th e deep tran sverse m etatarsal
ligam ent, and the collateral ligam ents. Atten uation of th ese
structures can result in dorsal subluxation and dislocation.
Th e MTP join t of th e h allux h as a ran ge of m otion of 70
degrees allowin g for th e toe-off ph ase of th e gait cycle.
Interphalangeal Joints
Th e in terph alan geal join ts are gin glym us join ts with cam sh aped condyles an alogous to th ose in the hand, with sim ilar anatomy and ligam en tous support. More flexion occurs
Saphenous nerve
Flexor digitorum longus
Saphenous vein
Tibials posterior
Posterior tibial artery
Tibials anterior
Tibial nerve
structures as they course behind the medial malleolus. (Reproduced with permission from Rockwood CA, Green DP,
Bucholz RW. Rockwood and Greens Fractures in Adults.
6th ed. Philadelphia, PA: Lippincott Williams & Wilkins,
2006.)
758
prim ary fun ction is in version of th e foot, but it also con tributes to th e support of th e lon gitudin al arch . Th e FDL
travels beh in d th e m edial m alleolus with th e tibialis posterior superficial to the deltoid ligam ent an d into th e plantar
aspect of th e foot just plan tar to th e FHL. After join in g with
the quadratus plantae, it divides into four slips and inserts
on to th e base of th e distal ph alan x of th e lesser toes. Th e
FDL flexes th e MTP, PIP, an d DIP join ts of th e lesser toes
an d serves as a weak an kle plan tarflexor. Th e FHL is th e
m ost lateral m uscle of th e deep posterior compartm en t an d
courses between the posterior talar processes, under the
sustentaculum tali, an d th rough th e secon d layer of plan tar aspect of th e foot to in sert on th e distal ph alan x of th e
great toe. It is th e prim ary flexor of th e h allux an d a weak
an kle plan tarflexor. Th e tibial n erve in n ervates th ese th ree
m uscles.
The lateral compartm ent contain s the peroneus lon gus
an d peron eus brevis m uscles, wh ich are in n ervated by th e
superficial peroneal nerve. The peroneus longus is m ore
superficial and is posterolateral to the peroneus brevis behind the lateral m alleolus. The peroneus lon gus origin ates
from the upper two-th irds of the lateral fibula and interm uscular septum an d in serts on th e plan tar base of
the first m etatarsal and m edial cuneiform after traveling
ben eath th e cuboid. Th e m uscle plan tarflexes th e first ray
an d con tributes som e an kle plan tarflexion an d foot abduction . Th e peron eus brevis origin ates from th e distal twothirds of the interm uscular septum and inserts onto the
base of th e fifth m etatarsal an d serves as th e prim ary evertor of th e foot. In som e in dividuals, a th ird m uscle, th e
peron eus tertius, parallels th e peron eus brevis an d in serts
on th e dorsal base of th e m etatarsal. Th e ten don s are h eld
within the peroneal groove as th ey pass posteriorly and
aroun d th e lateral m alleolus by th e superior an d in ferior
peron eal retin aculum . Th e CFL lies deep to both ten don s
at th e tip of th e lateral m alleolus.
The tibialis anterior, the extensor h allucis longus (EHL),
an d th e exten sor digitorum lon gus (EDL) form th e an terior
compartm en t of the leg and are innervated by the deep peron eal n erve. As a group, th ese m uscles dorsiflex th e foot
an d an kle. Th e tibialis an terior origin ates from th e lateral
tibial con dyle an d th e in terosseous m em bran e an d in serts
on to th e m edial border of th e m edial cun eiform an d base
of th e first m etatarsal. In addition to dorsiflexion of th e
an kle, it in verts th e subtalar join t an d supports th e lon gitudin al arch of th e foot. Th e tibialis an terior m uscle is
the antagonist of the peron eus longus m uscle. The EHL,
the prim ary extensor of th e hallux, arises from the m iddle
two-th irds of th e an terior fibula an d in terosseous m em bran e an d in serts on to th e distal ph alan x of th e h allux. Th e
EHL weakly dorsiflexes the an kle and inverts the foot. The
EHL crosses from lateral to m edial over the dorsalis pedis
artery an d deep peron eal n erve just proxim al to th e an kle
join t. Th e dorsalis pedis artery an d deep peron eal n erve
are bordered by th e EHL m edially an d th e EDL laterally at
Neurovascular Structures
Five m ajor n erve bran ch es an d th ree arteries supply th e
foot and ankle. Most of the sensory and m otor inn ervation to the foot and ankle com e from the two portions of
the sciatic nerve, the com m on peroneal (L4 S2) an d tibial nerves (L4 S3). Th e com m on peron eal n erve divides in
the anterior compartm ent into the deep and superficial peron eal n erves after crossin g aroun d th e n eck of th e fibula.
At th is point, the nerve is m ost susceptible to injury, especially compression n europathy. The deep peroneal n erve
inn ervates the anterior compartm ent m uscles and travels
with th e an terior tibial artery across th e an kle un der th e
exten sor retin aculum . Ultim ately, it in n ervates som e of th e
intrinsic m uscles of the foot and provides sen sation in
the first dorsal webspace. Th e superficial peron eal nerve
inn ervates th e lateral compartm ent m uscles and provides
sen sation to th e dorsum of th e foot and toes. This n erve is
at risk durin g exposure of the fibula approxim ately 10 to
15 cm above the lateral m alleolus. It becom es subcutaneous at that level passing from the lateral in to th e an terior compartm en t of th e leg. Care sh ould be taken wh en
exposin g fractures of th e fibula above th e lateral m alleolus. Th e sural n erve is an oth er bran ch of th e com m on
peron eal n erve th at provides sen sation to th e lateral side
of th e foot. It travels separately from th e superficial an d
deep peron eal n erves run n in g posteriorly over th e gastrocsoleus com plex and even tually passin g m idway between
759
Gait Analysis
Th e gait cycle con sists of even ts occurrin g from h eel strike
to the next h eel strike of the sam e foot. It is divided into th e
stan ce an d swing phases. The stance phase m akes up 62%
of th e cycle an d th e swin g ph ase m akes up th e rem ain in g
38%. Th e stan ce ph ase is furth er separated in to th ree segm ents: the initial double-lim b support (loading response),
th e sin gle-lim b stan ce, an d th e term in al double-lim b support (preswin g). Sim ilarly, th e swin g ph ase is separated
into initial swing, m idswing, and term inal swing phases.
760
Physical Examination
A sound foot an d an kle exam in ation should follow th e
prin ciples of any orth opaedic exam in ation : in spection ,
palpation , ran ge of m otion , m an ipulation , an d n eurovascular exam in ation. A fun dam ental un derstanding of the
an atomy discussed earlier is critical in perform in g a com plete focused physical. Th e exam in ation begin s as th e
patien t walks in to th e exam in ation room , providin g an opportun ity to evaluate gait pattern s. It is importan t to rem ove
sh oes and socks for complete evaluation. Extrem ity alignm en t sh ould be assessed from th e fron t an d back with th e
subject stan ding an d sittin g. Gait should again be observed
Imaging
Plain radiograph s of th e foot an d an kle are th e best in itial form s of im aging; however, arthrography, computed
761
Figure 19.8 The anterior draw test is used to examine the competency of the ATFL. An anterior force is applied to the posterior heel with the ankle in 10 degrees of plantarflexion while the
tibia is stabilized. (Reproduced with permission from Johnson D,
Pedowitz RA. Practical Orthopaedic Sports Medicine and
Arthroscopy. Philadelphia, PA: Lippincott Williams & Wilkins, 2007.)
Pilon fractures are in juries of th e distal tibial articular surface or plafon d. Th ey are typically h igh -en ergy in juries an d
are associated with significant soft tissue injury. The exten t of th e soft tissue in volvem en t varies, but it affects th e
m anner in which these fractures are treated. Most often
th ese fractures require open reduction an d in tern al fixation (ORIF) to restore the join t surface and provide the
best possible outcom e. Th ese in juries accoun t for 10% of
all lower extrem ity fractures.
Classification
Pilon fractures h ave h istorically been classified accordin g to
Ru edi an d Allgo wer (Fig. 19.9). Type I fractures are n on displaced. Type II fractures are displaced with m in im al com m inution, whereas type III fractures are displaced with sign ifican t com m in ution . The AO / O TA classification is m ore
descriptive an d h as th ree m ain types. Type A fractures are
n on articular. Type B fractures in volve part of th e articular
surface, and type C fractures involve the entire articular surface. Th ese th ree types are furth er subclassified based on
th e am oun t of com m in ution .
Th e soft tissue en velope can be classified on th e basis
of a scale of 0 to 3, accordin g to Tsch ern an d Goetzen .
In creasin g grades are associated with m ore dam age to th e
surroundin g soft tissue.
Mechanism of Injury
Pilon in juries result from axial loads, with or with out a
rotation al compon en t, m ost com m on ly as a result of falls
from a height or the impact of m otor veh icle crash es. The
position of th e foot at th e tim e of im pact affects th e fracture location (Fig. 19.10). If th e foot is in dorsiflexion , th e
anterior portion of the tibia is fractured, wh ereas in plantarflexion , th e posterior tibia is fractured because of th e
impact of the talar dom e. With th e ankle in neutral at the
tim e of impact, the m iddle portion of the distal tibia is
m axim ally involved. Pilon fractures are distinguished from
ankle fractures with intraarticular exten sion by their m echanism and degree of injury. Ankle fractures are typically
rotation al in juries with th e m ain fracture lin es in volvin g
th e lateral, m edial, an d posterior m alleoli (Table 19.1).
Presentation
Patien ts com m on ly presen t with sign ifican t pain an d
swellin g about th e an kle and varyin g degrees of soft tissue
dam age. Because of th e h igh -en ergy m ech an ism s associated with these injuries, m any patients m ay have sustain ed
addition al orthopaedic or organ system in juries.
762
II
Physical Examination
Th e exten t of soft tissue in jury is importan t as it directs treatm en t. An open in jury or an in jury th at results in vascular
comprom ise, such as a fracture dislocation, is a surgical
em ergen cy. If th e in jury is several h ours old, fracture blisters about th e lower extrem ity are often presen t. Th e full
exten t of soft tissue in jury m ay n ot declare itself im m ediately, an d so serial exam in ation is warran ted. In addition
to evaluatin g th e soft tissue status an d docum en tin g a th or-
III
and Allgower.
Imaging
Stan dard an kle radiograph s are th e prim ary im agin g study.
CT scan is helpful to delineate fracture pattern s and determ ine the am ount of com m inution for surgical plannin g.
TABLE 19.1
Axial Load
Reproduced with permission from Rockwood CA, Green DP, Bucholz RW. Rockwood and Greens Fractures
in Adults. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.
Dorsiflexion
763
Ankle Fractures
Neutral
Plantarflexion
on the position of the foot at the moment of axial load. (Reproduced with permission from Rockwood CA, Green DP, Bucholz RW.
Rockwood and Greens Fractures in Adults. 6th ed. Philadelphia,
PA: Lippincott Williams & Wilkins, 2006.)
Treatment
Gross m alalign m en t an d associated dislocation s sh ould be
reduced im m ediately an d th e lim b im m obilized. Th is reduces th e patien t pain an d m in im izes addition al soft tissue traum a. Frequen tly, soft tissue swellin g and injury pre-
Classification
Th ere are a n um ber of classification s system s used, but th e
Weber an d Lauge Hansen system s receive the m ost recogn ition. The Weber system is based on th e level of the fibula
fracture: type Aare below the level of the syn desm osis, type
B fractures are at the level of the syn desm osis, and type
C fractures are above the level of th e syndesm osis (Fig.
19.11). Type C fractures are m ost likely to be associated
with a sign ifican t syn desm otic in jury. Th e LaugeHansen
classification system is based on th e m ech an ism of an kle
fractures. Injuries to bon es and soft tissues structures are
taken in to accoun t. Th e term in ology describes th e position
of th e foot at th e m om en t of in jury an d th en th e direction of the deform ing force (Fig. 19.12). For instance, in a
supin ation-external rotation (SER) injury, th e foot is in
Figure 19.11 The Weber classification of ankle fractures depends on the level of the fibula fracture in relation to the syndesmosis. (Reproduced with permission from Rockwood CA, Green DP,
Bucholz RW. Rockwood and Greens Fractures in Adults. 6th ed.
Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
764
External rotation
Adduction
I
Anterior tibfib sprain
Talofibular sprain or
avulsion of distal fibula
Transverse fibula
or rupture
of talofibular ligaments
II
II
Stable short oblique fracture
of the distal fibula
III
Similar to II with additional
rupture of posterior tibfib
ligament or fracture of
posterior margin
Posterior
malleolus
or
posterior tib
fib ligament
IV
Unstable short oblique
fracture of the distal
fibula with a medial
malleolus fracture or
a deltoid ligament disruption
Medial malleolus
or
deltoid
Figure 19.12 The LaugeHansen classification system is commonly used for the description of ankle fractures. The system identifies
the position of the foot at the time of injury as either supinated (A) or
pronated (B) followed by the direction of forces acting on the ankle.
(Reproduced with permission from Rockwood CA, Green DP, Bucholz
RW. Rockwood and Greens Fractures in Adults. 6th ed. Philadelphia,
PA: Lippincott Williams & Wilkins, 2006.)
765
Pronated foot
External rotation
Adduction
I
Isolated medial malleolus
or deltoid ligament rupture
Medial malleolus
fracture
or
deltoid rupture
Medial malleolus
or
deltoid
II
II
Chaput's
tubercle
or
anterior
tibfib
ligament
Chaput's
tubercle
or
anterior tibfib
III
III
Transverse or
laterally comminuted
fibula with
medial injury.
Anteriolateral tibial
impaction is
also possible
IV
Similar to stage
III with a posterior
malleolus or tibfib
ligament injury
Posterior malleolus
or
posterior tib
fib ligament
766
Mechanism of Injury
Ankle fractures usually result from low-en ergy forces that
have a rotational component as seen in athletic activities
or sligh t falls.
Presentation
Patien ts present with acute ankle pain and swellin g and,
often , th e in ability to bear weigh t.
Physical Examination
Ecchym osis and swelling are usually present. Obvious deform ity is a sign of an associated dislocation. Impendin g
open an d open in juries are un com m on , but a th orough
exam in ation of th e skin is im perative. A n eurovascular exam in ation is required before an d after any m an ipulation
Imaging
Stan dard radiograph s are sufficien t for m ost an kle in juries.
Stress radiograph s h elp rule out a syn desm osis in jury. Th e
Ottawa Ankle Rules provide direction as to when radiograph s are in dicated. Th ese four rules drastically decreased
the num ber of radiographs perform ed in em ergen cy departm en ts wh ile m ain tain in g 100% sen sitivity. If a patien t
is 55 years or older, un able to bear weight, or has bon e tendern ess alon g th e posterior edge or tip of eith er m alleoli, a
radiograph is in dicated. In a n orm al an kle, th e talus sh ould
sit under th e tibia with a tibiotalar space that is equal to the
distan ce from lateral border of th e m edial m alleolus to th e
m edial border of th e talus on the m ortise view, or approxim ately 4 m m (Fig. 19.13AD). Any tran slation of th e talus
indicates an unstable fracture pattern . The talocrural angle helps to judge fibular length and is usually 83 degrees
(Fig. 19.13B). Th e tibiofibular clear space is th e best way to
evaluate an un stable syn desm osis in jury on radiograph . It
is the distance between the m edial fibula and the incisura
of th e tibia m easured 1 cm above th e join t; it sh ould be
less th an 6 m m (Fig. 19.13D). This m easurem ent is m inim ally affected by rotation. The entire length of th e tibia
an d fibula should be im aged if there is any concern for a
proxim al fracture lin e.
Differential Diagnosis
A pilon fracture, simple an kle dislocation , subtalar dislocation, and even severe ankle sprain can also present with
eith er a deform ity or an an kle swellin g. In addition , patients m ay describe an kle pain , when in reality the foot is
the site of pathology, for example, in a fracture of the base
of th e fifth m etatarsal. Appropriate im agin g studies aid in
determ in in g th e correct diagn osis.
Treatment
If th e in jury is a fracture-dislocation , th e an kle sh ould be
reduced im m ediately. Defin itive treatm en t is depen den t
on stability of th e fracture pattern . Stable fibula fractures,
displaced less th an 5 m m , with out a m edial an kle in jury
can be treated with a walking cast or a fracture boot for
6 weeks. A fracture boot is n ecessary on ly for am bulation
an d thus can be rem oved for ran ge-of-m otion exercises to
preven t stiffn ess. It is importan t to repeat radiograph s at
1 week to ensure there is n o late displacem en t. For un stable fractures, operative in terven tion is recom m en ded. Th e
fibula is usually approach ed first. Wh en possible, an in terfragm en tary screw sh ould be placed from th e proxim al
fragm ent into the distal fragm ent and perpendicular to the
fracture line. A n eutralization plate provides rotational stability to th e con struct. Recen tly, th ere h ave been a n um ber
767
Mortise view
4 mm
Normal
Talocrural angle
(83 4)
Medial
clear space
B
B
Ant
Tibiofibular
clear space
(A-B)
ankle stability. The normal ankle (A). The talocrural ankle estimates fibula
length and is most accurate when compared with the uninjured side (B).
The medial clear space should be equal to the space between the tibia and
talus or 4 mm or less (C). The tibiofibular clear space is the most reliable
radiographic finding (D). It should measure less than 6 mm. (Reproduced
with permission from Rockwood CA, Green DP, Bucholz RW. Rockwood and
Greens Fractures in Adults. 6th ed. Philadelphia, PA: Lippincott Williams &
Wilkins, 2006.)
768
Classification
It is easiest to divide an kle sprain s in to acute in juries
an d ch ron ic in stability. Ch ron ic in stability results from repeated sprain s an d m an ifests as persisten t pain an d a feelin g of givin g way. Acute sprain s are graded on th e basis of
severity. In grade I in juries, the ATFLis stretched or partially
torn , with out complete disruption . Pain , swellin g, an d ten dern ess over th e ATFLare ch aracteristic of th is in jury. Th ere
is, h owever, n o laxity appreciable on physical exam in ation .
Grade II in juries in volve a complete tear of th e ATFL an d
m ay in clude in jury to th e CFL. Laxity m ay be eviden t. In
grade III in juries, th e ATFL an d CFL are torn , an d th e PTFL
or an terolateral capsule of th e an kle join t m ay also be affected. There is a complete loss of the n orm al hindfoot
contours due to swelling.
Mechanism of Injury
Th e n orm al m ech an ism for lateral sided in juries is
plan tarflexion -in version . In version in juries occurrin g with
the ankle positioned in n eutral or in dorsiflexion create isolated CFL disruption or subtalar dislocation . An extern al
rotation -eversion in jury m ay cause a sprain of th e deltoid
an d syn desm otic ligam en ts. Isolated syn desm osis in juries
result from dorsiflexion -eversion in juries.
Presentation
Th e patien ts typically presen t with pain , swellin g, an d ecchym osis over th e lateral side of th e an kle depen din g of
the severity of injury. With higher grades of injury, patien ts
ten d to h ave sign ifican t difficulty bearin g weigh t.
Physical Examination
Th e origin s an d in sertion s of th e an kle ligam en ts sh ould
be palpated, but th is can be difficult in th e presen ce of
significant swelling. As pain allows, the ankle is tested for
eviden ce of in stability. Th e an terior drawer test, a test of th e
ATFL, is perform ed with the ankle in 10 degrees of plantarflexion . Wh ile stabilizin g th e tibia, an an teriorly directed
force is applied to th e hindfoot. Translation of the talus is
an in dication of in competen ce of th e ATFL an d is m easured in m illim eters. Grade I in juries h ave m in im al tran slation with a firm en dpoin t. Grade II in juries h ave laxity
but a firm en dpoin t, wh ereas grade III in jures h ave a soft
en dpoin t. For th e talar tilt test, wh ich stresses th e CFL, th e
hindfoot is inverted with the an kle h eld in m axim al dorsiflexion. Translation an d tilt of the talus with varus stressin g
is compared with th e un in jured side.
The fibular squeeze test, perform ed by squeezing th e
fibula an d tibia togeth er at th e m idpoin t of th e calf, elicits
pain with syn desm osis in jury. Th e extern al rotation test,
in wh ich th e foot is extern ally rotated with th e an kle in
neutral flexion and th e knee flexed to 90 degrees, produces
pain over th e in terosseous m em bran e an d distal tibiofibular join t wh en a syn desm osis in jury is presen t.
Imaging
Stan dard th ree an kle views are obtain ed to rule out fracture
or fran k tran slation of th e talus. Stress views can be h elpful
to diagn ose ligam en t tears of th e lateral side of th e an kle.
Anterior translation of greater than 5 m m is considered
abn orm al. There is no consen sus on the degree of talar tilt
that is abnorm al, but if there is doubt, a stress radiograph
of th e un in jured an kle can be taken for com parison . To
assess syndesm otic injury, weight-bearing radiographs and
extern al rotation stress views can be obtain ed to evaluate
m ortise widen ing.
Differential Diagnosis
Th e differen tial diagn osis of lateral h in dfoot in juries associated with a plantarflexion-in version m echanism includes
peron eal ten don tears, peron eal ten don subluxation or dislocation , and fractures of th e an terior process of the calcan eus, base of th e fifth m etatarsal, lateral process of th e
talus, an d os trigon um .
Treatment
Grade I an d II an kle sprain s are un iform ly treated with rest,
ice, compression, elevation, (RICE) an d protected weightbearin g for 5 to 7 days, followed by physical th erapy em ph asizin g proprioception usin g tram polin es or wobble
boards, stren gth en in g, an d stretch in g. Th e reh abilitation
protocol th en focuses on agility an d sport-specific exercises to return the patient to the previous level of ath letic
activity and prevent recurrent sprains. Grade III sprains are
treated with a brief period of im m obilization followed by
reh abilitation , fun ction al reh abilitation alon e, or surgical
repair. Im m obilization for 3 weeks with eith er a walkin g
cast or a rem ovable walker boot with th e ankle in n eutral
or 10 degrees of dorsiflexion to approxim ate th e torn en ds
of th e ATFL sh ould be reserved for low-dem an d patien ts.
After the period of im m obilization, rehabilitation is the
sam e as that for grade I and II injuries. For athletes, it is
best to avoid im m obilization an d associated stiffn ess, by
initiatin g early m obilization with the protection of an extern al support, such as a lace-up brace or Aircast. Tapin g is
less effective as it loosens rath er rapidly during athletic activity. Patients treated with early m obilization h ave higher
satisfaction rates th an those treated with cast im m obilization and return to sports earlier. While there is no good
eviden ce to support it, an atom ic repair is an option for
h igh -perform ance ath letes.
Ch ron ic an kle in stability requires surgery wh en fun ctional rehabilitation fails to relieve pain and symptom s of
giving way. Surgical reconstruction can be either an atom ic
or n on an atom ic. An atom ic recon struction s recreate n orm al ankle and subtalar m otion and m echan ics, whereas
n on anatom ic reconstruction s do n ot. Th e Brostrum procedure is th e m ost popular an atom ic procedure, in wh ich
the ruptured ligam en t en ds are im bricated an d retension ed. Variation s in clude shortening the ligam en ts due to
attenuation an d reinforcem ent with the exten sor retinaculum (Gould m odification ) or fibular periosteum . There are
a num ber of n on-an atom ic reconstruction s that use a portion of the peroneus brevis tendon, free gracilis autograft
ten don , or an allograft ten don to stabilize th e lateral an kle.
Th ese m ore robust recon struction s h ave a greater complication rate with m otion loss, woun d healing, an d sural nerve
injury as the m ost com m on. At the tim e of surgical interven tion, all patien ts should un dergo an ankle arthroscopy, as
the rate of intraarticular pathology associated with chron ic
instability is as high as 90%. Injuries include osteoch on dral
lesions of the talus, chondrom alacia, m eniscoid lesions,
an d an terior impin gem en t from osteophytes. Appropriate
treatm ent of these associated injuries increases the chance
of successful resolution of sym ptom s.
proximal to the insertion on the calcaneus, which is a relative hypovascular zone. (Reproduced with permission from Kitaoka HB.
The Foot and Ankle. 2nd ed. Philadelphia, PA: Lippincott Williams
& Wilkins, 2002.)
769
Presentation
Patien ts presen t after a severe, sudden pain in th e back
of th e calf th at is described as bein g struck from beh in d
and is often associated with swelling. Unfortunately, the
pain resolves rath er quickly an d som e m ay still be able to
participate in sportin g activities, wh ich con tributes to th e
25% rate of m issed an d delayed diagn oses.
Physical Examination
Diagn osis is m ade by palpatin g a defect 2 to 6 cm above
th e in sertion of th e Ach illes ten don . It is often accen tuated
by holding the foot in m axim al dorsiflexion , which places
th e Ach illes on stretch . In obese patien ts an d in dividuals
with severe swellin g, a gap m ay n ot be eviden t. Stren gth
of th e gastrocsoleus com plex can be tested by h avin g th e
patien t perform a sin gle-leg h eel rise or by testin g plan tarflexion again st resistan ce. Because of th e participation
of th e posterior tibialis m uscle an d toe flexors, patien ts can
h ave rather sign ifican t plan tarflexion stren gth even with an
Ach illes rupture.
Havin g the patien t lie prone on the exam ination table
is helpful. Th e passive restin g tension of the tendon and
position of th e foot sh ould be n oted. With a defect in th e
Ach illes ten don , th e foot rests at 90 degrees to th e body
com pared with th e un affected extrem ity, wh ich rests in relative plantarflexion. Asim ilar observation can be m ade with
th e kn ee flexed to 90 degrees accordin g to th e Matles test.
Th e torn side will fall in to relative dorsiflexion with gravity and th e loss of tension from the Achilles tendon. The
Th ompson , or calf squeeze, test is perform ed by squeezin g
th e m id portion of th e gastrocn em ius, wh ich sh ould result
in passive plantarflexion of the foot if th e Achilles tendon
is in con tinuity (Fig. 19.15).
gastrocsoleus complex. When intact the complex is intact, squeezing the midcalf results in plantarflexion of foot. (Reproduced with
permission from Rockwood CA, Green DP, Bucholz RW. Rockwood
and Greens Fractures in Adults. 6th ed. Philadelphia, PA: Lippincott
Williams & Wilkins, 2006.)
770
Radiographic Findings
Radiograph s m ay reveal blun tin g of th e retrocalcan eal
space or rarely a bony avulsion fracture of th e posterior
calcaneus.
Special Tests
If th ere is any con fusion in th e diagn osis, ultrasoun d an d
MRI are useful in evaluatin g th e con tin uity of th e ten don .
MRI also provides th e added ben efit of revealin g any degen erative ch an ges of th e ten don th at m ay h ave played a role
in th e rupture. In up to 25% of cases, patien ts report previous symptom s in th e Ach illes. Path ological studies h ave
in dicated all ruptured ten don s h ave som e degree of degen eration prior to rupture.
Treatment
Historically, Achilles tendon injuries were treated non operatively because of woun d complication rates approach in g
30%. However, m ore recen tly, th e relatively h igh rerupture
rates have lead surgeons to surgical in tervention. Nonoperative treatm en t typically in volves 6 to 8 weeks in a n on
weigh t-bearing cast with the foot in gravity equinus followed by an addition al 4 weeks in a walkin g cast. After th is
period of im m obilization , a supportive lace-up sh oe with a
heel lift is worn for an addition al 1 to 2 m on th s. Som e authors support weight-bearing from the outset of treatm ent
an d th e use of fun ction al bracin g rath er th an castin g. Th e
advan tage of n on operative m eth ods is th e avoidan ce of surgical complication s, m ost n otably woun d breakdown an d
in fection . Th e m ajor disadvan tage of n on operative treatm en t is th e rerupture rate of approxim ately 13%. Oth er disadvan tages in clude a lon ger tim e before return in g to work
an d activity.
The high rates of woun d complication s have often deterred surgeon s from pursuin g surgery for th e treatm en t
of Ach illes ten don ruptures. However, with advan ces in
tech n iques, th ese rates h ave dropped. Th ese in juries can
be approach ed in an open fash ion or percutan eously an d
sh ould be repaired within 7 to 14 days. When perform in g th e surgery open , it is imperative to respect th e soft
tissue en velope. Th e ten don is repaired en d-to-en d, usin g
a Krackow stitch with n on absorbable h eavy suture. Obtain in g appropriate ten sion of repair is difficult but usin g
the plantaris tendon and observing the resting posture of
the foot can be helpful. The paratenon should be closed
over th e repair, an d th e skin flaps sh ould be closed with a
no-touch technique. Som e have advocated for augm en tation of th e repair with gastrocn em ius fascia, th e plan taris,
or artificial m aterials; h owever, th ese h ave yet to h ave a
proven ben efit. Wh ile percutan eous tech n iques m ay h ave
less woun d complication s, th e suture placem en t m ay n ot be
optim al an d th ere is a greater ch an ce of sural n erve in jury.
O perative in terven tion also allows for early fun ction al rehabilitation (weight-bearin g an d range of m otion), wh ich
is th ough t to h asten th e h ealin g of th e ten don .
Talus Fractures
Fractures of th e talus are typically h igh -en ergy in juries th at
are difficult to treat and can be debilitating even when
treated appropriately. Fractures can involve th e head, n eck,
body, lateral process, an d posterior process. Displaced body
an d neck fractures require extra diligence and are treated as
em ergen cies due to th e associated com plication s.
Classification
Talus fractures are m ost easily divided by the anatom ic location, that is, head, neck, body, lateral process, and posterior process. Talar n eck fractures are furth er classified on
the basis of a description by Hawkins, which was subsequen tly m odified by Can ale (Fig. 19.16). Type I fractures
are nondisplaced fractures without an associated join t dislocation . Type II fractures are displaced with subluxation
or dislocation of th e subtalar join t. Type III fractures h ave
dislocation s of th e subtalar join t an d th e an kle. Type IV
fractures have dislocations of th e subtalar, ankle, and talon avicular joints. The risk of osteonecrosis increases with th e
injury grade such th at nearly all type IV fractures develop
osteon ecrosis.
Mechanism of Injury
Talar n eck fractures, historically referred to as aviator astragalus, result from hyperdorsiflexion with an axial load usually from a fall from height or a m otor vehicle crash. As the
771
Presentation
Wh en resultin g from h igh -en ergy traum a, patien ts will h ave
swellin g and deform ity if a dislocation is presen t. Lowen ergy m ech an ism s m ay presen t sim ilar to an kle fractures
or sprain s.
Physical Examination
A th orough n eurovascular an d skin exam in ation is imperative. It is importan t to rule out other injuries that require
em ergen t treatm en t.
Imaging
AP, lateral, an d m ortise views of th e an kle provide good
visualization of the talar body, n eck, and processes. Additional inform ation con cern ing the m edial talar n eck can
be obtain ed by position in g th e an kle in plan tarflexion , th e
foot in 15 degrees of pronation , and directing the beam 75
degrees to the perpen dicular (Fig. 19.17). This view is especially h elpful in th e operatin g room to con firm adequate
reduction . CT can h elp to furth er defin e th e fracture pattern an d plan surgical reduction . MRI is less useful acutely
but is a sen sitive test for avascular n ecrosis.
Differential Diagnosis
Low-energy in juries such as lateral process fractures can
resem ble an kle sprain s an d fractures due to th eir sim ilar m echanism of injury. The swelling and ecchym osis of
772
75
15
Figure 19.17 The Canale and Kelly view for evaluation of the
high-energy m ech anism s can resem ble calcan eus an d pilon fractures.
Treatment
Talar neck and body fractures are true orthopaedic em ergen cies. Displaced fractures an d join t dislocation s require
im m ediate reduction to decrease th e risk of osteon ecrosis
an d protect th e overlyin g soft tissue. Th e goal of defin itive
treatm en t is to m ain tain an atom ic reduction wh ile m in im izin g posttraum atic arth rosis, osteon ecrosis, an d varus
m alalign m en t. Varus m alalign m en t greater th an 5 degrees
an d displacem en t m ore th an 5 m m h ave adverse effects on
the kinem atics of the h indfoot.
All displaced talar neck fractures require reduction and
surgical fixation . Nondisplaced fractures can be treated
successfully closed but m ust be m on itored closely with
serial im aging. Non weight-bearin g is m aintained for at
least 6 weeks or un til th ere is eviden ce of revascularization .
Surgical fixation can be perform ed eith er percutan eously
through a posterolateral approach or open via an anterom edial approach . In th e an terom edial approach , th e in terval of dissection is between th e tibialis an terior ten don
an d th e tibialis posterior ten don . Th is allows for adequate
visualization of th e m edial aspect of th e n eck an d can be
exten ded by a m edial m alleolar osteotomy. Fixation con structs are usually screws supplem ented with sm all plates
if com m in ution is presen t. Postoperatively, th e patien t is
im m obilized an d m ade n on weigh t-bearin g for at least 6
weeks. To avoid stiffn ess early range of m otion can be initiated.
Sign s of osteon ecrosis typically m an ifest by 8 to 10
weeks. The Hawkins, or crescent, sign seen on AP an d m ortise radiograph s is an in dication of a viable talar body. With
sufficien t vascularity th e talar body will be relatively os-
773
Presentation
Th e h igh est in ciden ce occurs in th e th ird decade of life.
Complaints of chronic ankle pain with or without interm ittent swelling an d instability after an episode of m inor
traum a such as an inversion ankle sprain is com m on. Locking can occur if the lesion becom es displaced.
Physical Examination
Th e an kle sh ould be exam in ed for sign s of join t laxity. An terolateral lesion s can be ten der to palpation with th e an kle
in m axim um plantarflexion. Tenderness behind the m edial
m alleolus with the foot in m axim um dorsiflexion can be a
sign of a posterom edial lesion .
Radiographic Findings
Stan dard an kle radiograph s are sufficien t to diagn ose lesions with evidence of a subch on dral fracture (Fig. 19.18),
subch on dral cysts, or localized sclerosis.
on a standard radiograph. (Reproduced with permission from Kitaoka HB. The Foot and Ankle. 2nd ed. Philadelphia, PA: Lippincott
Williams & Wilkins, 2002.)
posteromedial lesion of the talar dome. (Reproduced with permission from Kitaoka HB. The Foot and Ankle. 2nd ed. Philadelphia,
PA: Lippincott Williams & Wilkins, 2002.)
Special Tests
MRI is highly sensitive for iden tifyin g lesions before
changes are apparent on radiographs (Fig. 19.19). MRI has
th e added ben efit of providin g in sigh t in to th e stability an d
viability of the fragm ent. A CT scan can be useful for surgical planning and accurately iden tifyin g the location and
exten t of th e bon e lesion .
Treatment
Stage I and II lesions are treated with im m obilization in a
n on weigh t-bearin g sh ort-leg cast for 6 to 12 weeks. Non operative treatm en t is effective in less th an 50% of cases
overall. Stage III an d IV lesion s an d stage I an d II lesion s
th at do n ot respon d to n on operative treatm en t sh ould be
treated operatively either arthroscopically or through an
open approach . Treatm en t option s in clude ch on droplasty,
debridem en t an d in tern al fixation , an terograde or retrograde drillin g, excision with m arrow stim ulation , excision
with osteoch on dral tran splan tation , or excision alon e. Th e
stability of the lesion , size of the lesion , an d condition of
th e cartilage determ in e outcom e.
Ch ondroplasty is the simplest intervention . The goal
is to restore a stable edge to the lesion . Drilling of the
subch ondral lesion to stim ulate healing can be perform ed
usin g eith er an an terograde or retrograde tech n ique. Retrograde drillin g tech n iques avoid in jury to th e cartilage. If
th e fragm en t is n ot salvageable, it sh ould be excised an d th e
lesion debrided. The resulting defect is treated with a m icrofracture tech n ique to stim ulate fibrocartilage form ation .
Altern ative option s in clude th e tran splan t of osteoch on dral autograft plugs taken from th e n on weigh t-bearin g
portion of th e kn ee in to th e defect or th e use of autologous
chon drocyte transplantation.
774
There have been no good studies comparing the outcom es of the various treatm en t m ethods; however, th ere
does appear to good sh ort-term results regardless of th e
treatm en t tech n ique.
Calcaneus Fractures
Th e calcan eus is th e m ost com m on ly fractured tarsal bon e
usually resultin g from axial loadin g durin g falls or m otor veh icle crash es. Seven ty-five percen t of th ese fractures
are in traarticular an d com m in uted, m akin g th em ch allen gin g to treat. Th e severity of th ese in juries is h igh ligh ted
by th e fact th at 25% of patien ts will have an associated
lower extrem ity fracture an d 10% a spin e fracture. Un fortun ately, even appropriate treatm en t can result in lon g-term
disability.
Classification
Fractures were h istorically classified accordin g to radiograph s but are n ow m ore com m on ly classified by in form ation obtain ed with a CT scan . Fractures are divided in to
extraarticular or in traarticular types. Extraarticular fractures
in volve th e an terior process, th e tuberosity, th e body, th e
m edial process, an d th e lateral process. In traarticular fractures based on radiograph s are divided in to ton gue-type
an d join t-depression -type fractures. With th e ton gue-type
fractures, th e posterior facet rem ains attach ed to th e tuberosity fragm en t, wh ereas in th e join t-depression -type, th e
fragm ents are separate. Th e m ost com m only used classification for intraarticular fractures is the San ders classification based on coron al CT im ages taken th rough th e widest
aspect of th e posterior facet (Fig. 19.20). Th e location an d
num ber of fragm en ts determ in es the type. The posterior
facet is divided in to th ree colum n sth e lateral, cen tral an d
m edialor A, B, an d C, respectively. Non displaced fractures
regardless of th e n um ber of fracture lin es are type I. Type
II, III, an d IV fractures h ave two, th ree, an d four fracture
lin es, respectively. Each type is th en am en ded on th e basis
of wh ere th e in dividual fracture lin es en ter th e join t with
the letters A, B, and C.
Mechanism of Injury
High-energy injures includin g falls from h eights and m otor veh icle crash es are th e usual cause of calcan eal fractures.
Because of the force involved, th ey are often associated with
spin e fractures. The position of the foot determ in es th e exact fracture pattern . As th e lateral talar process is driven in to
the superior calcaneal surface, a prim ary fracture line runs
from th e posterior facet in a lateral to posterom edial direction , creatin g an terom edial an d posterolateral fragm en ts.
Th e an terom edial fragm en t usually con tain s th e susten taculum tali, wh ich is n on displaced because of its attach m en ts
to th e talus via th e in terosseous ligam en t, an d is often called
the constant fragm ent. Secondary fracture lines m ay
Presentation
Pain and swelling m ay be the only presenting complaints
for low-energy injuries such as those of the anterior process and tuberosity. Patients with h igh-en ergy, intraarticular fractures are often in significant pain and have obvious
deform ities. In addition , th ese patien ts often h ave oth er
injuries.
Physical Examination
Determ in in g th e appropriate tim in g an d treatm en t for calcaneus fractures requires adequate assessm ent of th e soft
tissues. Fracture blisters, open wounds, an d compartm ent
syn drom e effect h ow th ese injuries are approached. It is essential to respect th e soft tissue envelope, as failure to do so
h as devastatin g consequen ces. Patien ts sh ould be evaluated
for lower extrem ity fractures. The entire spine, especially the
lum bar spine, should be inspected and palpated.
Imaging
AP, lateral, the Harris h eel, and Broden views should be
initially taken for diagnosis. In addition, radiographs of
the pelvis and thoracolum bar spine m ay be indicated to
rule out associated fractures. Helpful radiographic angles,
the tuber angle of Bo h ler, an d th e crucial an gle of Gissan e are m easured on the lateral view (Fig. 19.21). The
tuber angle of Bo h ler is form ed by th e m ost posterosuperior aspect of th e calcan eal tuberosity, th e posterior facet,
an d th e anterior process and is norm ally 20 to 40 degrees.
With fracture and collapse of the posterior facet, this angle decreases. The crucial an gle of Gissane is form ed by
lateral m argin of the posterior facet and a strut of bone
leading to the beak of the calcaneus and usually m easures
about 100 degrees. With fracture of the posterior facet and
collapse the angle increases. The Harris heel view assesses
the loss of height, increase in width , and m alalignm en t of
the calcaneal tuberosity, usually into varus (Fig. 19.22). The
Broden view h elps to assess th e status of th e posterior facet.
Th e view is sim ilar to a m ortise view of th e an kle with th e
foot in internal rotation, an d by changing the angle x-ray
beam , differen t aspects of th e posterior facet are visualized
(Fig. 19.23). With th e wide availability of CT scans, they are
n ow becom in g a stan dard radiograph ic study. Th ese scans
provide fast an d accurate views of th e fracture pattern an d
am ount of displacem ent of the posterior facet that is critical
in directin g surgical interven tion.
Ce ntral
Med.
Su
st
.
Lateral
A B C
Typ e IIA
A B
Typ e IIB
Typ e III AB
Typ e IIC
BC
Typ e III AC
Typ e III BC
A B C
Type IV
Figure 19.20 The Sanders classification of calcaneus fractures. This is based on coronal computed
tomography images taken through the widest aspect of the posterior facet, which is divided into
three columns (AC). The number of displaced fractures determines the subtype. (Reproduced with
permission from Rockwood CA, Green DP, Bucholz RW. Rockwood and Greens Fractures in Adults.
6th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
775
776
Figure 19.21 The crucial angle of Gissane (A) and the tuber angle of Bohler
calcaneus fractures and to evaluate adequacy of reduction. (Reproduced with permission from Rockwood CA, Green DP, Bucholz RW. Rockwood and Greens Fractures in Adults. 6th ed. Philadelphia,
PA: Lippincott Williams & Wilkins, 2006.)
Differential Diagnosis
High-energy in juries are usually obvious. Anterior process
fractures can be m istaken for ankle sprains.
Treatment
Calcan eus fractures are ch allen gin g to treat, an d th is is
m ade m ore complicated by a lack of con sen sus on acceptable treatm ent. Nonoperative treatm ent is typically reserved for n ondisplaced fractures. However, recen t studies
have shown better functional outcom es with nonoperative
treatm en t for sm okers, laborers, patien ts in volved in workers com pen sation suits, bilateral in juries, an d fractures
with significan t com m in ution of th e posterior facet. Cast
im m obilization for approxim ately 3 m on th s is required
ankle and helps in assessment of the posterior facet. An intraarticular fracture is denoted with arrows. (Reproduced with permission
from Rockwood CA, Green DP, Bucholz RW. Rockwood and Greens
Fractures in Adults. 6th ed. Philadelphia, PA: Lippincott Williams &
Wilkins, 2006.)
Navicular Fractures
Th e tarsal n avicular bon e is an importan t structure of th e
m edial colum n involved in both hindfoot m otion through
its articulation with the talus and m ain ten ance of the longitudin al arch via the cuneiform s. Navicular fractures are
classified as dorsal lip, tuberosity, body, and stress fractures.
AP, lateral, and m edial oblique radiographs of the foot are
usually adequate for diagn osis.
Dorsal lip fractures are th e m ost com m on , occurrin g
from an eversion m echan ism , resulting in talonavicular
join t capsule an d deltoid ligam en t avulsin g a fragm en t of
bon e. Th e fracture fragm en t is best iden tified with a lateral radiograph . Th e differen tial diagn osis in cludes an accessory ossicle of the navicular and talus. The m ajority of
cases are treated with a short-leg walking cast for 4 to 6
weeks. With sign ifican t articular surface in volvem en t, O RIF
sh ould be perform ed. Persistent displacem en t can generate
a painful prom inence and is treated with excision.
Tuberosity fractures result from an eversion m ech an ism
an d eccentric contraction of the posterior tibial tendon.
Local tenderness is elicited, and there is pain on resisted
777
Cuboid Fractures
Cuboid fractures are typically associated with other injuries
of th e m idfoot an d rarely occur in isolation . Th e two com m on pattern s are the avulsion type and compression injuries to th e cuboid. Th e avulsion -type in jury results from
778
Lisfranc Injuries
In juries to th e tarsom etatarsal join t, or Lisfran c join t, in clude a spectrum from subtle sprains to fran k dislocation s. Un fortun ately, even wh en appropriately diagn osed
an d treated with an atom ic reduction of th e join t, fun ction al
outcom es can be poor, especially with h igh -en ergy in juries.
Th e tarsom etatarsal join t complex is composed of th e th ree
cuneiform s, the cuboid, and the five m etatarsal bases. The
bony arch itecture is sim ilar to th at of a Rom an arch in design and stability. The keystone of the arch is the second
m etatarsal, wh ich h as a wedge-sh aped base recessed between th e m edial an d lateral cun eiform s. Th e stron g plan tar in terosseous ligam en ts an d tran sverse in term etatarsal
ligam en ts furth er support th e stable bon e con figuration .
Th e in term etatarsal ligam en ts con n ect th e four lesser
m etatarsal; h owever, th ere is n o such ligam en t between th e
first an d secon d m etatarsal. Th e Lisfran c ligam en t span s th e
plan tarlateral aspect of the m edial cun eiform to the m edial base of th e secon d m etatarsal an d fun ction s to resist
lateral tran slation of th e lesser m etatarsals (Fig. 19.24). Th e
first m etatarsalm edial cun eiform join t is stabilized by th e
join t capsule an d by th e in sertion s of th e an terior tibialis
an d peron eus lon gus ten don s. Th e lack of ligam en tous support between th e first an d secon d m etatarsal ren ders it susceptible to injury and is the weak link of th e tarsom etatarsal
join t complex. Successful treatm en t is m ost depen den t on
restorin g an d m ain tain in g th is an atomy.
Classification
A num ber of classification system s have been proposed;
however, not a single classification system provides an algorith m for treatm en t or progn ostic value. Quen u an d Kuss
described th ree types based on th e pattern of displacem en t
of th e m etatarsalsisolated, h om olateral, an d divergen t
(Fig. 19.25). In isolated type, on e or two of th e m etatarsals
displaces relative to th e oth ers. Hom olateral refers to all
of th e m etatarsals displacin g eith er m edially or laterally.
In th e divergen t type, th e first ray is displaced m edially
while the lesser ones laterally. It is probably m ost h elpful to
divide th ese in juries in to purely ligam en tous an d th ose in -
Mechanism of Injury
Both direct an d in direct m ech an ism s h ave been described
(Fig. 19.26). The direct m echan ism is a crush injury to the
dorsum of th e foot, resultin g in plan tar displacem en t of
the m etatarsals. High-energy traum a and heavy crush injuries produce sign ifican t in jury to th e soft tissue, vascular injuries, compartm ent syndrom es and open wounds.
Axial an d rotational loading on a plantarflexed foot can
injury th e Lisfranc joint in directly. This pattern is seen in
m otor vehicle crashes, equestrian in juries, falls, and during
sports participation . Th e m etatarsals are usually displaced
laterally and dorsally. With abduction of the forefoot, the
cuboid can be fractured.
Presentation
Patients with low-energy injuries usually complain of pain
in th e m idfoot and inability to bear weight after a twisting
injury to the foot. Crush m echanism s are m ore obvious,
an d th ese patients m ay also have other injuries.
Physical Examination
Up to 20% of th ese injuries are m issed on initial evaluation because of th eir broad spectrum of presen tation .
Gross deform ity of th e m idfoot m ay n ot be apparen t if
there was spontaneous reduction. Tendern ess, ecchym osis, and swellin g over th e tarsom etatarsal join ts are typical.
Pron ation -abduction stress m ay recreate th e pain an d deform ity. Incon gruity an d crepitus of the m idfoot is n oted
on severely un stable in juries. Careful in spection of th e
soft tissues an d a thorough neurovascular exam in ation is
779
Figure 19.25 Quenu and Kuss classified Lisfranc injuries as homolateral, isolated, or divergent.
(Reproduced with permission from Rockwood CA, Green DP, Bucholz RW. Rockwood and Greens
Fractures in Adults. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
Imaging
AP, lateral, and 30-degree m edial oblique radiographs
are obtain ed to evaluate the in jury. On the AP, the first
m etatarsal should line up with the m edial cuneiform an d
the m edial border of th e second m etatarsal base should
line up with the m edial aspect of the m iddle cuneiform . An
avulsion fracture from the base of the second m etatarsal,
from the pull of the Lisfranc ligam ent, is diagnostic for the
injury occurring in m ore than 90% of cases. On the oblique
view, the lateral border of the third m etatarsal sh ould
line up with th e lateral edge of the lateral cuneiform and the
m edial aspect of the fourth m etatarsal should align with the
m edial aspect of th e cuboid. On the lateral view, the dorsal
borders of th e first an d secon d m etatarsals sh ould lin e up
with th eir respective cun eiform s with out eviden ce of stepoff. Because th ese in juries m ay spon tan eously reduce, it is
best to obtain weigh t-bearin g, sim ulated weigh t-bearin g,
or stress views to iden tify in stability of th e tarsom etatarsal
join t com plex if n on weight-bearin g radiographs are norm al (Fig. 19.27). Comparison views or CT scans are helpful
wh en th e in jury is subtle.
Differential Diagnosis
Th e differen tial diagn osis in cludes n avicular fracture,
cuboid fracture, second m etatarsal base fracture, stress fracture, and rupture of the posterior tibialis tendon.
Treatment
Th e m an agem en t of tarsom etatarsal join t in juries in volves
obtain in g a stable, pain less plan tigrade foot by m ean s of
anatom ic restoration of articular congruency. Treatm ent
option s ran ge from closed reduction an d cast im m obilization for nondisplaced in juries to ORIF for displaced injuries. Given th at K-wire fixation frequen tly fails, th ese are
best stabilized with screw fixation . All fracture-dislocation s
sh ould be reduced an d im m obilized urgently to m inim ize
th e risk of vascular an d soft tissue com prom ise. In cision s
are m ade over the first an d third interm etatarsal spaces on
th e dorsum of th e foot. Care sh ould be taken to m ain tain th e soft tissue bridge between . Reduction an d prelim inary fixation starts m edially and proceeds laterally. After
con firm in g an atom ic reduction with appropriate im agin g,
defin itive screw fixation follows. If th ere is in stability of
th e fourth an d fifth tarsom etatarsal join ts, th ese sh ould
be reduced an d h eld with K-wires (Fig. 19.28). Th e lateral side of th e foot is rath er m obile; th erefore, screw fixation is too rigid. If a nutcracker injury to the cuboid is
presen t, restoration of th e lateral colum n len gth is n ecessary. An external fixator m ay be needed to m ain tain len gth
of th e lateral colum n . Postoperatively, th e patien t is placed
in a non weigh t-bearing cast for 6 to 8 weeks, followed by
progressive weigh t-bearin g in a cast for an addition al 4 to
6 weeks. If K-wires are used for the fourth and fifth tarsom etatarsal join ts, th ey should be rem oved at 8 weeks.
Screws are rem oved 6 to 9 m onths after treatm en t. Com plication s in clude posttraum atic arth rosis, ch ron ic pain ,
m alunion, and deform ity. Secon dary arthrosis develops in
780
21
Brake
pedal
B
C
Figure 19.26 Lisfranc injuries occur from axial loads to the foot during athletics (A), direct forces
related to motor vehicle crashes (B), and axial loads due to a fall from height (C). (Reproduced with
permission from Rockwood CA, Green DP, Bucholz RW. Rockwood and Greens Fractures in Adults.
6th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
Metatarsal Fractures
Metatarsal fractures are th e m ost com m on fracture of th e
foot and usually occur from a direct blow. For high-energy
in juries such as th ose sustain ed in m otor veh icle crash es
or by h eavy objects, in jury to th e soft tissue can be significant. AP, lateral, an d oblique radiographs are usually
adequate for diagn osis an d treatm en t. Low-en ergy in juries
with m inim al displacem en t are treated conservatively with
n on weigh t-bearin g im m obilization for 3 to 4 weeks. Fractures with significant deform ity are best treated surgically
with an atom ic reduction . Residual deform ity can result in
chronic pain an d transfer m etatarsalgia. Distal fractures are
m ore likely to displace due to lack of soft tissue attachm ents
providin g stability to th e m etatarsal n eck an d h ead. ORIF
with plate an d screw con structs are gen erally used for th e
first m etatarsal, whereas K-wire fixation m ay be adequate
for the lesser m etatarsals. For intraarticular fractures, the
articular congruity should be restored. The goals of surgery
are to restore the length, rotation, and angulation to ensure
proper weigh t distribution am on g th e m etatarsals.
Fractures of th e base of th e fifth m etatarsal are divided in to three zon es (Fig. 19.29). Zon e 1 fractures, the
m ost com m on type, are avulsion fractures of th e peroneal
brevis or lateral plan tar fascia caused by a plan tarflexion
and inversion force. The fracture line travels into the tarsom etatarsal join t th rough cancellous bone, giving these
A
Figure 19.27 Stress views are important in the evaluation of Lisfranc injuries. A normal-appearing
radiograph (A) taken without stress. A weight-bearing view of the same foot indicates gross instability
(B). (Reproduced with permission from Rockwood CA, Green DP, Bucholz RW. Rockwood and Greens
Fractures in Adults. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
Wire fixation
Screw fixation
A
Figure 19.28 A typical construct for fixation of tarsometatarsal injuries. (Reproduced with permission from Rockwood CA, Green DP, Bucholz RW. Rockwood and Greens Fractures in Adults. 6th
ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2006.)
782
II
III
I
Figure 19.29 Fractures of the base of the fifth metatarsal
are divided into three zones. Zone 1 fractures enter the tarsometatarsal articulation. Zone 2, or Jones, fractures enter the intermetatarsal joint. Zone 3 fractures occur distal to the diaphyseal
metaphyseal junction (Reproduced with permission from Rockwood
CA, Green DP, Bucholz RW. Rockwood and Greens Fractures in
Adults. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins,
2006.)
Sesamoid Fractures
Fractures of th e sesam oid bon es occur as a result of direct traum a, fran k overuse, or avulsion in juries associated
with hyperdorsiflexion (turf toe). Disruption of the soft
tissue surroun din g th e sesam oid com plex an d dislocation
causing diastasis of the in tersesam oid ligam ent can occur. Radiographic evaluation includes AP, lateral, and axial
views. It is importan t to distin guish fractures from a bipartite sesam oid, wh ich occur in approxim ately 25% of
in dividuals. Wh ile fractures h ave irregular edges, a bipartite sesam oid h as sm ooth , sclerotic edges. Con tralateral
radiographs or bone scan can assist in diagnosis. Acute
fractures are treated with a cast or hard-soled shoe for 3
to 6 weeks. Pain associated with a n on un ion m ay require
partial or total excision . Com plication s in clude h allux val-
Phalangeal Fractures
In jury to th e toes caused by stubbin g, axial loads, or a
dropped object m ay result in join t dislocation or ph alangeal fracture. The proxim al phalanx of the fifth toe is
the m ost com m only involved. Phalangeal fractures m ay either be displaced or nondisplaced, but there is frequen tly
an gulation. The fracture sh ould be reduced and buddytaped to th e adjacen t toe, an d th e patien t sh ould wear a
stiff-soled shoe or san dal. A fracture that extends into the
join t sh ould be reduced an d stabilized with eith er K-wires
or screw fixation . Sequela of th ese in juries in cludes join t
instability, in congruence, and arthrosis.
783
B
Figure 19.30 A typical appearance of the rheumatoid forefoot. (Reproduced with permission from
Kitaoka HB. The Foot and Ankle. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2002.)
Presentation
Nearly 95% of patien ts with rh eum atoid arth ritis develop
foot and ankle pain. It is th e initial m an ifestation of the
disease in 15% of cases. Pain , swellin g, an d stiffn ess in
the affected joints are early complaints. Pain in the ball
of th e foot, m etatarsalgia, is due to th e prom in en ce of th e
plan tar m etatarsal h eads. Sh oe wear leads to callosities an d
pain over th e PIP join ts of th e lesser toes. Wh en th e h in dfoot is involved, patients m ost often complain of vague
an kle pain or lateral pain secondary to peroneal ten don or
fibular im pin gem en t. With progression of th e disease, th e
ch aracteristic deform ities described earlier develop.
Physical Examination
Th e physical exam in ation sh ould be system atic wh ile focusin g on th e m ost com m on ly in volved areas of th e
ankle an d foot. The relative flexibility or rigidity of th e deform ity should be determ ined. The forefoot will typically
sh ow claw toe deform ities of the lesser toes, with calluses
un der th e m etatarsal h eads an d over th e PIP join ts. Eviden ce of a sym ptom atic h allux valgus deform ity is n oted.
Th e an kle an d subtalar join ts are in spected to determ in e th e
join t respon sible for a h in dfoot valgus deform ity. Laxity of
th e deltoid ligam en t an d resultan t an kle in stability will often m asquerade as h in dfoot valgus. An AP weigh t-bearin g
radiograph of th e an kle assists in m akin g th e distin ction .
In th e m idfoot, m an ual stress m ay reveal hyperm obility
of th e m idtarsal join ts in both th e sagittal an d tran sverse
plan es an d detect th e presen ce of m ild warm th an d edem a.
Discom fort is elicited with ran ge of m otion of th e cen tral
th ree tarsom etatarsal join ts. Patien ts ten d to walk with a
prolon ged stan ce ph ase, sh ort strides, an d a slow velocity
to decrease stresses through a painful forefoot.
Radiographic Findings
weigh t-bearin g radiograph s are h elpful to docum en t th e
progression of disease an d for surgical plan n in g. Juxtaarticular osteopenia, subchon dral cyst form ation, narrowing
of th e join t space, bon e destruction , an d soft tissue swellin g
are com m on findin gs on plain radiograph s. Radiographic
changes usually precede clinical symptom s and the developm en t of gross deform ity.
Th e severity of lesser digit MTP subluxation an d h allux
valgus is noted. Th e cause of hindfoot valgus is assessed
and attributed to either the ankle or subtalar join t. The m idfoot is in spected for subluxation of the first tarsom etatarsal
join t. An in creased talar-first m etatarsal an gle is con sisten t with an acquired flatfoot an d forefoot abduction
deform ity.
784
Treatment
Ph arm acological treatm en ts for rh eum atoid arth ritis in clude nonsteroidal an ti-inflam m atory drugs (NSAIDs),
corticosteroids, and disease-m odifying antirh eum atic
drugs (DMARDs). A rh eum atologist typically m an ages
these m edications; however, it is important for th e orthopaedic surgeon to verify that patients receive appropriate treatm en t.
In the forefoot, nonoperative m anagem ent seeks to decrease peak pressures on th e m etatarsal heads an d dorsal
aspects of th e PIP join ts. Soft trilam in ate full-len gth orthotics and stiff-soled rocker sh oes offload the MTP joints
an d m in im ize deform in g stresses. Th ese m easures relieve
symptom s but do n ot restore norm al gait. Toe spacers, toe
sleeves, and toe crests pad painful callosities, an d parin g
of calluses provide sh ort-term pain relief. Physical th erapy
aim ed at in creasin g m obility m ay also improve fun ction .
When n on operative m an agem en t fails to provide relief,
surgery is indicated. Operative in tervention aim s to reduce
pain , im prove am bulatory status, sim plify sh oe-wear alteration s, an d en h an ce cosm esis. Surgery in volves th e stabilization of th e first ray, th e reduction of th e lesser MTP
join ts, an d th e relocation of th e fat pads so as to provide a
suitable weight-bearin g structure. It includes arth rodesis of
the first MTP joint to provide perm anent stability to the m edial colum n alon g with PIP an d m etatarsal h ead resection al
arth roplasty to align th e lesser toes. Complication s in clude
problem s with woun d h ealin g, in fection , n on un ion , m alunion, recurrence of deform ities of the lesser toes, and recurrent m etatarsalgia.
Non operative treatm en t of h in dfoot arth rosis in cludes
the use of a soft University of California Biom echanics Laboratory (UCBL) orth osis with a rocker sole, a sm all h eel
lift, an d m edial or lateral flarin g on th e outer sole to add
stability. With early hindfoot collapse (increased valgus),
an off-th e-sh elf ath letic an kle brace is h elpful for stabilization but an an klefoot orthosis is necessary for advanced
deform ities. Operative treatm en t of rh eum atic disorders of
the hin dfoot includes arthrodesis of the subtalar joint, the
talon avicular join t, an d th e calcan eocuboid join t (triple
arth rodesis). A ten doach illes len gth en in g is n orm ally a
part of th is procedure. Hin dfoot surgery, in th e presen ce of
oth er m ajor in volvem en t of th e lower extrem ity, requires
that the hip or knee be aligned initially so as to determ ine
overall align m en t an d th us position th e h in dfoot properly.
Th e goal of h in dfoot arth rodesis in a rh eum atoid patien t
is to provide pain relief, improve fun ction an d align m en t,
an d provide a stable platform for am bulation .
Man agem en t of a rh eum atoid an kle arth rosis in cludes
activity m odification , in term itten t corticosteroid in jection s, th e use of an an klefoot orth osis and sh oe m odification s. Surgical option s in clude syn ovectomy, an kle
arth rodesis, an d total an kle arth roplasty. Syn ovitis in th e
an kle can be treated with an open or arth roscopic syn ovectomy. Irrigation procedures m ay decrease th e syn ovitic load
on th e an kle join t but are temporizin g m easures at best.
Arth rodesis rem ain s th e on ly reliable an d durable procedure to treat a pain ful rh eum atoid an kle. In dication s in clude in tractable pain , sign ifican t deform ity, loss of ran ge
of m otion , an d failed total arth roplasty. Tech n iques are
sim ilar to those described for osteoarthritis of the an kle,
but th ere is th e n eed for addition al fixation due to th e poor
bon e quality. In th e presen ce of subtalar join t in volvem en t,
as seen in cases of global talar avascular necrosis resulting
from steroid use, a tibiotalar calcaneal arth rodesis m ay be
required. It can be perform ed by in tern al fixation usin g
can n ulated screws, specialized plates, or a retrograde in tram edullary rod.
Total an kle arth roplasty h as h istorically been plagued
by dism al long-term results; however, newer system s appear to yield better results. Its advan tage over arth rodesis in
th e rh eum atoid patien t is th e m in im ization of stress tran sference to adjacen t joints as occurs following an isolated
ankle fusion. In addition , m aintaining a m obile segm ent
between th e MTP an d kn ee join ts avoids a severely stiff gait
if th ere is bilateral involvem ent. Total ankle arthroplasty is
con train dicated with severe coron al plan e deform ity.
Man agem en t of m idfoot arth ritis con sists of arrestin g
pain ful syn ovitis by m ean s of a sh ort-leg, weigh t-bearin g
cast for 4 weeks followed by an orth osis with a m edial
h eel wedge or, in advan ced cases, an an klefoot orthosis. Stretchin g the Ach illes tendon helps relieve m idfoot
stresses. Cortison e in jections are norm ally lim ited to the
first tarsom etatarsal joint in conjunction with a short period of im m obilization . Surgery is reserved for patien ts
with greater fun ction al dem an ds wh o can n ot tolerate bracing. The technique involves stabilizing th e m edial arch
with arth rodesis. Typically, th e first, secon d, an d th ird tarsom etatarsal join ts are fused; rarely, th e fourth and fifth
m etatarsal cuboid joints are included.
Presentation
Diabetic patien ts are often un aware of th e sen sory an d vascular changes occurring in their feet placing them at risk for
areas of breakdown and infection. Patien ts can experience
neuropathic symptom s such as burning, deep ach es, and
hypersen sitivity. However, even with th ese sym ptom s, th ey
often lack protective sen sation . Patien ts m ay also presen t
for evaluation of a worsen ing foot deform ity.
Physical Examination
Routine foot exam in ations are essential for diabetic patients. While a yearly comprehensive exam in ation by a
physician is recom m en ded, patien ts sh ould be proactive
in their own care, inspecting their feet on a regular basis
for callosities an d areas of skin breakdown. Light touch,
pin -prick, two-poin t discrim in ation , an d proprioception
sh ould be evaluated. Most typically, the sensation loss follows a stocking and glove distribution. Sem m esWein stein
m on ofilam ent testing is helpful to determ ine a patien ts
threshold of sensation , and the ability to feel a 5.07
m on ofilam ent indicates protective sensation . Chronic vascular in sufficiency can m anifest as hair loss and thin, sh iny
skin. Th e presence or absence of the dorsalis pedis an d
posterior tibial pulses sh ould be n oted.
Diabetic patien ts often presen t for th e evaluation of a
red, swollen foot, an d it is imperative to distin guish in fection from Charcot arthropathy of the foot. O n physical
exam in ation , th e lim b sh ould be elevated above th e level
of th e h eart. Any eryth em a an d swellin g related to Ch arcot
785
Radiographic Findings
Standard radiographs of the foot and ankle should be obtain ed if th ere is suspicion of traum a, Ch arcot arth ropathy,
or osteomyelitis.
Special Tests
If th e diagn osis of in fection is in question , MRI is h elpful for establish ing the diagn osis, determ ining th e exten t
of disease, an d distin guish in g it from Ch arcot arth ropathy. Tech n etium -99m an d in dium -111 labeled leukocyte
scan s are altern atives but are used less frequently with the
widespread availability an d speed of MRI.
Vascular evaluations are important to determ ine th e
h ealin g potential of chron ic ulcers an d in fection s. Th e arterial pressure at differen t levels in th e leg can be m easured with Doppler ultrasoun d. Toe pressures greater than
45 m m Hg are th ough t to be n ecessary for h ealin g. Tran scutan eous oxygen m easurem en t is th e m ost accurate m easure
of h ealin g poten tial. A level greater th an 30 m m Hg in dicates adequate circulation for h ealin g.
Treatment
Ideally th e treatm en t of th e diabetic foot sh ould focus on
preven tion of ulcers an d in fection . Tigh t glycem ic con trol is
an essential. The orthopaedist should always inquire how
well patien ts are m an agin g th eir glucose levels an d en sure physician s are overseeing their m edication s. Patients
sh ould in spect their feet daily and keep their skin well
m oisturized. Areas of pressure should be relieved with shoe
m odifications and the use of inserts. Extradepth shoes with
a wide toe box are recom m ended. Rigid insoles should be
avoided as th ese can h asten skin breakdown . Orth otics an d
bracin g m ay h elp un load areas of h igh pressure, especially
wh en deform ity is presen t. Surgery m ay be n ecessary to
address bone deform ities causing areas of h igh pressure.
On ce ulceration occurs, early and aggressive treatm ent
m ust be initiated to prevent a deep infection . Necrotic tissue
and areas of hyperkeratosis should be debrided, and local
woun d care is essen tial. If th ere is n o eviden ce of in fection ,
patien ts are treated with total con tact castin g to un load th e
area of breakdown to allow healing. Casts are placed with
little padding to allow appropriate m olding and, therefore,
m ust be placed by an individual experienced in their application . Un fortun ately, it is n ecessary to ch an ge th em frequen tly to m on itor h ealin g an d en sure th e correct fit of th e
cast.
In fection s require a com bin ation of surgery an d an tibiotic treatm en t. Th e vascular workup is critical to operative
plan n in g to assess h ealin g poten tial. Serial debridem en ts
786
Charcot Arthropathy
Ch arcot, or n europath ic, arth ropathy is a progressive destruction of joints, resulting in deform ity, ulceration, and
poten tially am putation . Wh ile un derlyin g causes in clude
syrin gomyelia, myelom enin gocele, alcoholism , syphilis,
heavy m etal in toxication , con genital in sensitivity to pain ,
an d leprosy, th e m ost com m on cause in th e Un ited States
is diabetes m ellitus.
Presentation
Patients with stage 0 and I disease present with erythem a,
swellin g, hyperem ia, and warm th. Th ese stages are com m on ly confused with infection. Fevers are not typical
with Ch arcot an d support th e diagn osis of in fection wh en
presen t. Th e swellin g m ay be severe en ough th at ordin ary
sh oe wear is difficult. In stage II, th e symptom s of erythem a, swellin g, an d warm th dim in ish, and by stage III,
these usually resolve. Even th ough m any patients have sign ifican t neuropathy, up to 75% h ave discom fort in th e foot
an d ankle associated with this pathology. Only approxim ately 20% recall a traum atic event before developin g the
sym ptom s related to Charcot.
Physical Examination
As noted earlier, patients in the early stage have erythem a,
swellin g, an d warm th of the foot and ankle. The swelling
an d erythem a related to Ch arcot often respon d to elevation above the level of th e heart as opposed to infection,
wh ich does n ot. Patien ts typically exh ibit a den se n europathy. Good vascular perfusion m ay be present. Th e lim b
sh ould be th oroughly in spected for ulceration and areas
of skin breakdown .
Radiographic Findings
Radiograph s of th e foot an d an kle sh ould be obtain ed on
all diabetic patien ts presenting with a red, swollen foot.
First, radiograph s m ay aid in rulin g out osteomyelitis. Secon d, th e radiograph s h elp to determ in e th e stage of th e
disease process an d th e appropriate treatm en t. Th e radiograph ic fin din gs for each stage h ave been discussed earlier. Third, characterizing the deform ity is necessary to plan
surgical intervention . Ideally these radiographs should be
weigh t-bearin g to iden tify subtle in stability pattern s.
Special Tests
MRI is becom ing m ore popular, especially in diagnosing
early stages of disease. Stress reaction s an d bon e m arrow
edem a are eviden t in th e periarticular an d subch on dral
region s of m ultiple bon es. Th ese fin din gs differ from osteomyelitis, wh ich m ost often is diffuse with in on e bon e.
Bon e scan s can also be used, but th ey h ave low specificity. Th ey are m ore useful to rule out osteom yelitis wh en
n egative.
Differential Diagnosis
Clearly, it is m ost important to distinguish Charcot
arthropathy from osteomyelitis in its early stages. Patien ts
with in fection often h ave fevers, open woun ds, hyperglycem ia above th eir norm al blood sugar levels, nondepen dan t rubor, an d associated MRI fin din gs. Ch arcot can
also be m isdiagnosed as gout, rheum atoid arthritis, ankle
Treatment
Th e treatm en t goal is to establish a stable, plan tigrade foot
with out deform ity. Treatm en ts vary depen din g on th e stage
of disease, th e presen ce of open woun ds, an d th e join ts affected. For patients who presen t early in th e disease course,
nonoperative m anagem en t should be attempted. Total con tact castin g is in itiated after a few days of elevation to decrease the swelling. Total contact casting allows for the even
distribution of th e forces across th e plan tar aspect of th e
foot. Every 2 to 4 weeks, the cast is chan ged until the process has entered the coalescence phase when the foot is
no longer warm , erythem atous, and swollen and radiograph s sh ow sign s of stability. Approxim ately 4 m on th s of
casting is expected; afterwards, patients are transition ed to
custom -m ade shoes with orthotics. Historically, patients
were told to rem ain n on weigh t-bearin g; h owever, som e
specialists n ow allow m odified weight-bearin g. There is no
defin itive eviden ce th at n on weight-bearing increases the
risk of developin g Ch arcot in th e oth er lim b due to th e in creases in forces. Deep ulcers complicate the n onoperative
m anagem ent of Charcot arthropathy because of th e risk
of osteomyelitis. Wh en associated with in fection , ulcers require debridem en t an d eviden ce of local con trol prior to
initiation of total contact castin g. Altern atives to total contact castin g in clude rem ovable casts an d Ch arcot restrain t
orth otic walker (CROW) devices. Th ese fun ction in a m an ner sim ilar to total con tact casts by distributing forces on
the plantar aspect of the foot. Their advantages over total
con tact castin gs is that soft tissue can be m ore closely m on itored and they do not require specialized trainin g in th eir
application.
With sign ifican t deform ity, recurren t ulceration , an d
join t in stability surgical in terven tion m ay be n ecessary for
the treatm ent of Charcot arthropathy an d its residual deform ity. Tradition ally, surgery was not perform ed during
the fragm entation phase of the disease because of the risk
of n on un ion , m alun ion , an d in fection . It was typically delayed un til the consolidation ph ase. More recently, this h as
been question ed, especially with tech n iques usin g external fixation. There is no consen sus on the optim al tim ing
of surgical in terven tion . Surgical in terven tion s ran ge from
exostectomy to com plex recon struction s an d arth rodesis.
Im m obilization is con tin ued un til th e eryth em a, swellin g,
an d warm th resolve. Patients are then placed into custom m olded orthotics.
787
Ten din opathy is a broad term th at en com passes both ten din itis an d ten din osis, wh ich are con firm ed with path ological evaluation . Ten din itis h as an acute in flam m atory
compon ent, whereas tendin osis is m ore of a chronic degenerative n oninflam m atory condition.
Path ology of th e Ach illes ten don m ust be divided in to
in sertion al an d n on in sertion al as well as acute an d ch ron ic.
Non in sertion al path ology occurs approxim ately 4 to 6 cm
proxim al to th e in sertion site in an area of relative poor
vascularity. Symptom s can result from acute in flam m ation
of th e paraten on (paraten on itis) or from a m ore ch ron ic
degen eration of th e ten don itself (ten din osis). In sertion al
path ology causes posterior h eel pain an d is com m on ly
associated with retrocalcan eal bursitis an d a Haglun d
deform ity.
788
Imaging Studies
Stan dard radiograph s are n ot usually n ecessary for n on in sertion al path ology but m ay sh ow calcification s related
to th e ten din osis. More distally, radiograph s can sh ow a
Haglund deform ity or calcification of the tendon . MRI is
m ore useful to evaluate th e un derlyin g path ology both
proxim ally an d at th e in sertion site. Th is can easily distin guish between periten din itis, th icken in g of th e outer
sh eath , tendinosis, and in traten din ous degeneration .
Differential Diagnosis
System ic disorders such as gout an d spon dyloarth ropath ies sh ould be ruled out. Posterior in sertion al h eel pain
m ust also be distin guish ed from plan tar fasciitis an d calcan eal stress fractures. Reiter syndrom e m ay present with
in sertion al Ach illes ten don pain an d retrocalcan eal bursitis. Th ere is also a kn own association of Ach illes ten don
path ology an d fluoroquin olon e use.
Treatment
Th e goal of treatm en t for n on in sertion al Ach illes ten dinosis is to reverse th e degenerative process an d allow n orm al h ealin g of th e ten don . Non operative m an agem en t is
recom m en ded in itially; h owever, it ten ds to be less effective when the condition is m ore chronic. Treatm en t
typically in cludes NSAIDs, rest, sh oe m odification , an d
physical th erapy. In correct th erapy regim en s such as con centric strengthening can often worsen symptom s. Eccentric stren gth en in g is recom m en ded. A h eel lift an d th e use
of open -backed sh oes m ay be h elpful in reducin g sym ptom s durin g daily activities. Altern ative m odalities in cludin g ultrasoun d an d extracorporeal sh ock wave th erapy h ave
sh own good results. Use of local steroid injection s is n ot
recom m en ded because of th e poten tial for ten don rupture
an d subcutan eous atrophy.
If nonoperative m anagem ent h as failed to provide relief
of sym ptom s after 4 to 6 m on th s, surgery m ay be in dicated.
Th e ten don is split lon gitudin ally an d all path ological tissue is excised. The rem aining ten don is repaired side-toside. In cases of severe, exten sive tendin osis, augm en tation
with the adjacent FHL ten don is recom m ended.
The treatm ent of isolated retrocalcan eal bursitis is n onoperative. Heel lifts h elp to m ove th e bursal prom in en ce
Given th e association with certain deform ities, th e position of the hindfoot sh ould be noted.
Radiographic Findings
Wh ile th e overall yield of radiograph s m ay be low, th ese
help to evaluate the an atomy of th e foot an d rule out certain space-occupyin g lesion s such as exostoses, accessory
ossicles, an d fractures.
Special Tests
Electromyograph ic n erve con duction studies are h elpful in
ruling out lum bar disk disease as the source of sym ptom s.
Diagn ostic fin din gs for m edial plan tar n erve in volvem en t
include term inal latency in the abductor hallucis of m ore
than 6.32 m illiseconds. Sim ilarly, a prolonged latency of
m ore than 7 m illisecon ds in th e abductor digiti m ini is consistent with lateral plantar nerve involvem ent. Sensory laten cies are th e m ost sen sitive tests because th ese are th e first
fibers affected. MRI is useful to delin eate space-occupyin g
lesions.
Differential Diagnosis
Radicular lum bar path ology, plan tar fasciitis, periph eral
neuropathy, stress fractures, an d in flam m atory arth ropath ies can presen t with sim ilar sym ptom s.
Treatment
Treatm ent includes NSAIDs to control pain and orthotics to
con trol hindfoot valgus and decrease the ten sion across the
tun nel. Cortisone injections to decrease inflam m ation an d
bracin g to rest th e n erve m ay be h elpful. Surgery in volves
decom pressin g from th e proxim al aspect of th e flexor retinaculum to th e bifurcation of the tibial n erve. This sh ould
be exten ded to release th e superficial calcan eal bran ch of
the tibial nerve and trace the plantar branches distally
through the abductor hallucis m uscle. Resection of any
space-occupying lesion should be perform ed, in cluding
an om alous m uscles. Internal neurolysis is indicated if there
is evidence of n erve fibrosis. Good results are expected in up
to 95% of patien ts wh en a space-occupyin g lesion is iden tified. When there is not, approxim ately 75% of patients
improve after tarsal tun nel release.
789
790
Treatment
First-lin e treatm en t of peron eal complex path ology is n on operative an d in cludes activity m odification , brief im m obilization , an d NSAIDs. After th e acute ph ase, physical
therapy can be initiated. Wh en this fails and surgery is
plan n ed, it is essen tial to address th e un derlyin g con dition an d an atom ic variation respon sible. Th e m ost im portan t an d probably m ost com m on is lateral an kle in stability.
Th is m ust be addressed to improve th e ch an ces of successful treatm ent.
Ten din itis an d ten osyn ovitis are treated with syn ovectomy an d debridem en t. Ten don tears less th an 50% of th e
cross-sectional area are treated with debridem ent and tubularization . If th e tear is complete, a ten odesis is perform ed
between th e peron eus lon gus an d peron eus brevis. For a
tear or rupture of both ten don s, a ten don tran sfer or ten don graft m ay be n ecessary. Tran sfer option s in clude FDL
to peron eus brevis an d plan taris to peron eus lon gus. Surgical treatm en t option s for peroneal tendon subluxation or
dislocation in clude an atom ic repair of th e superior retin aculum , tissue tran sfers for recon struction , groove-deepen in g
procedures, an d ten don reroutin g un der th e CFL.
Presentation
Patients present with pain , swelling, and fullness localized
to th e posterior m edial h in dfoot an d n ote difficulty with
am bulation. Only approxim ately 50% of patients report a
traum atic even t. With progressive deterioration of the tendon an d in com peten t fun ction , a progressive asym m etrical
flatfoot deform ity develops. Late symptom s include progression of deform ity, difficulty with sh oe wear, an d lateral
calcaneal-fibular impingem ent.
Examination
Clinical exam ination in the early stages reveals tender,
boggy edem a at th e level of th e m edial m alleolus, a secon dary Ach illes con tracture, an d weakn ess of isolated posterior tibial ten don stren gth testin g (resisted in version with
the foot in a plantarflexed and abducted in a non weigh tbearin g position ). Patien ts are un able to perform a sin gleleg heel rise and often there is no inversion of th e hindfoot on double-stance toe rise (Fig. 19.31). Flexibility of
the subtalar and transverse tarsal joint is evaluated, as this
alters treatm ent. The Jack test consists of passively dorsiflexing the h allux, which results in restoration of the m edial
longitudinal arch in flexible con ditions. With advanced
forefoot abduction an d collapse, th e too m any toes sign
occurs wh en observin g a patien t from beh in d in restin g
stan ce (Fig. 19.32). With advanced collapse, th ere is eviden ce of loss of m edial lon gitudin al arch , an d th ere are
varyin g degrees of rigidity. Because of the association with
Achilles tendon con tracture, the range of th e m otion of the
an kle sh ould be noted. Wh en doin g so, th e talonavicular
join t sh ould be reduced to avoid m isin terpretin g m otion
through the m idfoot as dorsiflexion.
Th e lateral side of th e an kle sh ould be exam in ed as sign ifican t valgus deform ity can result in impin gem en t of th e
fibula on to th e calcan eus. Ten dern ess in th is area m ay be
appreciated.
Radiographs
Diagn ostic studies con sist of weigh t-bearin g AP an d lateral
radiograph s of th e foot, as th e deform ity m ay n ot be appreciated on n on weigh t-bearin g film s (Fig. 19.33). O n th e AP
view, the coverage of the talus is evaluated for talon avicular subluxation . This is estim ated by calculatin g the an gle
between th e m edial articular edge of th e talus an d th e n avicular. A coverage an gle greater th an 10 degrees is con sidered
an abn orm al am oun t of forefoot abduction. On the lateral
radiograph , Meary an gle is form ed between th e axis of th e
talus an d th e first m etatarsal ray. Norm ally, th ese two axes
are parallel; however, they becom e divergent with collapse
of th e m idfoot. weigh t-bearin g radiograph s of th e an kle
sh ould be evaluated for asym m etry and arthrosis.
791
A
Figure 19.31 (A) Posterior photograph demonstrating the flatfoot deformity associated with
posterior tibial tendon dysfunction. (B) When the patient attempts to perform a single heel rise the
heel does not leave the ground. (Reproduced with permission from Kitaoka HB. The Foot and Ankle.
2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2002.)
Treatment
Th e stage of th e disease dictates th e treatm en t. Stage I disease with m in im al deform ity is treated with NSAIDs, orthotics, and physical therapy. In fulm inate ten osynovitis,
Figure 19.32 The too many toes sign due to advanced forefoot abduction. (Reproduced with permission from Kitaoka HB. The
Foot and Ankle. 2nd ed. Philadelphia, PA: Lippincott Williams &
Wilkins, 2002.)
792
Plantar Fasciitis
Heel pain is one of the m ost com m on and potentially disablin g con dition s to affect th e foot. Th ere are a m ultitude
of poten tial causes for h eel pain , in cludin g tum ors, in fection, stress fractures, inflam m atory arthropathies, and
compressive or m etabolic neuropathies. The m ost com m on plan tar h eel pain is associated with a ch ron ic in juryreparative process th at leads to m icrotears, n ecrosis, an d
ch on droid m etaplasia at th e origin of th e plan tar fascia
on th e m edial calcan eal tuberosity. Th e con dition is m ore
of a ch ron ic degen erative on e th an a true in flam m atory
process an d is m ore appropriately referred to as plantar
fasciosis.
Pathophysiology
Th e plan tar fascia origin ates on th e m edial aspect of th e calcan eal tuberosity and inserts on th e base of the proxim al
ph alan x of each toe after dividin g in to five ban ds. With
Presentation
Th e on set is in sidious an d is often preceded by overuse in
wom en aged 40 to 65 years old. Sym ptom s in clude m orn ing stiffness and pain that resolves durin g the day with
walkin g. Classically, pain is m ost severe when arising in
the m orning or gettin g up after sitting and takin g the first
step. Jum ping and run nin g can exacerbate the pain . Nigh t
pain is n ot com m on , an d its presen ce sh ould warn th e
physician to rule out m ore serious con dition s. High -h eeled
sh oes typically alleviate symptom s, whereas going barefoot
an d wearin g flat shoes worsens symptom s.
Examination
Physical exam in ation reveals a poin t of ten dern ess at th e
plan tar m edial origin of th e plan tar fascia on th e os calcis.
Th ere is often a m oderate to severely tigh t Ach illes ten don
complex and restricted an kle dorsiflexion. There m ay be
som e fullness and warm th in th e area of th e plan tar m edial h eel an d, occasion ally, h eel pad atrophy. Th e cen tral
ban d in th e m idfoot is typically n ot ten der, but passive
dorsiflexion of th e toes resultin g in ten sion on th e plan tar
fascia m ay elicit pain .
Radiographs
Diagn osis of plan tar fasciitis is based on h istory an d physical exam in ation. While radiographs m ay reveal specific
fin din gs, th ey are reserved for patien ts wh o do n ot respon d
to treatm en t to rule out oth er causes of h eel pain . Lateral
weigh t-bearin g views m ay dem on strate a plan tar spur at th e
origin of th e FDB in approxim ately 50% of patien ts, wh ich
signifies chronicity of the con dition. It is thought th at the
spur is a result of th e disease process an d not a cause of it.
A spur does n ot usually develop at th e origin of th e plan tar
fascia. A bon e scan is positive in alm ost all cases, but th is
fin din g is n ot specific an d is of little value. MRI an d ultrasound can also help to confirm diagn osis when n eeded.
Differential Diagnosis
Th e differen tial diagn osis for h eel pain is a lon g procedure
but can be easily separated in to n eurological, bony, an d soft
tissue causes. Neurological causes include tarsal tunn el syn drom e, en trapm en t of th e first bran ch of th e lateral plan tar
(Baxter) or m edial calcaneal nerves, peripheral n europathy,
or S1 radiculopathy. Atrophy of th e h eel pad, ten din itis of
the Achilles, FHL, or posterior tibial tendons, and plantar
fibrom atosis can all cause h eel pain . Bon e sources in clude
stress fractures, infections, con tusions, tum or, and arth ritis.
Treatment
In alm ost all cases of h eel pain , m an agem en t is prim arily nonoperative. Treatm ent usually consists of rest, cold
therapy, NSAIDs, Ach illes stretching, and orthotic devices;
however, there is little evidence to support these m odalities
individually. Studies have sh own that an inexpensive, overthe-coun ter heel cushion is as effective as a custom -m ade
orth osis wh en com bin ed with a stretch in g regim en . Various stretch in g program s h ave been described an d usually
are plantar fascia specific or focus on th e Achilles tendon .
Nigh t splin tin g h elps to keep th e posterior calf m uscles an d
plan tar fascia on stretch wh ile sleepin g. For patien ts wh o
have failed to show progress with in 2 m on th s, a cortisone
injection at the m edial calcaneal tuberosity can be given.
Regardless of the regim en chosen, it is important to stress
to patien ts th at patien ce an d dedication to stretch in g is required. Relief from pain m ay take 6 m on th s to 1 year.
An alternative therapy receiving m ore attention is extracorporeal shock wave therapy for refractory cases of
plan tar fasciitis treated with at least th ree oth er n on opera-
793
Hallux Valgus
Hallux valgus is a disorder of the first ray that involves
m etatarsus prim us varus, lateral deviation of the great toe,
and a m edial prom inence of the first MTP join t. This prom in en ce is th e m ost visible aspect of th e con dition an d is com m only referred to as a bunion (Fig. 19.34). Wh ile gen etics
and certain anatom ic factors such as a planovalgus foot deform ity, heel cord contracture, and ligam entous laxity predispose patien ts to developin g th e con dition , it is alm ost
exclusively related to sh oe wear.
794
Presentation
Sym ptom s associated with h allux valgus deform ity in clude
pain , swellin g, an d in flam m ation over th e m edial em inence caused by shoe wear as well as secon dary hypertrophy of th e overlyin g bursa. Patien ts often com plain th at
they are unable to fin d com fortable shoes, while being able
to am bulate barefoot with out difficulty. By con trast pain
in th e h allux MTP join t wh ile am bulatin g barefoot is a sign
of first MTP join t arth ritis.
Physical Examination
Evaluation of the foot should be perform ed while sitting
an d weigh t-bearin g, as th is m ay m ake th e deform ity m ore
obvious. Th e foot sh ould be assessed for a pes plan ovalgus deform ity, Ach illes ten don con tracture, ligam en tous
laxity, an d sign s of a n eurom uscular disorder. Associated
lesser toe deform ities, in cludin g subluxation or dislocation
of th e lesser MTP join ts (especially th e secon d digit com m on ly referred to as a crossover toe), tran sfer callosities under th e m etatarsal h eads, bun ion ette deform ity, corn s, an d
ham m ertoes are noted. The degree of pron ation and the
correctibility of the deform ity should be judged. Range
of m otion of th e MTP join t sh ould be m easured, keepin g in m in d th at 70 degrees of dorsiflexion is n ecessary
for norm al gait. Th e presence of crepitus is a sign of
osteoarth ritic ch an ge with in th e join t. Fin ally, th e first
m etatarsocun eiform join t sh ould be assessed for hyperm obility by com parin g m otion of th is articulation to th at of
the fifth m etatarsal with the cuboid.
Radiographic Findings
weigh t-bearing AP and lateral radiographs are essen tial for
proper diagn osis of th e deform ity an d surgical plan n in g, as
not all bunions are treated th e sam e. The degree of h allux
valgus and m etatarsus prim us varus deform ity, first MTP
join t con gruity, degen erative ch an ges of th e MTP join t,
an d eviden ce of sesam oid subluxation determ in e th e optim al treatm en t approach an d are assessed on radiograph s
(Fig. 19.35).
used to assess severity of hallux valgus. (Reproduced with permission from Johnson D, Pedowitz RA. Practical Orthopaedic Sports
Medicine and Arthroscopy. Philadelphia, PA: Lippincott Williams &
Wilkins, 2007.)
Differential Diagnosis
Hallux valgus interphalan geus is a deform ity of th e in terph alan geal join t of th e great toe. Th e an gle between th e
proxim al an d distal ph alan x on an AP radiograph n orm ally
m easures 10 degrees. This deform ity can resem ble h allux
valgus.
Treatment
Treatm ent of hallux valgus in the early stage is non operative and includes selection of appropriate sh oes with a high ,
wide toe box. If an associated plan ovalgus deform ity exists,
orth otic devices m ay be h elpful. Surgical in terven tion is in dicated wh en con servative m easures fail, an d th ere is progression of th e deform ity, in creasin g difficulty with sh oe
wear, an d in volvem en t of th e secon d MTP join t m an ifested
as a crossover deform ity. Contraindication s in clude spasticity, ligam en tous laxity from Marfan or EhlersDan los syn drom e, an d vascular or skin in sufficien cy.
Th e prin ciple of surgical treatm en t is to correct all deform ities while m ain taining a functional foot. A num ber of
surgical option s exist, ran gin g from soft tissue procedures
to m ultiple osteotom ies an d fusion s. Th ere is n o clear-cut
con sensus on optim al treatm ent (Fig. 19.36). Decisions are
795
based on th e age an d activity level of th e patien t, th e presen ce of arth rosis, hyperm obility of th e first ray, con gruen cy
of th e MTP join t, physical sh ape of th e m etatarsal h ead, an d
th e h allux valgus an d in term etatarsal an gles.
A distal m etatarsal osteotomy is th e preferred treatm ent for a m ild hallux valgus deform ity, with the Mitchell
and ch evron osteotom ies being m ost com m on. In m ost
bun ion ectom ies, a distal soft tissue procedure to realign th e
MTP join t is perform ed. The m odified McBride procedure
achieves this by correcting all soft tissue components of the
MTP joint deform ity. A m oderate hallux valgus is treated in
a sim ilar fash ion but m ay require a proxim al osteotomy,
rath er th an a distal osteotom y.
For severe h allux valgus, a proxim al m etatarsal osteotomy is com m on ly perform ed in con jun ction with a
distal soft tissue procedure. Proxim al m etatarsal osteotom y
provides powerful correction of m etatarsus prim us varus
greater th an 15 degrees. Tech n iques in clude crescen tic,
open in g an d closin g wedge osteotom ies, as well as a proxim al chevron osteotomy. When hyperm obility of th e first
ray is presen t, a m etatarsocun eiform fusion m ay be required with a distal soft tissue procedure.
Arthrosis of the first MTP joint associated with h allux
valgus can be aggravated by surgery. In th is situation , a resection arthroplasty or arthrodesis of the first MTP joint
is indicated. A resection arthroplasty, or Keller procedure,
involves excising a segm ent of the proxim al phalanx an d
th e m edial em in en ce. Th is decom presses th e MTP join t,
resultin g in relaxation of th e con tracted lateral structures.
Alth ough it was a popular procedure in th e past, curren t
prim ary in dication s for its use in clude im pen din g m edial
skin breakdown and patients who walk only m inim ally.
Occasionally, it is used as a salvage procedure in failed
bun ion surgery. Arth rodesis of th e first MTP join t h as been
a reliable and durable procedure that is indicated for m anagem ent of severe deform ities associated with degen erative
join t disease, n eurom uscular con dition s, an d salvage procedures. Th e toe sh ould be fused in 10 to 15 degrees of
dorsiflexion an d 15 to 20 degrees of valgus.
Hallux Rigidus
Hallux rigidus is a pain ful loss of m otion of the first MTP
join t due to arth rosis. Degen erative ch an ges result in a
dorsal m etatarsal osteophyte an d loss of dorsiflexion . Alth ough it m ay occur bilaterally, often on e side is usually
m ore advanced. It generally occurs in m iddle-aged and
older person s but m ay also occur in active youn g people.
796
loss of range of motion and pain with dorsiflexion. (Reproduced with permission from Kitaoka
HB. The Foot and Ankle. 2nd ed. Philadelphia,
PA: Lippincott Williams & Wilkins, 2002.)
Presentation
Patien ts com m only complain of pain, swelling, and loss of
m otion in th e great toe. Symptom s are worse in th e m orn in g an d are aggravated by prolon ged walkin g or stan din g.
Sh oes with elevated h eel lifts exacerbate pain by furth er
lim itin g th e am oun t of dorsiflexion .
Examination
Th e first MTP join t ten ds to be en larged, warm , an d swollen
with decreased dorsiflexion . If th e pain is severe, patien ts
m ay limp in to th e office. Adorsal prom in en ce is m ost often
palpable at th e dorsom edial m etatarsal h ead, an d sign ifican t join t line tenderness m ay be present. With tim e an d
severity, a m ediolateral exostosis m ay develop.
Radiographs
Radiograph s sh ow a decrease in th e join t space, sclerotic
join t m argin s, flatten in g of th e first m etatarsal h ead, an d
subch ondral cyst form ation consistent with progressive
arth rosis.
Treatment
In itial treatm en t is n on operative m an agem en t with
NSAIDs an d sh oe an d activity m odification . NSAIDS h elp
to reduce th e in flam m ation an d pain related to syn ovitis
about th e first MTP joint. High-impact activities can be substituted with low-impact activities such as swim m ing and
bikin g. Modification s to sh oe wear in clude a stiff sole with
a steel sh an k or carbon fiber footplate, or a rocker-bottom
attachm ent to m inim ize stress and m otion across the MTP
join t durin g th e toe-off ph ase of gait. In traarticular steroid
injections should be used sparingly.
Wh en n on operative m an agem en t fails, surgical options
include ch eilectomy, interpositional arthroplasty, joint replacem en t, MTP join t fusion , an d resection al arth roplasty.
A cheilectomy is indicated for patien ts with m ild to m oderate disease, wh ose sym ptom s are related to th e dorsal
impingem ent during toe-off. Approxim ately 20% to 30%
of th e dorsal aspect of th e m etatarsal h ead is rem oved alon g
with th e dorsal exostosis an d osteophytes on th e proxim al
ph alan x to ach ieve 60 degrees to 80 degrees of dorsiflexion (Fig. 19.38). If arthrosis of th e joint is severe an d m ore
diffuse, a first MTP fusion is a reliable operation to relieve
Morton Neuroma
Morton neurom a is a compression neuropathy of the plantar in terdigital n erves th at is a com m on cause of forefoot
pain .
797
Presentation
Patien ts presen t with vague, in term itten t, burn in g pain in
th e area of th e m etatarsal h eads th at in creases in in ten sity
and duration durin g weigh t-bearing. Th e adjacent toes m ay
h ave n um bn ess. Wearin g wide sh oes an d rubbin g the feet
typically helps.
Physical Examination
Deep palpation between th e m etatarsal h eads or passive exten sion of th e toes m ay reproduce th e pain . Sen sation m ay
be dim in ish ed in th e th ird an d fourth toes. Compression of
th e m etatarsal h eads m ay result in a palpable Mulder click
as the n eurom a pops out between th e m etatarsal heads.
Diagn osis is con firm ed by in jectin g a local an esth etic in to
th e webspace with relief of sym ptom s.
Special Tests
CT, MRI, and ultrasoun d have all been used to diagn ose
Morton neurom a; however, these are seldom necessary an d
sh ould not be obtain ed routinely.
Differential Diagnosis
Other causes of forefoot pain include m etatarsalgia, osteon ecrosis of th e m etatarsal h ead, stress fractures, in flam m atory arthropathy, and ganglion cysts.
pressed by the intermetatarsal ligament. (Reproduced with permission from Kitaoka HB. The Foot and Ankle. 2nd ed. Philadelphia,
PA: Lippincott Williams & Wilkins, 2002.)
Treatment
Treatm ent consists of m odifying shoes and placing
m etatarsal pads proxim al to the third and fourth m etatarsal
h eads to h elp spread th e tran sverse m etatarsal ligam en t
and un load th e impingem ent on th e nerve. External shoe
m odifications, in cluding a m etatarsal bar, m ay also h elp to
un load th e forefoot. Physical th erapy, cryoth erapy, an d ultrasound are alternatives. Steroid and/ or alcohol injections
h ave also been advocated.
Operative intervention is reserved for refractory cases.
Options include neurectomy with or without n erve burial
into m uscle, transverse interm etatarsal ligam ent release,
and en doscopic decompression. Morton neurom a is m ost
com m on ly approach ed dorsally but can exposed via a plan tar in cision . Surgical in terven tion h as excellen t results in up
to 85% of cases. Complications in clude symptom atic endstum p n eurom a an d recurrence. With recurrence, a plantar
798
RECOMMEND READINGS
Herscovici D Jr, An glen JO, Arch deacon M, Can n ada L, Scaduto JM.
Avoidin g com plication s in th e treatm en t of pron ation -extern al
rotation ankle fractures, syndesm otic injuries, and talar neck fractures. J Bone Joint Surg Am. 2008;90:898 908.
Mann RA. Disorders of the first m etatarsophalangeal joint. J Am Acad
Orthop Surg. 1995;3:34 43.
Rech t MP, Don ley BG. Magn etic reson an ce im agin g of th e foot an d
ankle. J Am Acad Orthop Surg. 2001;9:187 199.
Robin son HN, Pasapula C, Brodsky JW. Surgical aspects of th e diabetic
foot. J Bone Joint Surg Br. 2009;91:1 7.
Index
Note: Page n um bers followed by f an d t in dicates figure an d table respectively.
800
Index
cartilage m atrix, 12
cartilage n utrition , 13
ch on drocytes, 11
collagen , 12
extracellular m atrix, 13
m etabolism , 13
path ologic ch an ges
aging, 14
osteoarth ritis, 14, 15f
traum a to articular surface, 14
Articular fractures, 214, 215f
Asth m a, 184 185
AtasoyKlein ert V-Y advan cem en t flap,
613f. See also Skin an d n ail
traum a
Atlan ta Scottish Rite brace, 327
Atlan toaxial in juries, 394f, 395
Atlan toaxial rotatory displacem en t, 382,
383f
Atlan toaxial rotatory subluxation ,
radiographic findings, 383f
Atlan toden s in terval (ADI), 441
Atlas fractures, 393, 394f, 395
Atraum atic m ultidirection al bilateral
reh abilitation in ferior capsular
sh ift (AMBRI), 528
Atypical lipom as, 160
Autoan tibodies, 119
Autologous ch on drocyte implan tation
(ACI), 718
Avascular n ecrosis (AVN), 502, 666,
668
Aviator astragalus, 770
Axillary radiograph , usage of, 545
Axon otm esis, 71 72, 72f
Index
Biom aterials and implan ts
im plan t failure, 26 27
corrosion , 27
fatigue, 27
wear, 27, 27f
m etals, 25 26
polym ers, 26
study of, importan ce of, 20, 25
Biom ech an ics
elasticity, 21
force, 20 21
loadin g, 23
m echan ical properties of tissues
articular cartilage, 24 25
bon e, 24
collagen ous tissues, 25
stress an d strain , 21 22
stress con cen tration effects, 23
stressstrain curve, 22 23, 22f
study of, importan ce of, 20
viscoelasticity, 24
Biostatistics, definition of, 29
Bipartite patella, in anterior knee pain, 728
Birth day syn drom e, 244
Bisph osph on ates
in osteoporosis treatm en t, 106 107,
107t
adverse effects of, 106, 107f
for Pagets disease, 114
Bite woun ds
path ophysiology of, 650
presen tation / physical exam in ation of,
650
radiograph ic fin din gs/ special studies of,
650
treatm en t of, 650
-lactam an tibiotics, 80, 81t
Blockin g, 70
Bloun t disease (tibia vara), 334
differen tial diagn osis, 335 336
Lan gen skio old classification , 334, 334f
path ophysiology, 334
presen tation an d physical exam in ation ,
334, 334f, 335f
radiograph ic evaluation , 335, 335f
treatm en t, 336, 336f
Bon e, 15
cells, 16 17
osteoblast, 16, 18f
osteoclast, 17, 18f
osteocytes, 16 17
circulation , 16, 17f
composition of, 18t
fun ction s, 207
m aterial properties of, 101
m atrix and form ation, 17 18, 18f
bon e collagen , 18, 19f
h ole zon es, 18
m echan ical properties of, 24
m ineral phase of, 19
calcium in , 54
m orph ology and physiology, 15 16
can aliculi, 15
can cellous (trabecular) bon e, 15, 16f,
24
cortical (compact) bon e, 15, 24
Haversian system , 15
801
802
Index
Index
Chondrocytes, 11
Chondroectoderm al dysplasia, 272
Chondrom alacia, 727. See also
Patellofem oral pain syn drom e
Chondrosarcom as, 156, 158f
Chopart joint. See Tran sverse tarsal join t
Chordom a, 158, 161f, 490 491. See also
Spin e
MRI in, 490, 490f
CiernyMader staging system , for adult
osteomyelitis, 83t
Cinacalcet hydrochloride, 112
Circum ferential binder, 217
Clavicle fractures and dislocations, 404,
405f
Clavicle fractures, in shoulder
classification of, 520, 521f
differen tial diagn osis, 522
m echan ism of injury, 520
patien ts presen tation , 520
physical fin din gs, 520 521
radiograph ic evaluation , 521, 522f
special tests, 522
treatm en t of, 522 523, 523f
Clavicle, role of, 502f
Clin damycin , 80, 81t
Closed reduction and percutaneous
pin n in g (CRPP), 410,
411, 413
Clubfoot (talipes equinovarus), 344 346,
345f
Cobb angle, m easurem en t of, 362, 363f
Cohens kappa, 36
Cold illn ess, 187
Colem an block test, 255, 255f
Collagen, 12
Collagenase, 13 14, 19
Com m inuted fractures, 213
Com m otio cordis, 179
Compartm en t syn drom e, 181 182,
202 205, 203f, 204f, 731. See
also Midsh aft tibia an d fibula
fractures occurrence of, 570
Complem ent activation pathways,
120 121, 120f
Complex regional pain syndrom e (CRPS)
classification of, 641
differen tial diagn osis of, 641
path ophysiology of, 641
presen tation / physical exam in ation of,
641
radiograph ic fin din gs/ special studies of,
641
treatm en t of, 641
Complex repetitive ischarges (CRDs), 67
Compound m uscle action potential
(CMAP), 62, 62f
Compression fractures, x-ray of a stable,
449f. See also Upper cervical
spin e traum a
Compressive neuropathies, 625 626
Computed tom ography (CT), 46 47
and calcaneal fractures, 46, 48f
of cervical radiculopathy, 462
of cervical spin e, 441
of coron oid fractures, 568, 569f
of distal h um eral fractures, 563, 563f
803
804
Index
Index
Dorsalis pedis artery, 759
Dorsal lip fractures, 777. See also Navicular
fractures
Dorsal radiocarpal ligam en ts, 585f
Down syn drom e (trisomy 21)
in ch ildren , 383 384
path ophysiology, 280
presen tation an d physical exam in ation ,
280 281, 281f
radiograph s, 281
screen in g tests for, 281
treatm en t, 281 282
h ip disorders, m anagem ent of, 282,
282f
Dual en ergy x-ray absorptiom etry (DEXA),
58, 101
for diagn osis of osteoporosis, 103 104
Duch en n e m uscular dystrophy, 2, 256
diagn ostic studies, 257
differen tial diagn osis, 257 258
history an d physical exam ination,
256 257
path ophysiology, 256
presen tation an d n atural h istory, 256
treatm en t, 258
Dull ach e, 546. See also Adh esive
capsulitis
Duloxetin e, 130
Dupuytren disease
ch aracterization of, 641
Grayson ligam ent, 642, 642f
palm ar an d digital fascia in , 643f
path ophysiology of, 641 642
physical exam in ation of, 642
presen tation of, 642
radiograph ic fin din gs of, 642
treatm en t of, 642 643
Dyn am ic compression plate, 212
Dyn am ic tech n ique, ultrason ograph ic
m ethod in DDH, 304
Dyskin esia, 241
Dystroph in , 256
805
806
Index
Felon
path ophysiology of, 647
presen tation / physical exam in ation of,
647
radiograph ic fin din gs of, 647
treatm en t of, 647
Fem ale ath letic triad, 188
Fem oral h ead
fractures, 669
classification of, 670
complication s of, 672
CT scan for, 671
differen tial diagn osis of, 672
m echanism of in jury, 670 671
patien ts presen tation in , 671
physical exam in ation of, 671
Pipkin s classification of, 670,
670f
radiograph ic exam in ation of, 671,
671f
special tests in , 671 672
treatm en t of, 672
vascular supply of, 658 659, 659f (See
also Hip an d fem ur)
Fem oral n eck fractures
anteroposterior radiograph of, 676f,
677f
classification of, 672 673
complication s of, 677, 677t
CT scans of, 675
differen tial diagn osis of, 675 676
fem oral h ead n eck jun ction, 675,
675f
garden align m en t index in, 675, 676f
Garden classification of, 672, 673f
m echanism of in jury, 673
MRI of, 675
patien ts presen tation in , 673 674
Pauwelsclassification of, 672, 674f,
675f
physical exam in ation of, 674 675
radiograph ic exam in ation of, 675
special tests in , 675
treatm en t of, 676 677
Fem oral sh aft fractures
classification of, 683 685
differen tial diagn osis of, 685
intram edullary nails usage in, 686
m echanism of in jury, 685
physical exam in ation of, 685
presen tation of, 685
radiograph ic exam in ation of,
685, 685f
special tests for, 685
treatm en t of, 685 687, 686
Win quist Han sen s classification for,
684, 684f
Fem oroacetabular impin gem en t, 662
Fibrillation poten tials, 67, 67f
Fibrillin , 282
Fibroblast growth factor receptor-3
(FGFR-3), 270
Fibrocartilage, 11
Fibromyalgia, 130
Fibromyxosarcom a, 162
Fibrosarcom a, 161
Fibrous dysplasia, 155, 155f
Index
Fourier tran sform ed in frared spectroscopy
(FTIR), 101
Fracture classification system s, 206 207
AO/ O TA system , 206, 206f
Garden classification, for fem oral n eck
fractures, 206
Hawkin s classification , for talus
fractures, 206
Sch atzker classification , for tibial
plateau fractures, 206
utility of, 206
Fracture-dislocation s, 201, 203f
Fracture fixation
in dication s for, 210
m ethods
external fixation, 210, 212f
in tern al fixation , 210, 212, 213f
splin tin g an d casting, 210
traction , 210
Fracture In terven tion Trial, 106
Fracture Risk Assessm en t Tool (FRAX),
104 105
Fran kel gradin g system , in SCI, 436
Freiberg in fraction , 346
Frostbite, 187
Frozen sh oulder, 546
diagn osis of, 547
Fun nel plots, 35
807
808
Index
Hand stiffness
classification of, 640
intrinsic tightness test in, 640, 640f
presen tation / physical exam in ation of,
640 641
radiograph ic fin din gs/ special studies of,
641
treatm en t of, 641
Hangm an s fracture, 395, 396f, 446 448
incidence of, 446
Levin e an d Edwards classification of,
447, 447f
treatm en t of, 447 448
Type IIa traum atic spondylolisthesis,
448f
Hawkin s im pin gem en t sign, 537, 538f. See
also Sh oulder
Heat illn ess, 185 186
fluid replacem en t guidelin es, 186t
heat cramps, 186
heat exh austion , 186
heat rash , 186
heatstroke, 186
heat syn cope, 186
and hydration , 186
preven tion of, 186
Hem an giom as, 155, 488 489
jail house vertebra of, 156f
Hem iarthroplasty, 546
in proxim al hum erus fractures
treatm en t, 525
Hem iarthroplasty for displaced fem oral
n eck fracture, 212, 213f
Hem iplegia, 241
Hem oph ilia, 2
Herniated disk, defin ition of, 465, 474. See
also Cervical spine; Lum bar spine
Herpetic whitlow
differen tial diagn osis of, 648
infection, 648f
path ophysiology of, 647
presen tation / physical exam in ation of,
647
radiograph ic fin din gs/ special studies of,
648
treatm en t of, 648
Heterotopic ossification (HO) form ation ,
563
Heulter-Volkm an n law, 9
Hibb angle, 255
High ankle sprain s, 767
High tibial osteotomy (HTO), 742
Hilgenreiner epiphyseal angle (HEA), 329,
330f
Hilgenreiner lin e, 304
Hill-Sachs lesion , of hum eral head, 529,
530f
Hip and fem ur, 656f, 657f
anatomy of
em bryology of h ip, 653
pelvis an d proxim al fem ur, osteology
of, 653 655
soft tissue an d m usculature in hip
joint, 655
arterial supply, 658f
assistive device usage, 660
atraum atic hip condition s
Index
presen tation , 359 360, 361f
radiograph ic evaluation , 361 362, 362f,
363f
special tests for, 363
treatm en t, 364 367
anterior fusion with anterior
instrum entation, 366, 368f
bracin g, 365 366, 366f
posterior spin al in strum en tation an d
fusion , 366, 367f
serial castin g, 364, 364f
surgery, 366
use of growin g in strum en tation , 364,
365f
Idiopath ic toe-walkin g, 339 340
Iliotibial (IT) ban d, 662, 700
Im agin g, in orth opaedic surgery
bon e den sitom etry, 58
com puted tom ography, 46 47
con ven tion al arth rography, 45 46
m agnetic resonance im agin g, 47 53
n uclear scin tigraphy, 54 58
plain radiography, 39
cervical spin e, 39 , 39 40
foot an d an kle, 43 45
h an d an d wrist, 41 42
kn ee, 43
pelvis an d h ip, 42 43
sh oulder, 40 41
and radiation exposure considerations,
58 59
ultrason ography, 53 54
Im m un e system , 117
com pon en ts of, 117 118
antigen -presenting cells, 118
B cells, 119
com plem en t system , 120 121
im m un oglobulin s, 119 120, 119t
m onocyte/ m acrophages, 120
n eutroph ils, 120
T cells, 118 119
im m un oregulation and
im m un opathology, 121
type I, 121
type II, 121
type III, 121
type IV, 121
n on specific im m un e respon se, 117
specific im m un e response, 117
Im m un e toleran ce, 118
Im m un oglobulin s, 119 120, 119t
Impin gem en t syn drom e, 513, 540
IM rod, 212
In dium -111-labeled leukocyte scannin g, in
spin e in fections, 494
In dom eth acin , 132
In fectious arth ritis
bacterial agen ts, 137 138
n on bacterial agen ts, 138
viral agents, 138
In feren ce, 31
defin ition of, 29
errors in, 31
bias, 31
ch an ce, 32, 32t
con foun ders, 31 32, 32t
m easurem en t bias, 31
m issing data, 31
publication bias, 31, 32f
recall bias, 31
sampling bias, 31
selection bias, 31
random error, 31
system atic error, 31
Inferior transverse ligam en t (ITL), 756f
Inflixim ab, 132
Infraspinatus m uscle, role of, 508
Intercalary segm en t, 583
Interlukin-6 (IL-6), 91
Interm alleolar distan ce, m easurem en t of,
237, 238f
Internal tibial torsion , in ch ildren , 235,
236f
Internation al Com m ission on
Radiological Protection (ICRP),
59
Internation al n orm alized ratio (INR),
747
Internation al Society for Clin ical
Den sitom etry (ISCD), 104
Interosseous m em bran e (IOM), 756f
Interosseus m uscles, in h an d and wrist,
588
Interphalan geal join ts, 757
Intersection syn drom e, 646f
differen tial diagn osis of, 646
path ophysiology of, 645
presen tation / physical exam in ation of,
645
radiographic findings of, 646
treatm en t of, 646
Intertrochan teric h ip fractures, 677 678,
679, 680f
ceph alom edullary device usage in , 679,
680f
classification of, 678
clin ical presen tation of, 678
complication s of, 680
differen tial diagn osis of, 679
Evansclassification of, 678, 678f
m echanism of injury, 678
physical exam in ation of, 678 679
radiographic findings of, 679
sliding screw plate device usage in , 679,
679f
special tests in , 679
treatm en t of, 679 680
Intra-articular corticosteroid injections,
usage of, 741. See also
Osteoarth ritis (OA), of knee
Intram edullary (IM) n ailin g, 561
Intram em bran ous bone form ation, 2 3
Intrinsic han d m uscles, 588 590. See also
Han d an d wrist
superficial an d deep, 592f
Involucrum , 88
Isthm ic spondylolisthesis, 477
IT band syn drom e, 702
differen tial diagn osis of, 729
m echanism of injury, 729
Ober test in, 729
patien ts presen tation of, 729
physical exam in ation of, 729
radiographic exam ination of, 729
809
810
Index
Kn ee (Contd.)
traum atic in juries of
distal fem ur fractures, 710 712
patella dislocation, 716 717
patella fractures, 713 714
patella ten don ruptures, 715 716
quadriceps ten don rupture, 714 715
tibial plateau fractures, 712 713
Kn ee an d leg in juries
ballottem en t test in , 705
ch ron ic patellar in stability, 717 718
ACL sprain s, 721 723
kn ee dislocation , 718 720
LCL sprain, 724 725
MCL sprains, 720 721
PCL sprain , 723 724
evaluation of
arthroscopy, 710
CT scans for, 710
h istory, 703 704
physical exam in ation of, 704 709
radiograph ic an alysis of, 709 710
fluid wave test in , 705
fun ction al an atomy of, 697 703
initial dislocation of, 717
joint effusion, detection of, 705
m edial and lateral condyles, 698f
patella articulation , 698f
superior surface of tibia, 699f
Kn eeankle foot orth oses (KAFOs), 253
Kn ee, osteoarth ritis of
causes of, 737
crystallin e arth ropath ies in , 739 741
hyaluron ic acid usage in , 741
inflam m atory arthritides, 739
intra-articular corticosteroid injections,
usage of, 741
lum bar disc disease in, 738
m en iscectomy, 737
non operative treatm ent of, 741 742
osteoch on dritis dissecan s, 737
path ophysiology of, 737 738
patien t evaluation
clin ical presen tation of, 738
differen tial diagn osis, 739 741
im aging of, 738 739
physical exam in ation of, 738, 738f
risk factors of, 736 737
surgical treatm en t of
arthroscopy, 742
kn ee arth rodesis, 744
osteotomy, 742 743
UKA, 743 744
total knee arthroplasty
complication s of, 746 747
indications, 744 745
infection, 747 748
instability, 749
loosening/ wear, 748 749
outcom es of, 746
periprosth etic fracture, 749 751
postoperative pain , 747
postoperative recovery, 746
stiffn ess/ arth rofibrosis, 749
surgical procedure, 745 746
th rom boem bolic disease, 747
varus deform ity in , 742
Leg
four com partm en ts of, 703f
n on traum atic in juries of
exertion al compartm en t syn drom e,
734
m edial tibial stress syndrom e,
733 734
tibial stress fractures, 732 733
traum atic in juries of
m idshaft tibia and fibula fractures,
731 732
Legg-Calve-Perth esdisease (LCPD), 321,
695
classification system s, 321
Catterall classification, 321, 323f
lateral pillar classification, 322, 324f
SalterTh ompson classification ,
321 322
differen tial diagn osis, 325 326
long-term progn osis, 328
path ophysiology, 321, 322f
physical exam in ation , 322 323
presen tation , 322
radiographs for, 323, 324f, 325f
special studies, 324 325, 326f
treatm en t, 326 328, 327f, 328f
Letourn el classification , of acetabular
fractures, 222f, 223
Leukocyte scan s, 82
Levator scapula, role of, 511
Levin e an d Edwards classification , of
Han gm an s fracture, 447, 447f
Levin s classification , of posterior an d
anterior hip dislocations, 666t
Lich tm an classification system , 604
Lift-off test, 517, 518f
Ligam en t, 25
Ligam en t recon struction ten don
interposition (LRTI), 636
postoperative radiograph of, 636f
Lim b girdle m uscular dystrophy, 257 258
Lim b len gth discrepan cy, 351
etiology, 351
evaluation, 351 353, 352f, 353f
treatm en t, 353 356
extern al fixator, use of, 355, 356f
growth-rem ain ing m ethod, 353, 354f
guidelines for, 353t
Moseley straight-line m ethod, 353,
355f
percutan eous epiphysiodesis, 354,
355f
rule-of-th um b m eth od, 353
Lim b rotation , n orm al, 3f
Limpin g ch ild, 356
diagn osis, 357 358
diagn ostic studies, 357
differen tial diagn osis, 357t
h istory an d physical exam in ation ,
356 357
Lipom as, 160
Lisfran c in juries
avulsion fracture, 779
classification of, 778
differen tial diagn osis of, 779
im aging of, 779
lisfranc ligam ent span s, 778f
Index
m echanism of injury, 778
physical exam in ation of, 778 779
presen tation of, 778
Quenu and Kuss classification of, 779f
treatm en t of, 779 780
Loadin g, 23
com pressive, 23
tensile, 23
Lon g h ead of th e biceps ten don (LHBT),
509
Loosers lin e, 109 110, 110f
Lower Extrem ity Assessm en t Program
(LEAP) study, 226 227
Lum bar disc disease, 738
Lum bar spin e
algorithm , 480 482, 481f
adult scoliosis, 484 486, 486f
con servative treatm en t, 482
epidural steroids, 483
radicular pain , causes of, 484
refractory patients with anterior thigh
pain , 484
refractory patients with low-back
pain , 482 483
refractory patients with posterior
th igh pain , 484
refractory patients with sciatica,
483 484
h ern iation -clin ical features, 475t
h istory of, 473
lum bar spine-clinical entities, 474 480
physical exam in ation of, 473 474
referred pain , 473
Lum bar strain , 179
Lun ate, 583
fractures (See also Hand and wrist)
classification of, 604
com plication s, 604
m echanism of injury, 604
presen tation an d physical
exam in ation, 604
radiograph ic fin din gs, 604
special studies, 604
treatm en t of, 604
types an d fun ction of, 583
Lun atotriquetral sh ear test, 611
Lym e disease, 138
in ch ildren
diagn ostic studies, 292
differen tial diagn osis, 292
h istory an d physical exam ination ,
292
path ophysiology, 291 292
presen tation , 292
treatm en t, 292
Lymph om a of bon e, 158, 160f
811
812
Index
Index
Navicular fractures, 777
CT scan in, 777
dorsal lip fractures, 777
navicular body fractures, 777
Neck Ach e, 465. See also Cervical spin e
Neck pain , predom in an ce of, 472 473
Neck Sprain , 465. See also Cervical spine
Necrotizin g fasciitis, 93 94, 233
classification
type 1 in fection s, 94
type 2 in fection s, 94
type 3 in fection s, 94
diagn ostic studies, 94
differen tial diagn osis, 94 95, 651
history an d physical exam ination, 94
path ophysiology of, 650
presen tation , 94, 650
radiograph ic fin din gs/ special studies of,
650
treatm en t, 95, 651
Neer classification , of proxim al h um erus
fractures, 523, 524f
Neer impin gem en t sign , 537, 538f. See also
Sh oulder
Neisseria gonorrhoeae, 650
septic arth ritis by, 85
Nerve an atomy, of h an d an d wrist,
594 595. See also Han d and wrist
Nerve con duction study (NCS), 533, 626
Nerve con duction velocity (NCV), 560
Nerve in jury, in h an d an d wrist
comparison of sun derlan d an d seddon
classification of, 621t
differen tial diagn osis, 622
path ophysiology/ classification of, 620
presen tation / physical exam in ation , 620
radiograph ic fin din gs, 622
ten odesis effect, 622
treatm en t of, 622
Nerve in jury, respon ses to, 70 73
Neural crest cells, 3
Neural tube, 4
closin g of, 5f
form ation , 4f
Neurapraxic lesion s, 71
Neurofibrom a, 162
Neurom uscular scoliosis, 367
differen tial diagn osis, 370
history an d physical exam ination,
368 369, 369f
path ophysiology an d classification ,
367 368
presen tation , 368
radiograph s, 369, 370f, 371f
special tests for, 369 370
treatm en t
n on operative, 370, 371f
surgical, 370 371, 372f
Neuropath ic arth ropathy, cause of, 544
Neurotm esis, 71, 72, 72f
Neurovascular structures, of elbow,
552 554, 555f
elbow disorders, evaluation of
h istory, 554 556
physical exam in ation , 556 557
im agin g, 558
neurovascular assessm ent, 557 558
palpation , 557
physical exam in ation , 557, 557f
radiography, 558
ran ge of m otion , 557
stability, 557
Neutroph ils, 120
Nigh tstick fractures, 608
Nodular ten osyn ovitis, causes of, 644
No m an s lan d, 616. See also Flexor ten don
injuries
Non ossifyin g fibrom a, 152, 153f, 154
Non steroidal an ti-in flam m atory drugs
(NSAIDs), 139, 527, 629, 687,
704, 741
ch aracteristics of, 140 142t
in hallux rigidus treatm ent, 796
side effects of, 143
for sports in juries, 189
in tarsal tunn el syndrom e treatm ent,
789
Non un ion s, 228 229
atrophic, 229, 229f
and host factors, 230
hypertroph ic n on un ion , 229, 229f
infection and, 230
oligotroph ic, 230, 230f
Nuclear scin tigraphy, 54 56, 58
gam m a cam eras, use of, 55
skeletal scin tigraphy (bone scan ), 55 56
wh ite blood cell scan , 58
Nutrition al rickets, 261. See also Rickets
813
Open fractures
classification of, 199, 199f
type III in jures, 199
type II in jures, 199
type I in jures, 199
defin ition of, 197
diagn osis of, 197 198
incidence of infection in, 199
as surgical em ergency, 198 199
tetanus prophylaxis, indications for,
198, 199t
treatm en t, 199 200
Open pelvic fractures, 220
Open reduction and internal fixation
(ORIF), 523, 563, 599, 713,
750, 761
Open reduction of hip, 308 309
Open section defect, 23
Opponens digiti m inim i (ODM), 590
Opponens pollicis (OP), 589
Th e Orth opaedic Traum a Association ,
670, 672
Orthopaedic Traum a Association
classification , of distal h um erus
fractures, 561, 562f
Orthopaedic traum a, m anagem ent of
acetabular fractures, 220 224
posterior wall fractures, 224 225
amputation, traum atic, 225 227
articular fracture, 214
com partm en t syn drom e, 202 205,
203f, 204f
diagn osis in un con scious patien t an d
pediatric population , 203 204
m anagem ent schem e for patient with,
204f
physical exam in ation , 203
pressure m easurem en t, 204
surgical release of fascial
com partm en ts, 204
com plication s an d
m alun ion s, 228
necrotizin g fasciitis, 233
non un ion s, 228 230
osteomyelitis, 230 231
septic arth ritis, 231 233
diaphyseal fracture, 212 214
fracture classification system s, 206 207
fracture-dislocation s, 201, 203f
fracture m an agem en t, 207
bon e biology an d physiology, 207
fixation m eth ods, 210, 212
fracture h ealin g, 207, 208f, 209f, 210f
preoperative plan n in g, 207, 210,
211f, 212f
fractures with n eurovascular
com prom ise, 200, 200f
open fractures, 197 200
open pelvic fractures, 220
pelvic rin g in juries, 214 220
polytraum a patien t, 205 206
spin al cord in jury, 200 201, 201f, 202f
traum a patien t, evaluation of, 193
blood loss in acute fractures, 194t
lower extrem ity, sensory distribution
of, 196f
physical exam in ation , 193 196
814
Index
Orthopaedic traum a,
m anagem ent of (Contd.)
spin al cord in jury, 196 197
tertiary exam ination, 197
upper extrem ity, sen sory distribution
of, 195f
vascular in juries with fracture, 197
Ortolani test, 301, 301f
Osgood Schlatter syndrom e, 331, 709, 728
Os odon toideum , 381 382, 382f
Ossification groove of Ranvier, 9
Ossification of secon dary cen ters of distal
h um erus, 407f
Osteitis deform ans. See Pagets disease of
bon e
Osteoarthritis (OA), 128 130, 542, 576,
687
articular cartilage and, 14, 15f
diagn osis of, 129
differen tial diagn osis of, 578
of h ip
ch aracteristics of, 687
and inflam m atory arthritis,
radiograph ic criteria for, 687t
prevalen ce of, 687
im aging studies, 129
path ologic m ech an ism s, 129
path ophysiology an d classification of,
577
physical exam in ation in , 578
presen tation of, 577
radiograph ic fin din gs of, 578
risk factor for, 128
special tests in , 578
treatm en t, 129 130, 578
Osteoarthritis (OA), of kn ee
causes of, 737
crystallin e arth ropath ies in , 739 741
hyaluron ic acid usage in , 741
inflam m atory arthritides, 739
intra-articular corticosteroid injections,
usage of, 741
lum bar disc disease in, 738
m en iscectomy, 737
non operative treatm ent of, 741 742
osteoch on dritis dissecan s, 737
path ophysiology of, 737 738
patien t evaluation
clin ical presen tation of, 738
differen tial diagn osis, 739 741
im aging of, 738 739
physical exam in ation of, 738, 738f
risk factors of, 736 737
surgical treatm en t of
arthroscopy, 742
kn ee arth rodesis, 744
osteotomy, 742 743
UKA, 743 744
total knee arthroplasty
complication s of, 746 747
indications, 744 745
infection, 747 748
instability, 749
loosening/ wear, 748 749
outcom es of, 746
periprosth etic fracture, 749 751
postoperative pain , 747
Index
Palm aris lon gus (PL), 584
Pan n us, 782. See also Rheum atoid foot
Paraten on , 587. See also Muscles and
ten dons, of hand and wrist
Parathyroid h orm on e (PTH), 98, 261
Paraxial m esoderm , 4
ParkHarris growth lines, 400, 401f
Paronych ia
ch ron ic, surgical m an agem en t of, 647,
647f
differen tial diagn osis of, 647
path ophysiology of, 647
presen tation / physical exam in ation of,
647
radiograph ic fin din gs of, 647
treatm en t of, 647
Passivation layer, 27
Patella dislocation
classification of, 716
differen tial diagn osis of, 717
m echan ism of injury, 716 717
patien ts presen tation of, 717
physical exam in ation of, 717
radiograph ic exam in ation of, 717
relevant anatomy of, 717
special tests for, 717
treatm en t of, 717
Patella fractures
classification of, 713, 713f
complication of, 714
differen tial diagn osis of, 714
m echan ism of injury, 714
patien ts presen tation of, 714
physical exam in ation of, 714
radiograph ic exam in ation of, 714
relevant anatomy of, 714
special tests for, 714
treatm en t of, 714, 714f
Patella glide test, role of, 709
Patellar ten don itis, 728
Patellar tilt sign , 728
Patellar tilt test, for patellofem oral join t
assessm en t, 709, 709f
Patella ten don ruptures, 715
classification of, 716
complication of, 716
differen tial diagn osis of, 716
m echan ism of injury, 716
patien ts presen tation of, 716
physical exam in ation of, 716
radiograph ic exam ination of, 716, 716f
relevant anatomy of, 716
special tests for, 716
treatm en t of, 716
Patellofem oral join t, 14
Patellofem oral join t assessm en t, 708 709,
708f
patella glide test for, 709
patellar tilt test for, 709, 709f
Patellofem oral pain syn drom e, 708
classification of, 727
complication s of, 729
differen tial diagn osis of, 728
Fulkerson procedure in, 729
m echan ism of injury, 727
patien ts presen tation of, 727
physical exam in ation of, 727 728
815
specific in juries
atlantoaxial injuries, 395
atlas fractures, 393, 394f, 395
Hangm an fractures, 395
occipitocervical in juries, 393
odon toid fractures, 395
SCIWORA, 398
subaxial cervical spin e in juries,
395 397
th oracolum bar fractures, 397 398
spin e traum a, 391 393
spon dylolysis an d spon dylolisth esis,
384 387
Pediatric Traum a Score, 401, 404t
Pelvic rin g in juries, 214 216
bleedin g, m an agem en t of, 217 218
classification system s for, 218, 219f
com plication s related to, 219 220
m anagem ent of, based on varying
h em odyn am ics, 216f, 217
and m obilization, 218 219
open in juries, 220
radiograph ic assessm en t, 218
Pem berton osteotomy, 308
Pen icillin s, 80
Periarticular fractures, 201
Perich on dral vessels, 9
Perich on drial rin g of La Croix, 9
Periorbital con tusion , 175
Periosteum , in ch ild, 399
Periph eral myelin protein (PMP)
gene, 254
Periph eral n erve repair, tech n iques of,
624f
Periprosth etic in fection , 91
classification , 91
diagn ostic studies, 91 92, 92f
differen tial diagn osis, 92
h istory an d physical exam in ation , 91
incidence, 91
presentation , 91
spread of, 91
treatm en t, 92 93
Peron eal artery, 759
Peron eal n erve, 195 196
Peron eal ten don path ology
exam in ation of, 789
path ophysiology an d classification of,
789
presen tation of, 789
radiograph s of, 789 790
treatm en t of, 790
Peron eus lon gus, 758
Ph alan geal dislocation s
classification of, 597
m echanism of in jury, 597
presen tation an d physical exam in ation ,
597
radiograph ic fin din gs, 597
treatm en t of, 597 598, 598f
Ph alan geal fractures, 782
Ph alen test, in CTS, 626
Ph ocom elia, 651
Physeal fractures, 399 401
SalterHarris classification of, 400f
Pigm en ted villon odular syn ovitis ( PVNS),
162
816
Index
Pilon fractures
classification of, 761, 762f
im aging of, 762 763
m echanism of in jury, 761
physical exam in ation of, 762
presen tation of, 761
rotational and axially loadin g fractures,
ch aracteristics of, 762t
treatm en t of, 763
Pipkin s classification , of fem oral h ead
fractures, 670, 670f
Piriform is m uscle, role of, 655
Pisiform fractures. See also Han d an d wrist
classification of, 606
m echanism of in jury, 606
presen tation an d physical exam in ation ,
606
radiograph ic fin din gs, 606
treatm en t of, 606
Pivot sh ift test, for ACL, 706
Plan ovalgus, 246, 247f
Plan tar fasciitis
differen tial diagn osis of, 793
exam ination of, 793
heel pain , 792
nigh t splin tin g in , 793
path ophysiology of, 792
presen tation of, 792
radiograph s of, 793
treatm en t of, 793
Plasm a cell tum or, 158
Plexopathy, diagn osis of, 76
Pn eum atic an tish ock garm en ts,
217 218
Pn eum oth orax, 180
Poisson s ratio, 23
Polar m om en t of in ertia, 23, 23f
Polydactyly, 349 350, 351f. See Preaxial
duplication
Polym erase ch ain reaction (PCR), 82
Polym ethyl m eth acrylate (PMM), 26
Polym ethylm eth acrylate (PMMA),
84
Polymyalgia rh eum atica (PMR), 137
Polyn europathy, diagn osis of, 74 75
Polytraum a patien t, 205
m anagem ent of
dam age con trol orth opaedics, 205,
205f
early total care, 205
Popliteal cysts, 332
Positive sh arp waves, 67, 67f
Positron em ission tom ography (PET)
im aging, 58
Postcon cussive syn drom e, 171
Posterior atlan toden tal in terval (pADI),
469
Posterior cord syn drom e, 436. See also
Spin al cord in jury (SCI)
Posterior cruciate ligam en t (PCL), 699,
745
godfrey test for, 707
posterior drawer test, 708f
quadriceps active test for, 707
sprain
classification of, 723
complication s of, 724
Q tests, 35
Quadriceps active test, for PCL, 707
Quadriceps strain s, 715
Quadriceps tendon rupture, 714
classification of, 715
complication of, 715
differen tial diagn osis of, 715
m echanism of injury, 715
Index
patien ts presen tation of, 715
physical exam in ation of, 715
relevan t anatomy of, 715
special tests for, 715
treatm en t of, 715, 715f
Quadriplegia, 241
817
fibromyalgia, 130
infectious arthritis, 137 138
osteoarth ritis, 128 130
ph arm acologic th erapy for, 138 139
analgesics, 139
corticosteroids, 143
NSAIDs, 139 143
SAARDs an d cytotoxic drugs, 144,
144t
polymyalgia rh eum atica, 137
rh eum atoid arth ritis, 125 128
seron egative spon dyloarth ropath ies,
130 133
system ic lupus eryth em atosus, 135 137
Rheum atoid arthritis (RA), 125 128,
468 470, 469f
atlantoaxial instability, 469
classification of, 126, 127t
in elbow, 543, 549
differen tial diagn osis of, 576 577
Mayo classification of, 576
path ophysiology an d classification
of, 576
physical exam in ation in , 576
presentation of, 576
radiograph ic fin din gs of, 576
special tests in, 576
treatm en t of, 577
extraarticular m an ifestation s of, 128
h allm ark of, 126
in hand and wrist
classification of, 638
differen tial diagn osis of, 639
Mannerfelt lesion, 638
path ophysiology of, 638
presen tation / physical exam in ation of,
638 639
radiograph ic fin din gs/ special studies
of, 639
treatm en t of, 639
Vaugh n Jackson lesion, 638
h an d in volvem en t in , 127 128
join ts in volved in , 126, 127f
laboratory and radiographic testing,
126 127
treatm en t, 128
treatm en t of, 470
Rheum atoid factor (RF), 119, 120
Rheum atoid foot
appearance of, 783f
h in dfoot surgery in , 784
path ophysiology an d classification of,
782 783
physical exam in ation of, 783
presen tation of, 783
radiograph ic fin din gs of, 783
treatm en t of, 784
weigh t-bearin g radiograph s for, 783
Rib fractures, 179
Rib vertebral angle difference (RVAD),
m easurem en t of, 362, 364f
Riche Cann ieu anom aly, 66
Rickets, 261
classification , 261
diagn ostic tests, 263
differen tial diagn osis, 263 264
etiology of, 263, 263t
818
Index
Rickets (Contd.)
and osteom alacia
bioch em ical ch an ges in , 109t
causes of, 108t
clin ical presen tation , 108 109
defin ition s of, 107 108
etiology of, 108
laboratory investigation s, 109
prevalen ce, 108
radiograph ic features, 109 110
treatm en t, 110
path ophysiology, 261
calcium m etabolism , 261, 262f
presen tation an d physical exam in ation ,
261 263
radiograph ic fin din gs in , 263, 264f
treatm en t, 264 265
Rifampin , 80, 81t
Risser sign, 364f
Rituxim ab, 128
Rockwood classification, of injuries to AC
joints, 526, 526f. See also
Sh oulder
Rolando fracture, 600, 600f
Rotator cuff disease, 543
Rotator cuff m uscles, 508 509
defin ition of, 508
role of, 508
Rotator cuff pathology, of shoulder pain.
See also Sh oulder
differen tial diagn osis, 538 539
Hawkins im pin gem ent sign, 537, 538f
Neer impin gem en t sign , 537, 538f
path ophysiology an d classification ,
536 537
patien ts presen tation , 537
physical exam in ation , 537
radiograph ic fin din gs, 537
special tests, 537 538
th eories in , 536
treatm en t of, 539 540
Rotator interval, definition of, 509
Rugger jersey appearan ce, of spin e, 268,
270f
Run ners knee, 701, 729
RussellTaylors classification, of
subtroch an teric fem ur fractures,
681, 683f
Index
fun ction of, 501
inspection of, 514
instability classification, 528t
internal rotation assessm ent of, 515f
n eurovascular assessm ent of, 517 518
pain , source of, 507
palpation of, 514
problem s, evaluation of
h istory, 512 514
m ultiple im agin g m odalities, 518 520
physical exam in ation , 514 518
ran ge of m otion in , 514 516
stren gth testin g of, 516 517
tests for exam in ation of, 514t
traum atic in juries to
acrom ioclavicular joint sprains,
525 528
clavicle fractures, 520 523
glen oh um eral in stability, 528 533
proxim al h um erus fractures,
523 525
SLAP lesion s, 533 536
zan ca view of, 518, 521, 522f, 527
Shoulder separation , 525
Simple bon e cyst, 152, 153f
Sin gle-even t m ultilevel surgery (SEMLS),
244
Sin gle-fiber EMG (SFEMG), 69 70
fiber den sity, an alysis of, 69
jitter, an alysis of, 69 70
myasth en ia gravis (MG), diagnosis of,
70
Skiers th um b, 601
Skin an d n ail traum a
AtasoyKlein ert V-Y advan cem en t flap,
613f
classification of, 612, 613f
cross-fin ger flap, usage of, 613, 615f
Moberg advan cem ent flap, 613,
614f
presen tation an d physical exam in ation ,
612
radiograph ic fin din gs, 612 613
th en ar flap in , 613, 615f
treatm en t of, 613
Slidin g screw plate device, in
intertrochanteric h ip fractures,
679, 679f
Slipped capital fem oral epiphysis (SCFE),
263, 263f, 312, 312f
classification , 312 313
com plication s, 316, 320f
avascular n ecrosis (AVN) of fem oral
h ead, 318, 321f
joint space n arrowing with
ch on drolysis, 316, 318, 320f
im aging studies, 315, 315f, 316f
path ophysiology, 312
physical exam in ation , 313 314, 314f
presen tation , 313, 313f
radiograph s, 314 315, 314f, 315f
treatm en t, 316, 317f, 318f, 319f
Slow-actin g an tirh eum atic drug (SAARD),
132, 144, 144t
Sm all-fiber polyn europathy, 75
Sm ith Peterson s approach , in THA, 688,
689f
819
820
Index
Strain
defin ition of, 22
norm al strain, 22
shear strain, 22
Streptococcus, 646
Stress, 21 22
defin ition of, 21 22
norm al stress, 22
shear stress, 22
Stress con cen tration effect, 23
Stress fractures, 182 183, 183f
Stress radiograph s, usage of, 542
Stressstrain curve, 22, 22f
elastic region , 22
m odulus of elasticity, 22 23
plastic region , 22
ultim ate ten sile stren gth (UTS), 22
yield point, 22
Stron g capsular ligam en t (SC ligam en t),
505
Struth ers, arcade of, 630f
Studen ts t test, 30, 36
Study design
analytic observational studies, 33
case-con trol studies, 33 34
case series, 33, 34
case studies, 33
coh ort studies, 34
cross-section al studies, 33, 34
descriptive observation al studies, 33
experim ental study, 34
m eta-analysis, 34
prospective coh orts, 35
prospective studies, 34, 34f
random ized clinical trial, 34, 35
retrospective studies, 34
reviews, 35
Subacrom ial bursa, role of, 507
Subacrom ial space, 501, 502f, 507
Subaxial cervical spin e in juries, 395
burst fractures, 395, 397
com pression fractures, 395
facet dislocation s, 395
ligam entous disruptions, 395, 396f
Subaxial cervical spin e traum a, 448. See
also Upper cervical spin e traum a
classification of, 448
Subdural h em atom a, 173 174,
174f
Subluxation , defin ition of, 528. See also
Glen oh um eral (GH) join t
Subscapularis m uscle, role of, 509
Subtalar join t, an atomy of, 756
Subtroch an teric fem ur fractures, 680 681
classification of, 681
deform in g forces on , 681f
differen tial diagn osis of, 682
Fieldin gs classification of, 681
m echanism of in jury, 681
patients presen tation of, 681
physical exam in ation of, 681
radiograph ic exam in ation of, 681 682
RussellTaylors classification of, 681,
683f
Sein sheim ers classification of, 681, 682f
special tests for, 682
treatm en t of, 682 683, 684f
Sulfasalazin e, 132
Superior glen oh um eral ligam en t (SGHL),
503
Superior labrum an terior to posterior
(SLAP) lesions, in shoulder
bucket-h an dle tear, 533
classification of, 533, 534f
differen tial diagn osis for, 535
Mayo sheer test, 535
m echanism of injury, 533
MRI of, 535, 535f
OBrien test, 534, 535f
patien ts presen tation , 534
physical exam in ation , 534 535
radiographic findings, 535
special studies, 535
treatm en t, 535 536
Superior labrum an terior to posterior
(SLAP) tears, 519
Supination-external rotation (SER), 763
Supracon dylar h um erus fractures, 407
complication s of, 410
deform ity resultin g from , 412, 412f
exten sion -type, 407, 408f
flexion -type, 407, 408f
Gartland classification, 407 408, 409f
hyperexten sion loadin g an d, 407
inciden ce of, 407
m echanically vulnerable area, 407, 408f
and physical an d neurologic
exam in ation , 410
radiographic m easurem ents for, 408,
409f, 410
treatm en t of, 410
vascular in juries associated with , 410,
412f
volkm ann ischem ic contracture by,
411 412, 412f
Supraspin atus cuff m uscle, role of, 508
Supraspin atus dysfunction, 516
Surgical n eck, 501
Syn dactyly, 346, 349, 350f
Syn ovial ch on drom atosis, 162
Syn ovial fluid, 501
Syn ovial fluid an alysis, 86
Syn ovial sarcom a, 163, 163f
System atic reviews, 35
System ic lupus eryth em atosus (SLE),
135 137, 136t
ACR diagn ostic criteria for, 137t
clin ical symptom s, 136t
Talus fractures
Can ale an d Kelly view for, 772f
classification of, 770
differen tial diagn osis of, 771 772
Hawkins classification of, 771f
im agin g of, 771
m echanism of injury, 770 771
MRI in , 772
physical exam in ation of, 771
presen tation of, 771
treatm en t of, 772
Tarsal coalition , 343 344, 344f
Tarsal tun n el syn drom e
cortison e in jection s in , 789
Index
differen tial diagn osis of, 789
NSAID in , 789
path ophysiology an d classification of,
788
physical exam in ation of, 788 789
presen tation of, 788
radiograph ic fin din gs of, 789
special tests for, 789
treatm en t of, 789
Tarsom etatarsal joint, 757
injuries, m an agem ent of, 779
Tartrate-resistant acid ph osphatase
(TRAP), 100
T cells, 118 119
99m
Tc-m ethylen e diph osph on ate (MDP),
55
T-con dylar fractures, 416, 417f
Techn etium bon e scan s, usage of, 710
Teleoroen tgen ogram , 352, 352f
Tendin opath ies, in h an d an d wrist,
644 646. See also Hand and
wrist
Tendo calcan eus, 757
Tendon , 25
Tenn is an d golfers elbow. See Lateral and
m edial epicondylitis
Teriparatide, in osteoporosis treatm en t,
107
Terrible triad, defin ition of, 571
Test ch aracteristics, 37
negative predictive value, 37
positive predictive value, 37
sen sitivity, 37
specificity, 37
Testosteron e, 190
Tethered cord, sign s of, 251, 251f
Tetracyclin es, 80, 81t
Th en ar flap, 613, 615f
Thigh foot an gle, n orm ative values for,
237f
Third-body wear, 27
Thoracic outlet syndrom e
adson test in , 633
differen tial diagn osis of, 633
path ophysiology/ classification of, 632
physical exam in ation of, 633
presen tation/ m ech anism of in jury, 632
radiograph ic fin din gs of, 633
roos test in, 633
special studies in , 633
treatm en t of, 632
Thoracolum bar fractures, 397 398
Thoracolum bar spine, fracture dislocation
of, 458 460, 459f460f. See also
Upper cervical spine traum a
Thoracolum bar traum a, 452 458. See also
Upper cervical spine traum a
burst fractures, 454 456, 455f
chan ce in juries, 456 458, 457f
radiograph ic ch aracteristics of, 457f
classification of, 453
compression fractures, 453 454
stable L3, 454f
CT scan in , 453
Thoracolum bosacral orthosis (TLSO), 486
un derarm brace, 365 366, 366f, 379
Throm boem bolic disease, 747
821
822
Index