Testable Concepts in MCQ

Testable
Concepts
in
Multiple Choice Questions

Based on
Orthobullets Free Question Bank
2016

Mahmoud Desouky

Testable Concepts in M.C.Q.
TRAUMA
DR. MAHMOUD DESOUKY 1

General Trauma
Previously healthy, poly-trauma patients, presenting with platelet counts of

<70,000 will fall into the pathophysiological category of 'in extremis'. This will
support the role of damage control orthopaedics in the decision making
process of this patients fracture management .
In "compensated" shock despite normal vital signs and urine output

parameters , there is maldistribution of blood flow and tissue oxygenation as
splanchnic organs have less distribution of the cardiac output compared to the
heart and the brain. Serum lactate (normal < 2 mmol/L) is the best indicator of
peripheral organ perfusion and tissue oxygenation. It also states that base
deficit (between -2 and +2) and gastric mucosal pH (>7.3) are appropriate end
points to determine the complete resuscitation of trauma patients.
Septic shock is different from hypovolemic shock in that the systemic vascular
resistance is decreased, whereas it is increased in hypovolemic shock .
Frontal airbags had no significant protective effect on pelvic fractures.
The risk of viral transmission following a screened blood donation is highest

for HBV .
The factor most likely to adversely affect long term outcome in poly-trauma
patients with severe brain injury is intraoperative hypotension.
To avoid compression of the inferior vena cava in pregnant patient who is in

her second or third trimester, the left lateral decubitus position (left side down)
should be used.
The majority of missed skeletal injuries result from failure to image the
affected extremity.
If the floating knee injury is an isolated injury and the patient is

hemodynamically stable then immediate intramedullary nailing of the tibia and
femur is acceptable .
A favorable response to fluid replacement therapy includes increased urinary

output (at least 0.5ml/kg/hr) , and pulse pressure greater than 15mmHg.
A loss of 15-30%of normal circulating blood is needed for a patient to become

tachycardic with a narrowed pulse pressure (class II shock) .

APC injuries of the pelvis are highly unstable and can produce high mortality
rates by pelvic exsanguination. Pelvic venous bleeding is far more common
than arterial bleeding. The initial treatment intervention should be to reduce
the pelvic volume by any means possible (sheet, binder, ex-fix) to reduce
further intrapelvic bleeding. After application of the pelvic sheet, the patient
has become stabilized and can undergo further workup to rule out other life
threatening injuries ( CT chest , abdomen , and pelvis ) .
An 8cm open segmental tibia fracture requiring skin grafting (but not a skin
flap) qualifies as a Gustilo Type IIIA .
Ten or more years after severe polytrauma, premenopausal women,

compared to men, demonstrate a higher incidence of posttraumatic stress
disorder (PTSD) ,lower quality-of-life scores and take more sick leave time
from work .
Severe lower extremity injury patients undergoing reconstruction have a

higher rate of rehospitalization at 2 years.
The total score for the MISS, is the sum of the squares for the highest injury
score grades in the three most severely injured body regions .
The mangled extremity severity score (MESS) system consider the following
(not time from admission to surgery) :
• Skeletal / soft-tissue injury

• Limb ischemia
• Shock
• Age
Extent of soft tissue injury has been shown in Level 2 evidence as having the
highest impact on the decision to undergo limb salvage or amputation.
The NISS (New Injury Severity Score) differs from the ISS (Injury Severity
Score) in that the NISS sums the squares of the 3 most significant injuries
(even if they occur in the same anatomic area). The ISS sums the 3 most
significant injuries in 3 separate anatomic areas.
Current initial recommendations for type II open fractures include tetanus

prophylaxis/update and a first generation cephalosporin (if no
allergies). Fluoroquinolones ( Ciprofloxacin ) can be used in these injuries as
second-line agents if allergies are present . While penicillin and gentamicin
can be added in contaminated type III injuries.

High-pressure pulsatile lavage for open fractures damages bone structure and
disrupts soft tissue , so saline solution is applied by low pressure gravity flow
device .
Algorithm to provide appropriate tetanus prophylaxis
In patients with chronic osteomyelitis and an infected nonunion complicating

previous IM nailing , successful treatment requires debridement, removal of
the existing tibial nail, placement of an antibiotic-impregnated rod and IV
antibiotics.
The general trend is increasing energy requirement for more proximal

amputations. The only exception is the Syme which was the most energy
efficient even though it is more proximal to the midfoot amputation. A
transfemoral level amputation requires the greatest increase in energy
expenditure of the amputation levels, and a Syme amputation the least .
A through-knee amputation, or knee disarticulation, is the most proximal level

of amputation a child can undergo and still maintain a self-selected walking
speed without significantly increasing their energy expenditure.
In modified Lisfranc (tarsometatarsal) amputation unopposed pull of

gastrocnemius-soleus and posterior tibialis results in an equinovarus
deformity . Therefore, Several surgical techniques have been described to
address or prevent equinovarus deformities after Lisfranc amputation. Open
or percutaneous achilles tendon lengthening, open gastrocnemius recession,
or endoscopic gastrocnemius recession have shown to address the equinus
deformity. Split tibialis anterior tendon transfer (STATT), 4th and 5th digit
flexor-to-extensor tendons tenodesis, as well as peroneus brevis (PB) to
peroneus longus (PL) tendon transfers have shown to address the varus
deformity. Preserving the soft-tissue envelope (peroneus brevis, tertius and
plantar fascia) around the fifth metatarsal base prevents the patient from
having a supinated foot during gait.
Adductor myodesis is a critical part of a transfemoral amputation . It balances

the pull of the hip abductors and flexors that insert proximally .This prevents
an abducted and flexed deformity that encumbers ambulation. It also creates
a soft tissue envelope that pads the distal bony amputation and enhances

suction fitting of the prosthesis . But it does not preserve femoral length. A
little extra distal femur is actually resected to facilitate the myodesis insertion
Hyperbaric oxygen therapy (HBO) allows patients to breathe 100% oxygen in

a chamber under conditions of increased barometric pressure. It depends on
increasing the oxygen gradient for gas diffusion for a much greater distance
than under normal conditions The presence of a crush injury to an extremity is
an indication for hyperbaric oxygen (HBO) therapy , while COPD , history of
bleomycin treatment , presence of a pneumothorax , presence of an insulin
pump are contraindications .
Overgrowth is the most common complication following transosseous

amputation compared to disarticulations in pediatric patients.
"Dog ears" at the edge of a long posterior flap BKA incision are typically left
intact because removal risks posterior flap blood supply (Saphenous and
sural arteries)
A Syme amputation is effectively ankle disarticulation. It works better for

tumor and trauma, but the heel pad must be viable. The two most common
problems are 1) skin sloughing from compromised vascular supply and 2)
migration of the heel pad due to instability . An ankle-brachial index (ABI) less
than 0.5 for the posterior tibial artery in a patient with diabetes would be a
contraindication for this procedure as success is dependent on the vascular
supply of posterior tibial artery to the plantar flap and heel pad.
Knee disarticulation level is associated with the worst functional result 2 years
after injury (compared to transmetatarsal, Symes, AKA, or BKA). The
prosthetic use is decreased with a knee disarticulation as compared to a
transtibial amputation .
The most important predictor of wound healing is the serum albumin level >
3.0 g/Dl .
The Chopart (midtarsal) amputation results in equinus deformity that

eventually leads to stump breakdown. To prevent this complication it should
be coupled with Achilles tenotomy (vs. lengthening) as well as transfer of the
tibialis anterior insertion to the talar neck.
For gunshot wounds with bowel perforation and a retained bullet in the
vertebral body, if the patient is neurologically intact broad-spectrum
intravenous antibiotic coverage for 7 days is the most appropriate treatment.

A penetrating (but not perforating) missile with highest velocity (2v) and
largest yaw (90 degrees, or sideways travel) leads to greatest transfer of
kinetic energy.
Low velocity injuries (below 1,000 to 2,000 feet per second) with stable, non-
operative fractures can be treated with local wound care and oral antibiotics.
Risk factors for female victims IPV (intimate partner violence) include being in
the 2nd or 3rd decade of life, current pregnancy, alcohol dependency , shorter
length of relationship , having 1 or more prior children, and low socioeconomic
status. History of marriage ending in divorce has not been identified in the
literature as a risk factor for intimate partner violence . Reporting requirements
for adult abuse are not standardized amongst most states and physicians
must understand the importance of identification and documentation in cases
of suspected IPV . However there is no federal law mandating photographic
documentation of domestic violence injuries.
Interdisciplinary collaboration among healthcare workers was a predictor of

positive treatment outcomes in IPV . Included were more accurate
assessments of past history, more descriptive emotional symptoms as
displayed by victims and written documentation of recommendations
concerning intervention and linkage to community resources.
Gender has not been identified as an independent risk factor for elder abuse .
Intracompartmental pressure measurements should be performed when pain

with passive motion of the toes is found in young patients with insufficient
clinical data to establish a definitive diagnosis of compartment syndrome.
It is recommended that intraoperative compartment pressures be compared to

preoperative diastolic blood pressures (diastolic blood pressure may be
falsely decreased compared to normal pre- or postoperative measurements) ,
with delta p < 30 indicating the need for fasciotomies . An absolute intra-
compartmental value greater than 30 to 45mmHg can also be used to make
the diagnosis of compartment syndrome, but is more controversial than the
delta p.

Isolated compartment syndrome in the lateral compartment of the leg affects

superficial peroneal nerve (dorsum of the foot involving the hallux, 3rd, and
4th toes).
Release of deep posterior compartment of the leg cannot be done without

proper elevation of the soleus.
Agitation, anxiety, and increasing analgesic requirements are the "3 A's" of
pediatric compartment syndrome . Neutral to 30 degrees of plantar flexion
ankle position results in the safest compartment pressures in a casted lower
leg .
Mechanism of injury is not the best predictor of compartment syndrome

development or diagnosis in pediatric patients.
Common peroneal nerve is at risk during proximal dissection of a single

lateral perifibular approach for compartment syndrome of the leg .
The single most important symptom of impending compartment syndrome is

pain out of proportion to the injury .
A Marjolin's ulcer is a malignant tumor that develops around chronic

osteomyelitis. The increasing size and foul smell suggest malignant change.
These tumors are most commonly squamous cell carcinoma.
In contrast to acute osteomyelitis, chronic osteomyelitis is often not eradicated

with intravenous antibiotics alone. All necrotic bone (including the
sequestrum) must be resected as it serves as a nidus for infection. Antibiotics
should be guided off culture sampling of the infection.
Metaphyseal infections heal better than mid-diaphyseal infections.
A saline load test is commonly utilized to evaluate for traumatic arthrotomies

. A mininum of 155mL saline should be utilized . Injection of 175ml of saline
will diagnose 99% of knee arthrotomies.
Staphylococcus aureus is now the major cause of sternoclavicular septic

arthritis in intravenous drug users .
Exopolysaccharide glycocalyx allows bacteria to adhere to orthopaedic

implants and elude antimicrobial therapies through the creation of biofilms
The most sensitive parameter to detect inflammation elicited by implants and

infection is the C-reactive protein (CRP). CRP should peak by 48 hours after
surgical fixation of bony orthopedic injuries, and decrease thereafter.

When suspecting necrotizing faciitis , biopsy with a frozen section is effective

at rapidly confirming an early diagnosis. If the biopsy is performed in the
operating room, and is positive, then there will be minimal time delays in
performing the required radical debridement (the key to treatment involve
timely diagnosis) . Most common organism is group A ß-hemolytic
streptococci .
Caucasian race has not been found to be a predictor for transfer to a Level 1
trauma center.
Upper Extremity Trauma
Finger abduction is performed by the ulnar nerve, which is supplied by the

inferior trunk of the brachial plexus.
Findings that suggest a pre-ganglionic brachial plexus injury include Horner

syndrome (ptosis, miosis, anhidrosis), a medially winged scapula, loss of
paraspinal musculature activity on EMG, and a normal histamine test. These
injuries tend to have a worse prognosis than post-ganglionic lesions, which
show an abnormal histamine test and intact cervical paraspinal activity on
EMG.
The supraspinatus is innervated by the suprascapular nerve off the upper

trunk and therefore would not be affected by an injury to cords.
Anterior SC joint instability should primarily be treated conservatively.

Operative intervention for anterior SC joint instability is mainly cosmetic in
nature with little functional impact .
Symptomatic acute posterior sternoclavicular dislocations in adolescents

should undergo reduction with thoracic surgery back-up. If closed reduction is
not successful , then open reduction is indicated.
The treatment for spontaneous atraumatic subluxaton of the sternoclavicular

joint is observation.
Surgical management of displaced, shortened (>2 cm) clavicle fractures is

associated with a decreased rate of nonunion and malunion, while improving
shoulder strength and function at follow-up. Patients who have nonoperative
treatment of displaced midshaft clavicle fractures have significant decreases
in both strength and endurance

Small fragment plate fixation with possible coracoclavicular ligament

reconstruction is the most appropriate treatment for a displaced distal clavicle
fracture in a patient that wishes to avoid a second procedure.
Treatment of atrophic nonunions of the clavicle is with plate fixation in

conjunction with cancellous autograft.
Figure of eight braces have been shown to have no differences as compared

to simple slings in fracture clavicle regarding healing times, healing rates, and
alignment at final follow-up.
The risk of nonunion in patients sustaining middle 1/3 clavicle fractures is

increased in female patients.
In the posterior or modified Judet approach to the scapula , The interval

between the infraspinatus (suprascapular n.) and teres minor (axillary n.) is
utilized .
Significantly displaced extra-articular glenoid neck fractures, have

translational displacement greater than or equal to 1 cm or angulatory
displacement greater than or equal to 40°. These typically need ORIF.
Patients presenting to a trauma center with scapula fractures have an

increased rate of pulmonary complications and increased Injury Severity
Scores (ISS).
In scapulothoracic dissociation , neurologic status of the extremity is the

exam finding most predictive of functional outcome. If neurologic injury this
leads to flail limb.
The anterolateral branch of the anterior circumflex artery, called the arcuate
artery terminally, provides blood supply to the entire humeral head, lesser
tuberosity and greater tuberosity except for posterior portion of the greater
tuberosity and a small posteroinferior portion of the humeral head which are
supplied by the posterior circumflex artery.
Displaced greater tuberosity fracture more than 5mm of displacement is an

indication for surgery in patients that require overhead function of the arm.
The pectoralis major tendon is a reproducible structure from which the

humeral height and retroversion during shoulder arthroplasty can be based
upon. The superior edge of the pectoralis major tendon at its insertion on the
humerus is 5.6 cm below the top of the humeral head.

The most common complication with the use of locking plate for proximal
humerus fracture is screw penetration (cut out).
In the anterolateral acromial approach the axillary nerve is at particular risk of

injury and must be identified and protected. It is located approximately 7cm
from the tip of the acromion.
Varus collapse and intra-articular joint penetration of the the proximal locking
screws in proximal humeral fractures could have potentially been prevented
by the addition of an inferomedial calcar screw, which would have provided
greater strength to the fixation construct and resistance to fracture collapse .
In shoulder hemiarthroplasty passive external rotation of the shoulder placed

the most stress on the lesser tuberosity fixation.
ORIF for displaced proximal humeral fractures in young age, active lifestyle,
and the displacement of the greater tuberosity ; allows for restoration of
anatomical alignment, reducing the possibility of impingement and weakness
from the greater tuberostiy malunion.
Malunion of the greater tuberosity in humeral hemiarthroplasty is a known

complication of this procedure, and the most likely cause for loss of shoulder
elevation.
Chronic nonunion and loss of fixation of the proximal humerus in the elderly
should be treated with arthroplasty .
Malunions of the proximal humerus typically result in significant restrictions in

range of motion. In young patients with proximal humeral malunion, treatment
should include a corrective osteotomy .
The most likely underlying metabolic or endocrine abnormality with

oligotrophic nonunion is vitamin D deficiency.
In polytrauma patient humerus should be plated to facilitate early weight

bearing, allowing for mobilization with crutches.
The most likely cause of the radial nerve palsy in a high energy open humerus
fracture is laceration or complete disruption of the radial nerve (Neurotmesis).
A coexisting brachial plexus injury is an absolute indication for open reduction

and internal fixation of humeral shaft fractures.
Compared to plate fixation humeral shaft fractures treated with antegrade

intramedullary nailing (IMN) have a higher risk of receiving an additional

operation , a higher incidence of shoulder impingement and increased

complication rates. There has been no difference found between the
incidence of infection, union rates , elbow pain or radial nerve injury when
comparing the two treatment options.
The radial nerve enters the anterior compartment through the

intercompartmental fascia on average 10 cm proximal to the radiocapitellar
joint.
The posterior antebrachial cutaneous nerve (PABCN) branches from the

radial nerve in the axilla.
Motor recovery of radial nerve injury proceeds in a proximal to distal direction

: brachioradialis, extensor carpi radialis longus, supinator, extensor carpi
radialis brevis, extensor digitorum communis, extensor carpi ulnaris, extensor
digiti quinti, abductor pollicis longus, extensor policis longus, extensor policis
brevis, and extensor indicis proprius (Index finger MCP hyperextension is the
last to return).
A closed mid-diaphyseal humerus fracture with a radial nerve palsy on

presentation is not a contraindication to functional brace management.
Humeral shaft fractures treated with plating and full weightbearing did not
have any effect on the union or malunion rates.
Plate fixation (with bone graft as needed) is the procedure of choice for
humeral shaft nonunions.
With intramedullary (IM) nailing of the humerus, the distal interlocking

anterior-to-posterior screws placed the musculocutaneous nerve at high risk,
while lateral-to-medial screws placed the radial nerve at high risk as it courses
laterally distally along the humerus.
In case of residual radial nerve palsy 3 months after a humeral shaft fracture ,
EMG is indicated at this time to evaluate the status of the nerve recovery.
Total elbow arthroplasty (TEA) is ideal for treating comminuted osteoporotic

fractures of the distal humerus in low demand elderly patients.
Decreased elbow range of motion is the most common complication after

open reduction internal fixation of distal humerus fractures.
Shear fracture of the distal articular surface of the humerus which involves
coronal fractures of the capitellum and a portion of the trochlea has

characteristic radiographic finding "double-arc sign" which represents the

subchondral bone of the displaced capitellum and lateral trochlea ridge.
In simple elbow dislocation initial management should include closed

reduction, splinting or sling placement for comfort and early active ROM
exercises. Prolonged splinting of greater than 2 weeks after reduction can
lead to chronic stiffness and poor outcomes and should be avoided .
Anteromedial coronoid facet fracture and LCL injury following an elbow

dislocation is commonly associated with varus posteromedial rotatory
instability.
The lateral ulnar collateral ligament (LUCL) is often injured with elbow
dislocations, and is most commonly injured at the proximal origin.
Only 75% of the radial head articulates with the ulna. The remaining 25%
(approximately 90 degree arc) which does not articulate is considered the
"safe zone" and is important for placement of fixation.
In elbow dislocation , loss of terminal extension is the most common

sequelae.
In Mason Type I radial head fracture (minimally displaced, no mechanical

block, intra-articular displacement <2mm) , non-operative treatment is
recommended. Sling immobilization for 2 days followed by active mobilization
is recommended.
In the absence of DRUJ and elbow instability, and no wrist tenderness, radial
head resection for comminuted radial head fractures is the best treatment
option.
In the context of elbow instability, optimal treatment of a comminuted radial

head fracture with greater than three fragments is with a radial head
replacement.
When using the posterolateral (Kocher) approach to the radial head between
the anconeus and the extensor carpi ulnaris. They found that the safe zone
for posterior interosseous nerve increased with pronation and decreased with
supination.
The essential lesion that results in the most instability in a terrible triad injury
of the elbow is rupture of the lateral collateral ligament. Repair of this lesion
results in the greatest increase in elbow rotatory stability.

The anterior bundle of the medial collateral ligament of the elbow inserts at
the anteromedial process of the coronoid, also known as the sublime tubercle.
A terrible triad elbow injury consists of an elbow dislocation with fractures of

the radial head and coronoid. After surgical repair, splinting in flexion and
pronation is felt to help ensure reduction and aid stability. Flexion adds to the
bony congruity of the elbow and the elbow is more stable in increasing
degrees of flexion. Pronation tightens the lateral ulnar collateral complex
which acts like a sling to keep the radio-capitellar joint reduced. Their protocol
consisted of ORIF or replacement of the radial head, ORIF of the coronoid
fracture, repair of the LCL and capsule, and repair of the MCL and/or hinged
external fixation.
In low-demand, elderly patients with a comminuted olecranon fracture non-

operative treatment is the choice .
Bridge plating is most appropriately used for fixation of comminuted fractures

which are not able to be fixed .
Anterior interosseous nerve palsy/injury has been reported with tension band
fixation of olecranon fractures, especially with overpenetration of the anterior
cortex of the proximal ulna by the Kirschner wire. An inability to flex the thumb
interphalangeal joint or the index finger distal interphalangeal joint is indicative
of an anterior interosseous nerve palsy/injury.
Impaired pronation/supination can be seen after tension band fixation of an

olecranon fracture if the K-wire is advanced either too radial or too far through
the volar (anterior) cortex of the proximal ulna.
Tension-band construct construct converts distraction forces at the joint

generated by the pull of the triceps into compression forces.
Fragment excision and triceps advancement is most appropriate treatment in

elderly, osteoporotic patients with severely comminuted fractures involving the
proximal 30-40% of the olecranon.
The most common complication of an olecranon fracture treated with tension

band wiring is symptomatic implants. This is largely related to the
subcutaneous nature of the olecranon.
In pediatric Monteggia fractures the annular ligament is commonly interposed

in the radiocapitellar joint.
The most common injury pattern in Monteggia fracture is an extension type 1

with anterior radial head dislocation and apex anterior ulnar shaft fracture.

The interosseous membrane IOM includes 5 types of ligaments: central band,

accessory band, distal oblique bundle, proximal oblique cord, and dorsal
oblique accessory cord. The annular ligament is not a part of the IOM.
For minimally displaced and angulated isolated ulnar fracture, or "night stick"
fracture, nonoperative management has equivalent clinical outcomes to
surgical treatment.
Excision of heterotopic bone about the forearm or elbow can be done with
limited recurrence rates as early as 6 months .
Bone grafting in the primary fixation of fractures is typically limited to those

with segmental defects. While the increased surface area of a comminuted
fracture may aid in the healing potential, the segmental defect is a limiting
factor to fracture healing. Acute bone grafting in both bones forearm fractures
is only indicated if a large bony void, such as segmental bone loss of the
radius, is present to allow the displaced bone ends to heal together despite
their diastasis.
The patient has an open fracture with a large amount of bone loss. A higher
incidence of infection would be expected with the interposed strut graft
treatment option.
Post-osteosynthetic synostosis in both bone forearm fractures increases with

single incision approach to both bones ORIF.
Refracture rate after removal of radius and ulna plates increased with degree
of initial displacement and comminution, physical characteristics of the plate,
early removal and lack of postremoval protection. Plates removed under 15
months showed an increased risk of refracture. There were no fractures in this
series using the 3.5 DCP plate.
Structural corticocancellous bone grafts are used for the treatment of atrophic
nonunions.
Definitive plating of an open forearm fracture followed by primary closure of

the wound is acceptable treatment at the time of injury.
Restoration of the anatomy of the radial bow directly correlates with the range
of motion postoperatively (pronation-supination).
Galeazzi fracture-dislocations are fractures of necessity and must be

managed surgically. The first step involves surgical fixation of the radial
fracture. Next, the distal radioulnar joint (DRUJ) needs to be assessed for
stability by looking for gross motion of the distal ulna in forearm supination. If

DRUJ instability persists, this needs to be addressed with temporary

percutaneous pin fixation with one or two 1.2- or 1.6mm K-wires placed
transversely proximal to the sigmoid notch. Inability to reduce the distal
radioulnar joint in a closed fashion is most commonly secondary to
interposition of the extensor carpi ulnaris tendon.This is followed by
immobilization in above-elbow plaster casts in forearm supination for 6 weeks
postop. Anatomic reduction and rigid fixation of the radius alone does not
guarantee DRUJ stability.
DRUJ instability is a result of injury to the volar and dorsal radioulnar

ligaments which are the primary stabilizers of this joint.
The shuck test is performed after fixation of the distal radius to assess the
status of the DRUJ, namely the radioulnar ligaments.
The stability of comminuted fractures of the distal part of the radius with volar
fragmentation is determined not only by the reduction of the major fragments
but also by the reduction of the small volar lunate fragment.
Vitamin C administration has been associated with a lower incidence of

complex regional pain syndrome (CRPS) in patients with distal radius
fractures .
The proper management of nondisplaced distal radius fractures is to place

into rigid splint and follow-up in clinic .
An accompanying ulnar styloid fracture in patients with stable fixation of a

distal radial fracture has no apparent adverse effect on wrist function or
stability of the distal radioulnar joint.
In patients with displaced distal radius fractures , presenting with neurologic

deficits of acute carpal tunnel syndrome , release of the carpal tunnel is done
to prevent permanent dysfunction.
A rare complication of non-displaced or minimally displaced fractures of the

distal radius treated with a cast is a delayed rupture of the extensor pollicis
longus (EPL) tendon. The EPL is the primary extensor of the interphalangeal
joint of the thumb and also assists with metacarpophalangeal extension.
Extensor indicis proprius transfer to the EPL is the most widely used and
reported treatment for this condition.
Flexor Pollicis Longus is at greatest risk of rupture in distal radius fracture

treated with a volar locked plate.

Several factors have been associated with re-displacement following closed

manipulation of a distal radius fracture: the initial displacement of the fracture
(the greater the degree of displacement, particularly radial shortening), the
age of the patient (older patients with osteopenic bones displace late), and the
extent of metaphyseal comminution.
There are no significant benefits demonstrated with formal physical therapy

following distal radius fracture ORIF compared to a patient-guided home
exercise program
The most appropriate surgical treatment for a patient with dorsal angulation of
the old distal radius would include corrective osteotomy of the distal radius, as
long as there is no degenerative changes. If degenerative changes would be
present, a salvage procedure such as total wrist arthrodesis would become an
option.
Lower Extremity Trauma

Patients with multiple injuries including a pelvic ring fracture who present with
hemodynamic instability should have a pelvic binder or circumferential pelvic
sheet placed as part of their initial resuscitation. Applying an external frame is
appropriate in the setting of an unstable patient with intraperitoneal fluid and
labile blood pressure.
In skeletally immature pelvic ring fractures, the majority of cases can be

treated nonoperatively. Open reduction and internal fixation is required for
acetabular fractures with >2 mm of fracture displacement and for any intra-
articular or triradiate cartilage fracture displacement >2 mm. External fixation
is necessary for pelvic ring displacement of >2 cm to prevent limb-length
discrepancies.
In patients with open-book pelvic fracture with a pubic symphysis diastasis of

less than 2.5cm (AP) type 1 injury , treatment is protected weight-bearing and
symptomatic treatment.
In open-book type parturition-induced pelvic dislocation , nonoperative

treatment is applied with bedrest and a properly positioned pelvic binder in the
acute setting for patients with a symphyseal diastasis of 4.0 cm or less and
operative treatment for diastasis greater than 4cm.
Alternating single-leg-stance radiographs are used for the diagnosis of chronic

or subtle pelvic instability.

The outlet view best guides superior-inferior screw orientation during

percutaneous S1 screw placement. This is due to the relative forward flexion
of the sacrum and pelvis due to pelvic incidence. A lateral sacral view and an
inlet pelvis view would best guide anterior-posterior screw orientation. Outlet
view provides the best visualization of the neural foramina (and possible
screw placement into these foramina). During placement of the screws, the L5
nerve root is at risk. Injury to the L5 nerve root would typically result in
weakness in great toe extension and sensory changes on the dorsum of the
foot.
The posterior sacroiliac ligaments are spared in APC-II injuries, and

differentiate an APC-II injury from an APC-III injury, in which the posterior
ligaments are also torn.
Lateral compression type II fractures (as described by the Young-Burgess

Classification System) are associated with a crescent fracture of the iliac wing
located on the side of impact.
Of the pelvic ring injuries, APC type III have the highest rate of mortality,
blood loss, and need for transfusion. When massive transfusion protocol is
initiated FFP should be given early in a FFP:PRBC ratio of 1:1 to avoid
coagulopathy. In these injuries , with damage to the anterior ring, pelvic floor,
and posterior ligamentous stabilizing structures , a percutaneous iliosacral
screw and anterior ring internal fixation is the most stable construct.
The risk of postoperative loss of reduction is greatest with a vertical sacral

fracture pattern.
When using pelvic external fixation with supraacetabular pins , care must be
taken not to injure the lateral femoral cutaneous nerve (LFCN).
The three factors found to be predictive of mortality in unstable fracture pelvis

were: increased blood transfusions in the first 24 hours, age >60 years, and
increased ISS or RTS scores.
The most common urological injury with pelvic ring injuries remains the
posterior urethral tear, followed by bladder rupture.
Care must be taken when placing a retractor on the anterior aspect of the
sacrum, as the L4 and L5 nerve roots are both at risk
An anterior approach to the sacroiliac (SI) joint is indicated with displaced SI

joint dislocations that cannot be reduced with closed or percutaneous
techniques. One contraindication to anterior exposure of the SI joint is
comminuted sacral fracture patterns.

In an ipsilateral unstable pelvic ring and acetabular fractures, the pelvic ring
injury must be initially stabilized in order to reduce the acetabular fracture to a
stable base.
Dynamic fluoroscopic examination of the affected hip under anesthesia is

considered the best method of predicting hip stability. This helps in deciding
whether to manage posterior wall fractures conservatively or operatively.
The obturator oblique-inlet view , best demonstrates the position of a supra-

acetabular screw or pin relative to the tables of the ilium. While when placing
a retrograde pubic rami screw, the pelvic inlet iliac oblique view will best
determine the anteroposterior placement of the screw in the pubic ramus.
In T-type fracture of the acetabulum , the ilioinguinal approach provides

access to the anterior wall and anterior column for fracture fixation, in addition
to allowing fixation of the nondisplaced posterior transverse fracture line.
Kocher-Langenbeck approach allows direct exposure of both the posterior

column and posterior wall.
For difficult acetabular fractures with anterior displacement in which access to

the entire anterior column is required, the ilioinguinal or Stoppa approach is
ideal . Most both-column fractures can also be managed through these
approaches, but only if the posterior fragment is large and in one piece. If the
posterior column is in several pieces and requires either two approaches or
an extended approach, such as the iliofemoral.
Os acetabuli marginalis superior is a benign accessory ossification center

found in the superior aspect of the acetabulum. This can be commonly
confused with an acute fracture or avascular necrosis. Although the os
acetabuli marginalis superior occasionally persists into adult life, it usually
fuses to the acetabulum by the time an individual reaches age 20.
Negative outcome factors in acetabular fractures have been shown to include:

increasing patient age, time from injury to surgery (>3 weeks), intraoperative
complications, femoral head bone or cartilage injury, and fracture reduction >
1-2mm from anatomic. Choice of surgical approach has not been shown to
affect patient outcomes.
The highest pressure, eighteen megapascals, is recorded while the patient

with hip prosthesis is getting up from a chair using the affected leg and is
localized in the posterior superior portion of the acetabulum.

The "corona mortis" (translated as “crown of death”) artery is a vascular

variant that joins the external illiac and the obturator artery as it crosses the
superior pubic ramus.
In transverse acetabulum fracture , the iliopectineal (anterior column) and

ilioischial lines (posterior column) are interrupted, revealing bicolumnar
involvement.
The pelvic spur sign is indicative of a both column acetabular fracture ; an

acetabular fracture with no articular surface in continuity with the remaining
posterior ilium (and therefore, axial skeleton).
CT scanning is indicated in acetabular fractures for determination of surgical

approach and techniques, evaluation of marginal impaction and presence of
intra-articular loose bodies (especially after hip dislocation), and evaluation of
fracture piece sizes and relative positions but not degenerative changes.
Degree of displacement seen on postoperative pelvic CT scan correlate most
closely with good outcomes following ORIF of posterior wall fractures.
Early fixation of acetabular fractures is associated with lesser organ

dysfunction.
Sciatic nerve appeared to exceed published critical thresholds for alterations

of blood flow and neural function only when the hip was flexed to 90 degrees
and the knee was fully extended.
For neglected insufficiency fracture of the acetabulum , total hip arthroplasty

(THA), with use of flanged and/or custom acetabular components as needed,
is necessary to reconstruct the acetabulum and address the significant
femoral head damage.
The obturator oblique view reveals additional information about the anterior
column and posterior wall , while the iliac oblique view visualizes the posterior
column and anterior wall.
Diminished perianal sensation is concerning for an S2 nerve root injury.
Denis Zone 3 (medial to the foramina) sacral fracture has the highest
associated risk of nerve injury.
Combined iliosacral and lumbopelvic fixation (triangular osteosynthesis) for

sacral fractures has the greatest stiffness when used for an unstable sacral
fracture.

After reduction of hip dislocation, CT scans should be obtained to evaluate for

fractures or impacted areas of the femoral head or acetabulum, as well as
noncongruent reductions and free intraarticular joint fragments.
Traumatic hip dislocation results from the dissipation of a large amount of

energy about the hip joint. Clinically, these forces often are first transmitted
through the knee en route to the hip. It is therefore logical to look for
coexistent ipsilateral knee injury in patients with a traumatic hip dislocation.
A femoral neck fracture has been shown to have an estimated mortality rate
of 20% or more at one year after injury, and estimates regarding loss of
independence are at 50%.
1 year mortality is increased if femoral neck fixation is delayed greater than 4

days.
Pipkin Classification
Femoral neck fracture patients with chronic renal failure have a postoperative
mortality of 45% at 2-years post operatively.
Treatment of displaced right femoral neck fracture in an active, healthy elderly

patient with total hip arthroplasty (THA) has shown to have the lowest re-
operation rates and best functional outcome scores when compared to
internal fixation devices and hemiarthroplasty.
In femoral neck nonunion, with varus collapse and shortening the most
appropriate method to treat this complication is valgus intertrochanteric
osteotomy of the femur with blade plate fixation.

The optimal biomechanical cannulated screw configuration in femoral neck

fractures includes an inverted triangle pattern with the single screw in the
inferior aspect of the femoral neck adjacent to the calcar.
The addition of a "traction-internal rotation" view to standard hip radiographs

may assist with classification of femoral neck fractures by accounting for the
anteversion of the femoral neck.
The most common complication in femoral neck fracture fixation is AVN.
The advantages of hemiarthroplasty, compared with total hip arthroplasty, for

the treatment of displaced femoral neck fractures include the more limited
nature of the procedure (decreased blood loss and operative time) and the
lower risk of instability.
Patient age and pre-injury functional independence measure scores are
independent predictors of functional outcome after hip fracture. American
Society of Anesthesiologist (ASA) classification is predictive of post-surgical
mortality in hip fracture patients.
In ipsilateral femoral neck fracture with femoral shaft fractures , lag screw
fixation of the femoral neck fracture and reamed intramedullary nailing for
shaft fracture stabilization were associated with the fewest complications.
Fixation with a single implant, such as an antegrade cephalomedullary device,
has been shown to have the highest rate of fracture malreduction with
displaced fractures.
After a femoral neck fracture, patients often present with their injured hip in a
flexed, abducted, and externally rotated position due to decreased pain from
minimization of the capsular distension from fracture hematoma (if the
capsule isn't disrupted).
Tip-apex distance (TAD) as it relates to a lag screw in the femoral head is the
summation of the distance between the end of the screw and the apex of the
femoral head on AP and lateral radiographs. Tip-apex distance was the
strongest predictor of cutout (no cutout if <25mm).
Proximal humeral fractures in females independently increased the risk of a
subsequent hip fracture.
The use of intramedullary (cephalomedullary) devices has increased in the
last ten years despite a lack of evidence to support superiority over
extramedullary implants (sliding hip screws) regarding treatment of
intertrochanteric hip fractures.
Total hip arthroplasty is recommended for failed treatment of hip fractures in
the elderly.

In antegrade femoral nailing , anterior perforation of the femur has been

attributed to a simple mismatch in the radius of curvature of implants and the
apex anterior bowed femur (nail with a greater radius of curvature).
Intertrochanteric hip fractures with lateral wall fractures should be treated with
an intramedullary device as opposed to a sliding hip screw, as the intact
lateral wall provides a buttress for the proximal fragment facilitating fracture
impaction as well as rotational and varus stability.
Currently, cephalomedullary nails are used widely for reverse obliquity
fractures because they limit medialization of the shaft fragment unlike sliding
hip screws.
A two part stable intertrochanteric femur fracture can be treated with a sliding
hip screw, with minimum 2 screw holes needed in the side plate.
Left-sided unstable intertrochanteric hip fractures are at increased risk of
malreduction compared to unstable right-sided fractures fixed with dynamic
hip screws. In left-sided fractures the rotational torque imparted to the
proximal head and neck fragment can cause loss of reduction leading to
potential failures of fixation. With these left sided injuries, the rotational torque
can cause an anterior spike, whereas with right-sided injuries the rotational
torque causes compression and reduction of the fracture
Atypical subtrochanteric femoral fractures have been identified as a potential

complication of long-term bisphosphonate therapy for the treatment of
osteoporosis. Prodromal symptoms of thigh pain are common prior to fracture,
and bony failure is usually associated with low energy mechanisms.
In order for a fracture to be successfully treated with tension band principles
the bone must be eccentrically loaded, the construct must be applied on the
tensile side, and the opposite cortex must be able to withstand compressive
forces.
Subtrochanteric fractures will cause a proximal fragment to be flexed,
abducted, and externally rotated due to the imbalanced proximal muscular

attachments (the gluteus medius attaches to the greater trochanter, leading to

abduction, while the iliopsoas attaches to the lesser trochanter, leading to
flexion) . The proximal fragment would likely have to be extended, adducted,
and internally rotated to obtain a proper reduction.
The most common deformity after antegrade nailing of a subtrochanteric
femur fracture is varus and procurvatum (or flexion). This is caused by the hip
abductors and iliopsoas pulling the proximal fragment into abduction and
flexion, while the distal fragment is pulled into adduction from the adductors.
During intramedullary nailing of subtrochanteric femur fractures , the
advantages of the lateral position include: facilitates the retraction of the
vastus lateralis, allows hip flexion to aid reduction, improves access to the
proximal segment (easier to get starting point). Disadvantages of the lateral
position include: intraoperative imaging may be more difficult, rotation is more
difficult to judge, and lateral positioning may not be practical in the
polytraumatized patient.
For femoral shaft fracture in a patient that is not stable from a neurosurgical
perspective (GCS<14) , the most appropriate treatment at this time is
placement of an external fixator to limit the risk of intraoperative hypotension
and decreased cerebral perfusion pressure which lead to lower Glasgow
Coma Scale scores at the time of discharge from hospital.
Comminuted femoral shaft fractures treated with statically locked

intramedullary nails of appropriate diameter can be treated with immediate
weight-bearing, with little risk of nail/screw breakage or deformity. Immediate
range of motion and weight-bearing can be extremely beneficial to short-term
patient outcomes, especially in polytrauma patients.
A true lateral of the intramedullary nail is present when "perfect circle" views
of interlocking holes are present. Widening of the interlocking hole in the
proximal-distal direction signifies the need for an adjustment in the
abduction/adduction plane.
Computer-assisted navigation has been shown to reduce radiation exposure

for surgeons when performing interlocking of medullary nails compared to
free-hand technique.
Branches of the deep femoral artery and femoral nerve are most at risk during
placement of anterior to posterior interlocking screws below the level of the
lesser trochanter.

Femoral neck fractures are seen less than 10% of the time with femoral shaft
fractures, but they are frequently missed on initial evaluation (19%-31% of
patients).
Femoral malrotation after intramedullary nailing is unfortunately a possibility

with either antegrade or retrograde nailing techniques. There is a significant
difference depending on the time of surgery, with significantly more
malrotation during the night shift. Increased fracture comminution also
significantly increases malrotation rates. Internal malrotation is significantly
more common when the fracture table is used when compared to placement
of a nail using manual traction.
In femoral shaft fractures treated with an antegrade femoral nail , long term
deficits are weakness with knee extension (quadriceps) and hip abduction
(glutei muscles).
Antegrade femoral nailing was shown to have an increased rate of hip pain as
compared to retrograde femoral nailing, while having a similar rate of union,
time to union, rate of malalignment, and operative time. Retrograde nailing
had an increased rate of symptomatic distal interlocking screws, an increased
rate of need for dynamization.
Reamed intramedullary femoral nailing is associated with a higher rate of

union than nonreamed femoral nailing as, femoral intramedullary reaming
debris has been shown to have similar biochemical characteristics as iliac
crest autograft.
Heterotopic ossification (HO) prophylaxis with indomethacin has been shown

to increase the risk of long-bone nonunion.
Usage of a piriformis (straight) nail through a greater trochanteric entry portal

will bring the fracture into varus, as the greater trochanteric entry site's axis is
lateral to the femoral shaft, and advancement of the nail causes the two axes
to become colinear, leading to varus.
The greatest amount of injury to hip abductor musculature is seen with

piriformis starting points.
A starting point slightly anterior to the piriformis fossa (starting point for
standard antegrade femoral nail) has the benefit of improved placement of
screws through the nail and into the femoral head.
Usage of an anterior starting point for an antegrade femoral nail that is too
anterior leads to creation of significant hoop stresses in the proximal segment,
potentially leading to iatrogenic fracture of the proximal segment.

Bilateral femur fractures have not been shown to have increased rates of
rotational deformity. They have been shown to have increased rates of initial
hypotension, mortality, open skull fractures, and pelvic fractures.
locking distal femoral compression plate LCP affords better control of coronal
plane fractures than 95-degree angled blade plate ABP and dynamic condylar
screw DCS.
AP fluoroscopic imaging with the leg in 30 degrees of internal rotation is

important to prevent intercondylar screw prominence in distal femoral fracture
fixation.
The most common variation of a Hoffa fracture is a coronal fracture of the

lateral femoral condyle ; often missed on plain radiographs of supracondylar
and intercondylar femur fractures. The most appropriate screw placement in
this entity would be anterior to posterior screws across the lateral condyle for
fixation.
In comminuted metaphyseal distal femur fracture with intra-articular extension

in osteoporotic, the best fixation construct for treatment of this fracture in an
otherwise healthy and active patient is lag screw fixation followed by locked
plate application.
Isolated medial femoral condyle fracture is best treated with open reduction
internal fixation through a medial approach, with lag screw and buttress plate
fixation.
Oligotrophic femoral supracondylar nonunions have been shown to be best

treated with open reduction and plating (revision if previous surgery) and
usage of autologous bone grafting.
Locked plates are indicated for: indirect fracture reduction,

diaphyseal/metaphyseal fractures in osteoporotic bone, and with bridging
severely comminuted fractures.
Open reduction and internal fixation is the most appropriate treatment of

inferior pole patella fracture.
Symptomatic hardware following surgical fixation of patella fractures is the

most common complication, with ~18% of patients electing to undergo
hardware removal.
Partial patellectomy is a recommended treatment for a comminuted superior

or inferior pole fracture measuring <50% of the patella's height that are not
amenable to ORIF.

Approximately 40% of low-velocity anterior knee dislocations are associated

with popliteal vascular injury.
In posterolateral knee dislocation with a avascular limb , urgent surgical

intervention is warranted. The medial femoral condyle (MFC) has button-holed
through the medial capsuloligamentous structures, leaving skin and medial
subcutaneous tissues entrapped between the MFC and the joint cavity
producing a ‘pucker sign’. An anteromedial approach is necessary.
Stabilization is then best achieved with an external fixator. Persistent ischemia
(absence of pulses after reduction) is an indication for popliteal artery
exploration.
Schatzker IV tibial plateau fractures have the highest incidence of vascular

injury and most often require measurement of an ankle-brachial index (ABI) to
rule-out associated vascular injury. They are also the most likely to have a
concomitant medial meniscus tear.
Bicondylar tibial plateau fractures are best definitively treated with dual
incision technique using separate lateral plateau and posteromedial plates.
Displaced Schatzker II (lateral split-depression) tibial plateau fracture with

joint widening of 6mm are commonly associated with peripheral lateral
meniscal tears.
Post-operative gentle compressive loading may have a positive impact on
articular cartilage healing; however, excessive shear loading may be
detrimental.
The best fixation strategy for Schatzker type 2 tibial plateau fracture includes
reduction of the articular surface with metaphyseal support with bone graft or
bone substitute and a lateral plate for buttress support and subchondral screw
support of the articular fragment.
Appropriate treatment of tibial plateau fx Schatzker IV involves a medial
buttress plate to hold the medial tibial condyle in position.
Lipohemarthrosis is commonly seen with occult tibial plateau fractures but can
be associated with any intra-articular fractures.
Maintenance of mechanical axis and restoration of joint stability correlate
most with a satisfactory clinical outcome when managing an intra-articular
fracture of the proximal tibia and decreases the rate of degenerative arthritis
in the long-term.
In treating tibial plateau fractures, calcium phosphate cement was found to
have greater compressive strength than cancellous bone alone , so less
amount of articular subsidence on follow-up.

The medial tibial plateau is more concave and more distal relative to the
lateral tibial plateau.
There are 4 main types of plating techniques: 1. Bridging 2. Neutralization 3.
Dynamic Compression 4. Buttress plating. Plates can utilize locking or non-
locking screws. Buttress plating is best indicated for simple partial articular
fractures. Buttress plates can support a metaphyseal fragment and neutralize
the shear, bending, and compressive forces across the cancellous bone.
Depressed lateral tibial plateau fractures are classified as Schatzker III tibial
plateau fracture.
For significantly displaced, high-energy proximal tibia fracture with intra-
articular extension , appropriate initial treatment includes application of a
spanning external fixation device with fasciotomy if needed.
Proximal tibial shaft fractures treated with intramedullary nails are most
commonly malreduced with apex anterior and valgus deformities. Several
techniques are available to overcome this malalignment:
• Proximal and lateral nail starting point,

• Usage of a femoral distractor or temporary plating,
• Suprapatellar nailing (semiextended knee): do not affect valgus
deformity
• Lateral parapatellar approaches
• Blocking screws posterior and lateral to the nail in proximal fragment
The minimally invasive technique in long lateral locking plates in proximal
tibial fractures have been shown to put the superficial peroneal nerve at risk
due to its close proximity to LISS plate holes 11-13. SPN has a sensory
distribution to the dorsal foot.
Blocking screws can be used in tibial nailing to help obtain and maintain
reductions, increase construct stiffness, and neutralize translational forces.
The most appropriate steps in the management of distal tibial fractures would
include: Closed reduction and splinting, immediate fixation of the fibula,
external fixation, CT scan, and delayed open reduction internal fixation
(starting with anatomical reduction and stabilization of the articular surface) in
this sequence.
Brake travel time (BTT) has been shown to be significantly increased until 6
weeks after initiation of weight bearing in both long bone and articular
fractures of the right lower extremity.
Lower level of education is the parameter that correlated most closely with a
poor clinical outcome and inability to return to work in pilon fractures.
The Chaput fragment is the anterolateral fragment of the distal tibia and
attaches to the anterior inferior tibiofibular ligament.

In patients with multitrauma, combining reamed femoral nailing with fracture

fixation (ie. tibial shaft) under tourniquet control has been shown to increase
pulmonary morbidity.
Midshaft tibia fracture with an intact fibula places the fracture at increased
risk of varus malalignment during healing.
In patients with distal tibia and proximal fibula fractures dedicated imaging of
the ankle should be performed to exclude a posterior malleolus fracture.
The center of rotation of angulation (CORA) in diaphyseal tibial deformity is
defined as the intersection of the proximal mechanical(PMA) or anatomical
axis(PAA), and the distal mechanical(DMA) or anatomical axis(DAA).
Decreased extensor hallucis longus strength is consistent with transient
peroneal nerve neurapraxia.
Time to transfer to a definitive trauma center has a significant effect on the
incidence of infection for high-energy, open lower extremity fractures as, the
most important factor shown to reduce the risk of infection at the site of an
open fracture is early intravenous antibiotic administration.
Tibial diaphyseal hypertrophic nonunions have approximately an 85-90%
incidence of union with exchange reamed nailing.
The oblique tibial fracture is at risk of shortening, especially with a
concomitant fibular fracture.
Administration of rhBMP-2 at the time of definitive fixation has been shown to
decrease the need for subsequent bone grafting procedures and improve the
outcome in Gustilo-Anderson type IIIA and IIIB open tibia fractures.
Reamed exchange intramedullary nailing is used in diaphyseal tibial shaft
fractures in which there is less than 30% of cortical bone loss.
The safe zone for tibial nail placement as seen on radiographs is just medial
to the lateral tibial spine on the anteroposterior radiograph and immediately
adjacent and anterior to the articular surface as visualized on the lateral
radiograph.
Osteogenic Protein-1 (OP-1), which is also known as BMP-7, has been shown
in to be equivalent to autologous bone graft in tibial nonunions.
A significant malunion of the distal tibia has important consequences for
patient outcome, including ankle pain, stiffness , gait changes, and cosmesis.
Rotational malalignment is the most common type of malalignment after
intramedullary nailing of distal 1/3 tibia fractures.

Post-operative gapping at the fracture site in tibial shaft fractures significantly

increases the risk of reoperation due to nonunion or malunion.
Reamed nailing of closed tibial shaft fractures has been shown to lead to an
earlier time to union without an increased rate of complications when
compared to unreamed nailing. Reamed and unreamed tibias have similar
mineral apposition rates.
Anterior knee pain is the most common complication after intramedullary
nailing of the tibia (50-75%).
Intramedullary nailing shows no difference in compartment syndrome
incidence with closed treatment.
At 9 months, in atrophic nonunion of tibial fracture adjacent to a arthrofibrotic
joint , plate osteosynthesis has been shown to be an effective method of
treatment.
Typically, treatment of Type IIIB Pilon fractures should be staged.
Tibial fracture is appropriately classified as a Grade III when there is a highly

comminuted, segmental fracture which is always associated with significant
periosteal stripping , whatever was the wound size . If the patient's leg was
able to be closed primarily, it should be classified as IIIA.
In unstable, ankle fracture-dislocation , the most appropriate management
would be open reduction and internal fixation with an extended period of
restricted weight-bearing.
This patient has Lauge-Hansen supination-adduction

fracture-dislocation. There is a transverse fibula
fracture and a vertical medial malleolus fracture. The
vertical medial malleolar fracture is best treated by
screw fixation parallel to the joint (perpendicular to
the fracture line). Fixation is better if screws are
combined with one third tubular antiglide plate. This
type is associated with anteromedial marginal
impaction seen on CT scans.
Restoration of the proper syndesmotic relationship involves regaining fibular

length as well as reestablishing correct rotation and position of the fibula
relative to the tibia. In addition, removal of interposed tissue (deltoid ligament)

in the medial joint space may be necessary. However, deltoid reconstruction

is not routinely required.
Continued ankle pain and instability following open reduction and internal
fixation may be due to inadequate restoration of fibular length, likely leading to
continued tibiotalar instability.
Stress radiography is needed for proper medial ankle evaluation.
In an ankle syndesmosis injury, the fibula is most unstable in an anterior and
posterior direction.
A dynamic external rotation stress test with the ankle dorsiflexed to 90
degrees is the most accurate way to evaluate the integrity of the
syndesmosis.
Bosworth fracture-dislocation is a rare fracture-dislocation of the ankle where
the fibula becomes entrapped behind the tibia and becomes irreducible. It can
cause compartment syndrome. The posterolateral ridge of the distal tibia
hinders reduction and reduction often requires an open technique.
In the Lauge-Hansen classification, the characteristic fibular fracture pattern in
a pronation-abduction injury is a comminuted fibular fracture above the level
of the syndesmosis.
In ankle fracture-dislocation with diastasis of the distal tibia and fibula,
indicating a syndesmosis injury ; Open reduction internal fixation of the fibula
and medial malleolus with syndesmosis reduction and suture-button repair
should be done.
Presence of peripheral neuropathy has important implications in treating ankle
fractures in diabetic patients. Increased immobilization periods, attention to
tight glucose control, and adjunct/alternative operative techniques may be
necessary for an optimal outcome.
37% of operatively treated ankle fractures can have undetected syndesmotic
instability when examined intraoperatively. So, it is important to be assessed
intraoperatively.
Positive Cotton test "talar glide test" indicates disruption of the ankle
syndesmosis.
By nine weeks, the total braking time of patients who had undergone fixation
of a displaced right ankle fracture returns to the normal, baseline value.
The tibiofibular overlap is defined as the horizontal distance from the lateral
border of the posterior tibial malleolus (the incisura fibularis) and the medial
border of the fibula at the point where the posterior malleolus is widest on an
AP radiograph should be great than 6 mm.

Tibiofibular clear space is defined as the horizontal distance between the

medial border of the fibula and the lateral border of the anterior tibial
prominence on an AP radiograph, and should be <6mm.
The medial clear space, defined as the distance between the lateral aspect of
the medial malleolus and the medial border of the talus at the level of the talar
dome on the mortise radiograph should be less than 4 mm.
The talocrural angle is formed by the intersection of a line perpendicular to the
plafond with a line drawn between the malleoli (average = 83+/-4deg).
Compared to lateral neutralization plating in lateral malleolar fractures ,
posterior antiglide plating is associated with increased construct stiffness and
strength, decreased hardware prominence, decreased rates of ankle joint
screw penetration, and improved biomechanical findings in osteoporotic bone.
However, posterior plating is associated with an increased rate of peroneal
tendonitis and irritation.
The bands of the posterior tibiofibular ligament pass obliquely from the fibula
to the posterolateral aspect of the distal tibia.
In malaligned ankle with obvious syndesmosis widening and fibular
shortening, corrective osteotomy of a fibular malunion associated with open
syndesmosis reduction should be done.
In displaced talar neck fracture with extrusion of the talar body, reimplantation
of the talar body and ORIF of the talar neck fracture is the most appropriate
treatment.
The most common position of talar neck malunion is varus. Varus alignment
at the talar neck results in a decrease in subtalar eversion . Medial opening
wedge osteotomy of the talar neck has been described to restore the anatomy
of the talus and preserve hindfoot motion. Dorsal malunion can lead to
symptomatic impingement of the dorsal surface of the talus on the distal tibia
and restriction of ankle dorsiflexion.
A subchondral radiolucency of the talar dome after a talar neck fracture is
known as the "Hawkins sign" and is a well-described radiographic indication
of viability of the talar body.
Often, the deltoid branch of the posterior tibial artery, which lies between the
leaves of the deltoid ligament and supplies up to 1/2 of the medial talar body,
is the only remaining blood supply in displaced talar neck fractures. Therefore,
the deltoid ligament must be preserved to lower the risk of avascular necrosis.
In displaced talar neck fractures with subtalar dislocation/subluxation, the
treatment of choice is open reduction and internal fixation.There is no role for
closed reduction.

The most common complication following fixation of talar neck fractures is

subtalar and tibiotalar arthritis , followed by osteonecrosis.
Excision of a part of lateral process of talus is shown to sacrifice the entire
lateral talocalcaneal ligament.
Fractures of the lateral process of the talus are frequently overlooked and
should always be considered in the differential diagnosis of ankle pain in
snowboarders. So, CT scans are important in evaluating these injuries as
radiographs may fail to show the injury and amount of displacement and
comminution of the fracture.
While medial subtalar dislocations are more common, lateral subtalar
dislocations are more likely to be open and have associated fractures
(cuboid).
In medial dislocations, the extensor digitorum brevis, the deep peroneal
neurovascular bundle, or the joint capsule may block a closed reduction. In
lateral dislocations, the most common structure implicated as a block to
reduction is the posterior tibial tendon.
In subtalar dislocation , the most common symptomatic joint degeneration at
follow-up is subtalar joint.
Restricted weight bearing and magnetic resonance imaging of the foot is
indicated in this military recruit with a positive heel compression test and
suspicion for calcaneal stress fracture (low signal on T1 and increased signal
on T2-weighted images on MRI).
Subtalar distraction arthrodesis using a bone graft is not indicated in a patient
with full ankle dorsiflexion and no tibiotalar impingement.
The flexor hallucis longus runs along the medial aspect of the hindfoot. The
flexor hallucis longus (FHL) tendon wraps inferiorly around the superomedial
fragment of an intra-articular calcaneus fracture (sustentacular fragment). This
tendon can be injured with poor drilling technique or use of screws that are
too long during reduction and fixation of a calcaneus fracture using a lateral
plate. If present, the great toe will be in a fixed, flexed position from the
tendon being tethered over a screw.
Markedly displaced tongue-type calcaneus fracture may lead to posterior skin
necrosis.
Contracture of the intrinsic flexor muscles of the foot (clawing of the lesser
toes) can be the result of unrecognized foot compartment syndrome with
calcaneal fractures.
In calcaneal fractures the risk of early wound complications is highest in open
injuries, diabetics, and smokers.

Subtalar fusion technique for late complications of calcaneus fractures that

were treated conservatively (incongruous subtalar joint, loss of calcaneal body
height, and likely decreased lateral talocalcaneal angle) involves distraction of
the subtalar joint, insertion of a bone block, and rigid screw fixation. The
distraction allows correction of the talocalcaneal relationship, improves
anterior ankle impingement, and regains lost hindfoot height.
Surgical reduction and fixation of intra-articular calcaneal fractures has been
shown to have improved outcomes over nonoperative treatment in all patient
groups except previous calcaneus fracture.
Male worker's compensation patients who participate in heavy labor work with
a calcaneal fracture pattern with Böhler angle less than 0 degrees are the
most likely to undergo a subtalar fusion.
Patients with the following preoperative variables have improved outcomes
with ORIF vs non-operative treatment: women, non-workers' compensation,
younger males (<30), patients with a higher Böhler angle (>0-15°), patients
with a lighter workload, and fracture patterns with single, simple displaced
intra-articular calcaneal fracture.

SPINE

A Trendelenburg gait is caused by gluteus medius weakness ( innervated by

L5).
In the cervical spine the nerve roots exit above the corresponding pedicle.
This is different than in the lumbar spine where the nerve roots exit below the
corresponding pedicle.
The anterior spinal artery is the predominant blood supply to the spinal cord
and supplies the anterior 2/3rds of the spinal cord. There is only one anterior
spinal artery in comparison to the paired dorsal spinal arteries. The paired
dorsal spinal arteries supply the dorsal 1/3rd of the spinal cord, mainly to the
dorsal columns.
In the majority of patients all subaxial cervical vertebrae have a foramen
transversarium.
On average, thoracic pedicle diameter is maximal at T1 and T12, and
gradually "dips" to its smallest diameter at the T4 to T6 region.
The smallest pedicle diameter in thoracic and lumbar spine was most
consistently found at the L1 level.

Disc aging leads to an overall decreased water and proteoglycan content ,

increase in the degradative enzyme activity , keratan sulfate to chondroitin
sulfate ratio, and conversion to fibrocartilage.
The intervertebral disc consists of an outer annulus, with a high concentration
of Type I collagen, and an inner nucleus pulposus, with a high concentration
in Type II collagen.
Cells of the intervertebral discs are biologically responsive and increase their
production of matrix metalloproteinases, nitric oxide, interleukin-6, and
prostaglandin E2 when stimulated by interleukin-1 beta.
There are three general steps to define a spinal cord injury using the ASIA
classification system.
• Step 1: Identify the neurologic level, which is described as the lowest

segment where motor and sensory function is normal on both sides.
• Step 2: Determine if injury is complete or incomplete.
• Step 3: Assign ASIA impairment score.
Methylprednisolone should be administered for 24 hours in patients whose

injury occurred within 3 hours of arrival to the emergency department. The
accepted dose is a 30 mg/kg bolus followed by a 5.4 mg/kg/hr infusion. If the
injury occurred from 3-8 hours prior to presentation, the steroid drip was to be
continued for 48 hours. Contraindications to steroid therapy include injuries
that occur greater than 8 hours prior to presentation, pregnancy, gunshot
wounds, patients under the age of 13, and brachial plexus injuries.
Approximately 11% of patients with spinal cord injuries meet the criteria for
Major Depressive Disorder (MDD).
Spasticity is unrelated to the sympathetic system and usually occurs after the
acute phase of spinal cord injury (SCI), when spinal shock has resolved.
Functional electrical stimulation is a technique that rehabilitates patients with
spinal cord injuries by using electrical stimulation of skeletal muscles.

If the bulbocavernosus reflex is intact then the patient is no longer in spinal

shock and we can determine a final classification of their spinal cord injury
pattern.
Individuals with C5 tetraplegia have functional use of deltoid and elbow flexion
(biceps). So, they require an electric wheelchair with hand control for
extension mobilization.
Traumatic spinal cord injury is frequently associated with alterations in
respiratory and cardiovascular function that require critical care management.
Spinal shock and neurogenic shock are two conditions that can occur in the
acute phase.
Spinal cord injury without radiographic abnormality (SCIWORA) is common in
children under 10 years of age and is associated with more complete
neurologic injuries than in cases where the injuries can be seen on
radiograph. Severity of initial neurologic injury is the most important predictor
of her neurologic outcome.
Posterior deltoid-to-triceps transfer is considered for COMPLETE spinal cord
injuries at C5 or C6 with 5/5 delt/biceps, but 0/5 triceps.
The lateral corticospinal tract is the main descending motor tract. Its anatomic
position places the upper extermity motor tracts at greater risk than the lower
extremity tracts.
Central cord syndrome is characterized by motor deficits more pronounced in
the upper extremities than lower extremities. In addition, finger and wrist
motor function is more affected than shoulder and biceps function. Sensory
deficits are usually minimal. Patients with central cord syndrome usually
regain bowel and bladder function and their ability to ambulate. Return of
upper extremity function is less reliable, and patients are often left with deficits
in their upper extremity, worse distally, characterized by "clumsy" hands.
Brown-Sequard syndrome is defined as a unilateral cord injury with ipsilateral
motor deficit and loss of contralateral pain and temperature recognition.
In patients with incomplete spinal cord injuries, the severity of the neurologic
deficit is the most important prognostic variable.
If a patient has an incomplete spinal cord injury, progressive motor deficits
and a retained bullet leading to neurologic compression, surgery is indicated.
In patients with Cauda Equina Syndrome (CES). The most important next
step is identifying a source of compression in the lumbar spine by MRI.
In Cauda Equina Syndrome (CES) surgical decompression must be done in
less than 48 hours after symptom onset.

In a patient who cannot have an MRI such as those with pacemakers, a CT

myelogram should be performed.
In Whiplash, a soft cervical orthosis with early physical therapy is the most
appropriate treatment.
The safe zone for screw placement in the occiput for occipitocervical fusion is
in a triangular region created by connecting 2 dots 2cm lateral to the EOP
(External Occipital Protuberence) and a point 2 cm inferior to the EOP.
In cases of os odontoideum in asymptomatic patients may be managed with
cessation of contact sports alone. Neurologic findings and widened ADI are
both indications for a posterior C1-C2 fusion.
In a rigid collar orthosis for 6-12 weeks would be the most appropriate
treatment.
External cervical orthosis can be used for
• C1 posterior arch fractures

• Jefferson fracture of the C1 arch with intact transverse ligament
• Type 1 ,3 odontoid fractures
• Type 1 Hangman's fractures of C2 that have minimal displacement and
angulation
A combined lateral mass displacement of 8.2 mm or greater would indicate
injury to the tranverse ligament.
In fracture separation of the lateral mass treatment is posterior two-level
fusion involving both the level above and the level below.
A C1-2 fusion with sublaminar wiring or modern screw-rod constructs is
indicated in transverse ligament injuries.
Transverse ligament insufficiency with intact alar and apical ligaments results
in a maximal translation in ADI atlanto-dens interval of 5 mm. Displacement
>7 mm was associated with loss of integrity of the alar ligament and tectorial
membrane.
In odontoid fractures with an aberrant vertebral artery , C1-C2 transarticular
screws are an absolute contraindication in this scenario. The vertebral artery
is an important consideration when performing posterior cervical spine
surgery. Injury to this artery can lead to stroke and death.
In ununited type 2 odontoid fracture , posterior C1-C2 fusion is the most
appropriate treatment. This fracture pattern is at increased risk of nonunion
compared with the other fracture patterns shown due to the watershed blood
supply at this location. Nonunion correlates with a fracture gap (> 1 mm),
posterior displacement (> 5 mm), delayed start of treatment (> 4 days) and

further posterior displacement after application of a halo vest (> 2 mm). But
young age is not a risk factor.
Elderly individuals with odontoid fractures experience greater rates of
morbidity and mortality than younger patients with this injury. Treatment with a
halo vest (HV) has been associated with increased complications in the
elderly patient population, and does not allow for immediate mobilization
The axis (C2) develops from five
ossification centers; the body, two
neural arches, the odontoid, and a
secondary ossification center.
The secondary ossification center
appears around age of 3 years.
The subdental (basilar)
synchondrosis is an initial
cartilagenous junction between the
dens and vertebral body that does
not fuse until ~6 years of age.
The secondary ossification center
fuses with the odontoid at around 12
years of age.
If a patient has bilateral facet dislocations at C5-6, closed reduction prior to
obtaining an MRI should only be completed in a patient who is awake,
cooperative and neurologically intact. Open reduction should be completed
when closed reduction fails (ie. Fractured facet or lateral mass dissociation) or
neurologic deterioration occurs. In a patient who has an altered mental status,
obtaining an MRI is critical. This will help identify injuries to the posterior
ligamentous complex and the presence of myelomalacia. Of particular
importance is the ability to identify disc herniations. Closed reductions
completed in the setting of disc herniations can cause further injury to the
spinal cord.
Cervical spine injuries should be immobilized in a postion of relative extension
in both children and adults. Applying cervical traction with the external
auditory meatus in-line with the shoulders can serve as a guideline.
Facet dislocation is caused by flexion-distraction forces. Therefore, in a facet
dislocation the posterior structures (interspinous ligament, facet capsule,
liagmentum flavum, posterior annulus) are likely disrupted, whereas the
anterior structures (anterior longitudinal ligament) are usually preserved.

Cranial nerve VI palsy is the most common nerve palsy associated with halo
cervical traction. A cranial nerve VI palsy would result in paralysis of the
lateral rectus, causing a deficit in lateral eye movement.
The safe zone for anterior pin insertion with halo immobilization is an
approximately 1-cm region just above the lateral one third of the orbit
(eyebrow) at or below the equator of the skull. More lateral pin insertion risks
penetration of the thin temporal bone. More medial positioning risks injury to
the supraorbital and supratrochlear nerves
Normal anatomic cervical facet relationships.
The Halo vest immobilizes the skull relative to the torso. Therefore is is ideal
for controlling motion at upper cervical spine (occipitocervical junction and
atlantoaxial junction).
The mortality rate of patients with vertebral compression fractures exceeds
that of patients with hip fractures when they are followed beyond 6 months.
There is no beneficial effect of vertebroplasty as compared with a sham
procedure in patients with painful osteoporotic vertebral fractures.
Initial treatment of osteoporotic compression fractures without neurologic
compromise consists of pain control, progressive increase in activity levels,
and a TLSO, or thoracolumbosacral orthosis.
Evidence supports in patients with stable thoracolumbar burst fracture without
neurologic deficits, there is no advantages to surgical treatment, but does
have an increased complication rate. Spinal orthosis and early mobilization is
the most appropriate treatment.
In a patient presenting with cauda equina syndrome following a lumbar burst
fracture , urgent anterior decompression with strut grafting is indicated
followed by instrumented stabilization, which can be done with posterior
instrumentation.

In lumbar "bony" Chance fracture, the mode of failure of the posterior column
is tension.
When clinical presentation highly suspicious of vertebral osteomyelitis of the
lumbar spine, MRI of the lumbar spine with and without gadolinium is the most
appropriate next step in management. Then a CT guided biopsy is done to
identify the organism. When the organism is identified, organism specific
intravenous antibiotics would be the most appropriate next step in treatment.
An epidural abscess may present rapidly with neurological compromise.
Prognosis improves with prompt decompression. (neurologic deficit prompting
surgical decompression, If the epidural abscess is anterior, so an anterior
decompression would be most effective. Partial corpectomy will be required
so a fusion will be indicated).
In a patient with tuberculoid infestation in the spine (Pott’s disease) with
radiographic evidence of cord compression, surgical decompression followed
by pharmacologic therapy is indicated. Isoniazid, rifampin, pyrazinamide, and
streptomycin is the first line of medical therapy.
Professional horse racers (Jockeys) have the highest incidence of
degenerative changes of both the cervical and lumbar spine when compared
to age-matched, non-athletes.
Lhermitte maneuver is a provocative maneuver used in the diagnosis of
cervical myelopathy. When it is positive the patient will complain of electric
shock-like sensations that radiate down the spine and into the extremities.
In progressive cervical myelopathy with cord compression at 2 levels, the
most appropriate treatment is a 2-level ACDF.
Kyphosis of > 10 degrees is a contraindication to posterior decompression
(laminoplasty) , in cervical myelopathy making the correct choice to be
anterior decompression and fusion.
MRI of the cervical spine must be done if combined cervical and lumbar spine
disese.
The inability to preform a tandem gait, intrinsic wasting, a positive Hoffmann's
sign, and a finger escape sign (the two ulnar digits drift into abduction and
flexion within 30 seconds) are all signs of myelopathy. Obtaining a cervical
spine MRI is necessary to confirm the diagnosis and initiate treatment.
In patients with neuroradiologic evidence of spinal cord compression but no
signs of myelopathy should be managed non-operatively (physical therapy,
NSAIDs, and a cervical collar).
In patient with progressive and severe symptoms of cervical myelopathy,
cervical kyphosis, and compression at three levels (C3/4, C4/5, C5/6), anterior

procedure is mandatory to correct kyphosis and remove the anterior

compressive lesions. Possible treatment options in this case could:
1) multi-level ACDF with anterior plate fixation
2) hybrid C5 corpectomy with ACDF of C3/4 and anterior plate fixation
3) C3 and C4 corpectomy, anterior plate fixation, followed by posterior
decompression and fusion.
It is important to remember any two level corpectomy needs to be stabilized
posterior due to the high rate of graft migration.
Fasciculations are a clinical sign of a lower motor neuron disorders.
A C5 palsy (deltoid and biceps weakness) is the most likely neurologic
complication following cervical laminoplasty.
In patients with cervical myelopathy, nonoperative management is most likely
to be successful when there is a larger transverse area of the spinal cord
(>70mm2).
The Nurick Classification system is a classification system for cervical
myelopathy that focuses on the ambulatory status of the patient.
The natural history of spondylotic cervical myelopathy is characterized by
slow progression in a pattern of stepwise deterioration following periods of
stable symptoms.
Athletes sustaining multiple episodes of transient quadriparesis or bilateral
extremity symptoms with MRI evidence of cord injury should be advised to
avoid contact/collision sports. Abnormal Torg ratio does not appear to be
predictive of future spinal cord injury.
Two helpful tests for diagnosing cervical radiculopathy include the Spurling
test and the shoulder abduction test. Patients with a positive shoulder
abduction sign will have improvement of their symptoms with elevation of the
arm above the head. This is an important test to distinguish cervical pathology
from other sources of shoulder/arm pain or peripheral neuropathy.
Patients with RLN injury from the initial surgery may eventually become
asymptomatic. If revision surgery is planned from the opposite side, the vocal
cords need to be evaluated with laryngoscopy preoperatively. If there was
asymptomatic (left) RLN injury from the initial surgery, then the opposite side
approach is inadvisable for fear of developing bilateral vocal cord paralysis
and its catastrophic complications. The recurrent laryngeal nerve innervates
the posterior cricoarytenoid, the only muscle to open the vocal cords. So,
surgery is planned from the same old approach.
C6 radiculopathy most likely presents with dermatomal arm pain, paresthesias
in the thumb, weakness to brachioradialis and wrist extension, and a
diminished brachioradialis reflex.

C7 radiculopathy manifestations include middle finger pain, weak triceps

(elbow extension) and wrist flexion, and diminished triceps reflex.
C8 radiculopathy usually presents with sensory symptoms in the medial
border of the forearm and hand, and weakness in long flexor function in all
digits and thumb.
Posterior cervical foraminotomy is highly effective in treating patients with
cervical radiculopathy. The approach is effective in decompressing lateral
spinal roots that are compromised by soft disk herniations or osteophytic
spurs.
Despite increased complications, posterior cervical fusion is the treatment of
choice for symptomatic cervical pseudoarthrosis following anterior cervical
diskectomy and fusion due to its increased fusion rate and lower revision
surgery rate.
The hypoglossal nerve is the twelfth cranial nerve and innervates the tongue
muscles. If there is a unilateral injury to the hypoglossal nerve, the tongue will
deviate towards the side of injury.
Non-organic signs of low back pain (ie. Waddell Signs) include superficial and
non-anatomic tenderness, pain with axial compression or simulated rotation of
the lumbar spine, negative straight-leg raise with patient distraction, regional
disturbances which do not follow a logical dermatomal pattern, and
overreaction to physical examination.
A previously healthy patient with an acute onset of nontraumatic lower back
pain does not need diagnostic imaging before proceeding with therapeutic
treatment.
In patients with chronic disabling work-related musculoskeletal disorders, high
pre-rehabilitation ratings of pain intensity, as measured by high Visual Analog
Scale (VAS) scores, is a negative predictor for a successful outcomes.
Provocative discography leads to accelerated disc degeneration and the
development of reactive endplate changes.
Although less common than lumbar disc herniation, thoracic disc herniations
are a recognized cause of back pain. The majority of these patient improve
with nonoperative management including physical therapy
Thoracic level disk herniations with spinal cord compression causing
symptoms of thoracic myelopathy are treated with anterior diskectomy with or
without fusion as first line of treatment.
Intercostal neuralgia is the most common complication following endoscopic
transthoracic anterior surgery for a herniated disk.

Synovial facet cyst : a cause of mechanical back pain and radicular

manifestations.
Patients who undergo surgery for lumbar disc herniation have improved
outcomes in bodily pain and physical function at 4 years.
Age > 41 years, absence of joint problems, and married status are associated
with improved treatment effects in patients having surgery for lumbar disc
herniation. While patients with worker's compensation claims have less relief
from symptoms and less improvement in quality of life following surgical
treatment of lumbar disc herniations. Despite this, they have near equivalent
return to work status at 4 years.
In lumbar disc herniation with radiculopathy which failed to improve with
extensive nonoperative treatment, discectomy would lead to the greatest
improvement in physical functioning. Without evidence of degenerative
changes in the lumbar spine or evidence of spondylolisthesis, a posterior
spinal instrumented fusion is not warranted.
In recurrent lumbar disc herniation, if conservative measures fail, the most
appropriate treatment is revision microdiskectomy. Revision lumbar
discectomy has been shown to have outcomes (pain and function) equal to
that of primary lumbar discectomy.
A L4-5 foraminal (far lateral) herniated nucleus pulposis would most likely
cause symptoms in the L4 distribution (decreased patellar reflex and
quadriceps weakness) as foraminal herniations most commonly affect the
exiting upper nerve root at a given lumbar level.
In patients with paracentral disc herniation, with failed nonoperative
management a laminotomy and diskectomy would be the most appropriate
treatment. While, in far lateral disc herniation the Wiltse paraspinal approach
is ideal, which preserves segment stability by avoiding injury to the lamina and
facet joints. The potential complication to know from the Wiltse approach is
potential dorsal root ganglia injury resulting in dysesthesias.
Persistent intractable pain following non-surgical treatment for lumbar disc
herniation during a minimum 6 week period is the most frequent indication for
surgery.
For spinal postoperative surgical infection, treatment is surgical irrigation and
debridement with retention of hardware. Unless there is gross motion,
hardware should be retained as stability promotes fusion and aids in the
eradication of infection by promoting angiogenesis.
For spinal stenosis, without degenerative spondylolisthesis on flexion and
extension radiographs, if the patient has already failed an initial attempt at
nonoperative management, a decompressive laminectomy is the most
appropriate next step in management.

Residual foraminal stenosis due to inadequate decompression is the most

common explanation for persistent symptoms of leg pain following
decompressive laminectomy for spinal stenosis.
Bilateral resection of the L4 inferior articular process will destabilize the spine.
Dural tears are more common during revisions, but they can almost always be
repaired primarily, with a good or excellent outcome and without additional
complications. Closed suction wound drainage does not seem to aggravate
the leak and can be used safely in the presence of a dural repair.
Manifestations of cerebral spinal fluid leak due to an intraoperative dural tear
include severe headaches and occasional nausea which is worse with
standing. Once the diagnosis is confirmed, the gold standard treatment is
reoperation. Less invasive methods of treatment include percutaneous fibrin
glue, subarachnoid drainage or an epidural blood patch. If these fail to relieve
symptoms, reoperation is mandatory.
Patients with symptomatic spinal stenosis treated with surgical
decompression have improved clinical outcomes in pain and function at four
years compared to those treated without surgery.
Comorbid medical conditions is the most powerful preoperative prognostic
factor for clinical outcomes with surgical treatment of spinal canal stenosis.
Studies have shown major complications occur in 10% of patients that
undergo adult spinal deformity surgery.
In the surgical treatment of adult idiopathic scoliosis, a thoracoabdominal
approach has been shown to have higher rates of pseudoarthrosis compared
to posterior procedures.

In adult patients with spinal deformity, extension of a long fusion to the

sacrum is associated with improved correction and maintenance of sagittal
balance.
Sagittal balance is the most reliable radiographic predictor of clinical health
status in adults with spinal deformity.
In degenerative spondylolisthesis, the risk factor most associated with lower
functional outcomes scores after spinal surgery is smoking.
In degenerative anterior spondylolisthesis at L4/L5 which has failed
conservative management, the most appropriate treatment is a posterior
laminectomy and instrumented fusion.
In degenerative spondylolisthesis and associated spinal stenosis, lumbar
decompression with arthrodesis is indicated if nonoperative modalities fail.
Pedicle screws have been shown to decrease the pseudoarthrosis rate in
patients undergoing lumbar fusion for degenerative spondylolisthesis.
Pelvic Incidence PI is the angle subtended by an initial line from the center of
the femoral head to the midpoint of the sacral endplate and a second line
perpendicular to the center of the sacral endplate.
Pelvic Incidence (Angle X) = Pelvic Tilt (Angle Z) + Sacral Slope (Angle Y)
The first line treatment for adults with spondylolysis or spondylolisthesis is

observation, mobilization, and further treatment based on symptoms with no
restriction of physical activity.
In Grade 2 adult isthmic spondylolisthesis L5-S1 that was treated with
reduction and fusion, the L5 nerve root is at greatest risk of injury, and would
present with weakness to great toe extension.
In high grade spondylolisthesis that has failed nonoperative management,
surgery is indicated, and the procedure of choice is a posterior lumbar

decompression with an instrumented fusion from L4 to S1 with anterior

column support.
The most important predictor of the potential for neurological recovery after
operation for cervical myelopathy due to atlantoaxial subluxation in a patient
with rheumatoid arthritits was the preoperative posterior atlanto-odontoid
interval (PADI) >10 mm.
For atlantoaxial subluxation in a patient with rheumatoid arthritis and
symptoms of cervical myelopathy, posterior C1-C2 fusion is indicated.
Patients with ankylosing spondylitis are prone to spinal fracture due to their
rigid spine.
A cervical fracture in a patient with ankylosing spondylitis is often very difficult
to see on plain radiographs. In addition, there is a high mortality rate
secondary to epidural hemorrhage. Therefore, in a patient with AS and a high
suspicion for a neck injury, plain radiographs should be supplemented with
additional imaging studies to look for acute fracture and epidural hemorrhage.
If dorsal epidural hematoma led to cord compression, treatment should
include surgical decompression.
Juvenile Ankylosing spondylitis (AS) one of the spondyloarthropathies that is
characterized by sacroiliitis, spondylitis, enthesitis, HLA B-27, kyphosis,
asymmetric lower extremity inflammatory arthritis, decreased chest
expansion, and uveitis, but NOT Urethritis (which is typical of the triad of
Reiter syndrome).
Degenerative joint disease due to ankylosing spondylitis (AS) with a
concomitant hip flexion contracture increases post-operative rates of anterior
hip dislocations
In chin-on-chest deformity treatment is posterior extension osteotomy, then
posterior fusion and instrumentation. Extension osteotomy is performed at the
C7-T1 junction due to various anatomic advantages. The vertebral vessels
are anterior to the spine, the spinal canal is wider at this level, and the C8
nerve root tolerates migration better than nerve roots higher in the cervical
spine.
Pedicle subtraction osteotomy (PSO) provides greater sagittal kyphotic
correction than single-level opening wedge osteotomy and Smith-Petersen
osteotomies, with the advantage of working at a single level and not having to
resect the intevertebral disc.
Spontaneous atlantoaxial rotatory subluxation can occur after an acute upper
respiratory infection (Grisel Syndrome), and is felt to be caused by adjacent
inflammation of the soft tissues in the neck. Initial treatment for this is soft
collar immobilization and rest for 1 week. If subluxation persists, the patient
should be transitioned to halter traction, and be given muscle relaxants and
pain medications for up to 3 weeks. After a month of intractable symptoms,

the patient can be placed in halo traction. If this is ineffective, a C1-C2

arthrodesis should be considered.
Congenital muscular torticollis (CMT) is the most common cause of torticollis
in infancy. Neurologic disorders and osseous abnormalities, such as Klippel-
Feil, are less common. Ultrasonography is considered the modality of choice
for differentiating (CMT) from other more serious pathologies in the neck
when a palpable mass is present.
Tightness of the sternocleidomastoid muscle leads to muscular variety of
congenital torticollis.
Klippel-Feil syndrome is defined as congenital cervical fusion of cervical
vertebra characterized by a triad of a low, posterior hairline, a short neck, and
limited neck motion. Klippel-Feil patients with cervical spine fusions above C3
should not participate in contact sports (increased risk of sustaining a
transient neurologic deficit after minor trauma) . It is critical that patients
undergo a cardiac and renal evaluation upon their diagnosis to look for
cardiac septal defects and several different types of renal anomalies.
DISH is a common disorder of unknown etiology that is characterized by back
pain and spinal stiffness. The condition is recognized radiographically by the
presence of "flowing" ossification along the anterolateral margins of at least
four contiguous vertebrae and the absence of changes of
spondyloarthropathy or degenerative spondylosis.
It is a challenge to differentiate between DISH and ankylosing spondylitis.
Features that help distinguish DISH from AS include:
1) Nonmarginal syndesmophytes as shown in Illustration A (AS is
marginal).
2) No involvement of SI joint (biliateral sacroiliitis in AS).
3) Anterior cervical bone formation with preservation of disc space (AS
will typically show bone formation between vertebral bodies).
4) Radiographic findings on the right side of the thoracic spine.
Pseudosubluxation of the cervical spine, is considered a normal radiographic

finding in a young child, and reduces on extension radiographs.

In symptomatic spondylolysis, without listhesis or neurologic deficits, that has

failed nonoperative management:
• L4 and above treatment includes pars interarticularis repair
• L5-S1 treatment is in-situ fusion with bone grafting.
Single photon emission computed tomography (SPECT) is the most sensitive
imaging modality to diagnose spondylolysis when AP and lateral radiographs
are normal (increased signal of the pars is indicative of impending or acute
stress reaction spondylolysis).
Bracing and avoiding strenuous activities prevented the formation of pars
defects in patients with impending spondylolysis.
"Scotty dog"; parts of the dog are as follows: the transverse process-the nose;
the pedicle-the eye; the pars interarticularis-the neck; the superior articular
facet-the ear; the inferior articular facet-the front leg.
Childhood discitis is a continuum of spinal infections ranging from discitis to
vertebral osteomyelitis with soft tissue abscesses. Loss of normal lordosis ,
disk space narrowing , endplate changes , “Sawtooth” erosion of adjacent
vertebral end plates are seen respectively. Scalloping of the superior or
inferior endplates may be seen with longstanding infections. Vertebra magna
with resulting canal narrowing, permanent loss of disc height, or block
vertebra caused by spontaneous disc space fusion may be noted in patients
with resolved infections.
Tanner-Whitehouse III RUS (radius, ulna, selected metacarpals and
phalanges) correlates most closely with the curve acceleration phase for
children with idiopathic scoliosis.
An adequate physical exam in thoracolumbar curve includes an evaluation of
spinal balance, leg lengths, shoulder height, waist asymmetry, café-au-lait
spots, foot deformities and reflexes. An MRI is not part of the initial evaluation
in patients with idiopathic scoliosis without red flags or abnormal curve types.
Typical indications for MRI include patients with a left thoracic curve,
abnormal reflexes, rapid curve progression, neurologic symptoms, excessive
kyphosis and foot abnormalities.

Skeletal maturity can be determined by the stage of different apophyses. An

AP radiograph of the pelvis is one commonly used. When the iliac apophysis
has not yet begun ossification (Risser 0) and the triradiate cartilages are
open, the child has not yet entered the rapid phase of growth. This is seen in
the patient with the youngest skeletal age, and thus the highest risk of
progression of an idiopathic scoliotic curve.
TLSO bracing is indicated in adolescent idiopathic scoliosis for curves of 25-
40deg, apex below T7, in skeletally immature (Risser 0,1,2) patients.
Patient with untreated adolescent idiopathic scoliosis with a curve of 60
degrees or greater at skeletal maturity have an increased rate of low back
pain relative to normal controls. But, there is only an increased risk of
shortness of breath in patients with a curve greater than 80 degrees.
Sagittal vertical axis offset, or sagittal imbalance, is
determined by measuring the distance from the C7
plumb line (dropped from the center of the C7
vertebral body) to the posterior-superior corner of the
S1 vertebral body on a standing lateral radiograph.
Congenital scoliosis is caused by anatomic anomalies

of the vertebral bodies; divided into
• failure of formation (hemivertebrae, wedge
vertebrae, butterfly vertebrae)
• failure of segmentation (block vertebrae, bar
body).
The worst situation is when there is failure of formation with contralateral

failure of segmentation. An example of this is convex segmented
hemivertebra (failure of formation) associated with a concave unilateral bar
(failure of separation), an indication for surgery (excision of the hemivertebra
with short segment posterior instrumented fusion).
There is high incidence of intraspinal anomalies and other organic defects
associated with different types of congenital spinal deformity. These
anomalies can be assessed using MRI, echocardiography, renal ultrasound,
and a thorough clinical assessment.
Scoliosis caused by osteoid osteomas are typically non-flexible curves where
the osteoid osteoma occurs on the concavity of the curve. While peripheral
osteoid osteomas, far away from the neural elements CAN be treated with
radiofrequency ablation, treating osteoid osteomas of the spine with RFA
needs to be done on a case by case basis - depending on how close the
lesion is to the neural elements. Osteoid osteomas can occur in either the

vertebral body or the posterior elements of the spine, but typically occur in the
posterior elements.
The accepted range of normal T5-T12 kyphosis is 20-50 degrees. (Any
degree of kyphosis at the thoracolumbar area should be considered
abnormal.) Many adolescents will present with postural kyphosis, secondary
to slouching shoulders and poor posture, and thus will have normal
radiographs.

SPORTS

Knee
Superficial medial collateral ligament (MCL) of the knee originates slightly

posterior and proximal to the medial epicondyle.
For a PL corner injury in a high level athlete, PL corner repair or
reconstruction would be the suggested treatment.
The 45 degree PA flexion weightbearing view is the best for demonstrating
subtle joint-space loss, especially in the lateral compartment. This is because
the earliest loss of cartilage occurs in the 30 to 60 degree flexion zone which
is easily overlooked on x-rays in full extension. Weight-bearing views are
always preferrable when evaluating for arthritis.
Kinematic analysis of both menisci demonstrates anterior movement with
extension and posterior movement with flexion. The lateral meniscus has
more mobility than the medial meniscus because of less soft-tissue
attachments.
McMurray's test for medial meniscal pathology consists of: flexing the knee,
applying a valgus force, placing a hand on the medial joint line of the knee,
and finally bringing the knee from flexion to extension while rotating the tibia.
A palpable pop or click, or more commonly the elicitation of pain during this
maneuver is considered a positive test and can correlate with a meniscal tear.
The meniscus recieves its blood supply from the geniculate vessels at its
capsular attachment. The peripheral third of the meniscus is the most
vascular part, and is known as the red-red zone. This has the best potential
for healing following repair.
Various patterns of meniscal tears

The double PCL sign may be seen on a

sagittal MRI image when a torn meniscal
fragment is flipped and displaced into the
notch (Bucket-handle meniscal tear).
In bucket-handle lateral meniscus tear,
arthroscopic lateral meniscectomy or repair is
the treatment of choice. A young patient with
a peripheral bucket-handle meniscal tear
should be treated with meniscal repair. While
there is a trend towards using more all-inside
devices for smaller tears, the standard for
bucket-handle tears is an inside-out repair. Vertical mattress sutures have
been found to be the strongest suture configuration.
Saphenous nerve injury is one of the most common complications following
medial meniscus repair. Peroneal nerve injuries are more common with the
lateral-sided repairs. The inside-out technique involves retrieving the sutures
on the posteromedial aspect of the knee where they are tied over the capsule.
The saphenous nerve can be injured either by penetration of the needle or
become entrapped when tying sutures over soft tissue. An accessory incision
with careful dissection down to the capsule is recommended.
The posterior-lateral capsular exposure needed to protect the neurovascular
structures and allow suturing for an inside-out lateral meniscal repair is
performed by developing the interval between the iliotibial band and biceps
tendon. The lateral gastrocnemius is then retracted posteriorly and medially
where it helps protect the neurovascular structures. Splitting below the biceps
tendon puts the peroneal nerve at risk.
Variables associated with poor outcomes in meniscus transplantation include
size mismatch axial malalignment, anterior cruciate ligament insufficiency,
and the presence of significant arthritic changes such as femoral condylar
flattening. Grade IV chondral lesions represent a relative contraindication, if
not concurrently addressed with cartilage restoration techniques.
Patient age is not a contra-indication to isolated medial meniscal
transplantation.
Rim width tears have the highest effect on healing potential after meniscal
repair. The time from injury to surgery, medial versus lateral meniscal tears,
and the length of the tear have not been shown to consistently effect meniscal
healing.
No intervention is indicated for asymptomatic discoid menisci. When these are
symptomatic, surgical saucerization and possible repair are indicated.
Surgery for discoid menisci is indicated for persistent pain or motion loss in
order to prevent further meniscal damage.

A PCL deficient knee has an increased risk of early onset of degenerative

changes in the medial and patellofemoral compartments. Isolated PCL
reconstruction would not be recommended in these cases as the patient
already has arthritis and cruciate reconstruction in a mal-aligned knee is at
increased risk of failure. Either valgus producing osteotomy is reasonable, but
the opening wedge tends to increase posterior tibial slope which is helpful in
PCL-deficient knees.
The most appropriate treatment for combined posterior cruciate ligament
(PCL) and posterolateral corner (PLC) injury with 10° varus alignment when
standing and a varus thrust would be high tibial osteotomy to increase tibial
slope and correct varus malalignment and reconstruction of the PCL & PLC.
The primary function of the PCL complex is to restrict posterior tibial
translation. After acute PCL rupture or PCL reconstruction, resisted hamstring
strengthening is avoided as it pulls the tibia posteriorly. Therefore, therapy
should focus on quadriceps strengthening which pulls the tibia anteriorly.
For single bundle reconstructions, the PCL is usually tensioned in flexion and
the ACL is tensioned in more extension.
Overall the most common mechanism of PCL injury is a direct blow to the
proximal aspect of the tibia. The most common mechanism of PCL injury in
athletes is a fall onto the flexed knee with the foot in plantarflexion, which
places a posterior force on the tibia and leads to rupture of the PCL.
Age of menarche is the most accurate clinical factor to assess the degree of
skeletal maturity in the female athlete.Skeletal maturity is usually within 2
years from menarche with approximately 9mm of distal femoral and 6mm of
proximal tibial growth per year.
Transection of the anteromedial bundle of ACL leads to increased anterior
tibial translation at 90 degrees of knee flexion, whereas transection of the
posterolateral bundle shows an increased anterior tibial translation as well as
a combined rotatory instability at 30 degrees. This rotatory stability provided
by the PL bundle prevents the pivot shift phenomenon found in ACL deficient
knees.
Bone bruising occurs in more than half of all ACL

tears and is seen most commonly on the
posterolateral tibia and middle 1/3 of the lateral
femoral condyle (sulcus terminalis).
When considering transphyseal ACL reconstruction techniques in skeletally

immature patients, a horizontally or oblique oriented tunnel and interference
screw has the greatest potential to cause tibial physeal injury.

In infrapatellar contracture syndrome, resulting stiffness affects both active

and passive motion.
In acute anterior cruciate ligament (ACL) tear, there is an acute effusion
(hemarthrosis) with decreased motion. Acute ACL reconstructions in patients
with limited range of motion and weakness have been shown to lead to
postoperative arthrofibrosis and weakness. So, we should start with physical
therapy for range of motion and strength.
The pivot-shift examination may be a better measure of "functional instability"
than instrumented knee laxity or Lachman examination following anterior
cruciate ligament reconstruction.
The ACL is supplied mainly by the vessels that originate from the middle
genicular artery which leave the popliteal artery and directly pierce the
posterior capsule.
Any patient who presents with a sudden increase in knee effusion in a
delayed manner after ACL surgery should raise suspicion for infection,
whether or not a fever is present. If suspected, an aspiration should be
performed immediately and fluid sent for gram stain and cultures. If positive,
immediate arthroscopy is indicated.
Factors that have been implicated in the progression of OA in the ACL
deficient knee include meniscal lesions, osteochondral lesions, malalignment,
and concomitant ligamentous pathology. The painful pop on McMurray test is
indicative of a meniscal tear.
Segond fracture, most commonly caused by an anterior cruciate ligament
(ACL) injury.
A genotype within the COL5A1 gene is associated with reduced risk for ACL
ruptures in women.
Neuromuscular factors (increased valgus moments when jumping and landing
and a relative weakness of hamstrings compared to quadriceps) are present
in female athetes and may contribute to higher ACL tear rates.

Strengthening and proprioreceptive control of the knee flexors/hamstrings

protects against excessive or unopposed knee extensors which protect the
ACL from excessive tensioning.
Anterior cruciate ligament (ACL) prevention strategies currently focus on
increasing patient neuromuscular control and has been shown to decrease
ACL tear rates in certain populations.
Women's basketball has one of the highest rates of ACL tears. When there is
noncontact injury and hemoarthrosis likelihood of ACL injury is greater than
70%.
Biomechanical studies show that the quadruple semitendinosus and gracilis
tendons are the strongest of the tissues on maximal load to failure testing.
BTB autograft patients tend to have a higher incidence of knee pain and knee
stiffness not affecting function compared to hamstring autograft.
Patellar tendon rupture is a rarely reported complication of using a bone-
patella tendon-bone (BPTB) autograft in ACL reconstruction. Most cases have
been reported in the early post-operative period and should be treated with
patellar tendon repair or reconstruction to restore the extensor mechanism.
The saphenous nerve is at risk during hamstring harvest for ACL
reconstruction both at the site of the harvest incision and more proximally as a
result of the tendon harvester.
Injury to the infrapatellar branch of the saphenous nerve (IBSN) during ACL
reconstruction is common and can lead to numbness and paresthesias over
the anterolateral aspect of the knee and proximal leg. It can also be a cause
of anteromedial pain in the proximal stump.
Failure following primary ACL reconstruction has been associated with
surgical error in 65-75% of cases. Of these cases, tunnel malposition is the
most common, accounting for 70% of the errors.
The most common error in an ACL reconstruction is to place either the tibial
or femoral tunnel too anteriorly, leading to graft impingement and failure.
The femoral tunnel can be placed too anteriorly, thereby causing increased
strain on the graft in flexion because of the cam effect of the femoral condyle
which can result in graft stretching, laxity in extension, and subsequent failure,
but does not cause interference screw divergence.
A tibial tunnel drilled too anteriorly will limit full extension and causes tightness
in flexion.
Transtibial drilling through a tibia tunnel that is too far anterior can result in a
vertical (12:00) graft.
ACL reconstruction with 12 o'clock femoral fixation would lead to a vertically
placed graft and result in continued instability with cutting activities, and a
positive pivot shift exam due to failure to reconstruct the posterolateral bundle

of the ACL. Current standards for anatomic ACL reconstruction stress the
importance of more horizontal graft placement (10:30 in a right knee vs 1:30
in the left knee), to try and reconstruct both the anteromedial bundle which
provides anterior-posterior stability, and the posterolateral bundle which
provides the rotational stability. Improper femoral graft placement is one of the
most common reasons for ACL revision surgery.
Graft-screw divergence greater than 15-30 degrees from the trajectory of the
femoral tunnel may lead to failure of fixation and early ACL failure.
Isometric hamstring contractions at 60 degrees of knee flexion will produce
the lowest strain in this patient's ACL graft.
Isometric exercises such as quad sets and straight leg raises are encouraged.
Open chain isokinetic extension exercises, such as seated leg extensions at 0
to 30 degrees, are generally not allowed in the first 6 weeks of rehabilitation
after reconstruction of the ACL and reserved until after the graft attachment
sites have healed because they put increased stress on the graft.
It is felt that prophylactic bracing may decrease the incidence and severity of
medial collateral ligament (MCL) injuries.
Grade III indicates a complete rupture of the MCL with greater than 10mm of
opening on valgus stress. Careful evaluation is needed to evaluate for
concomitant injuries such as medial meniscus and ACL tears. However, the
presence of an ACL tear does not preclude nonoperative treatment.
MRI shown in Illustration is an
example of a PLC injury. The
iliotibial band (black arrow), lateral
collateral ligament (asterisk), and
popliteus (white arrow) are all
injured. The coronary ligament
(black arrowhead) is torn from the
tibia, causing displacement of the
lateral meniscus (plus sign).
The LCL is part of the posterolateral corner, but can be injured in isolation or
along with the rest of the posterolateral corner
Untreated grade 3 PLC injuries contribute to a significant increase in force on
the PCL reconstruction graft.
In the setting of primary varus malalignment (detected by long leg alignment
films) , a proximal tibial medial opening wedge osteotomy should be
completed prior to any attempted PLC reconstruction. Any PLC reconstruction
in the setting of untreated varus malalignment will have a higher failure rate as
a result of increased forces across the reconstruction. Grade 3 PLC injuries,

even if chronic, will typically not benefit from physical therapy or dynamic
bracing.
The lateral collateral ligament originates on

the lateral femoral condyle anterosuperior to
the insertion of the popliteus, runs superficial
to popliteus, and inserts anterolaterally to the
popliteofibular ligament on the fibula and
anterior to biceps femoris..
A positive "Dial Test" at 30 degrees of knee flexion would be expected in this

patient with a posterolateral corner (PLC) injury. The test is positive when
there is greater than a 10-15 degree difference compared to the uninjured
side. A positive dial test at 30 degrees alone indicates an isolated PLC injury
whereas a positive dial test at 30 and 90 degrees indicates a combined PLC
and PCL injury.
The fibular collateral ligament (also known as lateral collateral), Arcuate
ligament, and popliteus tendon are all components of the postero-lateral
corner (PLC). While, the posterior oblique ligament is a structure on the
medial aspect of the knee.
The pathologic motion of the lateral tibial plateau moving posteriorly to the
femoral condyle on a rotational stress examination is described as
posterolateral rotatory instability.
A postoperative physical therapy regimen consisting of no active flexion and
active extension from 90 to 0 degrees is most appropriate for a combined PCL
and posterolateral corner injury.
PCL reconstruction is not indicated in this patient as the physical examination
demonstrated a normal quadriceps active test and normal external rotation at
90 degrees of flexion.

Predisposing factors for chronic patellar tendinitis are quadriceps inflexibility

and atrophy, hamstring tightness, patellar hypermobility, playing on hard
surfaces, and increased training frequency.
Patellar tendon debridement is indicated in cases of severe tendinopathy,
extensor mechanism disruption, or cases refractory to prolonged conservative
treatment measures.
The femoral attachment of the medial patellofemoral ligament (MPFL) is
located between the femoral medial epicondyle and the adductor tubercle. It is
also located anterior to a line extended from the posterior cortex and just
proximal to the posterior extension of Blumensaat's line.
The most common site of medial patellofemoral ligament (MPFL) injury is a
soft-tissue avulsion injury of the ligament. Both midsubtance and soft tissue
avulsions are more common than bony avulsions.
The lateral patello-femoral angle is the angle formed by lateral patellar facet
and a line drawn across most prominent aspects of anterior portion of the
trochlea on a CT scan or Sunrise view radiograph. If there is a negative
patellar tilt on this measurement, the patient may benefit from a lateral release
for pain relief. Lateral release is not used for instability. The sulcus angle
refers to the depth of the trochlea; the congruence angle measures the
relationship of the center of the patella to the center of the trochlea. These are
used to assess malalignment and instability.
In lateral patellar dislocations medial facet of the patella impacts on the lateral
trochlear ridge. So, osteochondral fractures may originate from either site.
Risk of persistent patellar instability is highest among females 10 to 17 years
old and those with previous instability episodes.
Predisposing factors to lateral patellar dislocation include: excess femoral
internal rotation, external rotation of the tibia, lateral femoral condyle
hypoplasia, insufficiency of the VMO, an increased Q angle, a tight lateral
retinaculum, patella alta, patella tilt, generalized ligamentous laxity, and
patellofemoral dysplasia.
In lateral patellar tilt and lateral facet compression syndrome, the first line of
treatment is physical therapy. Rehab should focus on isometrics and closed
chain exercises. Lateral retinacular release is the most appropriate surgical
treatment.
Patellofemoral pain is the most common condition affecting adolescents and
is thought to have several different etiologies including biologic, mechanical,
and emotional causes. A classic symptom of patellofemoral pain is the
"theatre sign" which manifests as anterior knee pain with sitting for long
periods of time with the knee in flexion. This condition is most appropriately
treated with a physical therapy regimen emphasizing quadriceps (including
VMO) as well as hip and core strengthening in a non-painful fashion.

In the case of patellar or quad tendon repair, the initial focus is on regaining
range of motion while protecting the repair. Non-weightbearing movement
exercises like heel slides are encouraged. This can incorporate active knee
flexion with passive extension.
Following trauma, if the lateral radiograph demonstrates patella alta (Insall-
Salvati ratio greater than 1.2) this is indicative of a patellar tendon rupture.
Primary surgical repair within 2 weeks of injury is recommended to prevent
extensor mechanism contracture.
Microfracture is a marrow stimulation technique where stem cells from the
medullary canal are given access to the base of the lesion by making small
perforations in the subchondral bone. The reparative tissue is fibrocartilage.
Anteromedial tibial tubercle osteotomy (Fulkerson procedure) involves the
transfer of the tubercle to a more anterior and medial location. Changing the
vector of the extensor mechanism can help reduce lateral patellar
subluxation/dislocation and concomitantly unload areas of arthrosis on the
distal and lateral aspects of the patella. It is contraindicated in patients with
significant arthrosis of the medial facet of the patella and the medial femoral
condyle.
Joint space narrowing on a merchant view is a contraindication for autologous
chondrocyte implantation for patellofemoral arthritis.
Following mosaicplasty, appropriate post-operative rehabilitation and weight-
bearing status must be based upon the fixation of the osteochondral autograft
plugs. In addition, early non-weight bearing motion is important to prevent
stiffness and protect the joint surfaces with synovial fluid. Graft fixation
strength initially decreases during the early healing phase, and then increases
with subchondral bone healing.
The results of microfracture are better for contained defects less than 2cm
square. Autografts are generally reserved for smaller defects as well because
harvesting enough plugs to fill this defect may lead to significant donor site
morbidity. Osteochondral allograft plugs are used for lesions (2 x 2.5 = approx
5cm square).
Spontaneous osteonecrosis occurs most commonly in females over 55 years
of age and most frequently involves the medial femoral condyle. Treatment is
arthroplasty when conservative management fails.
More than 70% of JOCD lesions are found in the “classic” area of the
posterolateral aspect of the medial femoral condyle. The outcomes of distal
femur OCD in skeletally immature patients are good and these lesions usually
heal without surgical treatment. It is the best predictor of successful non-
operative management. Limitation of activity may diminish stresses across the
OCD lesion and prevent displacement.
Osgood-Schlatter disease is a traction apophysitis of the tibial tubercle that
commonly affects males between the ages of 12-15.

Patella baja is a well known complication of high tibial osteotomies, especially

opening wedge osteotomies. This procedure raises the tibiofemoral joint line
and can cause retropatellar scarring and tendon contracture, decreasing the
distance of the patellar tendon from the inferior joint line.
Shoulder
Posterior humeral circumflex artery, is the primary blood supply to the
humeral head, and most likely to lead to AVN when injured.
The superior glenohumeral ligament provides the most restraint to the

shoulder joint when the arm is at zero degrees of abduction or in adduction
and pulled inferiorly.
The primary function of the MGHL is to prevent anterior translation of the
humeral head with the arm in 45-60 degrees of abduction.
With the arm at 90 degrees abduction, the anterior band of the inferior gleno-
humeral ligament complex is the primary static stabilizer to anterior
translation.
The rotator cuff is the main dynamic stabilizer of the glenohumeral joint.

Numerous biomechanical studies have shown that the primary restraint to

anteroposterior translation of the clavicle is the ligamentous thickenings of the
acromioclavicular joint capsule. The strongest of these ligaments is the
superior one.
By age 17, the acromion has consolidated to form three separate ossification
centers along the periphery: the 1) PRE-ACROMIAL center which serves as
the attachment for the coracoacromial ligament and the anterior tendinous
origin of the deltoid; the 2) MESO-ACROMIAL center which anchors the
middle tendinous fibers of the deltoid; and the 3) META-ACROMIAL center
from which the posterior deltoid fibers originate. The most common form of
symptomatic os acromiale is failure of fusion between the meso-acromion and
meta-acromion.
Hornblower's test is completed by asking the patient to hold their shoulder in
90 degrees of abduction and 90 degrees of external rotation. The test is
positive if the arm falls into internal rotation or they are unable to actively
externally rotate against resistance. This suggests teres minor pathology.
The proton energy produced is about nine times greater for a 3.0 Tesla MRI
machine compared to a 1.5 Tesla machine.
The scapula has an integral role in the overhead throwing motion. It must
rotate during cocking and acceleration to clear the acromion to prevent
impingement on the rotator cuff.

During deceleration phase of throwing in the overhead athlete, the rotator cuff
is the principal decelerator of the arm. The rotator cuff is susceptible to tensile
failure due to eccentric loading during this phase.
In general, worker's compensation patients undergoing shoulder surgery have
been shown to have less functional improvement and lower patient
satisfaction than non-worker's compensation patients.
Supraspinatus tendon is the most common site for calcific tendinitis.
The coracohumeral and superior glenohumeral ligaments form a complex that
marks the superolateral margin of the subscapularis tendon.
Patient age older than 65 is the highest risk factor for nonhealing of the
surgically repaired rotator cuff.
Suture anchor drilling into the humeral head has been shown to increase
vascularity response during rotator cuff repair.
Infections after arthroscopic rotator cuff repairs are common. The typical skin
flora includes staph and strep as well as P. acnes, which has a propensity for
the shoulder. Because it is an anaerobic organism, cultures may only become
positive after 7-21 days.
The best indication for latissimus dorsi tendon transfer is a younger adult
patient with an irreparable posterosuperior rotator cuff tear, lack of advanced
glenohumeral arthritis, has an intact subscapularis function to stabilize the
humeral head after latissimus transfer, and who maintains some active
forward elevation. The most appropriate candidate for a latissimus transfer is
the young laborer with a massive rotator cuff tear and atrophy of the
supraspinatus fossa.Those patients with deficiency of the deltoid or
subscapularis, nonsynergistic muscle action after transfer, or fatty infiltration
of the posterosuperior cuff have worse clinical outcomes. Absence of the CA
ligament may allow anterosuperior escape in RC deficient shoulders but has
not been shown to lead to worse outcomes after a tendon transfer.

During open pectoralis major tendon transfer for chronic subscapularis

deficiency, the musculocutaneous nerve is most at risk. Injury to this nerve
would lead to weakness in elbow flexion.
In partial articular-sided supraspinatus tendon avulsion (PASTA), Physical
therapy including shoulder range of motion and rotator cuff/periscapular
stabilizer strengthening is the most appropriate initial treatment for the options
provided.
The prevalence of asymptomatic rotator cuff tears diagnosed with MRI or
ultrasound is quite high, with most studies noting tears in 30-55% of patients
over the age of 60.
Partial thickness rotator cuff tears on the articular side are more common than
their bursal counterparts; however, the bursal tears are typically more
symptomatic. Grading is based on depth (<25%, 25-50%, >50% for Grades 1,
2, and 3 respectively) and side (articular (A) or bursal (B)). For articular-sided
tears >6 mm in depth and for bursal-sided tears of >3 mm in depth, the
surgeon should consider repair.
Cadaveric studies have shown the average medial-to-lateral distance of the
supraspinatus tendon footprint on the greater tuberosity is 14-16mm.
Belly-press test is associated with a subscapularis tear.

The lift off test is an examination of the internal rotators of the shoulder, and in
particular, the subscapularis muscle (innervated by the upper and lower
subscapular nerves).
Rotator cable is thickened portion of the coracohumeral ligament, near its
avascular zone, running perpendicular to the supraspinatous tendon.
During arthroscopy in a patient with a subscapularis tear, the following may be
seen:
• Uncovered lesser tuberosity
• Retraction of the subscapularis tendon to the level of the glenoid
• Avulsed superior glenohumeral ligament
• Medial biceps subluxation

With repair of a large rotator cuff tear with tendon-bone tunnels, early passive
range of motion exercises are initiated to prevent adhesive capsulitis. Active
range of motion exercises should be initiated no earlier than 6 weeks
postoperatively.
Resection of the coracoacromial ligament results in increased glenohumeral
joint translation.
In rotator cuff arthropathy, a reverse total shoulder arthroplasty is most
appropriate. A humeral head arthroplasty (e.g. hemiarthroplasty) would also
be an appropriate treatment.
The long head of the biceps tendon has been implicated as a common source
of anterior shoulder pain. Surgical options to treat it include biceps tenodesis
by various methods and intraarticular biceps tendon release- tenotomy.
Concern for cosmetic deformity (“popeye” deformity) and muscle spasm or
cramping has been an argument against performing tenotomy in the past.
In acromio-clavicular (AC) separation graded as either Type I, II or III, non-
operative treatment is recommended for this patient. In type III surgical
treatment is not clearly any better than non-operative, has a higher
complication rate, and a longer recovery prior to return to sport/work.
A 20% increase in the coracoclavicular distance on AP radiograph compared
to the uninjured side would classify this AC separation as a Type II based on
the Rockwood classification.
Osteolysis of the distal clavicle is one cause of shoulder pain that can occur
after acute injury or repetitive microtrauma. It is more common in weight-
lifters. Open resection of the distal clavicle has been shown to be a reliable
treatment for isolated painful acromioclavicular (AC) joint pathology refractory
to nonoperative treatment.
The arthroscopic approach with an initial diagnostic arthroscopy of the
glenohumeral space prior to subacromial space is felt to be helpful in
confirming the diagnosis and identifying other pathology. So, arthroscopic
distal clavicle excision is better than open technique.
When there is chronic Bankart tear and an engaging Hill-Sachs lesion causing
anterior shoulder instability and engagement of the Hill-Sachs lesion in the
90/90 arm position, arthroscopic Barkart repair and a Remplissage procedure
would be the most appropriate treatment at this time.
The most appropriate treatment for bony Bankart lesion is open or
arthroscopic bony Bankart stabilization.
Acute traumatic shoulder dislocations in young athletes are associated with a
high rate of anteroinferior labral tears. Hill-Sachs lesion are the most common
associated intra-articular findings.
The clinical scenario of recurrent dislocation after isolated Bankart repair
suggests a failed Bankart repair or a missed concomitant injury.

Humeral avulsion of the inferior glenohumeral ligament (HAGL).
Open reduction and glenoid bone augmentation with graft or coracoid transfer
is ideal for chronic dislocations with anterior glenoid deficiency (inverted pear-
shaped glenoid) without significant Hill-Sachs (<20% of humeral head arc
impaction).
The axillary nerve is the mostly commonly injured nerve during a dislocation
because of its close association with the glenohumeral joint and its course
around the surgical neck of the humerus.
The Laterjet coracoid transfer has been described as creating a triple blocking
effect due to the function of the conjoint sling, bony augmentation, and CA
ligament support to the capsule.
The only consistent predictor of recurrence of shoulder dislocation has been
the age of the patient, reflecting the activity demands of the patient. In young
patients (<25 years old), recurrence rates have ranged from 60-94%.
The classic teaching is that HAGL lesions requires open repair of the capsule,
whereas the other lesions (GLAD-SLAP-ALPSA-PASTA) are felt to be better
addressed with an arthroscopic approach.
The Stryker notch view is best for identifying a Hill-Sachs defect.
Forceful posterior glenohumeral dislocations such as those resulting from
seizures or electric shock may sustain a large reverse Hill-Sachs defect
resulting in persistent instability in internal rotation or a locked posterior
dislocation. These patients may benefit from having the lesser tuberosity
along with the subscapularis advanced into the bony defect on the anterior
humeral head (modified McLaughlin procedure).
The posterior jerk test is a sensitive exam for ascertaining the presence of
posterior glenoid labral tears in the mid-range of the glenoid. The Kim test is
more sensitive for posterior-inferior labral tears.
Patients with posterior shoulder dislocations are often overlooked. They
present with the shoulder locked in internal rotation and adduction and lack
external rotation.

Posterior inferior labral tear, is also known as a Kim lesion.

Posterior shoulder dislocations occur during seizures and electrocution (due
to tetanic muscle contraction).
Blocking with the arm in forward flexion and internal rotation, is the most
common shoulder position for posterior instability.
Multidirectional instability (MDI) is defined by symptomatic global laxity of the
glenohumeral joint with increased translation in multiple planes (ie. anterior,
inferior, and posterior directions). It is usually an atraumatic patholaxity and
should be initially treated by physical therapy to strengthen and retrain the
proprioreceptive response of the muscular stabilizers of the shoulder.
Rotator interval closure involves plicating the anterior-superior region of the
capsule by suturing the superior and middle glenohumeral ligaments together.
This has been advocated as a treatment for certain recurrent instability
patterns such as multi-directional instability (MDI). It was felt to address
inferior subluxation in patients with a sulcus sign, however, the greatest effect
is a decrease in external rotation at the patient's side (0 degrees of
abduction). In general, a tighter anterior capsule tends to decrease external
rotation most, and a tighter posterior capsule causes a decrease in internal
rotation.
Excessive supination of the left arm is not listed as part of the Beighton 9-
point scoring system for hypermobility.
In Inferior shoulder dislocation (luxatio erecta), the patient presents with a
shoulder fixed in abduction
The most common type 2 SLAP repair rehabilitation protocols focus on limited
passive range of motion followed by regaining active motion, then finally
strengthening and sport specific activities.
Passive external rotation at 90 degrees of abduction and resistive biceps
exercises should be avoided in this early postoperative period after SLAP
repair.
The anatomy of the attachment of the long head of the biceps onto the
glenoid has been described as "posterior" or "posterior-dominant" in roughly
70% of patients. Only 25% of shoulders have an equal distribution of anterior
and posterior attachment to the glenoid, and very rarely ~5% is the
attachment anterior only.
A Buford complex, first described by Buford in 1994, is a normal anatomical
variant seen in 1.5% of individuals and consists of a cord-like MGHL and
absent anterosuperior labrum complex.
Internal impingement refers to the impingement within the glenohumeral joint
which occurs as the posterosuperior glenoid labrum makes contact with the
greater tuberosity, causing impingement on the posterior rotator cuff. This

occurs commonly among baseball pitchers during late cocking and early
acceleration as the shoulder joint reaches it's maximum external rotation.
Internal rotation contracture (GIRD - glenohumeral internal rotation deficit)
occurs most commonly in throwing athletes and is thought to be due to a tight
posteroinferior capsule. Biomechanical studies have shown that the humerus
is translated in a posterosuperior direction during the cocking phase of
throwing in the setting of a posterior capsular contracture. It typically presents
with pain while throwing and decreased velocity. It is linked most closely to
internal impingement.
Treatment of GIRD is directed at posterior capsule and rotator cuff stretching
(Sleeper stretches, cross-body stretches, periscapular strengthening).
The throwing shoulder in pitchers frequently exhibits excessive external
rotation at the expense of decreased internal rotation.
The Bennett's lesion is mineralization of the posterior-inferior glenoid
observed in overhead athletes (baseball pitchers). it is felt to be a traction
spur of the posterior inferior glenohumeral capsule which is repetitively
stressed during the deceleration and follow-through phases of the throwing
cycle.
Little Leaguer’s shoulder is the result of repetitive microtrauma to the physis of
the proximal humerus. Patients may report a recent increase in pitching
regimen. On examination, there is focal tenderness at the level of the physis.
Treatment focuses on rest, physical therapy and a progressive throwing
program. Pitching is often stopped for 2-3 months during rehabilitation.
The posterior branch of the axillary nerve travels within 1mm of the inferior
capsule of the glenohumeral joint and can be injured with suture passing
devices during posterior-inferior labral repairs. The superior-lateral brachial
cutaneous nerve and the nerve to the teres minor always arise from the
posterior branch. Injury can lead to teres minor weakness on external rotation
and sensory symptoms in the lateral arm in the region.
While both TSA and hemiarthroplasty are treatment options in shoulder
osteoarthritis , literature has shown the rate of revision surgery to be higher in
the hemiarthroplasty group compared to the TSA group.
Full-thickness supraspinatus tears have been historically rare in patients with
primary shoulder osteoarthritis, with most studies showing a rate of < 10%.
Inflammatory arthritis (e.g. JRA, RA) of the shoulder characteristically
demonstrates concentric glenoid erosion with medialization of the
glenohumeral joint. As a result of the often severe gleniod erosion, glenoid
resurfacing is not always feasible in these shoulder and some authors
recommend hemiarthroplasty.
The most common pattern of glenoid wear in osteoarthritis is central or
posterior.

On an MR arthrogram for adhesive capsulitis, a decrease of the intra-capsular

volume would be expected.
The rotator interval is the area between the anterior edge of the supraspinatus
tendon superiorly, and the superior edge of the subscapularis tendon
inferiorly. The medial border is comprised of the coracoid process and the
lateral border is formed by the transverse humeral ligament. The rotator
interval contains the biceps long head tendon, superior glenohumeral
ligament, and coracohumeral ligaments.
While most cases of adhesive capsulitis are idiopathic, risk factors include:
females, age 40-60, and some medical conditions such as diabetes and
hypothyroidism. It causes a restricted intra-capsular volume, pain, and global
loss of motion. Loss of both active and passive motion helps to identify
stiffness rather than weakness. Adhesive capsulitis is believed to involve a
fibroblastic process.
Diabetic patients are at greater risk of adhesive capsulitis than the general
population.
Appropriate treatment of adhesive capsulitis begins with gentle progressive
stretching exercises. Adjuncts such as NSAID's, intra-articular corticosteroids
and hyaluronic acid may be used as needed.
The most common outcome following non-operative management of adhesive
capsulitis with a stretching program is decreased range of motion compared
to the contralateral side.
The atraumatic lesion shown in

Figure A is most consistent with
osteonecrosis (also known as
avascular necrosis, or AVN).In
AVN, there is cellular death of the
subchondral bone following an
interruption in the vascular supply.
A spinoglenoid cyst could cause nerve compression on the suprascapular

nerve before its innervation to the infraspinatus, thus causing weakness in
external rotation. In contrast, compression at the suprascapular notch would
affect both the supraspinatus and infraspinatus muscles. The suggested
treatment in a young and competitive athlete with a spinoglenoid cyst would
be spinoglenoid cyst decompression with posterior labral repair.

A posterior SLAP tear is suspected with positive O'Brien's active compression

test.
Lateral scapular winging is caused by damage to the spinal accessory nerve,
or cranial nerve XI.
Classic medial winging of the scapula is due to paralysis of the serratus
anterior muscle which holds the scapula to the chest wall and prevents the
inferior angle of the scapula from migrating medially. It is innervated by the
long thoracic nerve (C5, 6, 7).
The thoracic outlet space is created by the clavicle, first rib, subclavius
muscle, costoclavicular ligament, and anterior scalene muscle. It most often
affects subclavian artery, vein, and the lower trunk (C8 & T1) of the brachial
plexus. The neurological exam may reveal sensory changes in the ring and
little finger and intrinsic weakness. Radiographs may show cervical ribs.
The axillary nerve passes through the quadrilateral space on its path to
innervate the teres minor and deltoid and provide sensation to the lateral arm.
Scapular dyskinesis is an alteration in the normal motion of the scapula during
coordinated scapulohumeral movements. It occurs as a sequela of prior
shoulder injury, especially injuries disrupting the activation patterns of
scapular stabilizing muscles. The principle is to treat the problem from
proximal to distal. The first stage involves attaining full motion of the scapula
and coordinating the scapula with trunk and hip motions. The second stage
involves strengthening the scapular musculature.
The innervation of the pectoralis major is the lateral and medial pectoral
nerves.
Pectoralis major injury most commonly occurs during downward deceleration.
Humeral avulsion of the pectoralis major muscle should be treated with
primary surgical repair.
Creatine supplement use has not been associated with triceps rupture.
Triceps ruptures have been reported in weightlifters who bench press heavy
weight, use anabolic steroids, have a history of local steroid injections to the
triceps tendon, patients with renal osteodystrophy, and with use of
fluoroquinolone antibiotics.
With conventional arthroplasty, the functional outcomes are dependent on the
integrity of the rotator cuff.
Placing the lesser tuberosity in a more lateral position will increase tension on
the subscapularis and likely lead to a deficit in external rotation.
The surgeon should consider eccentrically reaming the anterior glenoid when
performing a total shoulder arthroplasty on a patient with a retroverted glenoid
due to posterior deficiency associated with osteoarthritic changes. Glenoid
retroversion of greater than 15 degrees cannot be safely corrected with

eccentric anterior reaming when using a glenoid component with peripheral

pegs due to penetration into the glenoid vault.
Patients with brachial plexus palsies are not candidates for total shoulder
arthroplasty due to the substantial motor and sensory deficits associated with
these injuries.
Many of the traditional signs of infection such as fever, erythema and severe
pain are often not present with P. acnes.
The rotator cuff tendons can be inadvertantly cut or detached during a TSA if
the head cut is made either too distally or in excessive retroversion.
When a patient has advanced glenohumeral humeral arthritis, the treatment
that will lead to the best outcomes is a total shoulder arthroplasty (TSA).
The primary restriction after total shoulder arthroplasty (TSA) is passive
external rotation, as well as active internal rotation, to protect the
subscapularis repair. Rupture of the subscapularis was seen in all cases of
anterior dislocation following TSA.
Axial CT scan demonstrates significant glenoid retroversion and loss of
glenoid bone stock. If the glenoid is going to be re-surfaced posterior glenoid
bone grafting should be performed.
Subscapular insufficiency may occur with failure of tendon repair or

permanent changes to the subscapularis muscle after any anterior approach
to the shoulder with takedown of the subscapularis.
Superior placement of the glenoid component during reverse shoulder
arthroplasty can lead to inferior scapular notching. This is the most common
radiographic complication following the procedure.
Intact deltoid muscle function is a strict necessity when considering the
indications for a reverse shoulder arthroplasty. Indications for reverse
shoulder arthroplasty include: elderly patients over 70, glenohumeral arthritis,

massive irrepairable rotator cuff tears, intact deltoid muscle, and adequate
glenoid bone stock.
The choice between a standard total shoulder prosthesis and a reverse total
shoulder prosthesis should be based on the nature of the joint disease (either
centered humeral head and normal cuff function or migrated humeral head
and abnormal cuff function). Chronic massive rotator cuff tears may result in
rotator cuff arthropathy. In this case, the only effective treatment at present is
reverse total prosthesis.
Early reverse ball-and-socket designs of RSA failed because their center of
rotation remained lateral to the scapula, which limited motion and produced
excessive torque on the glenoid component, leading to early loosening.
A glenohumeral arthrodesis would be most beneficial to a patient with a flail
shoulder but intact elbow and hand function. This is especially important for a
laborer.
Elbow
Open reconstruction of the medial (ulnar) collateral ligament using ipsilateral
palmaris longus tendon is indicated in medial collateral ligament injuries in
high level overhand throwing athletes with symptoms recalcitrant to
conservative management.
The anterior bundle of the MCL was found to be isometric throughout the
flexion/extension arc of motion and provides the major contribution to valgus
stability. The posterior bundle of the MCL became elongated with elbow
flexion. It demonstrated the greatest change in length from extension to
flexion of all the elbow ligaments.
The moving valgus stress test is a sensitive and specific test for diagnosis of
MCL injury.
During a thrower's kinetic chain, increased shoulder internal rotation torque
contributes to increased valgus elbow loads.
The late cocking and early acceleration phase of the overhead throw causes
the greatest amount of valgus stress to the elbow.
The medial collateral ligament can be damaged with excessive resection of
posteromedial olecranon osteophytes.
Posterolateral rotatory instability is caused by insufficiency to an important
lateral staiblizer, the lateral ulnar collateral ligament (LUCL). Characteristic
symptoms include clicking and locking with extension and difficulty getting out
of a chair or performing tricep arm dips.
Distal biceps tendon ruptures occur most commonly in middle-aged men and
usually involve the dominant extremity. The mechanism of injury is usually a

single traumatic event with eccentric force on the flexed elbow. Distal biceps
tendon avulsion repair is the most appropriate treatment.The tear is
degenerative in nature, and is located along the radial border of the bicipital
tuberosity where spurring has occurred.
The lateral antebrachial cutaneous nerve is the nerve most commonly injured
during the repair of distal biceps rupture using a two-incision technique or a
single incision anterior approach. This purely sensory nerve supplies feeling
to the lateral aspect of the forearm.
While both elbow flexion and forearm supination strength are affected with
distal biceps brachii tendon rupture, there is a greater percentage loss of
supination strength.
.
• A represents the transverse bundle of the ulnar collateral ligament.
• B represents the posterior bundle of the ulnar collateral ligament.
• C represents lateral ulnar collateral ligament
• D represents the annular ligament.
• E represents the anterior band of the ulnar collateral ligament
It is important to distinguish between complete and partial tears as it guides
treatment decisions. Classic physical exam findings of complete tears include:
antecubital pain and ecchymosis, non-palpable distal biceps tendon
(abnormal hook test), proximal retraction of the biceps muscle, and weakness
with supination and flexion. A partial tear often has a normal hook test but has
pain with the examination worse with resisted supination. An MRI is most
appropriate for confirmation of a partial distal biceps rupture, while an MRI is
not always required for a complete tear if the exam is
conclusive. Conservative management consists of NSAID’s, splinting and
physical therapy. Surgical debridement and reattachment decreases pain.
Transfer to the brachialis improves flexion strength but not supination.
Pathologic changes with lateral epicondylitis (angiofibroblastic dysplasia)
include fibroblast hypertrophy, disorganized collagen, and vascular
hyperplasia.

Lateral epidondylitis show pathologic changes at the origin of ECRB mainly in

addition to ECRL, ED, ECU, and anconeus.
Total elbow arthroplasty is the most established definitive surgical treatment
for severe rheumatoid arthritis.
Osteochondritis dissecans commonly occurs in gymnasts and adolescent
throwing athletes presenting with symptoms of lateral elbow pain associated
with stiffness, catching, or clicking..
.
Little League elbow is a general term explaining medial elbow pain in
adolescent pitchers resulting from repetitive valgus stresses and tension
overload of the medial structures. The underlying pathology can include
medial epicondyle stress fractures, avulsion fractures of the medial
epicondyle, ulnar collateral ligament (UCL) injuries, or medial epicondyle
apophysitis
Athletes may develop an olecranon stress fracture. Initially, this is treated with
rest from activity. If it does not go onto union, ORIF with a compression screw
is indicated.
Static progressive splinting is useful treatment for certain patients with post-
traumatic elbow stiffness. Generalized accepted indications are flexion
contractures greater than 30 degrees, or flexion less than 130 degrees after a
failed trial of physical therapy.
A posterior medial portal is not often used during elbow arthroscopy as it
would lie very close to, or directly over the ulnar nerve.
TEA for rheumatoid arthritis has been shown to have very positive survival
analysis up to 15 years, with studies showing rates of survival rates of over
90%.
Chronic propionibacterium acnes infections of elbow arthroplasty are best
treated with two staged revision arthroplasty in healthy patients with adequate
bone stock for reimplantation.
Others
For iliac crest avulsion, treatment includes protected weight bearing and
activity limitations until asymptomatic.
Hip pointers are contusions of the iliac wing. They can be very painful
requiring icing, compression, and extended rest until symptoms improve.
Some advocate the use of corticosteroid injections.

Commonly tested areas of avulsion fractures involving the pelvis and hip.
The ASIS is the origin of sartorius and tensor fascia lata (TFL). Sartorius
inserts on the pes anserinus which is a common location of painful bursitis.
Avulsion of the anterior superior iliac spine (ASIS) typically occurs in patients
approaching skeletal maturity participating in running activities. Treatment is
progressive weightbearing with return to activities when pain free motion
achieved.
Adolescent athletes may sustain an avulsion of the anterior inferior iliac spine
(AIIS) which is due to the pull of the rectus femoris which is innervated by the
femoral nerve.
Extension-abduction of the leg with eccentric contraction of the adductors
leads to high shear stress on the rectus and may lead to tears of the
transversalis fascia, rectus muscle, and/ or adductor magnus origin. This may
lead to athletica pubalgia (sports hernia).
Classic findings of osteitis pubis including bony erosion and irregularity with
early widening of the pubic symphysis.
The most common anatomical pattern is a single sciatic nerve which passes
anterior to the piriformis muscle, however it is important to note that there are
other common anatomical variants.
The internal snapping hip syndrome (coxa saltans) has several proposed
etiologies including the iliopsoas tendon over the iliopectineal eminence,
iliopsoas muscle belly, or the femoral head. While the diagnosis is usually
made clinically, ultrasound is a dynamic imaging modality which can observe
tendons in motion.
The Ober test is positive with contracture of the tensor fascia lata or iliotibial
band which limits adduction of the hip while in an extended position. The

tensor fascia lata flexes and abducts the hip so a contracture would limit both
extension and adduction.
The False profile view (also known as Faux profil) is performed with the
patient standing with the affected hip on the cassette, the ipsilateral foot
parallel to the cassette and the pelvis rotated 65° from the plane of the
cassette. It can be used to assess anterior coverage of the femoral head for
patients with hip dysplasia (DDH) and FAI.
The zona orbicularis is the arthroscopic landmark for access to the iliopsoas.
Arthroscopic release of the iliopsoas can be performed for treatment of an
internal snapping hip, which is usually caused by the iliopsoas snapping over
the iliopectineal eminence or the femoral head.
Hip arthroscopy is currently effective for the treatment of loose bodies, labral
tears, chondral injuries, AVN, synovial disease, ruptured ligamentum teres,
impinging osteophytes, and unexplained mechanical symptoms. The
complications are rare but are associated with traction injuries, iatrogenic
chondral injuries, and neurovascular injury due to aberrant portal placement.
The posterolateral portal is made 2-3cm posterior to the tip of the greater
trochanter. The hip should never be externally rotated during this portal entry
as this brings the sciatic nerve closer to the portal. Internal rotation would
move the portal farther away from the sciatic nerve- this concept is similar to
internally rotating during a posterior approach to the hip for a total hip
arthroplasty.
The LFCN is at greatest risk of injury with placement of the anterior portal in
hip arthroscopy.
Adductor muscle avulsions are caused by muscle failure in tension as the leg
is abducted. Symptoms are localized to the groin along the medial aspect of
the pubic ramus. Treatment based on rest, ice, and mobilization with
protected weight bearing is recommended to avoid muscle scarring and

contractures. Muscle rehabilitation should include progressive gentle range of

motion, followed by progressive active muscle strengthening. There is no high
level evidence that surgical repair of adductor strains yields better outcomes
than nonsurgical management.
The primary role of satellite cells is to regenerate skeletal muscle after muscle
injury.
Avulsion injury of the ischial tuberosity is also referred to as a “hurdlers
fracture” which occurs during excessive hamstring tension. This injury in a
skeletally mature adult would most likely be a hamstring rupture. Hamstring
ruptures in adults most often occur at the myotendinous junction but can
occur at other areas including the muscle belly and tendinous insertion.
Flexion of the hip and extension of the knee most likely would injure the
hamstring. The hamstring is composed of the semimembranosus,
semitendinosus, and biceps femoris and all three components originate at the
ischial tuberosity.
In quadriceps contusion, acute management includes cold compression and
immobilization in flexion. Iliac crest contusions or “hip pointers” occur after
direct trauma and benefit from placing the affected leg in extension. Athletic
pubalgia or “sports hernia” is an injury to the muscles of the abdominal wall or
adductor longus that produces anterior pelvis and groin pain in the absence of
a true inguinal hernia.
During strenuous exercise, muscle fibers can swell up to 20 times their resting
size, leading to 20% increase in the muscle volume and weight. When the
blood flow is insufficient to meet the requirements of the muscle, the patient
experiences pain. Measuring the intracompartmental pressures at rest and
post-exercise have been shown to be the best method of confirming the
diagnosis of CECS chronic exertional compartment syndrome.
Gradual onset, progressive groin pain in a marathon runner is concerning for
a femoral neck stress fracture, which warrants further imaging such as an MRI
or bone scan. Normal radiographs are common and do not preclude the
presence of a stress fracture. While most compression-sided fractures may be
treated non-operatively with protected weightbearing, percutaneous screw
fixation is indicated for tension-sided fractures and compression-sided
fractures that extend greater than 50% of the way across the neck.
Tibial stress fractures are relatively common overuse injuries that can often be
difficult to treat. Nonoperative treatment with protected weightbearing is the
standard, but surgical intervention may be necessary if symptoms are not
responsive to initial nonoperative treatment. For shaft fractures,
intramedullary nailing may allow return to sport but does not guarantee
healing.
The anterior tibial cortex is a tension side stress fracture and it is a
problematic area to heal.

Rib stress fractures (RSF) occur more commonly in elite rowers than non-elite
rowers. The treatment involves rest, analgesia, and a slow return to rowing.
Nonhelmeted and recreational level horse racers are more at risk for head
and spine injuries (cervical neck strain), compared to helmeted professional
riders who more commonly sustain extremity injuries.
If a player has symptoms (i.e. diplopia, tinnitus, amnesia, loss of
consciousness, nausea, and/or headache) of a concussion, even with
negative advanced imaging or neurologic testing, that player should not be
allowed to play for at least that same day. But if the patient has evidence of a
"stinger" which resolves quickly further play shouldn't be inhibited.
The "Immediate Post-Concussion Assessment and Cognitive Testing" battery
(ImPACT) is a computer-based neurocognitive test that has proven useful in
the management of concussions. It tests attention, working memory, and
processing speed. A low baseline neuropsychological test would be the
athletes standard for comparison and not solely be a reason to disallow return
to competition.
During collision sports, such as football, the most common type of traumatic
neck injury involves fracture, dislocation, or ligamentous disruption of the
subaxial cervical spine. These are typically due to axial loading mechanisms
which, in football, most commonly occur during spear tackling by defensive
backs.
When football receiver becomes unconscious, following ATLS protocol,
airway management is the essential first step in the treatment algorithm. The
facemask must be removed rapidly to gain access to the airway. The cervical
spine should be immobilized in a neutral position. Attempting to remove the
helmet without simultaneously removing the shoulder pads is contraindicated
because it could pull traction on an injured c-spine or result in immobilization
in extension because the shoulder pads lift the chest forward.
Stingers (aka burners) are thought to result from traction injuries to the
brachial plexus in younger athletes and from nerve root compression in the
neural foramina in older athletes. Symptoms can vary, but often involve
numbness or tingling, weakness or complete inability to move the extremity,
and less commonly burning pain. Stingers are usually mild and transient, and
their prevalence is probably underestimated as athletes will often fail to
mention them to coaches or medical staff. If they recur in a given athlete, the
symptoms can become much more severe. If the symptoms do not resolve in
3 weeks, an EMG or imaging studies need to be obtained.
Patients with stingers (burners) have unilateral symptoms exclusive to the
upper extremity. Any evidence of bilateral upper extremity or lower extremity
symptoms should be evaluated for spinal cord injury by examination or MRI.
Heat stroke consists of hyperthermia (greater than 105.8 degrees F [41
degrees C]), central nervous system dysfunction, and cessation of sweating
with hot, dry skin. It is a medical emergency that results from failure of the

thermo-regulatory mechanisms of the body. It has a high death rate and

requires rapid reduction in body core temperature.
Tooth avulsion is a medical emergency. Survival of the tooth partially depends
on the length of time that the tooth is out of the socket. Water or saline can be
used to gently rinse off debris, but the teeth should not be brushed as this
may damage the root. During transport, the tooth must be kept moist. An
avulsed tooth can be transported in whole milk, saliva, sterile saline solution,
or commercially available kits with physiologic buffer solutions.
Commotio cordis is a rare condition with high mortality that arises after blunt
chest trauma. It results in a cardiac arrythmia, often ventricular fibrillation.
Treatment consists of immediate cardiac defibrillation.
An echocardiogram is the most effective test to screen for hypertrophic
cardiomyopathy (HCM).
The most common causes for sudden cardiac death in the athlete are
hypertrophic cardiomyopathy (36%), followed by coronary anomalies (19%),
and increased cardiac mass (10%). The other choices were much less
common causes: Ruptured aorta accounted for 5%, dilated cardiomyopathy
3%, and MVP 2%.
There are several reasons why electrocardiology (EKG) is not used for routine
pre-participation screening in US high school athletes, but it is not because it
cannot detect some of the potential causes for sudden cardiac death- it can.
A tension pneumothorax is a life-threatening emergency. The air trapped
between the pleura and the lung prevents lung expansion and must be vented
immediately to prevent hypoxia and cardiovascular collapse. A large bore
needle should be placed on the field to help stabilize the patient, who may
then be transferred by ambulance to the hospital for formal chest tube
insertion.
Mononucleosis infection causes acute splenic enlargement which also makes
the organ more susceptible to rupture from trauma. Mononucleosis is often
transmitted via oral mucosa in activities such as sharing water-bottles or
kissing. Clinical evidence supports a return to all sports 4 weeks after the
onset of symptoms provided that the spleen has returned to normal size.
Ultrasound has been used to demonstrate that the spleen has returned to
normal size.
Figure represents a MRSA pustule with

erythematous base. It is most
appropriately treated with topical
mupirocin for small lesions and incision
with drainage and administration of
trimethoprim/sulfa for larger lesions.

If a team experiences an outbreak of community acquired methicillin-resistant

staph aureus (MRSA), turf burns is most likely to be the etiology.
An evaluation of eating disorders, osteoporosis, and amenorrhea should be
performed in a young female athlete who presents with a stress fracture.
The female athlete triad consists of eating disorders, amenorrhea, and
osteoporosis. Treatment should consist of
1. Consultation with a psychiatrist or psychologist for counseling to deal
with self esteem issues and eating disorders.
2. Training should be limited until menses resume.
3. Supplemental vitamin D and calcium should be initiated as well as
consideration of oral contraceptive pills.
Insufficient caloric intake caused by either a poor diet or an eating disorder is
the most common cause for the loss of menses and stress fractures in a
female athlete.
Anabolic steroids decrease high-density lipoprotein levels. They may either
increase or have not effect on low-density lipoprotein levels. Elevations in
blood pressure have been observed in athletes who use anabolic steroids.
Stanozolol, and Methandrostenolone are a synthetic anabolic steroid derived
from dihydrotestosterone. Anabolic steroids have a long list of physiologic
side effects including increased levels of low-density lipoprotein (LDL) and
decreased levels of high-density lipoprotein (HDL), hypertension, liver
disease, changes in cholesterol, acne, testicular atrophy , injection site
pain and gynecomastia. The most commom behavioral side effects are
agression, hostility, and violence.
Muscle cramping is a side effect more common to creatine than testosterone.
Testicular atrophy, acne and male patterned baldness are all associated
primarily with testosterone use
Most governing bodies in sport use urine samples for drug testing. While there
is a blood test to detect higher than normal levels of hGH, there is not
presently a urine test.
Glucagon is the hormone of fasting or starvation. In contrast to insulin, which
promotes storage of nutrients when they are abundant, glucagon promotes
mobilization and utilization of stored nutrients to maintain the blood glucose
concentration in the fasting state; thereby it is catabolic to muscle.
An important feature of closed kinetic chain exercises in the shoulder is that
they allow for co-contraction of the periscapular and rotator cuff muscles.
In lacerated skeletal muscle the production of fibrous scar tissue is stimulated
by the presence of TGF-beta
Isokinetic exercise is characterized by constant speed despite variable effort.

Isotonic is an exercise physiology term which describes constant muscle

tension as a muscle changes length.
Iontophoresis is the use of an electrical current to drive charged molecules of
medicine through the skin to the deeper tissues using galvanic current and
medication
Exercises in water can minimize joint stress by decreasing the vertical
component of the ground reaction forces through buoyancy. Furthermore,
they are believed to prevent secondary injuries of the lower limb joints through
improved balance and muscle control. In addition, it has been found that
aquatic exercises can be beneficial to the cardiorespiratory system by
preventing abrupt increases in heart rate, and by requiring greater oxygen
consumption than equivalent exercises on land.
Open chain exercises are movements where the end of the kinetic chain (e.g.
the foot) is moving freely and not fixed to the floor or a wall. Leg extensions
and leg curls are examples. These are also examples of isotonic contraction.
Periodization refers to a planned variation in intensity and duration of a
specific workout over a predefined duration of time.
Dynamic exercise training can increase an athlete's cardiac output through
increased stroke volume.
Figure represents eccentric exercise and is the excercise that most efficiently
strengthens skeletal muscle. Eccentric exercise is a type of isotonic exercise
that includes constant muscle tension while the muscle is lengthening.

PEDIATRICS

Pediatric trauma
Child abuse is the 2nd most common cause of death in children > 1 year of
age, behind accidental injury.
Certain children are more vulnerable to abuse (hyperactive, precocious,

premature, adopted, and step child). Children without siblings have not been
shown to be at increased risk of abuse.
Any suspicion of child (<18 yrs) abuse should be reported to Child Protective
Services (CPS) as this is typically required by law.
A non-ambulatory infant presenting to the ER with a diaphyseal long bone

fracture, is suspected for child abuse.
Distal humeral physeal separations in the infant or young child are most often
the result of violent traction or rotation and are commonly associated with
child abuse.
Whether a child had not yet achieved walking age (toddler) is the strongest
predictor of likely abuse" in children with isolated femur fractures.
Skin lesions are the most common presentation in child abuse, followed by
fractures.
Fracture patterns associated with child abuse which should raise one's
suspicion include:
• metaphyseal corner fractures

• spiral fractures
• multiple fractures at different stages of healing
• single transverse long bone fractures
• posterior rib fractures
• skull fractures
Single transverse long bone fractures are the most common presenting
fracture pattern in abused children.
Intraosseous(IO) infusion is the most appropriate method of obtaining venous

access in a normotensive pediatric trauma patient who is unable to obtain a
peripheral IV line.
Long-term morbidity from trauma in children is most commonly secondary to

central nervous system injury, including traumatic brain injury.
A rough estimate of blood volume for pediatric patients of this age group is 75
- 80 mL/kg.

Spine fracture is associated with the highest risk of morbidity and mortality in
a pediatric trauma patient.
Approximately 80% of growth in the humerus bone occured from the proximal
humerus. Therefore, the distal humerus is responsible for the remaining 20%
of growth.
If a child has fracture of the distal clavicle with superior displacement of the
medial fragment, the preferred treatment is sling immobilization.
The vast majority of proximal humeral fractures in children can be treated

non-operatively due to high remodeling power. A moderate reduction often
occurs with simply positioning the patient upright and allowing gravity traction.
Surgical indications include open fracture, neurovascular injury, and severely
displaced fractures in a patient approaching skeletal maturity.
In distal humeral physeal separation (transphyseal fracture) posteromedial

displacement is most common. This injury pattern is associated with child
abuse, and may lead to cubitus varus deformity or avascular necrosis of the
medial condyle. Tardy ulnar nerve palsy is not associated with transphyseal
fractures. Most appropriately treated with closed reduction and percutaneous
pinning.
The elbow injury that most likely results in ulnar neuropathyis a flexion-type
supracondylar fracture and is manifested with intrinsic hand weakness.
Pin removal is recommended at 3-4 weeks after s percutaneous pinning of a

pediatric supracondylar fracture.
The most appropriate treatment in child with displaced supracondylar fracture

and extra-articular distal radius fracture is prompt closed reduction and
pinning of both the supracondylar humerus fracture and distal radius fracture.
While the external (lateral) epicondyle is the last apophyses to appear on

radiographs, internal (medial) epicondyle is the last to fuse at around 16 to 19
years.
Crossed (medial and lateral) pin fixation of pediatric supacondylar fractures

has been associated with a higher rate of ulnar nerve injury than lateral
pinning. Crossed pins were more stable.
Vascular insufficiency at presentation in supracondylar humeral fractures

should be managed initially by rapid reduction and pinning without
arteriography.
A gunstock deformity, also known as cubitus varus, is the most common

complication following a pediatric supracondylar humerus fracture.

Cubitus varus is typically caused by malreduction of the fracture at the time of

fixation; not usually by growth arrest.
Cubitus varus typically does not affect range of motion, pain, function or
growth. However, cosmetic concerns or recurrent elbow fractures may result.
Tardy ulnar nerve palsy may also result, but is not common.
The anterior interosseus nerve (AIN) is the most common nerve injured with
extension type pediatric supracondylar fractures. The AIN, a branch of the
median nerve, is principally a motor nerve and innervates the Flexor
Digitorum Profundus Index, Flexor Digitorum Profundus Middle, Flexor Pollicis
Longus and Pronator Quadratus. It DOES NOT innervate the Extensor Pollicis
Longus, which is innervated by the posterior interosseous nerve, a
continuation of the deep branch of the radial nerve.
In displaced medial epicondyle fracture > 5 mm surgical treatment with open

reduction and internal fixation is the choice.
Medial epicondyle fractures are the most common fractures patterns

associated with elbow dislocations in a child.
Medial epicondyle avulsion fractures can be treated with open reduction and
internal fixation when the fractured fragment is incarcerated in the
ulnohumeral joint or if there is significant ulnar nerve dysfunction.
The medial epicondyle is avulsed by forceful contraction of the common flexor

wad, which includes the pronator teres, flexor carpi radialis, palmaris longus,
flexor digitorum superficialis, and flexor carpi ulnaris.
With regards to lateral condyle fractures, the most common sequela in the
setting of nonunion with displacement is the development of progressive
cubitus valgus deformity. Valgus deformity can place an individual at risk for
the developement of tardy unlar nerve palsy.
Maximum displacement of the lateral condyle fracture can be best evaluated

on an internal oblique radiograph.
The predominant blood supply to the lateral condyle of the distal humerus
comes posteriorly.
For displaced lateral condylar fractures, open reduction internal fixation with k-
wires should be done.
Olecranon fractures in a skeletally immature patients are highly suspicious for

osteogenesis imperfecta.
The majority of pediatric radial neck fractures can be treated with closed
reduction. Up to 30 degrees of angulation is considered acceptable. For

residual angulation after reduction of radial neck fractures percutaneous

reduction and pinning is done. Direct reduction (inserting a pin into the head
or shaft fragment as a joystick) and indirect reduction (Metaizeau method
using a retrograde intramedullary pin) are possible options.
There is need for a high suspicion of compartment syndrome even in

skeletally immature patients with a minimally displaced fracture of the radial
neck.
Reduction of nursemaids elbow typically includes elbow flexion and supination

while placing a finger on the radial head to feel the snap of the reducing
annular ligament.
The optimal treatment for angulated distal diaphyseal both bone forearm
fracture is closed reduction and immobilization in a short-arm cast.
When a forearm fracture is properly reduced, the AP radiograph demonstrates

the radial styloid and biceps tuberosty 180 degrees apart. On the lateral, the
coronoid process and ulnar styloid will be 180 degrees apart.
Restoration of radial bow has been shown to be similar with both IMN and
ORIF in both bones forearm fracture.
Closed reduction of Monteggia fracture and immobilization of the arm in 110

degrees of flexion (as swelling allows) and full supination enhances the
stability of the injury by tightening the interosseous membrane and relaxing
the biceps tendon.
In Monteggia fractures with incomplete ulnar fracture with lateral radial head
dislocation that is successfully reduced, there is no need for surgical
management.
For dislocation of the radiocapitellar joint, if closed reduction was

unsuccessful, open reduction of radial head dislocation with casting in
supination and flexion is done.
After failed initial treatment with closed reduction and casting, displaced distal
radius/forearm fractures should be treated with repeat closed reduction.
Percutaneous fixation can decrease the risk of re-displacement.
Distal radius fractures are the most common fracture type in children less than
16-years-old.
The cast index is defined as the sagittal width of the cast divided by the
coronal width. Loss of reduction is associated with poorly molded casts and
high cast index > 0.79.

Causes for thermal burns during cast application are multi-factorial (not
including fracture pattern). Excessively thick plaster, dip-water temperature of
>24 degrees C, placing the limb on a pillow during the curing process, and
fiberglass overwrapping all increase the risk for thermal injury.
Greenstick forearm fractures are usually supination injuries with apex-volar

angulation , which can be reduced with varying degrees of forearm pronation.
Delayed reduction of posterior dislocation of the hip has been shown to

increase the risk of AVN.
Following successful reduction of a traumatic hip dislocation, a CT scan must

be obtained to evaluate for any entrapped osteochondral fragments.
Persistent joint incongruity after hip reduction is likely to be caused by soft

tissue interposition consisting of a torn labrum including the lateral acetabular
apophysis. A post-reduction CT can be performed to look for interposed
bone/osteochondral elements located within the hip joint. Surgical extirpation
of osteochondral fragments is warranted. If the patient had a posterior
dislocation, the posterior structures have already been disrupted, and further
disruption of the anterior structures through an anterior approach is not the
best choice.
Transphyseal screw fixation provides the most reliable fracture stability and is
recommended for treatment of most children’s hip fractures (age >6) despite
the secondary effect of premature physeal closure.
Femoral neck fractures in the pediatric population are associated with a high
rate of osteonecrosis.
Piriformis entry intramedullary nails have been associated with damage to the
deep branch of the medial femoral circumflex artery (MFCA) and a risk of
avascular necrosis in children and adolescents.
Titanium flexible nails for femoral fractures should be avoided in patients with
length unstable fractures and in those with > 11 years of age and weight >
108 lbs.
Early hip spica cast treatment is the current mainstay of treatment in

diaphyseal femur fractures in children less than 5 years of age. Complications
of this treatment method are relatively low, but those requiring early revision
of treatment most commonly involve loss of reduction.
External fixation of femoral fractures for polytraumatized adolescent that is

going to the operating room emergently for abdominal surgery is the most
appropriate step, and can be thought of as damage control orthopaedics.

When predicting complications associated with displaced physeal fractures of

the distal femur, the direction and amount of displacement does not
statistically correlate with outcome. Repeated reduction attempts should be
avoided, as this can lead to increased physeal damage. Crossing of the
physis with hardware should be avoided if possible.
Physeal bridge excision is a recommmended treatment option for patients

with a resulting deformity in which there is at least 2 years or 2 cm of growth
remaining and a physeal bridge that is less than or equal to 50% of the
physeal area. This procedure can prevent, correct, or improve deformity and
limb-length discrepancy by restoring growth potential.
Direction of fracture displacement is not related to increase risk of

complications with treatment of distal femoral epiphyseal fractures.
If radiographs of distal femoral physis show subtle physeal widening, but no

displacement so this is Salter-Harris I injury. Cast immobilization is acceptable
treatment. However, these fractures are associated with a high incidence of
deformity so close clinical followup is mandatory.
For displaced Salter-Harris II fracture of the distal femoral physis, closed

reduction with percutaneous pinning would be the most appropriate treatment.
Open reduction and internal fixation is reserved for SHIII and SHIV fractures
and irreducible displaced SH I or II fractures. If anatomic reduction cannot be
obtained via closed techniques, incision over the displaced physis to remove
interposed periosteum is necessary.
Intercondylar eminence fractures that occur in adolescent or adult patients

need to be counseled as to the risk of development of stiffness and
arthrofibrotic scar tissue.
Mid-substance ACL tears are seen in both children and adults, but tibial spine
fractures are seen primarily in the skeletally immature. The analogous injury in
the adult knee would be an ACL tear, and if associated with a fracture, that
would be a lateral capsule avulsion (Segond fracture).
Tibial tubercle avulsion fractures typically occur in late adolescent boys that
participate in jumping sports, such as basketball and volleyball. Non-displaced
fractures may be treated nonoperatively with casting or splinting. Displaced
fractures are best treated with open reduction and internal fixation.
In type III tibial tubercle avulsion fracture, anterior compartment syndrome is

at risk as anterior tibial recurrent artery may be disrupted.
Patella sleeve fractures occur most commonly in children aged 8-12. This
injury involves an avulsion of cartilage (and sometimes a small piece of bone)
from the inferior pole of the patella. Sleeve fractures should be accurately

reduced and stabilized using suture fixation thru bone tunnels in the patella. K
wires can be added if the fracture fragment is large enough.
Minimally displaced pediatric proximal tibia metaphyseal fractures are

common and heal reliably. However, a valgus deformity may become
apparent, an event termed "Cozens Phenomenon". The valgus deformity
seen with "Cozen fractures" has several possible etiologies. One of the most
common theories involves a stimulation of the medial physis resulting in
medial overgrowth. It has also been proposed that lateral tethering could
contribute to the valgus deformity. Regardless of the etiology, valgus
deformity is treated with observation as they almost always spontaneously
correct over time.
Management of toddler's fracture of the tibia includes long leg cast

application. Initial radiographs are often negative but follow-up radiographs
may demonstrate a healing periosteal reaction.
Distal tibial physeal fractures may be associated with malrotation of the foot.
An inability to reduce supination-inversion type ankle fracture in a closed

manner warrants an open approach to remove interposed structures and to
confirm anatomic reduction.
A Tillaux fracture occurs when the anterior-inferior tibiofibular ligament

(AITFL) avulses an epiphyseal fragment off the anterolateral tibia, typically
from an external rotation mechanism.
After reduction and casting of Tillaux fracture, the best thing would be to
obtain a CT scan to assess residual intra-articular displacement.
Pediatric conditions
Appropriate treatment of osteomyelitis should lead to a rapid decline in the
CRP, which peaks two days post-operatively, then begins to decline and
normalizes within a week.
Calcaneal osteomyelitis in children can occur via hematogenous seeding or

direct puncture wounds. The most common organism idenitified is
Stapylococcus Aureus, while Pseuodomonas infection is present in calcaneal
osteomyelitis cases caused by puncture wounds.
The involucrum is new bone growth from the periosteum that walls off the
sequestrum from the healthy bone. The sequestrum is the necrotic bone that
has become avascular and isolated from the healthy bone.

Risk factors for the development of a DVT in children with osteomyelitis

include surgical treatment, CRP > 6, MRSA, and age > 8 years. A fever of
greater than 38.5 has NOT been found to be a risk factor.
Surgery is indicated in patient who has failed to respond to appropriate

antibiotic treatment for osteomyelitis.
In a patient presenting with signs of infection, but a normal radiograph and

knee aspiration, osteomyelitis should be suspected, and MRI is the most
appropriate next step in management. If positive then percutaneous biopsy
with culture and antibiotics is done.
The most important aspect of treating children and adolescents with subacute
hematogenous osteomyelitis is ruling out tumors. Therefore, in addition to
cultures of involved tissue, a biopsy is needed. They also state that if infection
is confirmed, treatment consists of administration of appropriate antibiotics
and, when the osteomyelitis is chronic (with symptoms for more than one
month), débridement and removal of any sequestrum may be required.
Patients with tuberculosis can present with constitutional symptoms of fever,

night sweats, weight loss, and pain. The WBC is usually normal and the ESR
is often elevated. The purified protein derivative test (PPD) is positive. The
biopsy specimen shows multiple giant cells with caseous necrosis. The
special stain is a Ziehl-Neelsen stain that displays the mycobacterium as "red
snappers" against a blue background. Culture for acid-fast bacilli on
Lowenstein-Jensen medium is diagnostic.
Bones with an intra-articular metaphyses are the proximal humerus, proximal

radius, proximal femur, and distal fibula/tibia. This makes the shoulder, elbow,
hip, and ankle potential sources of septic arthritis secondary to direct
metaphyseal spead of osteomyelitis. The metaphysis of the knee is extra-
articular and as such proximal tibial or distal femur osteomyelitis does not
routinely spread to the knee.
Psoas abscess is rare and difficult to differentiate from septic arthritis of the
hip. Primary psoas abscess (in the absence of an underlying focus of
infection) has a predisposition to children. The most common organism is
Staphylococcus aureus.
Matrix metalloproteinases have been associated with the destruction of

cartilage in septic arthritis.
The likelihood of a patient having a septic hip can be ascertained with use of
the Kocher criteria (WBC > 12, ESR > 40, T > 38.5 and an inability to bear
weight on the affected hip). Temperature above 38.5 is the best predictor of
septic arthritis followed in decreasing order by CRP, ESR, refusal to bear

weight, and serum WBC count. Patients meeting all four criteria have a 99%
chance of having a septic hip, whereas patients having 3 out of the 4 Kocher
criteria, have a 93% chance of having a septic hip. The next best step in
management would be to take the patient to the operating room for an
emergent irrigation and debridement of the affected hip.
An aspiration of > 50,000 leukocytes per mL and >75% PMNs suggests

sepsis of the joint.
Kingella kingae is a fastidious organism which is recovered on blood culture

medium, recently with the addition of the BACTEC blood culture system.
Failure to diagnose an infected joint can lead to joint destruction and physeal
damage with resultant deformity. Surgical options for hip deformity following a
neglected infection include trochanteric osteotomy, proximal femoral varus
osteotomy, and a modified Albee arthroplasy.
Group B Streptococcus is the most common causative organism of neonatal

septic arthritis.
The differential diagnosis of an infectious presentation with NWB in a child

should include: discitis, sacroilitis, transient synovitis, septic hip, osteomyelitis,
and Iliopsoas abscess. Further imaging is required to confirm the diagnosis.
When suspicion of septic hip, hip aspiration should be done.
Staphylococcus aureus, which causes >50% of septic arthritis cases and most
cases of acute hematogenous osteomyelitis is gram positive cocci.
Regarding pediatric septic arthritis there are four poor prognostic signs: age
<6 months, joint effusion with underlying osteomyelitis, hip involvement, and
delay in treatment >4 days.
Sprengel's deformity is caused by failure of the shoulder to descend caudally

during fetal development. Patients have limitations in abduction and forward
flexion.
Congenital pseudarthrosis of the clavicle almost always involves the right

middle 1/3 of the clavicle.
Glenoid hypoplasia and retroversion is most commonly associated with

unresolved brachial plexus birth palsy.
At 18 months, a majority of children who have sustained an obstetric brachial

plexus birth (OBPBP) injury will have a complete recovery without weakness
or noticeable asymmetry.

The best prognosis is seen in patients with the classic 'Erb palsy' presentation
consisting of absent shoulder abduction and external rotation with intact wrist
and digit flexion and extension .Bicep activity is associated with a more
favorable prognosis.
Infants with total brachial plexus palsy (C5, C6, C7, C8, T1) with an
associated Horner's syndrome have a very little (<10%) chance of ever
recovering spontaneous motor function.
The biceps and brachialis muscles are supplied by C5-6 and as such a
brachial plexopathy affecting the C5 nerve root would affect the child's ability
to perform elbow flexion and forearm supination. The deltoid is also supplied
by C5 and palsy would lead to deficient shoulder abduction.
Perkins line is used in the assessment of developmental dysplasia of the hip

(DDH). It is a radiographic line drawn perpendicular to Hilgenreiner's line that
intersects the most lateral aspect of the acetabular roof through the anterior
inferior iliac spine.
The acetabular teardrop is comprised of the quadrilateral surface and cotyloid

fossa. In normal hips, all children have a teardrop figure by age 18 months of
age.
Ultrasound is necessary to avoid leaving an infant in a harness with an

unreduced hip which can erode the acetabulum.

For DDH in a patient with a closed triradiate cartilage, a peri-acetabular

osteotomy (Ganz) is the most appropriate treatment.
The ossific nucleus of the proximal femur is visible on radiographs by 6

months of age in most children.
A 4-month-old who fails Pavlik harness treatment is best treated with closed
versus open reduction of the hip and spica casting. Continued harness
treatment can be detrimental as there is risk of posterior acetabular erosion.
Barlow and Ortolani maneuvers are of limited use in older children (> 6
months) because the soft tissues about the hip tighten.
Interposition of gluteus medius is not associated with blocked reduction in

patients with DDH.
In patients with cerebral palsy, the hip is normal at birth, but a combination of
muscle imbalance and bony deformity leads to progressive hip
dysplasia. Spasticity or contracture usually involves the adductor and
iliopsoas muscles. Because of the pull of these muscles, the majority of hips
subluxate in the posterosuperior direction.
Patients >8 y.o. at the time of onset with Legg-Calve-Perthes (LCP) disease,
with a hip in the lateral pillar B group or B/C border group had a better
outcome with surgical treatment including either a femoral or pelvic
osteotomy.
With regards to the lateral pillar classification of Legg-Calve-Perthes (LCP)

disease, it was found that fragmentation occurred at an average of six months
after the onset of symptoms.
Children who present with Legg-Calve-Perthes (LCP) disease at an age < 6

years have an improved prognosis.
Proximal focal femoral deficiency (PFFD) is a developmental disorder that is

present at birth and caused by a defect in the cartilage anlage of the proximal
femur. It is associated with deficiency in development of the proximal femur,
cervical pseudoarthrosis, fibular hemimelia, coxa vara, and ACL deficiency.
Longitudinal growth usually arrest at the distal femur physeal growth plate
occurs in boys at 16 years of age and girls at 14 years of age.
For leg length discrepancy in a male who is one month after the onset of
puberty with a chronologic and skeletal age of 13 years (final projected LLD
will be 4.0cm), epiphysiodesis of the femur and tibia is the most appropriate
treatment.

A CT scanogram has the advantage of being able to calculate accurate length

measurement in the presence of joint contractures, and typically utilizes a
single anteroposterior scout film upon which digital length measurements can
be made. In the presence of severe flexion contractures, lateral scout films
can be added to improve measurement accuracy.
There are multiple ways to assess final limb length. One way, the arithmetic
method, assumes that girls and boys stop growing at 14 years of age and 16
years of age, respectively. Additionally, this method assumes a certain
contribution from each physis to longitudinal annual growth:
• Proximal femur – 4 mm per year

• Distal femur – 10 mm per year
• Proximal tibia - 6 mm per year
• Distal tibia – 5 mm per year.
LLD at maturity of <2cm is treated nonoperatively with observation and shoe

lift if needed.
For patients with stable slipped capital femoral epiphysis, in situ percutaneous
screw fixation is performed.
Slipped capital femoral epiphysis most commonly injures the hypertrophic

zone of the growth plate.
Southwick method accurately represents the method used to determine the

radiographic severity of the epiphyseal slip and help guide treatment. It is
accomplished by subtracting the epiphyseal-shaft angle on the uninvolved
side from that on the side with SCFE on the frog leg lateral pelvis
radgiograph.
The inability to bear weight, even with assistive devices, preoperatively

indicates an unstable SCFE, which is associated with significantly increased
rates of osteonecrosis.
In unstable SCFE, reduction attempts of unstable SCFE have been

associated with a higher rate of osteonecrosis after pinning. Osteonecrosis is
also more likely to develop in patients treated with multiple pins than in those
treated with a single cannulated screw.
Hypothyroidism is most commonly associated with SCFE.
Patients with endocrine disease such as hypothyroidism commonly

demonstrate prevalence of bilaterality (as high as 80% in some reports),
prophylactic treatment of the opposite hip should be considered. When adding
additional risks of contralateral hip slip of obesity and young age and the

significant morbidity of displacement of slipped capital femoral epiphysis, the

controversy of prophylactic contralateral pinning is diminished.
Hip pain is more common than knee pain in SCFE.
Patients with SCFE can present with an out-toeing gait, limb shortening,
decreased hip flexion, decreased hip abduction, and decreased hip internal
rotation.
The Imhauser osteotomy is described to correct the deformity often seen in

the late treatment of SCFE. The osteotomy produces flexion, internal rotation
and valgus .
The medial circumflex artery is the dominant blood supply to the femoral head
in children older than 4 years of age.
In an adolescent boy with knee pain, always examine the hips and consider
hip pathology, especially if the knee workup is negative.
If a mass is soft and non-tender, in the posterior knee in a young patient, this
suggests that this is a popliteal, or Baker’s, cyst. Observation is the first-line
treatment for most popliteal cysts.
Initial management of infantile Blount's disease in children less than 3 years

old consists of full time bracing with a knee-ankle-foot orthosis.
Children who are too old for bracing, morbidly obese, and have advanced
Blount's disease (Langenskiöld stages IV, V, or VI) are candidates for
proximal tibial osteotomy. Furthermore, it has been shown that overcorrection
of the deformity can lead to decreased recurrence rates.
Proximal tibial osteotomy is done for a child with Infantile Blount’s disease
who is < 3 year of age but has failed the first line of treatment which is
bracing.
The use of staples in treatment of Blount’s disease allows for compression to

be applied to the lateral portion of the physis. The resulting compression, per
the Heuter-Volkmann principle, will cause a slowing in longitudinal growth.
Adolescent Blount's disease with significant varus malalignment, a coexisting

leg-length discrepancy, and closed growth plates is best treated with a
proximal tibia osteotomy with placement of an external fixator.
Genu valgum in the skeletally mature individual is most appropriately treated

with a varus-producing distal femoral osteotomy. If the deformity were to be
addressed with a medial closing wedge tibial osteotomy an oblique joint line
would be maintained. Varus and valgus can be determined by measuring the

lateral distal femoral angle (normal=88 deg), medial proximal tibial angle
(normal=87 deg), or the tibiofemoral angle (normal=5-10 degrees).
Genu valgum in skeletally immature patient is most appropriately treated with.

temporary hemiepiphysiodesis across the bilateral medial distal femoral
growth plates.
In neurofibromatosis with associated anterolateral tibial bowing if there is no

fracture or pseudoarthrosis the treatment in this case is bracing in a total
contact orthosis, otherwise known as a clamshell orthosis. If the patient had a
fracture or a pseudoarthrosis, then you would treat him with surgery.
Anterolateral tibial bowing and congenital pseudoarthrosis of the tibia are

related conditions and represent a continuum of the same disease process. It
is most commonly seen in children with neurofibromatosis.
Posteromedial tibial bowing is thought to be a result of intrauterine positioning.

It is associated with calcaneovalgus foot deformity and leg length
discrepancy.
An amputation below the knee in tibial hemimelia has greater likelihood of

success if there is a functional quadriceps and no flexion contracture of the
knee. Otherwise, a knee disarticulation may be necessary.
The 5 components of Staheli's rotational profile include:
1) Internal and external hip rotation (up to 70 degrees)

2) Thigh-foot axis (-10 to 20 degrees)
3) Transmalleolar axis
4) Heel-bisector angle
5) Foot progression angle (-5 to 20 degrees)
The Q angle can be affected by femoral anteversion and tibial torsion, but
typically is not a part of the rotational profile.
"Red Flags" to prompt further evaluation in a patient with progressive

deformity include, positive family history for rickets, limb length discrepancy
(possible hip dysplasia), extreme limb rotational profiles and pain (possible
malignancy or fracture).
Out toeing gait in late childhood and early adolescence is most commonly
caused by excessive external tibial torsion.
The best orthotic for cavovarus correctible deformity is a semi-rigid orthotic

with a recess for the head of the plantarflexed first ray and lateral hindfoot
posting to correct the heel varus.

In cavovarus foot deformity correction of the hindfoot varus position in

Coleman’s (lateral) block test implies the hindfoot deformity is not fixed and
the forefoot is the primary deformity. Thus, the calcaneus is spared from an
osteotomy (e.g. Dwyer lateral closing wedge osteotomy) during surgical
correction. A dorsiflexion osteotomy of the first metatarsal and plantar fascia
release will help correct the cavus deformity as well as allow restoration of the
“tripod” foot alignment. Finally, the supple hindfoot will passively correct from
the varus position into a neutral position.
Abduction of the foot is increased incrementally with each

manipulation/casting for club foot until hypercorrection to 70° of foot abduction
is obtained.
Previous clubfoot release surgery is associated with dorsal bunion,

osteonecrosis of the talus, rigid pes planus, intoeing gait. While tarsal tunnel
has not been correlated with it.
In patients with idiopathic clubfoot, a correlation has been found between the
extent of the soft-tissue release and the degree of functional impairment.
In the surgical treatment of dynamic supination (result of medial overpull of

the anterior tibialis tendon) following Ponseti treatment, the accepted sites of
insertion for anterior tibial tendon transfer are the lateral cuneiform (more
common) and cuboid.
Subtalar rigidity is a contraindication to anterior tibial tendon transfer

for dynamic supination in club foot.
Cavus should be addressed first when using the Ponseti method to treat
clubfoot.
Cavus has been associated with clubfoot or residual clubfoot deformity in 22%
of children and is typically associated with placing the tarsal navicular in a
dorsally subluxated position at surgery.
In congenital talipes equinovarus, also known as clubfoot there is hindfoot

parallelism between the talus and calcaneus in lateral view radiographs
A helpful acronym is "CAVE" which describes both the clinical position and
the general order of deformity correction by Ponseti casting.
The preferred treatment of congenital vertical talus (CVT) is surgical reduction

of the navicular onto the reduced talus with soft-tissue releases in either a
staged or one-step procedure. Casting prior to surgery is helpful in stretching
the contracted dorsal soft-tissues but does not typically reduce the
talonavicular joint.
Congenital vertical talus (CVT) presents as a fixed rocker bottom foot.


Congenital vertical talus (CVT) is not associated with posteromedial bowing.
The plantarflexion lateral radiograph is key to differentiating between CVT and

congenital oblique talus. In congenital oblique talus, the talonavicular joint will
reduce and the talus will parallel the first metatarsal on plantarflexion
radiographs. However, the talus will not reduce in CVT, and with plantar
flexion the long axis of the first metatarsal remains dorsal to the long axis of
the talus.
Tarsal coalition, most commonly occurring as a talocalcaneal or

calcaneovnavicular coalition, is the leading cause of peroneal spastic flatfoot
and leads to a rigid pes planus deformity of the foot.
Recurrent ankle sprains may be associated with tarsal coalition.
For symptomatic patients with tarsal coalition a trial of nonoperative treatment

is the first line of treatment. A firm orthosis to decrease inversion and eversion
stress can be utilized or a short leg casting may be tried.
Coalition resection and interposition of extensor digitorum brevis is an

appropriate surgical option for most cases of calcaneonavicular coalition.
Alternatively, fat interposition may be performed as some authors have
demonstrated superior results with this method. Contraindications to resection
of calcaneonavicular coalitions are advanced degenerative changes in
adjacent joints or multiple coalitions, whereby an arthrodesis procedure is
indicated.
Symptomatic flexible pes planovalgus that has failed extensive conservative

management can be surgically treated with a calcaneal lengthening
osteotomy as described by Evans.
Conservative measures are the first line treatment for the symptomatic
accessory navicular. Surgical excision is a reliable intervention for cases
refractory to conservative management.
Kohler’s disease is avascular necrosis of the tarsal navicular. Treatment is

traditionally symptomatic and pain usually can be relieved by limiting
activities, and using orthotics. If this does not work, then a short leg walking
cast for 4-6 weeks would suffice. Surgery is not indicated for this entity since it
is self limiting.
Curly toe is a common congenital deformity characterized by flexion and

varus deformity of the interphalangeal joints. Third and fourth toes are
frequently affected and most patients don't have symptoms and requiring no
intervention.

Cerebral Palsy (CP) is defined as static encephalopathy with onset prior to 2

years of age, due to variably severe upper motor neuron dysfunction.
Types of CP:
• Hemiplegia: Affecting both limbs on one side, arm usually worse than
leg.
• Diplegia: Affecting right and left side equally. Minimal spasticity may be
present in upper limbs, but lower limb spasticity predominates. IQ may
be near normal.
• Paraplegia: Affecting both legs, sparing of arms.
• Quadriplegia: Both legs and both arms. Associated with low IQ and
higher mortality.
• Monoplegia: Affecting only one limb.
While botulinum toxin A, acetylcholinesterase, and baclofen all demonstrate a

decrease in spasticity, only botulinum toxin A does so by blocking the
presynaptic release of acetylcholine peripherally.
Decreased acetylcholine levels in the synaptic cleft weaken the strength of

muscle contraction through paralysis of the the portion of muscle whose
neuromuscular junctions are blocked. Botox exhibits this peripheral
mechanism of action in the treatment of spastic muscle disorders like cerebral
palsy.
Tendon transfer surgery is used to maximize function in patients with cerebral

palsy.
The Gross Motor Function Classification System Level (GMFCS) is commonly

used for cerebral palsy. Level V is characterized by physical impairment which
restricts voluntary control of movement and the ability to maintain antigravity
head and trunk postures. Children have no means of independent mobility
and are transported.
Hip reconstruction is recommended for CP children over 4 years of age with

severe subluxation or dislocation if severe degenerative changes are absent.
Hip reconstruction consists of a one-stage soft-tissue lengthening with varus
derotational femoral osteotomy and possible acetabuloplasty.
In spastic CP patients, factors that make the posterior leaf spring ankle-foot
orthosis (PLSO), most appropriate are the clinical presence of absent heel
strike and minimal (but some) dorsiflexion.
Hip dislocation in children with myelomeningocele may either be teratological

or paralytic. Paralytic dislocation of the hip occurs because of paralysis of the
hip abductors and extensors w/ unopposed pull of the hip flexors and
adductors. Surgical reduction of hips in patients with spina bifida is associated

with a high failure rate and therefore treatment indications are controversial. In
general, reduction for patients with L4 level is most controversial and may be
considered if unilateral. Dislocated hips in patients with L3 level and above
are typically left alone.
L1 level myelomeningocele patients have externally rotated and flexed hips,

equinovarus feet, require a HKAFO, and cannot functionally ambulate.
L3 level myelomeningocele patients have adducted and flexed hips,

recurvatum knee, equinovarus feet, require a KAFO, and are household
ambulators.
L5 or sacral level myelomeningocele patients have talipes calcaneus. They

underwent posterior transfer of the anterior tibial tendon to balance the
dynamic forces and obtain a plantigrade foot.
Patients with myelomeningocele have an allergic response (type 1

hypersensitivity) to latex. The allergic or hypersensitivity response is IgE
mediated.
A planovalgus foot deformity in patients with spina bifida may arise from distal
tibia (best treated with a supramalleolar osteotomy) or foot deformity.
The initial deforming force in cavovarus foot is the result of a weak anterior
tibialis being overpowered by the unaffected peroneus longus, bringing the
first ray into a plantarflexed position. This forces the hindfoot into varus
position leading to lateral column overload and pain.
The posterior tibial tendon retains its strength in CMT and can aid in
decreasing hindfoot varus while providing ankle dorsiflexion when transferred
to the dorsum of the foot.
Athrogryposis is a congenital disorder characterized by multiple joint

contractures and normal cognition, however, the joint contractures are not
progressive by nature.
Inferior lens dislocation is associated with homocystinuria while superior lens

dislocation is associated with Marfan syndrome.
Spinal deformities are common in patients with Marfan syndrome and are
usually refractory to conservative management.
Muscular dystrophies, of which Duchenne and Becker are two types, are
characterized by progressive skeletal muscle weakness, defects in muscle
proteins, and the death of muscle cells and tissue. Because Becker muscular
dystrophy has dystrophin (albeit abnormal), the progression of muscle
weakness is slower, with the diagnosis typically made after age 8 years.

Scoliosis of Duchenne muscular dystrophy behaves similar to neuromuscular

curves. Rapid progression of the curve (up to 2 degrees per month) ultimately
results in restrictive pulmonary disease. Bracing is not effective in halting or
slowing progression. Surgical intervention should occur prior to rapid
progression of the curve to prevent cardiac and pulmonary complications
before they occur (20-30 degree curve).
Morquio’s syndrome is the most common mucopolysaccharidosis.
Children with lysosomal storage diseases have increased rates of carpal

tunnel syndrome.
The quantitative disorders of type I collagen are associated with milder forms
of OI (Type I), whereas the qualitative disorders are associated with more
severe phenotypes (Types III and IV).
Dense parallel bands in xray are due to long-term bisphosphonate use (e.g.
Osteogenesis imperfect).
Children with severe forms of osteogenesis imperfecta and progressive

scoliosis should be treated with posterior spinal fusion with instrumentation
when the curve exceeds 35 degrees.
Basilar invagination is the most likely cause of myelopathy in a patient with

Osteogenesis imperfect.
Serologic testing may be useful to rule out other etiologies of JIA (formerly
juvenile rheumatoid arthritis). However, rheumatoid factor (RF), anti-nuclear
antibody (ANA), and HLA-B27 are neither sensitive nor specific enough to be
useful for screening or confirmation testing.
JIA specifically has a high association with iridocyclitis, particularly in those

with positive ANA studies.
The Beighton-Horan scale is used to evaluate patients with joint laxity and
Ehlers-Danlos syndrome.
Players with a blood test indicating the presence of sickle-cell trait (SCT) are
at risk for exertional sickling collapse which responds initially to rest, hydration
and oxygen.
Sickle cell disease is a genetic disorder of hemoglobin synthesis

characterized by 2 abnormal hemoglobin S alleles. Under low oxygen
conditions the affected blood cells become "sickle shaped" and unable to
pass through vessels. This results in vascular occlusion that may have a
variety of clinical consequences depending on the body part affected (hip
osteonecrosis).

Salmonella osteomyelitis is directly associated with sickle cell anemia.
Sickle cell crises resulting in bone infarcts can be difficult to differentiate from
acute osteomyelitis with physical exam and plain radiographs alone.
Diagnosis is confirmed by radionuclide scans. Infection is diagnosed by
normal uptake on the bone marrow scan and abnormal uptake on the bone
scan. Bone infarct is diagnosed by decreased uptake on the bone marrow
scan and abnormal uptake bone scan.
Most important inheritance patterns
Condition Gene Defect Manifestations
Neurofibromat AD NF1 neurofibromin Individual with any two of the

osis type 1 following criteria is diagnosed with
Chrom. 17 NF1:
1) Six or more café-au-lait macules
measuring at least 0.5 cm in
diameter (before puberty) or at
least 1.5 cm in diameter (after
puberty).
2) Two or more neurofibromas of
any type OR one plexiform
neurofibroma.
3) Freckling in the axillary or
inguinal regions (skinfolds).
4) Optic pathway glioma.
5) Two or more Lisch nodules (iris
hamartomas).
6) Dysplasia of the sphenoid bone,
or dysplasia or thinning of the
cortex of the long bones (e.g.,
tibia).
7) First-degree relative with NF.
Charcot- AD PMP22 Nerve Pes cavovarus
Marie-Tooth demyelination
disease Chrom. 17 Acetabular dysplasia
(CMT)
Friedreich's AR Frataxin Neuronopathy in the dorsal root

Ataxia ganglia
loss of peripheral sensory nerve

fibers
degeneration of the posterior columns

of the spinal cord
Marfan AD FBN1 gene fibrillin-1 Dural ectasia

Syndrome
Scoliosis

Ligamentous laxity
Superior lens dislocation
Duchenne's XR Dystrophin No dystrophin Rapid progression scoliosis

muscular
dystrophy
Pseudohypertrophy of the calves
Increased creatine kinase levels

Becker Few dystrophin
muscular
dystrophy
Achondroplasia AD FGFR3 Inhibition of Rhizomelic limb shortening

chondrocytes
proliferation Frontal bossing
"champagne glass" pelvis
Normal intelligence
Pseudoachondr AD COMP Cervical spine instability

oplasia
MEP AD COMP Delayed and
irregular
ossification of
the epiphyses
of the long
bones
Diastrophic AR DTD Undersulfation Dwarfism

dysplasia (Sulfate of cartilage
Transport proteoglycan Hitchhikers thumb
Protein)
Cauliflower swelling of the ears
Cleidocranial AD RUNX2 Involves bones formed by

dysplasia intramembranous ossification such as
facial bones, cranium, and clavicles
Failure of formation of midline

structures, such as the clavicle and
pubic symphysis.
Morquio’s AR Accumulation C1–C2 instability (due to odontoid

syndrome of keratan hypoplasia)………Myelopathy
sulfate
Waddling gait,
Genu valgum,
Thoracic kyphosis,
Cloudy corneas
Normal intelligence

Spinal Survival Progressive Tongue fasciculations

muscular motor loss of alpha-
atrophy neuron 1 motor neurons Absent deep tendon reflexes
(SMN1) in the anterior
Hypotonia
horn of the
spinal cord Die by the age of two
Klippel-Feil Congenitally Low hairline

syndrome fused cervical
segments. Webbed neck
Limited cervical spine range of motion
Osteogenesis I,IV COL1A1 Defect in Type Bone bowing,

imperfecta AD and I collagen
(OI) COL1A2 Multiple fractures,
II , Abnormal
III cross-linking Olecranon apophyseal fractures,
AR via a glycine
Dentinogenesis imperfecta resulting
substitution in
in brownish opalescent teeth,
the
procollagen Hearing loss,
molecule
Blue sclerae
Osteopetrosis AD Carbonic Defective Erlenmeyer flask femur

Adult / benign anhydrase osteoclastic Narrow femoral canals
II resorption of
immature bone Dense bone,
Osteopetrosis AR
Infantile / Loss of trabeculations
malignant
Rugger jersey spine with very dense
vertebral bodies
Gaucher Deficiency of
disease the enzyme
glucocerebrosi
dase
Deposition of
glucocerebrosi
de in cells of
the
macrophage-
monocyte
system
Sickle cell AR Hemoglobin
disease abnormality
(presence of
hemoglobin
S)

RECONSTRUCTION

The changes observed in articular cartilage affected by osteoarthritis include:

increased water content (as a result of the disruption in architecture of the
matrix molecules), decreased quantity of proteoglycans, decreased quantity of
collagen with decreases in cross-linking
Stromelysin is not inhibited by plasmin. Stromelysin and plasmin are two

examples of metalloproteinases, both secreted by chondrocytes, which have
degradative action against cartilage.
Regarding total joint arthroplasty, the rate of surgical intervention for African
American males is lower than either white or Hispanic males.
Combination of home and supervised exercise has the best supporting

evidence as a nonoperative method for the treatment of osteoarthritis.
Use of NSAIDs or tramadol for patients with symptomatic osteoarthritis of the

knee was most strongly supported according to the 2011 American Academy
of Orthopaedic Surgeons' Guidelines for the treatment of symptomatic
osteoarthritis of the hip or knee.
Arthroscopic partial meniscectomy is an option in patients with symptomatic

OA of the knee who also have primary signs and symptoms of a torn
meniscus, however it should be noted that the AAOS clinical practice
guidelines have assigned this as a Grade C recommendation supported with
Level 4 evidence.
Intra-articular hyaluronic acid is no longer recommended as an effective

method of treatment for patients with symptomatic knee arthritis based on the
revised AAOS clinical guidelines from 2013.
Perforation of the femoral canal is the most common intraoperative

complication in a patient with sickle cell disease undergoing a total hip
arthroplasty.
In avascular necrosis with femoral head flattening, narrowing of the joint

space and acetabular sclerosis, total hip replacement has good to excellent
outcomes. Higher failure rates have been seen in patients undergoing
cemented total hip arthroplasty in treatment of avascular necrosis of the hip,
so cementless prosthesis is used.
Treatment of avascular necrosis in older patients includes hip

hemiarthroplasty or a total hip replacement. With the former, development of
acetabular protrusio can contribute to groin symptoms. Functional outcomes
have been reported to be higher in those receiving total hip replacement for
AVN of the femoral head.

Tibial stress fractures are a known complication following free-fibula bone

grafting. Radiographs may be normal (MRI scan is required), or might show
the "dreaded black line" and/or new periosteal bone formation.
Untreated asymptomatic osteonecrosis of the femoral head in patients with

sickle cell disease has a > 75% likelihood of progression to pain and collapse.
Bisphosphonate therapy is a proven method of preventing femoral head

collapse in patients with avascular necrosis and subchondral lucency.
A younger, active patient with total hip arthroplasty will sustain more
polyethylene wear and osteolysis due to greater activity levels and more years
of use (but doesn’t increase metal ion level in MOM bearing).
Elution of an antibiotic is increased with increased porosity of a cement

spacer. This porosity increase can be obtained with hand mixing and avoiding
the use of a vacuum-type mixing device.
Irrigation and débridement with possible femoral head and polyethylene

exchange is the most appropriate treatment for persistent drainage within a
few weeks (less than 4 weeks) from total joint arthroplasty surgery.
Two-stage resection and replacement arthroplasty for hip and knee

arthroplasty is the gold standard for treatment of infection beyond 4 weeks.
When there is persistent pain after total joint arthroplasty, or radiographic

findings of periprosthetic infection (periosteal bone formation with scalloping
resorption), initial work-up starts with ESR, CRP and WBC. If these are
elevated, joint aspiration to confirm periprosthetic infection is warranted.
Articulating cement spacers and static spacers have been found to have
equivalent reinfection rates as well as equivalent functional outcomes.
WBC of 1,500 cells/ml and PMN 70% indicates the lowest synovial aspirate
suggestive of infection.
In bilateral TKA infection if bilateral TKA resection arthroplasty with cement

antibiotic spacer and course of IV antibiotics are applied, there will be
successful prosthesis reimplantation at 2-year follow-up with less than 20%
revision rate.
Deep prosthetic infection is the most common complication after hip

arthroplasty performed for salvage of failed internal fixation after pathologic
proximal femoral fracture secondary to malignancy.
The work-up of a suspected prosthetic infection after TKA includes an

evaluation of radiological (x-ray +/- bone scan and PET scan) and laboratory

(ESR and CRP) parameters as well as analysis of joint aspirate fluid (cell
count and differential, culture, gram stain +/- PCR).
In patient with an equivocal presentation of a periprosthetic joint infection and

recent history of antibiotic use, a repeat aspiration and culture in one week is
indicated.
The range of 50 to 400 microns is the optimal pore size for cementless porous
implants to allow for optimal bony ingrowth.
Precoating a stem with PMMA adds an additional interface at risk of failure.
Stiffer stem materials (higher Young's modulus) improve performance.
Calcar collar contact adds minimal strength to the construct, but does not lead
to premature failure.
Smoother corners decrease the rate of failure since they decrease stress
risers.
The increased porosity seen in osteopenia and osteoporosis actually helps

create a stronger bone-cement interface.
Hydroxyapatite-coated femoral stems have shown shorter times to biologic

fixation.
Compression molding and ram extrusion of polyethylene (PE) exhibit

equivalent wear rates, but compression molding has a lower susceptibility to
fatigue crack formation and propagation.
Polyethylene oxidation occurs in vivo regardless of sterilization technique

(although some methods of sterilization accelerate the oxidation process).
Irradiation of polyethylene sterilizes the polyethylene. When the irradiation

occurs in the presence of argon or nitrogen, free radicals are created leading
to cross-linking of the polymer, and a more abrasion resistant product.
However, irradiation in the presence of oxygen leads to excessive free radical
production and the polyethylene becomes more brittle with higher rates of
early failure. Sterilization techniques including ethylene oxide and gas plasma
do not create free radicals and there is no effect on polymer cross-linking.
Highly cross-linked ultra-high-molecular-weight polyethylene (UHMWPE) has

improved resistance to adhesive and abrasive wear.
Highly cross-linked liners that have been found to generate smaller wear
particles compared to conventional polyethylene liners.

UHMWPE stimulation significantly increased VEGF, RANK, and RANKL gene

expression. RANKL, RANK, and VEGF are upregulated in any process that
involves increased osteoclast activity.
Urinary N-telopeptide is a marker of increased bone turnover and is a

breakdown product of Type 1 collagen.
Macrophages initiate the inflammatory cascade associated with aseptic

loosening of orthopaedic implants by secreting platelet-derived growth factor
(PDGF), prostaglandin E2 (PGE2), TNF-alpha, IL-1, and IL-6.
Osteolysis is caused by macrophage activation from polyethylene particles.
In metal-on-metal articulations, particulate wear debris stimulates lymphocytic

invasion due to nanometer sized particles.
Smaller femoral head diameter and acetabular cup abduction angle >55
degrees are associated with elevated serum metal ion levels with metal-on-
metal hip resurfacing arthroplasty.
While the wear rates of old polyethylene liners increased with increasing
femoral head size, wear rates of the new highly cross-linked UHMW
polyethylene liners have shown to be independent of head size. This is
extremely advantageous, as increasing the femoral head size improves range
of motion and increases jump distance, thereby decreasing dislocation rates.
Metal-on-metal bearings used in total hip arthroplasty form smaller wear

particles compared to metal-on-cross linked polyethylene bearings. Metal-on-
metal bearings produce higher serum metal ion concentrations, have lower
volumetric wear rates.
A one-stage revision of the arthroplasty components is the most appropriate

next step in management in aseptic loosening.
Radiostereometric analysis is the most effective method to evaluate

polyethylene wear in arthroplasty. Radiopaque tantalum beads are inserted
into the bone in strategic positions surrounding the implants. An immediate
post-operative film records the position of the beads. The construct can then
be followed with repeated radiographs over time by evaluating the position of
the components relative to the beads.
Wear rates above 0.1 mm per year are at significant risk of osteolysis.
Osteoprotegrin (OPG) binds to RANK ligand (RANKL) to inhibit it from binding

to RANK which are present on osteoclast-precursor cells. Normally, RANKL
interacts with RANK to stimulate activation of osteoclasts.

Increasing shelf age, younger age, male gender, and a rough tibial baseplate
are all risk factors for wear-related failure in total knee arthroplasty when
using a polyethylene liner. Posterior cruciate retaining knee design is not a
documented risk factor.
Pencil lead mark on ceramic femoral head indicates transfer of metal from the
acetabular cup to the ceramic femoral head. This occurs during the
component on component impingement and excursion that occurs during
dislocation.
Stripe-wear is a distinct type of impingement from the classic impingement of

the femoral head on the acetabular socket found in episodes of instability (ie.
lift-off separation) during gait.
In hips with cementless circumferentially coated femoral stems no distal femur

osteolysis occurs.
Activity level does not affect serum metal ion levels in metal-on-metal (MOM)
hip replacements.
Austin Moore developed the most popular long-stemmed prosthesis in the

1950s. The Austin-Moore prosthesis was a large, uncemented femoral stem
that didn't use polyethylene. The Austin-Moore prosthesis had fenestrations
for self-locking which later became the impetus for biological fixation.
The estimated failure rate at 35 years for all polyethylene acetabular shells is
20-30%.
To date, there is no correlation between metal serum levels and cancer risk.
As such, the link between metal on metal arthroplasty and an elevated cancer
risk has not been supported by hard data.
Restoration of limb length is essential following total hip arthroplasty. The

amount of limb-length change will be the vertical distance between the center
of rotation of the femoral component and the center of rotation of the
acetabular component. Thus, when the femoral center of rotation on
templating is inferior to that of the acetabular component, the limb will be
shortened. Restoring femoral offset is also important. If the center of rotation
of the prosthetic head lies lateral to that of the cup on templating, the
reconstruction will produce decreased offset.
The anterior Smith-Peterson approach to the hip uses an inter-nervous plane

dissecting between sartorious and tensor fascia lata innervated by the femoral
and superior gluteal nerves.

The posterior approach has been shown in numerous studies to lead to a

greater rate of dislocation in both hemiarthroplasty and THA when compared
to lateral, anterolateral, and anterior approaches.
During a minimally invasive approach to total hip arthroplasty if femoral

periprosthetic fracture occurs, transitioning to an extensile approach to
adequately visualize and reduce the fracture should be performed.
With knee flexion, the normal tibia typically internally rotates relative to the
femur and conversely, externally rotates with knee extension (i.e., screw
home mechanism).
The difference in tibiofemoral geometry between the medial and lateral knee
causes the distal femur to pivot about a medial axis as the knee moves from
full extension to flexion.
Axial rotation is the same between ACL deficient (ACL-D) knees and normal
knees in less than 30° of flexion. Normal and ACL deficient (ACL-D) knees
have similar pattern of posterior femoral translation during progressive knee
flexion (0-120°).
Hip biomechanics can be simplified by the equation (Force Abductors x

Distance to center of head) = (Force from body weight x Distance to center of
head). This relationship can be altered by changing the offset (affects
distance of abductor to center of head) or cup position (medial or lateral
position of cup affects distance of body weight to center of head). If the force
of the abductor can't be improved by changing the distance to the head
(offset) patients get a trendelenburg gait. The reason they therefore lurch to
the affected side is so that they shift the force of body weight laterally thus
decreasing the BW to center of head distance.

Femoral component offset is measured as distance between the center of the

femoral head and a line drawn down the center of the femoral shaft.
A cane held in the contralateral hand reduces joint reactive forces through the
affected hip up to 50% by reducing abductor muscle pull.
If a patient has a Trendelenburg sign as evident by the pelvis tilting down on

the right during a single-leg stance on the left lower extremity secondary to
weak abductors of the left hip, decreasing femoral offset would exacerbate
this condition because this shortens the abductors, putting the gluteus medius
under less tension and therefore placing it at a decreased mechanical
advantage and exacerbating any baseline abductor deficit.
High offset stems in THA are a tool to assist in increasing abductors tension
and improving stability in the appropriate patient.
With the larger head (larger head to neck ratio), the distance to travel before
subluxation and dislocation is greater, and more ROM is allowed before the
neck impinges on the shell wall and levers the head from the shell.
The use of a skirted femoral head actually decreases the head to neck ratio,
and leads to increased risk of hip impingement and dislocation after THAs.
Decreased hip offset places the hip at risk for the femoral bone impinging
against the pelvis at the extremes of motion.
Groin pain, pain with passive hip extension, and snapping pain in the groin
following THA raise the suspicion of iliopsoas tendonopathy. Cross-table
lateral imaging and CT scan can be used to evaluate for protrusion of the
anterior rim of the acetabular cup causing impingement with the tendon. The
diagnosis is confirmed by relief of pain with anesthetic injection of the tendon
sheath. After diagnosis of iliopsoas impingement, iliopsoas muscle tenotomy
or resection is the treatment of choice if radiographs are within normal limits.
In contrast, if imaging shows anterior acetabular overhang, then acetabular
revision would be the next appropriate step in management.
Comparing minimal-incision technique to a standard incision in THA there is

no significant difference with respect to postoperative hematocrit, blood
transfusion requirements, pain scores, or analgesic use. There were also no
differences in early walking ability or length of hospital stay and no differences
in component alignment, but only better cosmetic result.
The optimal position for hip arthrodesis is 0-5 degrees of adduction, 0-5
degrees of external rotation, and 20-35 degrees of hip flexion.
Failure of the acetabular component was the most common reason for
revision at thirty-years for the Charnley "low-friction" total hip arthroplasty.

Paprosky devised a classification for femoral bone loss following THA. Type
IIIA may be treated with a fully coated stem. Type IIIB should consider a
tapered, modular stem and/or bone grafting. Type IV likely needs a
megaprosthesis.
In Pelvic discontinuity, which is consistent with a AAOS Type IV defect,

acetabular antiprotrusio cage with screw fixation and a posterior column plate
is a reasonable treatment option.
In cases of minor, contained, acetabular defects, morcellized allograft and/or

autograft bone, combined with a cemented or cementless acetabular
component can lead to successful reconstruction. However, these constructs
do not confer enough stability when the loss of bone stock is more extensive
and encroaches on the acetabular columns, or compromises >50% of the
weight-bearing surface. So, revision using an ilioischial reconstruction ring
acetabular component and structural corticocancellous graft is performed.
Regarding the conversion of hip arthrodesis to total hip arthroplasty, function

of gluteus medius is predictive of ambulatory status.
Periprosthetic fracture, specifically femoral neck fracture, is the most common

cause of early revision less than 20 weeks following surgery.
Modern hip resurfacing implants utilize metal-on-metal bearing components,

thus polyethylene debris and its potential subsequent osteolysis is not an
option.
Hip resurfacing is associated with higher rates (compared to conventional

THA) of AVN, higher serum levels of metal ions, and higher rates of early
postoperative fractures, specifically femoral neck fractures. However, the
dislocation rate is significantly lower with hip resurfacing due to the larger size
of the femoral component and more accurate restoration of anatomic hip
biomechanics.
Absolute contraindications for resurfacing include deficiency of femoral head

or neck bone stock or a small or bone-deficient acetabulum. Relative
contraindications including coxa vara, female sex, large bone cysts greater
than 1cm, or major osteophytic changes in the head neck junction.
Active golfers who undergo total knee arthroplasty (TKA) typically have a
significant increase in their handicap when they return to the game.
Femoral stem subsidence effectively decreases the neck length of the

prosthesis resulting in a lax abductor complex which causes an increase in
the joint reactive force. This decrease in leg length can also lead to increased
hip instability.

Patients at highest risk of THA dislocation are female patients, osteonecrosis,

an acute fracture or nonunion proximal femur treated with THA, history of
inflammatory arthritis, and age greater than 70. Lower risk is present with
posttraumatic arthritis of the hip.
Medializing the acetabulum decreases the lever arm of the abductors

resulting in reduced soft tissue tensioning, greater laxity, and thus decreased
stability.
Hip extension and external rotation put the hip at risk for anterior dislocation
following an anterior approach. Hip flexion and internal rotation put the hip at
risk for posterior dislocation following a posterior approach.
Post-operative hip instability can be caused by several factors: soft tissue

imbalance, and component malposition (The optimal acetabular component
alignment is 30-50 degrees of abduction and 15-20 degrees of anteversion).
Component malposition (cup retroversion- vertical cup) should be treated with
revision of the offending component.
Use of a constrained acetabular liner is indicated in the setting of recurrent

instability with well positioned components.
Instability due to polyethylene wear alone is not a reason to use a constrained

component, though revision of the acetabular component may be necessary.
The most common complication of revision surgery with polyethylene

exchange is dislocation.
Ring failure (ring dissociation of the liner) is associated with increased risk of
hip dislocation.
According to the Vancouver classification, a type B2 fracture occurs around or

just distal to a loose femoral stem with adequate proximal bone. Revision of
the femoral component is necessary, with uncemented stems showing
superior clinical results to cemented stems in most studies. The revision
prosthesis should bypass the distal fracture by 2 cortical widths.
B1 fractures are most appropriately treated with plate fixation.
Vancouver B3 periprosthetic fractures are fractures around or just below the

tip of a loose stem with poor proximal femoral bone stock. Options for
management of this fracture include a fully coated stem, a fluted tapered
stem, a proximal femoral replacement with megaprosthesis, allograft-
prosthesis composite, and impaction bone grafting. In elderly patients with co-
morbidities and an inability to maintain the strict weight-bearing precautions
that impaction bone grafting and allograft prosthetic replacements require,
proximal femoral replacement with a megaprosthesis is the best option.

Female gender is a risk factor for intraoperative calcar fracture.
Interprosthetic fracture has increasing in incidence due to increasing numbers

of patients with ipsilateral hip and knee arthroplasty. Open reduction and
fixation with a plate with screws and cerclage cables should be done.
Acetabular fracture during total hip arthroplasty is a known complication that

typically occurs during acetabular component impaction. If noticed intra-op,
the stability of the component should be assessed by the surgeon to
determine treatment. If the component is stable, no additional treatment is
necessary. If the acetabular component is unstable, then it should be changed
and/or supplemented with component screws until stability is obtained.
Appropriate care of an intraoperative calcar fracture during total hip

arthroplasty requires removal of the stem to adequately evaluate the fracture.
The fracture should then be stabilized with cerclage wiring, and a long stem
should be inserted to ensure stability of the stem in the postoperative period.
Female gender, DDH, revision surgery, extremity lengthening, posttraumatic

arthritis, cementless femoral fixation, and the posterior approach are all risk
factors for the development of a post-operative sciatic nerve palsy following
total hip arthroplasty. Rheumatoid arthritis , AVN, obesity are not risk factors.
Patients with DDH undergoing THA are at risk for post-operative sciatic nerve
palsy due to intra-operative limb lengthening which increases tension on the
sciatic nerve.
Appropriate management after discovering a sciatic nerve palsy after surgery

should include immediate knee flexion and hip extension to decrease tension
on the sciatic nerve.
If patient is suffering from a peroneal nerve injury most likely from errant
retractor placement during the hip replacement resulting in a foot drop, the
most appropriate next treatment is an ankle-foot orthosis. Posterior tibialis
tendon transfer is done if failed conservative treatment.
In patients with peroneal nerve palsy after total hip arthroplasty, the likelihood
of complete functional recovery to preoperative strength levels is 35% to 40%.
Abductor muscle weakness (evident by Trendelenberg gait) is most likely

found in the setting of a total hip arthroplasty performed through a lateral
approach.
Increasing the femoral neck offset does not lengthen the limb. Rather it
increases the horizontal distance of the stem away from the femoral head.
This increases abductor tension improving stability. It should be noted that

weakness of the abductors can result in patient sensation of leg lengthening

in the absence of any true LLD.
In THA low hemoglobin level < 130g/L preoperatively, revision hip, and
bilateral knee are associated with increased frequency of transfusion post op.
Unilateral osteoarthritis normally causes a leg length discrepancy because of

cartilage loss and bone deformity. Post-operatively, some patients take
months to adjust to this apparent lengthening, even though they have been
made equal to the non-operative side.
Patellectomy is an indication to use a posterior stabilized TKA implant. The

PS implant will offer better femoral rollback and reduce the risk of potential
anteroposterior instability that may occur with use a cruciate retaining
prosthesis.
Neuropathic arthropathy, which can occur in the setting of chronic diabetes

mellitus is an indication for constrained prosthesis of some type (semi-
contrained condylar prosthesis or hinge prosthesis). The main problem with
these patients after total knee arthroplasty is persistant instability that occurs
secondary to ligamentous laxity.
Walldius hinge total knee prosthesis has a higher rate of aseptic loosening (up
to 20%) secondary to a high-degree of constraint.
Contraindications to using a posterior cruciate retaining knee include any

condition that may render the PCL incompetent at the time of surgery or in the
future including prior PCL rupture, inflammatory arthritis, patellectomy, and
over-release of the PCL during surgery. Valgus deformity is not a
contraindication.
Adding a polyethylene-metal interface by making it modular leads to more

wear on the backside, not the articular surface.
Non-linked, constrained total knee arthroplasty prosthesis (has a tall tibial post
and a deep femoral box) constrains varus-valgus (allows 2°-3°) and internal-
external rotation (allows 2°). A linked, rotating-hinge prosthesis constrains
anterior-posterior translation in addition to varus-valgus and internal-external
rotation.
Mobile-bearing knee systems are distinguished from conventional, fixed-

bearing systems in that they allow dual-surface articulation between an ultra-
high molecular weight polyethylene insert and metallic femoral and tibial tray
components. This reduces polyethylene shear stresses and should lessen
polyethylene wear rates.

In TKA with an unresurfaced patella, there is an increased risk of anterior

knee pain and secondary resurfacing.
Antibiotic impregnated bone cement is used with the goal of reducing deep
infection following arthroplasty.
As with difficulties in any minimally invasive exposure, conversion to a larger

or more traditional exposure is indicated when the exposure is causing
difficulties or potential complications.
The mechanical axis of lower limb: vertical line drawn from the femoral head
through the center of the knee down to the center of the ankle.
An isolated release of the popliteus tendon during TKA is most appropriate in

the setting of a valgus knee deformity that is tight in flexion.
General principles to remember:
1. Changing the distal femur only affects extension,

2. Changing the femoral component size only affects flexion
3. Changing the proximal tibia/polyethylene insert affects both extension
and flexion.
Cutting too much posterior femur will lead to larger flexion gap.
If the knee is too loose in flexion, it is possible for the femoral component to
"jump the post", causing a posterior dislocation.
Increasing the size of the femoral component posteriorly will balance knee
loose in flexion and stable/balanced in extension.
For a TKA to achieve greater flexion, options include downsizing the femoral
component, recessing the PCL, and increasing the posterior tibial slope. More
flexion can also be achieved by resecting more tibia or decreasing the height
of the tibial insert; however, changes to the tibial side affect both the flexion
and extension gaps.
If the knee is both tight in flexion (tibial tray lift-off) and extension (unable to
fully extend), resection of the proximal tibia will provide more room in both
flexion and extension.
This patient has two problems: 1) loose in flexion (flexion laxity); 2) tight in
extension (flexion contracture). Both of these should be addressed by
upsizing the femoral component and resecting additional femur.
Techniques that lead to increase Q angle and lateral patellar laxity include:
• internal rotation of the femoral prosthesis

• internal rotation of the tibial prosthesis

• medialization of the femoral component

• lateralization of patellar component
During TKA if the patella is noted to sublux laterally during range of motion,
the alignment and rotation of the femoral, tibial, and patellar components all
appear perfect, reevaluation of patellar tracking after deflation of the
tourniquet is done before performing lateral release.
The transepicondylar axis is perpendicular to the anteroposterior axis

(Whiteside's line).
The posterior condylar axis is normally 3 degrees internally rotated to the

transepicondylar axis.
Failure to identify a hypoplastic lateral condyle will lead to internal rotation of

the femoral component if a posterior condylar referencing guide is used for
total knee arthroplasty.
Implant rotational malalignment is assessed by CT.
External rotation of femoral component decreases the need for a lateral

release during TKA.
Lateral closing wedge high tibial osteotomies are commonly associated with
anterior knee pain due to the high incidence of patella baja post-operatively.
During TKR iatrogenic patella baja and an elevated joint line caused by
excessive resection of the distal femur and contracture of the patellar tendon
likely as a result of lateral patellar release.
Patella baja may indicate that there is patellar tendon contracture. In this
instance, a tibial tubercle osteotomy TTO can be used to prevent inadvertent
patellar tendon avulsion which is difficult to repair and may lead to loss of
function.
In osteolysis around both tibial and femoral components, surgical

management should consist of revision of both components using a
constrained prosthesis with stems and/or augments.
The extensile rectus snip exposure is an extension of the standard medial

parapatellar arthrotomy. The exposure is carried superiorly and laterally
across the rectus femoris tendon. It allows greater exposure of the knee to
enhance bone cuts and component insertion without compromising clinical
results. Its use as an extensile procedure had no adverse effect on outcome
regarding WOMAC function, pain, stiffness and satisfaction scores
demonstrated no statistical difference.

Continuous passive motion (CPM) devices have not demonstrated superior

clinical outcomes following total knee arthroplasty.
Contraindications to performing a unicompartmental/unicondylar knee

arthroplasty include: inflammatory arthritis, fixed varus/valgus deformity more
than 10 degrees, flexion contracture more than 10 degrees, less than 90
degrees of flexion pre-operatively, ACL insufficiency, significant arthritis in the
other compartments, and joint subluxation of more than 5mm( but not
including osteonecrosis of the medial femoral condyle).
If a patient has knee pain following a unicompartmental knee replacement

with a normal radiograph and uptake under the prosthesis on bone scan, he
may have a stress fracture.
In a patient with valgus deformity and lateral compartment arthritis, a varus

producing distal femoral osteotomy would likely give this patient the best
outcome correcting his valgus deformity and unloading his lateral arthritic
compartment.
Classic contraindications to knee osteotomy include inflammatory arthropathy,

cruciate deficiency, flexion contracture >15 deg, or <90 deg flexion.
Unicompartmental knee arthroplasty has been shown to result in faster

rehabilitation and improved rate of recovery compared to total knee
arthroplasty.
Lateral compartment arthroplasties have not been shown to have higher

failure rates than medial compartment arthroplasties.
Revision with a long stem tibial component that bypasses the fracture is an
appropriate treatment for tibial shaft fracture at the level of the implant with
evidence of implant loosening.
Rheumatoid arthritis, Parkinson's disease, chronic steroid therapy,

osteopenia, and female gender have all been found to be risk factors for
postoperative periprosthetic supracondylar femur fractures. Male gender has
not been found to be a risk factor.
Females undergoing total knee arthroplasty with standard (non-gender

specific) components show improved implant survivorship compared to males.
In total knee arthroplasty patients with arthrofibrosis, the next most

appropriate option includes a manipulation under anesthesia to increase the
patient's flexion.
Peroneal nerve palsy following a total knee arthroplasty has been shown to be
associated with postoperative epidural analgesia, correction of large valgus
deformities, and preoperative diagnosis of neuropathy in the involved

extremity (either centrally or peripherally). One may also sustain peroneal

nerve palsies following aberrant retractor placement intraoperatively.
Valgus and flexion contracture puts a patient at most risk for a postoperative
peroneal nerve palsy after total knee arthroplasty.
Heterotopic bone ossification (HO) following TKA has not been associated
with valgus knee deformity.
Posterior instability following PCL retaining TKA may be due to posterior

cruciate insuffiency. Revision to a posterior stabilized component leads to
improved outcomes in patients with flexion instability.
Immediate treatment of a peroneal nerve palsy following a total knee

replacement consists of removing any compressive dressings (which may
compress the nerve) and flexing the knee to release tension on the peroneal
nerve.
In chronic patellar tendon rupture following a TKA, primary repair with or

without local tissue augmentation have had disappointing results. Allograft
reconstruction in such cases could restore active extension and improve
ambulatory function.
Closed suction drainage increases the transfusion requirements after elective

hip and knee arthroplasty.
Medial gastrocnemius muscle flap transfer and skin grafting is the most
appropriate treatment for skin necrosis following TKA.

HAND

The dorsum of the wrist is subdivided into six compartments. The PIN is the
only nerve found in the dorsal compartments. It is consistently found on the
base of the fourth compartment. Anatomic structures within each
compartment are:
• Compartment 1: Abductor pollicus longus, extensor pollicus brevis.

• Compartment 2: Extensor carpi radialis longus and brevis
• Compartment 3: Extensor pollicus longus
• Compartment 4: Extensor digiti communis, extensor indicis propius,
posterior interosseous nerve
• Compartment 5: Extensor digiti minimi
• Compartment 6: Extensor carpi ulnaris
A1, A3 and A5 are joint pulleys arising from the palmar plates of the MP, PIP,
and DIP joints respectively.
The deep palmar arch (deep volar arch) is an arterial network found in the
palm. In the majority of patients it is formed mainly from the terminal part of
the radial artery, with the ulnar artery contributing via its deep palmar branch.
The digital nerve is palmar to the artery in the finger. A helpful way of
remembering this orientation is that sensation is performed with the pads
(nerve is palmar) of your fingers and you test for cap refill at the fingernail
(artery is dorsal).
The single most effective intervention for increasing strength of a flexor

tendon repair is to increase the number of core sutures crossing the repair
site.
Ideally, tendon repairs should have 4-6 strands crossing the repair to allow for
early active motion. A running epitendinous suture is recommended to
improve tendon gliding and repair strength. Repair with core suture purchase
10mm from the cut edge, coupled with circumferential simple running
epitendinous suture will give the patient the best load to failure and gliding
resistance.
Ordinarily, adult flexor tendon repair postoperative rehab protocols call for
early light active digital flexion with wrist in gentle flexion as long as the
tendon has been repaired with a 4 or 6 strand core suture technique and
strong epitendinous suture.
4 strand core suture technique and cast immobilization for 4 weeks is the
preferred postoperative rehabiltation in children.
In zone II flexor tendon injuries, repairing only one slip of FDS has been
shown to improve gliding when compared to repair of both slips.

Early active range of motion protocols are thought to decrease adhesions but
risk rerupture or gap formation.
A patient with a partial flexor tendon laceration involving < 60% of the width of
the tendon should have trimming of the frayed tendon edges and begin early
protected range of motion.
The median nerve sits immediately ulnar to the flexor carpi radialis (FCR).
In zone 2 of the digital flexor tendons, the primary nutritional supply is from
synovial diffusion through the parietal paratenon which allows for passive
nutrient delivery to the flexor tendon within the sheath.
Kleinert protocol is categorized as a low force and low excursion rehabilitation

for tendon repair.
"Rugby jersey finger is an avulsion of the flexor digitorum profundus (FDP)

tendon.
In chronic jersey finger, it is more amenable to grafting rather than direct

repair given retraction of the FDP tendon that occurs with time that makes
direct repair impossible.
Trigger thumb requires the release of the A1 pulley. During the dissection, the
radial digital nerve crosses the operative field and is at risk.
Unlike adults, release of the A-1 pulley in a pediatric trigger finger alone may
not resolve triggering symptoms. One or both limbs of the sublimis tendon
need to be released.
The most clinically relevant structure in Dupuytren's disease, is the spiral cord
lies lateral and deep to neurovascular bundle and may place it at risk during
surgical resection.
Dermatofasciectomy and full-thickness grafting has not demonstrated superior

finger range of motion, recurrence rate, or patient satisfaction in comparison
with traditional fasciectomy in patients with Dupuytren's contracture.
CBFA-1 has NO known role in the pathogenesis of Duputryen's contracture.

Growth factors such as (FGF), (PDGF), and (TGF-beta) may signal the
overproduction of the myofibroblasts and/or myofibroblastic activity of the
fibroblasts. In addition, high levels of TGF-Beta may hinder apoptosis of the
active myofibroblasts, unlike normal tissue healing.
In non-displaced bony mallet finger without joint subluxation, extension

splinting of the DIP joint for 6-8 weeks is the most appropriate treatment.

In displaced bony mallet injury with volar subluxation of the distal phalanx
after splinting of the DIP joint in extension reduction and pinning is done.
“Boxer’s knuckle” refers to injury to the extensor hood mechanism in which

both the sagittal band and the dorsal capsule are torn. Physical examination
shows pain over the MCP with a palpable defect in the dorsal capsule.
Sagittal band injuries seen within 3 weeks of injury may be treated
nonoperatively with an MP joint flexion blocking splint. Patients presenting
later than 2 to 3 weeks after the injury, athletes, or patients who failed a trial of
splinting are candidates for surgical repair.
There is an association between the postpartum state and de Quervain’s

tenosynovitis.
Injection in de Quervain’s diseases is in first dorsal compartment near the

radial styloid
The recurrence of symptoms in de Quervain’s can be attributed to a failure to

recognize and decompress the EPB sub-sheath.
In intersection syndrome, injections of the second dorsal compartment, which

includes ECRL and ECRB, may relieve symptoms and quell inflammation.
Fixation of non-displaced scaphoid fractures with a percutaneous screw has

resulted in a shorter time to union (6-7 weeks versus 10-12 weeks) and faster
return to work or sports.
Optimal treatment for displaced scaphoid waist fracture is ORIF with screw
fixation.
Longer screw placed in the central axis of the scaphoid optimizes

biomechanical fixation of scaphoid waist fractures.
Scaphoid screw fixation should be just below the subchondral bone; this is
best judged by direct visualization better than percutaneous fixation.
With the wrist in neutral force is transferred across the joint via the lunate
fossa and scaphoid fossa almost equally (slight predominance to the scaphoid
fossa). However, with the wrist extended force transmission is shifted to pass
even more via the scaphoid fossa, and less via the lunate fossa. This is a
proposed explanation for scaphoid fractures resulting from falls onto an
outstretched hand with the wrist extended.
In patients with scaphoid waist fracture nonunion before collapse and

progressive arthritis open reduction internal fixation with autologous bone
graft is the best option.

Tenderness with palpation of the anatomic snuffbox should raise suspicion of

a scaphoid fracture. If radiograph does not show any findings, but scaphoid
fractures are often not initially visualized on plain radiographs. Appropriate
treatment for any patient with snuffbox tenderness entails cast immobilization
with repeat radiographs at 2-3 weeks or advanced imaging with MRI to
evaluate for a fracture that is not identified with plain radiographs.
In patients with a perilunate dislocation and carpal tunnel symptoms,

reduction of the dislocation must be done in the emergency room, and if
unsuccessful, immediate reduction and stabilization in the operating room is
indicated.
Hook of the hamate fracture is demonstrated by carpal tunnel view radiograph

and CT scan of the wrist. Most favorable results and ability to return to
preinjury activities are with excision of the fracture fragment.
Treatment of symptomatic nonunions of the pisiform is by pisiformectomy.
In a patient presenting with mutliple injuries. Multiple metacarpal shaft

fractures are best managed with open reduction and internal fixation as non-
operative management is associated with loss of motion, asynchronous grasp
and decreased grip strength.
Open reduction and internal fixation of distal phalanx fracture frequently

requires the post-operative removal of the fixation implant after complete
fracture healing.
Volar plate prevents closed reduction of dorsal dislocation of the DIP joint.
Dorsal fracture dislocation of the PIPJ is usually associated with middle

phalanx palmar lip fractures. Anatomic reconstruction of the articular surface
is desirable but not necessary for successful clinical outcome.
In volar PIP dislocation, central slip of the extensor tendon is frequently

ruptured and will lead to a boutonneire deformity if left untreated. The PIP
must be immobilized in extension for 6 weeks to allow the extensor
mechanism to heal. Open reduction and repair of the central slip would be the
appropriate treatment for a developing boutonneire deformity that presents in
a subacute or chronic time basis.
In oblique fracture of the distal proximal phalanx that extends into the joint
with an articular step off, open reduction internal fixation will correct the
deformity, expedite finger rehabilitation, and prevent early degenerative
arthritis.

Transverse proximal phalanx fracture has an apex palmar angulated

deformity under the indirect pull of the central slip on the distal fragment and
the interossei insertions at the base of the proximal phalanx.
Open reduction and lag screw fixation through a radial approach is the
treatment of choice for long oblique proximal phalanx fractures.
Treatment of a nail bed avulsion and physeal separation distal phalanx is

irrigation and debridement, physeal reduction, nail bed repair and
immobilization.
Octylcyanoacrylate (Dermabond) has been found to be a viable method in

nailbed repair, and has the advantage of being a faster procedure.
Hemorrhagic blister due to acute frostbite injuryis drained with the overlying
skin left intact.
High-pressure injection injuries are characterized by extensive soft tissue

damage associated with a benign high-pressure entry wound. They should be
treated with immediate irrigation & debridement, foreign body removal and
broad-spectrum antibiotics. There is a higher rates of amputation when
surgery is delayed.
The primary deforming forces in Bennett and Rolando fractures are the
Abductor pollicis longus and adductor pollicis.
The proper ulnar collateral ligament(PCL) resists ulnar stress with the thumb
MCPJ in flexion. The accessory ulnar collateral ligament (ACL) resists ulnar
stress with the thumb MCPJ in extension.
The cardinal signs of pyogenic flexor tenosynovitis (Kanavel signs) include:
1) partially flexed resting posture of the involved finger

2) pain with passive extension
3) fusiform swelling of the finger
4) volar tenderness along the flexor sheath
Abscess in the hand in IV drug abusers is most commonly caused by MRSA.

Volar thumb defect which can be best covered with a Moberg advancement
volar flap (if < 2 cm). It would necessitate IPJ flexion >45 degrees, increasing
the risk of IPJ stiffness.
First dorsal metacarpal artery (FDMA) flap is an excellent option for large soft
tissue defects on either side of the thumb.
Emergent replantation is not indicated in distal fingertip amputations.
In transverse fingertip amputation,
In young children with a fingertip amputation, ointment and dressing changes

is the most appropriate treatment even if bone is exposed.
Distal fingertip amputations can be successfully managed with local wound

care and healing by secondary intention if no bone is exposed and the soft
tissue defects are minimal. If exposed bone shortening of the distal phalanx,
nail bed removal, and dorsal V-Y flap would be the most appropriate
treatment.
One of the most commonly used techniques for lengthening scar contracture
in hand surgery is the Z-plasty 60 degree triangular flaps which increases the
scar length by approximately 75%.
Cross finger flaps are indicated in patients > 30 years of age when the lesion
is a volar oblique finger tip lacerations or a volar proximal finger lesions.
In thenar flap, the digit is flexed at the PIPJ and extended at the DIPJ during
the period prior to flap division, leading to PIPJ stiffness and flexion
contracture. .
Indications for single digit replantation:
1) Level of the amputation is distal to the insertion of FDS.

2) Amputations at the level of the distal phalanx.
3) Ring avulsion injuries involving both the dorsal and palmar skin and
blood supply in an isolated finger, as long as FDS is intact.
4) Any amputation in a child.
5) Thumb amputation , regardless of the level (opposition and pinch).
Replantation of a single finger amputated proximal to the insertion of the
flexor superficialis tendon is a relative contraindication because of the severe
stiffness and poor function encountered after repairs in this location.
Wrist-proximal amputations should be performed before 12 hours of cold

ischemia time or 6 hours of warm ischemia time have elapsed.

Allopurinol is a xanthine oxidase inhibitor and may have a beneficial role in

replantation. Inhibition of xanthine oxidase also decreases uric acid in patients
with gout.
In through the palm amputation with the intact digits, anatomic replantation of
the entire hand is indicated.
Transpositional replantation is indicated in multidigit amputation.
Mechanism of injury is the most important factor influencing the survival rate
of digit replantation (Crushing injury).
Arterial thrombosis after digit replantation typically occurs within the first 12
hours postoperatively whereas venous thrombosis/congestion occurs after the
first 12 hours postoperatively.
Leeches excrete Hirudin, which is 100 times more potent than heparin, but
are typically used for the treatment of venous thrombosis/congestion and not
arterial thrombosis.
Surgical time in multiple digit replantation is increased by digit-by-digit repair

techniques and decreased by structure-by-structure repair techniques.
Axonomesis is a disruption of the nerve axon following injury.

Repair/regeneration of the nerve occurs via proximal budding, followed by
antegrade (or distal) axon migration.
Following a Sunderland second-degree injury, axon regeneration is possible

because the endoneurium is intact.
The epineurium is a supportive sheath surrounding peripheral nerves that

cushions fascicles against external pressure. It is comprised of a loose
meshwork of collagen and elastin fibers that are aligned parallel with the
nerve fibers.
After a graft repair
• excellent recovery potential: the radial, musculocutaneous, and femoral

nerves
• moderate recovery potential: the median, ulnar, and tibial nerves
• poor recovery potential: the peroneal nerve.
Compressive neuropathies are typically neuropraxias with ischemia origin,
with local myelin damage but not compromise of the major components of the
nerve.
Repair of segmental nerve loss in the hand using collagen conduits allows for
nutrient exchange and accessibility of neurotrophic factors to the axonal
growth zone during regeneration.

Vitamin B12 deficiency is a known cause of peripheral sensory neuropathy.
Merkel's skin receptors are slowly adapting skin receptors that detect
pressure, texture, and low frequency vibration and can be appropriately
evaluated by static two-point discrimination.
The dominant arterial blood supply to a medial gastrocnemius muscle flap is

the sural artery.
Soft tissue defects of the palm are most appropriately treated with flap
coverage followed with full-thickness grafts.
For PIN palsy, the most beneficial transfers includes transferring the flexor
carpi radialis to the finger extensors (to restore finger extension) and palmaris
longus to the extensor pollicis longus (to restore extension of the thumb). In
contrast with a radial nerve palsy, with a PIN palsy the patient has adequate
wrist extension due to intact ECRL (providing radial wrist extension) supplied
by the radial nerve proximal to the PIN.
When carpal tunnel syndrome is caused by an atypical space occupying

lesion (gout), the most appropriate next step is referral to a rheumatologist
where medical therapy could be initiated.
Standard sterilization and prepping for carpal tunnel release will have the
greatest influence on minimizing the risk of a surgical site infection.
local steroid injection or splinting are effective methods for the nonoperative
treatment of carpal tunnel syndrome. Phonophoresis, Vitamin B6 (pyridoxine),
heat therapy, bumetanide, and physical therapy are not considered the most
appropriate options for carpal tunnel syndrome management.
Use of neutral wrist splints for carpal tunnel syndrome is most useful for
improving noctural symptoms. Functional position of the wrist is approximately
30 degrees of extension increases carpal tunnel pressure.
The only neurovascular structure that runs in the carpal tunnel is the median
nerve. Flexor carpi radialis is (FCR) is not a tendon within the carpal tunnel.
EMG's detect the electrical potential generated by muscle cells when these
cells are electrically activated. They give information about the muscle motor
unit and can display the presence of fibrillations, sharp waves, motor
recruitment, and insertional activity of the muscle.
The nerve conduction (NCV) portion of the electrodiagnostic study measures

the speed at which the nerve impulse travels down the axon. Large,
myelinated nerve fibers conduct impulses the fastest and thus only these
fibers are evaluated in the nerve conduction portion of the electrodiagnostic
study. Distal latencies and conduction velocities are measured with NCV's.

General parameters for NCV diagnosis of carpal tunnel syndrome include a

distal motor latency of >4.5 msec, a distal sensory latency of >3.5msec, or a
conduction velocity of < 52 m/sec.
grip strength would be expected to be 100% of preoperative level at 3 months

after carpal tunnel release.
Loss of small digit adduction (Wartenberg sign) is not predictive for

diagnosing carpal tunnel syndrome.
AIN syndrome often seen in conjunction with brachial neuritis (Parsonage-

Turner Syndrome). It leads to motor palsies of the flexor pollicis longus and
the two radial profundus ( weak pinch and grip). The pronator quadratus is
also involved and can be tested with the elbow held in a flexed position to
neutralize the humeral head of the pronator teres muscle. No sensory
changes occur and electromyographic (EMG) and nerveconduction
(NCV)studies are often helpful in establishing the diagnosis.
F roment's sign on the patient's right hand, which is characterized by

interphalangeal (IP) flexion during attempted key pinch, and is found in
patients with ulnar neuropathy.
The ulnar nerve passes posterior to the medial epicondyle and medial to the
olecranon, then enters the cubital tunnel. The roof of the cubital tunnel is
primarily made up of Osborne's ligament, and the floor consists of the medial
collateral ligament.
There are five sites of potential ulnar nerve entrapment around the elbow:
arcade of Struthers, medial intermuscular septum, medial epicondyle, cubital
tunnel, and deep flexor pronator aponeurosis.
Simple decompression of the ulnar nerve is less invasive and achieves clinical
outcomes equivalent to decompression with transposition in cubital tunnel
syndrome.
Compression of the ulnar nerve within Guyon's canal, termed ulnar tunnel
syndrome, is most commonly caused by a ganglion cyst. A lack of dorsal ulnar
sensory deficit helps differentiate entrapment here from at the elbow because
the dorsal ulnar cutaneous nerve branches proximal to Guyon's canal.
The PIN innervates the EDC, EDM, ECU, EPB, EPL, EIP, APL and
sometimes the ECRB.
Radial tunnel syndrome presents with insidious onset of pain and tenderness
several centimeters distal to the lateral epicondyle, and pain elicited with
active extension of the long finger against resistance can help differentiate the
condition from lateral epicondylitis.

Failure to splint the hand in an intrinsic positive position leads to increased

extrinsic finger flexor tension, leading the DIP and PIP joints to have an
increasing flexion position (claw hand deformity). Imbalance between strong
extrinsics and deficient intrinsics is the pathoanatomic process of a claw hand,
also called intrinsic minus hand deformity.
Boutonniere deformity is characterized with the PIP in flexion and the DIP in
hyperextension. It is caused by central slip rupture or attenuation. Volar
subluxation of the lateral bands leads to increased deformity as the lateral
bands become flexors of the PIP. Relocation of the lateral bands to their
original dorsal position to counteract the pathophysiology of the deformity is
an option.
The quadrigia effect is characterized by an active flexion lag in fingers

adjacent to a digit with a previously injured or repaired flexor digitorum
profundus tendon. Quadrigia syndrome occurs when a flexor digitorum
profundus (FDP) tendon is shortened and advanced with overtensioning.
Lumbrical plus finger is a potential complication of an amputation at the level

of the distal interphalangeal joint. A lumbrical plus finger is descibed as
paradoxical extension of the IP joints while attempting to flex the fingers.
Ulnar variance describes the cranio-caudal position of the distal ulna in

relation to the distal radius at the wrist. In neutral ulnar variance, 80% of the
compressive load across the wrist is accepted by the distal radius, and 20% is
accepted by the distal ulna. With -2.5mm of ulnar variance (negative ulnar
variance), approximately 5% of the wrist load is accepted by the distal ulna.
With +2.5mm of ulnar variance (positive ulnar variance), approximately 40%
of the wrist load is accepted by the distal ulna.
Ulnar positive variance causes an "ulnar impaction syndrome" as the distal

ulnar styloid can cause damage to the triangular fibrocartilage complex
(TFCC), and ulnocarpal joint.
The extensor carpi ulnaris tendon sheath is part of the triangular fibrocartilage
complex (TFCC).
Fall from standing onto an extended and pronated wrist is a risk factor for
injuries to TFCC which presents with pain with resisted ulnar deviation and
ulnar catching are all concerning for injury to the TFCC.
Ulnar shortening osteotomy is the best procedure for young adults with
longstanding ulnar sided wrist pain due to ulnar positive variance and
associated distal radioulnar joint (DRUJ) incongruity.

For patient's with ulnar impaction syndrome, concomitant arthrosis in the

distal radioulnar joint (DRUJ) is a contraindication to ulnar shortening
osteotomy.
Temporary scaphotrapeziotrapezoidal (STT) pinning is indicated for treatment

of Kienbocks disease in adolescents.
In stage 2 Kienbock's disease treatment options include a joint leveling

procedure (radial shortening osteotomy or ulnar lengthening), or radius core
decompression (creates a local vascular healing response facilitating vascular
recovery prior to collapse and degeneration of the lunate).
The imaging study most sensitive for identifying early lunate collapse in
Kienbock's disease is CT scanning of the wrist.
Scaphoid Nonunion Advanced Collapse (SNAC wrist) starts at radioscaphoid

area and progresses to pancarpal arthritis. Radiolunate arthritis only occurring
at the very end stages of disease.
In scapho-lunate ligament tear. Watson test is positive. If plain radiographs

are normal, a PA clenched fist radiograph should be performed.
Surgical treatment of SLAC wrist is stage dependent. Stage I disease

(scaphoid-radial styloid arthritis) is treated with AIN/PIN neurectomy. This
procedure can also be done in addition to other bony procedures for Stages
II-III disease. Stage II (scaphoid-entire scaphoid facet) is treated with PRC or
scaphoid excision with 4-corner fusion (4CF). Stage III (capitolunate arthritis
with proximal migration of the capitate into the scapholunate interval) is
treated with either scaphoidectomy with 4CF or total wrist fusion.
In patient with midcarpal instability, the most common finding on physical

examination is a clunk as the wrist is moved from a neutral position and
forearm pronation to ulnar deviation with an axial and palmarly directed load.
With 1st CMC arthritis, the patient avoids painful thumb abduction and an
adduction deformity gradually develops, with 1st webspace contracture.
When thumb CMC (basilar) joint arthritis is associated with MCP joint arthritis,
arthrodesis of the MCP joint is the treatment of choice when thumb MCP
hyperextension exceeds 40°, the deformity is not passively correctable, or
advanced degenerative changes are noted to affect the articulation.
When MCP joint hyperextension is:
• 0° to 10°= Surgical intervention is not necessary

• 10° to 20°= Percutaneous pinning of the MCP joint in 25° to 35° of

flexion for 3-4 weeks may be performed independently or as an adjunct
to EPB transfer.
• 20° to 40°= Capsulodesis of the volar aspect of the MCP joint is
recommened to provide a check rein for hyperextension and
Sesamoidesis has also been investigated as an adjunctive procedure.
The most important step in a 1st CMC arthroplasty for basilar thumb arthritis
is excision of trapezium.
In patients with basal joint arthritis of the thumb there is no advantage of

steroid or hylan over saline.
Mucous cyst is a benign mass originating from the DIP joint, and is secondary
to arthritis. It may be treated with aspiration or surgical excision. However,
recurrence occurs frequently with aspiration. Debridement of any osteophytes
from the DIP joint is crucial to preventing recurrence with surgical excision.
The 1-2 wrist arthroscopy portal is the only portal listed that places the
superficial branch of the radial nerve (SBRN) at risk.
Radial club hand is associated with a number of congenital anomalies

including Fanconi’s Anemia (FA), thrombocytopenia absent radius (TAR),
Holt-Oram syndrome, VACTERL syndrome, and VATER syndrome (NOT
osteogenesis imperfect).
FA is an autosomal-recessive condition resulting in aplastic anemia and

eventual death. Genetic testing will reveal increased chromosomal breakage.
A CBC will show decreased leukocytes, red blood cells and platelets.It
requires bone marrow transplantation for survival.
If a patient has radial club hand with a viable thumb and good active elbow
flexion, therefore the treatment of choice is ulna centralization and possible
tendon transfers.
Leri Weill dyschondrosteosis is a skeletal dysplasia characterized by short

stature and bilateral Madelung deformities of the wrist. The SHOX gene is
located on the X and Y chromosomes and a mutation on either of the sex
chromosomes leads to the dysplasia (sex linked dominant).
Madelung's deformity is that of excessive ulnar/palmar angulation of the distal

radius caused by impaired growth of the volar and ulnar aspect of the distal
radial physis.
Proximal radioulnar synostosis is a rare congenital deformity most frequently

a pronation deformity, but is not frequently a functionally limiting deformity.
Observation is the treatment of choice in most cases. Surgical osteotomy and
fusion is beneficial for bilateral involvement with the objective of achieving one

arm fixed in modest pronation and the other fixed in modest supination to
facilitate competence in activities of daily living and hygeine.
Web creep, the most common complication of surgically corrected syndactyly.

It is the distal migration of the web commissure.
Symbrachydactyly is most commonly associated with Poland's syndrome.
Syndactyly is one of the most common congenital hand deformities and is

associated with Poland's syndrome, Apert syndrome, Holt-Oram syndrome,
and Carpenter syndrome. There is no association of syndactyly with Tay-
Sach's disease.
Apert syndrome
Apert's syndrome is a congenital disorder causing deformity of the skull, face,

hands, and feet. It is consistent with a mutation in FGFR2.
Postaxial polydactyly is rare in Caucasian individuals and deserves further

workup for underlying syndromes. Postaxial polydactyly is ten times more
common in African Americans and does not require further workup.
The Bilhaut-Cloquet procedure (central portions of bone and nail are removed
and the radial half of one thumb is combined with the ulnar half of the other to
create one thumb) has been shown to be successful in Wassel Type 1, 2, and
3 deformities.
Macrodactyly is a rare congenital malformation enlarging all structures of the

digit. Epiphysiodesis is performed once the finger reaches the length of the
same sex parent, using their digit as a template for final growth.
Constriction band syndrome (CBS) when associated with lymphatic

obstruction or vascular compromise, the treatment of CBS is band excision.
Stability of the carpometacarpal joint in cases of hypoplastic thumb is

essential for success of thumb reconstruction procedures. If CMC stability is
deficient, then ablation and pollicization is preferred.

Histology of a ganglion cyst would show a mucin filled synovial cyst.
Concerning ganglion cyst of the wrist, 79% of these cysts resolved

spontaneously within 1 year.
In Buerger's disease, or thromboangiitis obliterans, arteriography is the best

method for diagnosis of this condition.
Traumatic palmar artery aneurysms and pseudoaneurysms are rare and

crequire surgical exploration with either ligation, excision, or repair depending
on the extent of the lesion.

FOOT

Chronic deficiency of calcaneonavicular ligament (Spring ligament) can lead

to a flatfoot deformity.
During the normal gait cycle, the foot changes from a flexible structure at heel
strike (Eversion of the subtalar joint unlocks the transverse tarsal joints and
the transverse tarsal axes are parallel so that it is flexible and provides shock
absorption) to a rigid structure at toe-off. The mechanisms that bring about
this conversion are
(1) tightening of the plantar aponeurosis,

(2) progressive external rotation of the lower extremity, which begins at the
pelvis and is passed distally across the ankle joint to the subtalar joint,
(3) stabilization of the transverse tarsal joint which results from progressive
inversion of the subtalar joint.
Plantar aponeurosis transmits large forces between the hindfoot and forefoot
during the stance phase of gait.
The Silfverskiöld test differentiates gastrocnemius tightness from an achilles

tendon contracture by evaluating ankle dorsiflexion with the knee extended
and then flexed. Increased ankle dorsiflexion with knee flexion indicates
gastrocnemius tightness.
Os trigonum syndrome is most appropriately surgically treated with

arthroscopic or open excision. An os trigonum can cause impingement with
plantar flexion of the foot, especially in ballet dancers. The FHL tendon runs
through a fibro-osseous tunnel posterior to the hindfoot formed by the
posterolateral (os trigonum) and posteromedial tubercle of the talus.
One stride (heel strike to heel strike of one leg) of normal gait has been
divided into the stance (62%) and swing (38%) phases. The stance phase is
further divided into heel strike, foot flat, and toe off. Proper gait requires
coordinated contraction of the leg muscles.
The tibialis anterior (TA) muscle fires eccentrically at heel strike to lower the
foot to the ground, while the gasto-soleus (GS) complex is dormant.
Quadriceps weakness is most likely to affect the stance phase of the gait
cycle
The primary antagonist of the anterior tibial tendon is the peroneus longus,
which is innervated by the superficial peroneal nerve.
Post-traumatic tibiofibular synostosis may occur following a high ankle sprain

where the interosseous membrane was disrupted. The heterotopic ossification
usually develops within 6 to 12 months. Typically, patients are able to return
to sports despite the lack of normal ankle dorsiflexion and mobility between
the tibia and fibula. Surgical excision is reserved for persistent pain that fails

to respond to nonsurgical management once the ossification is “cold” (does

not show increased uptake) on bone scan.
High ankle sprains are external rotation injuries of the ankle and syndesmosis.
They often occur in competitive slalom skiers, and the anterior inferior
tibifibular ligament is the initial ligament injured.
The lateral stress test, or Cotton test, has been shown to have the least false
positive results in an acute syndesmotic injury.
To minimize the risk of recurrent ankle sprains, following a period of initial ice
and elevation functional bracing with early proprioceptive training is the
optimal non-operative treatment. Surgery can be a reasonable option when an
adequate trial of nonsurgical treatment fails to control symptoms. Good or
excellent outcomes can be expected regardless of which treatment above is
provided.
The modified Brostrom procedure is an anatomic reconstruction of the lateral

ankle ligaments (ATFL and/or CFL) and augmentation with the inferior
extensor retinaculum.
The ATFL is the most common ligament injured with ankle sprains. It has
positive anterior drawer test with the ankle in 20 degrees of plantarflexion.
The calcaneofibular ligament becomes most taut with the ankle dorsiflexed
and inverted. Conversely, the anterior talofibular ligament is most tensioned
with the ankle plantarflexed and inverted. The anterior and posterior
tibiofibular ligaments contribute stability to the tibiofibular articulation and
syndesmosis. The deltoid ligament is the primary stabilizer medially and is
stressed with ankle eversion testing.
Cavovarus positioning of the foot leaves the ankle susceptible to inversion

sprains and lateral ligament attenuation.
The most common acute skeletal injury in the dancer is the inversion sprain of
the ankle and thought to be due to relative peroneal muscle weakness.
Lateral talar OCDs are also usually less common, smaller and more shallow
than medial talar OCDS. Lateral talar OCDs are usually anterior in
comparison to medial based OCDs, and are harder to treat with conservative
treatment due to a lower incidence of spontaneous healing.
In approximate 10% of ankle sprains that do not improve, an osteochondral

lesion of the talus and persistent instability must be considered. Theses
lesions can be evaluated by MRI.
Transverse instability of the Lisfranc joint is the result of injury to both the
interosseous first cuneiform-second metatarsal ligament (Lisfranc's ligament)

and the plantar ligament between the first cuneiform and the second and third
metatarsals.
In Lisfranc fracture dislocations Open reduction is preferred over closed

reduction. Fixation should be with screws or joint spanning plates and screws.
Primary arthrodesis of the medial two or three rays has a better short and
medium-term outcome than ORIF.
Base of 5th metatarsal avulsion fracture is initially treated with protected

weight-bearing and gradual return to activity as pain allows.
Jones fracture (metadiaphyseal fracture of the fifth metatarsal) in a high

performance athlete is a relative indication for operative intervention (fixation
with IM screw), however increased rates of failure are seen if the athlete
returns to athletic participation prior to radiographic union.
Stress fractures of metatarsals are classically described in amenorrheal

dancers. These are coined a march fracture and occur in the 2nd, 3rd and 4th
metatarsals, with 2nd being the most common. Technetium-99 bone scan is
the most useful diagnostic imaging modality. They can be successfully treated
with a short-leg cast, low walking boot, or hard-soled shoe with arch support.
Non union and delayed union are the two most common complications of both
conservative and surgical treatment in navicular stress fracture.
Cast immobilization and non-weight bearing can be used to treat most

navicular stress fractures, even in high level athletes.
There is increased complications rates with operative management of acute

Achilles tendon ruptures compared to nonoperative treatment except lower
rate of rerupture compared to immobilization in a short leg cast for 6 weeks.
Recent studies have demonstrated that re-rupture rates are diminished with
early protected range of motion when compared with non-weight bearing cast
immobilization.
In the setting of a deep infection and a re-ruptured Achilles tendon , the first
step should be a thorough irrigation and debridement with excision of any
necrotic or infected tendon. Culture-specific antibiotics are administered for a
duration of 6 weeks. Once this has been completed, issues such as soft
tissue coverage and reconstruction of the re-reptured Achilles tendon may be
entertained.
Risk factors for wound complications following Achilles tendon repair include
tobacco abuse, steroid use, female gender, and diabetes mellitus.

Flexor hallicus longus (FHL) is the preferred tendon transfer to augment

tissue loss in chronic tendon Achilles rupture due to its proximity and
vascularity.
Eccentric exercises are important to implement into a functional rehabilitation

program for Achilles tendinopathy. Eccentric exercises most efficiently
strengthen skeletal muscle.
In large Haglund's deformity with failure of conservative management surgical

management is applied through tendon debridement and calcaneal
exostectomy.
4 stages of posterior tibial tendon (PTT) insufficiency are listed. They are:
• Stage 1: tenosynovitis of the PTT and maintenance of the ability to

perform a single-leg heel raise
• Stage 2: flexible valgus hindfoot deformity and unable to perform single
leg toe raise
• Stage 3: fixed valgus hindfoot deformity
• Stage 4: Stage III changes with the addition of ankle degenerative
changes and possible deltoid ligament complex insufficiency
Stage I (PTTD) is treated nonoperatively.
Stage 2: Operative management of Stage II disease is controversial. Lateral

column lengthening, medializing calcaneal osteotomy, and FDL transfer to the
navicular.
Stage 3,4 : triple arthrodesis with derotation through the transverse tarsal
joints as part of the arthrodesis procedure can address the forefoot varus and
prevent lateral border foot pain.
Ankle-foot orthosis (AFO) and is most appropriately used in the setting of a

flexible flatfoot deformity.
When the FDL and FHL are in the ankle, FDL is medial to the FHL ("Tom,
Dick and Harry"). However they cross each other at the Knot of Henry, where
the FHL goes anterior to the FDL, and then tracks immediately deep (dorsal)
to the FDL in the midfoot.
Achilles tendon contracture will likely be present in adult-acquired flatfoot

deformity secondary to posterior tibial tendon dysfunction.
Plantarflexion opening wedge medial cuneiform osteotomy (Cotton

osteotomy) is an adjunctive procedure used to correct the forefoot varus
component of a flatfoot deformity.

In the retromalleolar sulcus at the level of the ankle joint the peroneus brevis
tendon lies anterior to the peroneus longus tendon.
Tearing of the superior peroneal retinacular ligament may result from

inversion injury to a dorsiflexed ankle with rapid reflexive contraction of the
peronii. It can lead to peroneal tendon subluxation. This can be felt during the
foot and ankle physical examination by palpating for peroneal tendon
snapping over the fibula during ankle dorsiflexion and eversion. After a trial of
non-operative management, surgical options include repair of the SPR, with
or without fibular groove deepening.
In chronic anterior tibialis rupture, surgical reconstruction with plantaris tendon

interposition augmentation is done.
Passive motion of the great toe causes movement of the inflamed FHL tendon
at the ankle joint and resulting pain.
Plantar fasciitis is characterized by : “start-up” inferior heel pain with patients

often preferring to walk on their toes for the first few steps when getting out of
bed. The pain lessens with ambulation and then increases again with
increased activity.
Management options for plantar fasciitis include
• Initially: padding and strapping, therapeutic orthotic insoles, oral anti-

inflammatories, and regular Achilles and plantar fascia stretching.
• Later: night splints, repeat corticosteroid injections or cast
immobilization.
• Last after 6 months of treatment with measures in (2):Surgical
therapies and extracorporeal shockwave therapy.
In hallux valgus, big toe deformity is valgus and pronation.
Distal metatarsal osteotomy (Chevron) includes a lateral translation of the

metatarsal head after osteotomy. The Chevron osteotomy can be used for a
congruent or incongruent deformity that have hallux valgus angles less than
25-30 degrees and intermetatarsal angles less than 13 degrees.
Metatarsus primus varus and hypermobility of the first ray are both indications
for including metatarsocuneiform arthrodesis in the surgical correction of
hallux valgus. Anatomic plantarflexion of the first metatarsal is crucial to
prevent loading of the lesser metatarsals following surgery.
The Modified McBride procedure is indicated in patients 30-50 years old with
an incongruent joint, a HVA less than 25 degrees, and an IMA deformity less
than 15 degrees. This soft tissue procedure should be avoided in moderate or
severe hallux valgus deformity due to the increased risk of recurrence.

A Scarf osteotomy is done for moderate hallux valgus deformity (HVA=26-40).
Morton's extension orthotic is used to conservatively treat conditions such as

hallux rigidus, sesamoid disorders, and 1st MTP sprains (turf toe), as it limits
extension of the 1st MTP joint during the push-off phase of gait.
Cheilectomy (removal of 25-30% of the dorsal aspect of the metatarsal

head along with dorsal osteophyte resection) will relieve dorsal impingement
pain associated with Grade 1-2 MTP arthritis.
Resection arthroplasty (Keller) is the best option for the treatment of

advanced hallux rigidus in older, low demand patients. Silicone implants are
less desirable due to the potential for synovitis and implant failure which
necessitates implant removal and synovectomy.
Excision of the tibial sesamoid alone can lead to hallux valgus. Excision of the
fibular sesamoid alone can lead to hallux varus. Excision of both sesamoids
should always be avoided since it can lead to a cock-up deformity.
Tibial sesamoidectomy would be the most appropriate and reliable treatment

in tibial sesamoid fracture after failure of conservative management.
In claw toe deformity, and hammertoe surgical treatment is based on whether

or not the PIP joint is flexible or fixed. The Girdlestone-Taylor procedure
(transferring the FDL to the extensor surface of the affected toe) is only
effective in the presence of a flexible deformity. PIP arthrodesis, MTP
capsulotomy, and PIP joint resection arthroplasty are only indicated in varying
degrees of a fixed claw toe deformity.
Plantar plate deficiency resulting in MTPJ hyperextension is most commonly

associate with cross-over toe deformity.
Regarding metatarsal shortening osteotomies; Helal osteotomy has increased

rate of malunion or pseudoarthrosis compared to Weil osteotomy.
Second metatarsal osteotomy (Weil) with extensor tendon and dorsal

capsular release achieves longitudinal decompression through shortening and
will correct the longer 2nd metatarsal in relation to the first metatarsal. It is
the most appropriate option to address the second MTP metatarsalgia. The
most common associated complications are the development of a floating-toe
deformity and dorsiflexion deformity of the MTP.
A bunionette, "tailor's bunion", is a lateral prominence of the fifth metatarsal

head. A distal chevron osteotomy is reliable for those with a lateral bow to the
fifth metatarsal with normal 4-5 IM angle, but a diaphyseal osteotomy of the
5th is needed if the 4-5 IM angle is widened.

A single rocker sole shoe modification is indicated for use in patients with
severe tibiotalar or subtalar arthritis, or those status-post fusion of these
joints.
The rocker sole best reduces forefoot plantar pressure.
Neuropathic joint disease is a contraindication for a total ankle arthroplasty.
Syndesmotic nonunion may be a source of persistent pain following ankle

arthroplasty.
In ankle arthrodesis, long term follow-up has shown the increased rate of
ipsilateral midfoot and hindfoot arthritis.
Use of structural allograft not autograft is a risk factors for nonunion or

delayed union following subtalar arthrodesis.
Tibiotalar impingement during dorsiflexion with concomitant mild arthritis can

be treated with arthroscopic anterior ankle cheilectomy/debridement.
Ankle arthroscopy is not effective in treatment of diffuse ankle arthritis.
The superficial peroneal nerve is the most commonly injured nerve and is at
risk with use of the anterolateral portal of ankle arthroscopy.
The optimum position of ankle arthrodesis of the ankle appears to be neutral

flexion, slight (zero to 5 degrees) valgus angulation, and approximately 5 to
10 degrees of external rotation.
The lateral plantar nerve innervates the plantar skin covering the lateral half of
the fourth toe and the entire fifth toe and providing motor innervation to many
of the deep muscles in the foot may be injured with ankle arthrodesis.
Ankle arthrodesis is most commonly performed for post-traumatic ankle

arthritis.
At least a 6 month delay is required between cerebral injury and

reconstructive surgery because of the possibility of various degrees of
functional recovery. The critcial components to nonoperative management
include AFO fitting, early intervention with physical therapy, stretching and
strengthening, and maintenance of joint range of motion. Phenol or botox
injections can also be useful nonsurgical adjuvants.
The most common physical finding in patients who have had a

cerebrovascular accident is spastic equinovarus deformity of the foot and
ankle from an upper motor neuron injury. After failure of conservative
management, surgical treatment is needed. Equinus deformity is treated with

lengthening of the Achilles tendon. Varus deformity is treated with a split

anterior tibialis tendon transfer (SPLATT).
The first branch of the lateral plantar nerve (Baxter's nerve) innervates the
abductor digiti quinti, flexor digitorum brevis, and quadratus plantae. Baxter's
nerve compression is a common pattern of entrapment found in the running
athlete.
Superficial peroneal nerve entrapment by the fascial opening in the distal leg
is classically exacerbated by plantar flexion and inversion of the foot.
Treatment involves fascial release and superficial peroneal neurolysis.
Post-polio syndrome may occur in up to half of patients who have previously

been afflicted with polio. The syndrome is characterized by muscle weakness,
myalgia, and fatigue. Onset is typically 20-40 years following the initial
infection.
The primary risk factor for the development of a diabetic foot ulcer is loss of
protective sensation and this is commonly tested with a 5.07 Semmes-
Weinstein monofilament.
Forefoot ulcers are exacerbated by a fixed plantarflexion contracture

secondary to either a tight Achilles or gastrocnemius tendon.
When bone is probed in a diabetic ulcer, the likelihood of osteomyelitis being

present is between 60-70%.
Wound culture are often positive in all stages of a diabetic foot ulcer, even
when osteomyelitis is not present.
Isolated forefoot gangrene in the presence of a palpable posterior tibial artery

pulse can be definitively managed with a Syme amputation.
Wagner grade 1 and 2 ulcers (abscence of osteomyelitis) should be treated

with total contact casting AND gastrocnemius recession (Strayer procedure)
when indicated to decrease the risk of ulcer recurrence as lengthening can be
helpful in reducing plantar forefoot pressure. Surgical debridement and
antibiotics are not indicated if is there is no sign of clinical infection.
Wagner Grade 3 ulcer due to the presence of exposed bone should be initially
treated with surgical debridement, IV antibiotics and local wound care.
Intravenous antibiotics tailored to bone biopsy culture sensitivities have the

best chance of successful treatment of foot osteomyelitis in diabetics.
In evaluation of a non-healing diabetic foot ulcer the patient's capacity for

healing can be assessed with several methods. An ABI of < 0.45 or

transcutaneous oxygen pressure of <30 mmHg are negative predictors of

healing. Systolic blood pressure has not been shown to be predictive.
Initial treatment of Charcot arthropathy includes a total contact cast (TCC)

continued for up to 4 months. The goal of treatment in the first phase is to
prevent further collapse and deformity. When the active disease phase has
ended, the patient can be fitted with a CROW (charcot restraint orthotic
walker) and, later with a custom shoe with orthoses.
In a diabetic associated Charcot neuroarthropathy that has failed conservative

management with total contact casting, in the setting of a stable deformity,
exostectomy of bony projections is a reasonable option.
Possible causes of neuropathic joint include diabetes mellitus, syringomyelia,

leprosy, and neurosyphilis.
Dissipation of foot erythema with elevation is the key finding differentiating

neuropathic arthropathy from infection. A foot with osteomyelitis or a deep
abscess will remain erythematous with elevation.

PATHOLOGY

Doxorubicin (Adriamycin) is a key chemotherapeutic agent used in the

treatment of osteosarcoma. Main side effect is cardiomyopathy. Mechanism of
action is apoptosis.
Tyrosine kinase inhibitors are currently being used for cancer chemotherapy.
Apoptosis is not one of the steps in the development of a malignant tumor and
the ability to metastasize.
The method of radiotherapy administration has not been shown to increase

the risk of post-radiation fracture.
In the setting of malignant tumor, prior to instituting any treatment, patient

needs complete staging (CT of the chest, bone scan, and MRI should be
performed before biopsy)
Tumor induced osteolysis, commonly seen in metastatic bone disease, is

caused by increased osteoclastic bone resorption. This cascade is caused by
tumor induced cytokine signaling through the RANK to RANK ligand pathway
which activates the osteoclast and encourage local bone resorption. Medical
blockade of this pathway is through the use of bisphosphonates or
deactivators of the RANK/RANK ligand pathway like denosumab.
Benign tumors that are USUALLY treated with curettage and bone grafting
include giant cell tumor, chondroblastoma, chondromyxoid fibroma, and
osteoblastoma. Benign conditions that are OCCASIONALLY treated with
curettage and bone grafting include unicameral bone cyst (UBC),
enchondroma, and nonossifying fibroma (NOF). There is no role for curettage
and bone grafting in patients with osteofibrous dysplasia.
Osteoid osteoma
• small size (less than 2 cm)

• severe pain at night that is dramatically relieved by NSAIDs
• increased in cyclooxygenase activity
• percutaneous drilling under CT guidance / percutaneous
radiofrequency ablation for extraspinal lesions
• Treatment in incidentally found spinal lesions is observation
Intramedullary osteosarcoma
• most common malignant bone tumor in children

• distal femur > proximal tibia > proximal humerus > axial skeleton
• children and young adults
• mutations in the retinoblastoma gene

• Alkaline Phosphatase is a marker for bone turnover and an increased

level indicates tumor activity. Therefore, elevated (not low) serum
alkaline phosphatase is a risk factor for progression
• Neoadjuvant chemotherapy, wide resection, adjuvant chemotherapy
• Rotationplasty (an alternative to above knee amputation): in children
offers safe and negative margin resection and maximizing patient
function.
• most common chemotherapy agents include adriamycin (doxorubicin),
cis-platinum, methotrexate, and ifosfamide
• Low grade central osteogenic sarcoma: surgery with wide margins
alone and chemotherapy and radiation are not indicated.
• The most common site of metastasis is the lung.
Parosteal osteosarcoma
• posterior aspect of the distal femur / proximal tibia / proximal humerus

• Wide resection alone is sufficient
Periosteal osteosarcoma
• high grade osteosarcoma

• grow in a "sunburst" fashion
Enchondroma
• 2nd most common type of benign cartilage lesions (following

osteochondromas)
• 20-60 years of age
• hand (60%), distal femur, proximal humerus, and tibia
• histological picture of enchondromas of the hand is often more
aggressive than those seen in the long bones.
• asymptomatic lesions: observation only with serial radiographs.
• painful, growing enchondroma would be best treated with curettage
and bone grafting.
• 1% malignant transformation into chondrosarcomas.
Maffucci’s syndrome
• multiple enchondromas and soft-tissue hemangiomas

• at least 50% of patients developing malignancies
Osteochondromas
• the most common benign bone tumor

• most common location for exostoses is around the knee
• subungual exostosis most commonly occurs on the hallux
• in direct connection to the medullary cavity
• grow away from the physis
• Tumor resection with an osteotomy through the base of the tumor

Hereditary multiple exostoses
• multiple osteochondromas
• autosomal dominant condition
• mutations in EXT family of tumor suppresor genes
• defect in the EXT-1, EXT-2, or EXT-3 gene
• EXT1 had a higher rate of sarcoma
• Deformities: short stature, limb-length discrepancies, genu valgum,
bowing of the radius with ulnar deviation of the wrist, and subluxation of
the radiocapitellar joint.
• 10% risk of malignant transformation to chondrosarcoma
• New onset of pain and growth of the lesion in an adult are highly
suspicious for malignant transformation
Chondroblastoma
• benign aggressive cartilage tumor

• second decade
• lytic epiphyseal lesion with a surrounding sclerotic border
• "cobble stoning" pattern of monotonous cells + stromal based "chicken-
wire" calcification
Chondrosarcoma
• second most common primary malignant bone tumor (osteosarcoma

being number one)
• pelvis, proximal femur, scapula. Axial and proximal extremity
• destructive, lytic lesion + hazy or speckled calcifications with either a
diffuse "salt & pepper" pattern or a more discrete "popcorn" pattern.
• wide resection alone
• neither chemo- nor radiosensitive
• adjuvant chemotherapy is added for mesenchymal chondrosarcoma
• Maffucci's syndrome have the highest risk of malignant transformation
• Rates of reccurrence for patients with chondrosarcoma are most
directly related to increased telomerase activity in tumor samples.
Clear cell chondrosarcoma:
• epiphyseal
• chondrocytes with a clear, vacuolated cytoplasm in a chondroid matrix
Multiple myeloma
• proliferation of plasma cells

• Affected B-cells produce a single, non-functional antibody (ie
“monoclonal”, and this can either be the light chain or the heavy chain,
most commonly part of an IgG protein)
• monoclonal light chains are detected in urine (excreted by the kidneys)

• "cold" on bone scans

• bone marrow aspiration and biopsy essential for diagnosis
• Durie and Salmon criteria consider findings of plasmacytomas on
tissue biopsy, plasmacytosis in bone marrow, monoclonal
immunoglobulin spike on serum or urine electrophoresis, and
radiographic evidence of lytic bone lesions (commonly in the spine,
long bones and skull).
Lymphoma
• round cells
• immunohistochemistry stains positive for CD20 and CD45
• multiagent chemotherapy such as a combination of cyclophosphamide,
doxorubicin, prednisone, and vincristine.
• Consolidative irradiation is often used for persistent disease.
• Surgery is generally used only to stabilize pathologic fractures or
prophylactic stabilization for impending pathologic fractures
Nonossifying fibroma
• the most common benign bone tumors in childhood

• metaphysis of long bones
• knee (distal femur and proximal tibia) and distal tibia
• eccentric, "bubbly" lytic lesion surrounded by a sclerotic rim
• biopsy is not required
• Accidentally discovered
• reassurance and follow up radiographs in three months time
• Casting immobilization may be indicated in cases of pathologic fracture
Malignant fibrous histiocytoma
• Undifferentiated pleomorphic sarcoma (UPS)

• radiation and wide surgical resection.
Chordoma
• Common in sacrum
• symptoms of mass effect: low back pain, constipation
• wide surgical resection
• high local recurrence rate
Unicameral bone cyst
• most commonly in the proximal humerus in children

• serous fluid-filled
• injection with steroid or bone marrow, curettage and bone grafting, and
internal fixation.
• Recur no matter what treatment is chosen.
• pathologic fracture proximal humerus … immobilization

• pathologic fracture trochanteric region … Open reduction and internal

fixation with bone grafting of the bone cyst
• progressively shrinks as the patient approaches skeletal maturity and
may heal spontaneously after growth is completed.
Aneurysmal bone cysts
• <20 years old

• multi-loculated cysts
• MRI showing multiple fluid-fluid levels
• Pathology: (“lake of blood”)
• curettage and bone grafting with or without adjuvant treatments such
as sclerotherapy, cryotherapy, or radionuclide ablation.
• Pathological fractures: nonoperative management is preferred
Fibrous dysplasia
• mutation in the GS alpha protein, which increases cAMP

• scalloped border and a ground glass appearance
• McCune-Albright syndrome (MAS) is a condition characterized by:
1) precocious puberty (endocrine abnormalities),
2) café-au-lait spots with the jagged borders
3) polyostotic fibrous dysplasia.
Osteofibrous dysplasia(OFD)
• tibia of children
• lytic lesion in the anterior cortex of the diaphysis or metaphysis
• painless swelling
• anterior-posterior bowing , procurvatum deformity
• multi-loculated appearance
• observation as most of these lesions regress prior to adulthood.
Paget's bone disease
• excessive bone resorption (by abnormal osteoclasts) and disordered

bone formation.
• Paget's bone has a rich blood supply
• Increased blood loss is the most common complication associated with
total hip arthroplasty
• Activity of disease can be assessed before surgery by measuring:
1) serum alkaline phosphatase
2) urine hydroxyproline, N-telopeptide, alpha-C-telopeptide,
deoxypyridinoline
3) normal serum calcium

• Secondary osteosarcoma is the most common malignant

transformation associated with
• Asymptomatic patients: observation and supportive therapy
(physiotherapy, orthoses, and NSAIDS, or oral analgesics).
• Bisphosphonates for symptomatic Pagets
• surgical management is recommended when failure of conservative
measures,
• Teriparatide (Forteo) is a recombinant form of parathyroid hormone,
used in the treatment of some forms of osteoporosis. Administration is
contraindicated in the patient with Paget's disease.
Paget sarcoma
• While osteosarcoma is the most common histologic sub-type,

fibrosarcoma and chondrosarcoma sub-types also occur
• less than 1% of patients with Paget's disease
• The 5-year survival for non-metastatic Paget's sarcoma is less than 5%
• treated with chemotherapy, wide resection, and reconstruction
Eosinophilic granuloma
• proliferation of histiocytes
• skin, or skeleton (spine or the flat bones of the pelvis or shoulder girdle,
long bones, and skull).
• coffee bean indented nuclei in Langerhans cells
• self-limiting and may be managed conservatively
• Worsening pain and further destruction of the cortical bone would be
indications for radiation therapy or curettage and grafting/cementation
to prevent pathologic fracture
Myositis ossificans
• common after trauma, burns, or surgery

• Common sites include the quadriceps and brachialis.
• peripheral bone formation and central lucency
• Treatment is conservative and if required, it is recommended treatment
be delayed until complete ossification.
• Fibrodysplasia ossificans progressiva (FOP, Stone Man Disease),
ý rare subtype of heterotopic ossification
ý mutation of the ACVR1 gene (activin A type I receptor gene, a
BMP type-1 receptor)
ý BMP4 is implicated in this disease.
ý progressive heterotopic ossification
ý Congenital malformation of the great toe

Heterotopic Ossification
• staging by radiographs
• Risk factors
1) Prolonged ventilator time,
2) brain injury,
3) spinal cord injury,
4) burns,
5) amputation thru the zone of injury in a patient injured in a blast
6) direct lateral approach in THA and extensile approaches for
acetabular fractures
7) may occur in quadriceps following placement of a large-diameter
Steinmann pin at distal femur
8) ISS score
• in high risk individuals 700-800 cGY delivered less than 4 hours
preoperatively or within 72 hours postoperatively appeared to be more
effective than indomethacin 75mg daily for 6 weeks.
Giant cell tumor
• lytic lesion in the metaphysis and epiphysis of long bones

• The bone destruction in giant cell tumors is caused by the tumor cell
activation of the osteoclasts and the secondary osteoclast resorption of
bone.
• locally aggressive
• multi-nucleated giant cells
• distal femur/proximal tibia, distal radius, and the sacrum
• spine is an uncommon location (usually occur in the vertebral body, not
the posterior elements)
• They are not typically found in the diaphysis of bone.
• extended curettage followed by cement or bone grafting
• metastasize to the lungs
Ewing’s sarcoma
•second most common primary tumor of bone in children

•translocation and fusion protein is t (11:22), EWS-FL1
•"onion-skinning."
•small round cells
•Bone marrow biopsy is a routine part of the staging workup
•neoadjuvant chemotherapy, surgical resection, and adjuvant
chemotherapy
Adamantinoma
• low-grade malignant primary bone tumor

• tibia

• association with osteofibrous dysplasia

• en bloc resection with wide margins followed by appropriate
reconstruction
Metastases
• biopsied prior to definitive treatment

• surgical decompression, stabilization, followed by radiation for patients
with metastatic cancer to the spine leading to a neurologic deficit if their
life expectancy is greater than six months.
• Due to the vascular nature of renal cell carcinoma, excessive
intraoperative bleeding may occur, and preoperative embolization is
indicated.
• Endothelin 1 has been shown to be a crucial protein involved in the
formation of osteoblastic bone metastases
• Metastatic carcinoma is the most common cause of a destructive bone
lesion in older adults.
• Bone is the third most common site of metastasis, behind the lung and
liver.
• While the spine is the most common site for all boney metastasis, the
proximal femur is the most common site for pathologic fracture
secondary to metastasis to bone.
• Metastatic bony lesions that occur distal to the elbows or knees are
most likely to occur from primary lung and kidney tumors.
• Lung, breast, prostate, renal, and thyroid are the five most common
sites of origin.
• Bony metastatic lesions may be:
1) Osteoblastic: Prostate
2) Osteolytic: Renal, lung and thyroid
3) Mixed: breast
• Statically locked cephalomedullary nail or a proximal femoral
replacement would be acceptable treatment for pathological proximal
femoral fracture/ impending fracture with metastatic lesion.
• Placement of an intramedullary nail through a tumor contaminates the
entire bone
• Malignant cell metastasis requires at a minimum tumor cell
intravasation (entry into blood vessels), avoidance of immune
surveillance, target tissue localization, and induction of angiogenesis.
• life expectancy in order : Lung < renal < breast < prostate < thyroid
• Occult lytic metastatic adenocarcinoma to bone without an identified
primary source after bone scan and CT of the chest, abdomen, and
pelvis is most commonly of lung origin.

Soft tissue sarcoma
• Without a history of injury, trauma, or bleeding diathesis, the diagnosis

of a hematoma must be entertained only after ruling out malignant
causes for the symptoms.
• After radiographs, a contrast-enhanced MRI scan is the next step in the
work-up.
• If the MRI scan is diagnostic, and the mass is benign and symptomatic,
excision of the mass can be entertained without obtaining a biopsy.
• If the MRI scan is indeterminate, a core needle or open biopsy should
be obtained before treatment is initiated.
• Sixty Gy (or 6000 cGy) is a typical radiation dose for adjuvant radiation
therapy for a soft-tissue sarcoma.
• Radiation therapy reduces the risk of local recurrence
• The size of the operative margin is the most important treatment-
related factor.
• Deep lesion requires advanced imaging prior to surgical excision
• Incompletely excised soft tissue sarcomas need tumor bed re-excision
Pigmented villonodular synovitis
• Synovectomy (either open or arthroscopically), which is considered an

intralesional excision.
• Arthroscopic image shows the deep red fronds
• hemosiderin deposition in the synovium
• analogous histologic disease process when located away from the
synovial lining of joints, which is giant cell tumor of tendon sheath
Synovial chondromatosis
• painful synovial proliferative disorder

• cartilage metaplasia
• intra-articular loose bodies
• requires symptomatic treatment only
• in hip when symptomatic is treated by removal of the loose bodies with
synovectomy, chondroplasty, and labral debridement as needed.
Synovial sarcoma
• chromosomal translocation t(X:18)

• fusion protein SYT-SSX1
• The cell of origin in synovial sarcoma is unknown.
• occur in younger adults < 40 years
• do not occur inside joints or in relation to the synovial tissue
• in peri-articular locations
• the most common sarcoma found in the foot

• immunohistochemistry can be positive for cytokeratin, vimentin,

sporadic S-100, and epithelial membrane antigen.
• wide surgical resection with neoadjuvant or adjuvant radiotherapy
and/or chemotherapy.
• lungs is the most common site for metastatic spread.
• metastasize to the lymph nodes
Epithelioid sarcoma
• a small, nodular, slow-growing mass on the hand

• Most common soft tissue sarcoma of the hand
• frequently metastasizes to regional lymph nodes
• immunohistochemical reactivity for epithelial markers including keratin,
vimentin and CD34
• surgical excision with adjuvant radiotherapy
Extraabdominal fibromatoses (desmoid tumor)
• shoulder, chest-wall/back, and thigh regions

• wide surgical resection with external beam radiation therapy.
• positive for estrogen receptor-beta expression
• estrogen receptor blockade chemotherapy (tamoxifen) for inoperable
lesions
• high incidence of local recurrence
Miscellaneous
• S100 is a frequently tested cellular marker which is specific for

melanomas, nerve tumors, and clear cell sarcomas.
• The most common malignant SOLID tumor of childhood is
neuroblastoma
• Immunohistochemisty staining for smooth muscle actin suggests a
tumor of smooth muscle origin (leiomyosarcoma).
• Rhabdomyosarcoma is the most common soft tissue sarcoma in a
child.
• Pain in hemangiomas is thought to occur due to vascular engorgement
secondary to activity, dependant position and increased blood flow to
the lesion.
• CD31 is a sensitive marker for angiosarcoma.
• Marjolin’s ulcers are a squamous cell carcinoma that develop in
patients with burn scars, or chronic drainage from osteomyelitis sinus
tracts or pressure sores.
• Glomus tumor is found in the hand and under the fingernails.
• Glomus tumor is often quite painful. Placing the finger in cold water can
exacerbate the pain.

• Intramuscular myxoma is slow growing deeply seated mass confined to

the skeletal muscle.
• Treatment of intramuscular myxoma is Surgical excision.
• Sarcomas with lymph nodes metastasis include: epithelioid sarcoma,
rhabdomyosarcoma, clear cell sarcoma, synovial sarcoma, and
vascular sarcomas.

BASIC SCIENCE

Mesenchymal stem cells do not form osteoclasts. Osteoclasts orginate from

hematopoietic cells from a macrophage cell lineage.
Osteoclasts are multinucleated giant cells possess a ruffled border.
Osteoblasts express PTH receptors and make M-CSF and RANKL which are
essential factors for osteoclastogenesis. The RANK receptor is expressed on
premature stem cells of the osteoclastic lineage. OPG is a decoy molecule
made by osteoblasts that binds to RANKL and inhibits osteoclast
differentiation. Thus, osteoblasts have both positive and negative regulatory
effects on the activity of osteoclasts.
Osteoclasts attach to bone surfaces by means of integrins and vitronectin and

then seal the space below. A ruffled border is then created and bone matrix is
removed by proteolytic digestion through the lysosomal enzyme cathepsin K
(bone resorption).
Cbfa1/Runx2 is a key transcription factor associated with osteoblast

differentiation.
SOX-9 is considered a “master switch” for the differentiation of cells of

chondrocytic lineage.
Canaliculi are a system within the lacunar network used by osteocytes to

communicate with each other.
Haversian canals are found in the center of an osteon in compact bone. They
contain blood vessels and nerves.
Bone is composed of both organic and inorganic components. Inorganic

components include calcium hydroxyapatite and osteocalcium phosphate.
Organic components include collagen, proteoglycans, matrix proteins,
cytokines and growth factors. While Type I collagen is responsible for
providing the tensile strength of bone, proteoglycans and calcium
hydroxyapatite [Ca10(PO4)6(OH)2] are most responsible for providing
compressive strength they are also responsible for binding growth factors and
inhibiting mineralization.
Osteocalcin is the most prevalent noncollagenous protein in bone. It is

expressed by mature osteoblasts and is a marker of osteoblast differentiation.
Osteocalcin is the most specific marker of the osteoblast phenotype and is
expressed only in mature osteoblasts.
Osteonectin, (not osteocalcin) is a glycoprotein that binds calcium.
The chemical structure of hydroxyapatite is Ca10(PO4)6(OH)2.

Hydroxyapatite is a naturally occurring mineral form of calcium apatite with the

formula Ca5(PO4)3(OH), but is usually written Ca10(PO4)6(OH)2 to denote

that the crystal unit cell comprises two entities.
Blood supply to long bone comes from three sources:
1) nutrient artery system: (high pressure system) supplies the inner 2/3 of
the diaphysis via Haversian systems.
2) metaphyseal-epiphyseal system,
3) periosteal system: (low pressure system) supply the outer third of the
adult diaphyseal cortex.
Parathyroid hormone receptor activation primarily stimulates the pathway
involving adenylyl cyclase/G-alpha stimulatory protein/cAMP/protein kinase A
in osteocytes.
Calcitonin inhibits osteoclastic bone resorption directly by binding to the

osteoclast. Calcitonin decreases osteoclast number and activity, as well as
decreases serum calcium.
Osteoprotegerin, Calcitonin, Bisphosphonates, and Denosumab inhibit

osteoclastogenesis.
Estrogen has been shown to be important for both men and women in
attaining peak bone mass.
Most individuals attain their peak level of bone mass sometime between the
ages of 16 and 25 years.
Growth hormone acts preferentially at the proliferative zone where it

stimulates longitudinal bone growth.
Gigantism, like achondroplasia, affects the proliferative zone of the growth

plate.
Congenital unilateral transverse absence of the forearm results from insult to

the apical ectodermal ridge.
The function of the Hox genes is to regulate somitization of the axial skeleton.
The somites are mesodermal in origin; somites eventually form dermis

(dermatome), skeletal muscle (myotome), sclerotome or cartilage, tendons,
and endothelial cells. The sclerotome of the somites develops into the axial
skeleton. The neural crest forms the peripheral nervous system, the lateral
plate mesoderm becomes the dermis, and the dorsal myotome (epimere)
becomes the dorsal muscles.
Chondrocytes produce PTHrP, which slows the maturation of proliferative

chondrocytes. A deactivating mutation in (PTHrP) receptor would lead to
accelerated maturation in the zone of hypertrophy.

The groove of Ranvier is responsible for appositional growth of the physis.
The Heuter-Volkmann Law states that compression across the growth plate
slows longitudinal growth.
Physeal fractures occur in zone of provisional calcification, which is a part of

the hypertrophic zone. The transition from the soft cartilage to to the hard
calcified metaphysis puts this zone at risk for fracture.
Type X collagen is found in hypertrophic cartilage expressed during the

cartilage callus calcification phase of fracture healing.
Sclerostin is an osteocyte-derived negative regulator of Wnt signaling in

osteoblasts. They are thought to work by stimulating the production of
osteoblasts. By inhibiting the Wnt pathway, sclerostin leads to decreased
bone mass.
As the human body ages the cortical thickness/area decreases and

subsequently the diameter/volume of the medullary canal increases.
Fractures and osteotomies that are stabilized with rigid compression plating
undergo primary bone healing, also known as haversian remodeling.
Intramedullary nails function as internal splints that allow for secondary

fracture healing.
Expression of IGF-1 and IGF-2, myosin, actin, and VEGF mRNA were all
significantly decreased in the amino acid supplemented group compared to
the malnourished group.
Low-intensity pulsed ultrasound (LIPUS) treatment may significantly reduce

the time to fracture healing for fractures treated nonoperatively by producing
nanomotion at the fracture site.
Capacitive coupling involves externally placed electrodes with an alternating

current which creates an electrical field. This stimulates calcium translocation
which then activates calmodulin and upregulates many factors involved in
bone healing (BMP, cyclic adenosine monophosphate (cAMP), and TGF-
beta1).
Direct current (DC) stimulates an inflammatory-like response during fracture

repair while.
Pulsed electromagnetic fields (PEMFs) cause calcification of fibrocartilage but

not calcification of fibrous tissue.
Hypertrophic nonunions result from motion at the fracture site and generally
unite once the mechanical stability is increased.

Atrophic and oligotrophic nonunions, while multi-factorial, result from poor

biology at the fracture site (poor vascularity, lack of mesenchymal stem cells,
bone loss). Treatment of atrophic nonunions then entails takedown of the
nonunion and bone grafting (to improve the biology) with stabilization to
initiate a healing response.
Cycloxygenase-2 (COX-2) :
• converts arachidonic acid to prostaglandin endoperoxide H2.

• causes mesenchymal progenitor cells to differentiate into osteoblasts
• helps enchondral ossification in fracture healing (promoting new bone
formation). So, delayed effects of fracture healing when animals were
treated with COX-2 inhibitors.
BMP-3 is the most abundant BMP in demineralized bone matrix. It
antagonizes the activity of BMP-2. BMP-3 knockout mice have twice as much
trabecular bone as controls ( NOT osteoinductive).
All allograft materials carry immunogenic properties, which decrease as the

material is processed via the various sterilizing, freezing, or drying
process(es). As the processing increases, the mechanical characteristics of
the graft tends to decrease.
Calcium phosphate and sulfate materials have low tensile and shear stress
properties ( NOT scaffold). They serve as osteoconductive void-fillers.
Calcium sulfate bone graft substitute has demonstrated an increased rate of

serous drainage at the surgical site.
Calcium sulfate has a compressive strength similar to cancellous bone but

resorbs quickly within 4-12 weeks.
Calcium phosphate and coraline hydroxyapatite are resorbed slowly,

somewhere between 1-10 years.
Anterior iliac crest has higher complication rates as compared to posterior

harvesting.
The risk of viral transmission associated with blood properly screened for
Hepatitis C is 1 in 100,000. Risk of transmission in Hepatitis B is 1 in 63,000,
HIV is between 1 in 650,000 to 1 in 1,000,000 for blood transmission and
allograft transmission rates are estimated by the blood transmission rates.
Specific tests for allografts include: HIV, HBV, HCV, HTLV-I/II, and Syphilis.
The only bone graft material that contains live precursor cells are those
containing autologous marrow-fresh autograft or bone marrow aspirate.
Cancellous autograft is most osteoinductive.


By 5 years, the allograft cartilage will be completely acellular, so there will be

no residual donor chondrocytes.
The duration and speed of contraction is most dependent on the muscle fiber
type.
The force generated by the muscle is most dependent on the cross-sectional

area of the muscle.
Strength training is achieved by incremental progressive loading of muscles,

in effort to increase muscle fiber contraction coordination and eventually
hypertrophy of the muscle fibers themselves.
Neutrophils are the first cells to appear following acute muscle injury.
Concentric muscle contractions occur when a muscle shortens during

contraction.
Eccentric contraction occurs when a muscle lengthens with contraction.
There are two types of tendon/ligament insertion into bone: direct and indirect
insertion. The more common, indirect insertion, occurs when the superficial
ligament fibers insert into the periosteum. Direct insertion of tendon/ligaments
into bone occurs through a transition of 4 distinct phases: 1) ligament, 2)
fibrocartilage, 3) mineralized fibrocartilage, and 4) bone.
Toe region of the load-elongation curve of tendon: initial elongation during

which a small amount of tension causes crimped, randomly arranged fibrils to
become aligned parallel along the direction of loading.
Aggrecan molecules + hyaluronic acid molecules = proteoglycan aggregate,

which attracts water.
An ideal fluid film lubrication regime minimizes friction. It is inhanced by:
ý Larger head size

ý Decreased surface roughness
ý Radial clearance (incomplete congruence) between the ball and the
socket.
4 zones of articular cartilage:
• Superficial zone:
ý Articular cartilage progenitor cells found there
ý flattened chondrocytes oriented parallel with the tidemark
ý collagen fibrils oriented parallel to the tidemark.
• Transitional zone,

• Deep zone (also called middle or radial zone)

ý chondrocytes with spheroidal shape perpendicular to the joint
surface the largest diameter collagen fibrils
ý highest concentration of proteoglycans
ý lowest concentration of water
• Zone of calcified cartilage.
Cartilage exhibits significant stress shielding of the solid matrix components
due to its high water content.
Generalized thickening of articular cartilage in a marathon runner is most

likely secondary to the increased mechanotransduction from repeated load.
Synovial fluid is made by the fibroblast-like type B synovial cell.
Type A synovial cells are important phagocytic cells.
Type C synovial cell are of unknown significance.
Reverse transcription polymerase chain reaction (RT-PCR) is a variant of

polymerase chain reaction (PCR) used in molecular biology to generate many
copies of a DNA sequence from fragments of RNA.
The cell cycle consists of four distinct phases: initial growth (G1), DNA
replication/synthesis (S), a gap (G2), and mitosis (M).
The DNA bases are thymine, adenine, guanine, and cytosine (TAGC).
RNA bases are uracil, adenine, guanine, and cytosine (UAGC).
A plasmid is an extrachromosomal circular piece of DNA that replicates

independently of host DNA.
Tumor necrosis factor receptor 1 is involved in apoptosis.
A type IV, or delayed-type hypersensitivity reaction, can be seen with

placement of orthopedic hardware.

The process of antigen processing and presentation at major

histocompatibility complex (MHC) receptors by antigen presentation cells
(APC) like B cells and dentritic cells is the first step of the acquired immune
response. Once presented on the surface of the APC, the T-cell receptor
recognizes the MHC/antigen complex leading to T-cell activation. At no point
in this process are antigens phagocytosed by T cells.
IgM is the first class of antibody to appear in our serum after exposure to an
antigen. IgG is the most abundant immunoglobulin in our body.
Definition of genetic imprinting: the allele that is expressed is determined

solely on which parent contributes it.
Usually, diseases resulting from defective structural proteins are autosomal

dominant, while defective enzymes are autosomal recessive.
Anticipation is a phenomenon whereby the symptoms of a genetic disorder

become apparent at an earlier age as it is passed on to the next generation.
In most cases, an increase of severity of symptoms is also noted. Anticipation
is common in trinucleotide repeat disorders such as Huntington's disease,
myotonic dystrophy, Friedreich ataxia, and Fragile X syndrome.
Epigenetic changes are defined as inheritable genetic alterations that do not

involve DNA mutation.
Cytogenetic analysis performed for prenatal testing involves analyzing entire

chromosomes to detect genetic translocations.
Carcinoembryonic antigen (CEA) is most closely associated with colorectal

carcinoma.
Chromosomal translocations:
• Clear cell sarcoma t(12;22)

• alveolar rhabdomyosarcoma:t(2;13),
• synovial sarcoma:t(X;18),
• Ewing’s sarcoma: t(11,22),
• myxoid liposarcoma:t(12;16),
• chondrosarcoma:t(9;22).
A tumor suppressor is a gene whose presence normally prevents neoplasia
and whose absence leads to unregulated cell growth. e.g.
• P53 normally suppresses cell division by blocking the cell cycle

• RB-1 (retinoblastoma gene) may leads to retinoblastoma and
osteosarcoma.
Micromotion at the femoral head-neck junction can lead to fretting corrosion,
one of the most common causes of failure of a modular implant.

Young's modulus of elasticity is defined as the measure of stiffness of a

material in the elastic zone. A higher Young's modulus indicates a stiffer
material.
Bone cements are provided as two-component materials, a powder and a

liquid. The powder usually contains a polymer, benzoyl peroxide (initiator),
and barium sulfate (radio-opacifier). The liquid usually contains a monomer,
DMPT (accelerator), and hydroquinone (stabilizer). The two components are
mixed and a free radical polymerization occurs when the initiator is mixed with
the accelerator.
Fatigue is a characteristic of metal defined as failure below the ultimate tensile

strength after numerous loading cycles.
Creep: Progressive deformation response to constant force over an extended

period of time.
Ductility: A solid material's ability to deform under tensile stress.

Anisotropy: The ability of a materials mechanical properties to vary according

to the direction of load.
Load relaxation is characterized by decreased peak loads over time with the
same amount of elongation.
Objects in the elastic zone of the curve will return to their normal shape when
the load is removed (elastic deformation).
Objects in the plastic zone will not return to their normal shape when the load
is removed (plastic deformation).
The yield point marks the transition between the elastic and plastic zones.
Yield strength: stress at which a material begins to undergo plastic

deformation
Toughness: The amount of energy a material can absorb before failure.
Low toughness is a disadvantage of ceramic bearings in total hip arthroplasty.
Tensile (ultimate) strength, is the maximum stress a material can withstand

before undergoing breakage or failure. The ranking of ultimate strength, from
highest to lowest is: 1) cobalt chrome, 2)titanium, 3)stainless steel, and 4)
cortical bone.
Ligaments are viscoelastic material which means their stress-strain curve

patterns are time/rate dependent (as a result of the internal friction).
Titanium is extra-ordinarily light, strong, highly ductile, and corrosion resistant.

Titanium is however very notch sensitive and has poor wear resistance.
Chromium, molybdenum (add strength), and cobalt (corrosion resistance) are

basic components of Cobalt alloys.
Stainless steel is primarily an iron-carbon alloy.
Galvanic corrosion is a type of corrosion which results from an

electrochemical potential created between two metals in a conductive
medium.
Cobalt-chromium is the only material that is most susceptible to galvanic

corrosion.
Bone is weakest in shear and strongest in compression.
The bending rigidity of a solid cylindrical pin is related to the fourth power of
the pin’s radius.

A hollow, cannulated intramedullary nail has a bending rigidity related to the

3rd power.
The rigidity of a fracture plate is proportional to the plate thickness to the third
power. Thus, doubling the fracture plate thickness increases its bending
stiffness 8 times.
The bending rigidity of an external fixator pin is proportional to the fourth

power of the pin diameter.The bending stiffness of each pin is proportional to
the third power of the bone-rod distance.
The ACL has the biomechanical properties of viscoelasticity, creep, stress

relaxation, and nonlinear elasticity. It does NOT demonstrate isotropism.
To solve a problem with complex geometric form and material property

distributions, the finite element approach is used to break the problem up into
smaller “finite elements” with simple geometric form. Stress analysis of the
cement fixation of implants to bone is frequently carried out using finite
element analysis.
Pin diameter has the greatest influence on stability of unilateral external

fixator frames.
Methods used to increase the strength of an external fixation construct:
• Decreasing the distance from the bar to the bone

• Good bone-to-bone fracture end apposition
• increased number of pins
• Increasing the connecting bar diameter
• Increasing the pin diameter
• small distance from the near pins to the fracture site (smaller working
distance)
• increased spacing between the near and far pins
• Adding one stacked connecting bar
• bicortical pin fixation.
Axial strength is improved with locking plate fixation.
Unicortical locking plates have characteristically less torsional strength than

bicortical locking plates and bicortical non-locking plates.
Locked plates provide stiffer constructs than conventional plates and

intramedullary nails and thus reduce interfragmentary strain.
Placing a concave bend in the plate (prebending) during compressive plating

results in compressive forces at both the near and far cortices This technique
is most useful in transverse fractures.

Strain in fractures is calculated by dividing the interfragmentary movement by

the size of the fracture gap.
• (2%) for primary bone healing

• less than 10% for secondary bone healing
The definition of a bridge plate is one where
• no direct compression between the bone ends at the fracture site

• screws placed far from the fracture site (thus increasing the working
length of the construct) to prevent disturbance of the blood supply and
allow more motion of the construct.
A bridge plate with locking screws functions the same as an external fixator,
except that it is placed internally.
The working distance is defined as the distance between the 2 screws closest
to the fracture. Decreasing the working distance increases the stiffness of the
plate fixation construct.
Infraisthmal femur fracture for which a intramedullary nail remains the gold
standard treatment option.
Fractures that have demonstrated an increased risk of mechanical failure with

unlocked plates include proximal humerus, distal radius, distal femur, and
proximal tibia.
Fractures that have historically been treated successfully with traditional non-
locking plates (eg, humeral shaft, both-bone forearm, lateral malleolus)
require locked fixation in osteoporotic bone or fractures with segmental loss or
short-end segments as a result of comminution.
Absolute stability is achieved by lag screws and a neutralization plate. No

micromotion is seen with this technique, and healing is by primary (Haversian)
healing.

Locking screws provide a fixed angle support and can improve fixation in
osteoporotic bone while nonlocking screws can be used to reduce the plate to
the bone, lag fracture fragments together and increase the plate bone
frictional stability.
Locked plates are indicated for:
• indirect fracture reduction,

• diaphyseal/metaphyseal fractures in osteoporotic bone,
• bridging severely comminuted fractures,
• plating of fractures where anatomical constraints prevent plating on the
tension side of the bone.
But NOT for:
• Compression plating of transverse fracture

• Oligotrophic diaphyseal nonunions
Tapping prior to screw placement does not increase the pullout strength of a
screw in osteoporotic bone.
A long oblique diaphyseal fracture with 2 mm of residual displacement after

being internally fixed with lag screws has greater interfragmental strain than
comminuted fractures treated with bridge plating or fractures that are
anatomically reduced and internally fixed.
The radius of curvature of an intramedullary nail is generally greater than the

radius of curvature of the femur, which is why anterior distal femur penetration
is a known complication of intramedullary nailing procedures.
Stress shielding: decrease in physiologic stress in bone due to a stiffer

structure sharing load.
In a locking plate fixation model, use of bicortical screws, parallel screw

placement, increased plate length, increased number of screws, and screws
placed at appropriate angles into the screw hole all serve to increase fixation
construct stability.
The distance a screw traverses in a bone during fracture fixation is defined as

the working length (or less commonly "working distance") of that screw.
Limited contact dynamic compression LCDC plates have less contact with the
bone as compared to the standard dynamic compression plates. The
decreased surface area leads to less contact-induced osteopenia.
Standard plating results in greater compromise to both medullary and

periosteal bloodflow compared to minimally invasive submuscular plating
techniques.

(Swing-to) gait patterns are usually indicated for persons with bilateral lower
extremity weakness and requires good upper extremity strength and good
overall balance.
If a patient is toe-touch or non-weightbearing on one lower extremity then 2

axillary crutches are required for support during ambulation.
The most important factor when choosing an optimal lower limb prosthesis for
an adult patient is the current and potential functional requirements of the
patient.
In toe amputation, full-length steel shank and rocker sole shoe modifications
would most likely improve this patient's gait.
The term antalgic gait is non-specific and describes any gait abnormality
resulting from pain. A patient with knee arthritis maintains slight flexion
throughout the gait cycle and toe walking on the affected side.
In patients with upper extremity amputations:
Advantages Disadvantages
Body-controlled • require more
prosthesis harnessing
Myoelectric • heavy labor activities • less sensory

prosthesis • overhead manuevers feedback
• cosmetically appealing • heavier
• adapt well for sedentary use • more expensive
• require more
maintenance
Patients with transradial amputations are considered the best candidates for a
myoelectric prosthesis.
Traumatic amputations increase the metabolic demands of walking less than

those performed for vascular lesions. This is because patients who require
amputation for vascular disease likely have continued vascular pathology
above the amputation.
Energy expenditure:
• Bilateral transtibial amputee patients is 40% above baseline levels.

• unilateral transtibial amputee 9% higher
• unilateral transfemoral amputee 49% higher
• bilateral transfemoral amputee 280% higher
A polycentric knee in transfemoral amputee has a variable, not fixed, center of
rotation.

Disadvantages of the polycentric knee include cost, weight, and more

sophisticated maintenance.
The non-dynamic response foot known as the solid ankle cushion heel
(SACH) has shorter duration midstance of gait compared to the dynamic
response foot (energy storing).
Articulated dynamic-response prostheses have replaced SACH prostheses as

the standard foot. It is the best prosthetic for ambulation over uneven ground,
and functions best for below knee amputations.
"Drop-off" refers to knee buckling or excessive knee flexion as the limb

transitions from midstance (normally knee is extending) to terminal stance
(the start of heel-off phase leads to knee flexion).
Posterior placement of the prosthetic foot or a heel that is too hard will
increase knee flexion/instability at heel strike.
Recombinant parathyroid hormone (Forteo) has been demonstrated to cause

osteosarcoma.
Parathyroid hormone causes both bone formation and resorption, depending

on frequency of dosing.
1) intermittent PTH injections increase bone mass,

2) continous infusion lead to bone resorption,
3) dosing should not continue past 2 yrs.
Intermittent parathyroid hormone is anabolic to bone and is used as a
treatment of osteoporosis (forteo).
Continuous infusions of Teriparatide (Forteo) result in greater bone resorption

than do daily injections. Daily Teriparatide injections cause only transient
increases in the serum parathyroid hormone concentration and creates a net
anabolic effect on bone.
Phenytoin is an anticonvulsant which has been found to increase the risk of

osteoporosis and, subsequently, nontraumatic fractures.
Medical management of postmenopausal women with fragility fractures

includes(DEXA) testing.
25-hydroxy cholecalciferol (25 OH vitamin D) would be the most appropriate

laboratory test in this patient who sustained a fall from low energy.
The National Osteoporosis Foundation recommends a daily intake of 1,200-

1500mg of calcium 800-1,000 IUs of vitamin D and a protein enriched diet for
adults over the age of 50.

Calcium recommendations:
• Age 1-3yrs - 500mg/d

• Age 4-8yrs - 800mg/d
• Age 9-18yrs - 1000 to 1500mg/d.
Ceramic bearings have not been documented to be an etiology for pelvic
insufficiency fractures.
Polymorphisms in the genes for the calcitonin receptor, estrogen receptor-1,

vitamin D receptor, and the type I collagen alpha-1 chain have been shown to
be associated with osteoporosis.
With aging, there is a greater loss of mechanical strength in trabecular bone

more than cortical bone.
NSAIDs have not been shown to increase risk of osteoporosis.
NSAIDs have the potential to cause serious renal impairment.
Regarding DEXA
• Normal bone: T-score greater than -1

• Osteopenia: T-score between -1 and -2.5
• Osteoporosis: T-score less than -2.5
History of a prior vertebral fragility fracture is the strongest predictor of a
future fragility fracture. The strongest associations were observed between
prior and subsequent vertebral fractures.
Renal osteodystrophy:
• Decreased serum calcium

• Increased serum phosphate
• increased alkaline phosphatase
• increased parathyroid hormone (in CRF increased production of PTH)
The key pathophysiological steps in renal osteodystrophy:
• uremia related phosphate retention: most important

• bone mineralization deficiency due to the electrolyte and endocrine
abnormalities
• Hypocalcemia : due to the inability of the damaged kidney to convert
vitamin D3 into its active form calcitriol.
• damaged kidneys are also not able to adequately secrete phosphorus.
In X-linked hypophosphatemic rickets:
• Low serum phosphate

• normal serum calcium
• normal serum parathyroid hormone ( high in nutritional type)

Loss of function mutations in the 25 (OH) vitamin D hydroxylase gene cause

hereditary vitamin D dependant rickets type I.
Hereditary vitamin D dependant rickets type II is caused by a defect in

intracellular receptor for 1,25-(OH)2-vitamin D3.
Both forms of hereditary vitamin D dependent rickets show decreased serum

calcium/phosphorous, elevated alkaline phosphatase/PTH, but type I has a
decrease in the 1,25(OH)2 vitamin D and type II shows a increase in
1,25(OH)2 vitamin D.
When calcium is low, parathyroid hormone (PTH) levels become elevated

which activates 1-alpha-hydroxylase which converts it to the active Vitamin D
(calcitriol).
Gout is a disorder of nucleic acid metabolism that leads to monosodium urate

crystal deposition in the joints. The most common area of the body to be
affected by gout is the first toe. On radiographic evaluation, periarticular
erosions in the setting of tophaceous formations may be seen.
Chondrocalcinosis, or pseudogout : deposits of calcium pyrophosphate-

dihydrate crystals in the articular cartilage and menisci.
The most common cause of neuropathic arthropathy of the shoulder is

syringomyelia, although chronic alcoholism and diabetes have also been
reported. Workup for neuropathic arthropathy of the shoulder includes
magnetic resonance images of the cervical spine, to look for a syrinx of the
central cord.
Psoriatic arthritis :
• seronegative spondyloarthropathy ,
• "Sausage digit" (dactylitis) and nail pitting
• plantar fasciitis, achilles tendinitis, and posterior tibial tendonitis.
• HLA-B27 is positive in approximately 50%.
• "pencil-in-cup" radiographic deformity
Cement pressurization of the femoral canal increases methylmethacrylate
(MMA) and fat emboli into the venous system that can travel to the lungs.
During insertion of the femoral stem, the intramedullary pressures are

increased. Fat and marrow elements can become embolized into the
bloodstream resulting in fat emboli syndrome.
Compared to intra-medullary guidance systems used for total knee

arthroplasty, extra-medullary guidance systems show decreased embolization
risk for the patient.

Patients following long bone fractures are particularly susceptible to fat emboli
syndrome. The major clinical features of FES include hypoxia, pulmonary
edema, central nervous system depression, and axillary or subconjunctival
petechiae.
Factor V Leiden thrombophilia is a variant of human factor V that causes

hypercoagulability.
The most commonly seen signs in the EKG associated with pulmonary
embolism PE are sinus tachycardia, right axis deviation and right bundle
branch block. S-wave in lead I , Q-wave in lead III , T-wave inversion in lead
III is most likely associated with this diagnosis.
The most sensitive and specific recommended diagnostic procedure if

suspected DVT is a venous ultrasonography.
In pulmonary embolism, most patients are hypoxic (Pao2 < 80 mm Hg),

hypocapnic (Paco2 < 35 mm Hg), and have a high A-a gradient (> 20 mm
Hg). Pulse oximetry is not a reliable option to arterial blood gas
measurements because patients can hyperventilate to maintain adequate
oxygenation.
A history of a bleeding disorder (e.g., hemophilia, Von Willebrand's Disease),

recent GI bleed, or hemorrhagic stroke qualifies a patient as having an
elevated risk of major bleeding.
A history of hypercoagulable state (such as protein C deficiency) or previous

documented pulmonary embolism qualifies a patient as having an elevated
risk of pulmonary embolism.
Virchow's Triad of venothrombolic disease is composed of endothelial injury,

venous stasis, and hypercoagulability.
Thromboplastin release is part of the extrinsic coagulation pathway. While this

is useful for decreasing bleeding, it is the same mechanism by which a deep
venous thrombosis (DVT) develops.
The use of recombinant erythropoietin(EPO) preoperatively for patients

undergoing major elective orthopedic surgery has been associated with a
higher incidence of deep vein thrombosis (DVT). EPO interacts with
progenitor stem cells in the bone marrow to increase RBC production. The
use of erythropoietin does decrease transfusion rates, but has no effect on
renal function, bleeding times, wound complications, or bony healing.
External pneumatic compression devices have been shown to prevent the

formation of DVTs by increased venous blood flow.

Rivaroxaban (Xarelto), an oral anticoagulant, is a direct inhibitor of factor Xa.

Inhibition of Factor Xa interrupts the intrinsic and extrinsic pathway of the
blood coagulation cascade, inhibiting both thrombin formation and
development of thrombi.
Tranexamic acid (TXA): is an antifibrinolytic that promotes and stabilizes clot

formation. It works through the competitive inhibition of plasminogen
activation.
Unfractionated heparin works in the coagulation cascade by binding and

enhancing the ability of antithrombin III to inhibit factors IIa, III, Xa. A known
complication of unfractionated heparin use is Heparin Induced
Thrombocytopenia (HIT).
Aspirin is used as a thromboembolism prevention modality.
Ginkgo and ginseng are two common supplements used in the general
population that have inhibitory effects of platelet function.
Usage of low-molecular-weight heparins (LMWH) have been shown to have

an increased rate of postoperative hematomas and wound complications.
Protamine functions to partially reverse the pharmacologic effects of low

molecular weight heparin (LMWH).
Warfarin (coumadin) is an anti-coagulant that works by inhibiting vitamin K

dependent clotting factors II, VII, IX, X, and protein C and S. It exerts its
anticoagulation effect by inhibiting the carboxylation of normal clotting factors.
Amyotrophic lateral sclerosis (ALS) is the most common degenerative disease

of the motor neuron system. Nerve conduction studies and needle
electromyography (EMG) are useful for confirming the diagnosis of ALS and
for excluding peripheral conditions that resemble ALS.
In mangled extremity, rigid skeletal stabilization is recommended to enhance

soft-tissue healing.
Complex regional pain syndrome is a complex clinical problem for the

orthopaedic surgeon. In the acute stage (<3 months), burning or aching pain
that cannot be controlled by narcotics is the major feature. Swelling, cool and
shiny skin, allodynia and hyperpathia are also clinical features. Crepitus,
however, is not a clinical feature.
Vitamin C has been shown to decrease the likelihood of developing complex

regional pain syndrome (CRPS), type 1, when given post-operatively to
patients undergoing foot and ankle and wrist surgery after wrist fractures.

The primary goal of therapy in CRPS is to decrease pain and prevent

stiffness. Early gentle physiotherapy is recommended. Aggressive passive
range of motion is contraindicated in the early phases because it will provoke
pain and inflammation. Other treatment modalities are GABA agonists, alpha-
blockers, beta-blockers, occupational therapy, graded motor imagery, tactile
discrimination treatments, sympathectomy, local anesthetics, and even spinal
cord stimulators.
Patellar osteopenia is the most common radiographic finding in CRPS in

lower limb.
TNF-alpha medical therapy has revolutionized the treatment of rheumatoid

arthritis.
Entanercept (TNF-alpha antagonist) has been shown to increase the risk of

post-operative infection following orthopaedic procedures in patients with RA.
Infliximab is a tumor necrosis factor (TNF) inhibitor.
Rituximab is monoclonal antibody against the protein CD20, but DOES NOT
target tumor necrosis factor-alpha (TNF-alpha).
Medications such as sulfasalazine and penicillamine may be continued during

the pre and post-operative period. Anti-TNF-alpha medications should be
stopped 4 weeks prior to surgery.
Doxycycline (Tetracycline) is combined with methotrexate in the treatment of

rheumatoid arthritis.
A recombinant form of human IL-1Ra, anakinra, is used to manage

rheumatoid arthritis patients who are refractory to more conventional forms of
treatment.
Patients with rheumatoid arthritis who undergo a total knee arthroplasty

without patellar resurfacing are more likely to have anterior knee pain when
compared to the same patient population with resurfaced patellas.
MCP arthroplasty is the procedure of choice for severe finger MCP joint
arthritis involvement or fixed deformities in RA. Thumb MCP involvement is
treated with arthrodesis in most cases.
Vaughn-Jackson syndrome in rheumatoid arthritis describes the rupture of

the hand digital extensor tendons, which start on the ulnar side of the wrist
first and then move radially.
Sagittal band disruption is often associated with rheumatoid arthritis. When

this patient attempts to actively extend the affected digit, the extensor tendon
subluxates ulnarly as a result of the sagittal band rupture, and is left with an

extensor lag. If one passively extends the finger fully, the patient is able to
maintain this position, as the tendon is intact. Sagittal band reconstruction can
be performed.
Surgical treatment of a rheumatoid forefoot involves fusion of the 1st MTP and
lesser metatarsal head resections.
Rheumatoid factor is an auto-antibody most commonly seen with rheumatoid

arthritis. Rheumatoid factor is itself an IgM antibody that is directed against
the Fc portion of IgG antibody.
Doxycycline is a first-line treatment for Lyme disease arthritis. It works to

inhibit protein synthesis by binding to the 30s ribosomal subunit. It also binds
to the 50s ribosomal subunit, but to a much lesser extent.
Hypophosphatasia is associated with decreased serum alkaline phosphatase.
Scurvy is a disease resulting from a deficiency of vitamin C (ascorbic acid),

affects the spongiosa in the metaphysis.
Nitrogen containing bisphsphonates (alendrolate/Fosamax and Zoledronic

acid/Zometa) act by inhibiting farnesyl diphosphate synthase (FPPS),
resulting in decreased prenylation of small GTPases.
Non-nitrogen containing bisphosphonates (such as etidronate) are

metabolized into non-functioning ATP analogues which cause eventual
osteoclast apoptosis.
Bisphosphonates have been shown to decrease fracture incidence and bone

pain while improving bone density and overall function in (OI) patients.
Incidence of new vertebral fractures is reduced by 65% following one year of

treatment and by 41% following 3 years of treatement with bisphosphonates.
The primary mode of bisphosphonate excretion is renal.
Subtrochanteric stress reaction and fracture is a known complication of

longterm bisphosphonate use.
Radiographic changes suggestive of osteopetrosis (marble bone disease) are

a known complication of bisphosphonate usage.
Bisphosphonate-associated osteonecrosis occurs in the jaw.
In spinal fusion surgery, fusion masses were larger in the alendronate treated
rats despite lower fusion rates.

Staphylococcus epidermidis is a gram-positive bacteria that utilizes a

glycocalyx/biofilm to adhere to orthopedic implants and other surfaces and
resist phagocytosis.
Antibiotics exert their effects via five basic mechanisms:
1. Inhibition of cell wall synthesis (cephalosporins, penicillins,

vancomycin, imipenem).
2. Increasing cell membrane permeability (Bacitracin).
3. Ribosomal inhibition (gentamycin, erythromycins, linezolid,
tetracyclines).
4. interference with DNA metabolism (quinolones)
5. antimetabolite action (Trimethoprim).
Aminoglycosides and macrolides interfere with bacterial protein synthesis by
acting on the 30S and 50S ribosome subunits respectively.
Sulfonamides interfere with bacterial folic acid metabolism.
Methicillin-resistant Staphylococcus aureus is the most common carrier of the

mecA gene which encodes for a penicillin-binding protein that alters the
efficacy of beta-lactam antibiotics.
Quinolones inhibit early fracture healing through a toxic effect on

chondrocytes.
Rifampin is a bactericidal antibiotic that blocks the function of RNA

polymerase and subsequent RNA transcription. Because of the high rate of
cellular penetration, it is effective against intracellular phagocytized
staphylococcus.
Patients not allergic to penicillin should take 2 grams of Amoxicillin,

Cephalexin, or Cephadrine, by mouth one hour prior to the dental procedure.
IV antibiotics are very rarely used in dental offices. If allergic to penicillin,
clindamycin would be the next best alternative.
Basic recommendations for splenectomized patients include:
1. pneumococcal immunization.
2. haemophilus influenza type B vaccine.
3. meningococcal group C conjugate vaccine.
4. Influenza immunization should be given.
5. Lifelong prophylactic antibiotics
Indomethacin, commonly used to prevent heterotopic ossification, is
associated with a high rate of gastrointestinal toxicity.
Corticosteroids have not been shown to cause apoptosis of myocytes when

injected extra-articularly.

Aspirin binds irreversibly to the cyclooxygenase enzyme.
The most appropriate and accurate route for delivery of pain medication in the
morbidly obese is via intravenous patient controlled analgesia based on the
patient's ideal body weight.
Intra-articular infusion of lidocaine for pain control after shoulder surgery may
lead to chondrolysis.
Sensory neuropathy is the most common complication seen with interscalene

regional block.
Nitrous oxide is used as an induction agent during anesthesia, and leads to

bowel gaseous distension.
In the preparation and administration of platelet-rich plasma, the addition of

thrombin and calcium chloride initiates platelet activation and release of
growth factors contained within the platelets.
Lead toxicity inhibits the effects of parathyroid hormone-related peptide

(PTHrP).

ANATOMY &
APPROACHES

Horner's syndrome is a rare but known complication of anterior approaches to

the cervical spine. Horner's syndrome is characterized by ptosis, pupillary
constriction and anhidrosis.
The differential diagnosis of acute postoperative obstruction of the upper

airway after cervical spine surgery includes laryngospasm, hematoma,
paralysis of the vocal cords, allergic reaction and edema.
The illiocostalis, longissimus, and spinalis muscles share a common origin

sacrum, iliac crest, and lumbar spinous process. A mnemonic to help
remember the anatomy is from lateral-to-medial: "I(liocostalis)
L(ongissimus)ike S(pinalis)tanding". The iliocostalis muscle inserts on the ribs;
the longissimus on the thoracic and cervical transverse process and mastoid
process; and the spinalis muscle on the thoracic spinous processes.
The retroperitoneal approach to the lumbar spine is commonly used for

anterior lumbar corpectomies, fusions, and total disc replacements. The
approach is usually performed from the left as the aorta is more resistant to
damage than the inferior vena cava (IVC). The bifurcation occurs over the
vertebral body of L4. Anatomic features which are important to identify include
the genitofemoral nerve, ureter, lumbar sympathetic chain, and lumbar
segmental vessels.
Piriformis muscle originates from the ventral surface of the sacrum.
The ilioinguinal nerve travels with the round ligament or spermatic cord
through the superficial inguinal ring. It does not pass through the deep
inguinal ring, and therefore it only travels through part of the inguinal canal.
During the posterior approach to the

hip, the most predictable course of
the sciatic nerve is deep to the
piriformis and superficial to the short
external rotators exiting above the
superior gemellus.

Ischial spine is the site of attachment of the sacrospinous ligament which

anatomically divides the greater and lesser sciatic notches.
The following structures pass through the greater sciatic notch:
• Piriformis muscle
• Sciatic nerve
• Inferior gluteal nerve and artery
• Internal pudendal nerve, artery, and vein
• Nerve to obturator internus muscle
• Nerve to quadratus femoris
• Posterior cutaneous nerve of the thigh
The following structures pass through the lesser sciatic nothc:
• Tendon of obturator internus
• Nerve to obturator internus
• Pudendal nerve
• Internal pudendal artery
The pudendal nerve, sciatic nerve, inferior gluteal nerve, and inferior gluteal
artery all exit the sciatic foramen. The obturator nerve does not exit the sciatic
foramen.
The superior gluteal nerve arises from the posterior roots of L4, L5 and S1 in
the lumbosacral plexus, and leaves pelvis superior to the piriformis tendon.
The inferior gluteal nerve arises from the posterior roots of L5, S1 and S2 in
the lumbosacral plexus and exits the pelvis under the piriformis.
The superior gluteal nerve enters the deep surface of the gluteus medius
approximately 5 cm proximal to the tip of the greater trochanter. Splitting the
muscle, as in the Hardinge approach, has been reported to cause injury to
this nerve if the split is carried above 5 cm.
The lateral femoral cutaneous nerve (L2/3) is at risk of transection or traction

injury with utilization of the ilioinguinal approach to the acetabulum/pelvis. This
structure is most commonly found 10-15mm from the ASIS, passing
underneath the inguinal ligament.

Transtectal transverse fracture with impacted roof needs extended iliofemoral

approach.
Iliofemoral approach carries high risk of heterotopic ossification.
Both an ilioinguinal and modified Stoppa approach allow access to acetabular

fractures involving quadrilateral plate.
The ilioinguinal approach is typically used for anterior wall and column
fracture of the acetabulum. Mobilization of the external iliac vessels and the
iliopsoas or iliopectineal fascia creates the 3 windows of the ilioinguinal
approach:
• Medial window: medial to external iliac artery & vein.
• Middle window: between external iliac vessels and the

iliopsoas (or iliopectineal fascia)
• Lateral window: lateral to iliopsoas (or iliopectineal fascia).
While in the middle window of the ilioingunal approach, the obturator nerve
may be injured which gives sensory innervation the medial thigh.
The direct lateral approach of the hip (Hardinge) splits the fibers of the gluteus
medius which is innervated by the superior gluteal nerve.
The direct lateral (Hardinge) approach for total hip arthroplasty has been cited
to have the lowest associated dislocation rate .
The medial approach to the hip gives excellent exposure to the insertion of
the psoas tendon on the lesser trochanter. The medial femoral circumflex
artery is at risk when performing a psoas release with this approach.
The medial femoral circumflex artery is the primary blood supplier to the adult
femoral head. This artery anastamoses with the first perforating branch of the
profunda femoris just medial to the gluteus maximus insertion.
The psoas muscle serves to protect the iliac vessels from

retractors/instruments anterior to the acetabulum, and this muscle originates
off the transverse processes of L1-L5.
The ascending branch of the lateral femoral circumflex artery is at risk during
the Smith-Petersen approach to the hip. In this approach, an internervous
interval between the femoral nerve (sartorius, superficial; rectus femoris,
deep) and superior gluteal nerve (tensor fascia latae, superficial; gluteus
medius, deep) is utilized. The ascending branch of the lateral femoral
circumflex artery runs proximally in the internervous plane between the two
deep muscles.

Hunter’s canal is also known as the adductor canal, which runs behind the
sartorius muscle. It is located between the anterior and medial thigh
compartments.
The biceps femoris has two heads as its name implies. Each head has its own
nerve supply. The long head is innervated by the tibial branch of the sciatic
nerve (L5, S1, S2, and S3). The short head is innervated by the peroneal
branch of the sciatic nerve (L5, S1, and S2).
The superior lateral genicular artery is the one at greatest risk with a lateral
release of the patella.
Intra-articular administration of medications has been shown to be highest

with the injection performed lateral to the middle to proximal patella with the
knee in extension.
The deep peroneal nerve supplies the

extensor digitorum longus, along with
tibialis anterior, extensor hallucis longus,
extensor digitorum brevis, peroneus
tertius, and extensor hallucis brevis.
The deep peroneal nerve is at risk

during an anterolateral approach to the
distal tibia and ankle for open reduction
and internal fixation of pilon fractures.
The internervous plane of posterolateral approach to the tibia exists between

the gastrocnemius, soleus and FHL muscles posterior (tibial nerve) and the
peroneus longus and brevis anteriorly (superficial peroneal nerve).
The flexor digitorum longus and tibialis posterior lie on the posterior aspect of
the interosseous membrane and tibia. Flexor hallucis longus lies on the
posterior border of the fibula.
The axillary nerve divides into an anterior, a posterior, and a collateral branch
to the long head of the triceps brachii. The anterior branch winds around the
surgical neck of the humerus to provide innervation to the anterior deltoid and
overlaying skin. The posterior branch supplies the teres minor and the

posterior part of the deltoid and supplies the skin over the lower two-thirds of
the posterior deltoid.
Transposition of the ulnar nerve after ORIF of an intra-articular distal humerus

fracture has been shown to be associated with an increased incidence of
ulnar neuritis.
The PIN is at risk of iatrogenic damage when performing surgery on volar

aspect of the proximal forearm. This is particularly a concern during elbow
arthroscopy when working through a distally placed anterolateral portal.
The common interosseus artery is a branch high off the ulnar artery just distal
to the brachial artery bifurcation.
The internervous plane in Henry approach to the forearm is pronator teres

(median) and brachioradialis (radial nerve). The arm should be supinated in
proximal diaphyseal radius fractures to move the PIN away from the surgical
field.
The Thompson (posterior) approach to the radius involves the interval

between the radial nerve and the posterior interosseous nerve (a branch of
the radial nerve proper). Proximally, the interval is between the ECRB (radial
nerve) and the EDC (PIN), whereas more distally, the interval is between the
ECRB (radial nerve) and EPL (PIN).
Laceration that severs the brachioradialis would most likely injure the
superficial radial nerve.
The main blood supply to the abductor digiti minimi is the ulnar artery..
The 1st and 2nd lumbricals are unipennate and

originate on the flexor digitorum profundus
(FDP) to these fingers. The 3rd and 4th
lumbricals are bipennate and each have one
head that originates from the FDP from the
respective finger and a second head that
originates from the FDP of the middle and ring
finger, respectively.

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DR. MAHMOUD DESOUKY 1

Previously healthy, poly-trauma patients, presenting with platelet counts of

In "compensated" shock despite normal vital signs and urine output

Frontal airbags had no significant protective effect on pelvic fractures.

The risk of viral transmission following a screened blood donation is highest

To avoid compression of the inferior vena cava in pregnant patient who is in

If the floating knee injury is an isolated injury and the patient is

A favorable response to fluid replacement therapy includes increased urinary

A loss of 15-30%of normal circulating blood is needed for a patient to become

DR. MAHMOUD DESOUKY 2

Ten or more years after severe polytrauma, premenopausal women,

Severe lower extremity injury patients undergoing reconstruction have a

• Skeletal / soft-tissue injury

Current initial recommendations for type II open fractures include tetanus

DR. MAHMOUD DESOUKY 3

Algorithm to provide appropriate tetanus prophylaxis

In patients with chronic osteomyelitis and an infected nonunion complicating

The general trend is increasing energy requirement for more proximal

A through-knee amputation, or knee disarticulation, is the most proximal level

In modified Lisfranc (tarsometatarsal) amputation unopposed pull of

Adductor myodesis is a critical part of a transfemoral amputation . It balances

Hyperbaric oxygen therapy (HBO) allows patients to breathe 100% oxygen in

Overgrowth is the most common complication following transosseous

A Syme amputation is effectively ankle disarticulation. It works better for

The Chopart (midtarsal) amputation results in equinus deformity that

DR. MAHMOUD DESOUKY 5

Interdisciplinary collaboration among healthcare workers was a predictor of

Intracompartmental pressure measurements should be performed when pain

It is recommended that intraoperative compartment pressures be compared to

DR. MAHMOUD DESOUKY 6

Isolated compartment syndrome in the lateral compartment of the leg affects

Release of deep posterior compartment of the leg cannot be done without

Mechanism of injury is not the best predictor of compartment syndrome

Common peroneal nerve is at risk during proximal dissection of a single

The single most important symptom of impending compartment syndrome is

A Marjolin's ulcer is a malignant tumor that develops around chronic

In contrast to acute osteomyelitis, chronic osteomyelitis is often not eradicated

Metaphyseal infections heal better than mid-diaphyseal infections.

A saline load test is commonly utilized to evaluate for traumatic arthrotomies

Staphylococcus aureus is now the major cause of sternoclavicular septic

Exopolysaccharide glycocalyx allows bacteria to adhere to orthopaedic

The most sensitive parameter to detect inflammation elicited by implants and

DR. MAHMOUD DESOUKY 7

When suspecting necrotizing faciitis , biopsy with a frozen section is effective

Upper Extremity Trauma

Finger abduction is performed by the ulnar nerve, which is supplied by the

Findings that suggest a pre-ganglionic brachial plexus injury include Horner

The supraspinatus is innervated by the suprascapular nerve off the upper

Anterior SC joint instability should primarily be treated conservatively.

Symptomatic acute posterior sternoclavicular dislocations in adolescents

The treatment for spontaneous atraumatic subluxaton of the sternoclavicular

Surgical management of displaced, shortened (>2 cm) clavicle fractures is

DR. MAHMOUD DESOUKY 8

Small fragment plate fixation with possible coracoclavicular ligament

Treatment of atrophic nonunions of the clavicle is with plate fixation in

Figure of eight braces have been shown to have no differences as compared

The risk of nonunion in patients sustaining middle 1/3 clavicle fractures is

In the posterior or modified Judet approach to the scapula , The interval

Significantly displaced extra-articular glenoid neck fractures, have

Patients presenting to a trauma center with scapula fractures have an

In scapulothoracic dissociation , neurologic status of the extremity is the

Displaced greater tuberosity fracture more than 5mm of displacement is an

The pectoralis major tendon is a reproducible structure from which the