Tarascon Pocket Orthopaedica, 4E [4th Edition] 9781284050349, 1284050343, 9781284176780, 1284176789

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Tarascon Pocket Orthopaedica Fourth Edition From the publishers of the Tarascon Pocket Pharmacopoeia®

Damian M. Rispoli

World Headquarters Jones & Bartlett Learning 5 Wall Street Burlington, MA 01803 978-443-5000 [email protected] www.jblearning.com Jones & Bartlett Learning books and products are available through most bookstores and online booksellers. To contact Jones & Bartlett Learning directly, call 800-832-0034, fax 978-443-8000, or visit our website, www.jblearning.com. Substantial discounts on bulk quantities of Jones & Bartlett Learning publications are available to corporations, professional associations, and other qualified organizations. For details and specific discount information, contact the special sales department at Jones & Bartlett Learning via the above contact information or send an email to [email protected]. Copyright © 2020 by Jones & Bartlett Learning, LLC, an Ascend Learning Company All rights reserved. No part of the material protected by this copyright may be reproduced or utilized in any form, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without written permission from the copyright owner. The content, statements, views, and opinions herein are the sole expression of the respective authors and not that of Jones & Bartlett Learning, LLC. Reference herein to any specific commercial product, process, or service by trade name, trademark, manufacturer, or otherwise does not constitute or imply its endorsement or recommendation by Jones & Bartlett Learning, LLC and such reference shall not be used for advertising or product endorsement purposes. All trademarks displayed are the trademarks of the parties noted herein. [Title, Edition] is an independent publication and has not been authorized, sponsored, or otherwise approved by the owners of the trademarks or service marks referenced in this product. There may be images in this book that feature models; these models do not necessarily endorse, represent, or participate in the activities represented in the images. Any screenshots in this product are for educational and instructive purposes only. Any individuals and scenarios featured in the case studies throughout this product may be real or fictitious, but are used for instructional purposes only. Nursing/Medicine/Communication & Speech Disorders The authors, editor, and publisher have made every effort to provide accurate information. However, they are not responsible for errors, omissions, or for any outcomes related to the use of the contents of this book and take no responsibility for the use of the products and procedures described. Treatments and side effects described in this book may not be applicable to all people; likewise, some people may require a dose or experience a side effect that is not described herein. Drugs and medical devices are discussed that may have limited availability controlled by the Food and Drug Administration (FDA) for use only in a research study or clinical trial. Research, clinical practice, and government regulations often change the accepted standard in this field. When consideration is being given to use of any drug in the clinical setting, the health care provider or reader is responsible for determining FDA status of the drug, reading the package insert, and reviewing prescribing information for the most up-to-date recommendations on dose, precautions, and contraindications, and determining the appropriate usage for the product. This is especially important in the case of drugs that are new or seldom used. Production Credits Director of Product Management: Amanda Martin Product Manager: Teresa Reilly Product Assistant: Anna-Maria Forger Production Editor: Daniel Stone Marketing Manager: Lindsay White Manufacturing and Inventory Control Supervisor:   Amy Bacus Composition: S4Carlisle Publishing Services ISBN: 978-1-284-05034-9 6048 Printed in the United States of America 22 21 20 19 18 10 9 8 7 6 5 4 3 2 1

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Tarascon Pocket Orthopaedica Fourth Edition

Trauma Protocols

Initial Approach to Trauma Assessment and Management Trauma Radiographs Tension Pneumothorax Chest Tube IV Maintenance Therapy Cardiac Tamponade Foley Catheter Major Differences in Pediatric Versus Adult Polytrauma

1 1 2 2 2 3 3 3 5

Anatomy 7 Muscle Tables 7 Approaches 17 Cross Sections 21 Arteries 26 Ligaments 30 Nerve Plexi 36 Peripheral Nerves (Motor) 39 Peripheral Nerves (Sensory) 46 Nerves 47 Dermatomes 49

Suggested Antibiotic Prophylaxis If Urologic Criteria Are Met Suggested Antibiotic Prophylaxis for GI Procedures

Anticoagulation Therapy Blood Transfusion

76 76

76 77

Viral 77 Systemic Reactions 77

Ca++/Phosphate 78 Regulation of Calcium and Phosphate Metabolism

78

Laboratory 78 Joint Fluid Analysis 78 Gross Examination 79 Differential (% Neutrophils) 79 Culture 79 Polarized Microscopy 79

Tests For Infection

80

Metabolic Bone Disease

80

Arthritis—Septic 51 Total Joint Arthroplasty—Criteria for Infection 53 Antibiotics for Surgical Prophylaxis 63

Nerves, EMG/NCV

81

Compartment Syndrome 65 Acute Stabilization of the Pelvis Methods 72

Obesity 83

Antimicrobials 51

Emergency Procedures

65

GENERAL ORTHOPAEDICS Antibiotic Prophylaxis

75 75

Potentially Increased Risk 75 Suggested Antibiotic Prophylaxis If ­Surgeon Chooses Dental Prophylaxis 75

Gram Stain Tissue Frozen Section

Clinical and Radiologic Overview of Metabolic Bone Disease

80 80

80

EMG Findings/Meaning 81 Electrodiagnostic Findings in Various Peripheral Nerve Disorders 82 Nerve Injury Classification 83 Obesity Standards [World Health Organization] 83

Osteonecrosis 84 Etiologies 84 MRI 84

iv  Tarascon Pocket Orthopaedica Natural History Treatment Options Staging System for Osteonecrosis of the Hip

84 84 84

Osteoporosis 85 Osteoporosis 85 DEXA Osteoporosis Criteria 85 Osteoporosis Risk Factors 85 Calcium Recommendations 86 Vitamin D 86 Prophylactic Reccomendations 86

Reflexes 96 Characteristics of Myelodysplasia Levels 97

Growth Centers Growth Plates

97 97

Foot 99

Angles and Characteristics 100 Normal Talo-Calcaneal Angle Is 20–40 Degrees 100 Clubfoot Treatment—Ponseti Technique 100

Pain Management, Degenerative Arthritis 86

Brachial Plexus

Perioperative Management

General 101

1st Line of Treatment 2nd Line of Treatment

86 87

87

Perioperative Management in the Patient With Rheumatologic Disorders 87 Nonsteroidal Anti-Inflammatory Drug Half-Life 88 Supplemental Hydrocortisone for Surgical Stress 89

Tetanus 89

Wound Classification for Tetanus Prophylaxis 89 Tetanus Immunization Schedule 89

Tobacco Abuse

Tobacco’s Effects

90 90

Tourniquet 90 Tourniquet Use

Venous Thromboembolic Disease

90

91

Commonly Used Prophylaxis Options 92 Guidelines for Duration of Therapy 92

Wound Healing 93 PEDIATRIC ORTHOPAEDICS 95 Medications 95 Analgesics 95 Antihistamines 95

Milestones and Angles

95

Gait 95 Rotational Profile 96 Development of Cervical Spine 96

100

Brachial Plexus Birth Injuries 100 Osteochondroses (Osteonecrosis at Apophysis/Physis) 101 Arthroscopic Classification of Osteochondritis Dissecans (Guhl) 101 Night Pains 101 Back Pain in Children 102 Mucopolysaccharidosis 102

Dysplastic Conditions

103

Salter-Harris Classification

105

Disproportionate Dwarfism Proportionate Dwarfism Salter-Harris Classification of Physeal Injuries

103 104

105

Slipped Capital Femoral Epiphysis 106 Slipped Capital Femoral Epiphysis 106 Classification 106 Radiographic Evaluation 106 Physical Exam 106 Grading 106 Treatment 106

Limp 107

Evaluation 107 Radiographs 107 Ultrasound 107 MRI 107 Transient Synovitis vs. Septic Arthritis 108 Five Predictors of Septic Hip Arthritis 108 Osteomyelitis in Children 109 Limp—Differential Diagnosis 110



Tarascon Pocket Orthopaedica  v Vertebral Infection 110 Discitis 110 Genu Varum 110

Scoliosis 111 Neuromuscular Scoliosis Infantile Idiopathic Scoliosis Early Onset Idiopathic Scoliosis Adolescent Idiopathic Scoliosis Treatment Guidelines Progression Risk Factors Lenke Classification of Adolescent Idiopathic Scoliosis Congenital Spinal Deformities

Child Abuse

111 111 111 111 112 112

114 114

117

Skeletal Survey in Child Abuse 117 Differential Diagnosis in Child Abuse 117 Specificity of Musculoskeletal Findings in Child Abuse 117

Legg-Calves-Perthes 118 Legg-Calvé-Perthes Stages 118 Herring Classification 118 Risks 118 Physical signs 118 Key to prognosis 118

DDH 119

Developmental Dysplasia of the Hip 119 Risk With History 119 Distribution 119 Algorithm for Evaluation and Treatment of DDH 120

Physical Exam and Injections

121

Radiologic Views

143

Physical Exam: Hand Wrist Injection Wrist Block Physical Exam: Elbow Physical Exam: Shoulder Physical Exam: Spine Physical Exam: Hip Physical Exam: Knee Physical Exam: Ankle/Foot

Radiologic Views: Spine Radiologic Views: Upper Extremity MRI Signal Characteristics Radiologic Views: Hip/Pelvis Radiologic Views: Lower Extremity Radiologic Views: Foot/Ankle

121 128 128 129 132 136 138 138 140 143 149 151 154 158 159

Concussion 164 Concussion: Major Features Neuropsychological Testing Concussions in Athletes Stages of Concussive Injury

164 164 164 165

Spinal Evaluation

165

Low Back Pain Treatment

168

Spinal Cord Injury Syndromes

169

Steroids in Emergent Cord Injury 165 Autonomic Dysreflexia 166 Spondylolysis and Spondylolisthesis 166 Listhesis Grades 166 Muscle Strength Testing 166 Reflexes 166 Lumbar Spinal Stenosis 167 Spondylolysis 167 Frankel Grade 167 Acute Low Back Pain (≤ 6 wk) 168 Chronic LBP (> 6 wk), Worsening Radiculopathy 168 Spinal Cord Injury Treatment by Functional Level

169

Traction 171 Traction Setups Traction Pin Placement Distal Femoral Pin Proximal Tibial Traction Pin Traction Types

171 171 172 172 173

Trauma—Adult 177 Hand 177

Small Joint Fusion

179

Stress Fractures

201

Fingers 179 Thumb 179 Hand 179 Wrist 182 Radius/Ulnar Shaft 183 Elbow 184 Shoulder 189 Shoulder Girdle 194 Cervical Spine 196 Thoracic and Lumbar Spine 200 Fracture Types and Columnar Involvement 201 Pelvis Fractures 202 Pelvic Fractures With Hemodynamic Instability 203

vi  Tarascon Pocket Orthopaedica Periprosthetic Femur Fracture Classification and Treatment 207 Hip Fractures 207 Hip Dislocations 209 Femoral Shaft Fractures 211 Knee Fractures 211 Knee Dislocation/Soft Tissue Injury 212 Tibia/Fibular Fractures 213 Classification of Acute Lateral Ankle Sprains 214 Leg/Ankle Fractures/Dislocations 215 Foot Fractures and Dislocations 216

Trauma—Pediatric 221

Pediatric Trauma—Wrist and Hand Fractures 221 Wrist and Hand Fractures 222 Radius/Ulnar Shaft (Fracture/Dislocation) 223 Elbow 226 Shoulder 231 Spine Fractures 233 Hip Fractures and Dislocations 234 Apophyseal Avulsion Fractures 234 Apophyseal Avulsion Fractures Around the Pelvis 235

Pelvic and Acetabulum Fractures Femoral Shaft Fractures Knee Fractures and Dislocations Tibia and Fibula Fracture Ankle Fractures Foot Fractures

Trauma Scores/Classifications Gustillo Classification Open Hand Injuries Management of Severe Extremity Soft Tissue Trauma

235 237 238 240 241 243

245 245 246

247

Tumor 248

Staging System for Musculoskeletal Lesions (Enneking) 248 Scoring System to Predict Pathologic Fracture 249 Osteoblastic Metastasis 249 Skeletal Fixation of Metastatic Carcinoma 249 Lodwick’s Classification (Radiographs of Bone Lesions) 250 Malignant Lesions 251 Intra-Articular Tumors 251 Musculoskeletal Tumor Society (MSTS) Stages of Disease 251

Editorial Board Damian Rispoli, MD

Chief, Shoulder and Elbow Surgery Weirton Medical Center, Weirton, WV

David Carmack, MD

Tracy Popey, MD

Marc Deschaine, MPAS, PA-C

Eric Ritchie, MD

Chief, Orthopedic Surgery Department Medical Director, Orthopedic Trauma Service Eastern Maine Medical Center, Bangor, ME Faculty Specialist Orthopaedics Deputy Medical Director - MARC Clinic Department of Orthopaedics The University of Texas Health Science Center at San Antonio, San Antonio, TX

Orthopedic Surgeon Chief of Anesthesia, Chief of Surgery Highlands Hospital, Connellsville, PA Owner / Pediatric Orthopaedic Surgeon Trinity Adult and Pediatric Orthopaedic Specialists

Evan Jones, MD

Flight Commander Orthopaedic Surgery Chief of Hand Service Joint Base Elmendorf-Richardson, AK *Affiliations are given for information purposes only, and no affiliation sponsorship is claimed. Damian M. Rispoli authored this book in his private capacity. The views expressed in the book do not necessarily represent the views of either the United States Air Force or the United States government.

A NOTE FROM THE AUTHOR The Tarascon Pocket Orthopaedica is intended as a quick reference for orthopedic practice. It represents a compilation of facts and data that I have had the occasion to need at times—the basic information that was passed on to me from many talented individuals. If you find an error or wish to make a suggestion, please let us know (e-mail: [email protected]). A special thanks to my partner Vicki Rispoli, who makes everything better! Thanks and appreciation to Josh, Zach, Beth, Ben, and Erika, who never stop teaching their parents.



Trauma Protocols  1

TRAUMA PROTOCOLS Initial Approach to Trauma Assessment and Management PRIMARY SURVEY A Assess Airway (immobilize cervical spine)

• If poor or no air movement, perform jaw thrust or insert oral or nasal airway. • Intubate if Glasgow Coma Scale ≤ 8, poor response to above, severe shock, flail chest, or need to hyperventilate. • Cricothyroidotomy or laryngeal mask airway if needed. B • Examine neck and thorax to detect deviated trachea, Assess Breathing flail chest, sucking chest wound, and breath sounds. • Administer O2, apply pulse oximeter, measure ETCO2. • Needle chest for tension pneumothorax, apply occlusive dressing to 3 sides of sucking chest wound, reposition ET tube, or insert chest tubes (36–38 Fr) if needed. C • Apply pressure to external bleeding sites, establish two Assess Circulation large peripheral IV lines, obtain blood for basic labs and type and crossmatch, and administer 2 L NS IV prn. • Check pulses, listen for heart sounds, observe neck veins, assess cardiac rhythm, and treat cardiac tamponade. • Apply cardiac monitor, and obtain BP and HR (pulse quality). D Measure Glasgow Coma Scale or assess if: Assess Disability AVPU (Alert, responds to Verbal stimuli, Painful, (Neurologic Status) ­Unresponsive to pain) • Pupil assessment—size and reactivity E Exposure • Completely undress patient (but keep warm) and examine all surfaces. RESUSCITATION (Perform simultaneously during primary survey) Reassess ABCDEs • Reassess ABCDEs if patient deteriorates. Address ­abnormality as identified; place chest tube if needed. • Emergent thoracotomy if > 1.2–1.5 L of blood from initial chest tube, > 100–200 mL/h after 1st h, or persistent ↓BP. • Administer 2nd 2-L NS bolus, then blood prn. • Place NG tube and Foley catheter (unless contraindicated). Reproduced with permission from Tarascon Adult Emergency Pocketbook, 3rd ed. Lompoc, CA: Tarascon Publishing, 2005.

2  Tarascon Pocket Orthopaedica SECONDARY SURVEY History Physical Exam X-rays Address Injuries Disposition

• Obtain AMPLE history (see below). • Perform head-to-toe examination (including rectal/back). • Obtain cervical spine, chest, pelvic films, CT scans, etc. • Reduce/splint fractures, call consultants as soon as needed; administer analgesics, tetanus, and antibiotics prn. • Initiate transfer, admit, or ready OR. Document all findings, X-rays, labs, consultants, and talk to family.

Reproduced with permission from Tarascon Adult Emergency Pocketbook, 3rd ed. Lompoc, CA: Tarascon Publishing, 2005.

Trauma Radiographs • Chest and AP pelvis • Chest and pelvis radiograph may aid in resuscitative effort. TRAUMA HISTORY A Allergies M Medications currently using (legal, illicit, and herbal) P Past illness/pregnancy L Last meal E Events/environment related to the injury Chest and pelvis radiograph may aid in resuscitative effort. Abnormal C-spine film can identify pathology. Negative or inadequate films do not rule out pathology.

Tension Pneumothorax • Chest pain, air hunger, respiratory distress, tachycardia, hypotension, hyper-resonant percussion, tracheal deviation, unilateral absent breath sounds, jugular venous ­distention (JVD), and cyanosis. • Emergent treatment: Large-bore needle into the 2nd intercostal space in the midclavicular line. Definitive treatment requires a chest tube. Chest Tube • Transverse incision at nipple level (usually 5th rib) in the midaxillary line. Tunnel to rib midaxillary line, place curved clamp into chest over the top of the rib (protects neuro-vascular bundle on inferior surface). Spread with clamp, insert finger into chest to clear area. Insert chest tube, secure in place, attach to Pleur-evac or Heimlich valve.



Trauma Protocols  3 IMPORTANT TRAUMA NUMBERS Blood Volume 70 kg man ~ 5 L Child 80–90 mL/kg

Estimation of Systolic BP BP ~ 60 mm Hg carotid pulse BP ~ 70 mm Hg femoral pulse BP ~ 80 mm Hg radial pulse Warm All IV fluids!

Initial Fluid Management 1–2 L in adult; 20 mL/kg in child 1 unit of packed red blood cells should ↑ hemoglobin by 1.0 g/dL or hematocrit by 3.0%. NORMAL ACID–BASE VALUES Arterial Venous

pH 7.37–7.43 7.32–7.38

PCO2 37–43 42–50

HCO3 22–26 23–27

Shock = inadequate tissue perfusion.

IV Maintenance Therapy 0–10 kg = 4 cc/kg/h 10–20 kg = 40 cc/h + 2 cc/kg/h > 20 kg = 60 cc/h + 1 cc/kg/h Cardiac Tamponade Beck’s Triad: [1] Venous pressure elevation, [2] decreased arterial pressure, [3] muffled heart tones. • Echocardiogram or ultrasound may aid in diagnosis. • Monitor ECG during pericardiocentesis, 6-inch, 16- to 18-gauge needle, enter left and 1 cm inferior to xiphoid process, 45 degrees to the skin, advance while aiming at left scapular tip, aspirate as you advance. Foley Catheter • Assess prostate, scrotum, and perineum for signs of trauma. Consider retrograde urethrogram (RUG) with pelvic fracture. Mandatory with exam abnormality (blood at meatus, high-riding prostate, severe pelvic trauma).

AMERICAN COLLEGE OF SURGEONS ESTIMATED FLUID AND BLOOD LOSSES (ADULT) Class I Class II Class III Class IV Blood loss (mL) ≤ 750 750–1500 1500–2000 > 2000 Blood loss (%) < 15 15–30 30–40 > 40 Pulse rate (bpm) < 100 100–120 120–140 > 130 Blood pressure Normal Normal Decreased Decreased Pulse pressure Normal or ↑ Decreased Decreased Decreased

(continues)

4  Tarascon Pocket Orthopaedica AMERICAN COLLEGE OF SURGEONS ESTIMATED FLUID AND BLOOD LOSSES (ADULT)

Continued

Respiratory rate Urine output (mL/h) Mental status Fluid replacement (3:1 rule)

Class I 14–20 > 30

Class II 20–30 20–30

Class III 30–40 5–15

Class IV > 35 Negligible

Slightly anxious Crystalloid

Mildly anxious Crystalloid

Anxious, confused Crystalloid, blood

Confused, lethargic Crystalloid, blood

Reproduced with permission from Krantz BE (ed.). Advanced Trauma Life Support for Doctors, Student Course Manual, 6th ed. Chicago, IL: American College of Surgeons, 1997.

SYSTEMIC RESPONSES TO BLOOD LOSS (MILD, MODERATE, AND SEVERE) System < 30% Loss 30–40% Loss > 45% Loss Cardiac Weak and thready Marked ↑ heart rate, low Hypotension, pulse, increased normal pressure, ↓ pulse tachycardia, then heart rate pressure, absent peripheral bradycardia with weak and thready central pulses CNS Anxious, irritable, ↓ Level of consciousness Comatose confused and pain response Skin Cool, clammy, Cyanosis, markedly Pale, cold mottled skin, prolonged cap refill prolonged cap refill Kidneys Increased specific Minimal urine output No urine output gravity, decreased urine output

AMERICAN COLLEGE OF SURGEONS PEDIATRIC VITAL SIGNS Blood Heart Rate ­Pressure Age (years) Wt. (kg) (bpm) (mm Hg) 0–1 0–10 < 160 > 60 1–3 10–14 < 150 > 70 3–5 14–18 < 140 > 75 6–12 18–36 < 120 > 80 > 12 36–70 < 100 > 90

Respiratory (/min) < 60 < 40 < 35 < 30 < 30

Urine Output (mL/kg/h) 2.0 1.5 1.0 1.0 0.5

Data from Krantz BE (ed.). Advanced Trauma Life Support for Doctors, Student Course Manual, 7th ed. Chicago, IL: American College of Surgeons, 2004.



Trauma Protocols  5

Major Differences in Pediatric Versus Adult Polytrauma Pediatric patients (JAAOS 2013;21(3):170-179): • Develop hypotension at greater loss of blood volume (maintain equilibrium longer). • Organ failure occurs acutely and simultaneously. • Lower risk of lung injury but a greater risk of organ versus bony injury. • Higher local and lower systemic inflammatory response. • Low risk of death with pelvic injury but greater morbidity associated with organ injuries. • High rate of recovery from neurologic injuries. GLASGOW COMA SCALE Eye Opening (Score) Spontaneous (4) To verbal command (3) To pain (2) None (1)

Best Verbal (Score) Oriented, converses (5) Disoriented, converses (4) Inappropriate words (3) Incomprehensible (2) None (1)

Best Motor (Score) Obeys commands (6) Localizes pain (5) Flexion, withdrawal (4) Flexion (abnormal) decorticate (3) Extension, decerebrate (2) None (1)

The total of the scores from all three categories represents the Glasgow Coma Scale finding. A completely nonresponsive individual would have the lowest score of 3; a completely alert and functioning individual would have the highest possible score of 15.

PEDIATRIC VERBAL SCORE V-Score 5 4 3 2 1

Verbal Response Appropriate words or social smile, fixes, and follows Cries, consolable Persistently irritable Restless, agitated None

Data from Krantz BE (ed.). Advanced Trauma Life Support for Doctors, Student Course Manual, 6th ed. Chicago, IL: American College of Surgeons, 1997: 304.

9%

18%

1%

18%

18% Back

18% Front

9%

9%

Used with Permission from Tarascon Adult Emergency Pocketbook, 3rd ed. Tarascon Publishing, Lompoc, CA: 2005.

Carvajal’s solution 5,000 mI/m2 of burn + maintenance 2000 mI/m2 in 1st 24h, with ½ over the 1st 8 hours and ½ over the subsequent 16 hours.

CARVAJAL’S FORMULA

Lactated ringers 4 ml/kg/% burn body surface area in 1st 24 hours + maintenance fluid, with ½ over 1st 8 hours, & ½ over next 16 hours. (Hours calculated from time of injury not time of arrival)

Parkland Formula

ESTIMATION OF TOTAL BODY SURFACE AREA BURNED FLUID RESUSCITATION IN BURN VICTIMS

6  Tarascon Pocket Orthopaedica

Thoracodorsal

Dorsal scapular Dorsal scapular Dorsal scapular Lateral/medial pectoral

Medial pectoral Nerve to subclavius Long thoracic Axillary

Lower subscapular

Axillary Upper and lower subscapular Suprascapular Suprascapular

Latissimus dorsi

Rhomboid major Rhomboid minor Levator scapulae Pectoralis major

Pectoralis minor Subclavius Serratus anterior Deltoid

Teres major

Teres minor Subscapularis

Supraspinatus Infraspinatus

Nerve Spinal accessory

Muscle Trapezius

Shoulder Girdle

Supraspinatus fossa Infraspinatus fossa

Scapula, dorsolateral Ventral scapula

Ribs 3–5 Rib 1 Ribs 1–9 Lateral 1/3 clavicle, acromion, lateral 1/3 scapula Scapula, inferolateral

Spinous process T2–5 Spinous process C7–T1 Transverse process C1–4 Sternum, ribs, clavicle

Spinous process T6–S5, ilium

Origin Spinous process C7–T12

Humerus, greater tuberosity Humerus, greater tuberosity

Humerus, medial ­intertubercular groove Humerus, greater tuberosity Humerus, lesser tuberosity

Insertion Clavicle, scapular spine, acromion Humerus, intertubercular groove Scapula, medial border Scapula, medial spine Scapula, superior medial Humerus, lateral intertubercular groove Scapula, coracoid Clavicle, inferior Scapula, ventral medial Humerus, deltoid tubercle

C(4), 5, 6 (superior trunk) C(4), 5, 6 (superior trunk)

C5, 6 (posterior cord) C5, 6, 7 (posterior cord)

C5, 6, 7 (posterior cord)

C5 (root) C5 (root) C5 (root) C5, 6, 7, 8 T1 (lateral/ medial cord) C7, 8 T1 (medial cord) C5, 6 (superior trunk) C5, 6, 7 (roots) C5, 6 (posterior cord)

C6, 7, 8 (posterior division)

Spinal Segment CNXI, C2, 3, 4



ANATOMY—MUSCLE TABLES

Anatomy—Muscle Tables  7

Radial

Musculocutaneous— medial Radial—lateral

Triceps

Brachialis

Median

Median

Median

Flexor carpi radialis

Palmaris longus

Flexor digitorum superficialis Flexor carpi ulnaris

Ulnar

Median

Pronator teres

Forearm Region—Superficial Flexors

Nerve Musculocutaneous Musculocutaneous

Muscle Coracobrachialis Biceps

Arm Region

Humerus, medial epicondyle, anterior radius Humerus, medial epicondyle, dorsal ulnar border

Humerus, medial epicondyle

Humerus, medial epicondyle, coronoid Humerus, medial epicondyle

Origin Coracoid Coracoid—short head Supraglenoid tubercle—long head Long head—infraglenoid tubercle Lateral head and medial head— posterior humerus Anterior humerus

Pisiform, hamate, 5th metacarpal base

Middle phalangeal bases

Palmar aponeurosis

2nd–3rd metacarpal bases

Radius, mid lateral

Ulna, coronoid process

Ulna, olecranon

Insertion Humerus, mid/medial Radius (radial tuberosity)

C6, 7 (medial and lateral cords) C6, 7, (8) (medial and ­lateral cords) C7, 8 T1 (medial and lateral cords) C7, 8 T1 (medial and lateral cords) C7, 8 (medial cord)

C5, 6 (lateral posterior cord)

C6, 7, 8 (T1) (posterior cord)

Spinal Segment C6, 7 (lateral cord) C5, 6 (lateral cord)

8  Tarascon Pocket Orthopaedica

Nerve Median (anterior interosseous)-index/ long, Ulnar-ring/small Median (anterior interosseous) Median (anterior interosseous)

Radial

(Radial) Posterior interosseous Radial

Radial

Radial (posterior interosseous) Radial (posterior interosseous) Radial (posterior interosseous)

Brachioradialis

Extensor carpi radialis brevis Extensor carpi radialis longus Anconeus

Extensor digitorum communis Extensor digiti minimi Extensor carpi ulnaris

Forearm Region—Superficial Extensors

Pronator quadratus

Flexor pollicis longus

Muscle Flexor digitorum profundus

Forearm Region—Deep Flexors

Humerus, lateral epicondyle Humerus, lateral epicondyle Common extensor tendon Humerus, lateral epicondyle

Humerus, lateral supracondylar ridge Humerus, lateral supracondylar ridge Humerus, lateral epicondyle

Distal ulna

Radius, anterior and lateral

Origin Ulna, anterior and medial

C6, 7, 8 (posterior cord)

Small finger extensor apparatus 5th metacarpal base

C6, 7, 8 (posterior cord)

C6, 7, 8 (posterior cord)

Extensor aponeurosis

C7, 8 (posterior cord)

C(5), 6, 7, (8) (posterior cord)

Ulna, proximal dorsal

C(5), 6, 7, (8) (posterior cord)

2nd metacarpal base

C5, 6 (posterior cord)

C8 T1 (medial and lateral cords) C7, 8 T1 (medial and lateral cords)

Spinal Segment C7, 8 T1 (medial and lateral cords)

3rd metacarpal base

Radius, distal lateral

Thumb distal phalangeal base Volar distal radius

Insertion Distal phalangeal bases

Anatomy—Muscle Tables  9

Radial (posterior interosseous) Radial (posterior interosseous)

Extensor pollicis longus

Median

Median

Ulnar

Median Ulnar

Abductor pollicis brevis

Opponens pollicis

Adductor pollicis

Flexor pollicis brevis • Superficial head • Deep head

Hand/Wrist—Thenar Muscles

Extensor indicis proprius

Radial (posterior interosseous)

Nerve Radial (posterior interosseous) Radial (posterior interosseous)

Extensor pollicis brevis

Abductor pollicis longus

Muscle Supinator

Forearm Region—Deep Extensors

Capitate, 2nd–3rd metacarpal Flexor retinaculum, trapezium

Trapezium

Scaphoid, trapezoid

Ulna, dorsolateral

Ulna, dorsolateral

Radius, dorsal

Origin Humerus, lateral epicondyle, ulna Radius, dorsal ulna

Proximal phalangeal base, ulnar Proximal phalangeal base, ulnar

Proximal phalangeal base, radial Thumb metacarpal

Thumb dorsal phalangeal base Index finger extensor aponeurosis (ulnar)

Thumb proximal phalangeal base

1st metacarpal base

Insertion Radius, dorsolateral

C8 T1 (medial and lateral cord) C8 T1 (medial cord)

C8 T1 (medial and lateral cord) C8 T1 (medial and lateral cord) C8 T1 (medial cord)

C6, 7, 8 (posterior cord)

C6, 7, 8 (posterior cord)

C6, 7, 8 (posterior cord)

C6, 7, 8 (posterior cord)

Spinal Segment C5, 6, 7 (posterior cord)

10  Tarascon Pocket Orthopaedica

Nerve Ulnar Ulnar Ulnar Ulnar

Femoral

Rectus femoris (direct and indirect heads) Sartorius

Femoral

Femoral Femoral

Iliacus Psoas

Hip Flexors

Volar interossei

Direct: Ilium, anterior inferior spine Indirect: acetabulum, superior rim Anterior superior iliac spine

Iliac fossa Transverse process L1–L5

Metacarpal shaft

Ulnar

Dorsal interossei

Origin Transverse carpal ligament, palmar aponeurosis Pisiform Hamate, transverse carpal ligament Hamate, transverse carpal ligament

Median (index Flexor digitorum profundus (radially) and middle) Ulnar (ring and small) Ulnar Metacarpal shaft

Lumbrical

Hand/Wrist—Intrinsic Muscles

Muscle Palmaris brevis Abductor digiti minimi Flexor digiti minimi brevis Opponens digiti minimi

Hand/Wrist—Hypothenar Muscles

Tibial tubercle (quadriceps mechanism) Tibia, part of pes anserinus

Lesser trochanter Lesser trochanter

Proximal phalangeal base, ­extensor apparatus Proximal phalangeal base, ­extensor apparatus

Radial aspect of lateral bands

Insertion Ulnar palm (fascial) Proximal phalangeal base, ulnar Proximal phalangeal base, ulnar Small finger metacarpal

L2, 3, 4 (posterior)

L2, 3, 4 (posterior) L(1), 2, 3, 4 (posterior) L2, 3, 4 (posterior)

C8 T1 (medial cord)

C8 T1 (medial cord)

C7, 8 T1 (medial & lateral cords) C8 T1 (medial cord)

Spinal Segment C8 T1 (medial cord) C8 T1 (medial cord) C8 T1 (medial cord) C8 T1 (medial cord)

Anatomy—Muscle Tables  11

Nerve Obturator (posterior) Sciatic (tibial) [predominant] Obturator (posterior) Obturator (anterior) Obturator (anterior)

Inferior gluteal

Nerve to piriformis

Obturator

Nerve to obturator internus

Nerve to obturator internus Nerve to quadratus femoris Nerve to quadratus femoris

Gluteus maximus

Piriformis

Obturator externus

Obturator internus

Superior gemellus Inferior gemellus Quadratus femoris

Hip External Rotators

Adductor brevis Adductor longus Gracilis

Muscle Adductor magnus

Hip Adductors

Ischiopubic rami, obturator membrane Ischiopubic rami, obturator membrane Outer ischial spine Ischial tuberosity Ischial tuberosity

Ilium, posterior-to-posterior gluteal line Sacrum, anterior sciatic notch

Origin Inferior pubic rami, ischial tuberosity Inferior pubic rami Pubic rami, anterior Inferior symphysis pubic arch

Femur, medial greater trochanter Femur, medial greater trochanter Femur, quadrate line

Femur, medial greater trochanter

Posterior femur (gluteal sling), iliotibial band Femur, proximal greater ­trochanter (piriformis fossa) Femur, trochlear fossa

Insertion Femur, linea aspera, and ­adductor tubercle Femur, linea aspera/­pectineal line Femur, linea aspera Tibia, part of pes anserinus

L5–S3 (anterior) L4–S1 (anterior) L4–S1 (anterior)

L5–S3 (anterior)

L2, 3, 4 (anterior)

S1, 2 (posterior)

L5–S2 (posterior)

Spinal Segment L2, 3, 4 (anterior) L4, 5 (anterior) L2, 3, 4 (anterior) L2, 3, 4 (anterior) L2, 3, 4 (anterior)

12  Tarascon Pocket Orthopaedica

Superior gluteal

Superior gluteal

Gluteus minimus

Tensor fascia lata

Femoral Fermoral

Vastus intermedius Rectus femoris

Semimembranosus Semitendinosus

Biceps, long head Biceps, short head

Iliotibial line, greater trochanter, lateral linea aspera Iliotibial line, medial linea aspera, supracondylar line Femur, anterior proximal shaft Anterior inferior iliac spine

Origin Ilium, between posterior and ­anterior gluteal lines Ilium, between anterior and ­inferior gluteal lines Ilium, anterior iliac crest

Sciatic (tibial) Ischial tuberosity, medial Sciatic (peroneal) Lateral linea aspera, lateral ­intramuscular septum Sciatic (tibial) Ischial tuberosity, distal–medial Peroneal Ischial tuberosity, proximal/lateral

Femoral

Vastus medialis

Posterior Thigh

Femoral

Vastus lateralis

Anterior Thigh

Nerve Superior gluteal

Muscle Gluteus medius

Hip Abductors

L5, S1 (anterior) L5, S1, 2 (anterior)

L2, 3, 4 (posterior) L2, 5, 4 (posterior)

L2, 3, 4 (posterior)

L2, 3, 4 (posterior)

L4–S1 (posterior)

L4–S1 (posterior)

Spinal Segment L4–S1 (posterior)

Tibia, anterior crest L4, 5, S1 (anterior) Oblique popliteal ligament, p­ osterior L5, S1, 2 (anterior) capsule, posterior medial tibia, popliteus, medial meniscus

Fibular head, lateral tibia Tibia, lateral condyle

Lateral patella (quadriceps mechanism) Medial patella (quadriceps mechanism) Patella (quadriceps mechanism) Patella (quadriceps mechall)

Femur, anterior border of greater ­trochanter (base) Tibia, Gerdy’s tubercle via iliotibial band

Insertion Femur, greater trochanter

Anatomy—Muscle Tables  13

Superficial peroneal Superficial peroneal

Tibial

Tibial Tibial

Gastrocnemius

Soleus Plantaris

Medial cuneiform, 1st metatarsal 5th metatarsal tuberosity

5th metatarsal

Lesser toes, mid and distal phalanx

Insertion Medial cuneiform, 1st metatarsal Great toe, distal phalanx

Distal femur, posterior Calcaneus (Achilles tendon) medial and lateral femoral condyles Fibula, tibia Calcaneus (Achilles tendon) Femur, lateral femoral Calcaneus condyle

Leg Muscles—Superficial Posterior Compartment

Peroneus longus Peroneus brevis

Proximal fibula Distal fibula

Fibula, extensor digitorum longus tendon

Deep peroneal

Deep peroneal

Origin Lateral tibia Mid fibula, interosseous membrane Tibial condyle, fibula

Nerve Deep peroneal Deep peroneal

Leg Muscles—Lateral Compartment

Muscle Tibialis anterior Extensor hallucis longus Extensor digitorum longus Peroneus tertius

Leg Muscles—Anterior Compartment

L5, S1, 2 (anterior) L5, S1 (anterior)

L5, S1, 2 (anterior)

L4, 5, S1 (posterior) L4, 5, S1 (posterior)

L4, 5, S1 (posterior)

L4, 5, S1 (posterior)

Spinal Segment L4, 5, S1 (posterior) L4, 5, S1 (posterior)

14  Tarascon Pocket Orthopaedica

Nerve Tibial

Deep peroneal

Abductor hallucis Medial plantar Flexor digitorum brevis Medial plantar Abductor digiti minimi Lateral plantar

First Plantar Layer (Three Muscles)

Extensor digitorum brevis

Ankle/Foot Muscles—Dorsal Layer

Flexor hallucis longus Tibial Flexor digitorum longus Tibial Tibialis posterior Tibial

Muscle Popliteus

Calcaneal tuberosity Calcaneal tuberosity Calcaneal tuberosity

Superolateral calcaneus

Origin Femur, lateral femoral condyle Fibula, head Fibula Tibia Tibia/fibula, interosseous membrane

Leg Muscles—Deep Posterior Compartment

Great toe—proximal phalangeal base Lesser toes, distal phalanx Base of 5th toe

Lesser toes, proximal phalangeal base

Great toe, distal phalanx Lesser toes, distal phalanx Navicular, medial cuneiform

Insertion Proximal tibia

L4, 5, S1 (anterior) L4, 5, S1 (anterior) S1, 2 (anterior)

L4, 5, S1 (posterior)

L5, S1 (anterior) L5, S1 (anterior) L5, S1 (anterior)

Spinal Segment L5, S1 (anterior)

Anatomy—Muscle Tables  15

Medial plantar Lateral plantar

Insertion Flexor digitorum longus tendon Extensor digitorum longus tendon

Dorsal interossei Lateral plantar Metatarsal shafts Plantar interossei Lateral plantar 3–5 metatarsal shafts (This layer also includes the tendons of the peroneus longus and tibialis posterior.)

Base of proximal phalanx Proximal phalanx medially

Cuboid lateral cuneiform Great toe—proximal phalanx Oblique head—2nd–4th metatarsal Fibular sesamoid base, transverse head—plantar ­metatarso-phalangeal ligament; toes 2–4 Base of 5th metatarsal head Small toe, proximal phalanx

Fourth Plantar Layer (Two Muscles and Two Tendons)

Flexor digitorum minimi brevis Lateral plantar

Flexor hallucis brevis Adductor hallucis

Third Plantar Layer (Three Muscles)

Nerve Origin Lateral plantar Medial and lateral calcaneus Medial and Flexor digitorum longus tendon ­lateral plantar (This layer also includes the tendons of the flexor digitorum longus and flexor hallucis longus.)

Muscle Quadratus plantae Lumbrical

Second Plantar Layer (Two Muscles and Two Tendons)

S1, 2 (anterior) S1, 2 (anterior)

S1, 2 (anterior)

L5, S1 (anterior) L5, S1, 2 (anterior)

Spinal Segment S1, 2 (anterior) L4, 5, S1, 2 (anterior)

16  Tarascon Pocket Orthopaedica



Anatomy—Approaches 17

ANATOMY—APPROACHES Approach / Eponym Shoulder Deltopectoral—Henry Lateral Posterior

Interval—Muscle (nerve) Deltoid (axillary) and pectoralis major (medial/lateral pectoral) Deltoid splitting no internervous plane (~ 5 cm limit) Infraspinatus (suprascapular) and teres minor (axillary)

Proximal Humerus Anterior Anterolateral Posterior Lateral

Deltoid (axillary) and pectoralis major (medial/lateral pectoral) Medial brachialis (musculocutaneous) and lateral brachialis (radial) No true internervous interval Brachialis (radial) and brachioradialis (radial) No true internervous interval; long and lateral head of triceps superficial, medial head splitting deep (radial) No true internervous interval; Triceps (radial) and brachioradialis (radial)

Elbow Posterior Medial Anterolateral Anterior Posterolateral— Kocher

No internervous plane Proximal—Brachialis (musculocutaneous) and triceps (radial) Distal—Brachialis (musculocutaneous) and pronator teres (median) Proximal—Brachialis (musculocutaneous) and brachioradialis (radial) Distal—Pronator teres (median) and brachioradialis (radial) Proximal—Brachialis (musculocutaneous) and brachioradialis (radial) Distal—Pronator teres (median) and brachioradialis (radial) Anconeus (radial) & extensor carpi ulnaris (posterior interosseous)

Forearm Anterior—Henry Dorsal—Thompson

Ulnar

Proximal—Pronator teres (median) and brachioradialis (radial) Distal—Brachioradialis (radial) and flexor carpi radialis (median) Proximal—Extensor carpi radialis brevis (radial) and extensor digitorum communis (posterior interosseous) Distal—Extensor carpi radialis brevis (radial) and extensor ­pollicis longus (posterior interosseous) Extensor carpi ulnaris (posterior interosseous) and flexor carpi ulnaris (ulnar)

18  Tarascon Pocket Orthopaedica

Wrist Shoulder Dorsal Scaphoid—volar Scaphoid—dorsolateral

Interval—Muscle (nerve) No internervous plane; between 3rd and 4th dorsal compartments No internervous plane; between 3rd and 4th dorsal compartments No internervous plane; between flexor carpi radialis (median) and radial artery No internervous plane; between extensor pollicis longus and extensor pollicis brevis (posterior interosseous)

Pelvis Ilioinguinal Extended iliofemoral

No true internervous plane (along pelvic crest) Superficial—Sartorius (femoral) and tensor fascia lata (superior gluteal) Deep—Rectus femoris (femoral) and gluteus medius (superior gluteal)

Hip Anterior—Smith-Peterson

Anterior—Modified Stoppa

Anterolateral—Watson-Jones Lateral—Hardinge

Posterior—Kocher/Lagenbach Medial—Ludloff

Superficial—Sartorius (femoral) and tensor fascia lata (superior gluteal) Deep—Rectus femoris (femoral) and gluteus medius (superior gluteal) No true internervous plane Superficial—Splits rectus abdominus muscle (­thoracoabdominal nerves) Deep—Releases rectus abdominus from posterior pubic rami No true internervous plane; tensor fascia lata (superior gluteal) and gluteus medius (superior gluteal) No true internervous plane Deep—Splits gluteus medius proximally (superior gluteal)       —Splits vastus lateralis distally (femoral) No true internervous plane Splits gluteus maximus (inferior gluteal) Superficial—No true internervous plane; adductor ­longus and gracilis (anterior division obturator) Deep—Adductor brevis (anterior division obturator) and adductor magnus (sciatic [tibial]) and posterior division of obturator)



Anatomy—Approaches 19

Femur Shoulder Lateral Anteromedial Posterolateral Posterior distal femur

Interval—Muscle (nerve) No internervous plane; splits vastus lateralis (femoral) No true internervous plane Rectus femoris (femoral) and vastus medialis (femoral) Vastus lateralis (femoral) and hamstrings (sciatic) Biceps femoris (sciatic) and vastus lateralis (femoral)

Knee Medial parapatellar Medial Lateral Posterior

No true internervous plane Vastus medialis (femoral) and rectus femoris (femoral) No true internervous plane Vastus medialis (femoral) and sartorius (femoral) Iliotibial band (superior gluteal) and biceps femoris (sciatic) Semimembranosus/medial gastrocnemius (tibial) and biceps femoris/lateral gastrocnemius (tibial)

Leg Anterior Anterolateral

Posterolateral Fibula

No internervous plane; tibialis anterior (peroneal) and tibial periosteum Superficial—Peroneus brevis (superficial peroneal) and extensor digitorum longus (deep peroneal) Deep—Tibialis posterior (tibial) and extensor muscles (deep peroneal) Gastrocnemius, soleus, flexor hallucis longus (tibial) and ­peroneus brevis and longus (superficial peroneal) Peroneal muscles (superficial peroneal) and flexor muscles (tibial)

Ankle Anterior or Dorsal To Medial Malleolus To Lateral Malleolus Posteromedial Posterolateral

No internervous plane; extensor hallucis longus (deep peroneal) and extensor digitorum longus (deep peroneal) No internervous plane; direct approach Peroneus tertius (deep peroneal) and peroneus brevis (­superficial peroneal) No internervous plane; tibialis posterior or flexor digitorum longus (tibial) and flexor digitorum longus or flexor hallucis longus (tibial) Peroneus brevis (superficial peroneal) and flexor hallucis longus (tibial)

20  Tarascon Pocket Orthopaedica

POPSIQ Mnemonic Pudendal nerve and artery Nerve to Obturator internus Posterior femoral cutaneous nerve Sciatic nerve Inferior gluteal nerve and artery

Contents of the Sciatic Notch (Greater Sciatic Notch) Above the Piriformis Superior gluteal nerve Superior gluteal artery Below the Piriformis Inferior gluteal nerve Inferior gluteal artery Pudendal nerve Internal Pudendal nerve Nerve to the Obturator internus Sciatic nerve Posterior femoral cutaneous nerve Nerve to Quadratus femoris

Damian Rispoli 2009

Lesser Sciatic Notch

Greater Sciatic Notch



Anatomy—Cross Sections  21

ANATOMY—CROSS SECTIONS Proximal Arm Cross Section Cephalic v.

Short head, biceps Coracobrachialis

Pectoralis major

Median antebrachial cutaneous n. Basilic v. Median n. Ulnar n. Brachial a. and v.’s

Long head, biceps Musculocutaneous n. Humerus Lateral head, triceps

Medial brachial cutaneous n. Radial n.

Deltoid Long head, triceps Latissimus dorsi tendon

Teres major Damian Rispoli 2009

Mid Arm Cross Section Cephalic v. Brachialis

Lateral antebrachial cutaneous n. Humerus Medial intermuscular septum Biceps brachii Median n.

Posterior antebrachial cutaneous n.

Medial antebrachial cutaneous n.

Radial collateral a. Lateral IM septum Radial n.

Medial brachial cutaneous n. Basilic v.

Middle collateral a.

Brachial a. and v.’s

Lateral head, triceps Medial head, triceps Long head, triceps

Ulnar n. Superior ulnar collateral a. Damian Rispoli 2009

22  Tarascon Pocket Orthopaedica Distal Arm Cross Section Biceps

Brachial fascia

Cephalic v.

Brachialis

Lateral antebrachial cutaneous n.

Median n. Medial antebrachial cutaneous n.

Brachioradialis Radial n.

Brachial a. & v.

Extensor carpi radialis longus

Ulnar n. Medium IM septum

Posterior antebrachial cutaneous n.

Triceps Humerus

Lateral IM septum

Triceps tendon

Damian Rispoli 2009

Proximal Forearm Cross Section (volar=top, right=ulnar) Radius Brachioradialis

Superficial branch radial n. Medial antebrachial v. Radial a. Pronator teres Medial antebrachial cutaneous n. Palmaris longus Flexor carpi radialis Flexor digitorum superficialis

Cephalic v. Lateral antebrachial cutaneous n. Extensor carpi radialis longus

Ulnar n. Flexor carpi ulnaris

Extensor carpi radialis brevis

Flexor digitorum profundus

Radial n. Extensor digitorum communis Extensor digiti quinti minimi

Anconeus FP longus

Posterior antebrachial cutaneous n. Damian Rispoli 2009

Supinator Extensor carpi ulnaris

Median n., Ulnar a. & Common Interosseous a. (volar to dorsal) Ulna



Anatomy—Cross Sections  23

24  Tarascon Pocket Orthopaedica Proximal Thigh Cross Section (anterior=top, right=medial) Lateral femoral cutaneous n.

Sartorius

Femoral and Deep femoral a. & v. Femoral n. Adductor longus Saphenous n.

Rectus femoris Tensor fascia lata Vastus mediaIis

Pectineus Obturator n. (ant.) Adductor brevis Obturator n. (post.) Gracilis

Iliopsoas Vastus intermedius Femur

Adductor magnus Semimembranosus Semitendinosus

Vastus lateralis Gluteus maximus Sciatic n. Posterior femoral cutaneous n.

Biceps femoris Damian Rispoli 2009

Mid Thigh Cross Section (anterior=top, right=medial) Vastus medialis Femoral a. & v.

Rectus femoris

Saphenous n & n. to v. medius

Vastus intermedius

Sartorius Adductor longus Adductor brevis

Vastus lateralis

Gracilis

Femur Iliotibial tract Biceps femoris, short head Biceps femoris, long head Damian Rispoli 2009

Great saphenous v. Adductor magnus Deep femoral a. & v. Sciatic n. Semimembranosus Semitendinosus



Anatomy—Cross Sections  25 Distal Thigh Cross Section (anterior=top, right=medial)

Q femoris tendon Vastus intermedius

Vastus medialis

Articularis genu

Femur Adductor magnus tendon

Iliotibial tract

Saphenous n. Descending genicular a.

Vastus lateralis Popliteal a.

Sartorius Tibial n. Great saphenous v.

Common peroneal n. Biceps femoris

Gracilis

Semitendinosus Popliteal v.

Semimembranosus

Damian Rispoli 2009

Mid Leg Cross Section

(anterior = top, right = medial) (A)

Anterior tibial a. & v. Deep peroneal n.

(A)

Extensor hallucis longus

(A)

Extensor digitorum longus

Tibialis posterior(DP)

(L)

Superficial peroneal n. (L)

Great saphenous v. Saphenous n.

Peroneus longus

(L)

Tibialis anterior(A) Tibia

Flexor digitorum longus(DP)

Peroneus brevis Fibula

Posterior tibial a. & v. Tibial n.(DP) Soleus(SP)

(DP) Flexor hallucis longus Lateral sural cutaneous n. (SP)

Plantaris(SP) Medial gastrocnemius(SP)

Lateral gastrocnemius

Personeal communicating branch of lateral saphenous n. (A)

Medial sural cutaneous n.(SP) Lesser saphenous v. (L)

Compartments: Anterior , Lateral , Deep Posterior(DP), Superficial Posterior(SP) Damian Rispoli 2009

Axillary artery

Anterior humeral circumflex

Posterior humeral circumflex

Deltoacromial branch

Thoracoacromial trunk

Thoracodorsal artery

Damian Rispoli 2009

Circumflex scapular artery Subscapular artery

Pectoralis minor

Lateral thoracic artery

Supreme thoracic artery

Transverse cervical artery Thyrocervical trunk

Arteries about the Shoulder Suprascapular artery

26  Tarascon Pocket Orthopaedica

ANATOMY—ARTERIES



Anatomy—Arteries 27 Shoulder Spaces and Intervals (posterior view of shoulder) Supraspinatus Infraspinatus

Teres minor

Axillary n. Triangular space

Posterior humeral circumflex a. Quadrangular space

Circumflex scapular a.

Triceps, lateral head Radial n.

Teres major

Profunda brachii a. Triangular interval Triceps, long head

Damian Rispoli 2009

Arteries about the Elbow

Superior ulnar collateral a. Middle collateral a.

Inferior ulnar collateral a. Anterior ulnar recurrent a.

Radial collateral a.

Brachial a.

Posterior ulnar recurrent a. Ulnar recurrent a.

Radial recurrent a. Radial a. Interosseous recurrent a.

Ulnar a. Common interosseous a. Anterior interosseous a. Posterior interosseous a. Damian Rispoli 2009

28  Tarascon Pocket Orthopaedica

Structures at the elbow (Radial to Ulnar) Tendon – Artery – Nerve

Arteries of the Forearm Brachial a. Anterior ulnar recurrent a. Posterior ulnar recurrent a. Common interosseous a. Ulnar a.

Anterior interosseous a.

Dorsal carpal branch Superficial palmar branch

Radial recurrent a. Interosseous recurrent a. Posterior interosseous a. (behind IO membrane) Radial a. Palmar branch Anterior interosseous a. Palmar carpal branch Damian Rispoli 2009



Anatomy—Arteries 29

Nerves Frame the Wrist (Radial to Ulnar) Superficial branch of the radial nerve → radial artery → median nerve → ulnar artery → ulnar nerve Pelvic Arteries Iliolumbar a. Aorta External iliac a.

Common iliac a. Lateral sacral a. & branches

Internal iliac a. (hypogastric a.)

Middle rectal a. Internal pudendal a.

Superior gluteal a.

Superior vesicular a.

Obturator a. Damian Rispoli 2009

Vasculature of the knee Descending genicular a.

Descending branch of deep femoral a.

Hunter’s Canal

Femoral a.

Saphenous a.

Articular a.

Popliteal a. Medial superior genicular a. Lateral superior genicular a.

Lateral superior genicular a.

Middle genicular a.

Lateral inferior genicular a.

Lateral inferior genicular a.

Anterior tibial recurrent a.

Anterior tibial a.

Damian Rispoli 2009

Posterior tibial a.

Behind the Knee - Medial to Lateral Artery -Vein-Nerve

Medial inferior genicular a. Peroneal a.

30  Tarascon Pocket Orthopaedica

ANATOMY—LIGAMENTS Glenohumeral Ligaments (lateral disarticulated view) Coracoacromial ligament Superior glenohumeral ligament

Acromion

Coracoid

Biceps tendon (long head)

Subscapularis Middle glenohumeral ligament

Infraspinatus Axillary pouch Teres minor Damian Rispoli 2009

Anterior inferior glenohumeral ligament Posterior inferior glenohumeral ligament

Shoulder (Posteriorly) Triangular space—Circumflex scapular artery Quadrangular space—Posterior humeral circumflex artery, axillary nerve Triangular interval—Profunda brachii artery, radial nerve Axillary artery (divided into three parts by the pectoralis minor muscle) 1. Supreme thoracic artery (before muscle, one branch) 2. Thoracoacromial and lateral thoracic arteries (under muscle, two branches) 3. Subscapular, anterior, and posterior humeral circumflex arteries (after muscle, three branches) Medial Layers of the Knee (JBJS 61A:56-62, 1979) I. Sartorius and fascia II. Superficial medial collateral ligament, posterior oblique ligament, semimembranosus III. Deep medial collateral ligament, capsule Lateral Layers of the Knee (JBJS 64A:536-541, 1982) I. Iliotibial tract, biceps (peroneal nerve deep to layer I) II. Patellar retinaculum, patellofemoral ligament, popliteofibular ligament III. Arcuate ligament, fabella-fibular ligament, capsule, lateral collateral ligament



Anatomy—Ligaments 31 Elbow Ligaments

Annular Ligament

Radial Collateral Ligament

Lateral

Lateral ulnar collateral Ligament

Anterior Bundle

Posterior Bundle

Medial

Transverse Bundle

Most important to stability

Damian Rispoli 2009

Volar Wrist Ligaments

Deltoid ligament (V) Radial collateral ligament Radioscaphocapitate ligament Radioscapholunate ligament Radiolunate ligament (long radiolunate)

Triquetrocapitate ligament Space of “Poirier” Lunotriquetral ligament Ulnolunate ligament Short radiolunate ligament

Damian Rispoli 2009

32  Tarascon Pocket Orthopaedica Finger Extensor Apparatus

A A

H

B

I

C

D

D

K C

E F G

E L G F

A. Terminal tendon B. Triangular ligament C. Transverse retinacular ligament D. Conjoined lateral band E. Oblique & transverse fibers of the intrinsic apparatus F. Lumbrical muscle (originating on the radial side of the flexor digitorum profundus tendon) G. Interossei muscle H. Flexor digitorum profundus insertion I. Flexor digitorum profundus tendon J. Extensor digitorum communis tendon K. Flexor digitorum superficialis tendon L. Sagittal bands Damian Rispoli 2009



Anatomy—Ligaments 33 Finger Pulley System C1 A1 MC

C2 A3

A2 P1

C3

A4 P2

P3

Damian Rispoli 2009

A2 & A4 most important (prevents tendon bowstringing) A1 released in surgical treatment of a trigger digit

Damian Rispoli 2017

34  Tarascon Pocket Orthopaedica Pelvic Ligaments Iliolumbar Ligaments Anterior Sacral Ligaments Sacrum

Sacrospinous Ligament Sacrotuberous Ligament Arcuate Line (Pelvic Brim)

Ischial Spine Pubic rami Damian Rispoli 2009

Knee Ligaments Meniscofemoral ligaments Humphreys Anterior to PCL Wrisberg Posterior to PCL

Anterior cruciate ligament

Patellar tendon Transverse (intermeniscal ligament) Lateral Meniscus Popliteus

Medial Meniscus

Semimembranosus tendon

Posterior cruciate ligament

Damian Rispoli 2009

Lateral Meniscus more mobile (1-1.5cm/3x > medial) Medial Meniscus tethered by medial collateral ligament



Anatomy—Ligaments 35 Posterior Knee Ligaments/Tendons (medial=right, lateral=left) Plantaris

Medial gastrocnemius

Lateral gastrocnemius Adductor tubercle

Lateral collateral ligament Popliteus tendon

Semimembranosus

Five Insertions of the Semimembranosus 1. Oblique Popliteal ligament 2. Posterior capsule 3. Posteromedial tibia (main) 4. Popliteus 5. Medial meniscus

Oblique popliteal ligament Fabellofibular ligament Arcuate ligament Popliteus

Damian Rispoli 2009

Ankle Ligaments Posterior

Anterior Posterior inferior tibiofibular ligament

Deltoid ligament Posterior talofibular ligament (PTFL)

Anterior talofibular ligament (ATFL) Calcaneofibular ligament (CFL) Ligaments of the syndesmosis Anterior inferior tibiofibular ligament Posterior inferior tibiofibular ligament Transverse tibiofibular ligament Interosseous ligament Interosseous membrane

Anterior inferior tibiofibular ligament Superficial deltoid Deep deltoid (more horizontal)

Damian Rispoli 2009

36  Tarascon Pocket Orthopaedica

ANATOMY—NERVE PLEXI Brachial Plexus Roots

Trunks Divisions Cords

Branches

Trunks = upper, middle, lower Divisions = anterior and posterior Cords = lateral, posterior, medial

Dorsal scapular n. N. to Subclavius Suprascapular n. Long thoracic n. Lateral pectoral n. Medial pectoral n. Upper subscapular n. Thoracodorsal n. Lower subscapular n.

Musculocutaneous n. Axillary n. Radial n. Median n. Ulnar n. Medial brachial & antebrachial cutaneous n.

Plexus Mnemonic - Robert Taylor Drinks Cold Beer Roots, Trunks, Divisions, Cords, Branches Posterior Branches Mnemonic - STAR (medial to lateral) Subscapular (upper and lower surround thoracodorsal n.) Thoracodorsal Axillary Radial Damian Rispoli 2009



Anatomy—Nerve Plexi  37 Lumbar Plexus

Anterior Divisions

Posterior Divisions

T12

Subcostal n.

L1

Iliohypogastric n. Ilioinguinal n.

L2 L3

Anterior & Posterior Divisions

Lateral femoral cutaneous n. (L2,3)

L4 L5

Femoral n. (L2,3,4) Lumbosacral trunk Obturator n. (L2,3,4)

Accessory obturator n. (L3,4) Damian Rispoli 2009

Sacral Plexus (Posterior Division) L4 L5 S1 S2 Anterior Division S3

Perforating cutaneous n. Posterior femoral cutaneous n. (S1,2 & Anterior S2,3)

Superior gluteal n. (L4,5,S1) Inferior gluteal n. (L5,S1,2) N. to piriformis Common peroneal (L4,5,S1,2) Damian Rispoli 2009

38  Tarascon Pocket Orthopaedica Sacral Plexus (Anterior Division) L4 L5 S1 S2 S3 S4

Pudendal n. (S2,3,4)

Tibial n. (L4,5,S1,2,3)

Posterior femoral cutaneous n. (S2,3, & posterior S1,2) To obturator internus & superior gemellus

To quadratus femoris & inferior gemellus Damian Rispoli 2009



Anatomy—Peripheral Nerves (Motor)  39

ANATOMY—PERIPHERAL NERVES (MOTOR)

Axillary (C5,6) and Musculocutaneous (C(4),5,6,7)

Lateral cord Posterior cord Medial cord

Deltoid Lateral Brachial cutaneous n. Coracobrachialis Biceps, short head

Brachialis (medial 1/2)

Biceps, long head

Damian Rispoli 2009

Lateral antebrachial cutaneous n. anterior & posterior branches

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Median (C(5),6,7,8,T1) Anterior Interosseous n. -Flexor pollicis longus -Flexor digitorum profundus (index/long) -Pronator quadratus

Median n.

Pronator teres Palmaris longus Flexor carpi radialis Flexor digitorum superficialis Flexor pollicis longus

Lateral cord Posterior cord Medial cord

Median innervated hand muscles LOAF Lumbricals Opponens pollicis Abductor pollicis brevis Flexor pollicis brevis

Flexor digitorum profundus (to index/middle) Opponens pollicis

Abductor pollicis brevis

Flexor pollicis brevis Lumbricals Pronator quadratus Damian Rispoli 2009



Anatomy—Peripheral Nerves (Motor)  41

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Anatomy—Peripheral Nerves (Motor)  43

Femoral (L2,3,4(posterior)) & Obturator (L2,3,4(anterior))

Psoas major Iliacus Rectus femoris Sartorius Vastus medialis Obturator externus Pectineus Adductor longus Damian Rispoli 2009

Vastus lateralis Vastus intermedius Articularis genu Adductor brevis Gracilis Adductor magnus

Superior gluteal n. (L4,5,S1) - Gluteus medius, Gluteus minimus, Tensor fascia lata Inferior gluteal n. (L5,S1,2) - Gluteus maximus

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Sciatic - Tibial Division (L4,5,S1,2,3) L4 L5 S1 S2 S3 Biceps femoris, long head

Adductor magnus Semitendinosus Semimembranosus

Gastrocnemius Soleus Tibialis posterior Flexor hallucis longus Abductor digiti minimi Flexor digitorum brevis Quadratus plantae Flexor digiti minimi brevis & interossei Lumbricals

Popliteus Gastrocnemius Flexor digitorum longus

Abductor Hallucis Lumbricals Medial plantar n. Flexor hallucis brevis Adductor hallucis

Lateral plantar n. Damian Rispoli 2009



Anatomy—Peripheral Nerves (Motor)  45

Sciatic - Common Peroneal (L4,5,S1,2) L4 L5 S1 S2

Biceps femoris, short head Tibialis anterior Extensor hallucis brevis

Extensor hallucis longus Peroneus longus Peroneus brevis Extensor digitorum longus Peroneus tertius Extensor digitorum brevis Damian Rispoli 2009

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ANATOMY—PERIPHERAL NERVES (SENSORY) Upper Extremity Peripheral Nerve Sensory Innervation Anterior Anterior pectoral n. Lateral cutaneous n. Medial antebrachial cutaneous n. Ulnar n.Palmar cutaneous br. Ulnar n.

Posterior Supraclavicular n. Axillary n. Radial n. Inferior lateral brachial cutaneous n. Radial n. Posterior brachial cutaneous n. -

Lateral antebrachial cutaneous n.

Radial n. Posterior antebrachial cutaneous n.

Superficial branch radial n. Median n. Palmar cutaneous br.

Ulnar n.

Median n.

Damian Rispoli 2009

Upper Extremity Dermatome Anterior

Posterior C4 T1 C5 C6 C7 C8 Damian Rispoli 2009



Anatomy—Nerves 47

ANATOMY—NERVES

Lower Extremity Peripheral Sensory Innervation Anterior

Posterior FemoralGenitofemoral n. Obturator n. Lateral femoral cutaneous n. Posterior femoral cutaneous n. Saphenous n.

Tibial n.

Lateral sural cutaneous n. Sural n.

Lateral calcaneal n.

Superficial peroneal n.

Medial calcaneal n. Medial plantar n.

Deep peroneal n. Damian Rispoli 2009

Lateral plantar n.

48  Tarascon Pocket Orthopaedica

Lower Extremity Dermatome Anterior L1

Posterior L2 L3

S3 S4

L4

S5 C1

L2

L5 S2 S1

L3

L1 L2

L4

L5

S1 L4

L5

Damian Rispoli 2009



Anatomy—Dermatomes 49

ANATOMY—DERMATOMES

C2 C2 C3

C5 C 5T 1

C6 C7 C8

C4

T1 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 L1 T12 L2 L3

C8 C8

C6

C3 C4 C5 C6 C7 C8 T1 T2 T3 T4 T5 T6 T8 T7 T9 T10 T12 T11 L1 L2 L3 L4 L5 S1 S2

C7 C8 S2

S1 S2

L4

L5

S1

S1

S2

L S1 5 L4

REFERENCES FOR ANATOMY SECTION Hollingshead WH. Anatomy for Surgeons, Vol. 3, 2nd ed. New York, NY: Harper and Row, 1969. Hoppenfeld S, DeBoer P. Surgical Exposures in Orthopaedics: The Anatomic Approach, 3rd ed. Philadelphia, PA: JB Lippincott, 2004. Miller MD (Ed.). Review of Orthopaedics, 4th ed. Philadelphia, PA: WB Saunders, 2004. Netter FH. The CIBA Collection of Medical Illustrations, Vol. 8. Summit, NJ: CIBA-Geigy, 1991. Pansky B. Review of Gross Anatomy, 5th ed. New York, NY: Macmillan, 1984.

51

S. aureus 27 %, S. pyogenes and S. pneumoniae 14%, H. influenzae 3%, gram-negative bacilli 6%, other 14% (gonococci, N. meningitidis, unknown 36%)

3 months–14 years

Treatment/Notes 1st: MRSA not likely, nafcillin or cefazolin, and cefotaxime. 2nd: MRSA possible, vancomycin and cefotaxime. Note: Also consider contiguous osteomyelitis (occurs in 2/3 of patients), especially in femoral head, proximal humerus, and radial head (up to 60% have bony involvement). 1st (MRSA likely, high prevalence): Vancomycin and cefotaxime until culture results available, then tailor 2nd (MRSA unlikely, prevalence low): Cefazolin Note: H. influenzae decreased since widespread vaccination in use. 10-d therapy as good as 30-d if good clinical response and C-reactive protein levels normalize. (Clin Infect Dis. 2009;48:1201)

(continues)

MRSA (prevalence > 10%, PICU, immunocompromised) Clindamycin 30–40 mg/kg/d or (local clindamycin resistance > 10%) Vancomycin 10–15 mg/kg/d q4–6h. [Update on the management of pediatric acute osteomyelitis and septic arthritis, Int J Mol Sci 1 Jun 2016] 15+ years (sexually N. gonorrhoeae (more common and most 1st: Gram stain negative; ceftriaxone 1 g IV q24h or cefotaxime or ceftizoxime active) commonly missed), S. aureus, Streptococcus, 1 g IV q8h rare aerobic gram-negative bacilli 2nd: Gram-positive cocci in clusters; vancomycin 15–20 mg/kg IV q8–12h Note: S. aureus accounts for 50–80%. Cultures usually blood negative, joint positive. N. gonorrhoeae may not require operative irrigation and debridement. Note: Culture urethra, cervix, anal canal, throat, blood, and joint if suspect gonococcus. Add azithromycin 1 g po or doxycycline 100 mg po bid × 7 d if gonococcus suspected or proven.

Common Microbes S. aureus, Enterobacteriaceae, group B ­Streptococcus, N. gonorrhoeae (Blood cultures often positive.)

Age/Condition Birth–3 months

Arthritis—Septic Typically requires operative drainage and antibiotics. Empiric therapy is initiated following cultures (blood, synovial fluid, and/or ­biopsy). Duration 2 wk (H. influenzae, Streptococcus sp., N. gonorrhoeae) and 3 wk (Staphylococcus sp. and GNR) [Mader JT, J Bone Joint Surg. 2001;83A(12):1878–1890.] Acute Single Joint

ANTIMICROBIALS

Common Microbes S. aureus, Streptococcus, gram-negative bacilli

Treatment/Notes Gram-positive cocci on Gram stain: Vancomycin 15–20 mg/kg IV q8–12h. Gram-negative bacilli on Gram stain: Cefepime 2 g q8h IV or meropenem 1 g q8h IV. Negative Gram stain: Vancomycin 15–20 mg/kg IV q8–12h with ceftriaxone 1 g IV q24h or cefepime 2 g q8h IV. Note: Consider CPPD and gout (see joint fluid analysis section). Note: After an intra-articular aspiration the treatment is surgical with antimicrobial treatment based on culture results. Adult—Candidiasis Candida albicans and non-albicans spp. 1st: Fluconazole 400 mg (6 mg/kg) IV q24h or lipid-based amphotericin B 3–5 mg/kg IV q24h for several wk then oral fluconazole. Treat for at least 6 wk/indefinitely with retained hardware. Surgical debridement required. Total joint Coag. negative Staph 30–43%, S. aureus Best option is not clearly defined at present. 12–23%, mixed 10–11%, Strep spp. Most favor 1- or 2-stage exchange if the infection is not acute (symptoms Note: Empiric therapy 9–10%, gram-negative rods 3–6%, Entero- < 3 wk or infection within 30 days of implantation). is NOT recommended. coccus spp. 3–7%, anaerobes 2–4%, culture Antibiotic therapy is based on cultures and should involve an infectious Options: negative, oral bacteremia 6–13%. [N Engl disease specialist. 1. Debride and retain J Med. 2004;35(16):1645–1654] 2. 1-stage exchange 3. 2-stage exchange

Age/Condition 15+ years (not sexually active)

Acute Single Joint Continued

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Antimicrobials 53

Total Joint Arthroplasty—Criteria for Infection Major Criteria (1 of 2 needed) 1. There is a sinus tract communicating with the prosthesis. 2. A pathogen is isolated by culture from at least two separate tissue or fluid samples obtained from the affected prosthetic joint. Minor Criteria (4 of 6 needed) 3. Elevated serum erythrocyte sedimentation rate (ESR >30 mm/h) and serum C-reactive protein (CRP > 10 mg/L) concentration 4. Elevated synovial leukocyte count (1100–4000 cells/mcL) 5. Elevated synovial neutrophil percentage (PMN%: 64–69%) 6. Presence of purulence in the affected joint 7. Isolation of a microorganism in one culture of periprosthetic tissue or fluid 8. Greater than five neutrophils per high-power field in five high-power fields observed from histologic analysis of periprosthetic tissue at ×400 magnification Data from Parvizi J. New Definition for Periprosthetic Joint Infection: From the Workgroup of the Musculoskeletal Infection Society. CORR 2011 Nov;469(11):2992-2994.

INCREASED PROSTHETIC JOINT INFECTION RISK

• • • •

Obesity Psychiatric pathology Steroid injection < 3 months from surgery Low nutritional parameters 1. Albumin 2. Protein 3. Vitamin D 4. Iron 5. Transferrin 6. Zinc

CULTURE GUIDELINES

PreOp 1. Consider repeat aspiration if first is negative and high clinical suspicion. 2. Delay aspiration until off antibiotics for 2 wk. IntraOp 1. Obtain biopsies before irrigation. 2. Deep culture samples. 3. Avoid electrocautery in obtaining biopsies. 4. Best sites: intramedullary, prosthesis/bone interface. 5. Biopsy direct to bottle/media; avoid glove/drape contact.

N. gonorrhoeae, B. burgdorferi (Lyme), acute rheumatic fever, hepatitis B, parvovirus B19 rubella vaccine, staph and strep may also be causes.

1st: Ceftriaxone 1 g IV qd Gram stain not usually helpful! Remember to screen for sexually transmitted disease. Consider Lyme if indicated, polyarticular gout, autoimmune disease.

Treatment/Notes

Age/Condition Dog 80% of all bites (↑ adult/child ♂) [N Engl J Med. 1999;340:85–92] Cat 5–15% of all bites (↑ adult ♀) [N Engl J Med. 1999;340:138] Catfish barb

Toxins

P. multocida (75%), streptococci, S. aureus, Neisseria, Moraxella

Common Microbes P. canis (50%), S. aureus, streptococci, Bacteroides, Fusobacterium sp., Capnocytophaga canimorsus

Treatment/Notes 1st: Amoxicillin/clavulanate (po) 875/125 mg bid or 1000/62.5 mg, 2 tabs bid 2nd: Clindamycin 300 mg po 4×/d and fluoroquinolone (adults) or trimethoprim/sulfamethoxazole (children) Note: 5% of dog bites get infected; consider treating if severe or comorbidities. Consider rabies. 30–50% get infected. 1st: Amoxicillin/clavulanate (po) 875/125 mg bid or 1000/62.5 mg, 2 tabs bid 2nd: Cefuroxime 500 mg po q12h or doxycycline 100 mg po bid (no cephalexin) Note: Soft tissue rest, consider surgical drainage; hand is a common site. Beware puncture of teeth into tendon sheaths/joints and to bone. 1st: Amoxicillin/clavulanate (po) 875/125 mg bid or 1000/62.5 mg, 2 tabs bid Note: Antibiotics for prophylaxis. Barbs may need to be excised. Beware tendon sheath and joint penetration.

Bites **No pharmacological treatment substitutes for an adequate irrigation and, if indicated, a debridement of devitalized tissue. [J Am Acad Orthop Surg. 2015;23(1):47–57]

Adult

ACUTE MULTIPLE JOINTS Age/Condition Common Microbes

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Streptococcus and Staphylococcus, Streptobacillus moniliformis (rat)

Viridans strep 100%, Staph epidermidis 53%, Corynebacterium 41%, S. aureus 29%, E. corrodens 15%, Bacteroides 82%, Peptostreptococcus 26%

Miscellaneous—bat, raccoon, skunk, rat, pig

Human 2–3% of all bites Fight ♂ Occlusive ♂ & ♀

Snake (pit viper) Pseudomonas, Enterobacter, S. epidermidis, 70–80% ♂ Clostridium sp. [J Am Acad Orthop Surg. 2015;18(12):749–59]

1st: Antibiotics as necessary prophylaxis with ceftriaxone Note: Antivenom is treatment. Give until symptoms resolve. Rarely need fasciotomy. Think tetanus! Follow for compartment syndrome (2–8% require fasciotomy). Crotalidae is responsible for 99% of snakebites in the United States. 2nd: Ceftriaxone 2 g IV qd or PCN G 20–24 mU/d IV ×14–28 days. Note: Treat initially for 30 d. Increase to 60 d if incomplete response. Antivenin rather than surgery is the treatment of choice in severe rattlesnake envenomation in children (J Bone Joint Surg. 2002;84A(19)1624–1629). Adult snake bites 80% upper extremities. Children upper = lower extremities 1st: Amoxicillin/clavulanate (po) 875/125 mg bid or 1000/62.5 mg, 2 tabs bid 2nd: Doxycycline 100 mg po bid (pig), 3rd-generation cephalosporin, ticarcillin/clavulanate, ampicillin/sulbactam, imipenem Note: Consider rabies immune globulin and vaccine if animal not available for testing or tests positive. The most common source in the US are bats with racoons, skunks, & foxes also sources. 1st: Prophylaxis: amoxicillin/clavulanate (po) 875/125 mg bid ×5 d; Otherwise: ampicillin/sulbactam 1.5 g IV q6h or cefoxitin 2 g IV q8h or ticarcillin/clavulanate 3.1 g IV q6h or piperacillin/tazobactam 3.375 g IV q6h; PCN allergy: clindamycin and ciprofloxacin or trimethoprim/sulfamethoxazole Note: Fight bites: Unreliable history from intoxicated patient. Joint penetration = surgical drainage. Be sure to check location of wound in all degrees of joint range of motion. People punch with closed fists and sustain layered penetration! 67% penetration and injury to articular cartilage.

Antimicrobials 55

HIV, HBV, HCV, herpes simplex Rhabdoviridae (rabies) Hantavirus, rhabdoviridae (rabies) Simian B

Same as above plus the possibility of coliforms.

Add anaerobes to the above mix.

With systemic symptoms

Oral: Dicloxacillin 500 mg po 4×/d, or cephalexin 500 mg po 4×/d, or amoxicillin/clavulanate (unless MRSA) 875/125 mg po bid or doxycycline 100 mg po bid or Bactrim DS 1–2 tab po bid (MRSA) or clindamycin (MSSA, MRSA, Strep) 300–450 mg po tid. Oral: Same as above IV therapy: Based on susceptibilities Ampicillin-sulbactam, piperacillin-tazobactam, ertapenem and vancomycin (till r/o MRSA) IV therapy: Vancomycin plus β-lactam/lactamase inhibitor or vancomycin plus doripenem or imipenem or meropenem Note: May substitute daptomycin or linezolid for vancomycin. Ciprofloxacin or levofloxacin or moxifloxacin or aztreonam and metronidazole for β-lactam/lactamase inhibitor

S. aureus (usually MRSA) S. agalactiae (group B strep) S. pyogenes

Ulceration with significant inflammation/erythema (moderate infection)

Local wound measures. No antimicrobial therapy.

Skin flora, colonization

Simple ulceration without inflammation Ulceration with inflammation/ erythema (mild infection)

Treatment/Notes

Common Microbes

Age/Condition

Diabetic Foot General (BMJ 2006;339B:4905; Plast Reconstr Surg. 2006;117(7, suppl):2125): 1. Glucose control. 2. Relieve pressure in area of ulceration. 3. Obtain a culture/bone biopsy. Poor concordance with swab. Needle aspiration inferior. 4. Osteomyelitis risks—Ulcer >2 cm2, able to probe to bone, radiographic abnormalities, ESR > 70. 5. Always evaluate and treat vascular insufficiency.

Human Dog, Bat, Racoon, Skunk Rodents Monkeys

Viral Infections Associated With Bite Injuries

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Candida species

Water immersion

Age/Condition Adult

Common Microbes S. aureus > 80%, rare Mycobacterium tuberculosis and marinum

Herpes simplex

Herpetic whitlow

Bursitis (May need wound debridement)

Common Microbes S. aureus, MRSA possible

Age/Condition Nail biting

Hand/Paronychia

Treatment/Notes MSSA: Nafcillin 2g IV q4h or oxacillin 2g IV q4h or cefazolin 2g IV q8h MRSA: Vancomycin 15–20 mg/kg IV q8–12h or linezolid 600 mg po bid. Note: Consider MRSA coverage if risk factors are present or if in an area of high prevalence. Splint/soft tissue rest. 2–3 wk of antibiotics. Bursectomy uncommon.

Treatment/Notes 1st: Irrigation/debride, obtain cultures 2nd: Trimethoprim/sulfamethoxazole 160/800 mg po bid pending culture results 1st: Famciclovir or valacyclovir Notes: Gram stain and culture negative. May be confused for a felon! 1st: Topical clotrimazole Note: Avoid hand immersion

Antimicrobials 57

S. aureus, group A Streptococcus, rare gram-negative bacilli, K. kingae S. aureus, group A Streptococcus, rare gram-negative bacilli,

S. aureus, various other etiologies can occur

S. aureus most common, consider Salmonella

Children > 4 months

Adult > 21 Vertebral osteo (+/– epidural abscess)

Sickle cell anemia

Adult > 21 years

Common Microbes S. aureus, gram-negative bacilli, group B Streptococcus, K. kingae

Age/Condition 0–4 months

Treatment/Notes 1st: MRSA possible—Vancomycin and ceftazidime or cefepime 2nd: MRSA not likely—Nafcillin or oxacillin and ceftazidime or cefepime Note: Look for local signs/symptoms. Blood culture often positive (> 67%). 1st: MRSA possible—Vancomycin 2nd: MRSA not likely—Nafcillin or oxacillin Note: Vancomycin for PCN allergic. Tailor to culture results. Add ceftazidime or cefepime if Gram stain positive for gram-negative bacilli. Alternatives: Clindamycin, trimethoprim-sulfamethoxazole, linezolid (lacks FDA approval) 1st: Vancomycin 15–20 mg/kg IV q8–12h (trough 15–20 µg/mL) and ceftriaxone 2g po q24h or cefepime 2 g po q8h or levofloxacin 750 mg po q24h 2nd: Daptomycin 6 mg/kg IV q24h or linezolid 600 mg po q8h and ceftriaxone 2g po q24h or cefepime 2 g po q8h or levofloxacin 750 mg po q24h Note: No ceftriaxone if Pseudomonas detected. May use piperacillintazobactam for Pseudomonas or another gram-negative. MRI to evaluate and r/o epidural abscess. Note: Onset within 30 d of spinal implant treat for 3 months, after 30 d remove implant, culture, and treat. 1st: Ciprofloxacin 2nd: Levofloxacin Note: Due to increased Salmonella resistance to fluoroquinolones, add a 3rd-generation cephalosporin until susceptibility results offer more guidance.

Osteomyelitis A specific microbe diagnosis essential via blood and tissue cultures. The following represents the initial empiric treatment.

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S. aureus, Pseudomonas

S. aureus, gram-negative bacilli, Pseudomonas aeruginosa

Pseudomonas aeruginosa

Polymicrobial Most often in diabetics

S. aureus, Pseudomonas aeruginosa, Enterobacteriaceae Candida albicans and nonalbicans sp.

Dialysis

After open reduction internal fixation (ORIF)

Sneaker puncture

Vascular insufficiency

Chronic osteomyelitis

Adult—Candidiasis

S. aureus, Pseudomonas

Intravenous drug user

1st: Fluconazole 400 mg (6 mg/kg) IV q24h or lipid-based amphotericin B 3–5 mg/kg IV q24h for several wk then oral fluconazole. Treat for 6–12 months. Surgical debridement often required with removal of hardware/implants if possible.

1st: Penicillinase-resistant PCN and ciprofloxacin 2nd: Vancomycin and ciprofloxacin Note: Sternoclavicular joints, ribs, spine, and long bones 1st: Penicillinase-resistant PCN and ciprofloxacin 2nd: Vancomycin and ciprofloxacin 1st: Vancomycin 15–20 mg/kg IV q8–12h (trough 15–20 µg/mL) and ceftazidime 2 g q8h IV or cefepime 2 g q12h 2nd: Linezolid 600 mg IV/po bid (not FDA approved) and ceftazidime 2 g q8h IV or cefepime 2 g q12h IV Note: Think of in delayed union and nonunion. 1st: Ciprofloxacin 750 mg po bid or levofloxacin 750 mg po qd 2nd: Ceftazidime 2 g q8h IV or cefepime 2 g q12h IV Note: Look for foreign body and debride if necessary (1–2% in children), administer tetanus or tetanus booster. Base treatment on bone biopsy results; no acute treatment unless systemic illness Note: Surgery for exposed bone or osteomyelitis Based on results of deep culture. No empiric treatment.

Antimicrobials 59

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Recommended Antibiotic Choices for Pediatric Osteomyelitis (J Am Acad Orthop Surg. 2001;9(3):166–175) IV Antibiotics Nafcillin 150–200 mg/kg/d and Gentamicin 5–7.5 mg/kg/d or Cefotaxime 150 mg/kg/d < 3 years (Not Hib Nafcillin 150 mg/kg/d and immunized) Cefotaxime 150 mg/kg/d or single therapy with cefuroxime 150–200 mg/kg/d > 3 years (Hib Cefazolin 100–150 mg/kg/d or Immunized) Nafcillin 150–200 mg/kg/d or Clindamycin 30–40 mg/kg/d Neonate

PO Antibiotics (Divided 4/d) Dicloxacillin 75–100 mg/kg/d or Cephalexin 100–150 mg/kg/d or Clindamycin 30 mg/kg/d Dicloxacillin 75–100 mg/kg/d or Cephalexin 100–150 mg/kg/d or Clindamycin 30 mg/kg/d Dicloxacillin 75–100 mg/kg/d or Cephalexin 100–150 mg/kg/d or Clindamycin 30 mg/kg/d

MRSA (prevalence >10%, PICU, immunocompromised) Clindamycin 30–40 mg/kg/d or (local clindamycin resistance >10%) vancomycin 10–15 mg/kg/d q4–6h. [Update on the management of pediatric acute osteomyelitis and septic arthritis, Int J Mol Sci., 1 Jun 2016]

Cierny-Mader Staging System (Contemp Orthop. 1985;10:17–37) Description Anatomic Type Stage 1 Stage 2 Stage 3 Stage 4 Physiologic Class A Host B Host Bs Bl Bls C Host

Medullary osteomyelitis Superficial osteomyelitis Localized osteomyelitis Diffuse osteomyelitis Normal Systemic compromise Local compromise Systemic and local compromise Treatment worse than the disease

Systemic or Local Factors (Affecting Immune Surveillance, Metabolism, Vascularity) Systemic (Bs) Local BI Malnutrition Chronic lymphedema Renal, hepatic failure Diabetes mellitus

Venous stasis

Major vessel compromise Chronic hypoxia Arteritis Immune disease Extensive scarring Malignancy Radiation fibrosis Extremes of age Small vessel disease Immunosuppression/ Neuropathy deficiency Asplenic HIV/AIDS Ethanol/tobacco abuse

Polymicrobial: S. aureus (MSSA, MRSA), group A and anaerobic Streptococcus, Enterobacter, C. perfringens and tetani, Pseudomonas, Aeromonas (water exposure), Acinetobacter

S. aureus, group A, B, C, or G Streptococcus

S. aureus—possible MRSA

Infection—wound, severe

Post-op infection without sepsis

Post-op infection with gram-positive cocci on Gram stain

Cellulitis, inpatient

Common Microbes Group A Streptococcus, occasional group B/C/G, S. aureus (MRSA) Group A Streptococcus, S. aureus Splint and Elevation

Age/Condition Cellulitis, outpatient

Skin Infections

(continues)

Inpatient: Penicillin G 1–2 million units IV q6h or cefazolin 1 g IV q8h, change to outpatient oral regimen when afebrile (10d total treatment). PCN allergic: Vancomycin 15 mg/kg IV q12h. Note: Irrigation and debridement of abscess if present. Workup to include ruling out abscess. 1st: Clindamycin 300–450 mg po tid. With sepsis consider piperacillin/tazobactam or meropenem or doripenem (non-FDA) or ertapenem. Also add vancomycin 15–20 mg/kg q8–12h. 2nd: Minocycline 100 mg po bid or linezolid 600 mg po bid. With sepsis consider vancomycin 15–20 mg/kg q8–12h or daptomycin 6 mg/kg IV q24h or ceftaroline 600 mg IV q12h or telavancin 10 mg/kg IV q24h. Also add ciprofloxacin 400 mg IV q12h (q8h if culture + for Pseudomonas aeruginosa) or levofloxacin 750 mg IV q24h. Note: Tetanus! Surgical debridement if needed; splint for soft tissue rest. Tailor antibiotic to cultured bug. 1st: Clindamycin 300–450 mg po tid Gram stain = gram-negative bacilli add: β-lactam/lactamase inhibitor. Note: Early irrigation and debridement as indicated Needs culture and sensitivity and irrigation/debridement. Oral: Trimethoprim/sulfamethoxazole 160/800 mg po bid or clindamycin 300–450 mg po tid. IV: Vancomycin 15–20 mg/kg IV q8–12h or daptomycin 6 mg/kg IV q24h or ceftaroline 600 mg IV q12h or telavancin 10 mg/kg IV q24h.

Treatment/Notes Outpatient: Penicillin VK 500 mg po 4×/d 10d; PCN allergic—azithromycin 500 mg po qd ×1 d then 250 mg po qd ×4 d.

Antimicrobials 61

S. aureus, Streptococcus, gramnegative rods

Treatment/Notes 1st: Vancomycin 15–20 mg/kg IV q8–12h or daptomycin 6 mg/kg IV q24h or ceftaroline 600 mg IV q12h or telavancin 10 mg/kg IV q24h. Also add ciprofloxacin 400 mg IV q12h (q8h if culture + for Pseudomonas aeruginosa) or levofloxacin 750 mg IV q24h. Note: Early irrigation and debridement as indicated 1st: Cefazolin 1 g IV q8h 2nd: Nafcillin 1–2 g IV q4–6h, vancomycin 1 g IV q12h and gentamicin or imipenem 0.5–1 g IV q6h Note: IV antibiotics and observation if caught early (< 24 h); maintain a low threshold for irrigation and debridement. Need Gram stain/culture to determine pathogen. Initial therapy: Penicillin G if strep or clostridia. Imipenem or meropenem if polymicrobial. Add vancomycin or daptomycin if MRSA suspected. Definitive therapy based on intraoperative Gram stain and culture. Note: Wide immediate surgical debridement! Surgical delay > 24 h increases mortality rate. Remove all necrotic fascia and fat. Skin excision back to healthy bleeding tissue. 2nd look at 24–48 h, then as needed.

5 types: 1. Strep sp., group A, C, and G. 2. Clostridia sp. 3. Polymicrobial; aerobic & aerobic. 4. Community assoc. MRSA 5. K. pneumoniae Rare; 500–1500 cases/year (US) Involves fascia, subcutaneous tissue, and thrombosis of microcirculation Soft tissue crepitance (gas in the SQ tissue) may be the only early sign. Necrotizing fasciitis: Presents with exquisite pain, swelling, and fever (rapidly progressive!) Hard signs (late): Hemorrhagic bullae, skin necrosis, fluctuance, crepitance, gas (inconsistent sign ~ 17% in one series).

Necrotizing fasciitis [J Bone Joint Surg. 2003;84A:1454– 1459; J Am Acad Orthop Surg. 2009;17(3): 174–182] Surgical Emergency!

Flexor tenosynovitis

Age/Condition Common Microbes Post-op infection with S. aureus, group A, B, C, or G sepsis Streptococcus

Skin Infections Continued

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Antimicrobials 63

Infection Imitators • Gout/pseudogout (polarized light microscopy) • Calcific tendonitis (normal labs, intratendinous mineralization) • Pyoderma gangrenosum • Childhood leukemia masquerading as a septic joint Key Atypical Infections Organism Sporothrix schenckii Mycobacterium marinum Mycobacterium tuberculosis Mycobacterium avium

Systemic Therapy Ketoconazole, supersaturated solution of potassium iodide, amphotericin, surgical debridement Rifampin, tetracycline, minocycline, amikacin Isoniazid, rifampin, ethambutol, pyrazinamide Azithromycin, clarithromycin, ethambutol, rifabutin

Common Antibiotics—Mechanisms of Action Inhibits Cell wall synthesis Cell membrane function Protein synthesis Nucleic acid synthesis DNA gyrase Bacterial RNA synthesis

Antibiotics Carbenicillin, cephalosporin, methicillin, nafcillin, oxacillin, penicillin, piperacillin, ticarcillin Amphotericin, nystatin, polymyxin Aminoglycosides, chloramphenicol, clindamycin, erythromycin, tetracycline Sulfonamides Quinolones Rifampin

Antibiotics for Surgical Prophylaxis (J Am Acad Orthop Surg. 2008;16:283–293) Timing • Begin within 60 min of incision (cephalosporin, clindamycin) 120 min (vancomycin) • Complete infusion > 10 min prior to tourniquet inflation Dosing • Single preoperative dose recommended • Redose during a prolonged procedure and/or increased blood loss • Discontinue antibiotics 24 h after surgery • Dosage: ƒƒ Cefazolin 2 g (weight < 120 kg), 3 g (weight > 120 kg), Pediatric 30 mg/kg. ŠŠ Redosing interval 4 h. ƒƒ Cefuroxime 1.5 g (Pediatric 50 mg/kg) ŠŠ Redosing interval 4 h. ƒƒ Ceftriaxone 2 g (Pediatric 50–75 mg/kg) ŠŠ Redosing interval N/A ƒƒ Vancomycin 15 mg/kg (Adult & Pediatrics) ŠŠ Redosing interval 4–8h ƒƒ Clindamycin 900 mg (Pediatric 10 mg/kg) ŠŠ Redosing interval 6 h.

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Antibiotic Choice • 1st choice: Cephalosporin (cefazolin, cefuroxime) • β-lactam allergic: Clindamycin, vancomycin • History of MRSA (infection or colonization): Vancomycin • Consider no antibiotic prophylaxis in clean, simple hand surgery cases < 2 h. • Consider no antibiotic prophylaxis for hand, knee, and foot cases not involving the implantation of foreign materials. Antibiotic References • Gilbert DN, et al. The Sanford Guide to Antimicrobial Therapy 2017. Sperryville, VA: Antimicrobial Therapy Inc.; 2017. • Abrams RA, Botte MJ. Hand infections: Treatment recommendations for specific types. J Am Acad Orthop Surg. 1996;4(4):219–230. • Rizvi M, et al. The role of prophylactic antibiotics in elective hand surgery. J Hand Surg. 2008;33A:413–420. • Bratzler DW, et  al. Clinical Practice Guidelines for Antimicrobial Prophylaxis in ­Surgery. Am J Health Syst Pharm. 2013;70(3):195–283. Common Oral Antimicrobial Doses and Mixtures Antimicrobial Amoxicillin (Amoxil ) Amoxicillin/clavulanate (Augmentin) [ES] Ampicillin (Polycillin) Azithromycin (Zithromax) Cefaclor (Ceclor ) 2nd-generation Cefadroxil (Duricef ) 1st-generation Cefdinir (Omnicef ) 3rd-generation Cefixime (Suprax ) 3rd-generation Cefpodoxime (Vantin) 3rd-generation   

Formulations Susp: 125, 250 mg/5 mL Caps: 125, 250 mg Susp: 200, 400, [600] mg/5 mL Tabs: 125, 250, 500 mg Susp: 125, 250 mg/5 mL Caps: 250, 500 mg Susp: 100, 200, 1000 mg/5 mL Caps: 250 mg (max 500 mg) Susp: 125, 250 mg/5 mL Caps: 250, 500 mg Susp: 125, 250, 500 mg/5 mL Caps: 500, Tab: 1000 mg Susp: 125 mg/5 mL Caps: 300 mg Syrup: 100 mg/5 mL Tabs: 200, 400 mg Susp: 50, 100 mg/5 mL Tabs: 100, 200 mg

Dose (Frequency)1 30–50 mg/kg/d (bid–tid) Max dose 500 mg 45 mg/kg/d (bid) Max dose 500 mg 50–100 mg/kg/d (4×/d) Max dose 500 mg 10 mg/kg qd 1st day, then 5 mg/kg qd ×4 d 20–40 mg/kg/d (tid) Max dose 500 mg 30 mg/kg/d (bid) Max dose 1000 mg 14 mg/kg/d (qd–bid) Max daily dose 600 mg 8 mg/kg/d (qd/bid) Max dose 400 mg 10 mg/kg/d (bid) Max dose 400 mg



Emergency Procedures  65 Antimicrobial Cefprozil (Cefzil ) 3rd-generation Ceftibuten (Cedax ) 3rd-generation Cefuroxime (Ceftin ) 2nd-generation Cephalexin (Keflex ) 1st-generation Clarithromycin (Biaxin )

Formulations Susp: 125, 250 mg/5 mL Tabs: 250 mg/5 mL Susp: 90, 180 mg/5 mL Caps: 400 mg Susp: 125 mg/5 mL Tabs: 125, 250, 500 mg Susp: 125, 250 mg/5 mL Caps: 250, 500 mg Susp: 125, 250 mg/5 mL Tabs: 250, 500 mg Clindamycin (Cleocin ) Solution: 75 mg/5 mL Caps: 75, 150 mg (max 600 mg) Dicloxacillin (Dynapen ) Susp: 62.5 mg/5 mL Caps: 125, 250, 500 Doxycycline (> 8 years) Tabs/Caps: 50,100 mg Susp: (Vibramycin) 25 mg/5 mL, Syrup: 50 mg/5 mL, Erythromycin (ERYC, EES, Susp: 200, 400 mg/5 mL E-mycin) Tabs: 200 (chew), 250, 400, 500 Erythromycin/sulfisoxazole Susp: 200 mg and (Pediazole ) 600 mg/5 mL Penicillin (Pen-Vee K) Susp: 125, 250 per 5 mL Tabs: 125, 250, 500 mg Trimethoprim/ Susp: 40 mg and 200 mg/5 mL sulfamethoxazole Tabs: 80/400, 160/800 (Bactrim, Septra) Vancomycin (Vancocin ) Caps: 125, 250

Dose (Frequency)1 15 mg/kg/d (bid) Max dose 500 mg 9 mg/kg/d (qd) Max dose 400 mg 15–30 mg/kg/d (bid) Max dose 500 mg 25–50 mg/kg/d (4×/d) Max dose 500 mg 15 mg/kg/d (bid) Max dose 500 mg 10–30 mg/kg/d (tid/bid) (30–40 mg/kg/d if DRSP)2 25–100 mg/kg/d (4×/d) Max dose 500 mg 2–4 mg/kg/d (bid) Max dose 200 mg/d 20–50 mg/kg/d (4×/d) Max dose 500 mg 50 mg EM/kg/d (4×/d) Max EM dose 500 mg 25–50 mg/kg/d (4×/d) Max dose 500 mg 6–12 mg/kg/d TMP bid Max dose 160 TMP 40 mg/kg/d ×7 d Max dose 2000 mg/d

1

Max dose = maximum individual oral dose. 2 DRSP = drug-resistant S. pneumoniae. Modified with permission from Tarascon Pediatric Emergency Pocketbook, 5th ed. Lompoc, CA: Tarascon; 2007.

EMERGENCY PROCEDURES Compartment Syndrome (J Am Acad Orthop Surg. 1996;4:209–218) • Increased pressure within a confined space interferes with proper tissue perfusion within the space. • Pressure increase may be intrinsic ƒƒ Bleeding, edema, fluid • Or extrinsic ƒƒ Pneumatic antishock trousers, cast, tight dressing, over distraction external fixator

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• Findings: ƒƒ Pain out of proportion to physical findings (pain is the most reliable and earliest symptom) ƒƒ Increasing analgesic requirements in children or noncommunicative patients (may be equivalent to pain out of proportion) ƒƒ Pain with passive ROM (cardinal sign) ƒƒ Pain on palpation of the swollen compartment, tensely swollen compartment, tight shiny skin, hypesthesia, paresthesia, anesthesia (late finding), weakness, paresis (late finding). ƒƒ Late findings occur after irreversible damage has occurred! Compartment Pressure Values Compartment syndrome is felt to be present Within 30 mm Hg of diastolic pressure if compartment pressures are: OR Above 30 mm Hg—absolute pressure

Needle manometer measurements are generally allowed to be slightly higher. Most surgeons prefer to use the measurement of compartment pressure relative to diastolic pressure. A “zone of peak pressure” occurs within several centimeters of the fracture site; values can vary significantly at greater distances causing an underestimation of the compartment pressure. (J Bone Joint Surg. 1996;78B:99–104, J Bone Joint Surg. 1980;62A:286–291)

Traditional Compartment Measurement Set-Up Three-way stopcock - open, saline meniscus in proximal tube, insert needle, increase pressure in syringe until meniscus moves, read pressure

Meniscus Mercury Manometer Manometer and limb must be at the same level Damian Rispoli 2009

Measuring Techniques (Multiple) • Needle manometer (Clin Orthop. 1975;113:43) • Wick catheter (J Bone Joint Surg. 1976;58A:1016) • Slit catheter (J Trauma 1981;21:446–449) • STIC catheter



Emergency Procedures  67

The simplest technique utilizes the STIC catheter. It is a handheld device that is easy to use and usually readily available at larger institutions. Another simple technique is to use an arterial line setup. This can be connected to a standard pressure monitor at the bedside or in the OR. Additionally, the arterial line setup comes in a sterile package and can then be used intraoperatively with the help of the OR nurse or anesthetist. Ensure the setup is “zeroed” at the level of the limb being tested. Compartment Release (Fasciotomy) Techniques Finger Usually done on the ulnar side of the index, long, and ring fingers and the radial side of the thumb and small finger. Special attention and alteration of this should be based on the patient’s vocation and avocation. The incision is a standard midaxial incision as shown. The line for the mid axial incision is drawn off points that correspond to the dorsal extent of the flexion creases in maximal flexion. The volar neurovascular bundles are left volar, and the line of dissection is between them and the flexor tendon sheath (Green DP, ed. Operative Hand Surgery. New York, NY: Churchill Livingstone; 1993).

68  Tarascon Pocket Orthopaedica Dorsal incisions 2nd and 4th metacarpal

Damian Rispoli 2009

Incision for release of thenar compartment

Hand The volar incision lies in the crease between the thenar and hypothenar eminences. From it one can release the carpal tunnel and Guyon’s canal. The incision is curved over the wrist flexion crease to prevent contractures. The dorsal incisions are made in line with the second and fourth metacarpals as shown. The incisions split the dorsal interossei fascia and then course around the muscle to release the palmar interossei. The thenar and hypothenar compartments are released through incisions over the respective metacarpals. Forearm (Clin Orthop. 1978;134:225–229; 1981;161:252–261) Two incisions, one dorsal and one volar, are used to decompress the forearm. The volar incision includes the carpal tunnel release. Taking the incision ulnar after the carpal tunnel release leaves tissue to cover the median nerve as it exits from under the flexor digitorum superficialis. The dorsal incision should be used to decompress the dorsal and mobile wad compartments. Intraoperative pressure measurements can aid in making the decision to proceed with the dorsal release. Often the volar release is sufficient to lower the pressure dorsally to subcritical levels. Arm The volar incision can be carried up past the elbow and into an anterior lateral approach to the arm to release brachial compartments if necessary. Anterior and posterior compartments may then be released through the anterolateral incision.



Emergency Procedures  69

Thigh Fasciotomy (JBJS 68A:1439,1986) Anterior

Lateral

Damian Rispoli 2009

Thigh (J Bone Joint Surg. 1986;68A:1439) Thigh compartment syndromes are being more commonly reported. The incisions are anterolateral and if needed straight medial. The hamstring compartment is released via the anterolateral incision. Always consider extension to the gluteal compartment as clinically indicated.

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Leg (J Bone Joint Surg. 1977;59A:184–187) Three common techniques for fasciotomy of the leg exist: fibulectomy, perifibular fasciotomy, and the double-incision technique. The most commonly advocated is the double-incision technique. The two vertical incisions must be separated by at least an 8-cm skin bridge. Both incisions span from knee to ankle. The medial incision is at least 2 cm posterior to the posteromedial border of the tibia (avoids bone exposure and damage to the saphenous nerve and vein). The fascia overlying the gastrocnemius is split to release the superficial compartment. The deep compartment fascia is split over the flexor digitorum longus, and proximally the soleal attachment to the tibia is released to access the proximal portion of the deep posterior compartment (tibialis posterior). The lateral incision is made midway between the posterolateral tibial border and the anterolateral border of the fibula. The fascia is split 1 cm anterior and 1 cm posterior to the intramuscular septum. The superficial peroneal nerve must be protected. Leg Fasciotomy (JBJS 59A:184–187, 1977) Anterior

Medial

Damian Rispoli 2009

Ankle (J Bone Joint Surg. 2002;84B(1):11–14) Consider extensor retinaculum syndrome (severe pain and swelling of the ankle, hypoesthesia or anesthesia in the web space of the great toe, weakness of extensor hallucis longus and extensor digitorum communis, and pain on passive flexion of the toes, especially the great toe). Prompt recognition and decompression can potentially avoid negative long-term sequelae.



Emergency Procedures  71

Foot (J Orthop Trauma 1992;223–228, Orthopedics 1990;13:711–717) A foot compartment syndrome is difficult to detect. Clinical suspicion and pressure measurement are necessary to identify those requiring release. Two techniques are shown. The main compartments are medial, central, lateral, interosseous, and calcaneal. All involved compartments should be released if indicated. Important to note! (J Trauma 1996;40(3):342–344) There is universal agreement that acute compartment syndromes should be treated surgically. However, the treatment of compartment syndromes presenting late with evidence of compartment damage is less clear. The damage done in a compartment is a function of many variables including compartment pressure magnitude, time of pressure elevation, diastolic pressure, concomitant crush injury, and time since onset, among others. It has been shown that late release of compartments is associated with an unacceptable complication rate. Hard and fast rules regarding the treatment of compartment syndromes do not exist. The guidelines given along with heightened clinical suspicion and an educated response are most appropriate. Ensure you check serum CKs and place a Foley catheter to monitor urine color. If positive for myoglobinuria, treat with aggressive hydration and alkalization with sodium bicarbonate. NOTE: A urine dipstick positive for blood in the absence of RBCs on microscopic analysis is indicative of myoglobinuria. Foot Fasciotomy (J Orthop Trauma 223-228, 1992; Orthopedics 13:711-717, 1990)

Dorsal Incision

Medial Incision

Damian Rispoli 2009

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Acute Stabilization of the Pelvis Methods Pelvic Binder *Centered on greater trochanters* Sheet wrapped around the pelvis and clamped snugly Internal rotation of the legs and wrapping both together

• • • • • •

Skeletal traction Anterior external fixation frame

Persistent hemodynamic instability after binder placement: Rule out intra-abdominal bleeding Patient fully warm and resuscitated Consider: Pelvic angiography (rule out arterial injury) May rarely consider pelvic external fixation if in OR for exploratory laparotomy Some (rarely) advocate for retroperitoneal packing to control venous bleeding.

Pelvic External Fixation Iliac Crest Pins (Traditional) Use 5-mm pins with the threads placed in the anterior half of the iliac crest. Pins must be at least 1 cm apart. Use 2–3 pins per side. Incisions, 2–3 cm, are made along the crest and angled toward the umbilicus. The crest is identified, and the walls may be palpated, and/or the proper angle of the crest identified with a guidewire. The crest is perforated with a drill; the pin is then inserted and allowed to find its way between the inner and outer table. The pins should be directed toward the strong bone in the supra-acetabular region. All threads should be buried in the crest bone. Supra-Acetabular Pins Placed into the strong pillar of bone from the anterior inferior iliac spine posteriorly. The hip capsule reflection is usually 16 mm above the joint but may extend to 20 mm. The lateral femoral cutaneous nerve is at risk (usually 10 mm but at times as close as 2 mm). The anterior inferior iliac spine (AIIS) is identified (4–6 cm inferior to the anterior superior iliac spine and 3–4 cm medial). It may be identified percutaneously using fluoroscopy or by palpation via a small incision. The fluoroscopic image best utilized is the obturator oblique view. Positioning is then confirmed on the iliac oblique inlet view. The pin is confirmed to be proximal to the joint capsule and headed toward the sciatic buttress proximal to the greater sciatic notch. Lastly, the obturator oblique inlet view is used to demonstrate and advance the pin between the inner and outer tables. • Frame construction should take into consideration possible need for abdominal exploration, interventional venous thrombosis, and concomitant injuries (including potential need for acetabular/pelvic fixation). • Double frame can be helpful to allow access to belly without loss of fixation.



Emergency Procedures  73



General Orthopaedics—Antibiotic Prophylaxis  75

GENERAL ORTHOPAEDICS—ANTIBIOTIC PROPHYLAXIS Joint arthroplasty antibiotic prophylaxis and dental and urologic procedure recommendations (2002) Potentially Increased Risk Immunocompromised/Suppressed Inflammatory arthropathies (rheumatoid arthritis, systemic lupus erythematosus) Disease-induced immunosuppression Drug-induced immunosuppression XRT-induced immunosuppression

Patients With Comorbidities Previous prosthetic joint infection 1st 2 years post arthroplasty Hemophilia Insulin-dependent diabetes Malnourishment Malignancy HIV infection

American Academy of Orthopaedic Surgeons. Antibiotic Prophylaxis for Urologic Patients with Total Joint Replacements. Document 1023. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2002. American Academy of Orthopaedic Surgeons. Antibiotic Prophylaxis for Dental Patients with Total Joint Replacements. Document 1014. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2002. Whall CW, J Am Dental Assoc. 1997;128(7):1004–1008.

2012 Recommendations for prevention of orthopaedic implant infection in patients undergoing dental procedures 1. Surgeons may consider discontinuing this practice. (Limited recommendation AND only related to hip and knee arthroplasty) 2. The AAOS committee recommends neither for or against prophylactic antibiotics. (Inconclusive recommendation) 3. Joint arthroplasty patients should maintain good oral health. (Consensus recommendation) The AAOS recommends relying on the overall patient’s condition, mutual communication with patient and other professionals, and basing any decision on the available evidence. (J Am Acad Orthop Surg. 2013;21(3):180–189.) Suggested Antibiotic Prophylaxis if Surgeon Chooses Dental Prophylaxis PCN tolerant PCN allergic Can’t take po, PCN tolerant Can’t take po, PCN allergic

Amoxicillin, cephalexin, cephradine—2 g po 1 h prior Clindamycin—600 mg po 1 h prior Ampicillin—2 g IV/IM 1 h prior or cefazolin—1 g IV/IM 1 h prior Clindamycin—600 mg IV/IM 1 h prior

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Suggested Antibiotic Prophylaxis if Urologic Criteria Are Met PCN Tolerant (choice of quinolone or amp/gent) Ciprofloxacin Levofloxacin Ofloxacin Ampicillin and Gentamicin

Preprocedural Dosing 500 mg po 1–2 h prior 500 mg po 1–2 h prior 400 mg po 1–2 h prior 2 g IV and 1.5 mg/kg IV 30–60 min prior

PCN Allergic Vancomycin and gentamicin

Preprocedural Dosing 1 g IV over 1–2 h and 1.5 mg/kg IV 30–60 min prior

Suggested Antibiotic Prophylaxis for GI Procedures PCN Tolerant Ampicillin and gentamicin Amoxicillin

Preprocedure Postprocedure 2 g IV and 1.5 mg/kg (80 mg) IV 30 min prior 1.5 g po 6 h post

PCN Allergic Vancomycin and gentamicin

Preprocedure 1 g IV and 1.5 mg/kg IV (~80) 1 h prior

Postprocedure Repeat 8 h post

GENERAL ORTHOPAEDICS—ANTICOAGULATION THERAPY *See Commonly Used Prophylaxis Options Page 92 Management of anticoagulation or antiplatelet therapy is best performed by coordinating with the primary care provider in the setting of elective surgery. Factors to consider are the reason for anticoagulation, estimated thromboembolic risk, bleeding risk, and the need for a bridge. • Antiplatelet therapy irreversibly inhibits platelet function, which will recover in 7–10 d. • The half-lives of the antiplatelet drugs are short enough that after 24 h, they would have minimal anti-platelet effect on any transfusion. Efficacy of platelet transfusion to effect hemostasis is unclear. • Most authors note no significant adverse effect if anti-platelet therapy is required to continue concordant with an emergent or non-delayable orthopedic surgery. • Anticoagulant therapy has a variably reversible effect on blood clotting (see Anticoagulant Therapy Considerations).



General Orthopaedics—Blood Transfusion  77 Anticoagulant therapy considerations (assuming high/moderate bleeding risk) Drug Half-Life Hold (elective) Reversal Agent Restart Warfarin 36–72h 5 d (INR 100,000 mm3—Septic joint until proven otherwise The presence of crystals does not rule out infection with this presentation. Total Joint Arthroplasty 1100–4000 Minor criteria for a prosthetic joint infection (see page 53 in ANTIMICROBIALS)

Differential (% Neutrophils) < 50% Noninflammatory < 90% RA > 90% Infectious 64–69% Minor criteria for a prosthetic joint infection Culture Cultures are indispensable in directing antibiotic therapy. Sterile prep and handling are imperative! Blood culture vials could increase sensitivity. Gram stain 50–75% sensitive (do it yourself if necessary) Culture > 90% sensitive Polarized Microscopy • Monosodium urate crystals (gout): Needle-shaped or long with blunt ends, strongly negative birefringent (brilliantly bright against a dark background) • Calcium pyrophosphate crystals (CPPD or pseudogout): Rod-shaped/rhomboidal, weak positive birefringent Note: Intra-articular betamethasone can mimic gout crystals. Using polarized light microscopy • Gout—yellow when parallel, blue when perpendicular • CPPD—opposite

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TESTS FOR INFECTION 1. Heat fix slide until dry 2. Grams violet × 1 min, rinse 3. Grams iodine × 1 min, rinse 4. Decolorizer 30 s 5. Safranin × 1 min, rinse 6. Air dry

Gram Stain

Tissue Frozen Section • Tissue biopsy: Target the most inflammatory looking tissue. • 0 Polymorphonuclear cells/high-power field is evidence of the lack of infection. • 5–10 Polymorphonuclear cells/high-power field is evidence of a probable infection (Clin Orthop. 1982;170:175–183). • 10 Polymorphonuclear cells/high-power field increases specificity to 99% (J Bone Joint Surg. 1996;78A:1553–1558.)

GENERAL ORTHOPAEDICS—METABOLIC BONE DISEASE Clinical and Radiologic Overview of Metabolic Bone Disease

Disease Hypercalcemia Hyperparathyroidism Familial syndromes Hypocalcemia Hypoparathyroidism PHP/Albright’s Renal osteodystrophy

Etiology

Clinical Findings

Radiographic Findings

↑ PTH—adenoma Kidney stones, hyperreflexia PTH—MEN/Renal Endocrine/renal dysfunction

Osteopenia, focal lytic areas Osteopenia

PTH—idiopathic

Calcified basal ganglia Brachydactyly, exostosis

Neuromuscular irritability PTH receptor Short metacarpal/ dysfunction tarsal Obesity CRF—phosphate Renal abnormalities excretion

Rickets (osteomalacia) Vitamin D deficient Diet vitamin D, malabsorption

Osteomalacia, ­hypotonia, muscle weakness, tetany

“Rugger jersey” spine Rachitic rosary, bowed long bones, growth plates



General Orthopaedics—Nerves, EMG/NCV  81 Disease Vitamin D dependent (types I and II)

Etiology Clinical Findings I enzyme defect, II Similar but (I) to (II) receptor defect severity to vitamin D dependent, alopecia Vitamin D resistant Phosphate Hypophosphatemia, (hypophosphatemic) ­resorption lower limb deformi(tubular) ties, stunted growth Hypophosphatasia Alkaline Osteomalacia, early phosphatase tooth loss Osteoporosis ↓ Estrogen/ Kyphosis, fracture testosterone↓ bone mass Scurvy ↓ Diet vitamin C Fatigue, bleeding, effusions Osteosclerosis or Increased Osseous Density Paget’s (5th decade) Defunct osteoDeformity, pain, clasts, disordered ­congestive heart bone turnover failure, fractures Osteopetrosis

Osteo/chondroclastic activity (thymus)

Hepatosplenomegaly, anemia

Radiographic Findings Poor mineralization Poor mineralization Poor mineralization Insufficiency fractures Thin cortices, corner sign Coarse thick trabeculae, picture frame vertebrae, enlarged bone Bone within bone

Abbreviations: CRF, chronic renal failure; MEN, multiple endocrine neoplasia; PHP, pseudo-­hypoparathyroidism; PTH, parathyroid hormone. Adapted from Miller MD (Ed.). Review of Orthopaedics, 3rd ed. Philadelphia, PA: W.B. Saunders; 2000:25.

GENERAL ORTHOPAEDICS—NERVES, EMG/NCV EMG Findings/Meaning Finding Silence at rest, bi- and triphasic potentials Fibrillation potential at rest, positive sharp waves Polyphasic motor units New motor units No action potential

Significance Normal Partial denervation Chronic denervation Nerve regeneration Complete lesion

Plexus Lesion ↓ (focal) ↓ (focal) Normal Normal + (acute) + (chronic)

Root Lesion +/– ↓ Normal

Normal Normal + (acute) + (chronic)

Axonal Polyneuropathy ↓ (diffuse) ↓ (diffuse) Normal Normal + +

Focal Entrapment +/– ↓ +/– ↓ ↑ (focal) ↓ (focal) +/– (severe) +/– (severe)

Adapted from Robinson LR. Role of neurophysiologic evaluation in diagnosis. J Am Acad Orthop Surg. 2000;8:195.

Finding Motor nerve amplitude Sensory nerve amplitude Distal latency Conduction velocity Fibrillations Large polyphasic MUAPs

Electrodiagnostic Findings in Various Peripheral Nerve Disorders

↑ (diffuse) ↑ (diffuse) +/– +/–

Demyelinating Polyneuropathy +/– ↓ +/– ↓

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General Orthopaedics—Obesity  83

Nerve Injury Classification Seddon Neurapraxia Axonotmesis

Neurotmesis

Sunderland 1 2 3 4 5

Pathologic Findings Localized myelin damage (compression) Loss of axonal continuity; endo-, peri-, and epineurium intact Axonal and endoneurial continuity lost Axonal, endoneurial, perineurial continuity lost Complete nerve lesion

­­Sunderland S. Nerve Injuries and Their Repair: A Critical Appraisal. New York, NY: Churchill Livingstone; 1991. Seddon HJ. Surgical Disorders of the Peripheral Nerves. Baltimore, MD: Williams and Wilkins; 1972:68–88.

GENERAL ORTHOPAEDICS—OBESITY Obesity is an independent risk factor for: • VTE disease • Pulmonary embolism Surgically at risk for: • Passive ulceration • Position-related scalp alopecia • Leg/thigh compartment syndromes • Nerve palsies Obesity Standards [World Health Organization] Class Normal Overweight Obese Morbid Obesity Super Obese

BMI 19.5–24.9 25–29.9 ≥ 30 ≥ 40 ≥ 50

J Am Acad Orthop Surg. 22(11):683–90, 2014 J Bone Joint Surg. 94A(11):1045–52, 2012

BMI > 35: • Difficulty with intubation • Increased mortality in the obese in injury due to high-velocity trauma

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GENERAL ORTHOPAEDICS—OSTEONECROSIS Etiologies Alcoholism Dysbaric disorders Gaucher’s disease Hemoglobinopathies (HbS) Hypercoagulable states Irradiation Viral etiologies (hepatitis, HIV, CMV, rubella, rubeola, varicella Malignancy (metastatic carcinoma, acute promyelocytic and lymphoid leukemia)

Antiphospholipid antibody syndrome Endotoxic reactions/systemic bacterial infections Hyperlipidemia (types II and IV) Inflammatory (lupus, inflammatory bowel disease) Trauma (dislocation, neck fracture) Pregnancy Hypersensitivity states (anaphylaxis, ­allograft rejection) Hypercortisolism (endogenous [Cushing’s] and exogenous)

MRI Single best study to detect osteonecrosis: 98% specificity. Natural History • Necrotic sector small (< 15%)—May resolve, prognosis usually good • Necrotic sector large (> 50%)—Collapse and arthrosis 85%, usually needs a total hip replacement Treatment Options • Observation (crutches, unload joint) • Core decompression +/– curettage and grafting • Rotational osteotomy (rarely done) • Hip arthrodesis (rarely done) • Hip arthroplasty • Other Stages are graded on the quantity of the femoral head involvement. Involvement is calculated by finding the product of the % involvement of the coronal AP and the % involvement of the sagittal lateral. Staging System for Osteonecrosis of the Hip Steinberg Modification of the Ficat/Arlet Classification (J Bone Joint Surg. 1995;77B:34) Stage O I II III IV V VI

Criteria Normal radiographs, bone scan, and MRI Normal radiographs, positive bone scan, and/or MRI Abnormal radiographs—cystic or sclerotic changes in femoral head Abnormal radiographs—subchondral collapse/crescent sign Abnormal radiographs—femoral head flattening Abnormal radiographs—loss of joint space +/– acetabular changes Abnormal radiographs—degenerative changes (advanced)



General Orthopaedics—Osteoporosis  85 Stage II

III

IV

V

Grading A B C A B C A B C A B C

Criteria < 20% head involvement on radiographs or MRI 20–40% > 40% Crescent (subchondral collapse) < 15%, no flattening 15–30% crescent, no flattening > 30% crescent, no flattening < 15% collapse and < 2-mm depression 15–30% or 2–4 mm > 30% or > 4 mm Mild (IV and includes estimate of acetabular involvement) Moderate (IV and includes estimate of acetabular involvement) Severe (IV and includes estimate of acetabular involvement)

GENERAL ORTHOPAEDICS—OSTEOPOROSIS Osteoporosis Type I (postmenopausal) Type II Age-related (> 75 years old) • Affects 45% of women > 50 years old • Lifetime risk of 40% for fractures • Treatment may reduce risk by 50% (J Bone Joint Surg. 2008;90:1362–1374. J Am Acad Orthop Surg. 2004;12(2):67–71. J Am Acad Orthop Surg. 1999;7:19–31. J Bone Joint Surg. 2000;82A:1063–1070.) DEXA Osteoporosis Criteria • Based on 25-year-old control. Plain films reveal osteopenia > 30% • DEXA study is the most accurate. • DEXA has the least radiation. • T-score ƒƒ –2.0 SD without risk factors ƒƒ –1.5 SD with risk factors Osteoporosis Risk Factors • • • • • • • • • •

Sedentary Thin Caucasian N. European Smoker Alcohol Phenytoin Low calcium Low vitamin D Breastfeeding Any adult fracture

Bone density has the strongest relation with fracture, but fracture may occur even with normal bone density.

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Calcium Recommendations Age Range Infants   Birth–6 months   7–12 months Children   1–3 years   4–8 years   9–18 years   14–18 years  pregnant/lactating Adolescents/adult   19–50 years   19–50 years  pregnant/lactating   51–70 years  71+ years

RDA (mg/day) 200 260 700 1000 1300 1300

1000 1000 1000♂, 1200♀ 200

National Institutes of Health. Calcium: Fact Sheet for Professionals. https://ods.od.nih.gov/factsheets/Calcium-HealthProfessional/

Vitamin D 200 IU daily < 50 years 400 IU 51–70 years 600 IU > 71 years Vitamin D3 the preferred form Prophylactic Reccomendations Men and premenopausal women: Physiologic calcium, vitamin D (400–800 U/ day), adequate nutrition, fall prevention, balance and exercise programs • • • •

GENERAL ORTHOPAEDICS—PAIN MANAGEMENT, DEGENERATIVE ARTHRITIS 1st Line of Treatment Tylenol • Safest medication, no gastrointestinal irritation; however, has no anti-inflammatory properties • Maximum dose 4000 mg/day • Must be cautious of concomitant liver disease especially with alcohol abuse.

General Orthopaedics—Perioperative Management  87

2nd Line of Treatment NSAIDs (Aspirin and Cyclo-Oxygenase 1 Inhibitors) NSAIDs are the most common pharmacologic agent used to treat osteoarthrosis. • Decreased platelet function, renal toxicity, hepatic toxicity (rare), gastrointestinal irritation • Absolute risk of gastrointestinal irritation constant over time; cumulative risk increases with time • 100,000 hospitalizations annually for gastrointestinal side effects • 16,500 deaths annually • 2.5–5.5 times more likely to be hospitalized than without NSAIDs • Utilization with misoprostol, omeprazole, lansoprazole decreases gastrointestinal risk NSAIDs • Decrease the antihypertensive properties of the thiazide diuretics and angiotensinconverting enzyme inhibitors • Increase circulating warfarin levels • Increase circulating lithium levels Cyclo-Oxygenase 2 Inhibitors • No platelet inhibition • Lower gastrointestinal risk • Possible increased cardiovascular risk • Some studies suggest an opioid-sparing effect postoperatively • Cyclo-oxygenase 2 has been shown to be important in bone healing, but early studies don’t show a clinical effect (rabbit model) J Bone Joint Surg. 2002;84A(10):1763–1768. Several prostaglandins, notably E2, are implicated in new bone formation. Don’t use celecoxib in sulfonamide allergic patients. J Am Acad Orthop Surg. 2004;12(3):139–143.

GENERAL ORTHOPAEDICS—PERIOPERATIVE MANAGEMENT Perioperative Management in the Patient With Rheumatologic Disorders (58% will undergo an orthopedic procedure; 24% undergo large joint replacement) Medication Aspirin (non-reversible COX inhibitor) NSAIDs

Important Drug Interactions

Antihypertensive medications Warfarin

Perioperative Management Stop 7–10 days prior Restart immediately after Stop 5 half-lives before surgery (COX) Restart 7–14 days after [COX-2—may not need to stop]

88  Tarascon Pocket Orthopaedica Medication Corticosteroids (popular treatment—60% overall, 80% undergoing joint repl.) Methotrexate (DMARD)

Leflunomide

Sulfasalazine Hydroxychloroquine Tumor necrosis factor antagonists

Interleukin antagonists

Important Drug Interactions Increased risk of tendon rupture if used with fluoroquinolones Antifungal; clarithromycin may potentiate steroid effects Possible neutropenia if used with PCN IV

Perioperative Management May need stress dose management. Tailor to specific patient. Overall: ↑infection, weaken bones, ↓wound healing,

Minor procedures—continue Moderate or major procedures consider holding in patients with ↑infection risk or vascular insufficiency. May elevate levels of Minor procedures—continue warfarin or rifampin Moderate or major procedures (­controversial) consider holding 1 wk before, add cholestyramine May potentiate warfarin’s Continue effects Continue Avoid live vaccines Minor procedures—continue Moderate or major procedures consider holding etanercept 2 wk, adalimumab 3 wk, and infliximab 6 wk. Restart after wound healing. Minor procedures—continue Moderate or major procedures ­consider holding 1 week before, restart after wound healing.

Nonsteroidal Anti-Inflammatory Drug Half-Life Drug Celecoxib Diclofenac Etodolac Ibuprofen Indomethacin Nabumetone Naproxen sodium Piroxicam

Half-Life (h) 11 1.2–2 6–7 1.6–1.9 4.5 24–29 12–15 30

Overall: ↓immunity, cardiovascular disease (60% increased risk of death), interstitial lung disease, cervical spine disease (need to clear C-spine), and rheumatoid nodules. Multiple DMARDs increase the risk of infection. Sendhu K, et al. Perioperative management of rheumatoid medications in orthopaedic surgery. Orthopaedics, 2017;40;5:282–286.



General Orthopaedics—Tetanus  89

Supplemental Hydrocortisone for Surgical Stress Surgical Stress Minor Moderate Major

Procedure Hand or foot surgery Arthroscopy Joint replacement arthroplasty Ligament reconstruction Poly trauma Bilateral or revision arthroplasty Multilevel spine fusion

Recommended Supplemental Dose 25 mg hydrocortisone (5 mg prednisone) day of surgery 50–75 mg hydrocortisone (prednisone 10–15 mg) day of procedure tapering over 1–2 days to preoperative dose 100–150 mg hydrocortisone (prednisone 20–30 mg) day of procedure tapering over 1–2 days to preoperative dose

Modified from Howe CR, et al. Perioperative medication management for the patient with rheumatoid arthritis. J Am Acad Orthop Surg. 2006;14:544–551.

GENERAL ORTHOPAEDICS—TETANUS Wound Classification for Tetanus Prophylaxis Clinical Features Age of wound Configuration Depth Mechanism Devitalized tissue Contaminants (dirt, saliva)

Tetanus Prone >6h Stellate, avulsion > 1 cm Missile, crush, burn, frostbite Present Present

Nontetanus Prone ≤6h Linear ≤ 1 cm Sharp surface (glass, knife) Absent Absent

Tetanus Immunization Schedulea Tetanus Product Unknown, < 3 doses 3 or more doses a

Tetanus Prone Tdb TIG Yes Yes c No No

Nontetanus Prone Td TIG Yes No d No No

Data from Morbid Mortal Wkly Rep. 1990;39:37. Yes, if wound > 24 h old. For children < 7 yr, DPT (DT if pertussis vaccine contraindicated). For persons ≥ 7 yr, Td preferred to tetanus toxoid alone. c Yes, if > 5 yr since last booster. d Yes, if > 10 yr since last booster. b

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GENERAL ORTHOPAEDICS—TOBACCO ABUSE Tobacco’s Effects Decreased Bone mineral density WBC function, leukocytosis Serum immunoglobins Antibody response T-cell response Mass & cellularity of lymphoid tissue

Increased Mitogens Autoantibodies (RF) Perioperative complications • Nonunion, delayed union • Infection • Soft tissue/wound healing complications Low back pain & degenerative disc disease Risk of fracture and tendon rupture

J Bone Joint Surg. 2013;95A(9):850–859.

• 20% of our patients continue to smoke • Former smokers have better outcomes than current smokers! [MMWR 2010; 59(35):1135–40] • Perioperative cessation may mitigate risk Function Immune function Wound healing Pulmonary function Fracture risk

Time Needed to Improve Risk 2–6 wk 3–4 wk 6–8 wk Up to 10 yr

GENERAL ORTHOPAEDICS—TOURNIQUET Definitive data are lacking. Duration Inflation pressure

Tourniquet Use

Inflation time < 2 h safe, may extend to 2.5 safely. If anticipated OR time ≥ 2.5 h: Deflate tourniquet at 2 h (reperfusion interval) for 10 min the repeat q1h. Upper extremity ≤ 250 mm Hg Lower extremity ≤ 300 mm Hg A more specific number can be obtained by noting the pressure at which the Doppler pulse signal ceases (limb occlusion pressure) then choosing that number + a safety margin (25–50 mm Hg).



General Orthopaedics—Venous Thromboembolic Disease  91

GENERAL ORTHOPAEDICS—VENOUS THROMBOEMBOLIC DISEASE [J Am Acad Orthop Surg. 2017;25(12):789–798] Patient factors that increase DVT/PE risk: • Hypercoagulable states, previous documented VTE • Obesity, advanced age • Immobilization • Estrogen therapy • Cancer • Thrombophilia (antithrombin III deficiency, protein C & S abnormalities), molecular risk factors (Factor V Leiden, prothrombin 20210A) • Chronic obstructive pulmonary disease • Atrial fibrillation • Anemia • Depression • Elevated Charlson comorbidity index Patient factors that increase the risk for major bleeding • History of bleeding disorder • History of recent GI bleed • History of recent hemorrhagic stroke Decreases thromboembolic risk: • Epidural and spinal anesthetic, hypotensive anesthesia • Autologous transfusions, decreased blood loss (J Bone Joint Surg. 2000;82A:252–270) Due to improvements in operative and anesthetic technique that affords accelerated rehabilitation, the pulmonary embolism rate (including the rate for fatal pulmonary embolism) for total hip and knee arthroplasty has decreased independent of routine thromboembolic prophylaxis. A North American consensus to prophylaxis postoperatively exists for both total hip and knee arthroplasty. Most thrombosis in elective surgery occurs in the 1st ­postoperative week with the peak occurring at 4 days. Efficacy and safety: • Aspirin (low risk for postoperative bleeding complications) • Warfarin (lowest risk for proximal deep venous thrombosis and symptomatic pulmonary embolism) • Sequential compression devices (lowest risk for postoperative bleeding complication) • Low molecular weight heparins (lowest total deep venous thrombosis risk; increased risk of postoperative bleeding) • Low-dose heparin (increased risk of major and minor postoperative bleeding complications) Low molecular weight heparin (reports cite enoxaparin) with indwelling catheters contraindicated due to increased bleeding risk (occurrence of epidural hematomas with concomitant use)

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Commonly Used Prophylaxis Options Option Low Molecular Weight Heparin: Enoxaparin, dalteparin

Mechanism Factor IIa inhibitor (less than unfractionated heparin), Factor Xa inhibitor

Indirect Factor Xa Inhibitors: fondaparinux

Indirect Factor Xa inhibitor

Aspirin

Cyclo-oxygenase inhibitor

Warfarin

Vitamin K antagonist

Direct Factor Xa inhibitors: Direct Factor Xa inhibitor Apixaban, rivaroxaban

Intermittent pneumatic compression

Suspected decrease in ­stasis and possible ­activation of anticlotting factors.

Drawbacks Require subcutaneous injections Rate of bleeding complications Require subcutaneous injections Rate of bleeding complications Randomized controlled trials against newer agents pending. Drug & food interactions Bleeding risk Dose adjustments/­ monitoring requirements. Rate of bleeding complications. Consider delayed ­administration 18–24h postoperative. No commercially available reversal agent. Patient compliance Randomized controlled trials lacking

Guidelines for Duration of Therapy 10–14 d up to 35 d [Chest 2012;141(suppl 2):e278S–e325S] No recommendation due to lack of definitive data (AAOS) Warfarin, sequential compression devices, and low ­molecular weight heparin all individually decreased the risk of pulmonary embolism. No difference in the rate of fatal pulmonary embolism among the agents You would need a cohort of 100,000 patients to see a change in the incidence of fatal pulmonary embolism rate. Deep venous thrombosis may not lead to fatal pulmonary embolism in a predictable manner.



General Orthopaedics—Wound Healing  93

GENERAL ORTHOPAEDICS—WOUND HEALING Normal Wound Healing Indices Serum albumin > 3.5 g/dL Absolute lymphocyte count > 1500/mm3 Absolute Doppler pressure 70 mm Hg Differential pressure index (ABI) > 0.5 TCPO2 30 mm Hg

Malnutrition/Poor Wound Healing Total lymphocyte count < 1500/mm3 Serum albumin < 3.5 g/dL Serum transferrin level < 226 mg/dL



Pediatric Orthopaedic—Milestones and Angles  95

PEDIATRIC ORTHOPAEDIC—MEDICATIONS Analgesics Medication Acetaminophen drops Acetaminophen elixir Acetaminophen chew Acetaminophen tabs Aspirin

Product 80 mg/0.8 mL

Ibuprofen

100 mg/5 mL

160 mg/5 mL 80 mg 325 mg 81 mg

Diazepam Meperidine Morphine

Dosage* 10–15 mg/kg q4–6h 10–15 mg/kg q4–6h 10–15 mg/kg q4–6h 10–15 mg/kg q4–6h 10–15 mg/kg q4–6h 5–10 mg/kg q6–8h 0.12–.08 mg/kg/d divided tid–4×/d 0.04–0.2 q2–4h 1–1.8 mg/kg 0.1–0.2 mg/kg 0.1–0.2 mg/kg

Route po po po po

Maximum 5 dose/day (≤ 4000 mg/d) 5 dose/day (≤ 4000 mg/d) 5 dose/day (≤ 4000 mg/d) 5 dose/day (≤ 4000 mg/d)

po po

40 mg/kg/d

po/pr IV/IM

0.6/8h

IV/SC/po slow IV IV/IM/ 15 mg q4h SC po

* All doses mg/kg unless otherwise noted

Antihistamines Medication Hydroxyzine Diphenhydramine

Product 10 mg/5 mL 12.5 mg/5 mL 25, 50 mg

Dosage* 0.5 4×/d 5 mg/kg/d Divided 4×/d

Route po po/IV/IM

Maximum 300 mg/day

PEDIATRIC ORTHOPAEDIC—MILESTONES AND ANGLES Gait Milestone Sitting Cruises Independent walking Runs Mature gait kinematics

Approximate Time Frame 6 months 12 months (variable) 15 months 18 months 3–7 yr

Time/distance parameters (step length and velocity) continue to increase until growth complete.

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Rotational Profile Foot progression angle: 5–20 degrees external rotation Hip: Internal rotation: 30–60 degrees (< 20 degrees femoral anteversion) Hip: External rotation: 20–60 degrees (> 70 degrees femoral anteversion) Thigh foot angle: 0–20 degrees external rotation (< negative 10 degrees tibial torsion)

Maximum varus ~ Birth Genu rectus ~ 18 months Maximum valgus ~ 3 yr Femoral anteversion: 1 yr—31 degrees 8 yr—24 degrees 15 yr—15 degrees (Improves 15 degrees up to 15 yr old)

Development of Cervical Spine Age < 6 mo 1 yr 3 yr 3–6 yr 8 yr 12–14 yr 25 yr

Feature C1 body invisible and all synchondroses are open, vertebrate are normally wedged anteriorly, and there is often no lordosis to the noninjured spine. Body of C1 becomes visible radiographically. Posteriorly located spinous process synchondroses fuse. Dens becomes ossified (visible radiographically). Neurocentral (body) and C2-odontoid synchondroses fuse. Summit ossification center appears at the apex (top) of the odontoid. Anterior wedging of the vertebral bodies resolve (and is not normal if seen). Pseudosubluxation and predental widening resolve; lordosis is normal now. Secondary ossification centers appear at spinous process tips; summit ossification center of odontoid fuses (if it does not os odontoideum occurs); superior/inferior epiphyseal rings appear on body. Secondary ossification centers at tips of spinous processes fuse. Superior/inferior epiphyseal rings fuse to vertebral body.

Used with permission from Tarascon Pediatric Emergency Pocketbook, 5th ed. Lompoc, CA: Tarascon; 2007.

Reflexes Reflex Hand grasping Plantar grasping Moro Stepping Crossed extension Withdrawal Positive support response Extensor thrust Symmetric tonic neck Parachute

Disappears 2–4 months 1 year 4–6 months 1–2 months 1 month Should always be present 4 months 2 months Present by 6 months, no absolute time for disappearance Present by 6 months, persists through life



Pediatric Orthopaedic—Growth Centers  97

Characteristics of Myelodysplasia Levels Level L1 L2* L3* L4* L5

Hip External rotation/ flexion Adduction/ flexion Adduction/ flexion Adduction/ flexion flexion

Knee —

Feet Equinovarus

Orthosis HKAFO

Ambulation Non

Flexed

Equinovarus

HKAFO

Non

Recurvatum

Equinovarus

KAFO

Household

Extension

Cavovarus

AFO

Household +

Limited flexion

Calcaneovalgus

AFO

Community

Shoes

Near normal

S1

*Increased risk of hip dislocation in these groups. Abbreviations: AFO, ankle foot orthosis; HKAFO, hip knee ankle foot orthosis; KAFO: knee ankle foot orthosis.

PEDIATRIC ORTHOPAEDIC—GROWTH CENTERS Growth Plates Growth Plate Clavicular body Medial clavicle Acromion Coracoid Scapular body Glenoid Humeral body Humeral head (80% of humeral growth)

Appearance 6th fetal week 17 15–18 1 1st fetal week 18 6th–8th fetal week ♂: 6 mo–2 yr ♀: 3 mo–18 mo

Greater tuberosity Lesser tuberosity Lateral epicondyle Trochlea Capitellum

♂: 1/2–1, ♀: 1/4–1.5 3–5 ♂: 12, ♀: 11 ♂5 mo, ♀4 mo ♂: 5 mo, ♀: 4 mo (6 wk–8 mo) ♂: 5–7, ♀: 3–6 (3–7) ♂: 10, ♀: 8

Medial epicondyle Olecranon

Closure* 18–24 18–19 18–21 20–21 19 19 Head/tuberosities 4–6 Fuse with shaft ♂: 19–21, ♀: 18–20 “ “ ♂: 17, ♀: 14” “ “ ♂: 18, ♀: 15 ♂: 15–17, ♀: 14–15

(continues)

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Growth Plates Continued Growth Plate Radius body Radial head Radial tuberosity Distal radius

Appearance 6–12th fetal week ♂: 5, ♀: 4 (3–6) 10–12 3 mo–1.5

Closure* ♂: 15–17, ♀: 14–15 14–18 ♂: 19, ♀: 17

LEG GROWTH Femur 15% proximal, 38% distal; Tibia 27% proximal, 15% distal Growth Plate Ulna body Distal ulna Scaphoid Lunate Triquetrum Pisiform Trapezium Trapezoid Hamate Capitate Thumb metacarpal Proximal thumb P1 Proximal thumb P2 Distal I/M/R/S metacarpal Phalanges PI, II, and III Iliac crest Iliac tubercle ischial spine Pubic tubercle Acetabulum Ischial spine Femoral body Femoral head Greater trochanter

Appearance 6th–8th fetal week ♂: 6, ♀: 5 (4–9) ♂: 5.5, ♀: 4.5 (2.5–9) 4 (6 mo–9.5) ♂: 2.25, ♀:1.75 (1/2–4) ♂: 11, ♀: 9 ♂: 5, ♀: 4 (1.5–10) ♂: 6, ♀: 4 (2.5–9) 6 mo (0–1.5) 6 mo (0–1) ♂: 2.5, ♀: 1.66 (1–3.5) 5 mo–2.5 ♂: 1.5, ♀: 1 1–1.5 5 mo–2.5 Puberty 13–15 18–20 10–13 13–15 6th–12th fetal week 4 mo 3

Closure* ♂: 19, ♀: 17 Variable Variable Variable Variable Variable Variable Variable Variable 14–21 14–21 14–21 14–21 14–21 16–18 Fuse at puberty Fuse at puberty Fuse at puberty Fuse at puberty ♂: 17–18, ♀: 16–17 16–17



Pediatric Orthopaedics—Foot  99 Growth Plate Lesser trochanter Distal femur Patella Proximal tibia Tibial tuberosity Proximal fibula Distal tibia Distal fibula Calcaneus Calcaneal apophysis Talus Cuboid Navicular Cuneiforms Metatarsal Phalanges

Appearance ♂: 12, ♀: 11 36th fetal week ♂: 4–5, ♀: 3 40th fetal week 7–15 ♂: 4, ♀: 3 6 mo ♂: 1, ♀: 9 mo 24th–26th fetal week 5–12 26th–28th fetal week 40th fetal week ♂: 3, ♀: 2 3 mo–2 8–12th fetal week 6 mo–4 yr

Closure* 16–17 ♂: 18–19, ♀: 17 Fuse at puberty ♂: 18–19, ♀: 16–17 19 ♂: 18–20, ♀: 16–18 17–18 (med. mal. 16–18) 17–18 12–22 12–22 Variable Variable Variable Variable 18 11–22

*Range = age in yr except as noted.

PEDIATRIC ORTHOPAEDICS—FOOT

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Angles and Characteristics Metatarsus Adductus 20–40 degrees Adducted forefoot

Talo-calcaneal angle Characteristics

Talipes Equinovarus < 20 degrees Talus and calcaneus parallel

Normal Talo-Calcaneal Angle Is 20–40 degrees + Dorsiflexion Shape of sole Heel position

Calcaneovalgus Yes Deviates laterally “Banana” Valgus

Metatarsus varus Yes Deviates medially “Kidney” Valgus

Clubfoot No Deviates medially “Kidney” Varus

Clubfoot Treatment—Ponseti Technique (J Bone Joint Surg. 1992;74a(3): 448–454) • • • •

Long leg cast, changed weekly Usually requires Achilles tenotomy at 6 wk to correct equines Dennis-Brown bar and boots full-time for 3 months; nap and nighttime until 3 yr Correct in this order: Cavus Adductus Varus Equinus (“CAVE”)

PEDIATRICS—BRACHIAL PLEXUS Brachial Plexus Birth Injuries Name Erb-Duchenne

Roots C5/6

Klumpke Total plexus

C8/T1 C5–T1

• • • •

Loss Deltoid, elbow flexors, dorsiflexion at hand/ wrist, “waiter’s tip deformity” Hand intrinsics, wrist flexors Flaccid arm, sensory and motor loss

Prognosis Best Poor Worst

2 per 1000 births Clavicle and proximal humerus fractures may mimic with pseudo-paralysis. Treat by maintaining passive ROM. Return may be up to 18 months. No biceps function at 3 months is an ominous sign.

Pediatric Orthopaedics—General  101

Osteochondroses (Osteonecrosis at Apophysis/physis) Location Elbow (capitellum) Phalanges (hand) Spine Ischiopubic synchondrosis Femoral head Inferior patella Proximal tibial epiphysis Tibial tuberosity Calcaneus Tarsal navicular Metatarsal head Scaphoid Lunate

Eponym Panner’s Thiemann’s Scheuermann’s Van Neck’s Legg-Calvé-Perthes Sinding-Larsen-Johansson Blount’s Osgood-Schlatter’s Sever’s Köhler’s Freiberg’s Preiser’s Kienböck’s

PEDIATRIC ORTHOPAEDICS—GENERAL Arthroscopic Classification of Osteochondritis Dissecans (Guhl) Classification Intact Early-separated lesion Partially detached lesion Salvageable loose body Unsalvageable loose body

Stage I II III IV

Treatment Drilling (K-wire retrograde) In situ pinning Debride base, reduce, pinning Debride base, reduce, pinning Removal and debridement

NOTE: Attempt casting if physis is open in stages I & II.

Night Pains Awakens child at night; less or potentially gone during the daytime. Localized pain (short differential) Leukemia Acute osteomyelitis Generalized pain (long differential) Spinal dysraphism or tether Skeletal tumor Fibrous dysplasia Muscle—hemangioma Subacute osteomyelitis

Osteoid osteoma

Knee—osteochondritis Feet—deformity Perthes disease of the hips Joints—arthritis Köhler’s disease

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Back Pain in Children Diagnostic Workup According to Symptom Severity Clinical Situation No systemic signs (fever) Negative physical exam Pain < 3 months No systemic signs (fever) Pain > 3 months Negative exam Normal X-rays Positive bone scan Negative X-rays Positive ESR Positive neurologic findings Symptoms worsened at follow-up

Recommended Workup Often none Close follow-up +/– radiographs Radiographs CBC, ESR Bone scan with SPECT* Add CT (rule out bony tumor, spondylolysis) Add antinuclear antibodies and HLA-B27 MRI

*SPECT, single-photon emission computed tomography. Bhatia NN, et al. Diagnostic modalities for the evaluation of pediatric back pain. J Pediatr Orthop. 2008;28(2):230–233.

Mucopolysaccharidosis Syndrome MPS I: Hurler’s (most severe) MPS II: Hunter’s MPS III: Sanfilippo’s MPS IV: Morquio’s (most common)

Inheritance Autosomal recessive X-linked recessive Autosomal recessive Autosomal recessive

Intelligence Mental retardation Mental retardation Mental retardation Normal

Cornea Cloudy

Clear

Urinary Excretion Dermatan/heparin sulphate Dermatan/heparan sulphate Heparan sulphate

Cloudy

Keratan sulphate

Clear

Cartilage oligomeric protein (COMP)

Type II collagen

Pseudoachondroplasia

SED (congenital) SED (tarda) Chondrodysplasia punctata Kniest syndrome

Schmid metaphyseal chondrodysplasia Jansen metaphyseal chondrodysplasia

Fibroblast growth factor receptor-3

Achondroplasia (most common form)

AD AD

PTH-related peptide receptor

AD/SM XR AD AR (fatal) AD

AD

AD/SM

M

M

P

E E P

E

E

Zone

Detached retina, scoliosis, cleft palate Coxa vara, wide eyes, bow legs, waddling gait Severe limb shortening, prominent forehead, micrognathia

Abnormal facies and spine inhibition of endochondral ossification Normal facies, short limbed, ligamentous laxity, atlantoaxial instability, scoliosis, early OA Flattened facies Kyphosis, hip pain Flat facies

Clinical Findings

Disproportionate Dwarfism Mode

Type X collagen

Type II collagen

Error

Dysplasia

(continues)

Dumbbell femurs, osteopenia/ hypoplasia Flared metaphysis, wide irregular physes, bowed legs Flared metaphysis, wide irregular physes, bowed legs

Platyspondyly, delayed epiphysis Platyspondyly, dysplastic dens Stippled epiphysis

Lumbar stenosis, bow legs. At risk for atlantoaxial instability and spinal stenosis Metaphyseal flaring, delayed epiphyseal ossification, hypoplastic dens

Radiologic Features

PEDIATRIC ORTHOPAEDICS—DYSPLASTIC CONDITIONS

Pediatric Orthopaedics—Dysplastic Conditions  103

Error I- COMP II-type IX collagen

Zone E M D

Mode AD — AD

Delayed walking

Clinical Findings Mild dwarfing, delayed ambulation—waddling gait Bow legs

Disproportionate Dwarfism Continued

Symmetric cortical thickening

Hemienlarged epiphysis

Radiologic Features Irregular epiphyseal ossification

Sulfate transporter

Diastrophic dysplasia

AD

AR

Zone Clinical Findings P Corneal changes, urinary sugars, atlantoaxial instability P Short limbs and stature, kyphoscoliosis, cleft palate, cauliflower ears, hitchhiker thumb, rigid clubfoot M Absent clavicles, wide cranial sutures

Proportionate Dwarfism Inheritance AR/XR

Delayed physeal closure

Kyphoscoliosis, odontoid hypoplasia

Radiologic Features Thick bone, bullet-shaped metacarpals

Abbreviations: AD, autosomal dominant; AR, autosomal recessive; OA, osteoarthrosis; SED, spondyloepiphyseal dysplasia; SM, spontaneous mutation; XR, X-linked recessive. Zones: D, diaphyseal; E, epiphyseal; M, metaphyseal; P, physeal. Dietz FR, Matthews KD. Update of the genetic basis of disorders with orthopaedic manifestations. J Bone Joint Surg. 1996;78A(10):1583–1598.

Cleidocranial dysplasia

Error

Dysplasia Mucopolysaccharidosis

Abbreviations: AD, autosomal dominant; AR, autosomal recessive; OA, osteoarthrosis; SED, spondyloepiphyseal dysplasia; SM, spontaneous mutation; XR, X-linked recessive. Zones: D, diaphyseal; E, epiphyseal; M, metaphyseal; P, physeal. Dietz FR, Matthews KD. Update of the genetic basis of disorders with orthopaedic manifestations. J Bone Joint Surg. 1996;78A(10):1583–1598.

Dysplasia Multiple epiphyseal dysplasia Dysplasia epiphysealis hemimelica (Trevor’s) Progressive diaphyseal dysplasia

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Pediatric Orthopaedics—Salter-Harris Classification  105

PEDIATRIC ORTHOPAEDICS—SALTER-HARRIS CLASSIFICATION Salter-Harris Classification of Physeal Injuries Type I II III IV V VI

Description Transverse through growth plate Same as I with a metaphyseal fragment (Thurston-Holland fragment) Through growth plate with extension through epiphysis into joint Through epiphysis and metaphysis Crush injury to the growth plate Damage to the perichondral ring of Lacroix

Characteristics Younger age Older age (> 10) Intra-articular Growth arrest Late growth arrest Physeal bridge/asymmetric growth irregularity (angular deformity)

J Bone Joint Surg. 45A:587–622, 1963.

I

II ThurstonHolland Fragment

III

IV

V

VI

S - Sliding A - Above L - Lower T - Through E - Everything R - Periosteal Ring

Damian Rispoli 2009

Salter-Harris Classification (JBJS 45A:587-622;1963)

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PEDIATRIC ORTHOPAEDICS—SLIPPED CAPITAL FEMORAL EPIPHYSIS Slipped Capital Femoral Epiphysis • Prevalence 0.2/100,000 (Japan) to 10.08/100,000 (Northeastern US) • 60% male • Mean age = 13.5 in boys, 12 in girls 50% • > 95th percentile for weight • Bilaterality as high as 63%  (J Bone Joint Surg. 2000;82A:1185) Classification Preslip

Acute (10–15%)

Chronic (85%)

Acute on chronic

Stable: Walk without crutches (nearly 0% avascular necrosis) Unstable: Can’t walk without crutches (up to 50% avascular necrosis) Radiographic Evaluation • Radiographs show a superior and anterior slip of the proximal femoral metaphysis with respect to the capital femoral epiphysis. In a gradual slip, you may see superior and anterior remodeling on the femoral metaphysis and periosteal new bone formation. • Ultrasound to look for effusion and periosteal bone formation (unstable). • MRI and bone scans may also be used. Physical Exam Flexed and externally rotated position may mimic fracture in pain and presentation. (Represents a Salter-Harris I of the proximal femoral physis.) Grading Slips < 30 degrees mild, 30–50 degrees moderate, > 50 degrees severe (AVN risk increases with severity). Good results with in situ pinning with mild and moderate slips. Treatment In situ pinning favored—single pin under fluoroscopic guidance (still controversies especially with respect to traction, reduction). Treatments ranging from hip spica casting to osteotomies have been proposed. Prophylactic pinning of the contralateral side is controversial: • Incidence of bilateral slip ~20% • Should be strongly considered for age < 10 yr, endocrinopathy, renal failure, patients with predicted unreliable follow-up  (J Bone Joint Surg Am. 2004;86A(12):2658–2665.)



Pediatric Orthopaedics—Limp  107 Femoral Head below Kline’s line Blurring

Femoral Head above Kline’s line No Blurring

Metaphyseal Kline’s line should No Slip Blanch intersect a part of the lateral aspect of the femoral capital epiphysis Kline’s Line and Metaphyseal Blurring

Slip

Damian Rispoli 2009

PEDIATRIC ORTHOPAEDICS—LIMP Evaluation C-reactive protein more useful than ESR to follow trend and returns more quickly to normal. Radiographs • Obtain spine, pelvis, and extremity • Periosteal reaction ~ 2 wk • Medial joint space increased > 2 mm in hip is significant • Endosteal erosion, disc space mineralization in discitis Ultrasound Less invasive, easy to get, operator dependent MRI Good for soft tissue and differential between dead and living bone. Early Perthes: evaluate spinal cord and disc

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Transient Synovitis vs. Septic Arthritis Diagnosis Transient synovitis Septic arthritis

Sequelae Self-limited Osteonecrosis Growth arrest Sepsis Joint destruction

Differential diagnoses: Slipped capital femoral epiphysis Fracture Legg-Calvé-Perthes disease Rheumatoid arthritis Osteomyelitis Psoas abscess Pyogenic sacroiliitis Lyme disease

Five Predictors of Septic Hip Arthritis 1. ESR > 40 2. C-reactive protein > 2.0 mg/dL 3. WBC > 12,000 4. Nonweight bearing 5. Temperature > 38.5°C (101.5°F) C-reactive protein and fever are strongest independent risk factors. (Caird MS, et al. J Bone Joint Surg. 2006;88A:1251–1257) Number of Predictors Present No predictors 1 predictors 2 predictors 3 predictors 4 predictors 5 predictors

Percent Chance of a Septic Arthritis 16.9% 36.7% 62.4% 82.6% 93.1% 97.5%

Caird MS, et al. Factors distinguishing septic arthritis from transient synovitis of the hip in children. J Bone Joint Surg. 2006;88A:1251–1257.

~ 10–16% of septic arthritis from contiguous bacterial osteomyelitis (hip, shoulder, ankle). Song KM, Sloboda JF. Acute hematogenous osteomyelitis in children. J Am Acad Orthop Surg. 2001;9(3):166–175.

Pediatric Orthopaedics—Limp  109

Osteomyelitis in Children See antibiotic section (p. 60) for choice of antibiotics and common pathogens. Usually via a blood-borne route. Rarely crosses the physis (subacute osteomyelitis can) and usually resides in the metaphysis or epiphysis due to vascular anatomy. Physical exam may show pain, loss of function, erythema, warmth, and occasionally abscess. Osteomyelitis Algorithm Possible Osteomyelitis

Radiographs

Negative

Positive

Bone scan

Negative

MRI, CT, US

Consider Aspiration

Positive Antibiotics

Antibiotics

Negative

No clinical improvement for 48 hours Positive Biopsy and surgical debridement Antibiotics

Positive

Negative Antibiotics

MRI, CT, US, reassess diagnosis

Biopsy and surgical debridement

Song KM, Sloboda JF. Acute hematogenous osteomyelitis in children. J Am Acad Orthop Surg. 2001;9(3):166–175.

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Limp—Differential Diagnosis A hip radiograph is invaluable for any child with a limp and without an obvious etiology. Toddlers Developmental hip dysplasia Mild cerebral palsy Toddlers fracture Juvenile RA Discitis

4–10 yr Perthes Osteomyelitis Septic hip/joint Leg length difference > 1–2 inches

11–16 yr Slipped capital femoral epiphysis Toxic synovitis DDH (untreated) Tumor Tarsal coalition

Vertebral Infection > 5 yr: Low-grade fever, nonweight bearing, flexed spinal posture, +/– abdominal pain < 5 yr: Usually toxic appearing

Discitis Refusal to walk or sit, decreased ROM of spine, MRI is diagnostic early Radiographs may show late disc space narrowing Treat: Bed rest (no traction), immobilization, +/– antibiotics

Genu Varum Disorder of the posterior medial physis Blount’s disease = Drennan’s angle > 11° Metaphyseal beaking African-American, obese common

MetaphysealDiaphyseal Angle

Drennan’s Angle (JBJS 64:1158 –1163,1982)

Damian Rispoli 2009



Pediatric Orthopaedics—Scoliosis  111

Treatment Based on Age and Langenskiöld Stages Age < 18 months 18–24 months 2–3 yr 3–8 yr

Stage I–II I–II I–II III–V VI (bony bridge)

Treatment None Night bracing Daytime brace Osteotomy Resection of bony bridge

PEDIATRIC ORTHOPAEDICS—SCOLIOSIS Neuromuscular Scoliosis Common in neuromuscular conditions; may progress rapidly; may progress after maturation; often associated with pelvic obliquity, bony deformities, and involvement of the cervical spine. Infantile Idiopathic Scoliosis 2 months–3 yr Left-sided thoracic Male predominance Skull flattening

Other associated defects Most common in United Kingdom Curve < 20 degrees, rib vertebral angle difference < 20 degrees resolve MRI severe curves

Early Onset Idiopathic Scoliosis 3–10 yr High risk for progression

70% need treatment 50% surgery 50% bracing

Adolescent Idiopathic Scoliosis Scoliometer threshold = 7 degrees; progression = increased Cobb angle > 5 degrees (curve apex < T8 use Boston bucket, > T7 use Boston + Milwaukee) Hard or difficult to brace hypokyphosis/thoracic lordosis in a brace. Progression vs. Magnitude/Skeletal Maturity (expressed in percentage of progression) Risser Sign 5–19 degrees 20–29 degrees 1–2 22% 68% 2–4 1.6% 23% Lonstein JE, Carlson JM. The prediction of curve progression in untreated idiopathic scoliosis during growth. J Bone Joint Surg. 1984;66:1067.

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Treatment Guidelines Curve 0–25 degrees 25–30 degrees

Progression — 5–10 degrees

Risser stage 0–4 0–1

30–40 degrees

—

0–1

> 45 degrees > 50 degrees

— —

0–4 5

Therapy Serial observation Brace (halt or slow progression) Brace (halt or slow progression) Surgery* Surgery (young adults)

*Posterior spinal fusion

Progression Risk Factors • Curve > 20 degrees • < 12 yr • Risser 0–1 at presentation. MRI Criteria: Rapid Progression (Tumor, Tethered Cord, Syringomyelia) Structural abnormality in plain films Pain Excessive kyphosis Left thoracic curve and focal neuro finding Juvenile onset (< 11) Radiographic abnormality Abnormal neurologic exam Associated syndromes

King Curves (Patterns of Idiopathic Scoliosis) (J Bone Joint Surg. 1983;83A:1302–1313) Type Definition I S-shaped thoracolumbar curve, crosses midline II S-shaped thoracolumbar curve, crosses midline III Right thoracic curve, T4 does not tilt into the curve IV V

Long thoracic curve, T4 tilts into the curve Double thoracic curve

Flexibility Lumbar > thoracic Lumbar < thoracic Lumbar vertebrae highly flexible L4 tilts to thoracic curve T1 tilts to upper curve

1

2

3

Risser Stages (5 = Fusion of Iliac Apophysis)

Damian Rispoli 2009

4

Pediatric Orthopaedics—Scoliosis  113

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Lenke Classification of Adolescent Idiopathic Scoliosis Proximal Thoracic Nonstructural

Thoracolumbar/ Lumbar Nonstructural

Nonstructural

Main Thoracic Structural (major) Structural (major) Structural (major) Structural (major) Nonstructural

Nonstructural

Structural

Structural (major*)

Type 1

Curve Type Main thoracic (MT)

2

Double thoracic (DT) Structural

3

Double major (DM)

Nonstructural

4

Triple major (TM)

Structural

5

Thoracolumbar/ lumbar (TL/L) Thoracolumbar/ lumbar-main thoracic (TL/L-MT)

6

Nonstructural Structural Structural Structural (major*)

Note: *Major = largest Cobb measurement, always structural. Minor = all other curves with structural criteria. (J Bone Joint Surg. 83A(8):1169–1181, 2001)

Congenital Spinal Deformities Associated with genitourinary abnormalities (25%), cardiac (10%), and dysraphism (25%; commonly diastematomyelia) Risk of Progression Unilateral unsegmented bar and contralateral hemivertebrae Unilateral unsegmented bar Fully segmented hemivertebrae Partially segmented hemivertebrae Incarcerated hemivertebrae Nonsegmented hemivertebrae

Curve Progression Rapid and relentless Rapid Steady Less rapid, 40 degrees

Classification Notation Curve type (1–6) + lumbar spine modifier (A, B, or C) + thoracic sagittal modifier (–, N, or +) Scheuermann’s Kyphosis (Thoracic) • Kyphosis > 45 degrees, 5 degrees or more anterior wedging at three consecutive vertebrae. • Other radiographic findings = disc narrowing, end-plate changes, spondylolysis (30–50%), scoliosis (33%), and Schmorl’s nodes. • More common: adolescents with poor posture and occasionally aching pain. • Hyperkyphosis that does not improve with hyperextension (if hyperkyphosis improves with hyperextension diagnosis = postural kyphosis, tight hamstrings. • Brace progressive curves (Risser 1–3), > 1 year, may improve curve. • Risser 5, > 75 degrees, consider fusion. Lumbar Scheuermann’s: Athletes/manual laborers, less common, end-plate changes, Schmorl’s nodes, ↓ disc height, lacks wedging, mechanical back pain Usually self-limited Lowe TG. Scheuermann disease. J Bone Joint Surg. 1990;72A:940–945.

Pediatric Orthopaedics—Child Abuse  117

PEDIATRIC ORTHOPAEDICS—CHILD ABUSE Skeletal Survey in Child Abuse • AP bilateral hands, forearms, arms, thighs, legs, and feet • AP/lateral axial skeleton and trunk • AP/lateral skull Differential Diagnosis in Child Abuse Diagnosis Accident

Factors and/or characteristics Age, mechanism of injury, assoc. injuries, no delay in seeking care Birth trauma Obstetric history, callus within 2 wk of birth, humeral or clavicle fracture, distal humeral physeal separation Osteogenesis imperfecta Family history, osteopenia, blue sclera, dental abnormalities, wormian bones, skin-test abnormalities Caffey’s disease Family history, diffuse periosteal elevation, mandibular ­involvement, irritability, inflammation, swelling, stiffness Rickets Physeal widening, metabolic abnormalities, deformity, ­osteopenia, Looser’s lines, laboratory abnormalities Congenital syphilis Metaphyseal erosions, periosteal bone formation, positive serological tests, pseudoparalysis Congenital insensitivity to Infection, joint destruction, neurologic abnormalities, family pain, Riley-Day syndrome history Coagulation disorders Leukemia Normal radiographic variants

Bruising, coagulopathy, laboratory abnormalities Metaphyseal lucencies, systemic symptoms, hematologic abnormalities, + bone marrow biopsy Angulation of ossifying metaphysis, cortical irregularities, spurring, juxtaphyseal variants

Adapted from Kocher MS, Kasser JR. Orthopedic aspects of child abuse. J Am Acad Orthop Surg. 2000;8:10–20.

Specificity of Musculoskeletal Findings in Child Abuse High specificity Moderate specificity Low specificity (but common in child abuse)

Metaphyseal corner lesions, posterior rib, scapular, spinous process, or sternal fractures Multiple fractures, fractures of different ages, epiphyseal separations, vertebral body, digital, or complex skull fractures Clavicular, long-bone shaft, or linear skull fractures

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PEDIATRIC ORTHOPAEDICS—LEGG-CALVES-PERTHES Osteonecrosis of the proximal femoral epiphysis • Boys 4–8 yr • Delayed skeletal maturation Legg-Calvé-Perthes Stages Stage Initial Fragmentation Reossification Healed

Characteristics Physeal irregularity, metaphyseal blurring, radiolucencies Radiolucencies and radiodensities Normal density returns Residual deformity

Herring Classification A = normal pillar height, B = > 50% height, C = < 50% (J Pediatr Orthoped. 12:143–150, 1992) Herring’s Modified Lateral Pillar Classification and Surgical Indications Chronological Age ≤8

Skeletal Age ≤6

Herring Group A, B, B/C border

>8

>6

B, B/C border

Any

Any

C

Surgical Treatment No benefit from surgical treatment (tend to do well) Innominate osteotomy or varus femoral osteotomy No benefit from surgical treatment (tend to do well)

J Bone Joint Surg. 2004;86A:2121–2134.

• Positive family history • Low birth weight • Abnormal birth presentation

Risks

Physical signs • Trendelenburg gait • Hip or knee pain • Decreased range of motion (especially abduction and internal rotation) Key to prognosis Age > 6 yr = worse Bilateral 12–15%

Pediatric Orthopaedics—DDH  119

PEDIATRIC ORTHOPAEDICS—DDH Developmental Dysplasia of the Hip Developmental dysplasia of the hip (DDH) (Risk = 1:1000) Associated conditions: metatarsus adductus, clubfoot, calcaneovalgus, torticollis Increased in Native Americans and Laplanders Rare in individuals of African descent Risk With History 6% risk with normal parents and 1 affected sibling 12% risk with 1 affected parent 36% risk with 1 affected parent and sibling

Distribution 80% Female Left 60%, right 20%, both 20% Increased risk with breech or firstborn Twice as common in subsequent siblings

Radiographs may be confirmatory, but do not rule out the diagnosis of DDH. If subluxation suspected, dynamic ultrasound may be helpful.

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Algorithm for Evaluation and Treatment of DDH (J Am Acad Orthop Surg. 1999;8:232–242) Abnormal hip at birth Subluxated

Dislocated or dislocatable

Observe at three weeks

Nonreducible

Stable

Subluxation

No treatment

Pavlik harness

Stable/no dysplasia Wean from harness

Reducible

Neuromuscular examination Operative treatment

Subluxation Neuromuscular examination

The surgeon places Pavlik initially Weekly follow-ups till full ROM If not reduced/stable by 3 weeks,consider other treatment options 2-week follow-ups till clinically and radiographically stable AP pelvis out of brace; wean out of brace If residual acetabular dysplasia persists, the harness may be worn 12 hours/day until radiographs show no dysplasia

Pavlik harness* Reduced

Full-time wean No dysplasia

Not reduced at 2 weeks Reevaluate

Dysplasia

End harness Abduction brace

Closed or open reduction

*6 weeks plus 2 times the age (weeks) at application



Physical Exam and Injections  121

PHYSICAL EXAM AND INJECTIONS Physical Exam: Hand Test Allen’s (J Trauma 1981;21: 471–479) Carpal tunnel compression Crossed finger test (J Hand Surg. 1980;5:560–565) Elbow flexion Elson test (J Bone Joint Surg. (Br) 1986;68: 229–231) Finkelstein

Flexor digitorum profundus Flexor digitorum superficialis

Froment’s

Passive test of continuity Phalen’s (J Bone Joint Surg. 1966;48:211–228)

Description Compress radial and ulnar arteries at wrist, make fist, relax fist, release arteries one at a time, shows ulnar and radial artery patency (can be performed on fingers). Direct pressure over the carpal ­ tunnel just distal to distal wrist flexion crease, 30–60 sec. Cross long and index finger (tests 1st volar and 2nd dorsal interosseous muscle). Hyperflexion elbow ~ 30–60 sec, reproduces ulnar nerve symptoms. Flex finger at proximal interphalangeal joint over table edge, have patient extend the joint against resistance. Distal joint should remain supple. Thumb in palm, ulnar flex wrist, clenching fist can give a false positive result. Reproduces pain in 1st dorsal compartment. Hyperextend MCPJ, lock PIPJ in extension, have patient flex DIPJ. Isolate finger by extending all others, have patient flex finger. Flex finger with metacarpophalangeal joint extended; otherwise, hand intrinsics contribute. Have patient pinch a piece of paper. Weak pinch and flexion of DIPJ of thumb signify ulnar neuropathy (weak adductor pollicis and flexor pollicis brevis). Flex wrist, grasp forearm just proximal to wrist flexion crease, squeezing here will flex fingers. Volar flex wrist ~ 30–60s (reproduces median nerve findings)

Positive Findings Arterial patency in the hand

Reproduces median nerve symptoms Intact ulnar nerve Ulnar nerve compression Central slip intact

DeQuervain’s tenosynovitis Tendon continuity Tendon continuity

Ulnar neuropathy

Tendon continuity Median nerve compression

(continues)

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Physical Exam: Hand Continued Test Quadriga effect

Regan test Spurling’s

Tenodesis effect Tinel’s Watson test (J Hand Surg. 1980;13: 657–660)

Description The four flexor digitorum profundus tendons share a common muscle belly. Shortening of one tendon causes the muscle tendon units of the remaining three tendons to functionally lengthen. Shucking ulnar wrist while stabilizing the lunate. Axial load skull with the neck in extension and deviation to the symptomatic side worsens nerve root compression. Flex wrist, fingers extend. Extend wrist, fingers flex (resting tone— intact tendons). Tap directly over peripheral nerve, symptoms in distribution of nerve. Thumb over volar distal pole of scaphoid, radial deviation of wrist flexes scaphoid, with torn scapholunate ligament the proximal pole of the scaphoid slips over the dorsal lip of the radius.

Flexor Digitorum Profundus Damian Rispoli 2009

Positive Findings Limits full flexion of uninvolved digits

Lunotriquetral ligament Nerve root compression, radicular pain Tendon continuity Nerve irritation, neuroma Scapholunate interosseous ligament tear

Flexor Digitorum Superficialis (You must isolate and test each finger separately)



Physical Exam and Injections  123 Quick Neurologic Assessment of the Hand

Anterior Interosseous Nerve

Ulnar Nerve

Posterior Interosseous Nerve

-Tests the flexor digitorum profundus (index) and flexor pollicis longus

-Active finger abduction -See crossed finger test

-Tests the extensor indicis proprius and digiti quinti minimi Damian Rispoli 2009

Flexor and Extensor Tendon Zones Flexor Zones

I

I

I

I II TI III

IV

TII TIII

V Damian Rispoli 2009

I. Distal to flexor digitorum superficialis insertion II. Within finger flexor retinaculum (“No man’s land”) III. The palm IV. Carpal tunnel V. Wrist and forearm TI. Distal to flexor pollicis longus insertion TII. Thumb flexor retinaculum TIII. Thenar eminence Extensor Zones I. Distal interphalangeal joint II. Middle phalanx (PII) III. Proximal interphalangeal joint IV. Proximal phalanx (PI) V. Metacarpal VI. Dorsal wrist VII. Distal forearm VIII. Mid/proximal forearm

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Flexor Sheaths, Radial, and Ulnar Bursa

Tendon Sheaths

Ulnar Bursa

Radial Bursa

Flexor Tendons Damian Rispoli 2009



Physical Exam and Injections  125

Tenodesis Effect

Manual compression proximal to wrist causes passive finger flexion

Damian Rispoli 2009

Mallet Finger

Loss of continuity of the terminal tendon of the extensor apparatus Patient lacks the ability to actively extend terminal phalanx Damian Rispoli 2009

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Swan Neck Deformity

Lax or disrupted volar plate Dorsal subluxation of the sagittal bands Flexion of the distal phalanx Hyperextension of the proximal interphalangeal joint Damian Rispoli 2009

Judgement of the Rotational Alignment in the Fingers and Hand

Rotational alignment of the fingers is estimated by the fact that as the fingers are flexed into a first they will point to the tubercle of the scaphoid. Additionally, at resting flexion the nail beds of the fingers will be roughly parallel. Damian Rispoli 2009



Physical Exam and Injections  127 Finger Block - Flexor Tendon Sheath Block Direct volar injection midline and down to bone over the A2 pulley. Slowly withdraw while injecting. Inject when you feel a loss of resistance to avoid injecting the substance of the tendons. You can feel the fluid flow into the flexor sheath.

Damian Rispoli 2009

Digital nerve block may also be performed by blocking the volar and dorsal sensory branches at the level of the metacarpophalangeal joint.

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Wrist Injection Inject dorsally through the fourth dorsal compartment 1 cm distal to Lister’s tubercle aiming for the capitolunate (mid-carpal interval or 3-4 portal) interval. Palpate/­ visualize the fluid entering the wrist joint. Wrist Block • Ulnar nerve—Inject radial and dorsal to the flexor carpi ulnaris (FCU) at the proximal wrist flexion crease. Beware the ulnar artery just radial to the nerve. Raise a wheal ulnar to the FCU tendon to get the dorsal branch. • Median nerve—Inject ulnar to the palmaris longus tendon at the distal wrist flexion crease. Angle needle 30 degrees to the skin, aiming distally. Stop needle or injection for any median nerve symptoms. • Radial nerve—Inject radial to the radial artery at the level of the radial styloid. Raise a wheal around dorsally and radially to get all the branches at this level.

Wrist Block Sensory Branch of the Radial nerve

Ulnar Nerve

Median Nerve

Damian Rispoli 2009



Physical Exam and Injections  129

Physical Exam: Elbow Test Lateral pivot shift

Milking maneuver

PIN compression

Tennis elbow

Valgus instability Posterolateral rotatory drawer (J Bone Joint Surg. 1991;73:440–446)

Moving valgus stress (Am J Sports Med. 2005;33(2):231–239) Radiocapitellar plica (Arthroscopy 2001;17(5): 491–495)

Description Patient supine, elbow flexed; hold wrist in supination and apply valgus load; other hand holds forearm and adds an axial load. Grasp thumb of supinated hand and pull lateral while applying counterforce to lateral elbow. Pain and instability occur in midrange from flexion to extension. Resisted supination with the elbow flexed reproduces pain over PIN at the proximal volar forearm. Pain just distal to the lateral epicondyle with resisted wrist extension (elbow extended). Valgus load applied to the extended elbow with the wrist in supination. Stabilize the humerus, elbow extended; grasp the proximal forearm with the thumb under the radial head, supinate the forearm, slowly flex the elbow; subluxation reaches maximum at 40 degrees flexion. Constant moderate valgus force is applied to the fully flexed elbow; quickly extend the elbow. Full extension of the elbow in supination Full flexion of the elbow in pronation

Positive Findings Apprehension = lateral ­collateral ligament insufficiency Medial collateral ligament laxity

Posterior interosseous nerve compression Lateral epicondylitis

Medial collateral ligament insufficiency Posterolateral rotatory instability

Medial elbow pain at 120–70 degrees, medial collateral ligament tear (total/partial) Click at terminal flexion or ext. reproduces pain with a symptomatic plica

130  Tarascon Pocket Orthopaedica Posterolateral Rotatory Drawer

Damian Rispoli 2009

Patient supine Shoulder flexed to 90° and stable Posterior and lateral force on the proximal radius External rotation force ~40° of flexion

Moving Valgus Stress Test (AJSM 33(2):231–9, 2005)

Support Elbow Quickly Extend Valgus Stress

Damian Rispoli 2009

Pain = MCL injury (usually 120−170)



Physical Exam and Injections  131

Lateral Pivot Shift Test

Valgus Force Axial Compression Maximal Supination Damian Rispoli 2009

From Flexion to Extension (radiocapitellar joint subluxed to reduced)

Elbow Joint Injection/Aspiration

Damian Rispoli 2009

Inject in the center of a triangle formed by the radial head, lateral epicondyle, and the olecranon. Alternately you can inject directly into the olecranon fossa from the posterolateral edge of the olecranon.

132  Tarascon Pocket Orthopaedica Carrying Angle

The angle formed by the arm and the forearm. Important to observe when treating elbow fractures. Normally a variable valgus angulation

Damian Rispoli 2009

Physical Exam: Shoulder Test Apprehension (J Bone Joint Surg. 1984;66B:551–556) Belly press (J Bone Joint Surg. 1996;78A:1015–1023) Cross arm

Description 90 degrees of abduction and external rotation; apprehension of dislocation. Hands flat on stomach, have patient actively keep elbows anterior to frontal plane of body. Bring arm from 90 degrees forward flexion to across the chest, causing pain at acromioclavicular joint. Drop arm Slowly lower arm from 90 degrees abduction to the side; drop arm is positive. Drop sign 90-degree elevation, near full (J Shoulder Elbow Surg. external rotation, elbow flexed 1996;5:307–313) to 90 degrees; support elbow, release wrist.

Positive Findings Anterior capsular instability Intact subscapularis Acromioclavicular arthrosis

Rotator cuff tear Drop wrist = infraspinatus tear



Physical Exam and Injections  133

Physical Exam: Shoulder Test External rotation lag sign (J Shoulder Elbow Surg. 1996;5:307–313) Hawkins test (Am J Sports Med. 1980;8:151–158) Horn blower’s Jobe test (Clin Orthop. 1983;173:117–124 and Clin Sp Med. 1983;2:281–289) Lag sign (J Bone Joint Surg. 1996;78A:1015–1023) Liftoff (J Bone Joint Surg. 1991;73B:389–394) Load shift

Description Elbow passive flexed at 90 degrees, 20 degrees elevation, near max external rotation

Positive Findings Can’t hold position = superior or posterior cuff tear

Impingement with internal rotation at 90 degrees forward flexion (labral and AC joint pathology → false +) Lifts arm up to 90 degrees external rotation and 90 degrees abduction, weak 5 abnormal Shoulder at 90 degrees abduction, 30 degrees forward flexion, internal rotation (thumb pointed down)

Pain = impingement

Maximum internal rotation at shoulder. Unable to maintain lift off position is + Patient lifts flat hand off back: ability to lift off = intact subscapularis (test negative). Axially applied force to humerus while bringing the arm from straight lateral abduction to 90 degrees of forward flexion Causes apprehension or ­posterior shift Neer impingement sign No pain with test after subacromial injection. Neer impingement test Passive forward flexion > 90 (Clin Orthop. 1983;173: degrees, scapula stabilized by 70–77) examiner (arthrosis, stiffness, Ca11 tendonitis, and bony lesions → false +) O’Brien 1. Shoulder 90 degrees forward (Am J Sports Med. flexion, 30 degrees ad1998;26(5):610–614) duction, resisted forward flexion with thumb pointed to ground 2. Rotate to full supination and resisted forward flexion again.

Posterior rotator cuff tear Weakness = supraspinatus tear

Subscapularis pathology Subscapularis pathology Posterior capsular instability

Pain relief = impingement Pain = impingement

1. Pain/click suggests SLAP lesion 2. Ant/superior pain ­suggests AC pathology

(continues)

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Physical Exam: Shoulder Continued Test Posterior drawer (J Bone Joint Surg. 1966;66B:557–560) Relocation Speed’s (J Bone Joint Surg. 1966;48:1496–1502) Sulcus sign Yergason

Description Patient supine, posterior directed force with shoulder at 80–120 degrees abduction and 30 degrees forward flexion Supine apprehension; apprehension resolves with a posterior directed force on humerus. Flex shoulder against resistance, elbow extended, forearm supinated. Pain in the bicipital groove = +. Downward axial load to ­humerus subluxates humeral head inferiorly Resisted supination, elbow at 90 degrees, forearm in pronation.

Positive Findings Posterior subluxation = posterior instability Anterior capsular instability Pain = bicipital ­tendonitis, SLAP Ligamentous laxity (test symmetry) Pain = bicipital tendonitis

Abbreviations: AC, acromioclavicular joint; SLAP, superior labrum anterior-posterior.



Physical Exam and Injections  135

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Physical Exam: Spine Test Adson’s test (Ann Surg. 1927; 85:839–857) Babinski

Bowstring Crossed straight leg raise Femoral nerve ­traction test Clonus

Hoffmann’s

Lhermitte’s Nonorganic signs (Waddell’s signs) (Spine 1980;5:117–125)

Straight leg raise

Description Patient seated, arm dependent, neck toward side being tested and extended, deep breath. ↓ pulse is positive Stroking the bottom of the foot causes reflex toe extension.

Positive Findings ↓ pulse = thoracic outlet syndrome

Upper motor neuron lesion Myelopathic sign (myelopathy, stroke, multiple sclerosis) Hip flexed to 90 degrees, knee flexed to Reproduces radicular pain reduce radicular symptoms, pressure placed on tibial nerve in popliteal area. Passive lifting of contralateral straight 98% specific for HNP (lower leg, flex hip with straight knee. lumbar radiculopathy) Place the patient laterally on the Reproduces radicular unaffected side, examiner passively pain (upper lumbar extends the hip and flexes the knee of radiculopathy) the affected side. Forced dorsiflexion of the foot Reflex rhythmic plantar flexion response > 4 beats Upper motor neuron lesion Myelopathic sign (myelopathy, stroke, multiple sclerosis) Flicking DIPJ of middle finger causes Upper motor neuron lesion involuntary flexion of DIPJ of index and Myelopathic sign (myIPJ of thumb. elopathy, stroke, multiple sclerosis) Forward flexion of neck causes Stenotic sign causing lancinating pain down spinal cord to myelopathy arms/legs. 1. Pain (out of proportion) to superfi- May indicate heavy cial touch (superficial tenderness) psychosocial overlay 2. Pain with axial rotation of the pelvis (three or more of five signs and with axial loading on the top of present) the skull (simulation) 3. Sitting straight leg raise < lying SLR (distraction) 4. Nonanatomic weakness or sensory changes 5. Overreaction Passive lifting of straight leg, flex hip Reproduces radicular with straight knee, ± dorsiflexion of symptoms; dorsiflexion foot (Lasègue maneuver). should reproduce symptoms at less hip flexion (lower lumbar radiculopathy)



Physical Exam and Injections  137 Femoroacetabular disease patterns No Impingement

Cam Normal Clearance Impingement

Pincer Impingement

Over-coverage of Femoral Head by the Acetabulum

Combined Impingement

Reduced Femoral Head and Neck Offset

Combination of Cam and Pincer Modified from Lavigne M. Parvizi J. Beck M. Siebenrock KA. Ganz R. Leunig M. Anterior femoroacetabular Impingement Part I. Clin Orthop Rel Res 2004, 18:61–66.

Developmental Hip Dysplasia

Barlow

Hold thigh gently (like holding a tomato), don’t press too hard on the thigh Relaxation (the baby) is imperative, sleeping is perfect.

Damian Rispoli 2009

OrtolanI (Out to In)

138  Tarascon Pocket Orthopaedica

Physical Exam: Hip Test Anteroposterior impingement Barlow FABER Galeazzi Ober

Ortolani Posteroinferior impingement Resisted straight leg raise

Description Patient supine with the hip in 90 degrees of flexion. Internal rotation and adduction ­recreates the symptoms. Infant relaxed, hips flexed; gently ­adduct, hip may sublux or dislocate. Flexion, abduction, and external rotation may cause pain in sacroiliac joint, hip joint, or iliopsoas insertion. Infant relaxed and supine, feet flat, knees flexed. Asymmetric knee height = DDH Lateral position, contralateral side down, hip and knee at 90 degrees. ­Examiner abducts and extends hip (ipsilateral knee at 90 degrees); adduct hip toward the contra­lateral leg. Infant relaxed hips flexed; gently abduct, hip should relocate. Supine position, patient slides buttocks to the end of the table and extends the hip, externally rotate the hip. Active straight leg raise against resistance reproduces groin or low posterior buttock pain (also known as the Stinchfield test).

Positive Findings Pain is indicative of femoroacetabular impingement Subluxable or dislocatable DDH Sacroiliac joint, hip joint, tendonitis DDH, dislocated hip Contracture in the iliotibial band or tensor fascia lata prevents adduction past midline Developmental hip dysplasia (DDH) Pain is indicative of femoroacetabular impingement Hip irritability or arthrosis

Physical Exam: Knee Test Anterior drawer Asymmetric external rotation

Description Pull tibia forward with knee at 90 degrees. Patient prone, knees flexed at 90 degrees, externally rotate both feet at 30 degrees and 90 degrees. Asymmetric external rotation > 10–15 degrees = posterolateral corner injury; if asymmetric at both 30 degrees and 90 degrees, then PLC and PCL.

Positive Findings Laxity = ACL injury (test symmetry) PLC or PLC/PCL injury



Physical Exam and Injections  139

Physical Exam: Knee Test Dial test (Clin Orthop Rel Res. 1991;264:235–238)

External rotation recurvatum Lachman’s McMurray’s (J Bone Joint Surg (Br). 1942:29:407–414) Patellar apprehension Pivot shift Posterior drawer

Varus/valgus at 0 degrees Varus/valgus at 30 degrees

Description Supine with hip flexed to 90 degrees or prone with the hip at 0 degrees. Test with knee at 30 degrees and 90 degrees. Grasp both feet and maximally externally rotate. Compare sides. Pick up leg by great toe, knee goes into varus and recurvatum and tibial external rotation. Posterolateral tibial subluxation. Pull tibia forward with respect to femur with knee flexed to 30 degrees. Supine, knee and hip flexed to 90 degrees. Valgus load and tibial internal and external rotation.

Positive Findings Asymmetry at: 30 degrees = posterolateral corner, 90 degrees = posterior cruciate ligament

Laterally push patella with the knee in 20–30 degrees of flexion. Take extended and internally rotated knee and flex with a valgus force, relocation = ACL injury. Knee flexed at 90 degrees, foot flat and fixed, posterior force on tibia. Subluxation of condyles toward or anterior to the anterior tibial ­margin = PCL laxity/deficiency. Flex knee 0 degrees off exam table edge, stress varus and valgus. Flex knee 30 degrees off exam table edge, stress varus and valgus.

Apprehension = patellar dislocation or subluxation ACL injury (test symmetry)

Combined posterior lateral and ACL or PCL injury Laxity = ACL injury (test symmetry) Pain at medial joint line and click = medial meniscal tear

PCL injury or insufficiency

MCL/LCL and PCL or ACL Valgus laxity = MCL Varus laxity = LCL

140  Tarascon Pocket Orthopaedica Knee Injection/Aspiration Reliability of Intra-articular delivery: Lateral mid patellar 93%, Anteromedial 75%, Anterolateral 71% (JBJS 84A 1522-1527, 2003.)

Tilt patella away from needle. Insert needle under the patella and into the knee joint. May go either medial or lateral. This can also be done with the knee flexed at 90° using standard inferior arthroscopy portal landmarks.

Damian Rispoli 2009

Physical Exam: Ankle/Foot Test Ankle squeeze test

Description Squeeze calf above syndesmosis, pain at syndesmosis or below = injury. Ant. drawer Knee flexed, quad relaxed, cup heel, stabilize tibia, pull forward on heel Asymmetric anterior excursion = ankle instability (anterior tibiofibular ligament injury). Coleman block test Place a block under the lateral hindfoot; supple hindfoot deformities accommodate for the block, fixed do not accommodate. Silfverskiöld Test dorsiflexion of the ankle with the knee extended and then flexed at 90 degrees.

Positive Findings High ankle sprain, syndesmosis injury Asymmetric excursion = ankle instability

Fixed hindfoot deformity

Dorsiflexion > with knee flexion = isolated gastrosoleus contracture



Physical Exam and Injections  141

Physical Exam: Ankle/Foot Test Single leg heel raise

Talar tilt (J Am Acad Orthop Surg. 1998;6: 368–377) Thompson’s

Description Patient standing, lift one foot off ground, raise heel of contralateral side. Lack of ability to perform or weakness with lack of hindfoot ­inversion is positive. Inversion at ankle causes tilting and lifting of the talus from the mortise.

Patient prone, knee flexed, squeezing calf should cause ankle plantar flexion. Too many toes sign Patient standing, examine from ­behind looking for number of toes laterally. Asymmetric examine is positive.

Positive Findings Posterior tibial tendon dysfunction

Asymmetry = ankle instability > 5 degrees comparison, > 10 degrees absolute Absence of plantar ­flexion = Achilles rupture Too many toes = posterior tibial tendon dysfunction

Ankle Joint Aspiration/Injection Palpate the joint line, direct the needle at the medial or lateral corner and under the tibial plafond. Avoid saphenous vein medially, the superficial peroneal nerve laterally, and the dorsalis pedis artery centrally. Damian Rispoli 2009

142  Tarascon Pocket Orthopaedica Ankle Block Posterior View (medial left, lateral right)

Saphenous n. Tibial n. Deep peroneal n.

Sural n. Achilles tendon

Superficial peroneal n.

Extensor retinaculum

Damian Rispoli 2009

Anterior View (lateral left, medial right)

Tibial nerve block—Inject behind the medial malleolus, halfway between the malleolus and the calcaneus. Deep peroneal nerve block—Inject lateral to the extensor hallucis longus and anterior tibial artery level with the inferior extensor retinaculum. Superficial peroneal nerve block—Inject subcutaneously anterior to the extensor tendons. Saphenous nerve—Inject subcutaneously anterior to the medial malleolus. Sural nerve—Inject midway between the posterior border of the lateral malleolus and the calcaneus.



Radiologic Views  143

RADIOLOGIC VIEWS Radiologic Views: Spine Line/Angle Atlanto dens interval (ADI)

Normal 3 mm: adults 4 mm: children

Description Distance from the anterior odontoid to posterior border of the anterior arch of C1

Significance In trauma: 3–5 mm: rupture of transverse ligament 5–10 mm: alar ligament stretched 10–12 mm: rupture of all ligaments ADI increased with atlantoaxial instability (Down’s, Morquio’s, Larsen’s, achondroplasia, SED, rheumatoid arthritis, trauma) Anterior spinal Within 1–2 mm Longitudinal projection from Posterior spinal canal laminar line at each level the opisthion and the anterior alignment cortex of the posterior arch of C1 (atlas) and the C2/3 laminae. Basion-dens < 12 mm Distance from the basion to Craniocervical joint Interval upper odontoid tip. alignment Basion-axis 4–12 mm Distance between a line Craniocervical joint interval projecting cranially from the alignment posterior cortex of C2 body to the basion. Cobb angle 0 degrees Cobb method is the method chosen by the Scoliosis Research Society for measuring and following scoliotic curves. Can also be used to measure kyphosis and lordosis.

(continues) Cervical Radiographic Lines Anterior Skull Base

Wackenheim’s McCrae’s

Chamberlain’s

Posterior Skull Base

McGregor’s C1

Hard Palate

C2

ADI

SAC

Damian Rispoli 2009

144  Tarascon Pocket Orthopaedica

Cobb Angle Choose the “end vertebra,” the most tilted from the horizontal above the apex and below the apex of the curve. Draw a horizontal line across the upper end plate of the upper vertebrae and the lower end plate of the lower vertebrae. Draw lines perpendicular to these tangents until they intersect each other. The angle of the intersection is the Cobb angle.

Damian Rispoli 2009

Radiologic Views: Spine Continued Line/Angle Normal Chamberlain’s Odontoid tip line 7 mm

The distance between a line drawn from tip of dens to basion and second line drawn parallel to the posterior border of the dens. Distance between the lateral aspect of the dens and the medial aspect of the lateral mass of C1. Combined horizontal distance for the lateral border of C1 to that of C2 (open mouth odontoid radiographs or CT images).

Significance Intrusion of odontoid into foramen magnum Basilar invagination. Seen in rheumatoid arthritis, congenital conditions. Occipitocervical injury

Atlantoaxial alignment

Transverse atlantal ligament rupture and atlanto-axial instability

(continues)



Radiologic Views  145

C1 Lateral Mass

C2 Vertebrae

a

b a + b = lateral mass displacement

Power’s Ratio - AB/CD, Normal < 1.0 Skull Base

Anterior C1

Damian Rispoli 2009

Anterior C2

146  Tarascon Pocket Orthopaedica

Radiologic Views: Spine Continued Line/Angle McCrae’s line

Normal Odontoid tip should be below this line

Description Lateral C-spine: Diameter line drawn in the plane of the foramen magnum opening.

McGregor’s line

Odontoid tip not > 4.5 mm above this line

Pavlov’s ratio

> 0.8

Prevertebral soft tissue swelling Power’s ratio

< 7 mm at C2/3

Upper corner of the most posterior aspect of the hard palate to the lowest border of the occipital skull. Distance from the posterior margin of the vertebral body to the anterior margin of the spinous process divided by the distance from the anterior to the posterior margin of the vertebral body. AP thickness of soft tissue stripe anterior to C2/3 vertebral cortex. Ratio of lines drawn from basion to C1 posterior arch and opisthion to C1 anterior arch.

Sacral inclination Scotty dog Space available for the cord (SAC) Slip angle

Wackenheim Line

Significance Any existing compression will likely be asymptomatic if the tip is below this line Landmarks identifiable in all age groups < 0.8 is consistent with cervical stenosis

Increased swelling in this space can indicate upper C-spine injury. < 0.9 normal > 1 Anterior atlantooccipital dissociation. Does not identify posterior dislocation or distraction injuries. Normal < 30 Angle formed by a line drawn Risk for progression degrees parallel to the posterior of slip sacrum at S1 and one perpendicular to the floor. No collar Oblique view of the lumbar Defect in the pars spine. interarticularis (spondylolysis) 13–14 mm at Distance from posterior asSmaller distances craniocervical pect of odontoid (craniocervi- indicative of cord junction; 12 cal junction) or vertebral body compression/stenosis mm below C2 (below C2) to the nearest posterior structure. < 10 degrees Angle formed by a line Risk for progression of perpendicular to the sacrum slip if > 10 degrees at S1 and the inferior end plate of L5. Lines up within Straight projection from the Craniocervical joint 1–2 mm of the caudal posterior projection of dissociation of odontoid tip the clivus toward the upper dislocation C-spine.



Radiologic Views  147

Lumbar Oblique Radiographs Spondylolysis 80% seen on lateral view, additional 15% seen on oblique view. Collar

Damian Rispoli 2009

Measurements in Spondylolisthesis Slip Angle Sacral Inclination

Listhesis is also graded on the percentage of displacement of the superior vertebrae on the inferior vertebrae.

Damian Rispoli 2009

I. 0–25% II. 25–50% III. 50–75% IV. > 75%

148  Tarascon Pocket Orthopaedica

Damian Rispoli 2009

Scapholunate Angle

Capitolunate Angle

Normal 30–60 degrees

Normal < 30 degrees

Anterior and Posterior Fat Pad Sign

Damian Rispoli 2009

Hemarthrosis lifts the capsule and pericapsular fat out of the coronoid and olecranon fossae. Posterior sign is highly significant; anterior may be present without injury/trauma.



Radiologic Views  149

Both lines should bisect the central 1/3 of the capitellum

Radiocapitellar Line Anterior Humeral Line Damian Rispoli 2009

Radiologic Views: Upper Extremity Line/Angle Anterior humeral line

Normal Line passes through mid-third of the lateral condylar ossific nucleus Capitolunate 0–15 degrees angle Carrying angle

Radial inclination

Description Line carried straight down from the anterior cortex of the humeral diaphysis

Intersection of the capitate axis and lunate axis on the lateral wrist view 10–15 degrees Angle formed by the longi15–20 degrees tudinal axis of the humerus 15 degrees in and the longitudinal axis of children the ulna measured in the frontal plane with the elbow in extension. 22 degrees The angle formed by the in(24 ± 2.5 degrees) tersection of a line between the most distal points on the lateral and ulnar edges of the distal radius with a line perpendicular to the longitudinal axis of the radius on a PA view of the wrist

Significance Asymmetric, anterior, or posterior to the middle third of the capitellum indicative of fracture > 20 degrees suggests carpal instability Carrying angle is usually symmetric and can be used as an indicator of malalignment Useful in estimating the degree of deformity of distal radius fractures

(continues)

150  Tarascon Pocket Orthopaedica

Radiologic Views: Upper Extremity Continued Line/Angle Radiocapitellar line Radiolunate angle (lunate tilt)

Normal Line passes thru mid 1/3 of capitellum 0 degrees

Radial volar tilt

11 degrees volar (11 degrees ± 2 degrees)

Scapholunate angle

30–60 degrees

Scapholunate interval

< 3 mm

Ulnar variance

0 degrees mm

Wrist arcs

Collinear

Description Line drawn down the longitudinal axis of the radius

Significance Dislocation/subluxation of radial head (Monteggia fracture) Longitudinal axis of the > 15 degrees flexradius with the axis of the ion = VISI lunate > 10 degrees extension = DISI On lateral view, angle In fractures: > 5 mm formed by line drawn beof radial shortening tween the most distal volar on the PA or > 20 and dorsal tips of the distal degrees of dorsal anradius and a line drawn gulation on the lateral perpendicular to the longitu- is associated with a dinal axis of the radius poor outcome. Angle formed by the scaph- > 70 degrees = DISI. oid axis and the lunate axis < 30 degrees = VISI. ORIF scaphoid if > 60 degrees and displaced > 1 mm Gap between scaphoid and Gap > 3 mm suggests lunate on PA clenched fist scapholunate ligaview (consider comparison ment tear view or dynamic study) On PA of wrist, draw one line 0 mm = ulnar neutral, perpendicular to the longitu- stress distribution dinal axis of the radius and 80% thru proximal tangential to the articular radius and 20% thru pole of the distal ulna and proximal ulna. + 4 mm one line perpendicular to ulnar positive varithe longitudinal axis of ance. The ratio is 40% the radius and tangential radius, 60% ulna. With to the lunate fossa of the negative ulnar varidistal radius. Measure the ance, stress is 96% distance between the lines. radius, 4% ulna. Ulnar tangent distal to the radial tangent = positive ulnar variance. On lateral wrist, in neutral Asynchronous angulaposition, radial, lunate, and tion indicative of capitate axes are colinear. carpal instability Seen on the PA radiograph of the wrist.

Abbreviations: DISI, dorsal intercalated segmental instability; VISI, volar intercalated segmental instability.



Radiologic Views  151

Damian Rispoli 2009

Volar Tilt ~ 11 Degrees

Osteoarthrosis Osteophytes Sclerosis Asymmetric Subchondral cysts DIPJs

Rheumatoid Arthritis No osteophytes Osteopenia Symmetric Periarticular erosions PIPJs and MCPJs

Burnt-out rheumatoid arthritis may look like or mimic osteoarthrosis.

• • • • •

MRI Signal Characteristics Bright on T1: Fat, gadolinium, methemoglobin, proteinaceous fluid, melanin Bright on T2: Fluid Bright with gadolinium: Vascular tissue STIR (poor resolution): Fluid (profoundly suppresses fat signal) Gradient echo: Cartilage, “blooming” artifact in ferrous laden tissue (pigmented villonodular synovitis)

152  Tarascon Pocket Orthopaedica

Metacarpals Thumb Metacarpal

Hook of Hamate Hamate Trapezium

Triquetrum

Trapezoid

Pisiform

Capitate Ulna

Scaphoid Lunate Sigmoid Notch

Radius

Damian Rispoli 2009

Wrist Radiographic Lines

Damian Rispoli 2009

Radial Inclination ~ 21 Degrees



Radiologic Views  153 Metacarpals Thumb Metacarpal

Capitate

Trapezoid

Lunate

Scaphoid

Trapezium

Radius

Ulna Damian Rispoli 2009

Lateral Wrist Radiograph

DDH Lines and Radiographic Assessment DDH side

Normal side

HiIgenreiner’s Line

Acetabular Index

Shenton’s Lines Perkin’s Lines

Damian Rispoli 2009

Note: Break in Shenton’s line and absence of ossific nucleus on DDH side (ossific nucleus normally present at 4–6 months is delayed and small in DDH)

154  Tarascon Pocket Orthopaedica

Acetabular roof llioischial line lschial spine

Posterior acetabular lip

lliopectineal line Teardrop

Anterior acetabular lip

Damian Rispoli 2009

Pelvic Radiographic Lines

Radiologic Views: Hip/Pelvis Line/Angle Normal Acetabular Birth 15 through the longitudinal degrees merits considaxis of the 1st and 2nd eration of a proximal metatarsals osteotomy to correct deformity Angle formed by a line Decreased in clubfoot drawn through the (talipes equinovarus) longitudinal axis of the talus and a line drawn along the plantar surface of the calcaneus Lateral foot X-ray: An > 4 degrees convex angle formed by the upward = pes cavus. longitudinal axis of the > 4 degrees convex talus and the longitudown = pes planus. dinal axis of the first Can also be used to metatarsal grade deformity (mild < 15 degrees, moderate 15–30 degrees, severe > 30 degrees).



Radiologic Views  161

162  Tarascon Pocket Orthopaedica

Bohler’s Angle Normal 25-40 degrees

Gissane’s Angle Normal 120-145 degrees

Damian Rispoli 2018

Bunion Angles

Hallux Valgus Angle (Normal < 15 degrees)

Intermetatarsal Angle (Normal < 9 degrees)

Damian Rispoli 2009



Radiologic Views  163

Radiographic Assessment of Tarso-Metatarsal Joint Injuries Obtain Weight Bearing AP, Lateral, and 30° Oblique views If weight bearing is not possible take stress views (forefoot abduction stress) 1st/2nd Metatarsal base distance ≤ 3 mm (any doubt obtain comparison views) Medial border of the 2nd metatarsal is in line with the medial border of the middle cuneiform. 1st metatarsal aligns with the medial/lateral borders of the medial cuneiform 1st/2nd interspace continuous with the medial/middle cuneiform interspace 30° Oblique – Medial border of the 4th metatarsal is in line with the medial border of the medial border of the cuboid The lateral border of the 3rd metatarsal is in line with the lateral border of the lateral cuneiform 3rd/4th interspace continuous with lateral cuneiform/cuboid

AP View –

30 Degree Oblique

AP View

Damian Rispoli 2009

164  Tarascon Pocket Orthopaedica

CONCUSSION Defined as a complex pathophysiologic process affecting the brain, induced by traumatic biomechanical forces. Concussion: Major Features • Direct blow to an individual with an “impulsive” force transmitted to the head • Rapid onset short-lived impairment of neurologic function with spontaneous resolution • While it may result in structural changes more commonly the acute clinical manifestations reflect a functional disturbance. • Results in a graded set of clinical symptoms with/without loss of consciousness. Resolution usually occurs in a typical and sequential course, however, it may rarely result in prolonged post-concussive symptoms. • Results in no abnormalities on standard structural neuroimaging studies. (Clin J Sports Med. 2009;19:185–200) NOTE Any athlete who is symptomatic after a concussion requires serial evaluation. If at any point the exam reveals deterioration in mental status or loss of consciousness after a concussion, immediate transportation to an emergency facility is indicated. Neuropsychological testing • A very useful management tool • Protocols not clearly validated (e.g., Lovell MR. Neuropsychological assessment of the professional athlete. In: Echemendia RJ, ed., Sports Neuropsychology: Assessment and Management of Traumatic Brain Injury. New York: Guilford Press; 2006:176–189). • Preseason testing • 72h post-concussion • Repeat in 5–7 d if deficit present • Repeat q1–2 wk follow-up until patient returns to baseline. Concussions in Athletes Observe and evaluate for at least 15 min (Am J Sports Med. 1999;27:5 676–685). Grade 1

Symptoms Confusion, no amnesia

Duration Minutes

2 3

Retrograde amnesia Amnesia after impact

Hours to days Days

*Second episode—out for the entire season.

Recommended Return When symptoms resolve. Most now recommend against same-day return. 1 week* 1 month*



Spinal Evaluation  165

Stages of Concussive Injury Most athletes experiencing a concussion have resolution of physical ­symptoms in 2 wk and a return of neuropsychological testing to baseline in 7–10 d. Acute Concussion: Symptoms usually lasting 2 wk Physical: Headache, dizziness, hearing loss, balance difficulties, insomnia, nausea +/– ­emesis, decreased athletic performance Cognitive Deficits: Loss of short-term memory, difficulty concentrating, diminished attention, ­diminished work/school performance Emotional: Irritability, anger, fear, mood swings Sleep: Difficulty initiating sleep, hypersomnolence, drowsiness Diffuse Axonal Injury Defined by LOC > 6 h—consider avoidance of all future contact sports. Persistent Concussion: Symptoms lasting 1–6 wk postinjury Prolonged Concussion Syndrome: Symptoms lasting > 6 months Lowered concussion threshold, diminished athletic and work or school performance Chronic Traumatic Encephalopathy Emotional: Irritability, anger, fear, with/without mood swings. Personality disturbances, depression, alcohol and/or other substance abuse disorders. Suicidality/suicide. J Bone Joint Surg. 2012;94A(17):1618–1627

SPINAL EVALUATION Steroids in Emergent Cord Injury (Global Spine Journal 2017;7(3S):84S–94S; J Orthop Trauma 2016;33:S7-S13) Contraindications: • Age < 13 (controversial) • Nerve root or cauda equina • Gunshot wounds or other penetrating injury • Pregnancy • Already on steroids • Other life-threatening injury Therapy (methylprednisolone sodium succinate) initiated: Within 8 h after injury: After 8 h after injury: 30 mg/kg IV for the 1st hour Not recommended 5.4 mg/kg/h IV for the next 23 h Not recommended Remember to protect gastric mucosa with H2 blocker

166  Tarascon Pocket Orthopaedica

Autonomic Dysreflexia Catastrophic hypertensive event caused by impacted feces or an obstructed urinary catheter and occurs with complete spinal cord injury above T8–T10. Spondylolysis and Spondylolisthesis Class I II III IV V VI

Type Congenital Isthmic Degenerative Traumatic Pathologic Postsurgical

Age Child 5–50 Older Young Any Adult

Pathology/Other Dysplastic S1 superior facet Elongation/fracture of L5 S1 pars Subluxation due to facet (L4, L5) arthrosis Acute fracture (not pars) Bony elements destroyed/incompetent Over-resected arches/facets

Listhesis Grades

I. 0–25% II. 25–50% III. 50–75% IV. 75–100% V. > 100%

Muscle Strength Testing Score 0 1 2 3 4 5

Exam No movement Visible contraction Movement without gravity Movement with gravity Less than full strength Full strength

Reflexes Root Level C5 C6 C7 L4 S1

Reflex Biceps Brachioradialis Triceps Knee jerk Ankle jerk



Spinal Evaluation  167

Lumbar Spinal Stenosis Canal ≤ 12 mm; stenosis ≤ 10 mm AP diameter; lateral recess stenosis < 2 mm • • • • • •

Spondylolysis Defect in the pars interarticularis Most common cause of low back pain in children Fatigue fracture (gymnastics, football linemen) 80% visible on plain films, 15% on obliques (Scottie dog) Treatment is symptomatic, avoid extension Casting for more severe or symptomatic cases Frankel Grade

Grade A B C D E

Function Complete paralysis Sensory function only below level of injury Incomplete motor function (grade 1–2/5) below injury level Fair to good motor function (grade 3–4/5) below injury level Normal function (5/5)

Upper vs. Lower Motor Lesions Findings Strength Tone Deep tendon reflex Superficial tendon reflex Babinski Clonus Fasciculations Atrophy

UMN ↓ ↑ ↑ ↓ + + − −

Simon SR. Orthopedic Basic Science, 2nd ed. Rosemont, IL: AAOS; 1994:354.

LMN ↓ ↓ ↓ ↓ − − + +

168  Tarascon Pocket Orthopaedica Spinal Cross Section Dorsal Columns (Sensory – deep touch, proprioception, vibratory)

Arm/Leg/Trunk (Medial to Lateral)

Lateral Spinothalamic Tracts (Sensory – pain/temperature)

Damian Rispoli 2009

Ventral Corticospinal Tract (Motor – voluntary)

Lateral Corticospinal Tract (Motor)

Ventral Spinothalamic Tracts (Sensory – light touch)

LOW BACK PAIN TREATMENT • • • • • • • • •

Acute Low Back Pain (≤ 6 wk) 70% better in 2 wk, 90% better in 4–6 wk NSAIDs or acetaminophen Opioids/muscle relaxants of no additional benefit Minimize bed rest < 48 hr (encourage modified light activity) Radiographs or MRI in the presence of red flags Chronic LBP (> 6 wk), Worsening Radiculopathy Rule out cauda equina syndrome—surgical emergency Radiographs, MRI as indicated Enlist the aid of pain clinic, mental health, etc. Workmen’s compensation and pending litigation have worse long-term prognoses.



Spinal Cord Injury Syndromes  169

SPINAL CORD INJURY SYNDROMES

BrownSequard Root Central Anterior Complete

Mechanism of Injury/ Pathology Penetrating trauma Foraminal compression/ herniated disc Age > 50, extension injury, possible vascular etiology Flexion-compression Burst fracture, canal compromise

Characteristics Loss of ipsilateral motor, contralateral pain and temperature Based on level

Prognosis Best

Upper > lower extremities, motor and sensory loss Incomplete motor, some sensory loss No function below level of injury

Fair

Good

Poor Poor

Spinal Cord Injury Treatment by Functional Level Level < C4

Working —

C4 C5 C6 C7 T1

Diaphragm/trapezius Elbow flexors Wrist extensors Elbow extensors Intrinsics

T2–12

Upper extremities, abdominals Upper extremities, abdominals, quads Iliopsoas Quadriceps Tibialis anterior

L1 L2 L3 L4 L5 S1

Not Working Diaphragm, upper extremities Upper extremities Below elbow Elbow extensors Grasp Abdominals, lower extremities Lower extremities Lower extremities Knee/ankle Ankle Toe dorsiflexion, plantar flexors Plantar flexors

Extensor hallucis and digitorum longus Gastrocnemius, soleus Bowel/bladder

Treatment/Mobility Respirator dependent Wheelchair chin/puff Electric wheelchair, ratchet Wheelchair, flexor hinge Wheelchair, independent Wheelchair, independent Wheelchair, HKAFO (nonfunctional ambulation) KAFO, minimal ambulation KAFO, household ambulation AFO, community ambulation AFO, community ambulation AFO, independent 6 metatarsal bar

NOTE: Level = functional level (functional level is the most distal intact motor level (fair motor grade). HKAFO, hip knee ankle foot orthosis; KAFO, knee ankle foot orthosis; AFO, ankle foot orthosis. Data from Miller MD, ed. Review of Orthopaedics, 3rd ed. Philadelphia, PA: WB Saunders; 2000:458



Traction 171

TRACTION Traction Setups Zimmer Traction Handbook: A Complete Reference Guide to the Basics of Traction. Warsaw, IN: Zimmer; 1992. General Principles • Skin traction should not be used over an open wound. • Skin traction should not be used when it would impede or affect the neurovascular status of the limb. • Ensure no history of allergies to skin adhesives. • Do not reuse traction cord. • Pad all bony prominences. • All weights must hang free and must not lie above the patient. • Knots must be free from pulleys, especially in dynamic traction. Likewise, the moving parts of the traction setup should be free from interference from bed, bed sheets, etc. • You must communicate and explain the basic principles and dangers to the support staff. • Patient transport should be done under physician supervision, or the traction setup rechecked upon arrival at any new location. • Skin care and neurovascular status need to be monitored regularly. Traction Pin Placement Calcaneal Traction Pin The pin is placed on the bone via an incision through the skin and blunt dissection down to the calcaneus. It is placed from medial to lateral. The pin is positioned at a point 2.5 cm inferior and 2.5 cm posterior to the tip of the lateral malleolus on the medial aspect of the calcaneus. The pin is then drilled through the calcaneus and delivered via a stab incision laterally. Care is taken to protect the medial neurovascular structures and the subtalar joint.

172  Tarascon Pocket Orthopaedica Lower Extremity Traction Pin Placement

Distal Femoral Traction Pin

Proximal Tibial Traction Pin

Damian Rispoli 2009

Distal Femoral Pin • With knee flexed at 90 degrees if planning 90–90 position to prevent iliotibial band interference with traction • Parallel to the joint surface • 90 degrees to the shaft • 5/64- or 3/32-threaded Steinmann pin; when the pin tents the lateral skin, an incision is used to deliver it through the skin. • Pin level is 1 fingerbreadth above patella with the knee extended or just above the distal femoral flare. • If intramedullary fixation is planned, the pin must be placed anterior or posterior to the center to allow for rod passage. • Pin is passed medial to lateral to protect neurovascular structures through Hunter’s canal (adductor hiatus). Proximal Tibial Traction Pin • At the level of the tibial tubercle • 1–2 cm posterior to anterior tibial crest • Passed lateral to medial to protect common peroneal nerve • Not favored in children due to potential interference with growth plates • Consider knee stability prior to placement.



Traction 173

TRACTION IS NOT BENIGN! Traction Types Pediatric Traction In general, skeletal traction is not recommended as a method of treatment for children over 12 years old (increased incidence of shortening and angulation). Indications include unstable femur fracture < 6 years old, > 3 cm shortening; fracture < 6 years old, unstable in hip spica; associated other injuries in a child able to cooperate with bed rest. Skin complications can occur with > 5 lb skin traction. Bryant’s Traction • Rarely used, neurovascular complications. • Hips at 90 degrees, knees at 0 degrees, chest restraint, Bradford frame, weight adjusted to just lift the sacrum off the Bradford frame. • Do not use in > 2 years, > 25 lb, beware of serious neurovascular compromise. Modified Bryant’s Traction • Decreases incidence of neurovascular compromise. • May use in older patients with contraindications to a femoral traction pin. Russell Skin Traction/Split Russell Traction (adults and children) • Peroneal nerve neurapraxia possible. • Posterior bowing at fracture site possible. Buck’s Traction • Elevate the foot of the bed; closely monitor skin!

174  Tarascon Pocket Orthopaedica Application of Skin Traction

Damian Rispoli 2009

Benzoin to lateral and medial leg Horseshoe of adhesive backed felt Wrap loosely with an Ace wrap Include metal traction bar in felt loop

90–90 Skeletal Traction Hip and knee at 90 degrees Beware of overdistraction

**The distal femoral traction pin is placed with the knee flexed so the iliotibial band does not drag over the pin.

Damian Rispoli 2009



Traction 175 Russell’s Skin Traction Skin traction to leg Pillow or traction setup supporting femur Sling may also be placed on leg with pillow supporting the thigh

Damian Rispoli 2009

Balanced Suspension (with or without skeletal traction) –Elevate foot of bed

Damian Rispoli 2009

176  Tarascon Pocket Orthopaedica

Halo Placement • Halo is placed just below the area of greatest circumference, just above the eyebrows, 1 cm above ear tips, and below the skull equator. • Pins placed with local anesthetic; positions as shown. • Eyes closed tightly. Areas shaved. • Pins subsequently tightened circumferentially in a diagonal, opposite manner. ƒƒ Adults: 2 lb-in., 4 lb-in., and finally 6–8 lb-in. ƒƒ Child < 5 yr: 4–6 lb-in., 2 lb-in., or finger tight in infants/toddlers. • Children need multiple pins (up to 8). • Retighten at 24–48 h. Supraorbital nerve Frontal Sinus

Supratrochlear nerve Frontal Sinus

SA

AV

SA

SA = Safe Areas, AV = Avoid Area

SA

SA

Damian Rispoli 2009

Halo Placement

Gardner-Wells Tongs

Damian Rispoli 2009

-Pins positioned below the temporal ridges, 2 cm above the external auditory canal and temporalis muscle -Tongs are secure when pressure pin extrudes 1 mm



Trauma—Adult 177

TRAUMA—ADULT Hand Injury/Eponym Distal phalanx fracture

Classification/Limits Longitudinal, transverse, comminuted

Extensor digitorum avulsion (terminal tendon) Mallet finger

Stretched Torn Bony avulsion

Flexor digitorum profundus tendon avulsion

Leddy/Packer (J Hand Surg. 1979;2:66–69) I: Tendon retracts to palm II: Tendon retracts to PIPJ

Rugger jersey finger

III: Bony fragment retracts to A4 pulley IIIA (IV): Bony fragment and avulsed tendon Metacarpal and Indications for operative phalangeal fracture treatment: • Malrotation (spiral, oblique) • Intra-articular, open fracture (relative) • Subcapital phalangeal fracture • Bone loss, polytrauma, and hand fracture • Multiple hand/wrist fractures • Fracture with soft tissue injury • Reconstruction, shortening • (< 1 cm) Central slip disruption Soft tissue Boutonniere Bony fragment

Extensor tendon laceration

< 50% laceration > 50% laceration

Treatment Splint 3–4 wk (PIPJ free), Nail broken/avulsed—fix nail bed Nail intact—trephination alone (J Hand Surg. 1999;24A:1166) Splint distal interphalangeal joint in extension. Full time for 6 wk Then only at night for 6 wk Can alternate volar and dorsal splint to protect skin. If any break in treatment start back at 0 wk. Fix within 7–10 d. Fix within 2 wk (may repair late up to 3 months). ORIF (early) ORIF and reattach tendon (early) Goal—Full and rapid restoration of function! Surgeon’s choice (avoid > 4 wk immobilization): • ORIF (associated with stiffness) • Open reduction, ­percutaneous pinning • Closed reduction, ­percutaneous pinning • Traction (used uncommonly— PIPJ fracture/dislocations) • ORIF (composite wiring, intramedullary fixation, ­external fixation) Acute (< 1 month): extension splint × 6 wk Chronic: Regain passive range of ­motion, then Fowler tenotomy or ­central slip reconstruction Primary closure, rehabilitation Repair tendon, rehabilitation

178  Tarascon Pocket Orthopaedica Boutonniere Deformity

Damian Rispoli 2009

Note: Central slip disruption, volar subluxation of lateral bands, characteristic deformity. Tenderness over the PIPJ may be the only obvious acute clinical finding.

Thumb Metacarpal Fractures

Bennett’s

Rolando’s

Transverse

Oblique

Salter-Harris II Damian Rispoli 2009

Acceptable limits on phalangeal fractures: • < 10-degree rotation (some argue no rotational deformity) • < 1–2 mm of articular step off (goal is anatomic reduction of the joint) • 5 degrees in the sagittal/10 degrees coronal plane (shaft) • 20 degrees in the sagittal plane (metaphyseal) • < 25- to 30-degree apex volar (↑ risk of pseudoclawing) Acceptable limits on metacarpal fractures: • Minimal to no rotational deformity • 1–2 mm of step off (goal is anatomic reduction)



Small Joint Fusion  179

• < 10 degrees in the coronal plane • Sagittal deformity ƒƒ < 10 degrees index/long ƒƒ < 20 degrees ring ƒƒ < 30 degrees small • No pseudoclawing (limit apex volar malreduction)

SMALL JOINT FUSION Fingers • MCPJ: Index 25 degrees and add 5 degrees each additional digit • PIPJ: Index 40 degrees and add 5 degrees each additional digit • DIPJ: 0 degrees ± 5–10 degrees of supination Thumb • IPJ 0–15 degrees • MCPJ 5–15 degrees with 10 degrees pronation • CMCJ ƒƒ 40 degrees palmar abduction ƒƒ 20 degrees radial adduction ƒƒ aim for pulp-to-pulp contact with fingers Data from Green DP, Hotchkiss RN, Pederson WC, Wolfe SW. Green’s Operative Hand Surgery, 5th ed. Philadelphia: Elsevier; 2005. Hand Injury/Eponym Flexor tendon laceration

Classification/Limits Zone specific classification

4th/5th metacarpal neck Boxer’s fracture 2nd/3rd metacarpal neck Transverse metacarpal

20–45 degrees angulation acceptable Check rotation!

Oblique metacarpal

Treatment > 60% repair (J Bone Joint Surg. 2002;84A(9):1684–1706) Tendon repair may delay up to 2–3 wk, atraumatic technique, strict supervised rehabilitation postoperatively Closed reduction cast/ splint × 3–4 wk

15 degrees is acceptable

Percutaneous pinning to ­adjacent ­metacarpal or ORIF Accept 30 degrees 5th, 20 degrees 4th, Closed reduction/cast ver10 degrees 2nd and 3rd sus ­percutaneous pinning or ORIF < 5 mm short Closed reduction or open ­reduction, percutaneous pinning > 5 mm or malrotation Percutaneous pinning or ORIF

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Hand Continued Injury/Eponym Thumb metacarpal Bennett’s→ Rolando’s→

Classification/Limits Intra-articular volar lip Intra-articular Y Transverse Oblique

5th metacarpal base Baby Bennett DIPJ dislocation

Intra-articular base fracture Dorsal With collateral sprain With collateral tear

Volar PIPJ dislocation

Volar (central slip torn) Rotatory

Dorsal PIPJ dislocation

Dorsal (volar plate torn) I: Hyperextension II: Major ligament injury III: Proximal dislocation

Dorsal PIPJ fracturedislocation

Located Subluxated (V sign dorsally—Light)

MCPJ dislocation

Collateral ligament injury

Treatment Closed reduction, percutaneous pinning, ORIF if necessary ORIF (if noncomminuted) External fixation/traction (if comminuted) Closed reduction spica cast × 4 wk Closed reduction spica cast × 4 wk Most stable (if not) Closed reduction, ­percutaneous pinning Closed reduction, splint × 2 wk Buddy tape 3–6 wk Fix radial collateral ligament (index, ring, and middle) Fix ulnar collateral ligament (small finger, dominant hand) ORIF irreducible or incongruous Attempted closed reduction, open if fails closed reduction Closed reduction (open if not reducible) then: Buddy tape or extension block splint Extension block splint Extension splint × 4–6 wk, consider OR for > 4 mm residual displacement Extension block Volar plate arthroplasty, ORIF, traction splint, force couple pinning Splint MCP 50 degrees × 3 wk, ORIF > 2–3 mm or > 20% joint surface



Small Joint Fusion  181 Injury/Eponym

Classification/Limits Dorsal Simple Dorsal Complex (volar plate interposition) Volar

CMCJ dislocation

Thumb MCPJ ulnar collateral ­ligament injury Gamekeeper/ Skier’s Thumb MCPJ radial collateral ligament Thumb MCPJ dorsal dislocation Thumb CMCJ dislocation Hamate metacarpal fracture/ dislocation

Treatment Closed reduction (­translation without ­traction), splint × 7–10 d Open reduction

Open reduction (sesamoid in ↑ joint space, palmar skin puckered, less deformity seen) Small finger CMCJ dislocation Closed reduction, percutaneous pinning Multiple CMCJ dislocation Open reduction, percutaneous pinning Sprain (< 35 degrees on stress views) Thumb spica cast × 6 wk Tear (> 35 degrees or 15 degrees > Open repair than noninjured on stress views) (Stener lesion = adductor *Test in full extension and 30 degrees aponeurosis interposition of flexion between torn ends of ulnar collateral ligament) Sprain/tear Splint × 4 wk followed by removable splint × 4 wk Simple Complex

Reduce, cast × 3 wk Single reduction attempt (volar plate ± flexor pollicis longus interposition) Hyperpronation and percutaneous pinning Cast 6–10 wk Cain Reduce/stable: cast, reduce/ IA: Ligament injury unstable: percutaneous pinning IB: Dorsal hamate fracture Reduce/stable: cast, reduce/ unstable: ORIF II: Comminuted dorsal hamate fracture ORIF: restore dorsal buttress III: Coronal hamate fracture ORIF: restore joint surface (Goal: < 2 mm step off, < 5 mm short)

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Wrist Injury/Eponym Distal radius Colles’ (dorsal) Smith’s (volar)

Classification/Limits AO A: Extra-articular B: Intra-articular with part of metaphysis intact C: complex intra-articular (See box on pg. 184 for limits.)

Distal radius dorsal rim Dorsal Barton’s Radial styloid Chauffeur’s Volar rim Volar Barton’s

Treatment • Closed reduction+cast or closed reduction, pinning, +/– cast or ORIF

Reduce, pronation ORIF if necessary Reduce, percutaneous ­pinning or cannulated screw, cast in ulnar deviation ORIF

Note: Late osteoarthritis increases following distal radius fractures with residual dorsal tilt > 10 degrees or 1-mm articular step voff.

Damian Rispoli 2009

Dorsal Barton’s Fracture

Damian Rispoli 2009 Damian Rispoli 2009

Radial Styloid Fracture Volar Barton’s Fracture



Small Joint Fusion  183

Wrist Injury/Eponym Classification Distal radioDorsal ulnar joint dislocation Volar

Scaphoid (78% of all carpal fractures) [blood supply dorsal and distal] Dorsal chip Hook of Hamate Perilunate dislocation ± scaphoid fracture

Treatment Reduce, long arm cast in supination × 6 wk Reduce, long arm cast in pronation × 6 wk Open reduction ± internal fixation or percutaneous ­pinning if irreducible Can be classified based on time or anaStable/nondisplacedtomic configuration long arm cast up to 3+ Evaluate scapholunate i­nterval with months or closed reduction clenched fist views or intraoperative vs. ORIF stress view Displaced [1 mm, Consider splint × 1–3 wk and repeat X-rays ­scapholunate > 60 if not radiographically apparent fracture ­degrees, lunatocapitate > MRI if acutely or if pain persists 15 ­degrees]: ORIF Commonly triquetrum Short arm cast × 6 wk CT to evaluate Acute: Short arm cast × 6 wk Chronic: Excise for ­persistent pain Mayfield (stage II = I + II, Early (6–8 wk) III = II + III, etc.) Open reduction, ligament I: Scapholunate dissociation repair, percutaneous II: Lunocapitate dissociation pinning, ORIF scaphoid III: Lunotriquetral disruption fracture if present IV: Lunate dislocation

Radius/Ulnar Shaft Injury/Eponym Radius and ulna Both bone Ulna fracture

Classification Nondisplaced or displaced

Nightstick Proximal ulna fracture/radial head dislocation Monteggia

Displaced Bado (Clin Orthop. 1967; 50:71–86) I: Radial head anterior II: Head posterior III: Head lateral IV: Head anterior and both bone fracture Nondisplaced

Proximal radius

Nondisplaced

Displaced Distal radius frac- Eponyms: Galeazzi, Piedture and radioul- mont, reverse Monteggia, nar dissociation fracture of necessity, etc.

Treatment ORIF (selective ­nonoperative in nondisplaced) Long arm cast or fracture brace (accept 10 degrees and 50% displacement) ORIF: Beware wrist/elbow injury ORIF, closed reduction of radial head (open if nonreducible) (PIN most commonly injured nerve)

Long arm cast in supination, close follow-up ORIF ORIF

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Elbow Supracondylar Malgaigne Transcondylar Kocher Posadas Condylar Milch (lateral > medial)

Extension: Nondisplaced Displaced (very uncommon fracture) Intra articular-posterior fragment Intra articular-anterior fragment

Long arm cast ORIF (double plating) Reduce (closed treatment difficult, ankylosis common), percutaneous pinning, ORIF if necessary (no consensus in the literature) I: Lateral trochlear ridge intact Nondisplaced: Long arm cast (Salter-Harris IV) in supination (lateral), long arm II: Fracture through lateral troch- cast in pronation (medial), some lear ridge (Salter-Harris II) need ORIF Displaced: ORIF

Monteggia Fracture Proximal Ulna Fracture Dislocation of the Radial Head

Damian Rispoli 2009

Distal radius fracture limitations (consider ORIF): • ≥ 2 cm loss of radial height • Change in radial inclination ≥ 10 degrees • Loss of volar tilt ≥ 10 degrees • Loss of reduction of the distal radioulnar joint ƒƒ 1­–2 mm step off

Disrupted DRUJ

Radius Fracture

External fixation note: > 2-mm capitolunate gap = potential overdistraction and can result in stiffness.

Distal radioulnar joint is disrupted in distal radius fractures if dorsal tilt > 25–30 degrees and ulnar styloid > 3 mm displaced.

Damian Rispoli 2009

Galeazzi Fracture



Small Joint Fusion  185

Elbow Continued Injury/Eponym Bicolumnar

Classification/Limits AO (see illustration) A: Extra-articular B: Partial articular C: Complete articular

Olecranon

Colton (Inj 1973;5:121–129) I: Nondisplaced Cast/splint, 3 wk or less II: Displaced ORIF (tension band, lag screw, plate) A: Avulsion B: Oblique/transverse Oblique: Screw, plate Transverse: Tension band, plate C: Comminuted Attempt reduction and fixation if not possible to excise (coronoid and anterior structures must be intact for stability, advance/reattach triceps to bone). May also consider nonoperative treatment in the elderly/osteoporotic if joint is congruous. D: Fracture/dislocation ORIF (no excision) Regan/Morrey (J Bone Joint Surg. 1989;71A:1348–1354) I: Tip avulsion Early motion II: < 50% Early motion III: > 50% ORIF I: Large trochlear piece Nondisplaced: Splint Displaced: ORIF II: Minimal subchondral Nondisplaced: Splint bone (Kocher-Lorenz) Displaced: ORIF vs. excise III: Comminuted (rare) ORIF vs. excision Very rare Nondisplaced: Splint Displaced: ORIF Medial (Granger) more com- Manipulation/reduction, posterior mon than lateral splint with the elbow and wrist flexed × 10–14 d, then active motion is begun, symptomatic fragments can be excised late

Coronoid

Capitellar Hahn-Steinthall Kocher-Lorenz

Trochlea Laugier Epicondylar

Treatment Generally, these fractures are treated operatively. Restoration of the joint surface is paramount. Rigid fixation with early motion (immobilize < 2 wk) helps to avoid fibrosis/ankylosis that occurs with prolonged immobilization. Total elbow replacement may be considered in the elderly with osteoporotic bone where fixation may be difficult or impossible to attain.

(continues)

186  Tarascon Pocket Orthopaedica Coronal Shear Fractures

HahnSteinthall

KocherLorenz Damian Rispoli 2009

AO Classification of Distal Humerus Fractures

A1

A2

A3

B1

B2

B3

C1

C2

C3 Damian Rispoli 2009



Small Joint Fusion  187

Elbow Continued Injury/Eponym Classification/Limits Radial head Mason I: Nondisplaced II: Moderate displacement

II: Comminuted

Elbow dislocation

Humeral shaft

IV: With dislocation Hotchkiss (J Am Acad Orthop Surg. 1997;5:1–10) I: Non/minimally displaced, no mechanical block, < 2 mm displaced or marginal lip II: Displaced head > 2 mm or angulated neck, ± block or incongruity, without severe comminution (reconstructible) III: Severe comminution, not reconstructible (radiographic or intraoperative determination) General principles: • Ensure adequate anesthesia/relaxation. • Supinate forearm to rotate coronoid into trochlear groove. • Axial traction on forearm. • Flex elbow with direct anterior force on olecranon tip. • Palpable clunk signifies reduction. • Test for stability throughout ROM. Location/pattern [spiral fracture and radial nerve injury = Holstein-Lewis]

Treatment Early motion, ± aspiration Treat like type I for no mechanical block, ORIF for mechanical block, or consider ORIF if > 1/3 of joint, > 30 degrees angulation, > 3 mm step off ORIF versus excision + replacement for instability (elbow or DRUJ) Reduce dislocation, ORIF, replacement Early motion, ± aspiration ORIF (can excise radial head fragments < 25%) Excision with replacement for instability of elbow or DRUJ Stable: Closed reduction, < 7 d, immobilize Unstable: Open repair

Coaptation splint, cast brace, or hanging arm cast. ORIF: Floating elbow, segmental, pathologic, obesity, ipsilateral chest wall injury, polytrauma, bilateral fractures, spinal cord injury, need to weight bear, brachial artery or plexus injury, unacceptable alignment in splint (> 15 degrees varus/ valgus, > 20 degrees anterior/posterior, > 3 cm short, > 15-degree malrotation) or radial nerve palsy post reduction.

188  Tarascon Pocket Orthopaedica Essex-Lopresti

Radial Head Fracture

Disrupted Interosseous Membrane

Disrupted Distal Radioulnar Joint Damian Rispoli 2009

Proximal Humerus Anatomic Neck

Greater Tuberosity Lesser Tuberosity

Head

Surgical Neck

Damian Rispoli 2009

Classification/Limits Stable (< 20%) Unstable (20–50%) (> 50%) Proximal humerus Neer classification: 1 part (A part is defined as > 1 cm 2 part displaced or > 45 degrees angulated.) 3rd most common fracture 3 part (5%) but 3 & 4 part consist of < 5% of the total. 4 part

Injury/Eponym Impression Hill-Sachs

Consider nonoperative treatment with close radiographic follow-up. Many fractures do well without surgery. Hemiarthroplasty or reverse shoulder (older patients) for completely displaced humeral head segments with high likelihood of avascular necrosis (Hertel R, et al. Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. J Shoulder Elbow Surg. 2004;13(4):427–433.)

Early motion with nonoperative treatment Valgus affected most amenable to nonoperative treatment ORIF vs. closed reduction, percutaneous pinning/screw fixation

Prosthesis vs. osteotomy

Treatment Closed treatment Transfer lesser tuberosity to defect. Restore with bone graft.

Shoulder

Radial nerve exploration: Open fracture, penetrating trauma with radial nerve dysfunction, palsy following manipulation, > 3.5 months without recovery

Small Joint Fusion  189

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AO Classification of Proximal Humeral Fractures

A: Unifocal Extra-articular 2-part fracture Intact Blood Supply

B: Bifocal Extra-articular Possible injury to blood supply

C:

Articular fracture involving the anatomic neck High likelihood of necrosis Damian Rispoli 2009

Injury/Eponym Proximal humerus fracture/ dislocation Posterior (lesser tuberosity displaced) Head-splitting fracture Clavicle

May need CT to appreciate Group I: Middle 1/3 (85%) Group II: (see page 191) Distal 1/3 (Neer) (10%) I: Minimal displacement II: Medial to coraco-clavicular ligament A: Ligaments intact and with distal fragment B: Conoid torn, trapezoid with intact distal fragment III: Involving acromioclavicular joint IV: Periosteal sleeve V: Comminuted Group III: Medial 1/3 (5%)

Classification/Limits Anterior (greater tuberosity displaced)

Shoulder Continued

Consider ORIF for Groups I and II: • Absolute: ≥ 2 cm short (somewhat controversial), open fracture, displaced with skin compromise, vascular injuries needing repair, pathologic fracture + trapezius palsy, scapulothoracic dissociation. • Relative: 2 cm displaced, floating shoulder, neurologic disorder, bilateral injuries, multiple trauma, ipsilateral upper extremity fracture, prolonged need for recumbency, intolerance to immobilization.

Prosthesis, selective ORIF in young patient with reconstructible fracture (controversial) Group I: Majority will heal with nonoperative treatment Completely displaced fractures best treated with ORIF (J Bone Joint Surg. 2007;89A(1):1–10) Groups I, II, and IV: Conservative IIA and IIB and V: Selective ORIF in patients with high demands III: Closed, late acromioclavicular excision for arthrosis Group III: Nonoperative

Closed reduction, ORIF if 3-part

Treatment 5-mm displacement after reduction: ORIF

Small Joint Fusion  191

II. Combined

I.

III.

IIA. Anterior

IV.

IIB. Posterior

Normal extension of the articular surface under biceps anchor < or = 5mm

Damian Rispoli 2009

I. Fraying of the biceps anchor II. Tear of the biceps anchor/labrum anterior & posterior to midline A. Tear anterior to midline B. Tear posterior to midline Ill. Bucket handle–type tear with an intact biceps tendon IV. Tear extends from biceps anchor/labrum up into biceps tendon (Arthroscopy 6:274–279,1990) V. Anterior-inferior Bankart lesion extends into biceps anchor VI. Unstable labral flap tear with a tear of the biceps anchor VII. Tear of the biceps anchor extends inferior to the middle glenohumeral ligament (AJSM 23(1:93-98,1995)

Superior Labrum Anterior-Posterior (SLAP) Lesions

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Scapulothoracic dissociation

Injury/Eponym Scapula Relative indications: Articular step off = 3–10 mm 20–30% glenoid involvement 10–20 mm glenoid medialize Glenopolar angle 20–22 degrees Angulation 30–45 degrees [J Am Acad Orthop Surg. 2012;20(3):13041] Glenoid

Ideberg I: Anterior avulsion II: Transverse/oblique fracture inferior glenoid free III: Upper 1/3 glenoid and coracoid IV: Horizontal glenoid thru body V: Combination II–IV Internal forequarter amputation AP CXR-medial scapular border > 1.5 × other side

III: Neck and tubercle

Classification/Limits Zdravkovich and Damholt (Acta Orthop. 1974; 45:60–65) I: Body II: Coracoid and acromion

Shoulder Girdle

(continues)

Closed reduction, massive internal trauma, massive vascular and brachial plexus injuries

ORIF if > 25% glenoid involved or greater than 5 mm of step off and humeral head subluxated Up to 20% of the glenoid can be excised with the labrum repaired back to the rim.

Selective ORIF large displaced fragment (associated injury common) Selective ORIF large displaced fragment

Treatment Closed treatment

Small Joint Fusion  193

Seizure, electrical shock

Luxatio erecta Partial Complete

Posterior dislocation

Inferior dislocation Rotator cuff tear

Shoulder Girdle Continued

Classification/Limits Subcoracoid > subglenoid

Injury/Eponym Anterior dislocation

Treatment Reduce: Stimson: Prone, arm hanging with weight at wrist Milch: External rotation, abduction, posteriorly ­directed force on the anterior of the shoulder Traction/countertraction: Stabilize chest, distal/­ abduction traction on forearm, add gentle rotation Confirm reduction (X-rays), immobilize (classically comfortable adduction/internal rotation) Lateral upper arm traction, distal lower arm traction, and gentle rotation Reduce/immobilize Rehabilitation, debride if fails conservative treatment Rehabilitation, surgical repair in athletes or failed conservative treatment

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Biceps tendon

Sternoclavicular injury

Injury/Eponym Acromioclavicular injury (percent displaced in [ ]) Sling/range of motion Selective ORIF (controversy persists) Reduce/repair (controversy persists) Increased risk of type II SLAP in III & IV Reduce/repair (controversy persists) Increased risk of type II SLAP in III & IV Reduce/repair Closed reduction with traction Closed reduction with towel clip, open reduction if closed reduction fails (beware great vessels, have thoracic surgeon readily available or present) Nonoperative Surgical repair (nonoperative in selected cases: ~30% loss of flexion/supination strength) Rehabilitation versus tenodesis in young or active (cosmetic “Popeye” deformity will bother some people)

II: AC tear, coracoclavicular (CC) sprain [0–25%] III: AC, CC [25–100%] IV: Clavicular subluxated posterior into trapezius

Proximal

Atraumatic Distal

VI: Clavicle subcoracoid Anterior Posterior

V: Type III with large displacement [100–300%]

Treatment Sling/range of motion

Classification/Limits I: Acromioclavicular ligament (AC) sprain [0%]

Small Joint Fusion  195

C1 (Atlas) fracture (Jefferson = axial load) Lateral mass distance = combined distance of the overhang of the lateral aspect of C1 on C2. (See radiology section.)

Traction test: Controlled application of weight in OR under fluoroscopy.

NOTE: Consider craniocervical dissociation Craniocervical dissociation

Injury/Eponym Occipital condyle fracture

Cervical Spine Treatment

Cervical collar (minimal collapse) Halo vest (significant collapse) II: Plus skull fracture (shear injury) Cervical collar (minimal collapse) III: Transverse fracture, avulsed alar ligament Halo vest (significant collapse) I: MRI + (osseous and ligamentous injury Stable injury at craniocervical junction), ≤ 2 mm with Cervical collar for comfort traction test. II: MRI + (osseous and ligamentous injury Rigid posterior segmental stabilization, instrument from at craniocervical junction), > 2 mm with ­occiput to C2 (minimum) traction test. III: Craniocervical malalignnment > 2 mm Rigid posterior segmental stabilization, instrument from on static radiography ­occiput to C2 (minimum) Stable: Posterior arch fracture Soft or rigid cervical collar Anterior arch avulsion fracture Rigid collar, consider craniocervical dissociation C1 ring fracture (LMD < 7 mm) Rigid collar versus halo vest C1 ring fracture (LMD ≥ 7 mm) Posterior C1/C2 fusion versus traction followed by halo vest Unstable: Anterior arch fracture with posterior displacement (relative to dens) Halo vest versus posterior C1/C2 fusion Unilateral sagittal split fracture of lateral Recumbent traction for ≥ 3 wk then halo vest versus C1 mass ring ORIF

Classification/Limits Anderson/Montesano (Spine 13(7): 731–736,1988) I: Impaction (stable)

[J Am Acad Orthop Surg. 2014;22(11):718–729]

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Hangman’s

Traumatic spondylolisthesis of C2

Odontoid fracture [J Am Acad Orthop Surg. 2010;18(7):383–394] (high nonunion rate ~ 26–85%)

Odontoid fracture [J Am Acad Orthop Surg. 2010;18(7):383–394] (high nonunion rate ~ 26–85%)

Injury/Eponym Atlantoaxial dislocation

Cervical orthosis (beware associated injury) Posterior occiput: C2 fusion for instability

Treatment Closed reduction/immobilization Beware/evaluate for associated fractures Mid-substance tears: C1/C2 fusion Bony avulsion: Posterior C1/C2 fusion versus recumbent ­traction followed by halo vest C1/C2 fusion, include occiput if craniocervical junction (­occiput/C1 involved = craniocervical dissociation)

(continues)

(Controversial) IIA: Halo vest or non-rigid orthosis IIB: Anterior screw fixation if favorable body habitus. IIC: Posterior atlantoaxial spinal fusion. Risk for nonunion: Fracture pattern, displaced > 5 mm, posterior displacement, quality of reduction, smoking, age > 65 III: Fracture into body with involvement of the Halo immobilization vs. cervical orthosis C2 superior articular facet. Levine Cervical orthosis verus halo vest I: Nondisplaced (no angulation, < 2 mm) IA: Atypical (unilateral arch, contralateral Halo vest versus ORIF (displaced/spinal cord injury) vertebrae, + vertebral foramen—common) C2/3 ACDF, posterior C1/3 or C2/3 fusion) II: Significant angulation and translation Reduction/halo with some extension Careful not to overdistract

II: Base fracture without involvement of the C2 superior articular facet IIA: transverse, < 1 mm displacement IIB: oblique (ant. sup. to post. inf.) IIC: oblique (ant. inf. to post. sup.)

C: Distraction indicating craniocervical dissociation Anderson/D’Alonzo (J Bone Joint Surg. 1974;56A(8):1663–1674) Grauer Modification (Spine J. 2005;5(2): 123–129) I: Oblique apical/avulsion

Classification/Limits A: Rotation centered on the dens, transverse atlantal ligament intact B: Translation between C1 & C2, transverse atlantal ligament disrupted

Small Joint Fusion  197

C3-7 spinous process fracture C3-7 teardrop fracture

C3-C7 burst

C3-C7 fracture

C3-C7 facet dislocation

Injury/Eponym

Clay shovelers Flexion + axial load with anterior column injury and often posteriorly displaced vertebral body

> 3.5 mm: fusion > 11 degrees: fusion < 25% compression with intact posterior wall = nonoperative; stable = halo immobilization; unstable = fusion Symptomatic Neuro deficit: Corpectomy, fusion, +/– posterior instrumentation Neuro intact: Treat based on instability, collar vs. halo vs. anterior fusion

Traction (10 lb + 5 lb/level), open reduction/posterior fusion failed closed reduction, consider MRI rule out disc herniation

Open reduction and posterior C1/3 or C2/3 fusion

Treatment Reduction/halo versus fixation (posterior approach) Consider posterior C2/3 ACDF, posterior C1/3 or C2/3 fusion

Cervical Spine Continued

Classification/Limits IIA: C2/3 disc torn, anterior longitudinal ligament intact, slight or no translation but severe angulation III: Fracture/dislocation (C2 arch + C2/3 facet dislocation) Unilateral (< 25% displacement of ­vertebral body) Bilateral (25–50% displacement of ­vertebral body) Translation Angular displacement Canal compression

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Small Joint Fusion  199

Clinical instability in the lower cervical spine (Spine 1976;1:15) • 2 points each: ƒƒ Anterior elements destroyed or functionless ƒƒ Posterior elements destroyed or functionless ƒƒ Sagittal plane translation > 3.5 mm ƒƒ Relative sagittal plane rotation > 11 degrees ƒƒ Positive stretch test ƒƒ Spinal cord damage • 1 point each: ƒƒ Nerve root damage ƒƒ Abnormal disc narrowing ƒƒ Dangerous loading anticipated • > 5 is unstable Thoracolumbar Injury Classification and Severity Score Injury Characteristic Qualifier Points Injury morphology Compression ---1 Burst 2 Rotation/translation ---3 Distraction ---4 Neurologic Status ---Intact ---0 Nerve root ---2 Spinal cord, conus Incomplete 3 medullaris Complete 2 Cauda equina ---3 Posterior ligamentous ---complex integrity Intact ---0 Suspected/indeterminate ---2 Disrupted ---3 Spine 2005;30:2325–2333.

Thoracolumbar Injury Classification System and Severity Score Treatment Guide Management Points Nonsurgical 4

200  Tarascon Pocket Orthopaedica

Thoracic and Lumbar Spine Injury/Eponym Thoracolumbar Injury Classification and Severity Score [Spine 2005;30: 2325–2333]

Burst fracture

Classification/Limits Compression = loss of height of the vertebral body or disruption through the vertebral end plate. Rotation/translation = horizontal displacement of one thoracolumbar vertebral body with respect to another. Distraction = anatomic dissociation in the vertical axis. A: Axial load B: Axial and flexion C: Axial and flexion D: Axial and rotation E: Axial and lateral flexion

Flexion/ distraction Chance

Beware of intra-abdominal/seat belt injuries

Fracture-dislocation

Flexion-rotation Shear Zone I: Sacral ala (neurologic injury rare)

Sacral fracture

II: Sacral foramina (28% neural injury) III: Medial to foramina (> 50% neural injury)

Treatment See Chart

Stable = hyperextension cast/brace Unstable = early operative stabilization Height < 50% Angulation > 20 degrees Canal compromise > 50% Scoliosis > 10 degrees Neurologic injury Bony = hyperextension cast/brace Soft tissue = ORIF ORIF: Early mobilization Observation: Stable/ impacted, < 1 cm displacement Iliosacral fixation (ORIF vs. percutaneous) Unstable



Stress Fractures  201

Fracture Types and Columnar Involvement Type Compression Burst Seat belt Fracture/dislocation

Anterior Compression Compression None or compression Compression ± rotation/shear

Middle None Compression Distraction Distraction ± rotation/shear

Posterior None or distraction None or distraction Distraction Distraction ± rotation/shear

[Data from Spine 1983; Nov-Dec;8(8):817-31]

Stable spine fracture criteria: • No transient or persistent neurologic injury • Acceptable alignment • At least one column intact • No significant ligamentous disruption Gunshot wounds to the spine (remove bullet/fragment, decompress): • Progressive neurologic deficit due to neural compression (bullet, fragment, hematoma) • Persistent cerebrospinous fluid leak • Spinal instability • Consider decompression for cauda equina level injuries Define projectile path for broad-spectrum IV antibiotic coverage • Posterior entrance: 48–72 h • AP wound (transabdominal, no colon injury): minimum 5–7 d • AP wound (transcolonic): 7–14 d ƒƒ HIGH RATE OF INFECTION

STRESS FRACTURES Low Risk: Upper extremity, ribs, pars interarticularis, pelvis (sacrum, pubic rami), femoral shaft, tibial shaft, fibula, calcaneus, and metatarsal shaft High Risk: Femoral neck, patella, anterior cortex of the tibia, medial malleolus, talus, tarsal navicular, 5th metatarsal, 2nd metatarsal base, and great toe sesamoids

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See algorithm, page 203.

Pelvis Fractures

Injury/Eponym Pelvis (see page 204) LC = lateral compression Stress exam under anesthesia if posterior sacral fracture is complete

Classification/Limits Young and Burgess. (Skeletal Radiol. 1986;15:103–109) Lateral compression (LC) I: Sacral compression, transverse anterior ring injury (fracture vs. symphysis injury) LC II: Sacral/Iliac wing fracture, anterior ring fracture (sacrospinous (SS) and sacrotuberous (ST) ligament intact) LC III: LCII + SS and ST ligament torn and contralateral sacroiliac (SI) disruption APC = anterior posterior Anterior posterior comprescompression sion (APC) I: < 2.5 cm symStress exam under anesphysis pubis, ± sacroiliac thesia if anterior ring opens (SI) joint widening > 2.5 cm APC II: Disrupted symphysis or anterior ring, SS and ST torn

VS = vertical shear

APC III: APC II and postSI ligament (internal hemipelvectomy) Vertical shear: APC III and vertical displacement CMI: Combination mechanism injury

Treatment Weight-bearing status depends on stability of pelvic ring component, selected stabilization for unstable complete sacral fractures External fixation. ORIF vs. closed reduction percutaneous fixation External fixation vs. ORIF vs. closed reduction percutaneous fixation Symptomatic treatment

Anterior fixation if unstable Add posterior fixation if unstable posteriorly. Selective nonoperative if poor surgical candidate Same as APC II Same as APC II Same as APC II

Pelvic angiography to treat arterial bleeding

Hemodynamically unstable

Apply pelvic external fixator (consider retroperitoneal packing)

Intraperitoneal bleed requiring lapartomy

Monitor & Plan definitive fixation

Pelvic angiography to treat arterial bleeding

Monitor & Plan definitive fixation

No intraperitoneal bleed. No laparotomy

Hemodynamically stable

Hemodynamically unstable

Consider circumferential wrap

IV Fluid bolus (Twice), circumferential wrap, consider PRBC/Clotting products

Yes Hemodynamically stable

Pelvic ring Injury with Mechanical Instability

Hemodynamically unstable

Yes



Pelvic Fractures With Hemodynamic Instability

Stress Fractures  203

Damian Rispoli 2009

Anterior Posterior Compression

Lateral Compression

I

Vertical Shear

II

Young and Burgess Classification of Pelvic Fractures III

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Stress Fractures  205

Pelvis Fractures Continued Injury/Eponym Acetabular fracture (see page 206)

Classification/Limits Letournel Five simple fracture patterns Posterior wall Posterior column Anterior wall Anterior column Simple transverse Five complex/associated fracture patterns T-shaped Posterior wall and column Transverse and posterior wall Anterior with posterior hemitransverse Associated both columns

Treatment Nonoperative: Roof arc angle > 45 degrees as measured off the AP, iliac oblique, and obturator oblique < 50% posterior wall with stable reduction* < 2–3 mm displacement Severe osteoporosis Medical contraindication Relative nonoperative indications: Secondary congruence of the acetabulum with associated both column fracture ORIF-Unstable joint, incongruous joint Note: Consider exam under anesthesia using fluoroscopy to aid in determination of instablity. Note: Temporary skeletal traction

Damian Rispoli 2009

Proximal Femoral Neck Shaft Angle 124 +/– 7 degrees

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Head Neck Intertrochanteric

Subtrochanteric

Damian Rispoli 2009

Hip Fractures

Letournel Classification of Acetabular Fractures (JBJS 46A:1615-1647, 1964) Simple Acetabular Fractures (5 types) Posterior Wall

Posterior Column

Anterior Wall

Anterior Column

Transverse

Complex/ Associated Acetabular Fractures (5 types)

Damian Rispoli 2009

T-shaped Posterior Transverse Both Anterior Column & Posterior with Posterior Columns & Wall Wall Hemitransverse



Stress Fractures  207

Periprosthetic Femur Fracture Classification and Treatment Type I II IIIA IIIB

IIIC IV

Fracture Location Trochanteric region Proximal metaphysis/diaphysis not involving stem tip Diaphyseal fracture at stem tip Disruption of prosthetic interface (< 5%) Diaphyseal fracture at stem tip Disruption of prosthetic interface (> 25%)

Supracondylar fracture at tip of a long-stem prosthesis Supracondylar fracture distant to the stem tip

Recommended Treatment Nonoperative Nonoperative or cerclage fixation Long-stem ingrowth revision or ORIF: Plate with screws ± cerclage ORIF: Cortical struts with cerclage cables Cemented stem: Long-stem ingrowth revision Ingrowth stem: Long-stem ingrowth revision or ORIF: Plate with screws ± cerclage ORIF: Cortical struts with cerclage cables Nonoperative if stable or ORIF: Plate with screws ± cerclage Nonoperative if stable or ORIF: Plate with screws (must extend ­proximal to stem tip) ORIF: Supracondylar intramedullary nail Long-stem ingrowth revision

Data from Miller MD, ed. Review of Orthopaedics, 3rd ed. Philadelphia, PA: WB Saunders; 2000:252.

Hip Fractures Injury/Eponym Femoral neck fracture Avascular necrosis: Nondisplaced 8–18%, Displaced 15–33% Nonunion: Nondisplaced 1 cm ORIF Activity modification > 2 cm ORIF



Stress Fractures  209

Hip Dislocations Injury/Eponym Anterior

Posterior

Posterior with femoral head (type V ThomasEpstein)

Classification/Limits Epstein I: Superior A: No fracture B: Head fracture C: Acetabular fracture II: Inferior A: No fracture B: Head fracture C: Acetabular fracture

Treatment Emergent closed reduction, open if irreducible ORIF if irreducible unstable, or intra-articular bodies Methods: Stimson-Prone, leg hanging off table, immobilize pelvis, knee/ankle at 90 degrees, distal traction, and gentle rotation Allis-Supine, stabilize pelvis, lateral traction to inner thigh, long traction to femur, slight hip flexion, and rotation Reverse Bigelow-Supine, hip partial flexion and abduction, distal jerk, no reduction, then add internal rotation and extend Thompson/Epstein Emergent closed reduction, open if necessary I: No or minimal fracture ORIF if irreducible unstable, or intraII: Posterior acetabuarticular bodies lar rim Methods: III: Comminuted rim Stimson-Prone, leg hanging off table, immoIV: Acetabular floor bilize pelvis, knee/hip at 90 degrees, distal V: Femoral head traction, and gentle rotation (J Bone Joint Surg. Allis-Supine, stabilize pelvis, traction inline 1951;73A:746–778) with deformity, hip flexion to 90 degrees, and rotation Bigelow-Supine, stabilize pelvis, hand holds ankle; forearm behind knee to apply long traction, hip flexed to 90 degrees or more, abduction, external rotation, extension to lever head into acetabulum Pipkin (see page 210) I: Head caudad All: Emergent closed reduction Excise loose fragment if blocks motion or displaced; ORIF if large fragment II: Head cephalad ORIF if large fragment or part of weightbearing dome III: Femoral head and ORIF (young), selective arthroplasty (older) neck IV: Associated acetabu- ORIF (young), selective arthroplasty (older) lar fracture

210  Tarascon Pocket Orthopaedica Pipkin Classification (JBJS 39A:1027-1042, 1957)

I

II

III

IV Damian Rispoli 2009

Shatzker Classification (ClinOrthop 138:94-104, 1979)

I

II

III

IV

V

VI

Damian Rispoli 2009



Stress Fractures  211

Femoral Shaft Fractures Femur (2 cm from Winquist (Orthop Clin N Am. lesser trochanter to 1980;11:633–647) 8 cm above joint) I: Transverse, < 25% butterfly II: Transverse, 25–50% butterfly III: > 50% butterfly, no comminution IV: Comminuted, no cortical contact V: Segmental limits: < 15-degree malrotation, < 1- to 1.5-cm shortening Femoral neck and shaft Femoral shaft/tibial “Floating knee” shaft

Locked intramedullary nail (external fixator, ORIF, traction)

Closed reduction percutaneous pinning vs. ORIF of neck (first). Intramedullary rod or plate for shaft vs. cephalomedullary nail Intramedullary rod femur and tibia; consider external fixator for tibia or femur (based on extent of soft tissue injury) Can use external fixator for a temporary solution

Knee Fractures Injury/Eponym Supracondylar

Patella

Tibial plateau (treatment based on joint stability, displacement and articular congruity)

Classification/Limits AO

Treatment > 6–8 cm proximal-intramedullary nail anterograde < 6–8 cm condylar blade plate/screw, retrograde nail, distal femoral locking plate (required ORIF of displaced articular fragments) Nondisplaced, transverse, Nondisplaced = cylinder cast, knee imlower pole, upper pole, mobilizer if extensor mechanism intact comminuted, vertical ORIF: no active extension, < 2 mm separation, incongruent joint, consider excising comminuted fragment and reattaching tendon Shatzker (see page 210) I: Split lateral plateau Closed treatment if nondisplaced; closed reduction percutaneous fixation if no incarcerated meniscus by scope or MRI; ORIF if incarcerated meniscus II: Split/depression lateral Closed treatment if nondisplaced; ORIF plateau with elevation of the depressed joint surface for > 3 mm displacement (some accept as much as 4–10 mm) or instability

(continues)

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Knee Fractures Continued Injury/Eponym

Tibial spine

Tibial tubercle

Classification/Limits III: Isolated depression IV: Medial split/ depression V: Bicondylar VI: Type V and metaphyseal extension Meyer/McKeever (J Bone Joint Surg. 1959;41A:209–222) I: Anterior elevation

Treatment Closed treatment, ORIF (similar criteria as type II) Closed treatment (only for selected nondisplaced), otherwise ORIF ORIF versus external fixation ORIF versus external fixation

Long leg cast 15–20 degrees of flexion × 4–6 wk II: Anterior 1/3–1/2 Long leg cast 15–20 degrees of elevated flexion × 4–6 wk, unstable = MRI and treat like III IIIA: Displaced MRI, arthroscopic fixation versus ORIF IIIB: Displaced and rotated MRI, arthroscopic fixation versus ORIF ORIF

Knee Dislocation/Soft Tissue Injury Injury/Eponym Quadriceps rupture Patellar tendon rupture Patellar dislocation

Classification/Limits

Proximal tibia-fibula dislocation

Ogden • Subluxation • Posteromedial • Anterolateral • Superior

Knee dislocation

Descriptive of tibia in relation to femur

Treatment Surgical repair Surgical repair Conservative treatment. Rule out osteochondral injury. Evaluate medial patella-femoral ligament, consider repair Treat subluxation conservatively. Dislocations: closed reduction (knee 90 degrees) ± anesthesia Limited immobilization Selective ORIF for unstable injuries See algorithm page 213

ABI % 0.9 No risk of major arterial injury. Delayed thrombus still a risk (vascular exams q4–6h × 24 h. ABI , 0.9 Ultrasound versus CT angiogram



Stress Fractures  213 Knee Dislocation Algorithm Multiple ligament injured knee History/exam/radiographs Dislocated

Emergent closed reduction

Located

Vascular/neurologic status

+

Dislocated

Pulses? Doppler?

− Vascular consult arteriogram

Surgical reduction Located Consider external fixation to maintain reduction

+/- Vascular repair +/- External fixation Ankle—brachial index If > 0.9 low likelihood of significant arterial injury Consider arteriogram Beware of intimal tears presenting with late vascular involvement

Observation period Neurovascular status Skin—MRI Ligament surgery

Tibia/Fibular Fractures Tibia

Johner/Wruhs A: Simple 1: Spiral 2: Oblique 3: Transverse B: Butterfly 1: By torsion 2: One (bend) 3: Multiple (bend) C: Comminuted 1: Torsion 2: Segmental 3: Crush

Closed reduction and cast = low energy, ­minimal displaced, isolated All others-intramedullary nail, external fixator, plate **Maintain a high index of suspicion for ­compartment syndrome Acceptable reduction limits 5 degrees varus and valgus, 10 degrees anterior and posterior, 10 degrees rotation, and 1 cm shortening (Data from Rockwood CR, Green DP. Fractures in Adults. 4th ed. Baltimore, MD: LippincottRaven; 1996:2139)

214  Tarascon Pocket Orthopaedica Maissenouve Fracture Proximal Fibula Fracture

Injury to IO Membrane Distal Syndesmosis Injury

Weber Classification

C: Above the Joint Line B: At the Joint Line A: Below the Joint Line Damian Rispoli 2009

Damian Rispoli 2009

Classification of Acute Lateral Ankle Sprains Grade I II III

Description ATFL stretching without complete tear Partial to complete ATFL tear with a partial tear of the CFL ATFL and CFL tear, possible capsular disruption and PTFL tear

Abbreviations: ATFL, anterior talofibular ligament; CFL, calcaneofibular ligament; PTFL, posterior talofibular ligament. (J Am Acad Orthop Surg. 2008;16:608–615)



Stress Fractures  215

Leg/Ankle Fractures/Dislocations Injury/Eponym Ankle fractures AITFL = anterior inferior talofibular ligament PITFL = posterior inferior talofibular ligament

Classification/Limits Lauge-Hansen (Arch Surg. 1950;60:957–985) Supination: Adduction 1: Lateral malleolus or lateral collateral ligament 2: Medial malleolus (shear) Supination: External rotation 1: AITFL 2: Lateral malleolus (spiral) 3: Posterior malleolus or PITFL 4: Medial malleolus or deltoid ligament Pronation: Abduction 1: Medial malleolus or deltoid 2: AITFL/PITFL or posterior malleolus 3: Lateral malleolus Pronation: External rotation 1: Medial malleolus or deltoid 2: AITFL or bony avulsion 3: High fibular 4: Posterior malleolus or PITFL Danis/Weber A: Fibular fracture below the syndesmosis B: At the syndesmosis C: Above the syndesmosis

Tibial stress fracture Fibular shaft

Treatment Bimalleolar fracture or equivalent ORIF Selected nonoperative treatment for nondisplaced fractures without syndesmotic injury Syndesmotic stabilization (screw, suture button with braided suture, etc.) for widened mortise In general: A = Closed B and C = ORIF ± ­syndesmotic screw

Activity modification Cast for pain control

Syndesmotic Fixation • Tibiofibular diastasis > 1 mm ƒƒ 2 mm lateral talar shift • Tibiofibular clear space > 6 mm • Medial clear space> 4 mm on external rotation stress X-ray • < 10 mm tibia/fibula overlap on AP X-ray • < 1 mm tibia/fibula overlap on mortise X-ray Leg/Ankle Fractures/Dislocations Injury/Eponym Tibial plafond

Achilles tendon rupture

Classification/Limits Ruedi/Allgower I: Minimally displaced II: Incongruous III: Comminuted

Treatment Nonoperative stable/nondisplaced fractures II and III: ORIF vs. external fixation if displaced (min. invasive). Soft tissues are the key. You can always bridge and wait. Casting (higher rerupture) vs. surgical repair (skin necrosis)

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Foot Fractures and Dislocations Stress fracture, March Posterior talar process Shepard’s Lateral talar process Talar head Talar body Talar neck Aviator’s Astralgus

Subtalar dislocation Basketball foot

2nd metatarsal, calcaneus Activity modification and short leg cast Short-leg cast or excision of fragments Short-leg cast, excision of fragments, or ORIF Nondisplaced Nonoperative Displaced ORIF or fragment excision ORIF for displaced fractures Hawkins/Canale Short-leg Hawkins Sign I: Nondisplaced (< 1 mm), nonwalking Relative osteopo­ vertical cast rosis of the talar II: Displaced + subtalar ORIF: dome at 6–8 wk subluxation dislocation Anatomic signifies an intact reduction vascular supply. III: Displaced and talar ORIF: (J Bone Joint Surg. body dislocation Anatomic 1970;52A:991–1002). reduction IV: With talar head ORIF (lateral screw first to prevent dislocation varus): Anatomic reduction Calcaneus: Medial (85%) Closed reduction/cast, open reduction Calcaneus: Lateral (15%) if irreducible Blocks to reduction: Lateral: posterior tibial tendon, flexor digitorum longus Medial: extensor digitorum brevis, talonavicular joint



Stress Fractures  217 Calcaneus Fractures OTA Group B: Nonarticular Body

Group A: Avulsion, Process, or Tuberosity

Anterior Process

Non-Comminuted

Medial Sustentaculum

Comminuted

Group C: Articular Fractures Involving Posterior Facet

Tuberosity

Non-Comminuted Comminuted

Nondisplaced

2-Part

3-Part

4 or More Parts Damian Rispoli 2009

Foot Fractures and Dislocations Continued Injury/Eponym Calcaneal fractures

Midtarsal injury

Classification/Limits A: Avulsion, process, tuberosity B: Nonarticular C: Articular involving the posterior facet

Medial stress Longitudinal stress Lateral stress Plantar stress Crush Navicular (be vigilant Cortical avulsion for ­midtarsal injury) Tuberosity fracture Body fracture Stress fracture Cuboid, nutcracker

Treatment Short-leg non-walking cast vs. ORIF CT scan beneficial, selective ORIF for articular displacement and calcaneal body widening The overall goal is to restore congruous joint surface and the overall morphology of the calcaneus. Closed reduction percutaneous fixation vs. ORIF/percutaneous fixation The goal is restoration of the anatomic relationships Reduce/pin large fragment ORIF (screw/washer) ORIF displaced Short-leg non-walking cast ORIF and bone graft or external fixator (restore lateral column)

(continues)

218  Tarascon Pocket Orthopaedica

Foot Fractures and Dislocations Continued Injury/Eponym Tarso-metatarsal fracture/dislocation Lisfranc

Classification/Limits Homolateral isolated divergent

Metatarsal

Shaft

Pseudo-Jones→

Treatment Closed reduction percutaneous fixation vs. ORIF (usual; reliably reduces joints) Lisfranc ligament: Base of the 2nd metatarsal to the medial cuneiform Can consider primary fusion for predominantly ligamentous injuries (J Bone Joint Surg. 2006;88A(3): 514–520) Closed reduction/selective fixation displaced 1st metatarsal 2nd through 4th nonoperative unless it alters weight-bearing dynamics Closed reduction ± cast/pinning Symptomatic care in Ace wrap, hard sole shoe, or short leg walking cast

Head 5th metatarsal (Orthop Clin N Am. 1995;26:353–361) Zone I (tuberosity avulsion)

5th Metatarsal Fractures Peroneus Tertius Peroneus Brevis

Lateral Band of Plantar Fascia (Implicated in Zone I Fractures)

Zone III Zone II Zone I

Damian Rispoli 2009



Stress Fractures  219 Injury/Eponym Jones →

Classification/Limits Treatment Zone II Short-leg non-weight-bearing cast × 6 wk, ORIF (late or athlete) J Bone Joint Surg. Zone III (diaphyseal Short-leg non-weight-bearing 2002;84A:209–214→ stress fracture) cast × 6+ wk Type I (acute) Prolonged short-leg non-weight-bearing Type II (delayed) cast (sedentary); otherwise ORIF with/ Type III (nonunion) without bone grafting ORIF if symptomatic or high-­ performance athlete, may consider pulsed electromagnetic field (J Am Acad Orthop Surg. 2000;8(5):332–8) Metatarsophalangeal Reduce/buddy tape ± pinning joint dislocation (unstable) Phalanges Buddy tape ± cast or cast shoe Selective ORIF versus percutaneous pinning intra-articular displaced fracture

Proximal and middle phalanx

Jersey or reverse mallet (physeal E)

Seymour fracture (any distal phalanx fracture with a nail bed injury, open fracture)

Injury/Eponym Distal phalanx fractures

C: Phalangeal neck D: Articular/condylar

A: Physeal –Extra-articular Salter-Harris II –Intra-articular III/IV B: Shaft

Classification/Limits Extraphyseal A: Transverse B: Longitudinal split C: Comminuted Physeal (Mallet finger) A: Salter-Harris I or II B: Salter-Harris III or IV C: A and dislocation D: Avulsed extensor and Salter-Harris fracture E: Volar

Closed reduction ± percutaneous pinning (angulation > 20 degrees, age < 10 yr; 10–15 degrees, age > 10 yr), ORIF if needed Closed reduction/splint, percutaneous pinning (often), ORIF if needed ORIF (usually necessary) if displaced or incongruous

Extension splinting × 6 wk (rarely operative) Type B with large dorsal fragment > 50% or significant volar sag may need operative intervention. Types C and D need operative intervention to restore joint surface and extensor continuity. Type E requires tendon repair, retraction proximal to the A4 pulley likely means disruption of the vincular system—repair acutely (< 1 wk). Closed reduction/splint, percutaneous pinning if unstable, ORIF joint incongruity (> 25% of joint surface, displacement > 1.5 mm)

Treatment Closed reduction/splinting: stable Pinning: unstable

Pediatric Trauma—Wrist and Hand Fractures

NOTE: Displaced physeal fractures > 1 week old are at increased risk of physeal damage during any reduction maneuver.

TRAUMA—PEDIATRIC

Trauma—Pediatric 221

Thumb metacarpal dislocation

Finger metacarpal dislocation

Metacarpal fractures

Injury/Eponym Proximal interphalangeal joint dislocation (PIPJ)

All: Closed reduction vs. open reduction for failed closed, cast × 3 wk (­collaterals intact) (Collaterals torn, and volar plate torn and not in joint) (Collaterals torn and volar plate torn and interposed in joint)

Treatment Buddy tape Reduction under local anesthesia Without collateral or volar plate instability: buddy tape × 3 wk Collateral instability: immobilize at 20–30 degrees flexion × 3 wk, then buddy tape Volar plate laxity: dorsal splint at 45 degrees or extension block splinting × 3 wk Irrigation and debridement, reduction then treat as closed Closed, unstable: percutaneous pinning, displaced head splitting need ORIF Closed, unstable: percutaneous pinning Closed, unstable: percutaneous pinning, ORIF rare Closed reduction percutaneous pinning, ORIF if irreducible Closed reduction usually unsuccessful; operative reduction as needed

Wrist and Hand Fractures

Open injuries A: Epiphyseal and physeal B: Neck fracture C: Shaft fracture D: Metacarpal base fracture Dorsal (index finger most common) Farabeuf Incomplete dislocation Complete simple Complete complex

Classification/Limits Jammed finger Dislocation

222  Tarascon Pocket Orthopaedica

Closed reduction percutaneous pinning Cast immobilization (long arm thumb spica cast) Significantly displaced (considered based on skeletal age and angulation >10 degrees and > 1-mm displacement) or additional carpal injury consider open reduction percutaneous pinning vs. internal fixation

Closed reduction (treat like finger metacarpal fractures) Accept angulation < 20 degrees (treat like finger metacarpal fractures) Closed reduction, ± percutaneous pinning for instability Displaced type D fracture: ORIF, external fixation (severe open fractures), traction (complex injuries) Displaced Salter-Harris fractures need ORIF

Classification Salter-Harris classification

A: Transphyseal B: Intraphyseal (styloid)

Distal ulna

(continues)

Treatment Closed reduction/cast Operative indications: Soft tissue injury, associated proximal ipsilateral fracture, failed closed reduction, open, comminuted intraphyseal, carpal tunnel symptoms, compartment syndrome Closed reduction/cast Open reduction for failed closed reduction

Radius/Ulnar Shaft (Fracture/Dislocation)

Head Shaft Metacarpal base A: Distal to physis B: Salter-Harris II, fragment ulnar C: Salter-Harris II, fragment radial D: Salter-Harris III or IV Extremely rare A: Distal pole 1: Extra-articular, 2: Intra-articular B: Midwaist C: Proximal pole

Injury/Eponym Distal radius

CMCJ dislocation Scaphoid

Thumb metacarpal fractures

Trauma—Pediatric 223

Injury/Eponym Radius and ulna Both bone Acceptable angulation (see definitions that follow)

≤ 8 yr♀ & ≤ 10 yr ♂: 15 degrees angulation, 45 degrees malrotation ♀ >8–14 yr & ♂ >10–16 yr: 10 degrees angulation, 30 degrees malrotation Data from JAAOS 24(11):780-8, 2016.

Acceptable angulation, distal metaphysis

Treatment Majority closed reduction/cast Closed reduction percutaneous intramedullary pinning indications: Severe swelling, ipsilateral fracture, re-reduction (external fixation, open reduction uncommon) Limits of Acceptable Alignment: ≤ 8 yr ♀ & ≤ 10 yr ♂: 15 degrees angulation, 45 degrees malrotation, 100% displacement, ≤ 1 cm bayonet ♀ >8–14 yr & ♂ >10–16 yr: 10 degrees angulation, 30 degrees malrotation, 100% displacement, ≤ 1 cm bayonet Data from JAAOS 24(11):780-8, 2106.

Radius/Ulnar Shaft (Fracture/Dislocation) Continued

Classification Greenstick Compression Complete

224  Tarascon Pocket Orthopaedica

Radial head subluxation Radial head dislocation Ulnar fracture/radial neck fracture Radius fracture/distal radioulnar joint dislocation

Monteggia

Injury/Eponym Ulnar fracture/radial head dislocation

Minimally displaced head Displaced head Galeazzi

Classification Bado I: Anterior dislocation of the radial head with a fracture of the ulnar diaphysis II: Posterior dislocation of the radial head with an ulnar diaphyseal or metaphyseal fracture with posterior angulation III: Lateral or anterolateral dislocation of the radial head with a fracture of the ulnar metaphysis IV: Anterior dislocation of the radial head, fracture of the middle 1/3 of the radius, and an ulna fracture at the same or more proximal level Nursemaid’s (see page 230)

Reduce (traction/supination), long arm cast, 90 degrees flexion/supination Closed reduction percutaneous pinning if reduction unstable > 12-yr-old and failed closed reduction: ORIF

Flexion, supination, pressure over radial head Reduce (supination/pressure), long arm cast, 100 degrees flexion, supination Reduce ± ORIF

Reduce (supination), ± ORIF

Reduce (extension/pressure), long arm cast, 90 degrees flexion/supination

Reduce (traction/extension), long arm cast, some extension

Treatment Reduce (traction/flexion), long arm cast, flexion/supination [most common ~ 70%]

Trauma—Pediatric 225

Injury/Eponym Supracondylar

Data from JAAOS 20(2):69-77, 2012.

Closed Reduce/Pin Observe in OR Admit Observe closely Arm in a splint at 45 degrees

Pulseless and Pink

Elbow

Data from Azbug JM, Herman MJ. Management of supracondylar humerus fractures in children: current concepts. J Am Acad Orthop Surg. 2012;20(2):69–77.

Open fracture Dysvascular limb Skin puckering Floating elbow Median nerve palsy Evolving compartment syndrome Young age Cognitive disability

Factors Used to Determine Emergent Management of Supracondylar Humerus Fractures in Pediatric Patients

Classification Treatment Evaluate with quality AP and lateral X-rays 3% of all pediatric fractures (98% extension) 5- to 7-yr-old most common, Posterior fat pad: 76% occult fracture [J Bone Joint Surg. 1999;8(10):1429–1433] Nerve injuries > 11% (most common, Extension: AIN, Flexion: ulnar nerve) J Pediatr Orthop. 2010;30(3):253­–263.

Pulseless and White (Dysvascular) Closed Reduce/Pin Observe in OR (~20 min) Adequate perfusion: Admit Observe closely Arm in a splint at 45 degrees Inadequate perfusion: Explore/repair artery Observe closely Consider fasciotomy

Type III or IV Supracondylar Humerus Fracture With a Pulseless Hand

226  Tarascon Pocket Orthopaedica

Common 6 yr old

Lateral condyle fractures

Distal humeral physeal separation

Extension Gartland [Surg Gynecol Obstet. 1959;109(2):145–154] Wilkins (IIA & IIB) [Rockwood et al., Fractures in Children, 1984.] Leitch (IV) [J Bone Joint Surg. 2006;88(5):980–985] Supracondylar flexion

DeLee A: < 12 mo, Salter-Harris I B: 1–3 yr, Salter-Harris I C: 3–12 yr, Salter-Harris II Jakob I: Intact articular surface II: Articular surface disrupted III: Rotated fragment Milch I: Salter-Harris IV, fracture through capitella–trochlear groove II: Salter-Harris II, fracture through trochlea

I: Nondisplaced II: Displaced with contact III: No contact

I: Nondisplaced II: Displaced, posterior cortex intact IIA: No rotation/translation IIB: Rotation/translation III: No cortical contact (posterior medial and posterior lateral) IV: No intact hinge (unstable flexion & ext.)

(continues)

< 2 mm displaced on all radiographic views: Long arm cast and weekly radiographs for 3 wk, immobilize for 6 wk. > 2 mm: Closed reduction percutaneous pinning (< 2 mm after reduction) versus open or arthroscopic reduction and percutaneous pinning.

Closed reduction percutaneous pinning Closed reduction percutaneous pinning

Long arm cast vs. posterior splint Closed reduction, long arm cast vs. percutaneous pinning Closed vs. open reduction percutaneous pinning Be careful of neurovascular status with casting in flexion > 90 degrees. Closed reduction and cast

Closed reduction/percutaneous pinning (Multiple lateral pins favored by some over medial/lateral configuration due to 10% risk of ulnar nerve injury with medial pin)

Long arm cast: 90 degrees flexion, forearm neutral, 3–4 wk IIA: Closed reduction, long arm cast > 90 degrees, 3–4 wk IIB: Closed reduction/percutaneous pinning (some authors prefer this for all type IIs)

Trauma—Pediatric 227

Elbow dislocation

T-Condylar

Little Leaguer elbow

Medial epicondylar apophysis

Medial condyle fracture

Injury/Eponym Capitellum fracture

Limited open reduction and traction Young: Sedation, closed reduction Older > 9 yr old: general anesthesia, closed reduction Aftercare: active elbow flexion at 5 d, sling at 10 d

ORIF

Closed reduction percutaneous pinning vs. traction

Nonoperative: non/minimally displaced, displaced low demand Operative indications Absolute: Irreducible or unstable dislocation, incarcerated fragment, open fracture Relative: Ulnar nerve dysfunction, high demand

Splint vs. cast Closed reduction/cast vs. percutaneous pinning Closed or open reduction/percutaneous pinning vs. internal fixation

Treatment Closed reduction/cast vs. ORIF Excise vs. ORIF

Elbow Continued

Classification Hahn-Steinthall Kocher-Lorenz Kilfoyle I: Fracture to physis II: Complete, nondisplaced III: Displaced Acute injuries Non/minimally displaced Displaced Elbow dislocated Elbow located Incarcerated fragment Elbow dislocated Elbow located Chronic tension Toniolo/Wilkins I: Nondisplaced II: Displaced, no metaphyseal comminution III: Metaphyseal comminution Proximal radioulnar joint intact A: Posterior (posterior-medial and posterior-lateral) B: Anterior C: Medial D: Lateral

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Radial head and neck

Olecranon metaphysis

Lateral epicondylar apophysis Olecranon apophysis

I: Apophysitis II: Incomplete stress III: Complete fracture A: Pure apophyseal B: Apophysis and metaphysis A: Flexion B: Extension (1: Valgus, 2: Varus) C: Shear Group I: Head 1: Valgus fracture A: Salter-Harris I/II B: Salter-Harris IV C: Metaphyseal fracture 2: With elbow dislocation D: Reduction injury E: Dislocation injury Group II: Neck 1: Angular 2: Torsional Group III: Stress 1: Osteochondritis dissecans 2: Physeal injury + neck angulation

Proximal radioulnar joint dislocation A: Divergent (anterior-posterior and medial-lateral B: Radioulnar translocation

< 30 degrees, no angulation: Long arm cast vs. posterior splint, and early range of motion > 30 degrees: Closed reduction (general anesthesia) using flexion-pronation, long arm cast × 10–14 d > 45 degrees: Closed reduction (general anesthesia) using flexion-pronation, Ace wrap, or percutaneous pins, then long arm cast × 10–14 d Fixed 40 degrees angulation, < 60 degrees pronation/supination, 3 mm translation, head completely displaced: Wire reduction, open reduction ± internal fixation

Nondisplaced: Cast in extension Significantly displaced: ORIF

Immobilization, incarceration: Operative intervention Nondisplaced: Splint/cast in extension Displaced: ORIF vs. percutaneous pinning

Trauma—Pediatric 229

230  Tarascon Pocket Orthopaedica Milch Fracture Classification

Milch I (Salter-Harris IV)

Milch II (Salter-Harris II) Damian Rispoli 2009

Nursemaid’s Elbow Nursemaid’s Elbow -Refusal to move arm -Pain at elbow -May give characteristic history (longitudinal pull) Treatment -Supinate forearm -Flex elbow with pressure over radial head -Radial head should relocate -Success is walking away to return later and see the child using the arm

2. Flex Elbow

3. Gentle pressure on radial head 1. Supinate Forearm

Damian Rispoli 2009

Medial clavicle Sternoclavicular joint

Midshaft clavicle

Peak 5–11 yr old

Proximal humerus

Injury/Eponym Humeral shaft

0–2 yr old > 2 yr old Salter-Harris I and II Anterior Posterior

Classification Birth injury 0–3 yr 3–12 yr > 12 yr Salter-Harris Neer-Horowitz [Clin Orthop Relat Res. 1965; 41:24–31] I: ≤ 5 mm displaced II: ≤ 1/3 shaft III: ≤ 2/3 shaft IV: Complete shaft

Shoulder

(continues)

Treatment Splint Collar and cuff Velpeau Sugar tong splint Minimally displaced: splint vs. hanging arm cast Unstable ± percutaneous pinning Soft tissue interposition or open fracture: ORIF Two studies support nonoperative treatment even in the face of severe displacement or angulation [Baxter et al. J Bone Joint Surg Br. 2012;86;68:570–573 and Beringer et al. J Pediatr Orthop. 1998;18:31–37] Age criteria based on a systematic review [Pahlavan et al. J Child Orthop. 2011;5(3):187–194] Groups I < 10 yr old, II 10–13 yr old, III > 13 yr old. Group III limited remodeling due to age consider surgery for N-H Type II and IV. Criteria for angulation still controversial. Note: Biceps tendon interposition blocking reduction in < 10%. Supportive Figure-of-8, sling Sling Sling Closed vs. open reduction

Trauma—Pediatric 231

Shoulder Continued

Injury/Eponym Classification Treatment Medial clavicular physis is the last to close (~ 25 yr old). Sternoclavicular dislocations usually represent Salter-Harris type II fractures. Glenohumeral dislocation Traumatic Closed reduction, rehabilitation, ± reconstruction/repair Anterior and posterior Scapular fracture Anatomic Similar to adults Lateral clavicle I: Nondisplaced, intact ligaments Sling, figure-of-8, consider ORIF for certain type IIs IIA: Fracture medial to coracoclavicular ligaments IIB: Conoid ligament tear III: Fracture into acromioclavicular joint Acromioclavicular joint I: Sprain I–III: Closed treatment II: Partial tear dorsal periosteum III: Large tear dorsal periosteum IV: Posterior displacement Closed reduction vs. open reduction/repair V: Significant superior displaced Open reduction, repair, reconstruction (> 100% contralateral side) VI: Inferior displaced Closed reduction vs. open reduction (subcoracoid rare) Scapulothoracic dissociation ABCs, reconstruction/repair

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[J Am Acad Orthop Surg. 2013;21(12):707–16]

Thoracic and lumbar fractures

C2 fracture Hangman’s C2–C7 fracture

Occiput-C1 dislocation C1: Atlas fracture C1–C2 injuries

Injury/Eponym SCIWORA

Spine Fractures

Posterior ligament injuries Wedge/compression fracture Distraction/shear fracture Fracture: dislocation Facet dislocation/listhesis Flexion With compression Without compression Flexion-distraction (Chance/Seat belt injury) Shear Consider using the Thoracolumbar Injury Classification and Severity Score (see Adult Thoracic Spine)

Usually nonoperative Operative fixation: Unstable, open wound, progressive neurologic deficit, slipped vertebral apophysis Note: The spinal cord ends at L3 in newborns and migrates to L1 or L2 by adolescence.

Usually nonoperative Unstable: fuse

Classification Treatment Spinal Cord Injury Without Radio- High index of suspicion, CT and MRI graphic Abnormality High mortality Occiput: C3 fusion Minerva vs. HALO vest Ligament disruption C1–C2 fusion Rotatory subluxation I: No anterior shift < 1 wk: Soft collar, NSAIDs II: Anterior < 5 mm < 1 month: Relax, traction, collar/brace 4–6 wk III: Anterior > 5 mm 1–3 month: HALO IV: Posterior shift > 3 month: C1–C2 fusion Minerva cast vs. HALO immobilization

Trauma—Pediatric 233

Description Nondisplaced ≤ 2 cm displacement ≥ 2 cm displacement Symptomatic nonunion Painful heterotopic bone growth

Apophyseal Avulsion Fractures

Treatment Closed reduction and spica cast vs. open reduction percutaneous pinning (open treatment more common with head dislocation) Closed reduction vs. open reduction percutaneous pinning (AVN increases with displacement) III: Cervicotrochanteric Displaced Closed reduction vs. open reduction percutaneous pinning/compression screw Nondisplaced Abduction spica cast, close F/U, ORIF indicated for displacement in cast IV: Intertrochanteric Traction then casting vs. closed reduction and compression screw Devas Tension Percutaneous pinning Compression Nonweight bearing Anterior Closed reduction, open reduction (irreducible), CT scan Posterior (intra-articular bodies)

Hip Fractures and Dislocations

Classification I: Transepiphyseal (with and without dislocation) II: Transcervical (45–50%)

Data from McKinney et al. Orthopaedics 32(1):42,2009.

Type I II III IV

Hip dislocation

Stress fracture

Injury/Eponym Hip fracture Delbet

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Injury/Eponym Pelvic fracture

Short bedrest, advance partial weight bearing as tolerated

(continues)

Restore joint congruity and hip stability Short period of rest, relax muscles associated with spine/tuberosity, advance partial weight bearing as tolerated Short bedrest, advance partial weight bearing as tolerated Short bedrest, advance partial weight bearing as tolerated Short bedrest, advance partial weight bearing as tolerated

Treatment

Pelvic and Acetabulum Fractures

Classification Key and Conwell I: No ring break A: Avulsion fracture (ASIS, AIIS, ischial tuberosity) B: Pubis/ischium C: Iliac wing D: Sacrum/coccyx II: Single break Duverney→ A: 2 ipsilateral rami

See above See above See above

See above

Anterior inferior iliac spine Most common Pubic symphysis Iliac crest Greater and lesser trochanter

Treatment Consider surgery for > 15 cm displacement Consider surgery for displacement > 2 cm (most treat nonoperative) Chronic pain Consider surgery for displacement > 2 cm (most treat nonoperative) Chronic pain or femoral acetabular impingement Nonsurgical management Consider surgery for displacement > 3cm Nonsurgical Consider surgery for symptomatic non-union

Apophyseal Avulsion Fractures Around the Pelvis

Classification See above See above

Injury/Eponym Ischial tuberosity Anterior superior iliac spine

Trauma—Pediatric 235

Injury/Eponym

ORIF ORIF

Restore congruity

Bedrest × 6 wk, advance partial weight bearing as tolerated Bedrest, traction, ORIF > 3 cm Treat as pelvic fracture

Bedrest × 6 wk, advance partial weight bearing as tolerated

Short bedrest, advance weight bearing as tolerated

Treatment Short bedrest, advance weight bearing as tolerated

Pelvic and Acetabulum Fractures Continued

Classification B: Fracture/subluxation symphysis C: Fracture/subluxation sacroiliac joint III: Double break A: 2 anterior fracture/dislocation B: 2 vertical fracture/dislocation C: Severe multiple fractures IV: Acetabular fracture Straddle→ A: Small fragment, + dislocation Malgaigne→ B: Linear, nondisplaced pelvic fracture C: Linear, unstable joint D: Due to central fracture/ dislocation

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Subtrochanteric/Supracondylar

Injury/Eponym Femur fracture

Subtrochanteric Supracondylar

Treatment 0–6 mo: Stable: Pavlik Unstable: Immediate spica or traction and delayed spica 6 mo–5 yr: < 3 cm shortening: Immediate spica > 3 cm initial, > 2 cm in spica traction: Delayed spica Polytrauma: External fixator, flexible intramedullary nails 6–11 yr: Stable: Immediate spica Unstable: Traction, delayed spica, external fixator, flexible intramedullary nail ≥ 12 yr–Adult Flexible/rigid intramedullary nail based on maturity and fracture configuration Limits of acceptable angulation: 0–2 yr: 30 degrees varus/valgus, 30 degrees anterior/posterior, 15 mm short 2–5 yr: 15 degrees varus/valgus, 20 degrees anterior/posterior, 20 mm short 6–10 yr: 10 degrees varus/valgus, 15 degrees anterior/posterior, 15 mm short > 11 yr: 5 degrees varus/valgus, 10 degrees anterior/posterior, 10 mm short [Rockwood CA, et al. Fractures in Children, 4th ed. Philadelphia, PA: Lippincott-Williams and Wilkins; 1997:1201.] Traction and cast vs. cast brace Stable: Cast Unstable: Closed vs. open reduction internal fixation/percutaneous pinning

Femoral Shaft Fractures

2–10 yr old: Overgrowth averages 0.9 cm (J Bone Joint Surg. 2002;84A(12):2288–2300)

Treatment is very variable between centers!

Classification Anatomic/descriptive

Trauma—Pediatric 237

Tibial tubercle avulsion

Ogden (J Bone Joint Surg. 1980;62A:205–215) I: Tubercle II: Tubercle through the tibial apophysis and exiting anteriorly III: Tubercle through the tibial apophysis and anterior epiphysis and exiting though the articular surface IV: Tubercle through the apophysis exiting the posterior metaphysis

Treatment Fix one, usually the tibia Fix femur if: Severe head trauma with posturing Skeletal maturity Severe soft tissue injury Irreducible closed Nondisplaced: Long leg cast and close follow-up Displaced I, II: Closed reduction (< 2 mm residual displacement), long leg cast. Unstable: 2 smooth percutaneous crossed pins. III, IV: Closed reduction percutaneous pinning or screw fixation Nondisplaced: Long leg cast, 30 degrees flexion Displaced: Closed reduction (< 2 mm residual displacement) percutaneous pinning I & II, ORIF III & IV (re-establish joint congruity) Beware vascular injury. Neuro and vascular injuries: 14%, Consider ligament injuries (exam post fixation). Nondisplaced, minimally displaced with active extension to 0 degrees: Long leg cast Displaced: ORIF

Knee Fractures and Dislocations

Classification Letts/Vincent A: Diaphyseal/closed B: Metaphyseal/diaphyseal closed C: Epiphyseal/diaphyseal D: One fracture open E: Both open Salter-Harris

Proximal tibial physeal fracture Salter-Harris

Distal femoral physeal fracture

Injury/Eponym Floating knee

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Tibiofibular joint dislocation

Patellar dislocation

Knee dislocation

Patella fracture

Osteochondral fractures (knee)

8–14 yr old

Intercondylar eminence fracture

Initially treat with ↓ activity ± immobilization unless unstable or detached Operative treatment for failure on nonoperative × 3–6 mo (arthroscopy) < 1 cm excise and drill; ≥ 1 cm consider open curettage, reduction, and fixation Long leg cast ORIF (tension band)

I: Long leg cast/brace in (neutral-20 degrees) × 6–12 wk. II: Closed reduction. Treat as I if reduced. Open versus arthroscopic fixation for unreducible II, III, and IV.

Nondisplaced Displaced (2–3 mm step off or 3 mm) Periosteal sleeve (usually ORIF ± tension band 8–12 yr) Anterior: 40%: hyperextension Similar to adults except children may be primarily repaired; isolated ligament (beware vascular injury) injuries may be treated nonoperatively Posterior: 30%: dashboard, fall on flexed knee Lateral: 18%: varus Medial: 4%: valgus Rotatory: 4%: twisting (posterolateral most common of this type, may be unreducible) Closed reduction, cylinder cast Intra-articular osteochondral fracture may need excision vs. ORIF Subluxation Closed reduction, rest vs. cast Anterior/lateral Posterior/medial Superior

Myers/McKeever (J Bone Joint Surg. 1970;52A:1677–1684) I: Incomplete, nondisplaced II: Hinged (posterior) III: Supinated/rotated IV: Comminuted 33% bilateral, ♀ < ♂, 5–15 yr

Trauma—Pediatric 239

IV: Special Toddler’s Bicycle spoke Pathologic

II: Distal tibial metaphyseal fracture III: Diaphyseal fracture isolated tibial, isolated fibular, both

Soft tissue reconstruction/stabilization Based on pathologic condition and fracture ** Be sure to counsel for overgrowth and correction based on age Valgus deformity: Spontaneous correction to 3 yr postinjury

Nondisplaced: Long leg cast Displaced: Closed vs. open reduction, long leg cast, internal or external fixation (plate/screws, flexible nails) Long leg cast

Treatment Nondisplaced: Long leg cast 10 degrees flexion Displaced: Closed vs. open reduction, long leg cast Nondisplaced: Long leg cast Displaced: Closed reduction, long leg cast

Tibia and Fibula Fracture

Classification I: Proximal tibial metaphyseal fracture

***GOAL < 1 cm short < 10 degrees angulation (varus, valgus, or recurvatum)

Data from Rockwood CR, Green DP. Fractures in Adults. 4th ed. Baltimore, MD: Lippincott-Raven; 1996:2139.

Injury/Eponym Tibia and fibular fracture

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Injury/Eponym Ankle fracture

Acceptable ≥ 2 yr growth < 15 degrees plantar flex < 10 valgus No varus < 2 yr growth < 5 degrees all planes

Closed vs. open reduction, cast ± percutaneous pinning or screw fixation **Restore ankle mortise/joint surface Triplane > 3 mm initial or 2 mm residual articular step-off: ORIF Tillaux: Based on CT scan. ORIF displacement > 2 mm or translation > 1 mm. Generally: > 2 mm displacement and > 2 mm step off: ORIF > 3 mm physeal widening can indicate interposed periosteum Follow fractures for at least 1 yr post injury J Bone Joint Surg. 2012;94A(13):1234–1244

Treatment

Ankle Fractures

CT scan SH I and II post reduction due to higher incidence of malreduction (Data from JPedOrthop 23:733-739, 2003)

Classification Dias/Tachdjian Supination-inversion • Transverse fibula, shear medial malleolus • Pronation/eversion external rotation • High fibula, medial malleolar transverse physeal • Supination-plantar flexion • Transphyseal posterior • Supination-external rotation • Oblique fibular, oblique tibial Axial compression (SalterHarris V) Juvenile Tillaux (Salter-Harris III lateral tibial physis) Triplane (Salter-Harris III tibia anterior lateral, Salter-Harris IV posterior medial)

Trauma—Pediatric 241

242  Tarascon Pocket Orthopaedica Anterior Lateral Axial Section

Damian Rispoli 2009

Juvenile Tillaux

Tri-Plane Fracture

AP Damian Rispoli 2009

Lateral

Radiographic Representation

Base 5th metatarsal

Metatarsals

Lesser tarsal fracture Tarsometatarsal injuries

Osteochondral fracture

Injury/Eponym Talus fracture  

Jones Pseudo-Jones

Classification Neck I: Nondisplaced I: Minimally displaced II: Displaced Berndt/Harty I: Subchondral trabecular injury II: Incomplete separation II: Complete, nondisplaced V: Displaced Anatomic Hardcastle   A: Complete incongruity B: Partial instability C: Divergent or total instability

(continues)

Nondisplaced: Cast Displaced: Closed reduction percutaneous pinning vs. open reduction percutaneous pinning vs. internal fixation Nonoperative Unstable: Closed reduction percutaneous pinning Short leg nonwalking cast, ORIF ± graft Short leg cast vs. postoperative shoe

6 wk non-weight-bearing 6 wk non-weight-bearing Arthroscopy: Excision, microfracture, bone graft Arthroscopy: Excision, microfracture, bone graft Nonoperative

Cast Cast vs. closed reduction percutaneous pinning Closed reduction percutaneous pinning

Treatment

Foot Fractures

Trauma—Pediatric 243

Calcaneal apophyseal avulsion

Injury/Eponym Stress fracture Phalangeal fracture Calcaneus

Treatment Activity modification Nonoperative Historically treated nonoperatively Good results with operative treatment [J Pediatr Orthop. 2007;27(8):856–862] Older age and joint incongruity may need closed reduction percutaneous p­ inning vs. ORIF

Foot Fractures Continued

Essex-Lopresti Type 1 A: Tuberosity/apophysis B: Sustentaculum tali C: Anterior process D: Anterior inferior lateral process E: Body avulsion Type 2 Tuberosity posteriorly ± superior involvement Type 3 Body, no subtalar involvement Type 4 Subtalar involvement, Nondisplaced Type 5 Subtalar involvement, displaced A: Tongue B: Joint depression Type 6 Nonclassifiable See classification for apophyseal Long leg cast versus surgical treatment. This is a rare injury, and the literature injuries around the hip. is unclear as to the best treatment.

Classification

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Trauma Scores/Classifications  245

TRAUMA SCORES/CLASSIFICATIONS [J Trauma 1984;24:742–746] Grade I

II

III**

IIIA IIIB

IIIC

Gustillo Classification

Description Wound usually < 1 cm, clean, ­minimal muscle contusion, low energy fracture (usually ­inside-out type wound) Wound usually > 1 cm, significant soft tissue injury (flaps, avulsed skin, nerve injury extensive muscle contusions), minimal to moderate crush component, moderate energy fractures, minimal comminution Wound usually > 10 cm, extensive soft tissue damage, high energy fractures, crush/shear injuries

Antibiotic Choice 1st-generation cephalosporin such as cefazolin (Ancef) 1 gm IV q8h for 3 d (post wound closure)

I* 3L

1st-generation cephalosporin such as cefazolin (Ancef) 1 gm IV q8h for 3 d (post wound closure)

6L

Cefazolin for 5 d plus gentamicin 2 mg/kg and adjusted for serum levels or tobramycin, add 4 million units IV PCN G q6h for farmyard, highly contaminated, vascular injuries, or extensive crush injuries

9L

Soft tissue adequate for local coverage, gunshot wound (GSW), segmental fracture Periosteal stripping, exposed Consider antibiotic bead pouch*** bone, extensive soft tissue injury, contamination, requires soft tissue reconstructive surgery Type III with vascular injury requiring Consider antibiotic bead pouch*** repair for limb survival

9L 9L

9L

Data from Chapman MW, Olson SA. Open fractures. In Rockwood CA, Green DP, Bucholz RW, Heckman JD, eds. Rockwood and Green’s Fractures in Adults. 4th ed. Philadelphia: Lippincott-Raven Publishers; 1996: 305–352. Anglen JA, Wound Irrigation in Musculoskeletal Injury, JAAOS. 2001 9(4):219–226. *Irrigation: Additives (antiseptics, antibiotics, and surfactants) not universally recommended **Automatic type IIIs: Segmental fractures, farmyard injuries, fractures occurring in highly contaminated environments, shotgun wounds, high-velocity gunshot wounds ***Antibiotic beads: Tobramycin, gentamicin, vancomycin, or cephalosporin (0.5–1 g per 40 g cement). Topical antibiotics in the irrigant are controversial but favored by some. Consider culture. [Clin Orthop. 1986;212:227] Thorough and adequate debridement and irrigation are imperative and the keystone in the treatment of all open injuries.

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Open Hand Injuries Consider: 1. The patient as a whole 2. Other injuries; resuscitation 3. History 4. Physical exam 5. Restoration of blood flow 6. Debridement (repeat debridement) 7. Skeletal stability 8. Repair of damaged structures 9. Appropriate timing of closure and coverage (when in doubt, don’t close) 10. Proper dressings and elevation 11. Tetanus prophylaxis and antibiotics (antibiotics as useful “adjuncts.” Antibiotics never substitute for adequate debridement. Cover severe wounds with oxacillin or 1st-generation cephalosporin.) 12. Secondary reconstruction 13. Rehabilitation (as early as possible) 14. Tetanus prophylaxis [Brown PW. Open injuries of the hand. In: Green’s Operative Hand Surgery, 3rd ed. Philadelphia, PA: Churchill Livingstone; 1993:1607–1630.]

Early/late failure

Further limb salvage procedures

Reconstruction ladder tools: External fixation, internal fixation, vascular consultation, plastic surgery consultation, staged procedures

Limb salvage

Amputation (consider open length-preserving procedure, don’t close)

Yes

Warm ischemia < 6 hours, limb NOT contributing toward immediate mortality, salvageable (clinical decision)

Mangled limb (Broad definition)

Warm ischemia > 6 hours, limb contributing toward immediate mortality, not salvageable (clinical decision)

Yes

Management of Severe Extremity Soft Tissue Trauma

Trauma Scores/Classifications  247

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TUMOR Age Distribution of Various Common Bone Lesions Age Malignant Birth to 5 yr Leukemia Metastatic neuroblastoma Metastatic rhabdomyosarcoma Wilms’ tumor 10–25 yr Osteosarcoma Ewing’s sarcoma Leukemia Adamantinoma

40–80 yr

Metastatic bone disease Myeloma Lymphoma Paget’s sarcoma Post radiation sarcoma Malignant fibrous histiocytoma

Benign Osteomyelitis Osteofibrous dysplasia Osteochondroma (after 5 yr) Chondroblastoma (after 5 yr) Eosinophilic granuloma Osteomyelitis Enchondroma Fibrous dysplasia Aneurysmal bone cyst Giant cell tumor Simple bone cyst Hyperparathyroidism Paget’s disease Mastocytosis

Staging System for Musculoskeletal Lesions (Enneking) Stage IA IB IIA IIB IIIA IIIB

GTM G1T1M0 G1T2M0 G2T1M0 G2T2M0 G1 or 2 T1M1 G1 or 2 T2M1

Description Low grade, intracompartmental, no metastasis Low grade, extracompartmental, no metastasis High grade, intracompartmental, no metastasis High grade, extracompartmental, no metastasis Any grade, intracompartmental, metastasis Any grade, extracompartmental, metastasis

Grade: G1: low-grade, less common, metastasis < 25% G2: high-grade, metastasis > 25% Tumor site: T1 intracompartmental T2 extracompartmental Metastasis: M0: no metastasis (regional or systemic) M1: metastasis (regional or systemic) Skip lesions place the patient into a stage III category.

General Guidelines for Prophylactic Fixation in Metastatic Disease Pattern of bone destruction Size Location Pain Post irradiation Prognosis

Tumor 249

Purely lytic: High risk Purely blastic: Lower risk < 25–35% cortical destruction: Low risk > 50–75% cortical destruction: High risk High-risk regions: Femur neck, subtrochanteric, diaphysis Risk increased with activity-related pain (mechanical pain) Fixation to improve pain and increase mechanical strength (Beware of wound-healing complications post radiation.) Survival < 4 wk: Nonoperative treatment

Data from Frassica FJ, et al. Metastatic bone disease: Evaluation, clinicopathologic features, biopsy, fracture risk, nonsurgical treatment, and supportive management. AAOS Instructional Course Lectures. 2000;49:453–459.

Scoring System to Predict Pathologic Fracture Parameter 1 Pain Location Bone destruction Size

None Upper extremity Blastic < 1/3

Score 2 Moderate Lower extremity Mixed 1/3–2/3

3 Activity related Peritrochanteric Lytic > 2/3

Fracture group: median 10, range 7–12 Nonfracture group: median 7, range 4–9 Scores 9 or higher: fixation recommended Data from Mirels H. Metastatic disease in long bones: A proposed scoring system for diagnosing impending pathologic fractures. Clin Orthop. 1989;249:256–264.

Osteoblastic Metastasis “LBP”: Lung/breast/prostate 30–60–90% of respective lesions are blastic on radiographic evaluation. Skeletal Fixation of Metastatic Carcinoma • Goal is to maximize function and minimize pain. • The goal is not to effect a cure in metastatic disease. • Skeletal fixation or radiation therapy can meet goals (should generally radiate following skeletal fixation).

250  Tarascon Pocket Orthopaedica Laboratory Studies in Evaluation of a New Tumor Patient 5–40 yr Complete blood count with differential Erythrocyte sedimentation rate Peripheral blood smear

40–80 yr Complete blood count with differential Erythrocyte sedimentation rate Chemistry group, calcium and phosphate Serum or urine electrophoresis Urinalysis PSA

CBC: Myeloma, infection, any marrow-packing disorder ESR: Infection Peripheral blood smear: Lymphoma, leukemia, infection Chemistry, calcium, phosphate: Metabolic disease, diabetes, metastasis, osteosarcoma Serum or urine electrophoresis: Myeloma Urinalysis: Renal cell

Round Cell Lesions by Age Lesion Neuroblastoma Eosinophilic granuloma Ewing’s sarcoma Lymphoma Myeloma Metastasis Infection

Age 2–3 4–20 10–25 30–60 50+ 50+ Any

Subchondral bone lesions Giant cell tumor Chondroblastoma Clear cell chondrosarcoma

Five lesions that can look like anything (radiographically): • Fibrous dysplasia • Metastatic lesions • Chondroid lesions • Infection • Eosinophilic granuloma Lodwick’s Classification (Radiographs of Bone Lesions) IA: Well circumscribed, sclerotic IB: Circumscribed, minimally sclerotic IC: Poorly circumscribed II: Moth eaten (geographic) III: Permeative (diffuse)



Tumor 251

Malignant Lesions Bone Osteosarcoma1 Chondrosarcoma2 Ewing’s sarcoma3 Metastatic lesions Lymphoma Myeloma Chordoma Adamantinoma

Soft Tissue Soft tissue sarcoma Fibrosarcoma Liposarcoma4 Leiomyosarcoma Malignant spindle cell sarcoma (NOS) Malignant schwannoma/neurofibrosarcoma Rhabdomyosarcoma5 Synovial sarcoma6

1,2,3

1st, 2nd, and 3rd most common primary bone sarcomas. Most common soft tissue sarcoma in adults. Most common soft tissue sarcoma < 15 yr old. 6 Most common soft tissue sarcoma of the lower extremities. 4 5

• • • • •

Intra-Articular Tumors Pigmented villonodular synovitis (nodular or diffuse) Synovial chondromatosis Synovial cell sarcoma (rare) Synovial chondrosarcoma Lipoma arborescens Musculoskeletal Tumor Society (MSTS) Stages of Disease

Benign Disease 1 Benign, inactive (latent) 2 Benign, active 3 Benign, aggressive

Malignant Disease I Low grade II High grade III With regional or distant metastasis

Chondroblastoma

Osteosarcoma

Enchondroma Chondrosarcoma

Simple Bone Cyst Osteoblastoma

Chondromyxoid Fibroma

Osteoid Osteoma

Fibrous Cortical Defect Adamantinoma Fibrous Dysplasia

Modified from Madewell JE, Ragsdale BD, Sweet DE. Radiologic and Pathologic analysis of solitary bone lesions, Part I. Internal Margins. Radiol Clin North Am 1981;19(4):784-814 D i a p h y s i s

Damian Rispoli 2009

Giant-Cell Tumor (adult extends to Epiphysis end of bone)

M e t a Osteochondroma p h Giant-Cell Tumor— y Child s i s Non-ossifying Fibroma

Fibrosarcoma

Round Cell Lesions -Ewing’s Sarcoma (equally as common in the metaphysis) -Reticulum Cell Sarcoma -Myeloma

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Appendix A: Steroid Preparations  253

APPENDIX A: STEROID PREPARATIONS Steroid Preparations Solubility Most soluble Soluble

Slightly soluble Relatively insoluble Combination

Generic Name Betamethasone sodium phosphate Dexamethasone sodium phosphate Prednisolone sodium phosphate Prednisolone tebutate Triamcinolone triacetate Methylprednisone acetate Dexamethasone acetate Hydrocortisone acetate Prednisolone acetate Triamcinolone acetonide Triamcinolone hexacetonide Betamethasone sodium phosphate Betamethasone acetate1

Trade Name Celestone

Equivalent Dose (mg)* 0.6

Decadron Hydeltrasol

0.75

Prednisol TBA Aristospan Forte Depo-Medrol Decadron-LA Hydro-acetone Predalone Kenalog Aristospan Celestone Soluspan

5 4 4 0.75 20 5 4 4 0.6

5

*For example, 0.6 mg of betamethasone sodium phosphate is equivalent to 0.75 mg of dexamethasone sodium phosphate, which is equivalent to 5 mg of prednisolone. 1 Betamethasone acetate is slightly soluble Fadale PD, Wiggins ME. Corticosteroid injections: Their use and abuse. J Am Acad Orthop Surg. 1994;2(3):133–139.

Concerns Three Main Concerns: Postinjection flare Other Concerns: Crystal-induced synovitis

Long-term joint damage

Serious infection

Local cutaneous atrophy

Steroid arthropathy

Intra-articular steroid injections have been shown to be: • Good for short-term pain relief in osteoarthrosis flares • Good short-term relief ~1–3 weeks (placebo-controlled studies) • Recommended no more than four injections per year in a single joint [AAOS IMCA Osteoarthritis of the Knee, 2002] **Recent literature identified an increased risk of infection with steroid injections given within 3 months of total joint arthroplasty (hip, knee, and shoulder)**

254  Tarascon Pocket Orthopaedica

APPENDIX B: INTERNET RESOURCES Journals American Journal of Sports Medicine: www.ajsm.org Arthroscopy: www.arthroscopyjournal.org Clinical Orthopaedic and Related Research: www.clinorthop.org Journal of Arthroplasty: www.arthroplastyjournal.org Journal of Bone and Joint Surgery: www.jbjs.org Journal of Foot and Ankle Surgery: www.jfas.org Journal of Hand Surgery: http://www.sciencedirect.com/science/journal/03635023 Journal of Orthopaedic Trauma: www.journals.lww.com/jorthotrauma Journal of Shoulder and Elbow Arthroplasty: www.jshoulderelbow.org Journal of the American Academy of Orthopaedic Surgeons: www.jaaos.org Journal of Trauma: www.jtrauma.com Orthopaedic Blue Journal (Healio): www.healio.com/orthopedics/journals/ortho Orthopedics Today: www.healio.com/orthopedics Physician and Sports Medicine: www.physsportsmed.com Spine: www.spinejournal.com Companies Acumed: www.acumed.net Arthrex: www.arthrex.com DePuy/J&J: www.depuysynthes.com Exactech: www.exac.com Jones and Bartlett Learning: www.jblearning.com Orthofix: www.orthofix.com Skeletal Dynamics: www.skeletaldynamics.com Stryker: www.stryker.com Smith & Nephew: www.global.smith-nephew.com Tarascon Publishing: www.tarascon.com Wolters-Kluwer: www.lww.com Wright Medical Group/Tornier: www.wright.com Zimmer/Biomet: www.zimmerbiomet.com Orthopedic Web Sites AAOS Appropriate Use Criteria: www.aaos.org/auc American Academy of Orthopedic Surgery: www.aaos.org Orthogate: www.orthogate.org Orthoinfo (AAOS): www.orthoinfo.aaos.org Orthoillustrated (Arthrex): www.orthoillustrated.com Wheeless Online: www.wheelessonline.com Bone tumor information site: www.bonetumor.org General Web Sites U.S. Centers for Disease Control and Prevention: www.cdc.gov U.S. National Library of Medicine: www.nlm.nih.gov National Institutes of Health (NIH): www.nih.gov NIH Library: www.ncrr.nih.gov



Index 255

INDEX Note: Page number followed by “p” indicates that the entry is a pediatric reference A ABCDEs mnemonic, 1 acetabular fractures, 205, 206 acetabular index (DDH), 153, 154 acid–base values, 3 acromioclavicular joint injection/aspiration, 134 acute concussion, 165 acute lateral ankle sprains, classification of, 214 adolescent idiopathic scoliosis, 111–114 Lenke classification of, 114 Adson’s test, 136 adult trauma ankle, 214–215 elbow, 184–188 femur, 211 foot, 216–219 forearm, 183 hand, 177–181 hip, 207–210 knee, 211–213 leg, 215 pelvis, 201–205 periprosthetic, 207 shoulder, 189–195 spine, 196–201 wrist, 182–183 Allen’s test, 121 allogeneic blood transfusion risk, 77 analgesics, 95p angles, 95–97p ankle approaches, 19 block, 142 fasciotomy, 70 joint injection/aspiration, 141 ligaments, 35 muscles, 15–16 radiologic views, 159–160 tests, 140–141 trauma (fracture), 214–215, 241p

anterior drawer ankle, 140 knee, 138 anterior humeral line, 149 anterior interosseous nerve quick neurologic test, 123 schematic, 40 anterior spinal laminar line, 143 anteroposterior impingement, 138 anteroposterior talocalcaneal angle, 159 antibiotic doses, 64–65p antibiotic mechanisms, 63 antibiotic prophylaxis, 75–76 for dental procedures, 75 for GI procedures, 76 for urologic procedures, 76 anticoagulation therapy, 76–77 antihistamines, 95p antimicrobial antivenin, 55 bites, 54–55 bursitis, 57 diabetic foot, 56 flexor tenosynovitis, 62 hand, 57 necrotizing fasciitis, 62 osteomyelitis, 58–60, 109p septic arthritis, 51–54 skin infections, 61–62 apprehension test (shoulder), 132 arm cross section, 21–23 fasciotomy, 68–69 muscles, 8 trauma (fracture), 183 arteries axillary, 30 elbow, 27–28 forearm, 28 knee, 29 pelvis, 29 shoulder, 26–27

arthritis, degenerative, 86–87 arthroplasty, total joint, 53 arthroscopic classification, of osteochondritis dissecans, 101p asymmetric external rotation test, 138 atlanto dens interval (ADI), 144 atypical infections, 63 autonomic dysreflexia, 166 axillary nerve schematic, 39 B Babinski sign (spine), 136 Baby Bennett’s fracture, 180 back pain, in children, 102p Bado classification, 184, 225p balanced suspension, with/without skeletal traction, 175 Barlow (DDH), 137, 138p Barton’s fracture, 182 basion-axis interval, 143 basion-dens interval, 143 basketball foot, 216 bat bite, 55 belly press, 132 Bennett’s fracture, 178, 180 Berndt/Harty classification, 243p bites (traumatic), 54–55 viral infections associated with, 56 blanch sign (SCFE), 107p Blickenstaff/Morris class (femoral neck), 207 blood estimated loss, 3–4 pressure estimation, 3 systemic response, 4 transfusion risk, 77 volume, 3 Blount’s disease, 101, 110 Blumensaat’s line, 158 Bohler’s angle, 160, 162

256 Index bone lesions, radiographs of, 250 both bone fracture, 183, 224p Boutonniere deformity, 177, 178 bowstring (spine), 136 Boxer’s fracture, 179 brachial plexus, 36, 100–101p Brown-Sequard syndrome, 169 Bryant’s traction, 173 Buck’s traction, 173 burns, 6 bursitis, 57 C Cain classification, 181 calcaneal fractures, 217 calcaneal traction pin, 171 calcaneovalgus, 100p calcium metabolism, 78 calcium pyrophosphate crystals (CPPD), 79 calcium recommendations, 86 Capitolunate angle, 148, 149 cardiac tamponade, 3 carpal tunnel tests, 121 carrying angle (elbow), 149 Carvajal’s formula, for fluid resuscitation in burns, 6 cat bite, 54 catfish barb, 54 central cord syndrome, 169 cervical spine development, 96p cervical spine radiographic lines atlanto dens interval, 144 Chamberlain’s line, 144 McCrae’s line, 146 McGregor’s line, 146 Pavlov’s ratio, 146 Power’s ratio, 145, 146 space available for the cord (SAC), 146 cervical spine trauma, 196–201 Chamberlain’s line, 144 chance fracture, 200 Chauffeur’s fracture, 182 chest tube, 2 child abuse, 117p

chronic traumatic encephalopathy, 165 Cierny-Mader staging system, 60 clonus (spine), 136 clubfoot, 100p Cobb angle, 143, 144 Coleman block test, 140 Colles’ fracture, 182 Colton classification, 185 common peroneal nerve, 45 compartment syndrome, 65–67 complete cord syndrome, 169 concussion, 164–165 in athletes, 164 neuropsychological testing, 164 stages of injury, 165 congenital spine deformities, 114p congruence angle, 158 coxa vara epiphyseal angle, 154 neck shaft angle, 155, 205 cross arm test, 132 cross section arm, 21–22 forearm, 22–23 leg, 25 spinal cord, 168 thigh, 24–25 wrist, 23 crossed finger test, 121 crossed straight leg raise, 136 cyclo-oxygenase 2 inhibitors, 87 D Danis/Weber classification, 215 deep peroneal nerve block, 142 degenerative arthritis, 86–87 Delbet class, 234p DeLee classification, 227p dermatomes, 49 peripheral, 46, 48 developmental dysplasia of the hip (DDH), 119 evaluation and treatment, algorithm for, 120 lines/angles, 154–155

DEXA osteoporosis criteria, 85 diabetic foot infection, 56 dial test (knee), 139 Dias/Tachdjian classification, 241 diffuse axonal injury, 165 discitis, 110p discoid meniscus, 157 dislocation carpus/perilunate, 183 elbow, 187, 228–229p facet, 198 glenohumeral, 232p hand, 180–181, 221–223p hip, 209, 234p knee, 212–213, 239p patella, 212, 239p radial head, 225p scapulothoracic, 194, 232p shoulder, 194–195, 231–232p tibia-fibula, 240p distal femoral traction pin, 172 distal phalanx fracture, 177, 221 dog bite, 54 Drennan’s angle, 110 drop arm test, 132 drop sign, 132 Duverney fracture, 235p dysplastic conditions, 103–104p E early onset idiopathic scoliosis, 111p elbow approaches, 17 fat pad (x-ray), 148 flexion test, 121 injection, 131 ligaments, 31 radiographic views, 132 radiologic views, 149–150 tests, 129–132 trauma (fracture), 184–188, 226–230p Elson test, 121 EMG/NCV test, 81–82 epiphyseal angle, 154 Epstein classification, 209 Erb-Duchenne palsy, 100p

Essex-Lopresti fracture, 188 classification, 244p extensor digitorum avulsion, 177 extensor tendon zones, 123 external rotation lag sign, 133 external rotation recurvatum (knee), 139 F FABER test, 138 Fairbank’s changes, 157 fasciotomy ankle, 70 arm, 68–69 finger, 67 foot, 71 forearm, 68–69 hand, 67–68 leg, 70 thigh, 69 femoral nerve schematic, 43 traction test, 136 femur trauma (fracture), 211, 237p finger fasciotomy, 67 mallet finger, 125 finger block, 127 finger extensor apparatus, 32 finger puller system, 33 Finkelstein test, 121 first metatarsophalangeal angle (bunions), 160, 162 fleck sign, 160 flexor digitorum profundus tendon avulsion, 177 flexor digitorum profundus test, 121, 122 flexor digitorum superficialis test, 121, 122 flexor tendon block, 127 laceration, 179 sheaths, 124 test for continuity, 121 zones, 123 flexor tenosynovitis, 62 floating knee, 211, 238p fluid loss estimate, 3–4 fluid management, 3 fluid resuscitation in burns, 6

Foley catheter, 3 foot deformities, 99–100p fasciotomy, 71 muscles, 15–16 radiologic views, 159–160 trauma (fracture), 216–219, 243–244p forearm approaches, 17 arteries, 28 cross section, 22–23 fasciotomy, 68–69 muscles, 8–10 trauma (fracture), 183, 223–225p fractures acetabular, 205, 206 ankle, 215, 241p arm, 183, 223–225p carpal bones, 183, 222p elbow, 184–188, 226–230p femur, 211, 237p foot, 216–219, 243–244p forearm, 183, 223–225p hand, 177–181, 221–223p hip, 207–208, 234p knee, 211–212, 238–239p pelvic, 201–205, 235p periprosthetic, 207 Salter-Harris, 105p shoulder, 189–195, 231–232p spine, 196–201, 200, 233p tibia/fibula, 212, 213, 240p wrist, 182–183, 221–223p Frankel grading, 167 Froment’s sign, 121 frozen section, 80 G Galeazzi fracture, 183, 184, 225p Galeazzi test, 138 Gamekeeper’s thumb, 181 Garden classification, 207 Gardner-Wells tongs, 176 genu varum, 110p Gissane’s angle, 160, 162 Glasgow coma scale, 5 glenohumeral dislocation, 232p glenohumeral injection, 135 glenohumeral ligaments, 30

Index 257 gout, 79 Gram stain, 80 growth centers, 97–99p Guhl classification, of osteochondritis dissecans, 101p gunshot wounds (spine), 201 Gustillo classification, 245 H Hahn-Steinthall class, 185, 186, 228p halo placement, 176 hand fasciotomy, 67–68 infections, 57 injuries, 246 muscles, 10–11 rotational alignment, 126 tests, 121–127 trauma (fracture), 177–181, 221–223p Hangman’s fracture, 197 Hardcastle classification, 243p Hardinge approach, 18 Harris line, 144 Hawkins sign/test, 133, 216 Hawkins/Canale classification, 216 hematoma block, 127 Henry approach, 17 herpetic whitlow, 57 Herring classification, 118p Hilgenreiner’s line, 153, 154 Hill-Sachs lesion, 189 hip approaches, 18 muscles, 11–13 radiographic lines, 154–155 tests, 138 trauma (fracture), 207–210, 234p Hoffmann’s sign (spine), 136 Holstein-Lewis fracture, 187 Horn blower’s test, 133 Hotchkiss classification, 187 human bite, 55 Hunter’s syndrome, 102p Hurler’s syndrome, 102p hydrocortisone, supplemental, 89 hypercalcemia, 80 hypocalcemia, 80–81

258 Index I Ideberg classification, 194 iliac crest pins, 72 ilioischial line, 154, 155 iliopectineal line, 154, 155 impingement sign/test, 133 infantile idiopathic scoliosis, 111p infection imitators, 63 infection, laboratory tests for, 80 inferior gluteal nerve, 43 Insall ratio (patella), 158 intermetatarsal angle, 160, 162 intra-articular tumors, 251 IV, initial fluid, 3 IV maintenance therapy, 3 J Jakob classification, 227p Jefferson fracture, 196 Jersey fracture, 221p Johner/Wruhs classification, 213 joint fluid analysis, 78–79 Jones fracture, 219, 243p K Kellgren and Lawrence grading system, for knee osteoarthritis, 159 Key/Conwell class, 235p Kilfoyle classification, 227p King curves, 112p Kite’s angle, 159 Klein’s line, 155 Kline’s line, 107p knee approaches, 19 arteries, 29 diaphyseal angle, 110p injection/aspiration, 140 lateral and medial layers, 30 radiographic lines, 157–158 tests, 138–140 trauma (fracture), 211–213, 238–239p knee osteoarthritis, Kellgren and Lawrence grading system for, 159

Kocher approach, 17, 18 Kocher-Lorenz fracture, 185, 186, 228p Kocher’s fracture, 184 kyphosis, 116 L Lachman’s test, 139 lag sign, 133 Lagenbach approach, 18 lateral atlanto-dens interval, 144 lateral capsular sign, 157 lateral mass distance, 144 lateral patellofemoral angle (Laurin), 158 lateral pivot shift test, 129, 131 lateral talocalcaneal angle, 160 Lauge-Hansen, 215 Laugier fracture, 185 Laurin angle (patella), 158 leg approaches, 19 cross section, 25 fasciotomy, 70 muscles, 14–15 trauma (fracture), 215, 240p Legg-Calves-Perthes, 118p Lenke classification, scoliosis, 114 Letournel classification, of pelvic fractures, 205, 206 Letts/Vincent class, 238p Lhermitte’s sign (spine), 136 liftoff test, 133 ligaments ankle, 35 elbow, 31 knee, 34–35 pelvic, 34 shoulder, 30 syndesmosis, 35 wrist, 31 limp, in children, 107–111p Lisfranc injury, 218 Listhesis grades, 166 little leaguer elbow, 228p load shift test, 133 Lodwick’s classification, 250 low back pain, 168

lower versus upper motor neuron lesions, 167 Ludloff approach, 18 lumbar plexus, 37 stenosis, 167 trauma (fracture), 200 lunate tilt, 150 M Maissenouve fracture, 214 Malgaigne fracture, 184, 236p malignant lesions, 251 mallet finger, 125, 177, 221p March fracture, 216 Mason classification, 187 Mayfield’s stages, 183 McCrae’s line, 146 McGregor’s line, 146 McMurray’s test, 139 Meary’s angle, 160 median nerve innervated hand muscles (LOAF), 40 schematic, 40 meniscofemoral ligaments, 34 metabolic bone disease, 80–81 metacarpal fracture, 177–179 metaphyseal blanch sign, 107p metaphyseal-diaphyseal angle, 110p, 159p metastatic carcinoma, skeletal fixation of, 249 metatarsal fracture, 218 metatarsophalangeal joint dislocation, 219 metatarsus varus, 100p Meyer/McKeever classification, 212 midtarsal injury, 217 Milch classification, 227p, 230p Milch fracture, 184 milestones, 95–97p milking maneuver test, 129 modified Bryant’s traction, 173 monosodium urate crystals, 79

Monteggia fracture, 183, 184, 225p Morquio’s syndrome, 102p motor innervation axillary/MC, 39 common peroneal, 45 femoral/obturator, 43 inferior gluteal, 43 median, 40 obturator, 43 radial, 41 sciatic, 44 superior gluteal, 43 tibial, 44 ulnar, 42 moving valgus stress test, 129, 130 MRI signal characteristics, 151 mucopolysaccharidosis, 102p muscle strength testing, 166 muscles arm, 8 foot/ankle, 15–16 forearm, 8–10 hand/wrist, 10–11 hip, 11–13 leg, 14–15 shoulder, 7 thigh, 13 musculocutaneous nerve, 39 musculoskeletal lesions, staging system for, 248 Musculoskeletal Tumor Society (MSTS) stages of disease, 251 myelodysplasia levels, 97 Myers/McKeever classification, 239p N navicular fracture, 217 neck-shaft angle, 155, 205 necrotizing fasciitis, 62 needle manometer, 66 Neer classification, 189 Neer impingement test/ sign, 133 nerve injury, classification of, 83 neuromuscular scoliosis, 111p night pains in children, 101p

nightstick fracture, 183 90–90 skeletal traction, 174 nonsteroidal antiinflammatory drug (NSAIDs), 87, 88 Nursemaid’s elbow, 225p, 230p nutcracker fracture, 217 O obesity, 83 O’Brien’s test, 133 obturator nerve, 43 Ogden classification, 212, 238p Olecranon fracture, 185 open hand injuries, 246 oral antibiotic doses, 64–65p orthopaedic oncology. See tumor Ortolani test, 137, 138p osteoarthrosis (radiographic arthritis), 151 osteoblastic metastasis, 249 osteochondral fracture, 243p osteochondritis dissecans, Guhl classification, 101p osteochondroses, 101 osteomyelitis, 58–60p, 109p osteonecrosis, 84–85 osteoporosis, 85–86 risk factors, 85 osteosclerosis, 81 P pain management, 86–87 Parkland formula, for fluid resuscitation in burns, 6 paronychia, 57 passive test of continuity, 121 patellar apprehension, 139 pathologic fracture, scoring system to predict, 249 Pavlov’s ratio, 146 pediatric back pain, 102p calcium recommendation, 86p child abuse, 117p foot deformities, 99–100p genu varum, 110p growth plates/centers, 97–99p

Index 259 limp, 107–111p medications, 95p milestones and angles, 95–97p myelodysplasia levels, 97p night pains, 101p osteomyelitis, 58–60 reflexes, 96p rotational profile, 96p septic arthritis, 51, 108 traction, 173p verbal score, 5p vital signs, 4p pediatric trauma ankle, 241p elbow, 226–230p femur, 237p foot, 243–244p forearm, 223–225p hand/wrist, 221–223p hip, 234p knee, 238–239p leg, 240p pelvis, 235–236p shoulder, 231–232p spine, 233p Pelligrini-Steida lesion, 157 pelvic arteries, 29 pelvic external fixation, 72 pelvic ligaments, 34 pelvic radiographic lines, 154 pelvic stabilization, acute, 72 pelvis approaches, 18 radiologic views, 154–155 trauma (fracture), 201–205, 235–236p perioperative management, 87–89 peripheral dermatomes lower extremity, 48 upper extremity, 46 peripheral nerve disorders, electrodiagnostic findings in, 82 peripheral sensory innervation lower extremity, 47 upper extremity, 46 periprosthetic fractures, 207 Perkins vertical line, 153, 155 persistent concussion, 165

260 Index phalangeal fracture, 177, 178, 219 Phalen’s test, 121 phosphate metabolism, 78 physical exam/injections elbow, 129–132 foot/ankle, 140–141 hand, 121–127 hip, 138 knee, 138–140 shoulder, 132–135 spine, 136–137 wrist, 128 Piedmont fracture, 183 pig bite, 55 Pipkin classification, 209, 210 pivot shift (knee), 139 plexus brachial, 36 lumbar, 37 sacral (posterior), 37 sacral (anterior), 38 pneumothorax (tension), 2 polarized microscopy, 79 Ponseti technique, 100 POPSIQ mnemonic, 20 Posadas fracture, 184 post menisectomy radiographic changes, 157 posterior drawer knee, 139 shoulder, 134 posterior interosseous nerve schematic, 41 PIN compression, 129 quick neurologic test, 123 posteroinferior impingement, 138 posterolateral rotatory instability (elbow), 129, 130 Power’s ratio, 145, 146 prevertebral soft tissue swelling, 146 primary survey, 1 prolonged concussion syndrome, 165 proximal humerus, 17 proximal tibial metaphysealdiaphyseal angle, 159p proximal tibial traction pin, 172

pseudo-Jones fracture, 218, 243 pseudogout, 79 Q Q angle (knee), 159 quadrangular space, 30 Quadriga effect, 122 R raccoon bite, 55 radial bursa, 124 radial head dislocation, 225p radial inclination, 149 radial nerve exploration, 189 radial nerve, schematic, 41 radial volar tilt, 150 radiocapitellar line, 149 radiocapitellar plica, 129 radiologic views foot/ankle, 159–160 hip/pelvis, 154–155 lower extremity, 158–159 spine, 143–144, 146 upper extremity, 149–150 radiolunate angle, 150 rat bite, 55 reflexes, 96p, 166 Regan test, 122 Regan/Morrey classification, 185 relocation sign, 134 resisted straight leg raise, 138 resuscitation, 1 reverse mallet finger, 221p reverse Monteggia fracture, 183 rheumatoid arthritis (osteoarthrosis), 151 rheumatologic disorders, perioperative management, 87–88 Risser stages, 112p, 113p Rolando’s fracture, 178, 180 rotational profile, 96p round cell lesions, by age, 250 Ruedi/Allgower classification, 215 Rugger jersey finger, 177 Russell’s skin traction, 173, 175

S sacral inclination, 146 sacral plexus, 37–38 sacral spine trauma, 200 Salter-Harris classification, 105p, 223p, 238p Salter-Harris type II fracture, 178 Sanfilippo’s syndrome, 102p saphenous nerve block, 142 scaphoid fracture, 223p scapholunate angle, 148, 150 interval, 150 scapulothoracic dislocation, 194, 232p Scheuermann’s kyphosis, 116 sciatic nerve, 44–45 sciatic notch, contents, 20 scoliometer, 111p scoliosis, 111p Cobb angle, 143, 144 King curves, 112p progression risk factors, 112 Risser stages, 112p, 113p treatment guidelines, 112 Scotty dog, 146 secondary survey, 2 Seddon classification, 83 segond fracture, 157 Seinsheimer classification, 208 semimembranosus five insertions, 35 septic arthritis, 51–54, 108 severe extremity soft tissue trauma, management of, 247 Seymour fracture, 221p Shatzker classification, 210, 211 Shenton’s line, 153, 155 shoulder approaches, 17 arteries, 26–27 ligaments, 30 muscles, 7 spaces, 27, 30 tests, 132–135 trauma (fracture), 189–195, 231–232p Silfverskiöld test, 140 single leg heel raise test, 141

skeletal survey, in child abuse, 117p Skier’s thumb, 181 skin infections, 61–62 skin traction, 174 skunk bite, 55 slip angle (spondylolisthesis), 146 slipped capital femoral epiphysis, 106–107p Klein’s line, 155 small joint fusion, 179–181 Smith-Peterson approach, 18 Smith’s fracture, 182 snake bite, 55 space available for the cord (SAC), 146 Speed’s test, 134 spinal cord injury, 165–169 syndromes, 169 treatment by functional level, 169 spine gunshot wounds, 201 radiology, 143–144, 146 stable fracture criteria, 201 stenosis criteria, 167 tests, 136–137 trauma (fracture), 196–201, 233p split Russell’s traction, 173 spondylolisthesis, 147, 166 sacral inclination, 146 slip angle, 146 spondylolysis, 166 Scotty dog, 146 Spurling’s test, 122 steroids in cord injury, 165 straddle fracture, 236p straight leg raise, 136 stress fracture risk, 201 subacromial injection, 135 subchondral bone lesions, 250 sulcus angle (patella), 159 sulcus sign, 134 Sunderland classification, 83 superficial peroneal nerve block (ankle), 142 superior gluteal nerve, 43 superior labrum anteriorposterior (SLAP) lesions, 192

supra-acetabular pins, 72–73 sural nerve block, 142 surgical stress, hydrocortisone for, 89 Swan neck deformity, 126 syndesmosis, ligaments of, 35 systemic responses to blood loss, 4 systolic blood pressure, estimated, 3 T T-Condylar fracture, 228p talar tilt test, 141 talipes equinovarus, 100p talo-calcaneal angle, 100p tamponade (cardiac), 3 tarso-metatarsal fracture/ dislocation, 218 tarso-metatarsal injuries (x-ray), 163 teardrop, 154, 155 tendon laceration, 179 tennis elbow test, 129 tenodesis effect, 122, 125 tension pneumothorax, 2 tetanus, 89 immunization, 89 wound classification, 89 thigh approaches, 19 cross section, 24–25 fasciotomy, 69 muscles, 13 trauma (fracture), 211 Thompson approach, 17 Thompson/Epstein classification, 209 Thompson’s test, 141 thoracic spine trauma, 200 Thurston-Holland fragment, 105p tibial nerve block, 142 schematic, 44 tibial traction pin, proximal, 172 Tillaux fracture, 242p Tinel’s test, 122 tissue biopsy, 80

Index 261 tissue frozen section, 80 tobacco abuse, 90 Toniolo/Wilkins classification, 228p too many toes sign, 141 total joint arthroplasty, 53 tourniquet, 90 traction, 171–176 types of, 173 traction pins, placement of, 171–172 transient synovitis versus septic arthritis, 108 trauma. See adult trauma; pediatric trauma trauma radiographs, 2 tri-plane fracture, 242p triangular interval, 30 triangular space, 30 tumor, 248–252 intra-articular, 251 new patient, evaluation of, 250 Tylenol, 86 U ulnar bursa, 124 ulnar nerve quick neurologic test, 123 schematic, 42 ulnar variance, 150 upper versus lower motor nerve lesions, 167 V V-sign of Light, 180 valgus elbow test, 129 varus/valgus (knee), 139 vasculature elbow, 27–28 forearm, 28 knee, 29 pelvis, 29 shoulder, 26–27 venous thromboembolic disease (VTE), 91–92 verbal score, pediatric, 5p vertebral infection, 110p vital signs, pediatric, 4p vitamin D recommendation, 86 volar approach, 18 volar wrist ligaments, 31

262 Index W Wackenheim line, 146 Waddell’s signs, 136 Watson-Jones approach, 18 Watson test, 122 Weber classification, 214 white blood cell (WBC) count, 79 Wiberg center edge angle, 155 Winquist classification, 211

wound healing indices, 93 wrist approaches, 18 cross section, 23 ligaments, 31 muscles, 10–11 nerves framing, 29 trauma (fracture), 182–183, 221–223p wrist arcs, 150 wrist block, 128

wrist injection, 128 wrist radiographic lines/ angles, 152 capitolunate, 148 scapholunate, 148 Y Yergason’s test, 134 Young/Burgess classification, of pelvic fractures, 202, 204